Taking Control of an Emergency Room Visit

From NBC LA:

Knowing and enforcing your rights in the exam room will alleviate the anxiety that could accompany an uninformed visit to a bustling medical center.

An initial evaluation, called a Medical Screenings Exam, will tell doctors how quickly you need treatment. Sometimes, it’s right away – but other times, if your problem is not serious, you may have to wait.

If you do have to wait to be taken care of, you are entitled to treatment of your pain and anxiety as soon as possible.

9 PinnacleHealth System doctors resign over pressure to admit, discharge patients in ER

From Penn Live:

An effort to shorten emergency room waits might have broken the relationship between PinnacleHealth System and a group of doctors who specialize in caring for hospital patients.

The group of nine hospitalists led by Dr. Michael Hilden submitted resignations last week.

Hilden directed the hospitalists at Pinnacle. He said the resignations resulted from administrative interference in medical decisions and pressure to quickly admit or discharge patients.

Pinnacle officials said they don’t know the doctors’ exact reasons for resigning.

But they said it might have resulted from dissatisfaction over new policies intended to speed up the emergency room and increase quality and patient satisfaction.

Association of Direct Helicopter Versus Ground Transport and In-hospital Mortality in Trauma Patients

From Academic Emergency Medicine:

Objectives:  Helicopter emergency medical services (HEMS) transport of trauma patients has been used for decades. Its use, however, is still a subject of debate, including issues such as high costs, increasing numbers of crashes, and conflicting results regarding effectiveness in reducing mortality. The aim of this study was to examine whether mode of transport (HEMS vs. ground EMS) is independently associated with mortality among trauma patients transported directly from the scene of injury to definitive care.

Methods:  All trauma patients transported directly to a Level I or Level II trauma center by either air or ground EMS over a 4-year period were selected from the Oklahoma State Trauma Registry. Multivariable logistic regression was used to develop propensity scores based on variables measured at the scene of injury. The propensity scores represented the predicted probabilities of a patient being transported by HEMS given a specific set of characteristics and were used as a composite confounding variable in subsequent models of the association of mortality and mode of transport. Along with the propensity scores, Injury Severity Scores (ISS), initial Revised Trauma Score (RTS), and distance from the trauma center were included in a Cox proportional hazards model of the association of mode of transport and 24-hour and 2-week mortality.

Results:  Overall, the hazard ratio (HR) for 2-week mortality in patients transported by HEMS was 33% lower (HR = 0.67, 95% confidence interval [CI] = 0.54 to 0.84) than in patients transported by ground EMS from the scene of injury, after adjustment for the propensity score and other covariates. In subanalyses, the apparent association of a reduction in the hazard of early mortality among patients transported by HEMS was most evident for patients with an RTS based on injury scene vital signs of 3 to 7 (HR = 0.61, 95% CI = 0.46 to 0.82). The point estimate of the HR was similar (HR = 0.65 95% CI = 0.34 to 1.2) in the 75% of cases who had normal vital signs at the scene of injury, although it was no longer statistically significant because crude mortality was very low (1.7%) in this group. Among those with a RTS of 3 or less at the scene, crude mortality was 58%, and mode of transport was not associated with mortality (HR = 1.02, 95% CI = 0.68 to 1.6).

Conclusions:  Helicopter EMS transport was associated with a decreased hazard of mortality among certain patients transported from the scene of injury directly to definitive care. Refinements in scene triage and transport guidelines are needed to more effectively select patients that may benefit from HEMS transport from those unlikely to benefit.

One Idea for Reducing Health Care Costs: Keep Non-Emergencies Out of the ER

From Forbes:

Much of our skyrocketing health care costs are spent on unnecessary emergency room visits.  A Rand Corp. study last year found that we spend $4.4 billion annually on people who use the ER for routine, non-urgent care.  Though studies vary on the percentage of inappropriate ER visits (the CDC says its 8% but Health Affairs puts it at 27%), no one disputes that these patients could get better and less expensive care elsewhere.

