The ED Is a Safer Place…and Can Be Safer Still

Article Type
Changed
Wed, 12/12/2018 - 20:51
Display Headline
The ED Is a Safer Place…and Can Be Safer Still

Improving medication accuracy, transitions of care, health information technology, and other ED patient-safety strategies are offered in this month’s Emergency Medicine cover article, “Patient Safety in the Emergency Department,” by emergency physician (EP)/toxicologist Brenna M. Farmer, MD, a colleague for many years.

As Dr Farmer notes in her introduction, patient safety—in the ED and elsewhere—has received a great deal of attention since the publication of the two landmark Institute of Medicine (IOM) studies in 1999 and 2001 that documented an enormous number of medical errors and recommended improvements in medical care. More than a decade and a half after their publication, is there any evidence that these reports have led to a reduction in the number of serious adverse effects and deaths due to medical errors?

Although most EPs believe that ED safety measures have reduced the overall number of errors, there is a scarcity of published data demonstrating a direct cause-and-effect relationship in reducing the number of adverse events and deaths. A recent analysis of National Hospital Ambulatory Medical Care Survey data by EPs Kanzaria, Probst, and Hsia (Health Aff [Millwood]. 2016;35[7]:1303-1308) found that ED death rates dropped by nearly 50% between 1997 and 2011. Most of this reporting period includes the years following the IOM reports before the implementation of the Affordable Care Act measures. One might reasonably assume that the decrease in ED death rates since 1997 is at least partly due to the safety measures described by Dr Farmer. However, Kanzaria et al hypothesize that the reduction is probably due to palliative and prehospital care efforts which “shift the locus of deaths,” to recent advances in emergency critical care, and to public health successes in smoking cessation, motor vehicle safety, etc. Conspicuously absent from their list of possible measures responsible for the reduction in ED death rates are ED safety measures.

If Kanzaria et al are correct in attributing the reduction in ED deaths to measures taken by others to decrease the number of dying patients brought to EDs, then it may be reasonable to look for the benefit of eliminating serious ED errors to a decrease in death rates after patients leave the ED for inpatient services. Though inpatient death-rate data is available only since 2005, Kanzaria et al report no significant change in the inpatient death rate between 2005 and 2011. It is possible, however, that the improvements in ED critical care hypothesized by the authors to be partly responsible for reducing ED death rates enable sicker patients to survive longer and ultimately succumb to their serious illnesses as inpatients. If so, this could offset any evident reduction in inpatient mortality from the avoidance of serious errors in the ED.

In any case, Dr Farmer does present direct evidence that safety measures are effective in reducing morbidity, and probably mortality. For example, in one study cited, medication errors were 13.5 times less likely to occur when an ED pharmacist was present, and clearly, avoiding doubling the doses of potent cardiac medications or sedative hypnotics, avoiding dangerous drug interactions, and choosing the correct type, dose, and time of administration of antibiotics and all meds must be responsible for reducing morbidity and ultimately mortality. It is also worth recalling that with respect to patient safety, emergency medicine is undoubtedly the safest medical specialty ever created, pioneering from its inception 24/7 bedside attending presence and mandatory recertifications, years to decades before other specialties adopted these practices. Thanks to these efforts, EDs are much safer than they had been previously, and by implementing the measures described by Dr Farmer will be safer still.  

References

Article PDF
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Issue
Emergency Medicine - 48(9)
Publications
Page Number
390
Legacy Keywords
Editorial, emergency department, ED, Flomenbaum, safe
Sections
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Article PDF
Article PDF

Improving medication accuracy, transitions of care, health information technology, and other ED patient-safety strategies are offered in this month’s Emergency Medicine cover article, “Patient Safety in the Emergency Department,” by emergency physician (EP)/toxicologist Brenna M. Farmer, MD, a colleague for many years.

As Dr Farmer notes in her introduction, patient safety—in the ED and elsewhere—has received a great deal of attention since the publication of the two landmark Institute of Medicine (IOM) studies in 1999 and 2001 that documented an enormous number of medical errors and recommended improvements in medical care. More than a decade and a half after their publication, is there any evidence that these reports have led to a reduction in the number of serious adverse effects and deaths due to medical errors?

Although most EPs believe that ED safety measures have reduced the overall number of errors, there is a scarcity of published data demonstrating a direct cause-and-effect relationship in reducing the number of adverse events and deaths. A recent analysis of National Hospital Ambulatory Medical Care Survey data by EPs Kanzaria, Probst, and Hsia (Health Aff [Millwood]. 2016;35[7]:1303-1308) found that ED death rates dropped by nearly 50% between 1997 and 2011. Most of this reporting period includes the years following the IOM reports before the implementation of the Affordable Care Act measures. One might reasonably assume that the decrease in ED death rates since 1997 is at least partly due to the safety measures described by Dr Farmer. However, Kanzaria et al hypothesize that the reduction is probably due to palliative and prehospital care efforts which “shift the locus of deaths,” to recent advances in emergency critical care, and to public health successes in smoking cessation, motor vehicle safety, etc. Conspicuously absent from their list of possible measures responsible for the reduction in ED death rates are ED safety measures.

If Kanzaria et al are correct in attributing the reduction in ED deaths to measures taken by others to decrease the number of dying patients brought to EDs, then it may be reasonable to look for the benefit of eliminating serious ED errors to a decrease in death rates after patients leave the ED for inpatient services. Though inpatient death-rate data is available only since 2005, Kanzaria et al report no significant change in the inpatient death rate between 2005 and 2011. It is possible, however, that the improvements in ED critical care hypothesized by the authors to be partly responsible for reducing ED death rates enable sicker patients to survive longer and ultimately succumb to their serious illnesses as inpatients. If so, this could offset any evident reduction in inpatient mortality from the avoidance of serious errors in the ED.

In any case, Dr Farmer does present direct evidence that safety measures are effective in reducing morbidity, and probably mortality. For example, in one study cited, medication errors were 13.5 times less likely to occur when an ED pharmacist was present, and clearly, avoiding doubling the doses of potent cardiac medications or sedative hypnotics, avoiding dangerous drug interactions, and choosing the correct type, dose, and time of administration of antibiotics and all meds must be responsible for reducing morbidity and ultimately mortality. It is also worth recalling that with respect to patient safety, emergency medicine is undoubtedly the safest medical specialty ever created, pioneering from its inception 24/7 bedside attending presence and mandatory recertifications, years to decades before other specialties adopted these practices. Thanks to these efforts, EDs are much safer than they had been previously, and by implementing the measures described by Dr Farmer will be safer still.  

Improving medication accuracy, transitions of care, health information technology, and other ED patient-safety strategies are offered in this month’s Emergency Medicine cover article, “Patient Safety in the Emergency Department,” by emergency physician (EP)/toxicologist Brenna M. Farmer, MD, a colleague for many years.

As Dr Farmer notes in her introduction, patient safety—in the ED and elsewhere—has received a great deal of attention since the publication of the two landmark Institute of Medicine (IOM) studies in 1999 and 2001 that documented an enormous number of medical errors and recommended improvements in medical care. More than a decade and a half after their publication, is there any evidence that these reports have led to a reduction in the number of serious adverse effects and deaths due to medical errors?

Although most EPs believe that ED safety measures have reduced the overall number of errors, there is a scarcity of published data demonstrating a direct cause-and-effect relationship in reducing the number of adverse events and deaths. A recent analysis of National Hospital Ambulatory Medical Care Survey data by EPs Kanzaria, Probst, and Hsia (Health Aff [Millwood]. 2016;35[7]:1303-1308) found that ED death rates dropped by nearly 50% between 1997 and 2011. Most of this reporting period includes the years following the IOM reports before the implementation of the Affordable Care Act measures. One might reasonably assume that the decrease in ED death rates since 1997 is at least partly due to the safety measures described by Dr Farmer. However, Kanzaria et al hypothesize that the reduction is probably due to palliative and prehospital care efforts which “shift the locus of deaths,” to recent advances in emergency critical care, and to public health successes in smoking cessation, motor vehicle safety, etc. Conspicuously absent from their list of possible measures responsible for the reduction in ED death rates are ED safety measures.

If Kanzaria et al are correct in attributing the reduction in ED deaths to measures taken by others to decrease the number of dying patients brought to EDs, then it may be reasonable to look for the benefit of eliminating serious ED errors to a decrease in death rates after patients leave the ED for inpatient services. Though inpatient death-rate data is available only since 2005, Kanzaria et al report no significant change in the inpatient death rate between 2005 and 2011. It is possible, however, that the improvements in ED critical care hypothesized by the authors to be partly responsible for reducing ED death rates enable sicker patients to survive longer and ultimately succumb to their serious illnesses as inpatients. If so, this could offset any evident reduction in inpatient mortality from the avoidance of serious errors in the ED.

In any case, Dr Farmer does present direct evidence that safety measures are effective in reducing morbidity, and probably mortality. For example, in one study cited, medication errors were 13.5 times less likely to occur when an ED pharmacist was present, and clearly, avoiding doubling the doses of potent cardiac medications or sedative hypnotics, avoiding dangerous drug interactions, and choosing the correct type, dose, and time of administration of antibiotics and all meds must be responsible for reducing morbidity and ultimately mortality. It is also worth recalling that with respect to patient safety, emergency medicine is undoubtedly the safest medical specialty ever created, pioneering from its inception 24/7 bedside attending presence and mandatory recertifications, years to decades before other specialties adopted these practices. Thanks to these efforts, EDs are much safer than they had been previously, and by implementing the measures described by Dr Farmer will be safer still.  

References

References

Issue
Emergency Medicine - 48(9)
Issue
Emergency Medicine - 48(9)
Page Number
390
Page Number
390
Publications
Publications
Article Type
Display Headline
The ED Is a Safer Place…and Can Be Safer Still
Display Headline
The ED Is a Safer Place…and Can Be Safer Still
Legacy Keywords
Editorial, emergency department, ED, Flomenbaum, safe
Legacy Keywords
Editorial, emergency department, ED, Flomenbaum, safe
Sections
Article Source

PURLs Copyright

Inside the Article

Disallow All Ads
Article PDF Media

MCIs and the Orlando Nightclub Shooting

Article Type
Changed
Wed, 12/12/2018 - 20:50
Display Headline
MCIs and the Orlando Nightclub Shooting

While most Americans were still reacting in horror and disbelief to news of a mass shooting at the Pulse nightclub in Orlando, Florida in the early morning hours of June 12, 2016, the thoughts of most emergency physicians (EPs) were probably focused on the ongoing efforts to save as many victims as possible: What was the closest Level 1 trauma center, and how deep was the ED staffing there that night? Was there a need for additional resources, and perhaps even, could they get there in time to help? In this issue of Emergency Medicine (EM), Residency Program Director Salvatore Silvestri, MD, and his emergency medicine colleagues masterfully recount events from that night as they unfolded, both at the scene and two blocks away at the Orlando Regional Medical Center (ORMC) ED, in the minutes and hours following the first reported shootings.

