ED Push - November 2014 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
EDs Not Worst Offenders in Increased Opioid Prescribing, Related Mortality
LOS ANGELES – Emergency physicians have gotten a bad rap related to the dramatic increase in opioid prescriptions and unintentional deaths from painkillers, according to a new study.
The truth is that emergency departments prescribe significantly lower doses and numbers of pills for non-cancer pain than do office-based practices, according to researchers from the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California. The study was published recently in the Annals of Emergency Medicine.
Earlier this year, investigators from George Washington University reported in a study published in Academic Emergency Medicine that the rates of opioid prescribing in EDs shot up during a recent 10-year period, far exceeding the increase in visit rates for painful conditions.
Between 2001 and 2010, the percentage of overall emergency department visits in which an opioid analgesic was prescribed increased from 20.8% to 31%, according to that study. The increase in prescription rates was especially dramatic for some opioid painkillers, including Dilaudid, which went up 668.2%, according to the analysis of data from the National Hospital Ambulatory Medical Care Survey.
At the same time, the percentage of visits for painful conditions during the period only increased by 4%, from 47.1% in 2001 to 51.1% in 2010, the authors reported.
The new study suggested, however, that there was more to the story than those statistics revealed, pointing out that “high-dose opioid prescribing is rare in the ED setting (1 in 400 ED opioid prescriptions are for ≥100 MME) compared with office settings (1 in 39 office prescriptions for opioids are for ≥100 MME).”
The University of Southern California researchers also noted that, in response to a recent study identifying high-dose prescribing as an independent risk factor for opioid death, many state chapters of the American College of Emergency Physicians have developed safe opioid prescribing guidelines for EDs.
Calling the ED contribution to this epidemic “incompletely characterized,” the researchers said they sought to quantify strength of opioid prescriptions and frequency of high-dose prescriptions from the ED compared to other care sites. To do so, they analyzed the Medical Expenditure Panel Survey (1997-2011), a nationally representative sub-survey of the annual National Health Interview Survey.
A determination was made for each filled prescription, including where it was generated and exactly how much opioid was prescribed; patient records with ICD-9 codes indicating a history of malignancy were excluded. Researchers also created a model to predict the proportion of high-dose prescriptions, defined as exceeding 100 morphine milligram equivalent (MME), focused on site-of-care.
Based on review of 44,313 unique individuals -- mean age 48 and 63% female -- receiving 164,406 opioid prescriptions during the study period, results indicate that the average opioid prescription originating from EDs was for 44% fewer pills than prescriptions from office visits. In addition, the average compound prescribed from the ED had 17% lower MME than those from office visits.
While 1.9% of all opioid prescriptions from EDs were for more than 100 MME daily, ED prescriptions still were much less likely to be for greater than 100 MME per day compared with medical office settings, according to the report.
“EDs prescribe markedly lower doses and numbers of pills for non-cancer pain than office-based practices. Given the very low rate of high-dose prescribing from the ED, policy efforts to reduce risky opioid prescribing should not focus on ED settings,” study authors conclude.
Learning from Mistakes: CDC Issues New ED-specific Ebola Triage Guidelines
ATLANTA – With knowledge about Ebola virus disease and how to manage and treat it evolving by the minute, the CDC has released new guidelines for emergency departments based on recent experiences of U.S. hospitals caring for Ebola patients.
While the CDC provided some reassurance on the risk of exposure, it still urged a high level of vigilance by EDs.
“In general, the majority of febrile patients presenting to the ED do not have Ebola virus disease, and the risk posed by patients with early, limited symptoms is lower than that from a patient hospitalized with severe Ebola virus disease” public health officials noted. “Nevertheless, because early symptoms of Ebola virus disease are similar to other febrile illnesses, triage and evaluation processes in the ED should consider and systematically assess patients for the possibility of Ebola virus disease.”
That involves administrative and environmental controls, including a designated area for further evaluation of a patient with possible Ebola virus disease, as well as onsite management and oversight on the safe use of personal protective equipment (PPE), according to the CDC guidance, which added, “Best practice would include continuous safety checks through direct observation of healthcare workers during the process of putting on (donning) and taking off (doffing) PPE.”
