ED Push - August 2015 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Crystal Clear Persuasion? Google Glass for Toxicology Consults
WORCESTER, MA – Not sure how to treat a potentially poisoned patient? The answer could be right in front of you.
A study published recently in the Journal of Medical Toxicology found that Google Glass, a head-mounted streaming audio/video device, can be used by emergency physicians in community or rural hospitals for bedside toxicology consults.
The investigative team, led by University of Massachusetts Medical School researchers, produced preliminary data indicating that the hands-free device can help diagnose specific poisoning agents and recommend antidotes.
"In the present era of value-based care, a toxicology service using hands-free devices, such as Google Glass, could conceivably expand its coverage area and enhance patient care, while potentially decreasing overall treatment costs," said lead author Peter R. Chai, MD, toxicology fellow at UMass Medical School. "Our work shows that the data transmitted by Google Glass can be used to supplement traditional telephone consults, validate bedside physical exams, and diagnose and manage patients."
Study authors note that the compact device has significant advantages over traditional telemedicine devices – usually large desktop or laptop computers attached to carts that are rolled from one exam room to another – which are often unsuited for a busy and crowded emergency department.
"Glass is positioned perfectly as an emergency medicine telemedical device,” Chai pointed out. “It’s small, hands free and portable, so you can bring it right to the bedside and have a real-time specialist with you when you need one.”
Physicians can use to device to stream video of an exam, take and enlarge photos and consult with remote specialists.
For the study, ED residents performed 18 toxicology consults with Google Glass, evaluating patients at bedside while a secure video feed was sent to the toxicology supervising consultant. The supervising consultant then guided the residents, using text messages displayed on the device.
During the consult, photos of medication bottles, electrocardiograms and other pertinent information was exchanged in addition to standard verbal interaction.
Not only did consulting toxicologists reported being more confident in diagnosing specific toxidromes using Google Glass but medical care also was affected in more than half of the cases – six patients were given antidotes they otherwise would not have received.
Overall, 89% of the cases using the new technology were deemed successful by the consulting toxicologist.
"Placing an expert at the virtual bedside of the patient has huge advantages," Chai said in a university press release. "It brings a specialist to patients that might not otherwise have access to that kind of expertise. Because Google Glass is relatively unobtrusive to patients, can be operated hands free and is extremely portable, it has a distinct advantage over traditional telemedicine platforms."
To make sure patient information was kept private, each device was equipped with a third-party HIPAA-complaint platform called Pristine Eyesight. Information passing through Google Glass also was encrypted for security and privacy.
Will Future ED Physicians Actually Know Patients’ Medical Histories?
AKRON, OH –Imagine a future where, when a patient presents to your emergency department, you and other clinicians would have the complete medical history at your fingertips.
An emergency physician-led workgroup is trying to make that dream a reality. Published online by Annals of Emergency Medicine are five primary and seven secondary recommendations about how to maximize the value of health information exchange (HIE) in EDs.
"HIE helps emergency physicians – who usually do not have much information about their patients – access patient health information from multiple sources, which is essential for critical, time-sensitive decisions," co-author Jeffrey Nielson, MD, MS, of Summa Akron City Hospital in Akron, explained in an American College of Emergency Physicians press release. "The ultimate goal is a nationwide health information network that will allow physicians quick access to their patients' medical histories without compromising their privacy. It is a tall order for sure, but not an impossible one."
The study points out that a full longitudinal record more accurately reflects the way most patients obtain care: i.e., across multiple providers and provider organizations
The five primary recommendations are:
- Emergency physicians must be involved in regional and federal HIE activities;
- HIE policies must be based on best practices to promote liability protection related to HIE use;
- Federal regulatory standards must prioritize data elements specific to emergency care and have emergency-specific user design;
- Care standards and protocols for effective integration of HIE in emergency department electronic health records (EHRs) should be developed, including workflow optimizations and pushing of important HIE information to the clinician through flags in the EHR; and
- Local professional groups should participate with HIEs to assure delivery of appropriate emergency data.
The seven secondary recommendations would significantly improve HIE for emergency physicians, although they are not focused specifically on emergency medicine, according to the workgroup.
"Significant changes are needed to support a system of effective national HIE that can rapidly and efficiently yield useful health information to health care providers in emergency departments," added co-author Jason Shapiro, MD, of the Icahn School of Medicine at Mount Sinai in New York. "These changes should include support for emergency physician access to all relevant patient information in properly summarized understandable form. The goal of all emergency physicians is to provide safe, efficient and effective emergency care, and more access to well organized patient information helps us achieve that goal."