Being prepared for a mass-casualty incident (MCI) is an extraordinarily expensive requirement of a hospital: It must acquire and maintain adequate resources and communication capabilities; periodically perform unannounced drills that disrupt other hospital activities; and ensure that all EPs and staff are not only able to perform their own day-to-day roles as attending physicians, residents, nurses, etc, but are also capable of taking on even greater responsibilities during an MCI—depending on the day and time it occurs. As you will read in the pages that follow, in the early morning hours of June 12, many of the practiced exercises and rehearsed procedures proved useful, even life-saving, while others had to be discarded or ignored in favor of improvised solutions to rapidly transport and treat the large number of victims with unanticipated needs, under unique conditions. 

In any MCI, saving the largest number of victims invariably depends on rapidly instituting some deviations from standard operating procedures (SOPs) and standards of care (SOCs). As described by the ORMC EP authors, “...law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload….minimal interventions were performed and unlike standard procedure, EMS could offer no prearrival report to the hospital.”

Deviations from SOPs and SOCs during an MCI are not confined to prehospital care, but often extend into the ED and beyond. Most difficult for an EP participating in an MCI is the moment of realization that the sheer number of seriously injured and dying patients arriving en masse mandates a change from “ED triage” to “battlefield triage.” As Dr Ponder recalled, “One of the first few patients I saw was pulse­less, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’”

In EDs, dying patients are attended to first with extensive staff and resources, while, as a result, less seriously ill patients must sometimes wait longer for care. The opposite is true on the battlefield, where near-death victims of lethal injuries are provided only with comfort care, at most, in order to save those who have a chance of surviving their extensive or serious injuries. 

For hospitals and staff, the costs incurred by disaster preparedness are great and invariably exceed government funding provided for these efforts, but how much greater would be the human toll from an MCI without such efforts? All EPs should be proud of what our colleagues at ORMC accomplished on June 12. Though most EPs may never have to deal directly with an MCI, the Orlando nightclub shooting incident was only one of the latest MCIs, certainly not one of the last.

Previous editorials on MCIs may be found in EM September 2006 (9/11), June 2011 (first responders), September 2011 (9/11), November 2011 (surge capacity), and September 2012 (surge capacity/Hurricane Sandy).

Article PDF
Author and Disclosure Information

 

Neal Flomenbaum, MD, Editor in Chief

Issue
Emergency Medicine - 48(8)
Publications
Topics
Page Number
341
Legacy Keywords
Editorial, MCI, shooting, mass-casualty incident, Flomenbaum
Sections
Author and Disclosure Information

 

Neal Flomenbaum, MD, Editor in Chief

Author and Disclosure Information

 

Neal Flomenbaum, MD, Editor in Chief

Article PDF
Article PDF

While most Americans were still reacting in horror and disbelief to news of a mass shooting at the Pulse nightclub in Orlando, Florida in the early morning hours of June 12, 2016, the thoughts of most emergency physicians (EPs) were probably focused on the ongoing efforts to save as many victims as possible: What was the closest Level 1 trauma center, and how deep was the ED staffing there that night? Was there a need for additional resources, and perhaps even, could they get there in time to help? In this issue of Emergency Medicine (EM), Residency Program Director Salvatore Silvestri, MD, and his emergency medicine colleagues masterfully recount events from that night as they unfolded, both at the scene and two blocks away at the Orlando Regional Medical Center (ORMC) ED, in the minutes and hours following the first reported shootings.

Being prepared for a mass-casualty incident (MCI) is an extraordinarily expensive requirement of a hospital: It must acquire and maintain adequate resources and communication capabilities; periodically perform unannounced drills that disrupt other hospital activities; and ensure that all EPs and staff are not only able to perform their own day-to-day roles as attending physicians, residents, nurses, etc, but are also capable of taking on even greater responsibilities during an MCI—depending on the day and time it occurs. As you will read in the pages that follow, in the early morning hours of June 12, many of the practiced exercises and rehearsed procedures proved useful, even life-saving, while others had to be discarded or ignored in favor of improvised solutions to rapidly transport and treat the large number of victims with unanticipated needs, under unique conditions. 

In any MCI, saving the largest number of victims invariably depends on rapidly instituting some deviations from standard operating procedures (SOPs) and standards of care (SOCs). As described by the ORMC EP authors, “...law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload….minimal interventions were performed and unlike standard procedure, EMS could offer no prearrival report to the hospital.”

Deviations from SOPs and SOCs during an MCI are not confined to prehospital care, but often extend into the ED and beyond. Most difficult for an EP participating in an MCI is the moment of realization that the sheer number of seriously injured and dying patients arriving en masse mandates a change from “ED triage” to “battlefield triage.” As Dr Ponder recalled, “One of the first few patients I saw was pulse­less, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’”

In EDs, dying patients are attended to first with extensive staff and resources, while, as a result, less seriously ill patients must sometimes wait longer for care. The opposite is true on the battlefield, where near-death victims of lethal injuries are provided only with comfort care, at most, in order to save those who have a chance of surviving their extensive or serious injuries. 

For hospitals and staff, the costs incurred by disaster preparedness are great and invariably exceed government funding provided for these efforts, but how much greater would be the human toll from an MCI without such efforts? All EPs should be proud of what our colleagues at ORMC accomplished on June 12. Though most EPs may never have to deal directly with an MCI, the Orlando nightclub shooting incident was only one of the latest MCIs, certainly not one of the last.

Previous editorials on MCIs may be found in EM September 2006 (9/11), June 2011 (first responders), September 2011 (9/11), November 2011 (surge capacity), and September 2012 (surge capacity/Hurricane Sandy).

While most Americans were still reacting in horror and disbelief to news of a mass shooting at the Pulse nightclub in Orlando, Florida in the early morning hours of June 12, 2016, the thoughts of most emergency physicians (EPs) were probably focused on the ongoing efforts to save as many victims as possible: What was the closest Level 1 trauma center, and how deep was the ED staffing there that night? Was there a need for additional resources, and perhaps even, could they get there in time to help? In this issue of Emergency Medicine (EM), Residency Program Director Salvatore Silvestri, MD, and his emergency medicine colleagues masterfully recount events from that night as they unfolded, both at the scene and two blocks away at the Orlando Regional Medical Center (ORMC) ED, in the minutes and hours following the first reported shootings.

Being prepared for a mass-casualty incident (MCI) is an extraordinarily expensive requirement of a hospital: It must acquire and maintain adequate resources and communication capabilities; periodically perform unannounced drills that disrupt other hospital activities; and ensure that all EPs and staff are not only able to perform their own day-to-day roles as attending physicians, residents, nurses, etc, but are also capable of taking on even greater responsibilities during an MCI—depending on the day and time it occurs. As you will read in the pages that follow, in the early morning hours of June 12, many of the practiced exercises and rehearsed procedures proved useful, even life-saving, while others had to be discarded or ignored in favor of improvised solutions to rapidly transport and treat the large number of victims with unanticipated needs, under unique conditions. 

In any MCI, saving the largest number of victims invariably depends on rapidly instituting some deviations from standard operating procedures (SOPs) and standards of care (SOCs). As described by the ORMC EP authors, “...law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload….minimal interventions were performed and unlike standard procedure, EMS could offer no prearrival report to the hospital.”

Deviations from SOPs and SOCs during an MCI are not confined to prehospital care, but often extend into the ED and beyond. Most difficult for an EP participating in an MCI is the moment of realization that the sheer number of seriously injured and dying patients arriving en masse mandates a change from “ED triage” to “battlefield triage.” As Dr Ponder recalled, “One of the first few patients I saw was pulse­less, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’”

In EDs, dying patients are attended to first with extensive staff and resources, while, as a result, less seriously ill patients must sometimes wait longer for care. The opposite is true on the battlefield, where near-death victims of lethal injuries are provided only with comfort care, at most, in order to save those who have a chance of surviving their extensive or serious injuries. 

For hospitals and staff, the costs incurred by disaster preparedness are great and invariably exceed government funding provided for these efforts, but how much greater would be the human toll from an MCI without such efforts? All EPs should be proud of what our colleagues at ORMC accomplished on June 12. Though most EPs may never have to deal directly with an MCI, the Orlando nightclub shooting incident was only one of the latest MCIs, certainly not one of the last.

Previous editorials on MCIs may be found in EM September 2006 (9/11), June 2011 (first responders), September 2011 (9/11), November 2011 (surge capacity), and September 2012 (surge capacity/Hurricane Sandy).

Issue
Emergency Medicine - 48(8)
Issue
Emergency Medicine - 48(8)
Page Number
341
Page Number
341
Publications
Publications
Topics
Article Type
Display Headline
MCIs and the Orlando Nightclub Shooting
Display Headline
MCIs and the Orlando Nightclub Shooting
Legacy Keywords
Editorial, MCI, shooting, mass-casualty incident, Flomenbaum
Legacy Keywords
Editorial, MCI, shooting, mass-casualty incident, Flomenbaum
Sections
Disallow All Ads
Article PDF Media

The Case for Case Reports

Article Type
Changed
Wed, 12/12/2018 - 20:49
Display Headline
The Case for Case Reports

In The Case Report Issue, we feature four separate case reports presenting different conditions, much like patients may present in succession to a busy ED. Though considered of lesser importance than other types of peer-reviewed literature in this era of evidence-based medicine, case reports nevertheless fulfill an important role in clinical practice, medical education, and even medical research by identifying and tracking an important cause of a developing disease--especially one with a toxicologic or infectious etiology. In some instances, case reports also identify effective or ineffective treatments (though the latter is more rarely reported) and adverse effects of approved treatments, especially those of a newly introduced “Phase IV” medication.

Often, the ED is the initial setting for many reportable occurrences, and in recent years, patients first presenting to EDs have alerted the entire medical community to serious emerging illnesses such as Legionnaires’ disease, HIV and AIDS, anthrax, and Ebola. Most recently, firsthand reports by a pair of mother/daughter physicians in Brazil linked an alarming appearance of several new cases of microcephaly to a rash that followed a mosquito bite during pregnancy, and ultimately to identification of the mosquito-borne Zika virus.

Similarly, toxicologists at urban poison centers have been able to rapidly link cases of new and puzzling adverse effects and deaths reported by area emergency physicians to a dangerous new street drug or combination of drugs in that area, such as synthetic cannabinoid agonists, or heroin mixed with scopolamine, and then immediately alert other physicians and the public to these dangers.

As recently described by Florek and Dellavalle in Journal of Medical Case Reports (http://bit.ly/28PLi7w), case reports make meaningful contributions to the knowledge and education of medical students, residents, fellows, and (we would add) attendings. Written with the goal of sharing information for medical or scientific purposes, they often serve as a young physician’s first experience with medical writing and provide a solid foundation for manuscript preparation and publication.

Finally, a good ED case report that includes accurate descriptions of all relevant features along with any unique departures from classical presentations, followed by an up-to-date review of current treatments, presents most of us with a vivid means of identifying and remembering the salient features of a clinical problem or disease.

