Kasier goes after ED patients with insurance in Washington DC metro

From Bloomberg:

“When you pull out privately insured individuals from emergency departments, the people who end up going are people who don’t have access to other services,” said Jesse Pines, an associate professor of emergency medicine and health policy at George Washington University in Washington.

For Kaiser, “it makes a lot of sense,” Pines said in a telephone interview. “But it will horribly increase the uncompensated and under-compensated care burden of local emergency departments.”

Predicting Peripheral Venous Access Difficulty in the Emergency Department Using Body Mass Index and a Clinical Evaluation of Venous Accessibility

From the Journal of Emergency Medicine:


Peripheral venous (PV) cannulation, one of the most common technical procedures in Emergency Medicine, may prove challenging, even to experienced Emergency Department (ED) staff. Morbid obesity (body mass index [BMI] ≥ 40) has been reported as a risk factor for PV access failure in the operating room.


We investigated PV access difficulty in the ED, across BMI categories, focusing on patient-related predicting factors.


Prospective, observational study including adult patients requiring PV lines. Operators were skilled nurses and physicians. PV accessibility was clinically evaluated before all cannulation attempts, using vein visibility and palpability. Patient and PV placement characteristics were recorded. Primary outcome was failure at first attempt. Outcome frequency and comparisons between groups were examined. Predictors of difficult cannulation were explored using logistic regression. A p-value <0.05 was considered significant.


PV lines were placed in 563 consecutive patients (53 ± 23 years, BMI: 26 ± 7 kg/m(2)), with a success rate of 98.6%, and a mean attempt of 1.3 ± 0.7 (range 1-7). Failure at the first attempt was recorded in 21% of patients (95% confidence interval [CI] 17.6-24.4). Independent risk factors were: a BMI ≥ 30 (odds ratio [OR] 1.98, 95% CI 1.09-3.60), a BMI < 18.5 (OR 2.24; 95% CI 1.07-4.66), an unfavorable (OR 1.66, 95% CI 1.02-2.69), and very unfavorable clinical assessment of PV accessibility (OR 2.38, 95% CI 1.15-4.93).


Obesity, underweight, an unfavorable, and a very unfavorable clinical evaluation of PV accessibility are independent risk factors for difficult PV access. Early recognition of patients at risk could help in planning alternative approaches for achieving rapid PV access.

Telemonitoring did not reduce hospitalizations or ED visits in high-risk elderly patients

From the Annals of Internal Medicine:

QUESTION In elderly patients at high risk for hospitalization, does home telemonitoring reduce hospitalizations and emergency department (ED) visits compared with usual care? METHODS DESIGN Randomized controlled trial. ClinicalTrials.gov NCT01056640. ALLOCATION {Concealed}*.† BLINDING Blinded† ({outcome assessors}* and data analysts). FOLLOW-UP PERIOD 1 year. SETTING 4 primary care clinics in Minnesota, USA. PATIENTS 205 patients &gt; 60 years of age (mean age 80 y, 54% women) who were enrolled in the clinic’s Employee and Community Health program and had an Elder Risk Assessment Index score &gt; 15 (based on age, sex, previous hospitalizations, and comorbid conditions [stroke, dementia, heart disease, diabetes mellitus, and chronic obstructive pulmonary disease]). Exclusion criteria were residence in a nursing home, dementia, Kokmen mental status score ≤ 29, and inability to use the telemonitoring device. INTERVENTION Home telemonitoring using the Intel Health Guide (Intel-GE) device (n = 102) or usual care (n = 103). Telemonitoring comprised daily patient entry of symptoms and biometrics using peripheral scales, blood pressure cuff, glucometer, pulse oximeter, and peak flow meter. Data were reviewed daily by registered nurses who triaged patients using decision support from the medical record, consulted with primary physicians, and communicated with patients by telephone or videoconference as needed. OUTCOMES Primary outcome was a composite of hospitalizations and ED visits. Secondary outcomes included hospitalizations, ED visits, and mortality. With 100 patients per group, the study had 80% power to detect a 36% relative reduction (from 38% to 24%) in the composite endpoint at 1 year (α = 0.05). PATIENT FOLLOW-UP 81% (intention-to-treat analysis). MAIN RESULTS Telemonitoring did not reduce hospitalizations or ED visits, combined or alone, but increased mortality (Table). CONCLUSIONS In high-risk elderly patients, telemonitoring did not reduce hospitalizations or emergency department visits compared with usual care but increased mortality.Telemonitoring vs usual care in high-risk elderly patients‡OutcomesEvent ratesAt 1 yTelemonitoringUsual careRRI (95% CI)NNH (CI)Hospitalizations and ED visits64%57%11% (-11 to 40)NSHospitalizations52%44%19% (-11 to 59)NSED visits35%28%25% (-16 to 88)NSMortality15%3.9%279% (38 to 961)10 (6 to 33)‡ED = emergency department; NS = not significant; other abbreviations defined in Glossary. RRI, NNH, and CI calculated from event rates in article.

