ED Push - October 2014 Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
An ED Dilemma: Ebola Symptoms Often Mimic Other Common Conditions
BALTIMORE – If an isolated case of Ebola virus disease (EVD) shows up in a U.S. emergency department, it is highly likely to be confused with other, more common conditions, according to a new Ebola primer for clinicians.
In the absence of a clear epidemiological link such as travel or exposure history, an early case may be confused with flu, a later case assumed to be gastroenteritis, and a very late case identified as sepsis of any cause, according to the primer, published recently in the journal Disaster Medicine and Public Health Preparedness.
“The size and ongoing nature of the West African outbreak makes it clear that the further importation of EVD to the United States will remain a real possibility for the indefinite future. American clinicians, particularly those who work in emergency medicine, critical care, infectious diseases, and infection control, should be familiar the fundamentals of EVD including its diagnosis, treatment, and control,” write the article’s authors from the University of Pittsburgh Medical Center’s Center for Health Security in Baltimore and the university’s schools of medicine and public health in Pittsburgh.
The primer cautions that routine laboratory testing may show a variety of nonspecific abnormalities at various stages of the illness, including lymphopenia, leukocytosis with a left shift, thrombocytopenia, elevated transaminases, and evidence of disseminated intravascular coagulation (DIC).
The more specific test for Ebola, reverse transcriptase polymerase chain reaction, is available in many state public health laboratories and at the CDC.
Once the diagnosis of EVD is suspected or has been made, the article describes steps that must be undertaken to prevent further spread of the disease, including isolation with droplet/contact precautions and healthcare workers using appropriate personal protective equipment such as fluid-impervious gowns, gloves, respiratory protection, and eye protection. According to the journal article, Ebola enters the host through mucous membranes, breaks in the skin -- including microabrasions -- and punctures.
EDs Improve on Meeting Some Acute Asthma Guidelines, Fall Short on Others
BOSTON – How well are EDs doing in meeting nationally established treatment guidelines for acute asthma attacks? While use of appropriate medications improved over the study period, timeliness of care and other issues remained significant problems.
That’s according to a new study from Massachusetts General Hospital, which was published online recently by the Journal of Allergy and Clinical Immunology. The authors blame some of the lapses on continuing ED overcrowding.
"Asthma continues to be a significant health problem in the U.S., and while the improved ability of hospitals and other facilities to meet health quality guidelines for conditions such as heart attacks and pneumonia has been documented, changes in the quality of emergency asthma care have attracted less attention," said corresponding author Kohei Hasegawa, MD, MPH, MGH of Massachusetts General’s Department of Emergency Medicine. "We found that while emergency asthma care has become highly concordant with those guideline recommendations that are supported by strong scientific evidence, concordance with guideline-recommended care supported by weaker evidence declined. Our observations should encourage studies building more robust evidence for the latter."
For the current report, researchers analyzed data from three studies conducted by the Multicenter Airway Research Collaboration, a project of the Emergency Medicine Network, an international research consortium.
Data from two studies involving patients treated for acute asthma in the EDs of 48 U.S. hospitals between 1997 and 2001 were compared with similar data from patients seen in the same EDs in 2011-12. Treatment delivery was compared to guidelines established by the National Institutes of Health in 2007, with specific recommendations ranked according to their evidence-basis.
Overall, the researchers found that EDs did better with delivery of specific medications to patients at certain severity levels, which were considered level A guidelines.
On the other hand, the decline in adherence to level B and unranked guidelines – especially those relating to the assessment of pulmonary function and the timeliness with which care was delivered – actually appeared to outweigh improvement in the level-A recommendations, according to study authors.
New Medicaid Patients: Crush of ED Visits Subsides Over Time
LOS ANGELES – For emergency physicians wondering if the flood of newly insured Medicaid patients to ED will ever recede, here is an answer: If the other 26 states expanding Medicaid eligibility under the Affordable Care Act are anything like California, ED usage by those patients should decline sharply after the first year.
A new study by the UCLA Center for Health Policy Research suggests that the expansion of Medicaid to millions of uninsured residents will not continually drain state budgets because increases in ED and hospital inpatient usage are only temporary.
“We found that the surge doesn’t last long once people get coverage,” said lead author Nigel Lo, a research analyst at the UCLA Center for Health Policy Research. “Our findings suggest that early and significant investments in infrastructure and in improving the process of care delivery can effectively address the pent-up demand for health care services of previously uninsured people. Fears that these new enrollees will overuse health care services are just not true.”
For the study, researchers used two years of claims data from 182,000 low-income, formerly uninsured people enrolled in California’s state-run health insurance programs -- the Health Care Coverage Initiative, which ran from 2007 to 2010, and the Low Income Health Program, which ran from 2011 to 2013. At the beginning of this year, those enrollees were among the 1.5 million Californians who transitioned into Medi-Cal, California’s Medicaid program.