References

Article PDF
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Issue
Emergency Medicine - 48(7)
Publications
Page Number
299
Legacy Keywords
case reports, flomenbaum, editor in chief, case
Sections
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Article PDF
Article PDF

In The Case Report Issue, we feature four separate case reports presenting different conditions, much like patients may present in succession to a busy ED. Though considered of lesser importance than other types of peer-reviewed literature in this era of evidence-based medicine, case reports nevertheless fulfill an important role in clinical practice, medical education, and even medical research by identifying and tracking an important cause of a developing disease--especially one with a toxicologic or infectious etiology. In some instances, case reports also identify effective or ineffective treatments (though the latter is more rarely reported) and adverse effects of approved treatments, especially those of a newly introduced “Phase IV” medication.

Often, the ED is the initial setting for many reportable occurrences, and in recent years, patients first presenting to EDs have alerted the entire medical community to serious emerging illnesses such as Legionnaires’ disease, HIV and AIDS, anthrax, and Ebola. Most recently, firsthand reports by a pair of mother/daughter physicians in Brazil linked an alarming appearance of several new cases of microcephaly to a rash that followed a mosquito bite during pregnancy, and ultimately to identification of the mosquito-borne Zika virus.

Similarly, toxicologists at urban poison centers have been able to rapidly link cases of new and puzzling adverse effects and deaths reported by area emergency physicians to a dangerous new street drug or combination of drugs in that area, such as synthetic cannabinoid agonists, or heroin mixed with scopolamine, and then immediately alert other physicians and the public to these dangers.

As recently described by Florek and Dellavalle in Journal of Medical Case Reports (http://bit.ly/28PLi7w), case reports make meaningful contributions to the knowledge and education of medical students, residents, fellows, and (we would add) attendings. Written with the goal of sharing information for medical or scientific purposes, they often serve as a young physician’s first experience with medical writing and provide a solid foundation for manuscript preparation and publication.

Finally, a good ED case report that includes accurate descriptions of all relevant features along with any unique departures from classical presentations, followed by an up-to-date review of current treatments, presents most of us with a vivid means of identifying and remembering the salient features of a clinical problem or disease.

In The Case Report Issue, we feature four separate case reports presenting different conditions, much like patients may present in succession to a busy ED. Though considered of lesser importance than other types of peer-reviewed literature in this era of evidence-based medicine, case reports nevertheless fulfill an important role in clinical practice, medical education, and even medical research by identifying and tracking an important cause of a developing disease--especially one with a toxicologic or infectious etiology. In some instances, case reports also identify effective or ineffective treatments (though the latter is more rarely reported) and adverse effects of approved treatments, especially those of a newly introduced “Phase IV” medication.

Often, the ED is the initial setting for many reportable occurrences, and in recent years, patients first presenting to EDs have alerted the entire medical community to serious emerging illnesses such as Legionnaires’ disease, HIV and AIDS, anthrax, and Ebola. Most recently, firsthand reports by a pair of mother/daughter physicians in Brazil linked an alarming appearance of several new cases of microcephaly to a rash that followed a mosquito bite during pregnancy, and ultimately to identification of the mosquito-borne Zika virus.

Similarly, toxicologists at urban poison centers have been able to rapidly link cases of new and puzzling adverse effects and deaths reported by area emergency physicians to a dangerous new street drug or combination of drugs in that area, such as synthetic cannabinoid agonists, or heroin mixed with scopolamine, and then immediately alert other physicians and the public to these dangers.

As recently described by Florek and Dellavalle in Journal of Medical Case Reports (http://bit.ly/28PLi7w), case reports make meaningful contributions to the knowledge and education of medical students, residents, fellows, and (we would add) attendings. Written with the goal of sharing information for medical or scientific purposes, they often serve as a young physician’s first experience with medical writing and provide a solid foundation for manuscript preparation and publication.

Finally, a good ED case report that includes accurate descriptions of all relevant features along with any unique departures from classical presentations, followed by an up-to-date review of current treatments, presents most of us with a vivid means of identifying and remembering the salient features of a clinical problem or disease.

References

References

Issue
Emergency Medicine - 48(7)
Issue
Emergency Medicine - 48(7)
Page Number
299
Page Number
299
Publications
Publications
Article Type
Display Headline
The Case for Case Reports
Display Headline
The Case for Case Reports
Legacy Keywords
case reports, flomenbaum, editor in chief, case
Legacy Keywords
case reports, flomenbaum, editor in chief, case
Sections
Article Source

PURLs Copyright

Inside the Article

Article PDF Media

In Out-of-Hospital Care, IIb or Not IIb…

Article Type
Changed
Wed, 12/12/2018 - 20:49
Display Headline
In Out-of-Hospital Care, IIb or Not IIb…

The 2015 American Heart Association CPR/ACLS update categorizes amiodarone and lidocaine as IIb drugs that “may be considered” for ventricular fibrillation or pulseless ventricular tachycardia unresponsive to CPR, defibrillation, or vasopressors. Out-of-hospital use of these drugs has previously been shown to increase survival rate to hospital admission, but not necessarily to hospital discharge.

The effects of amiodarone and lidocaine on the rate of survival to hospital discharge are addressed in a recent randomized, double-blind, out-of-hospital trial comparing amiodarone, lidocaine, and placebo in the treatment of shock-refractory ventricular fibrillation or pulseless ventricular tachycardia (N Engl J Med. 2016;374[18]:1711-1722). This study was conducted by the Resuscitation Outcomes Consortium (ROC) in 3,026 patients at 10 US and Canadian sites. The ROC authors concluded that “overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo.” But the article raises concerns about its methodology, appropriateness of its primary and secondary outcomes to out-of-hospital (or prehospital) care, and the manner in which its findings were reported.

Because of the condition (unconscious) and circumstances (out of hospital) of the patients at the time medication or placebo must be administered, this NIH-supported trial was conducted under exception from informed consent in emergency research, with FDA and Health Canada oversight, and with approval by trial-site Institutional Review Boards. Notwithstanding the list of regulatory bodies that approved the exception, is the trial appropriate for drugs previously demonstrated to be efficacious in improving survival rates to hospital admission—long considered the goal of prehospital care—when subsequent care from admission to hospital discharge is not standardized or controlled across multiple sites in two countries?

Another concern is the way the results were reported. Will the authors’ conclusion that overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival  suggest to hurried readers that there is no benefit to any patient to hospital discharge from either antiarrhythmic agent? In the results section, the authors report “active drugs were associated with a survival rate that was significantly higher than the rate with placebo among patients with bystander-witnessed arrest but not among those with unwitnessed arrest.” Also noted in the accompanying editorial entitled “Out-of-Hospital Cardiac Arrest—Are Drugs Ever the Answer?” (N Engl J Med. 2016;374[18]:1781-1782), both drugs were associated with nonsignificant increases in survival rate, fewer subsequent shocks, and less administration of rhythm-control medications or need for CPR during hospitalization, compared with patients’ courses after placebo. 

The ROC trial is not the first or only out-of-hospital trial to use survival to hospital discharge as its primary outcome measure. A 1990-1991 study using death or discharge home to determine survival from out-of-hospital cardiac arrests in New York City found that of the 2,329 patients who met entry criteria for that study, overall survival was only 1.4%—which the authors attributed partly to lengthy elapsed time intervals at every step in the chain of survival, lack of adequate bystander CPR, and possibly sociodemographic features common to victims of cardiac arrest in large cities (JAMA. 1994;271[9]:678-683). The poor results  led to increases in first responders and AED availability but not the abandonment of properly performed CPR and ACLS. In the ROC trial, length of time from cardiac arrest to administration of medications clearly was shown to be a significant outcome determinant and was emphasized in the accompanying editorial. Here too shouldn’t we concentrate on optimizing the setting and timing of CPR and ACLS measures?  

References

Article PDF
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Issue
Emergency Medicine - 48(7)
Publications
Page Number
295
Legacy Keywords
editorial, hospital care, hospital, treatment, out-of-hospital, Flomenbaum, editor in chief
Sections
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Article PDF
Article PDF

The 2015 American Heart Association CPR/ACLS update categorizes amiodarone and lidocaine as IIb drugs that “may be considered” for ventricular fibrillation or pulseless ventricular tachycardia unresponsive to CPR, defibrillation, or vasopressors. Out-of-hospital use of these drugs has previously been shown to increase survival rate to hospital admission, but not necessarily to hospital discharge.

The effects of amiodarone and lidocaine on the rate of survival to hospital discharge are addressed in a recent randomized, double-blind, out-of-hospital trial comparing amiodarone, lidocaine, and placebo in the treatment of shock-refractory ventricular fibrillation or pulseless ventricular tachycardia (N Engl J Med. 2016;374[18]:1711-1722). This study was conducted by the Resuscitation Outcomes Consortium (ROC) in 3,026 patients at 10 US and Canadian sites. The ROC authors concluded that “overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo.” But the article raises concerns about its methodology, appropriateness of its primary and secondary outcomes to out-of-hospital (or prehospital) care, and the manner in which its findings were reported.

Because of the condition (unconscious) and circumstances (out of hospital) of the patients at the time medication or placebo must be administered, this NIH-supported trial was conducted under exception from informed consent in emergency research, with FDA and Health Canada oversight, and with approval by trial-site Institutional Review Boards. Notwithstanding the list of regulatory bodies that approved the exception, is the trial appropriate for drugs previously demonstrated to be efficacious in improving survival rates to hospital admission—long considered the goal of prehospital care—when subsequent care from admission to hospital discharge is not standardized or controlled across multiple sites in two countries?

Another concern is the way the results were reported. Will the authors’ conclusion that overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival  suggest to hurried readers that there is no benefit to any patient to hospital discharge from either antiarrhythmic agent? In the results section, the authors report “active drugs were associated with a survival rate that was significantly higher than the rate with placebo among patients with bystander-witnessed arrest but not among those with unwitnessed arrest.” Also noted in the accompanying editorial entitled “Out-of-Hospital Cardiac Arrest—Are Drugs Ever the Answer?” (N Engl J Med. 2016;374[18]:1781-1782), both drugs were associated with nonsignificant increases in survival rate, fewer subsequent shocks, and less administration of rhythm-control medications or need for CPR during hospitalization, compared with patients’ courses after placebo. 

The ROC trial is not the first or only out-of-hospital trial to use survival to hospital discharge as its primary outcome measure. A 1990-1991 study using death or discharge home to determine survival from out-of-hospital cardiac arrests in New York City found that of the 2,329 patients who met entry criteria for that study, overall survival was only 1.4%—which the authors attributed partly to lengthy elapsed time intervals at every step in the chain of survival, lack of adequate bystander CPR, and possibly sociodemographic features common to victims of cardiac arrest in large cities (JAMA. 1994;271[9]:678-683). The poor results  led to increases in first responders and AED availability but not the abandonment of properly performed CPR and ACLS. In the ROC trial, length of time from cardiac arrest to administration of medications clearly was shown to be a significant outcome determinant and was emphasized in the accompanying editorial. Here too shouldn’t we concentrate on optimizing the setting and timing of CPR and ACLS measures?  

