Emergency Medicine: Observation Saves Money

From MedPage Today:

Keeping selected patients under observation in a dedicated hospital unit with defined protocols could yield hundreds of millions of dollars in cost savings, researchers found.

Compared with patients who were observed in other areas of the hospital, those who received observation in a unit dedicated to the practice and with clear, condition-specific protocols had a total length of stay that was 23% to 38% shorter, a 17% to 44% lower likelihood of full inpatient admission, and were associated with an estimated $950 million in potential saved costs nationally, according to Michael Ross, MD, of Emory University in Atlanta, and colleagues.

In addition, an estimated 11.7% of short-stay emergency department inpatients (EDs) could receive treatment in these type I observation units nationally, which would be associated with cost savings of $5.5 to $8.5 billion, they wrote online in the emergency care-focused December issue of Health Affairs.

Health Affairs: The Future Of Emergency Medicine: Challenges & Opportunities

From Health Affairs:

This thematic issue of Health Affairs focuses on emergency care, long popularized by television dramas but less recognized for the array of activities in which its practitioners are engaged.

In an overview written with several colleagues, Arthur Kellermann—a leader in emergency medicine and the new dean of medicine at the Uniformed Services University of the Health Sciences—envisions a future for EDs based on four broad trends: Enabled by health information technology, they will become better integrated with traditional health systems in their communities (a concept more fully discussed in this issue by Ricardo Martinez and Brendan Carr); they will become regionalized to better serve victims of heart attack, stroke, and pediatric emergencies (as discussed by Brent Eastman and coauthors); they will become effective advocates for public health because ED providers see what occurs when prevention fails; and, if health care financing shifts from fee-for-service to value-based models, as is foreseen, EDs will be expected to do everything they can to avoid costly admissions.

A contrasting view is offered by Jesse Pines and coauthors, who hold that fee-for-service with new incentives based on currently lacking resource and quality measures (as Jeremiah Schuur and coauthors discuss) is the only feasible approach to paying for acute care.

A 2-Hour Diagnostic Protocol for Assessing Chest Pain in the ED

From CardioExchange (hat tip: NEJM Journal Watch):

CardioExchange’s John Ryan interviews Martin Than about a New Zealand study group’s randomized trial comparing a 2-hour diagnostic protocol with usual care for patients who report chest pain in the emergency department. The article is published in JAMA Internal Medicine.

THE STUDY

At a New Zealand hospital, researchers randomized 542 adults with acute chest pain consistent with ACS (all seen by an attending physician who planned further observation and troponin testing) to one of two diagnostic pathways:

  • an accelerated (experimental) protocol using TIMI score, ECG findings, and 0- and 2-hour troponin results
  • a standard (usual-care control) protocol of troponin testing on arrival, prolonged observation, and repeat troponin testing 6 to 12 hours after onset of pain

The rate of discharge within 6 hours after hospital arrival was significantly higher in the experimental group than in the control group (19.3% vs. 11.0%). An additional 12.9% of patients in the experimental group were classified as low-risk but were still admitted for cardiac investigation; none of the 35 received a diagnosis of ACS after inpatient evaluation.

Doctors face punishing pace in the ER every day

From the Globe and Mail:

Every day, there’s a new crop of sick patients who show up at the department. Some of them will need to be admitted, which will cause a scramble among staff to find a free bed in the ever-busy hospital. Many will have to wait for hours to be seen.

It’s just another day in the emergency department.

Evaluation of a Training Curriculum for Prehospital Trauma Ultrasound

From the Journal of Emergency Medicine:

Background

In the United States, ultrasound has rarely been incorporated into prehospital care, and scant descriptions of the processes used to train prehospital providers are available.

Objectives

Our objective was to evaluate the effectiveness of an extended focused assessment with sonography for trauma (EFAST) training curriculum that incorporated multiple educational modalities. We also aimed to determine if certain demographic factors predicted successful completion.

Methods

All aeromedical prehospital providers (APPs) for a Level I trauma center took a 25-question computer-based test to ascertain baseline knowledge. Questions were categorized by content and format. Training over a 2-month period included a didactic course, a hands-on training session, proctored scanning sessions in the Emergency Department, six Internet-based training modules, pocket flashcards, a review session, and remedial training. At the conclusion of the training curriculum, the same test and an objective structured clinical examination were administered to evaluate knowledge gained.

