The Emergency Room: Its Use And Abuse

From the Times-Herald:

The rapidly expanding use of hospital emergency rooms by the general public, along with decreasing availability of personnel to staff these departments, has given rise in recent years to misunderstand in many of our communities as to the purpose of this service.

This has come about largely because the emergency rooms of our hospitals are often misused by persons who consider them Outpatient Clinics or a substitute for a family physician.

‘Chirping’ EpiPen results in evacuation of ED

From the Observer:

Parts of the emergency room in Charlotte’s biggest hospital were evacuated Friday when a chirping battery in a tinted container aroused suspicion, official said.

They later learned the noise came from a medical needle, known as an electronic epinephrine auto injector, that allows users to inject themselves with a single dose of epinephrine after a life-threatening allergic reaction.

Shortly after 8 a.m., police and firefighters responded to Carolinas Medical Center after receiving reports of a “suspicious package” found in the emergency department, hospital spokesman Kevin McCarthy said.

He said some parts of the emergency room were evacuated, but he was unsure how many people were escorted out. There were other parts of the emergency department that were deemed safe and fully operational while emergency crews and media swarmed the hospital.

As emergency responders probed the package, MEDIC diverted all its units away from the hospital “out of an abundance of caution” and transported patients to other area hospitals, a spokesman said.

By 10:15 a.m., emergency officials started packing up and rolled away the caution tape after determining the injector’s “chirping battery” was the culprit, McCarthy said.

The medical device sounded because its battery was dying, he said. The needle had been thrown away in a “sharps box,” one of several containers hospital staff use to dispose of used medical needles.

Rural Health Gets a Hearing; Is Congress Listening?

From HealthLeaders Media:

If you’re an advocate for rural healthcare and the people who provide it, Tuesday was a good day at the U.S. Capitol.

The House Ways and Means Health Subcommittee hearing on “rural health disparities” included testimony from three rural providers who shared their complaints about the 96-hour rule, the lack of residency slots for new physicians, and overly burdensome regulations for physician supervision of nurse practitioners. These three issues are among the most pressing for rural providers.

People with knowledge of the challenges facing rural healthcare would be pressed to find anything new in testimony presented before the subcommittee, but that doesn’t mean these concerns aren’t worth reiteration.

ER Docs: Minnesota State Report Promotes Inaccurate Views about Emergency Patients

ACEP Press Release:

The American College of Emergency Physicians (ACEP) and Minnesota ACEP today jointly took issue with a new report being promoted by the Minnesota Department of Health (MDH) about “potentially preventable” health care events, including emergency care, saying it could put patients at risk.

The report assesses whether emergency visits could have been avoided, based on the patients’ final diagnoses, not their symptoms. This analysis does not take into consideration the national “prudent layperson” standard, which says emergency visits must be covered by insurance companies based on patients’ symptoms, not their final diagnoses. This standard was included in the Affordable Care Act (ACA).

“It is very alarming that a report like this is being issued that directly undermines language in the ACA and patients’ responsible use of the emergency department,” said Michael Gerardi, MD, FACEP, president of ACEP. “Patients never should be forced into the position of self-diagnosing their medical condition out of fear of insurance not covering the visit. This applies 20/20 hindsight to possibly life-threatening conditions and it violates the national prudent layperson standard designed to protect patients’ health plan coverage of emergency care.”

Dr. Gerardi adds that a report like this could lay down precedent barring emergency patients from receiving care.

The data in the MDH study are generated by a research tool designed by Professor John Billings of New York University’s Wagner School of Public Service. Professor Billings has said that his tool is not intended for use as a triage tool or as a mechanism to determine whether emergency department use is appropriate.

“A report like this only serves to potentially scare patients away from the emergency department when they may need it most,” said Thomas E Wyatt, MD, FACEP, president of the Minnesota Chapter of ACEP. “Insurance companies historically have denied payment for emergency care based on patients’ final diagnoses, not symptoms. But symptoms are what determine whether visits are appropriate. Patients with chest pain should get immediate medical attention to determine whether or not they are having a heart attack. If the doctor discovers it was a panic attack, it was still right for that patient to seek immediate medical care, and his or her insurance should absolutely cover the visit.”

The data in the MDH study do not correlate with the latest national data on emergency visits from the Centers for Disease Control and Prevention, which found 96 percent of emergency patients needed medical care within 2 hours in 2011.

“Patients in Minnesota are no different from patients anywhere else in the country,” said Dr. Wyatt. “The levels of urgency here are just as high as they are everywhere else.”

According to a study published in the Journal of the American Medical Association in 2013, researchers found that discharge diagnoses do not identify “non-emergency” ER visits. The small number of emergency patients who are ultimately discharged with “primary care treatable” diagnoses come to the ER with the same symptoms as other patients who need immediate or emergency care, hospital admission or surgery.

“Emergency departments occupy a unique place within the American health care system,” said Dr. Gerardi. “We see and treat anyone who needs us, regardless of their ability to pay, and we do so every hour of every day. To our patients, the emergency department is the right place at the right time.”

