Catherine A. Marco

A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behaviors

STUDY OBJECTIVE Ohio recently instituted an online prescription monitoring program, the Ohio Automated Rx Reporting System (OARRS), to monitor controlled substance prescriptions within Ohio. This study is undertaken to identify the influence of OARRS data on clinical management of emergency department (ED) patients with painful conditions. METHODS This prospective quasiexperimental study was conducted at the University of Toledo Medical Center Emergency Department during June to July 2008. Eligible participants included ED patients with painful conditions. Patients with acute injuries were excluded. After clinical evaluation, and again after presentation of OARRS data, providers answered a set of questions about anticipated pain prescription for the patient. Outcome measures included changes in opioid prescription and other potential factors that influenced opioid prescription. RESULTS Among 179 participants, OARRS data revealed high numbers of narcotics prescriptions filled in the most recent 12 months (median 7; range 0 to 128). Numerous providers prescribed narcotics for patients (median 3 per patient; range 0 to 40). Patients had filled narcotics prescriptions at different pharmacies (mean [SD] 3.5 [4.4]). Eighteen providers are represented in the study. Four providers treated 63% (N=114) of the patients in the study. After review of the OARRS data, providers changed the clinical management in 41% (N=74) of cases. In cases of altered management, the majority (61%; N=45) resulted in fewer or no opioid medications prescribed than originally planned, whereas 39% (N=29) resulted in more opioid medication than previously planned. CONCLUSION The use of data from a statewide narcotic registry frequently altered prescribing behavior for management of ED patients with complaints of nontraumatic pain.

Prehospital resuscitation practices: a survey of prehospital providers.

Numerous factors affect decision making in the prehospital provision of resuscitative care. This study was undertaken to determine current practices involved in the initiation, continuation and termination of resuscitative efforts, and the impact of advance directives, in the prehospital resuscitation setting. This cross-sectional mailed questionnaire surveyed 3807 members of the National Association of Emergency Medical Technicians. The study instrument included questions regarding the termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols and compliance with advance directives. Of 1546 respondents (41% response rate), with a mean 9.0 years of experience, most (89%) indicated that they would withhold resuscitative efforts in the presence of an official state-approved advance directive. However, very few providers would withhold resuscitative efforts if only an unofficial document (4%) or verbal report of an advance directive (10%) were available. Providers with more than 10 years experience were more likely to withhold resuscitation attempts in the presence of only a verbal report of an advance directive (p = 0.02, Chi-square), and were more likely to withhold resuscitation attempts in situations they considered futile (p = 0.001, Chi-square). Most (77%) respondents have local EMS guidelines for termination of resuscitation in the prehospital setting, but 23% of those consider existing guidelines to be inadequate. The majority of prehospital providers stated that they honor official state-approved advance directives, but do not follow directives from unofficial documents or verbal reports of advance directives. More experienced providers stated that they withhold resuscitative efforts more often in futile situations, or in the presence of unofficial advance directives. Advance directives should be utilized more uniformly among patients who wish to forgo resuscitative efforts in the event of cardiac arrest. Because many local protocols are judged to be inadequate, we support the institution of improved clinical guidelines regarding the prehospital termination of resuscitative efforts.

Fever in Geriatric Emergency Patients: Clinical Features Associated With Serious Illness☆☆☆★

STUDY OBJECTIVE To determine the clinical significance of fever in geriatric emergency department patients. DESIGN Case series with follow-up. SETTING Urban, university-affiliated community hospital. PARTICIPANTS Consecutive patients over the age of 65 years who presented to the ED during a 12-month period with an oral temperature of 100.0 degrees F (37.8 degrees C) or higher. RESULTS We considered the following features indicators of serious illness: positive blood culture(s), related death within 1 month of ED visit, need for surgery or other invasive procedure, hospitalization for 4 or more days, IV antibiotics for 3 or more days, and repeat ED visit within 72 hours for related condition. Four hundred eighty-nine patients were eligible for study. Of the 470 patients with complete follow-up data, 357 (76.0%) had indicators of serious illness. Clinical features found to be independently associated with serious illness included oral temperature of 103 degrees F (39.4 degrees C) or more, respiration rate of 30 or more, leukocytosis of 11.0 x 10(9)/L or more, presence of an infiltrate, and pulse of 120 or more. At least one indicator of serious illness was present in 63 of 128 patients (49.6%) with none of these independently predictive clinical features. The most common final diagnoses were pneumonia (24.0%), urinary-tract infection (21.7%), and sepsis (12.8%). CONCLUSION Fever among geriatric ED patients frequently marks the presence of serious illness. All such patients should be strongly considered for hospital admission, particularly when certain clinical features are present. The absence of abnormal findings does not reliably rule out the possibility of serious illness.

