ED Push - September 2015 First Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Even Moderate Heat Increases Spur More ED Visits
PROVIDENCE, RI – How would emergency departments be affected by climate change? In attempting to answer that question, a new study finds more visits for emergency care in one state even when rising temperatures are well below what would be considered extreme.
Temperatures above 75 degrees create a noticeable increase in medical distress among Rhode Island residents of all ages, according to the report published recently in the journal Environmental Health Perspectives.
For the study, researchers at Brown University and the Rhode Island Department of Health conducted a detailed statistical analysis of ED visits, deaths and weather data from recent years, including additional factors such as ozone levels. Medical records provided information on when emergency physicians deemed a patient's condition to be related to heat or dehydration.
"Our primary finding is that as temperatures increase, the number of emergency room visits and deaths increase," said lead author Samantha Kingsley, a Brown University public health graduate student. "But people were going to the hospital for heat-related reasons at temperatures below what we would typically consider extreme."
While the rate of heat-related ED visits jumped only 3.3% on days with a high of 75 degrees vs. days with a high of 65, those visits shot up 23.9% on days with a high of 85 degrees vs. 75. Study authors determined that overall temperature began to play an independent role in increasing ED visits beginning at about 75 degrees.
At the same time, Rhode Island’s death rate was 4% on a typical 85-degree day vs. a typical 75-degree day – even though neither temperature really is considered extreme, study authors point out.
"People should be aware that heat represents a significant public health threat," senior author Gregory Wellenius, ScD, associate professor of epidemiology, explained in a Brown University press release. "We do need to take heat seriously as a public health risk, even if there isn't a heat warning."
Interestingly, study results found the strongest association between heat-related ED visits and higher temperatures not among the elderly but among Rhode Islanders aged 18-64.
The study authors questioned whether some of those affected could be outside workers.
"Everybody believes that heat is dangerous but not for them," Wellenius said. "One of the messages is that this is really across the age spectrum. Heat remains one of the leading causes of weather-related deaths."
To investigate the possibility that the rate of heat distress would increase with climate change, the researchers projected how much greater ED visits and mortality would be if the current Rhode Island population were living with the increased temperatures forecast by two standard models of global warming. One projects a 6-degree rise by the end of the century and the other a 10-degree rise for two ranges of years: 2046-53 and 2092-99.
The researchers forecast that if days became 10 degrees hotter by the end of the century, the state's summertime death rate would rise by about 1.5% percent, representing about 80 more deaths each summer. The rate of heat-related ED visits would increase by about 25%, from about 6,000 to about 7,500 each summer, they add.
ED Screening Finds High Rates of HCV in Unaware Baby Boomers
OAKLAND, CA – Many Baby Boomers visiting an urban emergency department got some surprise – and likely unwelcome – news. They tested positive for hepatitis C.
High rates of infection were found among intravenous drug users and Baby Boomers, typically defined as those born between 1946 and 1964, according to results of a screening and rapid diagnostic testing program for hepatitis C. The online report in Annals of Emergency Medicine also notes that three-quarters were unaware they were infected.
"Given skyrocketing rates of injection heroin use around the country, we expect the already high rates of hepatitis C infection to explode," said lead study author Douglas White, MD, of Highland Hospital, part of the Alameda Health System in Oakland, CA. "Intervention by emergency departments, in the form of screening and referral for treatment, could help slow the spread of this potentially deadly, communicable disease."
During the screening program, researchers tested 10% of ED patients for hepatitis C virus (HCV), mostly but not exclusively testing those considered high-risk, such as intravenous drug users, Baby Boomers and patients with unspecified liver disease. Of patients tested, 10.3% tested positive for HCV with most of them, 70%, confirmed as chronically infected.
Among the factors associated with testing positive for hepatitis C virus included:
- injection drug use
- homelessness
- birth cohort, i.e. being a Baby Boomer
- male sex
The ED arranged follow-up appointments at the hepatitis C virus clinic for 57 of the 126 patients with confirmed positive results, and 30 showed up.
"In addition to the myriad public health functions they already perform, urban emergency departments may play an important role as safety net providers for HCV screening," White said in an American College of Emergency Physicians news release. "We have a better than even chance of reaching many of the three million people who are infected since they tend to be heavy emergency department users already. It gives us a chance to connect these people to ongoing care at HCV clinics or elsewhere in the health care system."
