ED Push - November 2014 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Look For Increasing Numbers of Atrial Fibrillation Patients in ED
KALAMAZOO, MI – Patients with atrial fibrillation (AF) are showing up in emergency departments in increasing numbers and the trend is likely to accelerate in coming decades, according to recent research.
A presentation at the recent American Heart Association's Scientific Sessions 2014 discussed the major healthcare burden caused by AF treatment in the ED. The study, led by researchers from the Western Michigan University School of Medicine, analyzed national data on patients presenting to the ED with AF listed as the first diagnosis from 2006-11.
Results indicate the rate of visits increased 24%, from 133 per 100,000 in 2006 to 165 per 100,000 in 2011.
Largely related to the aging of the population in the United States, those increases are likely to continue. A study last year predicted that AF incidence will double from 1.2 million cases in 2010 to 2.6 million cases in 2030. AF prevalence should increase, according to the American Journal of Cardiology report, from 5.2 million in 2010 to 12.1 million cases in 2030.
With an average AF hospital admission rate of 65%, according to the presentation, more than 2.7 million patients were too sick to be sent home. Blood clots, stroke, heart failure and other heart-related complications can result from common arrhythmia.
For those patients admitted, however, in-hospital death rates decreased from 1.18% in 2006 to 0.97% in 2011.
Patients requiring admission for AF tended to be elderly and female, have Medicare or Medicaid, live in areas with low median incomes, and present to teaching hospitals and those in the Northeast and metropolitan areas.
“This study reveals increasing burden of atrial fibrillation on US hospitals with 24% increase in ED visits from 2006-2011,” the authors note. “The decreasing in-hospital mortality rate points to improving care of hospitalized patients. Though the admission rates from ED visits have stayed fairly constant, the absolute numbers have increased.”
"The huge demographic and geographic variations highlight the unmet need for interventions to decrease hospitalization rates," added lead researcher Sourabh Aggarwal, MD.
Review Suggests EDs Use CT Scans Too Often in Children with Head Injuries
ST. LOUIS – Computerized tomography (CT) scans appear to be overused in children with head injuries, according to a new study that notes only 7% of the scans identified traumatic brain injuries.
The study, published as correspondence recently in the New England Journal of Medicine, looked at records of more than 43,000 children evaluated for head trauma in EDs.
Researchers from the Washington University School of Medicine in St. Louis and the University of California Davis School of Medicine reviewed data collected from 2004-06 from the EDs of 25 US hospitals. They determined that cranial CT was performed in 37% of the children, including 32% of those under age 2, 32% of those between 2 and 12, and 53% of those between 13 and 17.
Traumatic brain injuries were identified in a very small percentage of children who underwent imaging, suggesting CT scans may be overused during diagnosis, according to first author Kimberly S. Quayle, MD, professor of pediatrics at Washington University. Another 3% of children with CT scans had skull fractures without brain injuries.
“The original study was designed to identify children at low risk for brain injury who do not require CT scans because of the concerns of radiation and the costs of unnecessary testing,” Quayle said. “Criteria that suggest a low risk of traumatic brain injury and observing a child before resorting to a CT scan can reduce the use of unnecessary scans.”
Of all the children who were evaluated, 78 (0.2%) died.
“The rate of traumatic brain injury as seen on CT was 5% for children with mild injuries, 27% for those with moderate injuries, and 65% for those with severe injuries,” according to the report. “Overall, subdural hematoma was the most common injury, followed by subarachnoid hemorrhage and cerebral contusion, with great variability according to age and GCS [Glasgow Coma Scale] score Nearly half of children with traumatic brain injuries on CT had more than one type of brain injury.”
The study also points out that children brought to the ED with head trauma are likely to have suffered a fall, especially if they are younger than 2. Falls were the most common causes of head injuries in children ages 12 and younger, accounting for 77% of injuries in children under 2, and 38% in those 2-12.
“Head injuries in adolescents most often were caused by assaults, sports activities and motor-vehicle crashes,” Quayle said. In fact, 24% of the head-trauma cases in teenagers were due to assault, 19% were sports-related and 18% were caused by motor-vehicle accidents.
Among children who suffered brain injuries as a result of motor-vehicle accidents, fewer than half wore seat belts; children with head injuries caused by bicycle crashes wore helmets less than 20% of the time, the authors point out.
