ED Push - September 2015 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Modification to Valsalva Maneuver Significantly Improves Effectiveness
EXETER, UK – The Valsalva maneuver, while effective in some patients with supraventricular tachycardia, has a low success rate. That often necessitates an adenosine injection, which can cause side effects such as an uncomfortable sense of doom.
A simple modification to the physical technique improves its effectiveness by more than 25%, however, according to a study published recently in The Lancet.
During the Valsalva maneuver, patients are instructed to forcibly exhale or strain while keeping the nose and mouth closed, which changes the rate and volume of blood returning to the heart and causes a reflex slowing of the heart. Ideally, that returns the heart rhythm to a normal rate.
Yet, that is not usually the case because the technique has a success rate of between 5% and 20%. To try to improve effectiveness, a British research team, led by the Royal Devon and Exeter NHS Foundation Trust, embarked on a study across 10 UK National Health Service emergency departments involving more than 400 patients.
Results indicate that repositioning patients immediately after the strain – i.e., laying them flat with legs lifted by staff to increase blood flow back to the heart -- the Valsalva maneuver was much more successful in returning the heart rhythm to a normal rate.
The study reported that, while heart rate returned to normal in only 17.5% of patients using the traditional posture, the percentage rose to 43.5% in patients using the modified posture.
"While supraventricular tachycardia is rarely life threatening, it can be extremely distressing for patients. We thought that the Valsalva maneuver had potential to be yet more effective as a treatment option and our study has borne this out,” Andrew Appelboam, FRCEM, consultant in emergency medicine at the Royal Devon and Exeter NHS Foundation Trust, told The Lancet. “What it means is that more patients can benefit from it without the need for further treatments with significant side effects. It also means that, because the postural modification is cost-free with no identified disadvantages, it could be easily adopted worldwide."
Study authors recommend widespread adoption of the modified technique, noting, “In patients with supraventricular tachycardia, a modified Valsalva maneuver with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients."
Gray-Haired Bicycle Riders More Likely to Suffer Injuries
SAN FRANCISCO – Emergency departments treating a lot of older patients in spandex are part of a growing trend: an increase in bicycle-related injuries, especially in adults older than 45.
A study published recently in the Journal of the American Medical Association reports a significant increase in injuries related to riding a bicycle between 1998 and 2013.
Because nonfatal injuries sustained during cycling are rarely reported to the police or included in traffic statistics, the study team, led by researchers from the University of California San Francisco, had to find another data source. Study authors decided to query the National Electronic Injury Surveillance System, a national probability sample of approximately 100 emergency departments that gathers product-related injury data for injuries associated with bicycles from 1998 to 2013. The number of bicycle-related injuries in adults age 18 years or older was recorded in 2-year intervals.
Over the time period studied, the 2-year, age-adjusted incidence of injuries increased by 28%, while the incidence of hospital admissions increased by 120%.
Bicycle riders older than 45 made up a growing proportion of the injured, increasing 81%, from 23% to 42%. Hospital admissions also went up 66% in that cohort, from 39% to 65%.
In terms of types of injuries, head injuries increased from 10% to 16%, and torso injuries increased from 14% to 17%. The percentage of injuries occurring in the street also rose from 40% to 56%.
The study found no difference in rate of injury by sex.
"These injury trends likely reflect the trends in overall bicycle ridership in the United States in which multiple sources show an increase in ridership in adults older than 45 years," study authors note.
The researchers also point to an increase in street accidents as well as growing popularity for sport cycling, which tends to use faster speeds.
“As the population of cyclists in the United States shifts to an older demographic, further investments in infrastructure and promotion of safe riding practices are needed to protect bicyclists from injury,” according to the researchers.
EDs Reducing Pediatric CT Scans, Partly Because of Cancer Concerns
CINCINNATI – Pediatric emergency departments are reducing use of computed tomography (CT) scans for common childhood diagnoses including seizure, concussion, appendectomy and upper respiratory tract infection.
Instead, EDs and other hospital departments are employing alternate types of imaging, such as ultrasound and magnetic resonance imaging (MRI), for eight of 10 common diagnoses, according to an article published recently in the journal Pediatrics.