The 2015 American Heart Association CPR/ACLS update categorizes amiodarone and lidocaine as IIb drugs that “may be considered” for ventricular fibrillation or pulseless ventricular tachycardia unresponsive to CPR, defibrillation, or vasopressors. Out-of-hospital use of these drugs has previously been shown to increase survival rate to hospital admission, but not necessarily to hospital discharge.

The effects of amiodarone and lidocaine on the rate of survival to hospital discharge are addressed in a recent randomized, double-blind, out-of-hospital trial comparing amiodarone, lidocaine, and placebo in the treatment of shock-refractory ventricular fibrillation or pulseless ventricular tachycardia (N Engl J Med. 2016;374[18]:1711-1722). This study was conducted by the Resuscitation Outcomes Consortium (ROC) in 3,026 patients at 10 US and Canadian sites. The ROC authors concluded that “overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo.” But the article raises concerns about its methodology, appropriateness of its primary and secondary outcomes to out-of-hospital (or prehospital) care, and the manner in which its findings were reported.

Because of the condition (unconscious) and circumstances (out of hospital) of the patients at the time medication or placebo must be administered, this NIH-supported trial was conducted under exception from informed consent in emergency research, with FDA and Health Canada oversight, and with approval by trial-site Institutional Review Boards. Notwithstanding the list of regulatory bodies that approved the exception, is the trial appropriate for drugs previously demonstrated to be efficacious in improving survival rates to hospital admission—long considered the goal of prehospital care—when subsequent care from admission to hospital discharge is not standardized or controlled across multiple sites in two countries?

Another concern is the way the results were reported. Will the authors’ conclusion that overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival  suggest to hurried readers that there is no benefit to any patient to hospital discharge from either antiarrhythmic agent? In the results section, the authors report “active drugs were associated with a survival rate that was significantly higher than the rate with placebo among patients with bystander-witnessed arrest but not among those with unwitnessed arrest.” Also noted in the accompanying editorial entitled “Out-of-Hospital Cardiac Arrest—Are Drugs Ever the Answer?” (N Engl J Med. 2016;374[18]:1781-1782), both drugs were associated with nonsignificant increases in survival rate, fewer subsequent shocks, and less administration of rhythm-control medications or need for CPR during hospitalization, compared with patients’ courses after placebo. 

The ROC trial is not the first or only out-of-hospital trial to use survival to hospital discharge as its primary outcome measure. A 1990-1991 study using death or discharge home to determine survival from out-of-hospital cardiac arrests in New York City found that of the 2,329 patients who met entry criteria for that study, overall survival was only 1.4%—which the authors attributed partly to lengthy elapsed time intervals at every step in the chain of survival, lack of adequate bystander CPR, and possibly sociodemographic features common to victims of cardiac arrest in large cities (JAMA. 1994;271[9]:678-683). The poor results  led to increases in first responders and AED availability but not the abandonment of properly performed CPR and ACLS. In the ROC trial, length of time from cardiac arrest to administration of medications clearly was shown to be a significant outcome determinant and was emphasized in the accompanying editorial. Here too shouldn’t we concentrate on optimizing the setting and timing of CPR and ACLS measures?  

References

References

Issue
Emergency Medicine - 48(7)
Issue
Emergency Medicine - 48(7)
Page Number
295
Page Number
295
Publications
Publications
Article Type
Display Headline
In Out-of-Hospital Care, IIb or Not IIb…
Display Headline
In Out-of-Hospital Care, IIb or Not IIb…
Legacy Keywords
editorial, hospital care, hospital, treatment, out-of-hospital, Flomenbaum, editor in chief
Legacy Keywords
editorial, hospital care, hospital, treatment, out-of-hospital, Flomenbaum, editor in chief
Sections
Article Source

PURLs Copyright

Inside the Article

Article PDF Media

More Hospitals to Be Replaced by FSEDs

Article Type
Changed
Wed, 12/12/2018 - 20:49
Display Headline
More Hospitals to Be Replaced by FSEDs

If an ED is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Fueled by continued hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now replacing hospitals in previously well-served urban areas in addition to serving rural areas lacking alternative facilities.

According to The New York Times (http://nyti.ms/1TB8Z44), since 2000, 19 New York City hospitals “have either closed or overhauled how they operate.” As this issue of Emergency Medicine went to press, plans had been announced to replace Manhattan’s Beth Israel and Brooklyn’s Wyckoff Heights hospitals with FSEDs and expanded outpatient facilities. These hospitals and many others that have recently closed, including St Vincent’s (2010) and the Long Island College Hospital (2014), had been part of the health care landscape in New York for over 125 years.

What do FSEDs mean for emergency medicine (EM) and emergency physicians (EPs), and are they safe alternatives to traditional hospital-based EDs? Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers (UCCs) and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems. (See “Urgent Care and the Urgent Need for Care” at http://bit.ly/1OSrHSA). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDs with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and registered nurses (RNs) provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7—a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized EM has enthusiastically embraced and endorsed FSEDs, its position on UCCs has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I trauma center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Should you think that FSEDs are a new phenomenon, you might be surprised to discover that in 1875, after New York Hospital (now part of New York Presbyterian) closed its original lower Manhattan site to move further uptown, it opened a “House of Relief” in its old neighborhood that contained an emergency treatment center, an operating room, an isolation area, a dispensary, a reception area, examination rooms, an ambulance entrance, and wards to observe and treat patients until they could be safely transported to the new main hospital. FSEDs served 19th-century patients well, and in the 21st century may serve as a reminder that sometimes even in medicine, “everything old is new again!” (See http://bit.ly/1NSPlDG.)

Editor’s Note: Portions of this editorial were previously published in Emergency Medicine.

References

Article PDF
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Issue
Emergency Medicine - 48(6)
Publications
Page Number
245
Legacy Keywords
editorial, Flomenbaum, hospitals, free-standing emergency department, ED, emergency department, patient care, urgent care centers, UCC, FSED
Sections
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Article PDF
Article PDF

If an ED is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Fueled by continued hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now replacing hospitals in previously well-served urban areas in addition to serving rural areas lacking alternative facilities.

According to The New York Times (http://nyti.ms/1TB8Z44), since 2000, 19 New York City hospitals “have either closed or overhauled how they operate.” As this issue of Emergency Medicine went to press, plans had been announced to replace Manhattan’s Beth Israel and Brooklyn’s Wyckoff Heights hospitals with FSEDs and expanded outpatient facilities. These hospitals and many others that have recently closed, including St Vincent’s (2010) and the Long Island College Hospital (2014), had been part of the health care landscape in New York for over 125 years.

What do FSEDs mean for emergency medicine (EM) and emergency physicians (EPs), and are they safe alternatives to traditional hospital-based EDs? Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers (UCCs) and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems. (See “Urgent Care and the Urgent Need for Care” at http://bit.ly/1OSrHSA). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDs with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and registered nurses (RNs) provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7—a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized EM has enthusiastically embraced and endorsed FSEDs, its position on UCCs has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I trauma center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Should you think that FSEDs are a new phenomenon, you might be surprised to discover that in 1875, after New York Hospital (now part of New York Presbyterian) closed its original lower Manhattan site to move further uptown, it opened a “House of Relief” in its old neighborhood that contained an emergency treatment center, an operating room, an isolation area, a dispensary, a reception area, examination rooms, an ambulance entrance, and wards to observe and treat patients until they could be safely transported to the new main hospital. FSEDs served 19th-century patients well, and in the 21st century may serve as a reminder that sometimes even in medicine, “everything old is new again!” (See http://bit.ly/1NSPlDG.)

Editor’s Note: Portions of this editorial were previously published in Emergency Medicine.

If an ED is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Fueled by continued hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now replacing hospitals in previously well-served urban areas in addition to serving rural areas lacking alternative facilities.

According to The New York Times (http://nyti.ms/1TB8Z44), since 2000, 19 New York City hospitals “have either closed or overhauled how they operate.” As this issue of Emergency Medicine went to press, plans had been announced to replace Manhattan’s Beth Israel and Brooklyn’s Wyckoff Heights hospitals with FSEDs and expanded outpatient facilities. These hospitals and many others that have recently closed, including St Vincent’s (2010) and the Long Island College Hospital (2014), had been part of the health care landscape in New York for over 125 years.

What do FSEDs mean for emergency medicine (EM) and emergency physicians (EPs), and are they safe alternatives to traditional hospital-based EDs? Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers (UCCs) and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems. (See “Urgent Care and the Urgent Need for Care” at http://bit.ly/1OSrHSA). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDs with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and registered nurses (RNs) provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7—a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized EM has enthusiastically embraced and endorsed FSEDs, its position on UCCs has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I trauma center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Should you think that FSEDs are a new phenomenon, you might be surprised to discover that in 1875, after New York Hospital (now part of New York Presbyterian) closed its original lower Manhattan site to move further uptown, it opened a “House of Relief” in its old neighborhood that contained an emergency treatment center, an operating room, an isolation area, a dispensary, a reception area, examination rooms, an ambulance entrance, and wards to observe and treat patients until they could be safely transported to the new main hospital. FSEDs served 19th-century patients well, and in the 21st century may serve as a reminder that sometimes even in medicine, “everything old is new again!” (See http://bit.ly/1NSPlDG.)

Editor’s Note: Portions of this editorial were previously published in Emergency Medicine.

References

References

Issue
Emergency Medicine - 48(6)
Issue
Emergency Medicine - 48(6)
Page Number
245
Page Number
245
Publications
Publications
Article Type
Display Headline
More Hospitals to Be Replaced by FSEDs
Display Headline
More Hospitals to Be Replaced by FSEDs
Legacy Keywords
editorial, Flomenbaum, hospitals, free-standing emergency department, ED, emergency department, patient care, urgent care centers, UCC, FSED
Legacy Keywords
editorial, Flomenbaum, hospitals, free-standing emergency department, ED, emergency department, patient care, urgent care centers, UCC, FSED
Sections
Article Source

PURLs Copyright

Inside the Article

Article PDF Media

We Told You So—CDC Weighs In

Article Type
Changed
Wed, 12/12/2018 - 20:48
Display Headline
We Told You So—CDC Weighs In

According to a February 18, 2016 CDC report (http://www.cdc.gov/nchs/data/nhsr/nhsr090.pdf) that utilized data from the 2013 and 2014 National Health Statistics Reports, “approximately 20% of US adults [ages 18–64 years] seek care at the emergency room (ER) each year, a percentage that has remained largely unchanged in the last decade.” The report also found “few changes in ER use…between 2013 and 2014.” The January 2014 Emergency Medicine editorial predicted both of these findings, as well as the reasons adults seek care in our EDs.

One of the stated goals of the Affordable Care Act (ACA) signed into law by President Obama in March 2010 was to decrease ED visits by providing more access to primary care. We predicted at the time that ED visits would instead increase, as “Demographic data for the past decade indicate[d] that many more people [were] now choosing EDs for their care…including significant numbers with the means or insurance coverage to obtain at least some of that care elsewhere” (Emerg Med. 2010;42[4]:5). We further noted that “this [could] only be the result of two considerations operating in concert: faith in the quality of emergency department care and convenience or need to obtain that care when other providers are not available. With millions more Americans now gaining access to care that was previously unavailable to them, the desire or need for timely care may further increase the numbers of people choosing EDs for their care.”

