Improving the management of mild traumatic brain injury in the emergency department

From Figshare:

Background – Despite the availability of evidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED), variations in practice exist. Implementation research can contribute to reducing these variations in practice by studying the determinants, processes and effects of implementation efforts and providing evidence about what works when designing, selecting and improving implementation interventions. The ED environment has unique characteristics that can have an impact on its responsiveness to change. An understanding of these factors influencing practice change is essential to develop an effective implementation intervention that is feasible and acceptable. There is limited research on how to develop targeted, theory-informed implementation interventions in this setting.

Aims – The aim of this thesis is to describe the process of developing a targeted, theory-informed intervention to increase the uptake of evidence-based recommendations in the management of mTBI in the ED. Specifically to: 1) identify the key evidence-based recommendations to be implemented, 2) explore and identify the influencing factors (barriers and enablers) to change using relevant theoretical frameworks, 3) develop a targeted, theory-informed intervention by identifying intervention components to overcome these factors that is acceptable and feasible to deliver, and 4) describe the process of developing fidelity measures for intervention components.

Methods – A systematic scoping review was conducted to assess the volume and scope of implementation research in the ED setting; a systematic review of clinical guidelines for the management of mTBI, followed by a formal stakeholder consultation process, to develop locally applicable evidence-based recommendations for implementation; qualitative interviews with ED clinicians were used to explore the professional and organisational factors influencing uptake of the recommended behaviours using two theoretical frameworks. A systematic, stepped approach was developed to identify and operationalise intervention components to address the influencing factors and was informed by theory, evidence and feasibility considerations. A review of process evaluations of similar tailored interventions to that developed in the thesis was used to inform development of fidelity measures.

Results – The scoping review found a significant increase in the volume of implementation research, however most studies focused on identifying evidence-practice gaps or utilised weak study designs to evaluate the effects of implementation interventions. Four key evidence-based recommendations were identified to improve the management of mTBI in the ED. Interviews with 42 ED staff identified professional and organisational factors that influenced these recommendations and presented theoretically based targets for intervention components. The resulting five intervention components consisted of several behaviour change techniques (BCTs). Fidelity measures were developed for two of these intervention components.

Conclusions – This thesis provides a systematic, theory- and evidence-informed approach to developing an intervention aiming to improve the management of mTBI in the ED. Theoretical frameworks, evidence-based BCTs, evidence about the effects of modes of delivery and feasibility information were systematically brought together to develop the intervention. Implementation research is a cumulative science and this intervention is currently being evaluated in a national cluster randomised controlled trial, adding to the evidence of the effectiveness of theory-informed interventions to improve clinical practice.

Hydrocortisone Fails to Prevent Septic Shock

From Emergency Medicine News:

Hydrocortisone failed to reduce the risk of septic shock in severe sepsis patients in recent research, though its authors held out hope that a larger study could show a better result. Current guidelines recommend hydrocortisone for treating sepsis, but whether it prevents progression to septic shock has been controversial. The HYPRESS study, which its authors conceded was underpowered, found no benefit.

Palliative Care Decreases Emergency Department Visits for All, but Especially for Some

From the NEJM’s Journal Watch:

Palliative care improves quality of life for patients with terminal conditions and also decreases ED utilization. The field of research on palliative care initiated from the ED setting is burgeoning. This study joins others in demonstrating that a little extra effort up front (i.e., connecting the patient with palliative care) will not only alleviate suffering but also prevent a lot of future work managing avoidable visits.

Performance of Emergency Department Screening Criteria for an Early ECG to Identify ST‐Segment Elevation Myocardial Infarction

From the Journal of American Heart Association:

Background Timely diagnosis of ST‐segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Obtaining this test within 10 minutes of ED arrival is critical to achieving the best outcomes. We investigated variability in the timely identification of STEMI across institutions and whether performance variation was associated with the ED characteristics, the comprehensiveness of screening criteria, and the STEMI screening processes.

Methods and Results We examined STEMI screening performance in 7 EDs, with the missed case rate (MCR) as our primary end point. The MCR is the proportion of primarily screened ED patients diagnosed with STEMI who did not receive an ECG within 15 minutes of ED arrival. STEMI was defined by hospital discharge diagnosis. Relationships between the MCR and ED characteristics, screening criteria, and STEMI screening processes were assessed, along with differences in door‐to‐ECG times for captured versus missed patients. The overall MCR for all 7 EDs was 12.8%. The lowest and highest MCRs were 3.4% and 32.6%, respectively. The mean difference in door‐to‐ECG times for captured and missed patients was 31 minutes, with a range of 14 to 80 minutes of additional myocardial ischemia time for missed cases. The prevalence of primarily screened ED STEMIs was 0.09%. EDs with the greatest informedness (sensitivity+specificity−1) demonstrated superior performance across all other screening measures.

Conclusions The 29.2% difference in MCRs between the highest and lowest performing EDs demonstrates room for improving timely STEMI identification among primarily screened ED patients. The MCR and informedness can be used to compare screening across EDs and to understand variable performance.

Fair Medicare Hospital Payments Act of 2017: Rural Hospital Support

From the Free Press:

U.S. Sens. Mark R. Warner and Tim Kaine (both D-VA) introduced bipartisan legislation to ensure hospitals are fairly reimbursed for their services by the federal government and are able to remain open and functioning, especially in Virginia’s underserved and economically struggling regions.

The budget-neutral Fair Medicare Hospital Payments Act of 2017 (S.397) would correct a flawed formula that results in disproportionately low Medicare reimbursement payments to hospitals in rural and low-wage areas.

Provider Recruitment Trends

From Medicus:

The Medicus Firm, a national search firm specializing in permanent placement of physicians, NPs, and PAs, released its annual placement summary report, based on the hiring activity of more than 250 healthcare employers nationally, and hundreds of provider placements.

The key highlights from the 2017 Physician Placement Report, based on hiring patterns from 2012 through 2016, include the following trends:

  • International physicians comprised 31.77 percent of placements made in 2016. This statistic has been of particular interest due to the uncertainty about the future of U.S. immigration policy, in light of an Executive Order signed in late January, which has since been rejected. Nationally, internationally trained physicians comprise about 25 percent of the physician workforce, according to data from the AAMC and AMA.
  • Placement rate of advanced practice clinicians increased significantly for the fourth consecutive year. Placements of PAs and NPs have grown steadily since 2012, when only 1.32 percent of placements were NPs and PAs. In 2016, non-physician advanced practice placements comprised 12 percent of total provider placements, up from 8.3 percent in 2015. Physician assistants were the 2nd most frequently placed provider, and nurse practitioners were also among the top ten providers.

Rural Health Providers Head to DC To Flex Newfound Political Clout

From North Carolina Health News:

In the past six years, dozens of rural hospitals around the United States have discharged their final patients and turned out the lights, including three in North Carolina. The nation’s crisis of opiate addiction and overdose has been playing out most strongly in rural towns, where family and community ties are strong and overdose deaths hit hard.

And research shows there’s a persistent gap in life expectancy between rural and urban communities,  with data showing that rural areas experience poorer health on almost every measure and have less healthcare infrastructure to support residents.

Rural residents made their displeasure known during November’s presidential election, where they  gave the election to Pres. Donald Trump, sweeping Republicans into office on his coattails.

“My recommendation is to seize this political opportunity and turn it into a boon for rural America,” she told the crowd.