ED Push - October 2015 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
Should Family Physicians Be Ongoing Part of the ED Care Team?
WASHINGTON, DC – If you assume having family physicians practicing in emergency departments is a stop-gap primarily used by rural EDs unable to attract clinicians trained in emergency medicine, think again.
A new study finds that family physicians practice in EDs in all settings and argues the practice should continue.
In the 1-page report published recently in American Family Physician, researchers from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care found that family physicians submitted nearly 12% of the 15 million urban ED claims in 2012 and that filings by family physicians in urban settings filed the most, 67%, of the emergency care claims.
Overall, 25% of the emergency claims were from primary care physicians, including family medicine and general internal medicine professionals, according to the study.
"We know that family physicians in outlying rural settings are contributing to ERs, but nobody ever looked at their contribution in urban and suburban settings," co-author Gerald Banks, MD, MS, said in an American Academy of Family Physicians press release.
For the study, researchers used the AMA Physician Masterfile to determine how many family physicians were working in rural and urban EDs, comparing Medicare claims data from 2012 to determine their contributions by setting.
Overall, they found that 4,000 physicians working in EDs actually completed their last residency in family medicine. They also noted that, despite the misconception that family physicians only handled basic cases, their Medicare claims were for treating conditions such as strokes, heart attacks and fractures.
"The board-certified ER docs say family physicians are just treating colds and coughs, but if you look at the complexity of cases, there is no sign that's true," Banks said, adding that family physicians are vital to emergency care but that some urban hospitals are seeking to replace them with board-certified emergency physicians as a marketing tool to attract patients.
Yet because of a nationwide shortage of emergency physicians and increasing rates of ED visits, he suggested “a perfect storm” could be looming: "If family physicians were removed from all ER facilities because they don't have certification, that could represent one-third of the physician workforce in large cities.”
One solution, according to study authors, is to keep family physicians in the ED but develop an emergency medicine certification program for them, as is available in Canada.
“A shift in the credentialing standards may benefit ED physician recruitment and assure that emergency physicians are qualified, regardless of board certification,” the authors conclude.
Emergency Nurses Face Unique Moral Challenges Because of Work Environment
DES PLAINES, IL – The type of moral distress experienced by emergency nurses is unique to their work environment, according to a new study, and is distinct from the difficulties faced by nurses in other settings.
The challenges include working in a high-acuity, high-demand, technical environment with insufficient resources, according to the report appearing recently in the Journal of Emergency Nursing. The study team, led by authors from the Emergency Nurses Association, urges improvement in environmental factors in emergency departments and calls for research to develop and validate an instrument to measure moral distress in ED nurses.
The study points out that moral distress, which results when someone is constrained from taking the action he or she believes is right, is different for emergency nurses than nurses in other fields, partly because they don’t have time to build relationships with patients.
"Emergency nursing is life-saving nursing and requires an environment where nurses can act in the best interest of their patients with more consideration of time constraint challenges," ENA President Matthew F. Powers, MS, BSN, RN, said in a press release. "This study is an excellent beginning to understand the distinct causes of moral distress in emergency nurses and how to address it."
The study used semi-structured focus groups for data collection, and then analyzed transcripts for common themes. Specific factors found to create moral distress for ED nurses include excessive documentation and a focus on time-based metrics, inadequate or unsafe staffing, and patients who are frequent users of the ED, such as those with addictions or behavioral disorders. Overall, the researchers explain, emergency nurses often feel they are not able to provide adequate care for patients.
"Focus group participants expressed a common desire to provide high-quality, compassionate care to their patients but also described dysfunctional and challenging aspects of the care environment that contribute to feelings of moral distress by impeding their ability to provide safe, effective patient care," the authors note. "The implications for emergency nurses as individuals, as well as for the profession, are significant and demand attention from ED and hospital administrators, but also from staff."
CDC Study Finds Costs Much Higher for Intentional Injuries Treated in EDs
ATLANTA – The vast majority, 90%, of injuries treated at U.S. emergency departments are unintentional, but the costs per case were 57% higher for injuries resulting from assaults and 71% higher for injuries resulting from self-harm, according to a new study from the CDC.
The report, published recently in the Morbidity and Mortality Weekly Report, tallies the costs of ED-treated injuries for the U.S. healthcare system, as well as the substantial price tag for lost work days in 2013.
The rate of hospitalized injuries was 950.8 per 100,000, according to the analysis, and the rate of treated and released injuries was 8,549.8 per 100,000. The total cost of all ED-treated nonfatal injuries was $456.9 billion, according to the CDC.