Analysis indicates that those who previously had the least access to medical care initially used hospital EDs at a high rate of 600 visits per 1,000 people. Usage significantly declined 29% in the first quarter, however, to 424 visits, followed by another 25% drop the following quarter. Between 2011 and 2013, the overall decline was 69.5% to 183 ED visits. At the same time, hospital admissions saw a steep 78.5% decline from 192 to 42 per 1000.
“California’s success should set an example for states that are on the fence about expanding Medicaid,” suggested co-author Gerald Kominski, PhD, professor of health policy and management and director of the Center for Health Policy Research. “It’s an investment: Build more infrastructure and care delivery early on, and you can manage chronic care, address unmet health care needs, and keep cost increases to a manageable level.”
While the Affordable Care Act extends Medicaid eligibility in 27 states, many other states refused coverage because of concerns that state budgets would be depleted by the demands of the previously uninsured, especially when federal subsidies stop covering the full costs in 2017.
The UCLA study, funded by the California Department of Health Care Services and the Blue Shield of California Foundation, cites previously published research finding that ED visits in Oregon increased by 40% during the year after the state expanded Medicaid eligibility, adding that their longer term examination of data shows such usage spikes are temporary.
Easy to Use Tool Holds Promise for Improving Delirium Detection in Older ED Patients
BOSTON – As many as one in 10 older adults seen in hospital EDs in the United States experience delirium, but, in too many cases, the condition goes unrecognized, partly because of a lack of accurate screening instruments.
Now, a solution appears to be in sight for that issue, documented earlier this year by researchers from Indiana University and the Regenstrief Institute.
A 3-minute diagnostic assessment for delirium has been developed by investigators at Beth Israel Deaconess Medical Center (BIDMC) in Boston, and the instrument appears to be extremely accurate in identifying the condition in a group of older hospital patients.
In the study, which appeared recently in the Annals of Internal Medicine, the authors report that the assessment, the 3-Minute Diagnostic Interview for CAM-Defined Delirium (3D-CAM), detected delirium with more than 90% specificity and sensitivity when compared with a reference standard.
The 3D-CAM’s high rates of accuracy in identifying delirium in patients who have dementia were especially significant, because that group is harder to diagnose, according to the report.
"Prompt recognition of delirium is the first step to timely evaluation and treatment, preventing complications and keeping older patients safe while in the hospital," says lead author Edward Marcantonio, MD, SM, director of the Aging Research Program in the Division of General Medicine and Primary Care at BIDMC and professor of medicine at Harvard Medical School. "As growing numbers of older adults are being hospitalized, it's critically important that doctors, nurses and other hospital care providers be able to recognize delirium. We wanted to develop a brief and simple method to make this easier to accomplish, and we are extremely happy with the 3D-CAM results. It appears that this easy-to-administer interview could significantly improve detection of this common and morbid condition in vulnerable older hospital patients. "
Background in the article points out that delirium affects 30-to-40% of older medical patients and between 15-and-50% of older surgical patients, yet remains under-recognized. In most clinical settings, average detection rates are only 12-to-35%. Low recognition is especially the case for patients with hypoactive delirium because they tend to be quiet and lethargic, as opposed to agitated dementia patients who disrupt EDs and other medical settings.
The CAM algorithm was originally developed in 1990 by the study's senior author Sharon K. Inouye, MD, MPH, director of the Aging Brain Center in the Institute for Aging Research at Hebrew Senior Life and HMS Professor of Medicine in the Division of Gerontology at BIDMC. To date, the CAM has been translated into more than a dozen languages and used in more than 4,000 original studies. It requires that the assessor determine the presence or absence of four key features of delirium:
- acute change and fluctuating course;
- inattention;
- disorganized thinking; and
- altered level of consciousness.
To be diagnosed with delirium, a patient must have features 1 and 2 and either 3 or 4.
"We have found that there are many different cognitive tests that the person rating the CAM can use to assess for these four features, and we've shown that the quality of the assessment makes a big difference in the accuracy of identification of delirium," Inouye explained. "The 3D-CAM is a major advance since it provides a brief, easy-to-administer approach that operationalizes the CAM algorithm in three minutes, and provides highly accurate results compared to a gold standard clinical assessment."
An original list of 160 questions and observations was whittled down to 20 items to develop the 3D-CAM assessment tool. It then was tested in a prospective validation study that enrolled 201 patients older than 75 who were hospitalized in BIDMC's General Medicine Service between 2010 and 2012.
The authors first conducted a 60- to 90-minute "gold standard" clinical assessment for delirium and dementia, in which an experienced clinician conducted a full patient evaluation including a cognitive exam, a review of the patient's medical records and conversations with the patient's nurse and family caregiver. Whether each patient was diagnosed with delirium was then determined by an expert panel.
The gold standard assessment determined that 42 of 201 participants (21%) had delirium, with most of them, 88%, exhibiting the hypoactive type. At the same time, 56 patients (28%) were determined to have had dementia prior to being admitted to the hospital; some had both delirium and dementia.
Research assistants then administered the 3D-CAM assessment without knowledge of the gold-standard results.