Chest Pain in the Emergency Department: The Case Against Our Current Practice of Routine Noninvasive Testing.

From the Archives of Internal Medicine:

Current clinical practice for patients presenting to the emergency department with a resolved episode of chest pain and no electrographic or biomarker abnormalities is to conduct routine noninvasive testing, in accordance with American College of Cardiology and American Heart Association guidelines. The rationale is to further reduce the risk of missing a myocardial infarction, a major source of suits filed against emergency department physicians. Patients with negative stress test results may be reassured, with low event rates in the subsequent 30 days. Patients with positive stress test results have higher 30-day event rates, and a small fraction undergo revascularization procedures. Despite this endorsement, open questions remain. Does our current practice lead to the stenting of asymptomatic patients in the inevitable cases where the inciting pain was noncardiac? And, most importantly, does our practice improve outcomes? Randomized trials evaluating routine stress testing in other contexts have yielded negative results, despite diagnosing significant coronary artery disease. Population data suggest that our current practice may be increasing the diagnosis of coronary artery disease and the rate of intervention while failing to decrease rates of myocardial infarction. We propose that randomized trials be conducted to evaluate whether any testing is better than no further intervention. Data from such an evidence-based approach has the potential to reverse our current practice.

Hospital-Based Shootings in the United States: 2000 to 2011

From the Annals of Emergency Medicine:

Study objective

Workplace violence in health care settings is a frequent occurrence. Emergency departments (EDs) are considered particularly vulnerable. Gunfire in hospitals is of particular concern; however, information about such workplace violence is limited. Therefore, we characterize US hospital-based shootings from 2000 to 2011.


Using LexisNexis, Google, Netscape, PubMed, and ScienceDirect, we searched reports for acute care hospital shooting events in the United States for 2000 through 2011. All hospital-based shootings with at least 1 injured victim were analyzed.


Of 9,360 search “hits,” 154 hospital-related shootings were identified, 91 (59%) inside the hospital and 63 (41%) outside on hospital grounds. Shootings occurred in 40 states, with 235 injured or dead victims. Perpetrators were overwhelmingly men (91%) but represented all adult age groups. The ED environs were the most common site (29%), followed by the parking lot (23%) and patient rooms (19%). Most events involved a determined shooter with a strong motive as defined by grudge (27%), suicide (21%), “euthanizing” an ill relative (14%), and prisoner escape (11%). Ambient society violence (9%) and mentally unstable patients (4%) were comparatively infrequent. The most common victim was the perpetrator (45%). Hospital employees composed 20% of victims; physician (3%) and nurse (5%) victims were relatively infrequent. Event characteristics that distinguished the ED from other sites included younger perpetrator, more likely in custody, and unlikely to have a personal relationship with the victim (ill relative, grudge, coworker). In 23% of shootings within the ED, the weapon was a security officer’s gun taken by the perpetrator. Case fatality inside the hospital was much lower in the ED setting (19%) than other sites (73%).


Although it is likely that not every hospital-based shooting was identified, such events are relatively rare compared with other forms of workplace violence. The unpredictable nature of this type of event represents a significant challenge to hospital security and effective deterrence practices because most perpetrators proved determined and a significant number of shootings occur outside the hospital building.