Parents Would Avoid EDs If Primary Care Options Were Readily Available
IOWA CITY, IA – Many parents would be happy to avoid the hassles of taking their child to an emergency department if adequate primary care alternatives were available.
That’s according to a survey conducted in Iowa to identify the factors associated with pediatric emergency department (ED) visits and parental perceptions of the avoidability of their child's ED visit. The results were reported recently in the Emergency Medicine Journal.
To determine that, University of Iowa researchers did a cross-sectional study by performing secondary analysis of 2010–2011 Iowa Child and Family Household Health Survey data, which includes a statewide representative population-based sample of families with at least one child .
Among the eligible households, 2,386 families completed the survey, with a response rate of 80%. Study authors considered the main outcome measures to be a child visiting an ED in the past year as well as parents believing that ED care could have been provided in a primary-care setting.
Results indicate that, among children who needed medical care in the past year, 26% visited an ED. Younger children, non-Hispanic black children, non-Hispanic others, children whose parents were not married, children who were from food-insecure households and had poorer health status were more likely to visit an ED, according to the study.
Having a medical home was not associated with ED visits, however, even after stratifying by the child's health status.
Overall, about 69% of parents who took their child to an ED agreed that emergency care could have been provided in a primary-care setting. A primary-care preventable ED visit was more likely to be reported by parents of children with public insurance, those who were not referred to the ED and those who could not get routine care appointments, the results state.
“The majority of parents believed that pediatric ED visits could be avoided if adequate primary-care alternatives were available,” study authors conclude. “Expanding access to primary care could lead to a reduction in avoidable ED visits by children.”
Be Skeptical of Elderly Patients Who Claim Adequate Mobility at Discharge
CHAPEL HILL, NC – If elderly patients assure you that they can get along fine at home, don’t be too quick to believe them.
A study published online recently inAnnals of Emergency Medicine suggests that many older patients visiting EDs require more assistance with physical tasks than they let on. Failing to take that into consideration could lead to a future hospital admission, according to the study team led by University of North Carolina Chapel Hill researchers.
“Ensuring that older adults discharged from the emergency department are able to safely function in their home environment is important because those who are unable to function safely at home are at risk for falls and return ER visits," said lead study author Timothy Platts-Mills, MD, MSc. "Accurately determining the ability of these patients to care for themselves at home is critical for emergency physicians as they make decisions about whether to discharge patients home or elsewhere. A patient who reports they can walk with an assistive device but actually requires human assistance to walk is likely to be bed-bound or to fall if they go home alone."
The cross-sectional study of cognitively intact patients aged 65 years and older, who were neither nursing home residents nor critically ill, was conducted in two academic EDs. Researchers asked consenting participants whether they could get out of bed, walk 10 feet, turn around, and get back in bed without assistance, and, if not, whether they could perform this task with a cane, walker, or assistance. Each participant was then asked to perform the task and was provided with a mobility device or assistance as requested.
Results indicate that, overall, 77% of patients in the study accurately assessed their ability to perform tasks. Of patients who said they could perform the assigned tasks without assistance, 12% required some assistance or were unwilling to complete the tasks. Among patients who said they could perform the task with a cane or walker, 48% required either human assistance or were unable to perform the task. Finally, nearly a fourth, 24%, of those who said they could perform the task with human assistance were unable to perform the task even with someone helping them.
"Emergency physicians are experts in deciding who can go home and who needs to come in the hospital," Platts-Mills said in an American College of Emergency Physicians press release. "But we are not perfect and sometimes we make decisions based on patient statements about abilities, rather than direct assessments.
“Our results suggest that patient statements are sometimes inaccurate, and, particularly for older adults who need some assistance, directly observing the patient's ambulation can be informative. Of course being able to move around isn't the only determinant of whether an older adult can be safely sent home, but it is a critical piece of information and it's good to get it right."
UPCOMING CME/CNE WEBINARS
Live: Thursday, September 17 Credits: 1.5 CME & CNE per participant
Psych Patients in the ED: Medical Clearance through Multidisciplinary Collaboration
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Managing Acute Agitation in the ED: Evaluation and Treatment
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Give Falls the Slip: TJC & CMS Hospital CoPs & Standards
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Sepsis in the Era of 405 Regulations
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Telemedicine, the Cost-effective Alternative: Real-time CMS & TJC Standards