ED Push - June 2015 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
ED Pain Protocol Based on Yes-or-No Question to Patient
BRONX, NY – Want to know if patients in your emergency department need more pain medication? Just ask them.
That’s part of a new evidence-based protocol to treat acute severe pain in ED patients, published online recently by Annals of Emergency Medicine. It recommends a straightforward, yes-or-no question instead of a 1-to-10 scale or drawings of happy and sad faces.
During the study of the protocol, researchers from Montefiore Medical Center administered 1 milligram of intravenous (IV) hydromorphone to adult patients who answered in the affirmative. A half hour later, the patient again was asked, "Do you want more pain medication?"
The process was repeated at 30-minute intervals, and patients were given an additional 1 milligram IV hydromorphone each time they answered "yes". Patients responding in the negative received no additional opioid at that point but were asked again 30 minutes later, so that every patient was queried four times.
"The crowded conditions in most emergency departments in the U.S. are not conducive to fully individualized pain treatment," said Andrew Chang, MD, MS, of the Department of Emergency Medicine at Montefiore. "Our simple and easy to remember '1 + 1 + 1 + 1' protocol holds promise for safely providing adequate pain relief to patients with acute severe pain."
At the end of the study, satisfactory pain control was defined as declining additional pain medication on one or more occasions.
With 207 patients enrolled in the study, 114 received the initial dose of 1 milligram of hydromorphone, 78 received 2 milligrams, nine received 3 milligrams and six received 4 milligrams. Only two of the patients failed to reach satisfactory pain control within the study’s duration of 2 to 4 hours. Overall, patient satisfaction was high: 67% reported being very satisfied and 29% reported being satisfied.
"Pain perception is highly subjective and not necessarily correlated to pain scores," Chang explained. "Our pain protocol is a departure from the more traditional ways of assessing pain relief, which typically use the visual analog scale or the numerical rating scale. Instead, our use of a non-numerical, simple yes/no question offers patients the ability to decide for themselves whether their pain is adequately controlled and allows them to balance pain relief against medication side effects such as nausea and drowsiness. This likely explains the wide range of pain scores (as much as 0 to 10) for patients who did not ask for pain medication.”
Appendicitis Patients Treated With Antibiotics Usually Don’t Require Surgery
TURKU, FINLAND – Here’s some useful information for emergency physicians trying to decide whether to send uncomplicated appendicitis patients home with antibiotics or to a surgeon.
A new study finds that most patients with uncomplicated appendicitis did not require an appendectomy when treated with antibiotics, and those who eventually needed to undergo surgery did not experience significant complications.
Antibiotic treatment did not meet a pre-specified level of effectiveness compared with appendectomy, however, according to the study published recently in the Journal of the American Medical Association.
For the study, researchers from Turku University Hospital in Finland randomly assigned 530 patients with uncomplicated acute appendicitis confirmed by a computed tomography [CT] scan to receive antibiotic therapy for 10 days or a standard appendectomy.
In testing the hypothesis that antibiotic treatment was non-inferior to appendectomy, the researchers assumed that there would be sufficient benefits from avoiding surgery and that a 24% failure rate in the antibiotic group would be acceptable.
Only one of the 273 patients randomized to the surgical group did not undergo successful appendectomy, for an overall success rate of 99.6%.
After one-year follow-up on the 256 patients who received antibiotics instead, 72.7% did not require appendectomy. The remainder underwent surgical intervention within a year of initial presentation for appendicitis, with no intra-abdominal abscesses or other major complications associated with delayed appendectomy.
The intention-to-treat analysis yielded a difference in treatment efficacy between groups of negative 27%. Because of the pre-specified non-inferiority margin of 24%, the researchers were unable to demonstrate non-inferiority of antibiotic treatment relative to surgery in this specific study.
Despite that, the authors write that the majority of patients with uncomplicated acute appendicitis “were successfully treated with antibiotics. These results suggest that patients with CT-proven uncomplicated acute appendicitis should be able to make an informed decision between antibiotic treatment and appendectomy.”
The authors call for future studies focusing both on early identification of complicated acute appendicitis patients needing surgery and to prospectively evaluate the optimal use of antibiotic treatment in patients with uncomplicated acute appendicitis.
In an accompanying commentary, Edward Livingston, MD, deputy editor of JAMA in Chicago, and Corrine Vons, MD, PhD, of the Jean Verdier hospital in Bondy, France, suggest that “the time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis. The operation served patients well for more than 100 years. With development of more precise diagnostic capabilities like CT and effective broad-spectrum antibiotics, appendectomy may be unnecessary for uncomplicated appendicitis, which now occurs in the majority of acute appendicitis cases.
“These findings suggest that for CT-diagnosed uncomplicated appendicitis, an initial trial of antibiotics is reasonable followed by elective appendectomy for patients who do not improve with antibiotics or present with recurrent appendicitis,” they add.
