Is the drip-and-ship approach to delivering thrombolysis for acute ischemic stroke safe?

From the Journal of Emergency Medicine, via ScienceDirect:

Background: The drip-and-ship method of treating stroke patients may increase the use of tissue plasminogen activator (t-PA) in community hospitals. Objective: The safety and early outcomes of patients treated with t-PA for acute ischemic stroke (AIS) by the drip-and-ship method were compared to patients directly treated at a stroke center. Methods: The charts of all patients who were treated with intravenous (i.v.) t-PA at outside hospitals under the remote guidance of our stroke team and were then transferred to our facility were reviewed. Baseline NIHSS (National Institutes of Health Stroke Scale) scores, onset-to-treatment (OTT), and arrival-to-treatment (ATT) times were abstracted. The rates of in-hospital mortality, symptomatic hemorrhage (sICH), early excellent outcome (modified Rankin Scale [mRS] ≤ 1), and early good outcome (discharge home or to inpatient rehabilitation) were determined. Results: One hundred sixteen patients met inclusion criteria. Eighty-four (72.4%) were treated within 3 h of symptom onset. The median estimated NIHSS score was 9.5 (range 3–27). The median OTT time was 150 min, and the median ATT was 85 min. These patients had an in-hospital mortality rate of 10.7% and sICH rate of 6%. Thirty percent of patients had an early excellent outcome and 75% were discharged to home or inpatient rehabilitation. When these outcome rates were compared with those observed in patients treated directly at our stroke center, there were no statistical differences. Conclusions: In this small retrospective study, drip-and-ship management of delivering i.v. t-PA for AIS patients did not seem to compromise safety. However, a large prospective study comparing drip-and-ship management to routine care is needed to validate the safety of this approach to treatment.

Most providers get on-call compensation: survey

From Modern Healthcare:

Almost two-thirds (62%) of healthcare providers receive some form of additional compensation for on-call coverage—mostly in the form of a daily stipend or hourly rate—with compensation rates varying by specialty, group size and region, according to a new report by the Medical Group Management Association which surveyed online 317 medical practices representing 2,536 providers.

The survey, titled the Medical Directorship/On-Call Compensation Report, marks the first time the MGMA polled its members on this topic, and it found that 70% of providers in hospital-owned group practices received additional compensation, compared with 58% of providers in practices not owned by hospitals. At $2,000 a day, neurosurgeons reported the highest daily compensation for oncall coverage, while pediatricians and urologists received $895 and $500 respectively.

“Historically, on-call duties have been sporadically compensated by hospitals, however, we’re seeing more hospitals compensating physicians and we’re seeing hospitals paying more,” said Jeffrey Milburn with, MGMA Health Care Consulting Group in a news release. “Hospitals are realizing they must compensate group-practice physicians for on-call duties.”

Unplanned readmissions among Medicare patients seen as frequent, costly

From Modern Helathcare:

Unplanned rehospitalizations among Medicare beneficiaries are expensive and frequent, according to research published in the New England Journal of Medicine.

Researchers supported by the Commonwealth Fund found 19.6% of Medicare patients were readmitted to the hospital within 30 days of a discharge from 2003 to 2004. Within one year of a hospitalization, 56.1% were readmitted, according to the report. In addition, a study of physician claims indicated that about half of the patients rehospitalized within 30 days of their discharge did not receive follow-up care with a doctor between discharge and readmission. The researchers used data from the Medicare Provider Analysis and Review database from Oct. 1, 2003 to Dec. 31, 2004 to find discharge numbers, and studied 2003 claims data from the CMS Chronic Condition Data Warehouse to determine follow-up visits.

Unplanned rehospitalizations in 2004 accounted for $17.4 billion of $102.6 billion Medicare paid to hospitals, the study estimated. Readmission rates are being targeted by the CMS and other quality advocates as one area where costs can be reduced while quality improves.

Most hospitalists are good…

From Kevin MD:

It’s a good time to be a hospitalist, but, as this reader writes to me, that may lead to an increasingly variability in the quality of care. Here’s an account:

I work in a small hospital where the primary care docs have stopped seeing their own and a hospitalist group has taken over.