Study authors, led by researchers from Cincinnati Children’s Hospital Medical Center, posit that the decline in CT usage might be linked to evidence that ionizing radiation from CT scans leads to an increased risk of cancer in patients. Another factor, they suggest, is that electronic health records now allow for easier transfer of medical data and images, which could limit the need for duplicate scans.
"This study reinforces the pediatric community's commitment to think about both immediate and long term risks and benefits of our treatment," said lead investigator Michelle Parker, MD. "Minimizing potential for harm to our patients as we work to heal them should always remain a priority."
While CT scans provide more detail than conventional X-rays, they also emit 100 to 1,000 times more ionizing radiation, according to background information in the article. The report cites previously published literature raising the possible of one malignancy among every 10,000 children as a result of ionizing radiation in those exposed to CT scans.
Young patients requiring sophisticated imaging for diagnostic purposes might now be more likely to have an MRI, which uses magnetic fields, or ultrasound, which uses high frequency sound waves to show internal body images in real time, according to study authors.
"There may still be times when a CT scan is the most appropriate imaging tool to use, however parents should be encouraged by this study which shows that physicians and hospitals are likely incorporating new evidence and adapting to provide safe medical care ," Parker said.
For the study, the researchers used data from the Children's Hospital Association's Pediatric Health Information System, a comparative pediatric database of clinical and resource utilization information for inpatient, ambulatory surgery, ED and observation unit patient encounters for 45 children's hospitals.
Records of inpatients and observation patients for 10 specific diagnoses at 33 participating hospitals were analyzed from Jan. 1, 2004, to Dec. 31, 2012. The 10 diagnoses analyzed for imaging use included seizure, ventricular shunt procedure, craniotomy, concussion, severe head trauma, appendectomy, gastroenteritis, abdominal pain, upper respiratory tract infection and ENT conditions.
“For all included APR-DRGs except ventricular shunt procedures and nonbacterial gastroenteritis, the number of children imaged with any modality increased,” study authors conclude. “CT utilization decreased for all APR-DRGs (P values < .001). For each of the APR-DRGs except seizure and infections of upper respiratory tract, the decrease in CT was associated with a significant rise in an alternative imaging modality (P values ≤ .005).”
Cost of Multiple Observation Deductibles Can Exceed Inpatient Admission
PHILADELPHIA – If you think you are saving everyone money by assigning emergency department patients to observation care instead of admitting them, it’s not always that simple.
A single incidence of observational care can be a cost-saver all around, but multiple use within a 60 day period can actually cost patients more in co-payments than a hospital admission, according to a new study.
The report, published recently in the Journal of Hospital Medicine, found that situation for more than a quarter of beneficiaries with multiple observation stays.
“While most patients receiving observational care do spend significantly less in out-of-pocket co-payments, those with at least two observational stays within 60 days are potentially facing higher co-payments than if they were admitted," said lead author Shreya Kangovi, MD, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine. "Additionally, the design of the Medicare benefit allows several ways in which observation stays may become more costly to patients. For example, Medicare patients are required to pay a percentage of the cost of each service provided during an observation stay, as opposed to a single fixed cost for an inpatient stay."
The study notes that, according to the Medicare Payment Advisory Commission, 1.8 million patients were held for observation nationally in 2012, an increase of 88% over the previous six years. Medicare categorizes observation care as an outpatient service, although patients typically stay in beds in the ED or other areas of the hospital while they are tested, treated, and assessed.
For the study, the researchers used Medicare data to identify hospital observation stays among beneficiaries from 2010 to 2012, finding that patients owed an average of about $470 – an amount much lower than the standard deductible of $1,100 for an inpatient admission. When beneficiaries had to return to observation care within 60 days of a prior observation stay, however, their cumulative costs more than doubled to an average of about $947.
For 26.6% of the patients, the costs eventually exceeded the inpatient deductible. The number of patients with multiple observation visits within a 60-day period rose by 22% between 2010 and 2012, according to study results.
That especially is a problem, Kangovi noted, because Medicare beneficiaries who return to the hospital frequently tend to have fewer financial resources and could be disproportionately affected.
"Some have suggested capping the total out-of-pocket expense for observation care at the inpatient-deductible amount,” senior author David Grande, MD, pointed out in a Penn press release. “This warrants further study since observational care is already more costly than inpatient stay for a significant portion of the patient population."
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