ED Revisits Much Higher than Expected; But Why?
SAN FRANCISCO – If it seems as if you’re seeing the same patients over and over again in your emergency department, you’re not just having a case of serial déjà vu.
A new study, published recently in Annals of Internal Medicine, points out that one in five patients return to the ED within 30 days of an initial visit, and one in 12 returns after three days.
That’s much more frequent than previously reported, according to study authors from the University of California, San Francisco, and Philip R. Lee Institute for Health Policy Studies in San Francisco.
Noting that little is known about what happens to patients after they are discharged from the ED, researchers reviewed Healthcare Cost and Utilization Project databases for six states from 2006 to 2010 to determine ED revisit rates, variation in revisit rates by diagnosis and state and associated costs.
Across all six states, revisit rates were nearly twice as high as previously reported, according to the study results. Furthermore, only about half of all ED revisits involved a return to the original ED followed by a second discharge home.
With 8.2% of patients revisiting an ED within three days after their original presentation, 32% went to a different hospital. The highest rates occurred with skin infections, 23%. Of the states reviewed, Florida had higher risk-adjusted revisit rates for skin infections, 24.8%, than Nebraska, 10.6%, which had the lowest.
In general, researchers found that total cost of revisits was higher than the total cost of all initial visits. Florida was the only state with complete cost data and total revisit costs for the 19.8% of patients with a revisit within 30 days. The costs there were 118% of total index ED visit costs for all patients, including those with and without a revisit.
It is unknown, according to study authors, whether revisit rates reflect inadequate access to primary care, a planned revisit, the patient's non-adherence to ED recommendations, or poor-quality care at the initial ED visit.
In an accompanying editorial, Kumar Dharmarajan, MD, MBA, and Harlan M. Krumholz, MD, SM, of the Yale School of Medicine in New Haven, CT, write that the findings “highlight an underappreciated problem, the central question of which concerns the potential preventability of revisits.”
Dharmarajan and Krumholz ask, “To what extent do ED revisits represent gaps in quality as opposed to reasonable strategies that prevent admissions at the cost of additional revisits for acute care? How often do revisits represent failures of transitional care, such as poor integration of ED and primary care, suboptimal education of patients and caregivers, or lack of timely follow-up?”
Quality Improvement Project Lowers VTE Rate for Trauma Patients
ANN ARBOR, MI – How does your trauma center’s patient care measure up to others in your state?
That’s what a team of trauma surgeons from the University of Michigan in Ann Arbor, MI, found out when they participated in the Michigan Trauma Quality Improvement Program (MTQIP), a statewide program of 27 ACS Level 1 and 2 trauma centers.
What they discovered was alarming: The rate of venous thromboembolism (VTE) events at their facility was higher than the collaborative average. Drilling down in the data, it became clear that VTE rates were doubled among their trauma patients who received the anti-clotting agent unfractionated heparin as opposed to a different agent, enoxaparin, according to a report published online by the Journal of the American College of Surgeons.
MTQIP, sponsored by Blue Cross Blue Shield of Michigan and Blue Care Network, provides feedback reporting on a statewide basis. National level comparisons were available through the Trauma Quality Improvement Program sponsored by the American College of Surgeons.
After the UM Trauma Center switched from using unfractionated heparin as its first-line anti-clotting agent to enoxaparin, the rate of VTE dropped from 6.2% percent (about 36 cases a year) to 2.6% percent (14 cases a year), according to the study.
"What we've done is to use the collaborative as our mission control to see where we're heading and what our trajectory is," explained study coauthor David A. Machado-Aranda, MD, FACS. "Once we saw ourselves deviating from a favorable trajectory, we used the data derived from the collaborative to investigate our problem. We also accessed many different resources to review best practices, receive suggestions from other collaborative participants, and perform root cause analysis. An action plan was formulated, approved, and implemented to get our trauma service off of an unfavorable trajectory for VTE complications."
Here’s how study authors described their new plan: “consolidation to single VTE prophylaxis agent and dose, focused education of providers, initiation of VTE prophylaxis for all patients –with clear exception rules –and dose withholding minimization.”
Machado-Aranda cautioned that the study shouldn’t be interpreted as a head-to-head comparison of unfractionated heparin to enoxaparin in preventing VTE events; both products have been found to be effective in preventing blood clots based on factors such as how the agents are dosed and administered.
The changes weren’t made without a hitch, however. Enoxaparin is more expensive, creating concerns from hospital administration. Ultimately, the study team was able to prove how the additional costs were offset by reducing VTE.
Another issue was that neurosurgical colleagues had previously published a study finding higher rates of intracranial bleeding with enoxaparin in some surgical patients. "These results became extrapolated into the trauma setting, and it took us some time convincing our neurosurgeons to consider changing their practice for trauma patients," Machado-Aranda said.