The level of care the hospitalists give is very poor. They spend less than 30 seconds in each room. We play a game by timing them with the second hand of our watches — 25 seconds, tops, for most of them. They pile all the charts at a computer, walk into room after room for less than 30 seconds, make no notes, write nothing down anywhere, often don’t touch the patient, then they leave and go directly into the next room. They visit ten to twelve rooms in a row in exactly the same manner, then sit at the computer and write in chart after chart. It is astonishing.

Next, the name of the game is, how many tests can they order? The geriatrics who are failing, in their 80s and 90s, come in and get everything from echos, CT scans, MRIs, carotid and venous dopplers, all possible labwork, etc. Their H&Ps are a list a mile long of terminal fatal conditions, but the list of diagnostics and treatments they get is equally long. Some get complete neurology work ups for their natural loss of consciousness as their life ends. Yesterday I watched 2 COPD’ers put on a vent, each one got an echo, several x-rays, one a dobhoff [feeding tube], both got PICC lines, then inhaled morphine to deal with their terror. They were both managed by hospitalists.

It is frightening and unbelievable to be in the trenches and watch this.

Rural ED Catch-22: Crowded and Nowhere to Go

From Emergency Medicine News:

Crowded EDs, long assumed to be a dilemma only for urban hospitals, affect rural areas as well, sometimes in profoundly more complex ways.

When an urban ED fills up, it simply diverts ambulances to the nearest hospital. But for a crowded rural ED, the problem is more vexing when the nearest hospital is 100 miles away.

Every emergency department is coping in some way, said Mary L. Van Vonderen, RN, an advanced nurse practitioner at Hayward (WI) Area Memorial Hospital. If we could share our various coping mechanisms, we could probably develop some strategies that little departments could use.

John J. Rogers, MD, the chairman of the American College of Emergency Physicians’ rural emergency medicine section, said major obstacles complicate transfers from his rural ED to another facility. If that center is backlogged with patients in the emergency department because there are no beds available in the hospital, then the problem flows downhill. Those tertiary hospitals tend to stay full all the time, and their solution is to keep patients in the emergency department. That’s not a good solution.

And that scenario leaves rural hospitals and their patients in the lurch, forcing emergency physicians to scramble for a place to transfer patients who need advanced care.

Rural EDs provide care to a significant portion of the U.S. population, and provide services to those who visit or vacation in those areas. According to the article Challenges Facing Rural Hospitals in the American Hospital Association’s TrendWatch (2002;4[1]:1), more than 54 million people live in areas served by 2,200 rural hospitals.

PDA and Smartphone Usability in Clinical Practice

From Medgadget:

The Healthcare Human Factors Group, a research organisation affiliated with Canada’s University Health Network, has conducted a usability study assessing the intuitiveness of five different PDA’s and smartphones during four basic scenarios that nurses typically experience. This is all very interesting as the number of portable clinical applications we feature on these pages has been growing rapidly.

Here is a snippet from the summary findings:


9 patients made nearly 2,700 ER visits in Texas

From Yahoo News:

Just nine people accounted for nearly 2,700 of the emergency room visits in the Austin area during the past six years at a cost of $3 million to taxpayers and others, according to a report. The patients went to hospital emergency rooms 2,678 times from 2003 through 2008, said the report from the nonprofit Integrated Care Collaboration, a group of health care providers who care for low-income and uninsured patients.

“What we’re really trying to do is find out who’s using our emergency rooms … and find solutions,” said Ann Kitchen, executive director of the group, which presented the report last week to the Travis County Healthcare District board.

The average emergency room visit costs $1,000. Hospitals and taxpayers paid the bill through government programs such as Medicare and Medicaid, Kitchen said.

Eight of the nine patients have drug abuse problems, seven were diagnosed with mental health issues and three were homeless. Five are women whose average age is 40, and four are men whose average age is 50, the report said, the Austin American-Statesman reported Wednesday.