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

AMA Opioid Abuse Prevention Task Force & Resources

From the American Medical Association:

Thinking of prescribing an opioid? Learn the facts first:

  • More than 16,000 Americans died in 2013 from an opioid-related overdose.
  • More than 8,000 Americans died from a heroin-related overdose in 2013.

The AMA Task Force to Reduce Opioid Abuse has been charged to empower you to be an advocate for preventing opioid abuse and promoting appropriate prescribing.

Prescription Drug Monitoring Programs (PDMPs) are key screening tools to help determine whether to prescribe an opioid.

When used effectively, PDMPs can help assess your patient’s prescription history and immediately determine whether your patients have received prescriptions from other prescribers and dispensers, including those from other states.

Educate yourself and your colleagues about the effective use of PDMPs today.

It’s up to you to be the leader in solving our nation’s opioid abuse epidemic.

Resource Page

Rural hospitals blast ‘arcane’ policies

From Modern Healthcare:

The 96-hour rule and a possible direct-supervision policy are a danger to critical-access hospitals, rural health leaders said at a congressional hearing Tuesday.

They also told members of the House Ways and Means Committee’s Health Subcommittee that graduate medical education slots need to be more fairly allocated to help rural areas recruit providers.

‘Jaw-dropping’: Medicare deaths, hospitalizations AND costs reduced

From US Today:

The U.S. health care system has scored a medical hat trick, reducing deaths, hospitalizations andcosts, a new study shows.

Mortality rates among Medicare patients fell 16% from 1999 to 2013. That’s equal to more than 300,000 fewer deaths a year in 2013 than in 1999, said cardiologist Harlan Krumholz, lead author of a new study in the Journal of the American Medical Association (JAMA) and a professor at the Yale School of Medicine.

“It’s a jaw-dropping finding,” Krumholz said. “We didn’t expect to see such a remarkable improvement over time.”

Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013

From JAMA:

Importance  In a period of dynamic change in health care technology, delivery, and behaviors, tracking trends in health and health care can provide a perspective on what is being achieved.

Objective  To comprehensively describe national trends in mortality, hospitalizations, and expenditures in the Medicare fee-for-service population between 1999 and 2013.

Design, Setting, and Participants  Serial cross-sectional analysis of Medicare beneficiaries aged 65 years or older between 1999 and 2013 using Medicare denominator and inpatient files.

Main Outcomes and Measures  For all Medicare beneficiaries, trends in all-cause mortality; for fee-for-service beneficiaries, trends in all-cause hospitalization and hospitalization-associated outcomes and expenditures. Geographic variation, stratified by key demographic groups, and changes in the intensity of care for fee-for-service beneficiaries in the last 1, 3, and 6 months of life were also assessed.

Results  The sample consisted of 68 374 904 unique Medicare beneficiaries (fee-for-service and Medicare Advantage). All-cause mortality for all Medicare beneficiaries declined from 5.30% in 1999 to 4.45% in 2013 (difference, 0.85 percentage points; 95% CI, 0.83-0.87). Among fee-for-service beneficiaries (n = 60 056 069), the total number of hospitalizations per 100 000 person-years decreased from 35 274 to 26 930 (difference, 8344; 95% CI, 8315-8374). Mean inflation-adjusted inpatient expenditures per Medicare fee-for-service beneficiary declined from $3290 to $2801 (difference, $489; 95% CI, $487-$490). Among fee-for-service beneficiaries in the last 6 months of life, the number of hospitalizations decreased from 131.1 to 102.9 per 100 deaths (difference, 28.2; 95% CI, 27.9-28.4). The percentage of beneficiaries with 1 or more hospitalizations decreased from 70.5 to 56.8 per 100 deaths (difference, 13.7; 95% CI, 13.5-13.8), while the inflation-adjusted inpatient expenditure per death increased from $15 312 in 1999 to $17 423 in 2009 and then decreased to $13 388 in 2013. Findings were consistent across geographic and demographic groups.

Conclusions and Relevance  Among Medicare fee-for-service beneficiaries aged 65 years or older, all-cause mortality rates, hospitalization rates, and expenditures per beneficiary decreased from 1999 to 2013. In the last 6 months of life, total hospitalizations and inpatient expenditures decreased in recent years.

Trying to break the cycle that creates health care ‘super-users’

From CT Mirror:

“Many of these people fall between the cracks of many service provision systems, but the one place where they keep emerging is in the emergency room,” said Lydia Brewster, assistant director for community services at St. Vincent de Paul Middletown, which operates a supportive housing program and a soup kitchen. “The emergency room knows they’re not solving the problem. They’re getting the person band-aided together.

There are broader implications for the health care system too. Nationwide, 5 percent of patients accounted for half of total health care spending in 2012, according to federal data. Some health experts view focusing on “super users” as a key strategy in the quest to improve care while controlling health care costs.

Hospital and emergency services employees are often targets of violence

From WOWK:

The number violent crimes in hospitals across the United States went up in 2014.

Thomas Hospital in South Charleston was put on lock down in July when someone came into the emergency room and threatened violence.

Mike Jarrett, with the Kanawha County Emergency Ambulance Authority, said ambulance crews are also often the target of physical violence.