Traumatic brain injuries are the leading cause of death and medical complications in children older than 1 year.
Malpractice Reform Doesn’t Always Reduce ‘Defensive Medicine’ in EDs
LOS ANGELES – Even in states that make it more difficult to sue for malpractice, emergency physicians remain likely to practice “defensive medicine,” according to a new study from the RAND Corporation.
The study, published recently in the New England Journal of Medicine, looked at the practice of emergency physicians in three states that raised the standard for malpractice in the emergency room to “gross negligence,” meaning plaintiffs must prove clinicians knew their actions would cause harm. The stronger legal protections didn’t mean significantly less expensive care, however, despite contentions of malpractice reform advocates.
“Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending,” according to the study. “Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice.”
"Our findings suggest that malpractice reform may have less effect on costs than has been projected by conventional wisdom," added lead author Daniel A. Waxman, MD, a RAND researcher who also practices emergency medicine at UCLA’s David Geffen School of Medicine. "Physicians say they order unnecessary tests strictly out of fear of being sued, but our results suggest the story is more complicated."
The research focused on three states – Georgia, Texas and South Carolina – where the legal malpractice standard for emergency care had been changed to gross negligence for about the last decade. In those states, plaintiffs who bring suit must prove that doctors consciously disregarded the need to use reasonable care with knowledge that their actions were likely to cause serious injury.
"These malpractice reforms have been said to provide virtual immunity against lawsuits," Waxman pointed out. The more common “ordinary negligence” standard, or a failure to exercise reasonable care, is used in most other states.
For the study, researchers reviewed 3.8 million Medicare patient records from 1,166 hospital EDs from 1997 to 2011, comparing care in the three reform states, before and after the statutes took effect, to care in neighboring states without similar malpractice reform.
Noting that advanced imaging and hospitalization are costly and that physicians often identify those as common defensive medicine practices, the study examined whether computed tomography or magnetic resonance imaging were ordered, whether the patient was admitted after the ED visit, and how much was charged overall.
Results indicate that malpractice reform laws had no effect on the use of imaging or on the rate of hospitalization following emergency visits. In terms of overall visit charges, Texas and South Carolina showed no reduction. Compared to neighboring states, however, a drop of 3.6% in average ED charges was identified after Georgia’s 2005 reform law went into effect.
"This study suggests that even when the risk of being sued for malpractice decreases, the path of least resistance still may favor resource-intensive care, at least in hospital emergency departments," Waxman said.
Study: Use of Cardiac Biomarker Testing Too Often Unrelated to Symptoms
DALLAS – Emergency departments need to develop strategies for more appropriate use of cardiac biomarker testing, according to a new study.
The research, pub
lished online recently by JAMA Internal Medicine, finds that the tests are used even without common symptoms of acute coronary syndrome (ACS). Study authors from the University of Texas Southwestern Medical Center also point out that cardiac biomarker testing is frequently employed during visits with a high volume of other tests or services independent of the clinical presentation.
The article notes that cardiac biomarker testing is not routinely indicated in the ED because of “low utility and potential downstream harms from false-positive results.” Sensitivity of cardiac biomarkers is low in the first six hours after symptom onset, according to previous research.
For the retrospective study, researchers focused on ED visits by adults selected from the 2009 and 2010 National Hospital Ambulatory Medical Care Survey. The main outcome measured was use of cardiac biomarker testing during the ED visit.
Results indicate that, of 44,448 ED visits, cardiac biomarkers were tested in 16.9% of patients, representing 28.6 million visits. Furthermore, the authors assert, biomarker testing occurred in 8.2% of visits without ACS-related symptoms, representing 8.5 million visits.
For patients eventually admitted, cardiac biomarkers were tested in 47% of all visits, including 35.4% of visits without ACS-related symptoms, according to the study.
Researchers point out that, among all ED visits, the number of other tests or services performed was the strongest predictor of biomarker testing independent of symptoms of ACS.
Compared with 0 to 5 other tests or services performed, more than 10 other tests or services performed was associated with 59.55 times the odds of biomarker testing, the authors report, adding that the adjusted probabilities of biomarker testing if 0 to 5, 6 to 10, or more than 10 other tests or services performed were 6.3%, 34.3%, and 62.3%, respectively.