Though still too early to determine how successful ACA will be in achieving all of its goals, a study of a pre-ACA limited expansion of Medicaid coverage in Oregon, published in Science on January 2, 2014 (http://www.sciencemag.org/content/early/2014/01/02/science.1246183) found that a study group among the approximately 30,000 low-income people randomly selected by lottery to receive Medicaid in Oregon in 2008 made 40% more ED visits during the first 18 months, compared to a similar group among the 60,000 who entered the lottery but remained uninsured. As the New York Times noted, “the pattern was so strong it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings” (http://www.nytimes.com/2014/01/03/health/access-to-health-care-may-increase-er-visits-study-suggests.html).

Should EPs celebrate this latest affirmation of the strength and continuing growth of emergency medicine (EM)  as a health care provider of choice? Yes, and no.

Every new health care plan since managed care was first aggressively promoted in the 1980s has failed in its promise to decrease ED visits; compounding these miscalculations, none of the plans included adequate provisions to pay for the increased ED visits they failed to predict.

If ACA does result in long-term increases in ED visits, neither the current economic model for delivering emergency care nor the financial viability of EDs may be sustainable. Further exacerbations of ED overcrowding by Medicaid and/or inadequately insured patients may incentivize patients with the best insurance to seek alternative forms of care initially, though many will subsequently be referred to EDs nevertheless. It is almost certainly no coincidence that urgent care centers are suddenly springing up in the best neighborhoods of many cities; freed of federal requirements of EDs to screen and stabilize all regardless of their ability to pay, urgent care centers can be selective in who they treat.

Why have so many health care plans miscalculated the continuing and expanding role of EM? All have failed to recognize that modern emergency care is unique, valuable, and cannot be replaced by other types of primary care. Primary care providers increasingly send patients to EDs to complete their diagnostic evaluations and to treat, observe, or admit them to inpatient services when indicated. Additionally, few other providers—including many urgent care centers—are available 24/7.

References

Article PDF
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Issue
Emergency Medicine - 48(5)
Publications
Page Number
198
Legacy Keywords
editorial, CDC, Flomenbaum, ED
Sections
Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Author and Disclosure Information

Neal Flomenbaum, MD, Editor in Chief

Article PDF
Article PDF

According to a February 18, 2016 CDC report (http://www.cdc.gov/nchs/data/nhsr/nhsr090.pdf) that utilized data from the 2013 and 2014 National Health Statistics Reports, “approximately 20% of US adults [ages 18–64 years] seek care at the emergency room (ER) each year, a percentage that has remained largely unchanged in the last decade.” The report also found “few changes in ER use…between 2013 and 2014.” The January 2014 Emergency Medicine editorial predicted both of these findings, as well as the reasons adults seek care in our EDs.

One of the stated goals of the Affordable Care Act (ACA) signed into law by President Obama in March 2010 was to decrease ED visits by providing more access to primary care. We predicted at the time that ED visits would instead increase, as “Demographic data for the past decade indicate[d] that many more people [were] now choosing EDs for their care…including significant numbers with the means or insurance coverage to obtain at least some of that care elsewhere” (Emerg Med. 2010;42[4]:5). We further noted that “this [could] only be the result of two considerations operating in concert: faith in the quality of emergency department care and convenience or need to obtain that care when other providers are not available. With millions more Americans now gaining access to care that was previously unavailable to them, the desire or need for timely care may further increase the numbers of people choosing EDs for their care.”

Though still too early to determine how successful ACA will be in achieving all of its goals, a study of a pre-ACA limited expansion of Medicaid coverage in Oregon, published in Science on January 2, 2014 (http://www.sciencemag.org/content/early/2014/01/02/science.1246183) found that a study group among the approximately 30,000 low-income people randomly selected by lottery to receive Medicaid in Oregon in 2008 made 40% more ED visits during the first 18 months, compared to a similar group among the 60,000 who entered the lottery but remained uninsured. As the New York Times noted, “the pattern was so strong it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings” (http://www.nytimes.com/2014/01/03/health/access-to-health-care-may-increase-er-visits-study-suggests.html).

Should EPs celebrate this latest affirmation of the strength and continuing growth of emergency medicine (EM)  as a health care provider of choice? Yes, and no.

Every new health care plan since managed care was first aggressively promoted in the 1980s has failed in its promise to decrease ED visits; compounding these miscalculations, none of the plans included adequate provisions to pay for the increased ED visits they failed to predict.

If ACA does result in long-term increases in ED visits, neither the current economic model for delivering emergency care nor the financial viability of EDs may be sustainable. Further exacerbations of ED overcrowding by Medicaid and/or inadequately insured patients may incentivize patients with the best insurance to seek alternative forms of care initially, though many will subsequently be referred to EDs nevertheless. It is almost certainly no coincidence that urgent care centers are suddenly springing up in the best neighborhoods of many cities; freed of federal requirements of EDs to screen and stabilize all regardless of their ability to pay, urgent care centers can be selective in who they treat.

Why have so many health care plans miscalculated the continuing and expanding role of EM? All have failed to recognize that modern emergency care is unique, valuable, and cannot be replaced by other types of primary care. Primary care providers increasingly send patients to EDs to complete their diagnostic evaluations and to treat, observe, or admit them to inpatient services when indicated. Additionally, few other providers—including many urgent care centers—are available 24/7.

According to a February 18, 2016 CDC report (http://www.cdc.gov/nchs/data/nhsr/nhsr090.pdf) that utilized data from the 2013 and 2014 National Health Statistics Reports, “approximately 20% of US adults [ages 18–64 years] seek care at the emergency room (ER) each year, a percentage that has remained largely unchanged in the last decade.” The report also found “few changes in ER use…between 2013 and 2014.” The January 2014 Emergency Medicine editorial predicted both of these findings, as well as the reasons adults seek care in our EDs.

One of the stated goals of the Affordable Care Act (ACA) signed into law by President Obama in March 2010 was to decrease ED visits by providing more access to primary care. We predicted at the time that ED visits would instead increase, as “Demographic data for the past decade indicate[d] that many more people [were] now choosing EDs for their care…including significant numbers with the means or insurance coverage to obtain at least some of that care elsewhere” (Emerg Med. 2010;42[4]:5). We further noted that “this [could] only be the result of two considerations operating in concert: faith in the quality of emergency department care and convenience or need to obtain that care when other providers are not available. With millions more Americans now gaining access to care that was previously unavailable to them, the desire or need for timely care may further increase the numbers of people choosing EDs for their care.”

Though still too early to determine how successful ACA will be in achieving all of its goals, a study of a pre-ACA limited expansion of Medicaid coverage in Oregon, published in Science on January 2, 2014 (http://www.sciencemag.org/content/early/2014/01/02/science.1246183) found that a study group among the approximately 30,000 low-income people randomly selected by lottery to receive Medicaid in Oregon in 2008 made 40% more ED visits during the first 18 months, compared to a similar group among the 60,000 who entered the lottery but remained uninsured. As the New York Times noted, “the pattern was so strong it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings” (http://www.nytimes.com/2014/01/03/health/access-to-health-care-may-increase-er-visits-study-suggests.html).

Should EPs celebrate this latest affirmation of the strength and continuing growth of emergency medicine (EM)  as a health care provider of choice? Yes, and no.

Every new health care plan since managed care was first aggressively promoted in the 1980s has failed in its promise to decrease ED visits; compounding these miscalculations, none of the plans included adequate provisions to pay for the increased ED visits they failed to predict.

If ACA does result in long-term increases in ED visits, neither the current economic model for delivering emergency care nor the financial viability of EDs may be sustainable. Further exacerbations of ED overcrowding by Medicaid and/or inadequately insured patients may incentivize patients with the best insurance to seek alternative forms of care initially, though many will subsequently be referred to EDs nevertheless. It is almost certainly no coincidence that urgent care centers are suddenly springing up in the best neighborhoods of many cities; freed of federal requirements of EDs to screen and stabilize all regardless of their ability to pay, urgent care centers can be selective in who they treat.

Why have so many health care plans miscalculated the continuing and expanding role of EM? All have failed to recognize that modern emergency care is unique, valuable, and cannot be replaced by other types of primary care. Primary care providers increasingly send patients to EDs to complete their diagnostic evaluations and to treat, observe, or admit them to inpatient services when indicated. Additionally, few other providers—including many urgent care centers—are available 24/7.

References

References

Issue
Emergency Medicine - 48(5)
Issue
Emergency Medicine - 48(5)
Page Number
198
Page Number
198
Publications
Publications
Article Type
Display Headline
We Told You So—CDC Weighs In
Display Headline
We Told You So—CDC Weighs In
Legacy Keywords
editorial, CDC, Flomenbaum, ED
Legacy Keywords
editorial, CDC, Flomenbaum, ED
Sections
Article Source

PURLs Copyright

Inside the Article

Article PDF Media

Putting Quality Into Quality Indicators

Article Type
Changed
Wed, 12/12/2018 - 20:47
Display Headline
Putting Quality Into Quality Indicators

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

References

Article PDF
Author and Disclosure Information

Neal Flomenbaum, MD

Issue
Emergency Medicine - 48(4)
Publications
Page Number
148
Legacy Keywords
editorial
Sections
Author and Disclosure Information

Neal Flomenbaum, MD

Author and Disclosure Information

Neal Flomenbaum, MD

Article PDF
Article PDF

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

References

References

Issue
Emergency Medicine - 48(4)
Issue
Emergency Medicine - 48(4)
Page Number
148
Page Number
148
Publications
Publications
Article Type
Display Headline
Putting Quality Into Quality Indicators
Display Headline
Putting Quality Into Quality Indicators
Legacy Keywords
editorial
Legacy Keywords
editorial
Sections
Article Source

PURLs Copyright

Inside the Article

Article PDF Media

The 21st Century ED: Past Predictions and Current Trends

Article Type
Changed
Wed, 12/12/2018 - 20:46
Display Headline
The 21st Century ED: Past Predictions and Current Trends

In the October 2006 editorial, “A Design for the 21st Century,” I suggested that the first consideration in designing a new ED should be how long it is likely to remain in service before being replaced or substantially renovated, and then to consider which conditions are most likely to continue to present or increase in importance during the first several decades of the 21st century (Emerg Med. 2006;37[10]:7). I envisioned “increasing patient volume, an aging population, new and emerging viral infections, an even higher incidence of bacterial resistance, and more immunocompromised patients resulting from organ transplants and greater use of chemotherapy.” A decade after these predictions were made, how are they holding up?

