ED Push - February 2015 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Where Are Salaries Highest for Emergency Medicine Physicians?
SAN MATEO, CA – What do these states have in common: Texas, Florida and Minnesota.
Hint: It has nothing to do with weather.
Those three states report the highest compensation for emergency medicine physicians, according to a report from Doximity, the medical professional network. Doximity, which boasts of having more than half of U.S. physicians as members, recently launched Career Navigator, which looks at physician compensation trends.
According to the company, more than 18,000 verified practicing physicians shared anonymous compensation data over the past four months. The result is an interactive map that includes compensation trends for 48 specialties to the county level; it is available free to any U.S. physician.
That’s how Doximity also can list the three states with the lowest emergency medicine compensation: Massachusetts, New York, and California. It also can pinpoint opportunities such as this one described in a press release: “For example, an anesthesiologist in Massachusetts would on average increase their salary 61% by relocating to Wisconsin.”
"Healthcare is incredibly local. And pay trends in medicine are inverse that of most industries – high cost areas actually pay less," said Jeff Tangney, CEO and founder of Doximity. "Medical school teaches the science of medicine, but not the business of medicine. Our hope is that this up-to-date, local market data helps physicians level the playing field with HR departments in evaluating their opportunities."
Emergency medicine – followed by family medicine, occupational medicine and psychiatry – was the specialty with the greatest shortages of physicians, according to Doximity.
Overall, the survey found that physicians in rural areas earn an average of $1,500 more in salary each year compared to those in urban areas, and that physicians in areas with high obesity get paid slightly more than those in areas with a healthier populace.
Furthermore, the medical professional network noted that internists working in private practice make about 12% more (around $28,000) than those working in academic or government institutions. As for specialists, when a physician comes to a city of 100,000 people, the other specialists make an average of $1,500 less per year in salary.
To view the interactive compensation map, physicians can log into www.doximity.com/careers, and contribute their anonymous salary report.
ED Testing Strategy: No Effect on Risk of Future MI in Chest Pain Patients
HERSHEY, PA – To test or not to test – that often is the question when patients present to the emergency department with chest pain.
A new study provides some information helpful in making that decision: Chest pain patients seen in the ED who did not have a heart attack appear to be at low risk of subsequently experiencing a heart attack during short- and longer-term follow-up. Furthermore, according to the recent report in JAMA Internal Medicine, the risk was not affected by the initial diagnostic testing strategy.
Background information in the article notes that about 6 million patients are seen in EDs annually for chest pain or other symptoms suggestive of myocardial ischemia, explaining that patients without objective evidence of ischemia have been shown to have low risk for a major cardiovascular event. In fact, most patients do not even have a cardiac cause for their symptoms.
The study, led by researchers from the Penn State Milton S. Hershey Medical Center, compared chest pain evaluation to outcomes for ED patients using private health insurance claims data in 2011.
Patients with chest pain diagnoses were classified into 1 of 5 testing strategies:
- no noninvasive testing,
- exercise electrocardiography,
- stress echocardiography,
- myocardial perfusion scintigraphy (MPS), or
- (CCTA, CT imaging).
The researchers then measured the proportion of patients in each group who received cardiac catheterization, a coronary revascularization procedure or future noninvasive test, as well as those hospitalized for acute myocardial infarction (MI).
In 2011, the 693,212 emergency visits with a chest pain diagnosis accounted for 9.2% of all ED encounters, according to the study. The final study analysis included 421,774 patients, of which 293,788 did not receive an initial noninvasive test while 127,986 underwent testing, most frequently MPS.
Overall, only 0.11% of patients were hospitalized with heart attack at the seven-day follow-up and 0.33% at the 190-day follow-up, according to the results.
“Patients who did not undergo initial noninvasive testing were no more likely to experience an MI than were those who did receive testing,” according to the authors. “Compared with no testing, exercise electrocardiography, myocardial perfusion scintigraphy, and coronary computed tomography angiography were associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement in the odds of experiencing an MI.”
"More studies need to be conducted to clarify the best testing strategy for low-risk patients being evaluated for chest pain in the ED. … Given today's concerns regarding health care cost growth, especially the portion attributable to noninvasive cardiac imaging, and patient safety issues related to radiation exposure as well as over-diagnosis, performing such a study should be a priority," the study concludes.
In a related editor's note, JAMA Internal Medicine Editor Rita F. Redberg, MD, MSc, writes: "These findings suggest that the current practice of performing a stress test on low-risk patients in the ED is unnecessary and prolongs the length of stay in EDs as well as increases unnecessary medical imaging, with significant associated radiation risk for tests that include nuclear imaging. It is time to change our guidelines and practice for treatment of chest pain in low-risk patients. Such patients should be given a close follow-up appointment with a primary care physician who can determine, based on the patient's condition, whether further evaluation is necessary."
When EDs Should Screen for Abuse in Children with Bruising
PHILADELPHIA – Accidental bruising is common among mobile older infants and rambunctious toddlers. The challenge for emergency physicians is differentiating those innocuous bumps and bruises from injuries caused by abuse.