The CDC has made available an algorithm to help ED personnel identify, isolate and inform appropriately when a patient with Ebola presents at a facility. The agency cautioned that even before any determination of illness is made, all patients should be routinely managed using precautions to prevent any contact with blood or body fluids
The triage recommendations include taking a relevant exposure history immediately upon entrance to determine whether the patient has resided in or traveled to a country with widespread Ebola transmission or had contact with an individual with confirmed Ebola virus disease within the previous 21 days.
“Because the signs and symptoms of Ebola virus disease may be nonspecific and are present in other infectious and noninfectious conditions that are more frequently encountered in the United States, relevant exposure history should be first elicited to determine whether Ebola virus disease should be considered further,” the CDC advises. “If the patient is unable to provide history due to clinical condition or other communication barrier, history should be elicited from the next most reliable source (e.g. family, friend or EMS provider).”
If patients meet the exposure criteria, they should be further questioned about the presence of signs or symptoms compatible with Ebola virus disease. These include:
- fever (subjective or ≥100.4°F or 38.0°C);
- symptoms such as headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or
- hemorrhage, including bleeding gums, blood in urine, nose bleeds, coffee ground emesis or melena.
“If a relevant exposure history is reported and signs or symptoms consistent with Ebola virus disease are present, the following measures should be implemented IMMEDIATELY,” according to the CDC guidelines.
A patient suspected of being infected with Ebola should be isolated in a private room or separate enclosed area with private bathroom or covered, bedside commode, and the ED should adhere to procedures and precautions designed to prevent transmission by direct or indirect contact, including dedicated equipment, hand hygiene, and restricted patient movement, the algorithm states. It adds that, if the patient is arriving by EMS transport, the ED should be prepared to receive the patient in a designated area away from other patients and have a process for safely transporting the patient on the stretcher to the isolation area with minimal contact with non-essential healthcare workers or the public.
“To minimize transmission risk, only essential healthcare workers with designated roles should provide patient care,” the CDC states. “A log should be maintained of all personnel who enter the patient’s room. All healthcare workers who have contact with the patient should put on appropriate PPE based on the patient’s clinical status.” Other guidelines offer details on exactly what equipment should be used in each circumstance.
“The risk of transmission of Ebola virus from a patient to a healthcare worker depends upon the likelihood that the patient will have confirmed Ebola virus disease combined with the likelihood and degree of exposure to infectious blood or body fluids,” the CDC explains. “That risk depends on the severity of disease; severe illness is strongly associated with high levels of virus production. In addition, close contact with the patient and invasive medical care can increase opportunities for transmission.”
The guidelines also state that EDs should notify their hospital infection control programs and report patients with Ebola virus exposure to the local health department, regardless of the presence of symptoms.
Whether patients should be tested for Ebola should be made in consultation with public health officials, according to the CDC.
Emergency Residents Miss Opportunities to Diagnose Early HIV Infection
DETROIT — In up to two-thirds of cases, acute infection with human immunodeficiency virus presents as a mononucleosis-like illness. Yet, a survey of emergency medicine residents suggested they would rarely screen for acute retroviral syndrome (ARVS), missing opportunities for early diagnosis and treatment.
Study authors, who presented recently at IDWeek 2014 in Philadelphia, note that 20% of people unknowingly infected with HIV are responsible for more than 50% of new infections annually, adding, “A high index of suspicion is needed to screen for ARVS as there are no unique characteristics that distinguish it from other viral illnesses.”
Researchers from Detroit Receiving Hospital/Wayne State University in Detroit and colleagues sought to determine how often emergency medical residents consider ARVS in the differential diagnosis of general viral symptoms when patients present with fatigue, fever, muscle or joint aches, and sore throat. Symptoms usually appear within 7-14 days of infection, according to background in the article.
Results of an electronic survey of more than 700 emergency medical residents from more than 100 resident programs across the country were presented. The survey included case-based questionnaires: One in which the patient’s sexual orientation was identified as homosexual and another with no information on sexual orientation.