EDs Providing More Non-traumatic Dental Care for Uninsured Patients
SACRAMENTO, CA – From 2001 to 2008, emergency department visits for routine dental conditions – such as cavities, tooth pain and gingivitis – increased by 41% in the United States, while ED visits for all conditions rose by only 13% during the same time period, according to a new study.
In fact, more than 2% percent of all ED visits now are related to non-traumatic dental conditions, according to a study published recently in the journal Health Affairs. Even though Medicaid dental insurance is more readily available than in the past because of the Affordable Care Act, those numbers might not decline much because of access issues, according to California researchers and colleagues.
Many states don't provide dental coverage for adults under their Medicaid programs. In addition, rural communities often have too few dental providers, while many urban dentists are unwilling to take on new Medicaid patients, according to the study.
"Past research has shown that many dentists do not accept Medicaid," study co-author Kathryn Fingar, a researcher at Truven Health Analytics in Sacramento, said in a Stanford University press release. "Therefore people with Medicaid may find it difficult to get dental care in an office-based setting, even if they have dental insurance and even if there is an adequate supply of dentists in their community. In these instances, patients may need to use emergency rooms for dental problems, which generally can do little for patients seeking dental care except prescribe pain medications and antibiotics."
For the study, researchers examined county-level rates of ED visits for non-traumatic dental conditions in 29 states in 2010. An adequate supply of dental providers was associated with lower rates of ED visits for dental care by patients with Medicaid in rural counties, the study found. That was not the case in urban counties, however, where about 90% of the visits occurred.
The authors suggest several possibilities to reduce the number of ED visits for dental problems, including:
- Establish on-site dental clinics in emergency rooms.
- Expand dental coverage using less-expensive telehealth and mid-level dental providers who are not dentists, but trained to perform preventive and restorative care, such as fillings and minor extractions.
- Incentivize payers or providers to offer or refer patients to preventive dental care, similar to colon and cervical cancer screenings routinely offered today.
"The large number of visits to emergency rooms for dental conditions that could be treated in outpatient settings is indicative of the fact that our health-care system treats dental care differently than other preventive care,” said senior author Maria Raven, MD, MPH, associate professor of emergency medicine at the University of California San Francisco, “when, in fact, dental care should be considered part of a person's overall health and well-being,"
Patient Care Endangered By Less-Than-Smooth Handoffs
OMAHA, NE – How safe are handoffs from emergency departments to inpatient physicians for patients being admitted to the hospital?
The short answer might be that there is a lot of room for improvement, according to two recent studies.
One study, based on a survey of the clinicians involved, was published recently in the Journal of Hospital Medicine.
Another recent study, published in the Annals of Emergency Medicine, found that providers omitted communication of patient hypotension or hypoxia in nearly 1 in 7 ED handoffs, with study authors led by Yale University researchers noting, “These communication errors do not appear to be related to ED crowding or care interruptions.”
Noting that the handoffs involve “complex challenges,” the study team led by researchers from the University of Nebraska Medical Center College of Medicine assessed physicians' perceptions of the ED admission handoff process and identified potential barriers to safe patient care.
That study involved a cross-sectional survey at a 627-bed tertiary care academic medical center. Eligible participants included all resident, fellow, and faculty physicians directly involved in admission handoffs from emergency medicine (EM) and five medical admitting services. Communication quality, clinical information, interpersonal perceptions, assignment of responsibilities, organizational factors, and patient safety all were assessed using a 5-point Likert scale and an open-ended description of handoff-related adverse events.
Admitting physicians, with a 63% response rate, were more likely to report that vital clinical information was communicated less frequently for all eight content areas than the 86% of EM physicians who responded. The emergency physicians, meanwhile, were highly likely (94%) to say they felt defensive at least “sometimes.”
More than a fourth, 29% of all respondents, reported handoff-related adverse events, usually related to ineffective communication. Sequential handoffs were common for both EM and admitting services, with 78% of physicians reporting they negatively affected patient care.
“Physicians reported that patient safety was often at risk during the ED admission handoff process,” study authors point out. “Admitting and EM physicians had divergent perceptions regarding handoff communication, and sequential handoffs were common. Further research is needed to better understand this complex process and to investigate strategies for improvement.”
In the Yale-led study, researchers observed 1,163 patient handoffs during 130 ED shift rounds. Of 117 patients with episodes of hypotension and 156 patients with hypoxia, 42% and 74% were not communicated at rounds, respectively. Meanwhile, study authors point out, 166 handoffs included a vital sign communication error of omission.