“Bruising is the most common injury experienced by young victims of physical abuse,” according to a recent article in the journal Pediatrics. “Although abusive bruising usually does not require medical intervention, bruising may be the only visible sign of serious injuries, such as fractures or traumatic brain injury. Abusive bruising also is a frequent precursor to more severe forms of physical abuse, including fatal head trauma.”
Now, a new guideline offers advice to emergency physicians on when to perform an initial skeletal survey (SS) for children younger than 24 months presenting with bruising at the emergency department and elsewhere in the hospital.
A multispecialty panel of 10 experts, led by researchers from The Children’s Hospital of Philadelphia, Philadelphia and the University of Pennsylvania, used evidence from the literature and their own clinical expertise to rate the appropriateness of performing SS for 198 clinical scenarios involving young children with bruising.
“Accurate recognition and evaluation of abusive bruising can lead to identi?cation of additional injuries requiring treatment and allow for intervention and prevention of further injury,” the guideline states. “Performing an evaluation for suspected physical abuse is, however, not without risks and should not be performed if abuse is unlikely.”
The guideline suggests that a skeletal survey is necessary in children under 2 with bruising if any of the following are present:
- History of confessed abuse
- History of bruising occurring during domestic violence
- Additional injuries on physician exam, such as burns or whip marks
- Patterned bruising
- More than four bruises not limited to bony prominences, and
- Bruises on ears, neck, torso, buttocks, genital region, hands and feet if there is no history of trauma
For children young than a year, skeletal survey is necessary, according to the guideline, with the following:
- Bruising on cheeks, eye area, ear or neck
- Bruising on upper arms or legs not over bony prominences
- Bruising on hands or feet
- Bruising on torso, buttocks or genital region
- More than one bruise not limited to bony prominences
When the child is less than 9 months old, a skeletal survey is necessary with a bruise in any one location, the panel advises, adding that, for younger children, those less than 6-months old, skeletal survey should be done if there is bruising on bony prominences – such as head T-shaped area, frontal scalp, extremity, bony prominences – unless it is single bruise and the parent presents with a history of a fall.
“The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising,” the authors conclude.
Heart Failure Patients ‘Bounce Back’ to ED for Non-Medical Reasons
NASHVILLE – Not all of the issues that send acute heart failure patients back to the emergency department are strictly medical.
Often, patients are discharged from the hospital but find that they are unable to care for themselves. The result can be an exacerbation of their condition and a return to the ED.
A study published recently in Annals of Emergency Medicine says a new tool “holds promise” for improving patient outcomes and reducing hospital re-admissions. The tool is designed to assess what interferes with acute heart failure patients' ability to care for themselves after hospital discharge.
"In order to reduce the number of patients returning to the emergency department for heart failure exacerbations, we need a better handle on what they can and cannot do for themselves after hospital discharge and why," said lead author Richard Holden, PhD, of Indiana University. "More than three-quarters of acute heart failure patients in the ER are experiencing exacerbation of their condition, not something new. Many of those exacerbations are the result of self-care challenges, including inadequate access to medications or lack of knowledge, which theoretically can be modified for the better."
Holden and his research team based the report on a survey of 31 acute heart failure patients who visited the ED. Of 47 different self-care barriers – such as transportation problems, insurance problems and caregiver responsibilities – an average of 15 per patient were indicated as sometimes or often present. In fact, at least 25% of patients reported 33 of the barriers.
The 10 most common included the following:
- Co-morbidities
- Physical disability
- Degree of sickness
- Feeling frustrated
- Knowledge about disease
- Functional limitations
- Memory and attention deficits
- Special occasions (minor disruptions)
- Lack of control
- Disruptions (major disruptions)
Also frequently mentioned were weather, physical obstacles and a food culture incompatible with dietary restrictions.
The article noted that some barriers compounded each other, such as a patient who was sick herself but taking care of others while working full time, leaving little opportunity for self-care.
"The first step in addressing these barriers is to develop a focused, valid and feasible measurement instrument for self-care barriers in the ER," Holden said. "The social determinants of health, along with factors such as poverty and a lack of transportation, must be addressed in order to improve the ER bounce-back rate for acute heart failure patients."
Study authors conclude that an instrument assessing self-care barriers from multiple system sources “can be feasibly implemented in the ED. Further research is required to modify the instrument for widespread use and evaluate its implementation across institutions and cultural contexts. Self-care barriers measurement can be one component of broader inquiry into the distributed health-related ‘work’ activity of patients, caregivers, and clinicians.”
On Monday HHS announced its new goals and timeline for moving the “Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” The release also indicated that "quality improvements have resulted in saving 50,000 lives and $12 billion in health spending from 2010 to 2013 ... ." You can read the full article by clicking here.
Below is a listing of AHC Media’s quality improvement periodicals. We invite you to explore these offerings as they may serve as an aid in your own quality improvement efforts. As an added incentive to try one more of these we are offering $99 off each publication below when you order by Feb. 15th.
| Healthcare Risk Management | Hospital Infection Control & Prevention |
| Hospital Peer Review | Hospital Employee Health |
| Hospital Access Management | Hospital Medicine Alert |
Use the coupon code QUALITY99 when checking out online to receive an immediate $99 discount per product.
Alternatively, you can call us at 800-688-2421 or send us an email to place your order.