Since 2006, there have been over 40 epidemics worldwide and although most have not affected this country, easy travel and global emergency medicine missions have brought several distant viral illnesses to US EDs as well. In 2009, EDs throughout the country had to deal with a potentially disastrous epidemic of H1N1 influenza, and in the years since we have been challenged by MERS (2012), dengue fever (2013-), Ebola (2014), and now Zika and chikungunya—not to mention outbreaks of “older” bacterial and viral illnesses such as pertussis (2012), and measles (2014-2015). Though several of the newer viruses mentioned are mosquito borne, pathogens transmitted from human to human, or human to surface to human, along with the increasing incidence of antibiotic resistance (MRSA, Clostridium difficile, Carbapenem-resistant Enterobacteriaceae, etc) make the need for greater numbers of ED negative-pressure rooms undeniable.

One important design feature not specifically considered in 2006, but made apparent by the Ebola experience in 2014, is a need for the shortest possible route between the ambulance and non-ambulance ED entry points/triage and isolation facilities. As noted in 2006, a separate entrance and air handling for a designated infection-control unit in the ED is essential if it must be sealed off from the rest of the hospital and/or main ED.

The second major ED design issue considered in 2006 was the increasing numbers of elderly patients who will present to our EDs during the first half of this century. Isolation rooms and private rooms in the ED will help manage the rapidly rising number of elderly patients with contagious diseases, along with other conditions such as dementia and delirium. Significant needs of the elderly also include measures to prevent or mitigate falls, catheter-related UTIs, and bedsores.

One epidemic in the elderly that we are already facing is a significant increase in the number of trauma cases. In some Level I trauma centers, over 34% of trauma activations are for patients 55 years old and older. The 2003-2012 Oregon Trauma Registry Report containing data on 84,099 patients from 44 trauma hospitals, notes that the rate of trauma increased from 200.7 to 244.6 per 100,000 during that period, almost exclusively occurring in patients 55 years old or older who represented 21% of cases in 2003 and 34% by 2012—a rise largely attributed to a 159% increase in trauma due to falls (http://public.health.oregon.gov/providerpartnerresources/emstraumasystems/traumasystems/documents/reports/otr-report.pdf). In another study, Hsia et al reported that 27% of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses between January 1, 1999 and December 31, 2008  were older than 65 years (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121677/), and in Houston, Texas, 13% of 15,223 trauma patients admitted to one of its two level I trauma centers between January 2005 and December 2008 were 65 years old or older, according to Adams et al (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836632/). The Adams paper noted that trauma centers were originally designed to care for seriously ill patients without age-specific guidelines, but in patients 65 years or older there was a negligible amount of penetrating trauma, and a marked increase in blunt trauma, especially falls, while fatality rates, organ failure, and thromboembolic complications correlated with increasing age. Clearly EDs designed for the 21st century must be built not only to handle increasing numbers of trauma cases in the elderly, but for changing etiologies, characteristics, and comorbidities.

When I wrote “A Design for the 21st Century” in 2006, I was in the midst of actually designing an expansion to our (circa 1997) ED to increase capacity by 1/3. Readers who would like to see how the considerations presented here (and others) shaped the unit we opened in 2009, can view the short video below.

The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
References

Article PDF
Author and Disclosure Information

Issue
Emergency Medicine - 48(3)
Publications
Page Number
103
Legacy Keywords
Editorial,
Sections
Author and Disclosure Information

Author and Disclosure Information

Article PDF
Article PDF

In the October 2006 editorial, “A Design for the 21st Century,” I suggested that the first consideration in designing a new ED should be how long it is likely to remain in service before being replaced or substantially renovated, and then to consider which conditions are most likely to continue to present or increase in importance during the first several decades of the 21st century (Emerg Med. 2006;37[10]:7). I envisioned “increasing patient volume, an aging population, new and emerging viral infections, an even higher incidence of bacterial resistance, and more immunocompromised patients resulting from organ transplants and greater use of chemotherapy.” A decade after these predictions were made, how are they holding up?

Since 2006, there have been over 40 epidemics worldwide and although most have not affected this country, easy travel and global emergency medicine missions have brought several distant viral illnesses to US EDs as well. In 2009, EDs throughout the country had to deal with a potentially disastrous epidemic of H1N1 influenza, and in the years since we have been challenged by MERS (2012), dengue fever (2013-), Ebola (2014), and now Zika and chikungunya—not to mention outbreaks of “older” bacterial and viral illnesses such as pertussis (2012), and measles (2014-2015). Though several of the newer viruses mentioned are mosquito borne, pathogens transmitted from human to human, or human to surface to human, along with the increasing incidence of antibiotic resistance (MRSA, Clostridium difficile, Carbapenem-resistant Enterobacteriaceae, etc) make the need for greater numbers of ED negative-pressure rooms undeniable.

One important design feature not specifically considered in 2006, but made apparent by the Ebola experience in 2014, is a need for the shortest possible route between the ambulance and non-ambulance ED entry points/triage and isolation facilities. As noted in 2006, a separate entrance and air handling for a designated infection-control unit in the ED is essential if it must be sealed off from the rest of the hospital and/or main ED.

The second major ED design issue considered in 2006 was the increasing numbers of elderly patients who will present to our EDs during the first half of this century. Isolation rooms and private rooms in the ED will help manage the rapidly rising number of elderly patients with contagious diseases, along with other conditions such as dementia and delirium. Significant needs of the elderly also include measures to prevent or mitigate falls, catheter-related UTIs, and bedsores.

One epidemic in the elderly that we are already facing is a significant increase in the number of trauma cases. In some Level I trauma centers, over 34% of trauma activations are for patients 55 years old and older. The 2003-2012 Oregon Trauma Registry Report containing data on 84,099 patients from 44 trauma hospitals, notes that the rate of trauma increased from 200.7 to 244.6 per 100,000 during that period, almost exclusively occurring in patients 55 years old or older who represented 21% of cases in 2003 and 34% by 2012—a rise largely attributed to a 159% increase in trauma due to falls (http://public.health.oregon.gov/providerpartnerresources/emstraumasystems/traumasystems/documents/reports/otr-report.pdf). In another study, Hsia et al reported that 27% of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses between January 1, 1999 and December 31, 2008  were older than 65 years (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121677/), and in Houston, Texas, 13% of 15,223 trauma patients admitted to one of its two level I trauma centers between January 2005 and December 2008 were 65 years old or older, according to Adams et al (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836632/). The Adams paper noted that trauma centers were originally designed to care for seriously ill patients without age-specific guidelines, but in patients 65 years or older there was a negligible amount of penetrating trauma, and a marked increase in blunt trauma, especially falls, while fatality rates, organ failure, and thromboembolic complications correlated with increasing age. Clearly EDs designed for the 21st century must be built not only to handle increasing numbers of trauma cases in the elderly, but for changing etiologies, characteristics, and comorbidities.

When I wrote “A Design for the 21st Century” in 2006, I was in the midst of actually designing an expansion to our (circa 1997) ED to increase capacity by 1/3. Readers who would like to see how the considerations presented here (and others) shaped the unit we opened in 2009, can view the short video below.

The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel

In the October 2006 editorial, “A Design for the 21st Century,” I suggested that the first consideration in designing a new ED should be how long it is likely to remain in service before being replaced or substantially renovated, and then to consider which conditions are most likely to continue to present or increase in importance during the first several decades of the 21st century (Emerg Med. 2006;37[10]:7). I envisioned “increasing patient volume, an aging population, new and emerging viral infections, an even higher incidence of bacterial resistance, and more immunocompromised patients resulting from organ transplants and greater use of chemotherapy.” A decade after these predictions were made, how are they holding up?

Since 2006, there have been over 40 epidemics worldwide and although most have not affected this country, easy travel and global emergency medicine missions have brought several distant viral illnesses to US EDs as well. In 2009, EDs throughout the country had to deal with a potentially disastrous epidemic of H1N1 influenza, and in the years since we have been challenged by MERS (2012), dengue fever (2013-), Ebola (2014), and now Zika and chikungunya—not to mention outbreaks of “older” bacterial and viral illnesses such as pertussis (2012), and measles (2014-2015). Though several of the newer viruses mentioned are mosquito borne, pathogens transmitted from human to human, or human to surface to human, along with the increasing incidence of antibiotic resistance (MRSA, Clostridium difficile, Carbapenem-resistant Enterobacteriaceae, etc) make the need for greater numbers of ED negative-pressure rooms undeniable.

One important design feature not specifically considered in 2006, but made apparent by the Ebola experience in 2014, is a need for the shortest possible route between the ambulance and non-ambulance ED entry points/triage and isolation facilities. As noted in 2006, a separate entrance and air handling for a designated infection-control unit in the ED is essential if it must be sealed off from the rest of the hospital and/or main ED.

The second major ED design issue considered in 2006 was the increasing numbers of elderly patients who will present to our EDs during the first half of this century. Isolation rooms and private rooms in the ED will help manage the rapidly rising number of elderly patients with contagious diseases, along with other conditions such as dementia and delirium. Significant needs of the elderly also include measures to prevent or mitigate falls, catheter-related UTIs, and bedsores.

One epidemic in the elderly that we are already facing is a significant increase in the number of trauma cases. In some Level I trauma centers, over 34% of trauma activations are for patients 55 years old and older. The 2003-2012 Oregon Trauma Registry Report containing data on 84,099 patients from 44 trauma hospitals, notes that the rate of trauma increased from 200.7 to 244.6 per 100,000 during that period, almost exclusively occurring in patients 55 years old or older who represented 21% of cases in 2003 and 34% by 2012—a rise largely attributed to a 159% increase in trauma due to falls (http://public.health.oregon.gov/providerpartnerresources/emstraumasystems/traumasystems/documents/reports/otr-report.pdf). In another study, Hsia et al reported that 27% of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses between January 1, 1999 and December 31, 2008  were older than 65 years (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121677/), and in Houston, Texas, 13% of 15,223 trauma patients admitted to one of its two level I trauma centers between January 2005 and December 2008 were 65 years old or older, according to Adams et al (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836632/). The Adams paper noted that trauma centers were originally designed to care for seriously ill patients without age-specific guidelines, but in patients 65 years or older there was a negligible amount of penetrating trauma, and a marked increase in blunt trauma, especially falls, while fatality rates, organ failure, and thromboembolic complications correlated with increasing age. Clearly EDs designed for the 21st century must be built not only to handle increasing numbers of trauma cases in the elderly, but for changing etiologies, characteristics, and comorbidities.

When I wrote “A Design for the 21st Century” in 2006, I was in the midst of actually designing an expansion to our (circa 1997) ED to increase capacity by 1/3. Readers who would like to see how the considerations presented here (and others) shaped the unit we opened in 2009, can view the short video below.

The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
References

References

Issue
Emergency Medicine - 48(3)
Issue
Emergency Medicine - 48(3)
Page Number
103
Page Number
103
Publications
Publications
Article Type
Display Headline
The 21st Century ED: Past Predictions and Current Trends
Display Headline
The 21st Century ED: Past Predictions and Current Trends
Legacy Keywords
Editorial,
Legacy Keywords
Editorial,
Sections
Article Source

PURLs Copyright

Inside the Article

Article PDF Media

Safety First

Article Type
Changed
Thu, 03/28/2019 - 15:14
Display Headline
Safety First

The Latin dictum primum non nocere, or first cause no harm, has been applied to patient care for centuries. But first responders, health care providers, and humanitarians eager to help victims of natural and man-made disasters can also be harmed, along with those they inadvertently expose to harm afterward. The tragic consequences of attempting to help victims of the 9/11 World Trade Center destruction and, more recently, caring for patients infected with the Ebola virus are but two examples. Loss of humanitarian lives that can be anticipated and prevented or mitigated are especially tragic, considering the potential good such people could do for so many others over a long lifetime.