To crack down on “frequent flyers”, as patients who repeatedly use the ER are known, some states have adopted aggressive measures.  Washington state is trying to limit its Medicaid recipients to three non-urgent emergency room visits per year.  After that, they have to pay for the visits out of their own pockets. (A judge blocked implementation of the plan last week but policy makers say they’ll find a legal way to do it.)  Florida is tackling the problem by seeking to charge Medicaid patients $100 each time they use the ER for routine care.

These efforts may keep costs down in the short term by keeping folks with routine ailments out of the ER.  But they don’t address the larger problem of redirecting the patients to primary care physicians that will coordinate their care and keep them healthier.

Fatigue linked to safety problems among EMS workers, Pitt study finds

Pittsburgh School of Medicine Press Release, via EurekAlert:

Fatigue and poor sleep quality, which affect many emergency medical services (EMS) workers, are linked to higher reported rates of injuries, medical errors and safety-compromising behaviors, according to a study by University of Pittsburgh researchers that is now available online in Prehospital Emergency Care and appearing in the January-March 2012 print edition.

“Emergency medical technicians and paramedics work long hours in a demanding occupation with an unpredictable workload, which can easily lead to fatigue and poor sleep. Our study is one of the first to show that this may jeopardize patient and provider safety in the EMS setting,” said lead author P. Daniel Patterson, Ph.D., EMT-B, an assistant professor in the Department of Emergency Medicine at the University of Pittsburgh School of Medicine.

Dr. Patterson and his colleagues surveyed EMS workers from across the country, receiving complete data from 511 respondents. A previously tested tool called the Pittsburgh Sleep Quality Index was used to evaluate sleep quality, including such factors as sleep duration and use of sleeping medication. A questionnaire measuring fatigue and adapted for the EMS environment was used to assess physical and mental fatigue. The researchers also developed a new 44-item survey tool to elicit self-reported safety outcomes data, including provider injury, medical errors or adverse events and safety-compromising behaviors, such as excessive speeding.

In the survey sample, more than half of the respondents were classified as fatigued; 18 percent reported an injury; 41 percent reported a medical error or adverse event; and 90 percent reported a safety-compromising behavior. After controlling for extraneous variables, the researchers found the odds of injury were 1.9 times greater for fatigued respondents vs. their non-fatigued peers; the odds of medical errors or adverse events were 2.2 times greater; and the odds of safety-compromising behavior were 3.6 times greater.

Most survey respondents reported working between six and 15 shifts per month, and half reported regular shift lengths of 24 hours. A third of the respondents were regularly working at more than one EMS agency. In the sample, the number of shifts worked monthly was linked to reported errors and adverse events but not to injury or perceptions of compromised safety. Longer shift hours were not associated with higher odds of negative safety outcomes—perhaps because the study did not measure the varying workloads and ability to rest during each shift, the researchers speculated.

“While further research is needed to examine the association between self-reported and actual safety outcomes, our findings provide preliminary evidence that sleep quality and fatigue are important indicators of EMS safety,” said Dr. Patterson. “Our data also suggest that number of shifts and total fatigue, instead of shift length, may be important targets for intervention in this workforce.”

Hospital-based AED’s “could be costing lives”

From the Tuscon Sentinel:

Just over a decade ago, hospitals around the country began spending millions of dollars to buy automated defibrillators to save the lives of more patients who go into sudden cardiac arrest. The purchases were spurred by a recommendation from an American Heart Association committee that decided the new equipment would bring patients speedier emergency help.

But today the costly equipment switchover increasingly seems to have been a mistake. The latest, most extensive research suggests that the new gear, now found in nearly all hospitals, saves fewer lives than the old, lower-tech defibrillators.

By one estimate, the shortcomings of the automated equipment mean that close to 1,000 more hospital cardiac arrest patients die every year in the United States.

CDC to Track Use of Antibiotics in Hospitals

From MedPage Today:

The CDC has launched a new electronic tool to monitor antibiotic use in hospitals to help facilities curb overuse of the drugs.

The new tracking tool is part of the CDC’s National Healthcare Safety Network, a Web-based surveillance system that uses data from 4,800 hospitals to track infections.

Until now, the CDC has tracked antibiotic use in doctors’ offices, but not in hospitals.