Results

Thirty-three of 34 APPs completed training. The overall pre-test and post-test means and all content and format subsets showed significant improvement (p < 0.0001 for all). No APP passed the pre-test, and 28 of 33 passed the post-test with a mean score of 78%. No demographic variable predicted passing the post-test. Twenty-seven of 33 APPs passed the objective structured clinical examination, and the only predictive variable was passing the post-test (odds ratio 1.21, 95% confidence interval 1.00–1.25, p = 0.045).

Conclusion

The implementation of a multifaceted EFAST prehospital training program is feasible. Significant improvement in overall and subset testing scores suggests that the test instrument was internally consistent and sufficiently sensitive to capture knowledge gained as a result of the training. Demographic variables were not predictive of test success.

The Role of Prehospital Electrocardiograms in the Recognition of ST-Segment Elevation Myocardial Infarctions and Reperfusion Times

From the Journal of Emergency Medicine:

Background

Clinical outcomes in ST-segment elevation myocardial infarction (STEMI) are related to reperfusion times. Given the benefit of early recognition of STEMI and resulting ability to decrease reperfusion times and improve mortality, current prehospital recommendations are to obtain electrocardiograms (ECGs) in patients with concern for acute coronary syndrome.

Objectives

We sought to determine the effect of wireless transmission of prehospital ECGs on STEMI recognition and reperfusion times. We hypothesized decreased reperfusion times in patients in whom prehospital ECGs were obtained.

Methods

We conducted a retrospective, observational study of patients who presented to our suburban, tertiary care, teaching hospital emergency department with STEMI on a prehospital ECG.

Results

Ninety-nine patients underwent reperfusion therapy. Patients with prehospital ECGs had a mean time to angioplasty suite of 43 min (95% confidence interval [CI] 31–54). Compared to patients with no prehospital ECG, mean time to angioplasty suite was 49 min (95% CI 41–57), p = 0.035. Patients with prehospital STEMI identification and catheterization laboratory activation had a mean time to angioplasty suite of 33 min (95% CI 25–41), p = 0.007. Patients with prehospital ECGs had a mean door-to-balloon time of 66 min (95% CI 53–79), whereas the control group had a mean door-to-balloon time of 79 min (95% CI 67–90), p = 0.024. Patients with prehospital STEMI identification and catheterization laboratory activation had a mean door-to-balloon time of 58 min (95% CI 48–68), p = 0.018.

Conclusions

Prehospital STEMI identification allows for prompt catheterization laboratory activation, leading to decreased reperfusion times.

Duration of Resuscitation Efforts and Functional Outcome After Out-of-Hospital Cardiac Arrest

From Circulation:

Background—Functionally favorable survival remains low after out-of-hospital cardiac arrest. When initial interventions fail to achieve the return of spontaneous circulation, they are repeated with little incremental benefit. Patients without rapid return of spontaneous circulation do not typically survive with good functional outcome. Novel approaches to out-of-hospital cardiac arrest have yielded functionally favorable survival in patients for whom traditional measures had failed, but the optimal transition point from traditional measures to novel therapies is ill defined. Our objective was to estimate the dynamic probability of survival and functional recovery as a function of resuscitation effort duration to identify this transition point.

Methods and Results—Retrospective cohort study of a cardiac arrest database at a single site. We included 1014 adult (≥18 years) patients experiencing nontraumatic out-of-hospital cardiac arrest between 2005 and 2011, defined as receiving cardiopulmonary resuscitation or defibrillation from a professional provider. We stratified by functional outcome at hospital discharge (modified Rankin scale). Survival to hospital discharge was 11%, but only 6% had a modified Rankin scale of 0 to 3. Within 16.1 minutes of cardiopulmonary resuscitation, 89.7% (95% confidence interval, 80.3%–95.8%) of patients with good functional outcome had achieved return of spontaneous circulation, and the probability of good functional recovery fell to 1%. Adjusting for prehospital and inpatient covariates, cardiopulmonary resuscitation duration (minutes) is independently associated with favorable functional status at hospital discharge (odds ratio, 0.84; 95% confidence interval, 0.72–0.98; P=0.02).

Conclusions—The probability of survival to hospital discharge with a modified Rankin scale of 0 to 3 declines rapidly with each minute of cardiopulmonary resuscitation. Novel strategies should be tested early after cardiac arrest rather than after the complete failure of traditional measures.