Toxic exposures and infectious disease transmission have long been identified as potential risks to health care providers, but other conditions can also claim lives or result in lasting disabilities.

The middle of January brought the heartbreaking news of the deaths of three Columbia University undergraduates, who were killed when their bus plummeted 250 feet down a ravine in Honduras as they were returning from a mission to provide basic health care to underserved people. We knew one of the victims, 20-year-old Daniela Moffson, since she was a child. A bright, energetic Barnard College premed student planning to be a pediatrician, Daniella spent her vacations working in an AIDS clinic in South Africa, volunteering on the pediatric service at our hospital, and serving as a counselor in a sleep-away camp for children with cancer.

A second victim, Abigail Flanagan, was a 45-year-old nurse practitioner at our Columbia University Medical Center campus and a postbac premed student at the Columbia School of General Studies. Her 19-year-old son, a Columbia College undergraduate, also planning to be a doctor, survived the bus accident and tried unsuccessfully to resuscitate his mother with CPR. The third victim, Columbia College student Olivia Erhardt, was also planning a career in health care.

All emergency physicians (EPs) are reminded daily that accidents and other forms of trauma can happen anywhere, and staying close to home does not necessarily protect from harm. But is there also a specific role for EPs in treating and preventing serious and fatal injuries around the globe?

A January 16, 2016 New York Times article titled “Universities Focus on Safety of Trips Abroad After 3 Columbia Students Die” (http://www.nytimes.com/2016/01/16/nyregion/death-of-3-columbia-students-raises-fears-over-trips-abroad.html) points out that the US State Department has had a travel warning in effect for Honduras which “…is considered a particularly dangerous country to travel in…primarily because of the high levels of crime and violence….But [also]…because of poor road conditions, a lack of enforcement of traffic laws and a large number of vehicles that are old or in disrepair.”

The many humanitarian organizations and over 40 non-ACGME International (or Global) Emergency Medicine (IEM) fellowship programs in the United States have had a stellar safety record to date, but perhaps there is an additional role for IEM fellows and faculty to monitor and disseminate State Department foreign travel information and CDC health advisories and, working with affiliated medical schools and local college campuses, provide essential safety information and advice about changing conditions around the world. The Times article also notes that some universities have responded to the increased number of students studying or volunteering abroad by creating administrative positions devoted to ensuring and monitoring their safety. Shouldn’t EPs support these efforts in a proactive way?

Volunteers for humanitarian missions—especially young people—have a tendency to ignore personal safety warnings, and there are inherently dangerous situations that clearly require skilled professionals who should be remunerated adequately for the personal risks they are taking. But EPs devoted to providing IEM may be able to take additional steps to help reduce the dangers to everyone.

As this editorial was going to press, the CDC issued a warning for pregnant women to avoid travel to countries in the Americas where a new mosquito-borne zika viral epidemic has already caused thousands of cases of microcephaly in babies born to women who were infected during pregnancy.

References

Article PDF
Author and Disclosure Information

Issue
Emergency Medicine - 48(2)
Publications
Topics
Page Number
54
Legacy Keywords
Editorial,
Sections
Author and Disclosure Information

Author and Disclosure Information

Article PDF
Article PDF

The Latin dictum primum non nocere, or first cause no harm, has been applied to patient care for centuries. But first responders, health care providers, and humanitarians eager to help victims of natural and man-made disasters can also be harmed, along with those they inadvertently expose to harm afterward. The tragic consequences of attempting to help victims of the 9/11 World Trade Center destruction and, more recently, caring for patients infected with the Ebola virus are but two examples. Loss of humanitarian lives that can be anticipated and prevented or mitigated are especially tragic, considering the potential good such people could do for so many others over a long lifetime.

Toxic exposures and infectious disease transmission have long been identified as potential risks to health care providers, but other conditions can also claim lives or result in lasting disabilities.

The middle of January brought the heartbreaking news of the deaths of three Columbia University undergraduates, who were killed when their bus plummeted 250 feet down a ravine in Honduras as they were returning from a mission to provide basic health care to underserved people. We knew one of the victims, 20-year-old Daniela Moffson, since she was a child. A bright, energetic Barnard College premed student planning to be a pediatrician, Daniella spent her vacations working in an AIDS clinic in South Africa, volunteering on the pediatric service at our hospital, and serving as a counselor in a sleep-away camp for children with cancer.

A second victim, Abigail Flanagan, was a 45-year-old nurse practitioner at our Columbia University Medical Center campus and a postbac premed student at the Columbia School of General Studies. Her 19-year-old son, a Columbia College undergraduate, also planning to be a doctor, survived the bus accident and tried unsuccessfully to resuscitate his mother with CPR. The third victim, Columbia College student Olivia Erhardt, was also planning a career in health care.

All emergency physicians (EPs) are reminded daily that accidents and other forms of trauma can happen anywhere, and staying close to home does not necessarily protect from harm. But is there also a specific role for EPs in treating and preventing serious and fatal injuries around the globe?

A January 16, 2016 New York Times article titled “Universities Focus on Safety of Trips Abroad After 3 Columbia Students Die” (http://www.nytimes.com/2016/01/16/nyregion/death-of-3-columbia-students-raises-fears-over-trips-abroad.html) points out that the US State Department has had a travel warning in effect for Honduras which “…is considered a particularly dangerous country to travel in…primarily because of the high levels of crime and violence….But [also]…because of poor road conditions, a lack of enforcement of traffic laws and a large number of vehicles that are old or in disrepair.”

The many humanitarian organizations and over 40 non-ACGME International (or Global) Emergency Medicine (IEM) fellowship programs in the United States have had a stellar safety record to date, but perhaps there is an additional role for IEM fellows and faculty to monitor and disseminate State Department foreign travel information and CDC health advisories and, working with affiliated medical schools and local college campuses, provide essential safety information and advice about changing conditions around the world. The Times article also notes that some universities have responded to the increased number of students studying or volunteering abroad by creating administrative positions devoted to ensuring and monitoring their safety. Shouldn’t EPs support these efforts in a proactive way?

Volunteers for humanitarian missions—especially young people—have a tendency to ignore personal safety warnings, and there are inherently dangerous situations that clearly require skilled professionals who should be remunerated adequately for the personal risks they are taking. But EPs devoted to providing IEM may be able to take additional steps to help reduce the dangers to everyone.

As this editorial was going to press, the CDC issued a warning for pregnant women to avoid travel to countries in the Americas where a new mosquito-borne zika viral epidemic has already caused thousands of cases of microcephaly in babies born to women who were infected during pregnancy.

The Latin dictum primum non nocere, or first cause no harm, has been applied to patient care for centuries. But first responders, health care providers, and humanitarians eager to help victims of natural and man-made disasters can also be harmed, along with those they inadvertently expose to harm afterward. The tragic consequences of attempting to help victims of the 9/11 World Trade Center destruction and, more recently, caring for patients infected with the Ebola virus are but two examples. Loss of humanitarian lives that can be anticipated and prevented or mitigated are especially tragic, considering the potential good such people could do for so many others over a long lifetime.

Toxic exposures and infectious disease transmission have long been identified as potential risks to health care providers, but other conditions can also claim lives or result in lasting disabilities.

The middle of January brought the heartbreaking news of the deaths of three Columbia University undergraduates, who were killed when their bus plummeted 250 feet down a ravine in Honduras as they were returning from a mission to provide basic health care to underserved people. We knew one of the victims, 20-year-old Daniela Moffson, since she was a child. A bright, energetic Barnard College premed student planning to be a pediatrician, Daniella spent her vacations working in an AIDS clinic in South Africa, volunteering on the pediatric service at our hospital, and serving as a counselor in a sleep-away camp for children with cancer.

A second victim, Abigail Flanagan, was a 45-year-old nurse practitioner at our Columbia University Medical Center campus and a postbac premed student at the Columbia School of General Studies. Her 19-year-old son, a Columbia College undergraduate, also planning to be a doctor, survived the bus accident and tried unsuccessfully to resuscitate his mother with CPR. The third victim, Columbia College student Olivia Erhardt, was also planning a career in health care.

All emergency physicians (EPs) are reminded daily that accidents and other forms of trauma can happen anywhere, and staying close to home does not necessarily protect from harm. But is there also a specific role for EPs in treating and preventing serious and fatal injuries around the globe?

A January 16, 2016 New York Times article titled “Universities Focus on Safety of Trips Abroad After 3 Columbia Students Die” (http://www.nytimes.com/2016/01/16/nyregion/death-of-3-columbia-students-raises-fears-over-trips-abroad.html) points out that the US State Department has had a travel warning in effect for Honduras which “…is considered a particularly dangerous country to travel in…primarily because of the high levels of crime and violence….But [also]…because of poor road conditions, a lack of enforcement of traffic laws and a large number of vehicles that are old or in disrepair.”

The many humanitarian organizations and over 40 non-ACGME International (or Global) Emergency Medicine (IEM) fellowship programs in the United States have had a stellar safety record to date, but perhaps there is an additional role for IEM fellows and faculty to monitor and disseminate State Department foreign travel information and CDC health advisories and, working with affiliated medical schools and local college campuses, provide essential safety information and advice about changing conditions around the world. The Times article also notes that some universities have responded to the increased number of students studying or volunteering abroad by creating administrative positions devoted to ensuring and monitoring their safety. Shouldn’t EPs support these efforts in a proactive way?

Volunteers for humanitarian missions—especially young people—have a tendency to ignore personal safety warnings, and there are inherently dangerous situations that clearly require skilled professionals who should be remunerated adequately for the personal risks they are taking. But EPs devoted to providing IEM may be able to take additional steps to help reduce the dangers to everyone.

As this editorial was going to press, the CDC issued a warning for pregnant women to avoid travel to countries in the Americas where a new mosquito-borne zika viral epidemic has already caused thousands of cases of microcephaly in babies born to women who were infected during pregnancy.