Unintentional injuries accounted for $253.5 billion in lifetime costs, or about 87% of costs for hospitalized injuries, while assault injuries and self-harm injuries made up $26.4 billion and $11.3 billion of lifetime costs, respectively.
Interestingly, the researchers found a large age gap between intentional and unintentional injuries.
“Costs for hospitalized violent injuries were concentrated among adults aged 15-44 years, with 72% of costs for assaults and 67% of self-harm costs accounted for by these age groups,” the CDC authors write. “In contrast, adults aged ≥45 years accounted for 59% of costs associated with hospitalized injuries that were unintentional.”
For all ED-treated nonfatal injuries, 37% of costs were associated with injuries from falls and 21% from transportation-related injuries, such as automobile accidents. Only 2.6% of nonfatal injury costs were related to poisoning, yet, among fatal injuries, drug poisonings accounted for the highest percentage of costs, 27.4%.
“Although nonfatal injuries treated in EDs are common and costly, appropriate implementation of evidence-based strategies can reduce nonfatal injuries from the mechanisms that lead to the greatest cost burden,” study authors write. “For example, primary seat belt laws, motorcycle helmet laws, sobriety checkpoints, and alcohol interlocks are effective in preventing motor vehicle-related injuries and can produce substantial economic benefits that greatly exceed the implementation costs.”
They also suggest that the ED might be an ideal setting for promoting prevention: “Studies of some screening and brief intervention programs for reducing excessive alcohol use, which is a risk factor for both unintentional and violent injuries, have shown that this intervention can reduce the likelihood of a subsequent visit to the ED for injury or violence-related causes.”
Post-partum Visits to EDs Increasing for Young Medicaid Patients with Complicated Pregnancies
BALTIMORE – Your emergency department likely is seeing a lot of post-partum patients who had complicated pregnancies, and a new study suggests the reasons why.
The study, which appeared recently in the Journal of Women's Health, finds that Medicaid-insured, low-income women with gestational diabetes, gestational hypertension or preeclampsia during their pregnancies were significantly more likely to have an ED visit in the six months following birth than those without such complications.
For the study, researchers from Johns Hopkins School of Medicine analyzed more than 26,000 Maryland Medicaid claims, finding that beneficiaries with recent complications during their pregnancies used the ED at higher rates after delivery. The reason? They might not be getting the postpartum care and follow-up they need to prevent further health problems, according to the authors.
The issue was especially acute with young mothers under 25 years of age who had pregnancy complications. Furthermore, the study notes, most of the visits for emergency care occurred before the recommended 6-week postpartum appointment, indicating the need for earlier postpartum follow-up for women who suffered pregnancy complications.
"Our results offer clues to opportunities to improve the postpartum and longer-term health of many low-income women," said lead author Ashley Harris, MD, MHS. "Further study might lead to interventions and programs that target these women for intensive discharge planning and follow-up care that could improve access to care and prevent ER use.”
As with most insurance, Medicaid covers a postpartum visit six weeks after childbirth, offering an opportunity to address health conditions that arose or worsened during pregnancy, according to Harris. She explained that many women on Medicaid often miss the visits for a variety of reasons, including lack of childcare and too little understanding about the long-term health risks associated with pregnancy complications. Instead, many patients turn to the ED for care, she added.
For the study, the researchers analyzed the claims database for one of the seven Medicaid managed care programs in Maryland. Data was available on every live birth delivery between 2003 and 2010, as well as outpatient, inpatient and ED visit claims during pregnancy, six months preconception and 12 months after delivery. The study also included information on patient age, race/ethnicity, history of Cesarean delivery, and preconception conditions including type 2 diabetes, chronic high blood pressure, obesity, asthma, mental health issues and substance abuse.
Of the 26,047 pregnant women who had at least 100 days of continuous Medicaid coverage during pregnancy and at least 90 days of continuous Medicaid coverage postpartum, about 20% of the pregnancies were complicated by gestational diabetes, gestational hypertension or preeclampsia.
About a quarter of the patients – 70% of whom had become eligible for Medicaid because of their pregnancy – visited an ED within six months of delivery. Women who had one of the three pregnancy complications, however, were 14% more likely to seek emergency care than those without the complications. Further increasing the odds of an ED visit were being under age 25, having a Cesarean delivery or having certain pre-conception health issues.
Interestingly, the analysis also indicates that 60% of the ED visits occurred prior to the commonly recommended six-week visit, although they often continued after.
Study authors call for better hospital discharge planning and earlier postpartum care, adding that issues covered at the six-week visit with the obstetrician might not be enough to address the issues particular to a population with a high rate of pregnancy complications.
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