The survey’s four sections included treatment options for the scenario, knowledge of ARVS symptoms, likelihood of ordering a rapid HIV test, and recommendations following a negative result.
A link to one of the two versions of the survey – identified or unidentified sexual orientation – was randomly sent to all U.S. based EM residency training program directors with a request to forward it to the program’s residents. More than 700 responses were received from 101 out of 158 EM programs that received the link.
Overall, fewer than 27% of the emergency residents responding said they would order a rapid HIV test for the patient described as having fever, sore throat and swollen lymph nodes or hypoxia, cough and dyspnea. Yet the likelihood of ordering an HIV tests quadrupled with patients who identified as homosexual compared to those who did not identify their sexual orientation – 56.4% vs 14.6%.
Regardless of sexual orientation, however, more than half of the respondents said they would order the test if the patient had rash, weight loss and diarrhea.
The residents also were highly likely to order the tests in patients who identified themselves as sexual assault victims, female prostitutes and intravenous drug users.
Interestingly, 85% of the residents were able to correctly recognize the symptoms of AVRS, and 76% of respondents recognized a repeat HIV test was needed following an initial negative rapid test.
The authors note that the “residents do not consider ARVS in their differential diagnosis in patients with symptoms of viral illness, particularly in the absence of a high risk qualifier. This deficit in knowledge application may have significant negative public health consequences in the fight against HIV transmission."
Trauma Severity Scores Inaccurate Predictors of Mortality in Older Patients
CHARLOTTE, NC – Tools used to predict mortality in trauma patients do not work very well in an older cohort being treated at an urban Level 1 trauma center, according to a new study.
The research, led by in
vestigators from the Carolinas Trauma Network in Charlotte, instead suggested that traditional triage factors such as age, vital signs and anatomic injuries might require different weighting in the geriatric trauma population to account for age-related differences in injury characteristics and physiology. The study was presented recently at the Orthopedic Trauma Association annual meeting in Tampa.
For the study, researchers identified patients 55 or older who had presented to a Level 1 trauma center from 2008-2011, focusing on those with a predicted probability of survival of 10%-75% based on the Trauma Score-Injury Severity Score (TRISS).
After accounting for 10 patients who had died in the ED, a cohort of 237 patients was divided into eventual survivors and non-survivors for analysis. Noting that age, mechanism of injury, laboratory values, and vital signs upon arrival at the trauma center are triage variables reported to have a role in survival prediction, the researchers calculated the injury severity score (ISS) and TRISS were for both survivor and non-survivors.
During the index hospitalization, 109 (46%) of the patients and 28 (54%) survived, with no gender difference noted. The mean age for non-survivors, 74, was significantly higher than for survivors, who average 67, however, and a much higher percentage of the non-survivors, 68%, were injured as result of a low energy mechanism, i.e. a fall from a standing height, compared to the survivors, 43%.
The Glasgow Coma Scale was notably lower for non-survivors vs. survivors as were temperature, respiratory rate and hematocrit, according to the study. Pulse rate, blood pressure, shock index and base deficit on arrival were not significantly different, however.
The review found that the TRISS was predictive of survival (TRISS 0.35 vs. 0.46; P < 0.001) while the ISS was significantly lower for non-survivors than survivors (ISS 23 vs. 26; P <0 .001).
“In spite of its widespread adoption and use, the ISS is a poor predictor of mortality in an intermediate-risk geriatric trauma population as evidenced by lower triage scores for non-survivors when compared with survivors,” the authors conclude. “Those patients in our cohort who survived had a higher probability of survival based on the TRISS, but the difference between groups was quite small, suggesting that the TRISS lacks the requisite specificity to be used as an accurate prediction model in the geriatric patient.”
The researchers note that older age, lower GCS, and a low-energy mechanism of injury were associated with a higher mortality rate at the urban Level I trauma center.
“Given the inability of existing measures to adequately predict mortality in older adults, existing measures may be missing key variables that impact survival of traumatic injuries,” they add. “This information sets the stage for the development of a triage tool specific to the geriatric trauma population with appropriately weighted risk factors.