References

References

Issue
Emergency Medicine - 48(2)
Issue
Emergency Medicine - 48(2)
Page Number
54
Page Number
54
Publications
Publications
Topics
Article Type
Display Headline
Safety First
Display Headline
Safety First
Legacy Keywords
Editorial,
Legacy Keywords
Editorial,
Sections
Article Source

PURLs Copyright

Inside the Article

Article PDF Media

The "Bottom Line" - Part II

Article Type
Changed
Thu, 03/28/2019 - 15:15
Display Headline
The "Bottom Line" - Part II

Continuing last month’s review of quotes and analogies from past editorials illustrating key points, I found similarities between a scripted exchange from a now famous aviation emergency and a fundamental principle of emergency-medicine practice and resident education. When his aircraft suddenly lost both engines to a flock of geese upon take-off, Captain Chesley Sullenberger immediately took control from his copilot by placing his hand on the controls and announcing “my aircraft.” He then safely brought the plane down on the Hudson River 4 minutes later, saving all 155 passengers and crew on board (“My Patient” Emerg Med. 2009;41[3]:5 and Emerg Med. 2013;45[4]:1). I wrote: “…for some potentially catastrophic medical occurrences, everything depends on who is operating and who is standing a few feet away, ready to take over the controls on a moment’s notice. Emergency Medicine is one of an increasing number of specialties that have found the resources to adopt the concept of “my patient” at all hours.…”

The typical first question on ED patient satisfaction questionnaires is “apart from the wait, how would you rate your overall experience?” To me, this sounded very much like asking “apart from that Mrs Lincoln, how did you enjoy the play?” (“Patient Satisfaction,” Emerg Med. 2010;42[7]:5).

Although the Affordable Care Act of 2010 promised millions of Americans access to timely care, there were no provisions to increase the number of health care providers. As a result, ED visits continued to increase, along with the risk of compromising care due to overcrowding—even in so-called “safety-net” hospitals. “[With] the large and growing number of patients vying for space to land on the safety net, it is inevitable that some will hit the rim or miss the net entirely.”

“A National Disgrace” (Emerg Med. 2012;44[8]:2 and Emerg Med. 2015;47[7]:292), referred to continuing nationwide medication shortages, recalling “cold war images of empty shelves in Russian supermarkets which still remain vivid reminders of a failed system of government. So who would have predicted that in the 21st-century the mighty United States of America… would have hospital pharmacy shelves bereft of essential medications, including many of the sterile, injectable, crash cart meds that we rely on during resuscitations?”

“A Wintry Mix of Patients” (Emerg Med. 2013;45[3]:1 and Emerg Med. 2015;47[7]:101) considered the terrible, inexcusable plight of patients who require acute psychiatric inpatient care, waiting days or weeks in EDs for beds. It ended with “as a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of bed [capacity] is not the only lack of capacity from which we suffer.”

“Will You Still Need Me, Will You Still Feed Me…?” (Emerg Med. 2013;45[5]:1) called for age-appropriate reductions in EP night shift requirements, pointing out that “the greatest professional baseball players cannot play professionally in their 50s or 60s…”, and suggested that “staffing and running attached or satellite urgent care centers could utilize the interpersonal and clinical skills EPs have acquired over years of EM practice, while allowing their ED group to maintain financial viability…”

“We Told You So! Now What?” (Emerg Med. 2014;46[1]:5 1/14) noted that published data confirmed our prediction that the Affordable Care Act would not reduce the numbers of ED visits; and asked “…why do so many people continue to go to EDs despite the overcrowding and all of the efforts to dissuade them?” The question was answered by paraphrasing … Winston Churchill on democracy as a form of government: “for many, many people and many, many problems, EDs may be the worst form of care, except for all of the others.”

Finally, in “’Tis the Season” (Emerg Med. 2014;46[12]:5), we asked readers if they “would be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season.” Referencing some famous advice to internists who must be able to recognize rare diseases, but more frequently favor more common diagnoses, we suggested that “determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.”

Before you gallop off on your own horse or zebra, we once again wish you a happy and healthy New Year.  

References

Article PDF
Author and Disclosure Information

Issue
Emergency Medicine - 48(1)
Publications
Topics
Page Number
5
Legacy Keywords
Editorial,
Sections
Author and Disclosure Information

Author and Disclosure Information

Article PDF
Article PDF

Continuing last month’s review of quotes and analogies from past editorials illustrating key points, I found similarities between a scripted exchange from a now famous aviation emergency and a fundamental principle of emergency-medicine practice and resident education. When his aircraft suddenly lost both engines to a flock of geese upon take-off, Captain Chesley Sullenberger immediately took control from his copilot by placing his hand on the controls and announcing “my aircraft.” He then safely brought the plane down on the Hudson River 4 minutes later, saving all 155 passengers and crew on board (“My Patient” Emerg Med. 2009;41[3]:5 and Emerg Med. 2013;45[4]:1). I wrote: “…for some potentially catastrophic medical occurrences, everything depends on who is operating and who is standing a few feet away, ready to take over the controls on a moment’s notice. Emergency Medicine is one of an increasing number of specialties that have found the resources to adopt the concept of “my patient” at all hours.…”

The typical first question on ED patient satisfaction questionnaires is “apart from the wait, how would you rate your overall experience?” To me, this sounded very much like asking “apart from that Mrs Lincoln, how did you enjoy the play?” (“Patient Satisfaction,” Emerg Med. 2010;42[7]:5).

Although the Affordable Care Act of 2010 promised millions of Americans access to timely care, there were no provisions to increase the number of health care providers. As a result, ED visits continued to increase, along with the risk of compromising care due to overcrowding—even in so-called “safety-net” hospitals. “[With] the large and growing number of patients vying for space to land on the safety net, it is inevitable that some will hit the rim or miss the net entirely.”

“A National Disgrace” (Emerg Med. 2012;44[8]:2 and Emerg Med. 2015;47[7]:292), referred to continuing nationwide medication shortages, recalling “cold war images of empty shelves in Russian supermarkets which still remain vivid reminders of a failed system of government. So who would have predicted that in the 21st-century the mighty United States of America… would have hospital pharmacy shelves bereft of essential medications, including many of the sterile, injectable, crash cart meds that we rely on during resuscitations?”

“A Wintry Mix of Patients” (Emerg Med. 2013;45[3]:1 and Emerg Med. 2015;47[7]:101) considered the terrible, inexcusable plight of patients who require acute psychiatric inpatient care, waiting days or weeks in EDs for beds. It ended with “as a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of bed [capacity] is not the only lack of capacity from which we suffer.”

“Will You Still Need Me, Will You Still Feed Me…?” (Emerg Med. 2013;45[5]:1) called for age-appropriate reductions in EP night shift requirements, pointing out that “the greatest professional baseball players cannot play professionally in their 50s or 60s…”, and suggested that “staffing and running attached or satellite urgent care centers could utilize the interpersonal and clinical skills EPs have acquired over years of EM practice, while allowing their ED group to maintain financial viability…”

“We Told You So! Now What?” (Emerg Med. 2014;46[1]:5 1/14) noted that published data confirmed our prediction that the Affordable Care Act would not reduce the numbers of ED visits; and asked “…why do so many people continue to go to EDs despite the overcrowding and all of the efforts to dissuade them?” The question was answered by paraphrasing … Winston Churchill on democracy as a form of government: “for many, many people and many, many problems, EDs may be the worst form of care, except for all of the others.”

Finally, in “’Tis the Season” (Emerg Med. 2014;46[12]:5), we asked readers if they “would be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season.” Referencing some famous advice to internists who must be able to recognize rare diseases, but more frequently favor more common diagnoses, we suggested that “determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.”

Before you gallop off on your own horse or zebra, we once again wish you a happy and healthy New Year.  

Continuing last month’s review of quotes and analogies from past editorials illustrating key points, I found similarities between a scripted exchange from a now famous aviation emergency and a fundamental principle of emergency-medicine practice and resident education. When his aircraft suddenly lost both engines to a flock of geese upon take-off, Captain Chesley Sullenberger immediately took control from his copilot by placing his hand on the controls and announcing “my aircraft.” He then safely brought the plane down on the Hudson River 4 minutes later, saving all 155 passengers and crew on board (“My Patient” Emerg Med. 2009;41[3]:5 and Emerg Med. 2013;45[4]:1). I wrote: “…for some potentially catastrophic medical occurrences, everything depends on who is operating and who is standing a few feet away, ready to take over the controls on a moment’s notice. Emergency Medicine is one of an increasing number of specialties that have found the resources to adopt the concept of “my patient” at all hours.…”

The typical first question on ED patient satisfaction questionnaires is “apart from the wait, how would you rate your overall experience?” To me, this sounded very much like asking “apart from that Mrs Lincoln, how did you enjoy the play?” (“Patient Satisfaction,” Emerg Med. 2010;42[7]:5).

Although the Affordable Care Act of 2010 promised millions of Americans access to timely care, there were no provisions to increase the number of health care providers. As a result, ED visits continued to increase, along with the risk of compromising care due to overcrowding—even in so-called “safety-net” hospitals. “[With] the large and growing number of patients vying for space to land on the safety net, it is inevitable that some will hit the rim or miss the net entirely.”

“A National Disgrace” (Emerg Med. 2012;44[8]:2 and Emerg Med. 2015;47[7]:292), referred to continuing nationwide medication shortages, recalling “cold war images of empty shelves in Russian supermarkets which still remain vivid reminders of a failed system of government. So who would have predicted that in the 21st-century the mighty United States of America… would have hospital pharmacy shelves bereft of essential medications, including many of the sterile, injectable, crash cart meds that we rely on during resuscitations?”

“A Wintry Mix of Patients” (Emerg Med. 2013;45[3]:1 and Emerg Med. 2015;47[7]:101) considered the terrible, inexcusable plight of patients who require acute psychiatric inpatient care, waiting days or weeks in EDs for beds. It ended with “as a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of bed [capacity] is not the only lack of capacity from which we suffer.”

“Will You Still Need Me, Will You Still Feed Me…?” (Emerg Med. 2013;45[5]:1) called for age-appropriate reductions in EP night shift requirements, pointing out that “the greatest professional baseball players cannot play professionally in their 50s or 60s…”, and suggested that “staffing and running attached or satellite urgent care centers could utilize the interpersonal and clinical skills EPs have acquired over years of EM practice, while allowing their ED group to maintain financial viability…”

“We Told You So! Now What?” (Emerg Med. 2014;46[1]:5 1/14) noted that published data confirmed our prediction that the Affordable Care Act would not reduce the numbers of ED visits; and asked “…why do so many people continue to go to EDs despite the overcrowding and all of the efforts to dissuade them?” The question was answered by paraphrasing … Winston Churchill on democracy as a form of government: “for many, many people and many, many problems, EDs may be the worst form of care, except for all of the others.”

Finally, in “’Tis the Season” (Emerg Med. 2014;46[12]:5), we asked readers if they “would be able to diagnose the first case of Ebola in a febrile patient who has no travel history and presents to an ED during flu season.” Referencing some famous advice to internists who must be able to recognize rare diseases, but more frequently favor more common diagnoses, we suggested that “determining when hoofbeats are caused by a horse and when they are caused by a zebra is one of the most difficult challenges of emergency medicine.”

Before you gallop off on your own horse or zebra, we once again wish you a happy and healthy New Year.  

References

References

Issue
Emergency Medicine - 48(1)
Issue
Emergency Medicine - 48(1)
Page Number
5
Page Number
5
Publications
Publications
Topics
Article Type
Display Headline
The "Bottom Line" - Part II
Display Headline
The "Bottom Line" - Part II
Legacy Keywords
Editorial,
Legacy Keywords
Editorial,
Sections
Article Source

PURLs Copyright

Inside the Article

Article PDF Media