A study of the workforce in emergency medicine: 2007

INTRODUCTION This study was undertaken to describe the current status of the emergency medicine workforce in the United States. METHODS Surveys were distributed in 2008 to 2619 emergency department (ED) medical directors and nurse managers in hospitals in the 2006 American Hospital Association database. RESULTS Among ED medical directors, 713 responded, for a 27.2% response rate. Currently, 65% of practicing emergency physicians are board certified by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine. Among those leaving the practice, the most common reasons cited for departure include geographic relocation (46%) and better pay (29%). Approximately 12% of the ED physician workforce is expected to retire in the next 5 years. Among nurse managers, 548 responded, for a 21% response rate. Many nurses (46%) have an associate degree as their highest level of education, 28% have a BSN, and 3% have a graduate degree (MSN or higher). Geographic relocation (44%) is the leading reason for changing employment. Emergency department annual volumes have increased by 49% since 1997, with a mean ED volume of 32 281 in 2007. The average reported ED length of stay is 158 minutes from registration to discharge and 208 minutes from registration to admission. Emergency department spent an average of 49 hours per month in ambulance diversion in 2007. Boarding is common practice, with an average of 318 hours of patient boarding per month. CONCLUSIONS In the past 10 years, the number of practicing emergency physicians has grown to more than 42 000. The number of board-certified emergency physicians has increased. The number of annual ED visits has risen significantly.

From hippocrates to HIPAA: Privacy and confidentiality in emergency medicine: Part II: Challenges in the emergency department

Part I of this article reviewed the concepts of privacy and confidentiality and described the moral and legal foundations and limits of these values in health care. Part II highlights specific privacy and confidentiality issues encountered in the emergency department (ED). Discussed first are physical privacy issues in the ED, including problems of ED design and crowding, issues of patient and staff safety, the presence of visitors, law enforcement officers, students, and other observers, and filming activities. The article then examines confidentiality issues in the ED, including protecting medical records, the duty to warn, reportable conditions, telephone inquiries, media requests, communication among health care professionals, habitual patient files, the use of patient images, electronic communication, and information about minor patients.

Pain management: association with patient satisfaction among emergency department patients.

BACKGROUND Patient satisfaction with emergency care is associated with timeliness of care, empathy, technical competence, and information delivery. Previous studies have demonstrated inconsistent findings regarding the association between pain management and patient satisfaction. OBJECTIVES This study was undertaken to determine the association between pain management and patient satisfaction among Emergency Department (ED) patients presenting with acute painful conditions. METHODS In this survey study, a standardized interview was conducted at the Emergency Department at the University of Toledo Medical Center in May-July 2011. Participants were asked to answer 18 questions pertaining to patient satisfaction. Additional data collected included demographic information, pain scores, and clinical management. RESULTS Among 328 eligible participants, 289 (88%) participated. The mean triage pain score on the verbal numeric rating scale was 8.2 and the mean discharge score was 6.0. The majority of patients (52%) experienced a reduction in pain of 2 or more points. Participants received one pain medication dose (44%), two medication doses (14%), three medication doses (5%), or four medication doses (2%). Reduction in pain scores of 2 or more points was associated with a higher number of medications administered. Reduction in pain scores was associated with higher satisfaction as scored on questions of patient perceptions of adequate assessment and response to pain, and treatment of pain. CONCLUSIONS There was a significant association between patient satisfaction and a reduction in pain of 2 or more points and number of medications administered. Effective pain management is associated with improved patient satisfaction among ED patients with painful conditions.

End-of-life issues in the acute and critically ill patient

The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.

Ethical issues of resuscitation : an American perspective

Challenging issues confront emergency physicians routinely when performing cardiopulmonary resuscitation. Ethical issues surrounding resuscitation may include issues of futility, withholding or withdrawing interventions, advance directives, family presence, practising procedures on the newly dead, palliative care, and communication. Principles of bioethics can be valuable in assessing and debating ethical dilemmas. In many cases where curative care is not possible or is not desired, the goal of medical care at the end of life is to provide comfort to the patient and family, rather than initiating technological interventions that are unlikely to benefit the patient.

Factors associated with self-reported pain scores among ED patients ☆

INTRODUCTION Pain is a common presenting complaint among emergency department (ED) patients. The verbal numeric pain scale is commonly used in the ED to assess self-reported pain. This study was undertaken to describe and compare pain scores in a variety of painful conditions and identify factors associated with self-reported pain scores. METHODS The study was a prospective, observational, descriptive survey study conducted at an urban university hospital ED. Eligible participants included consenting adults 18 years and older, with an acute painful condition, who spoke English, and were not in severe distress. Through a structured interview, collected data included pain score; diagnosis; medical history; previous painful experiences; and demographic information including age, insurance status, and highest level of education completed. RESULTS Among 268 eligible participants, 263 (98%) consented and completed the study protocol. Seventy-one percent of participants were 50 years old or younger; 55%, women; and 68%, white. Fifty-four percent had private insurance, and 81%, high school education or higher. The most common chief complaints were soft tissue injury (33%), abdominal pain (18%), and chest pain (13%). The median self-reported pain score was 7/10 (mean, 6.7; interquartile range, 6-9; range, 0-10). The most common previous painful experiences were childbirth (21%), major trauma (18%), and surgery (14%). Participants cited reasons for self-reported pain scores, including current feeling of pain (62%), comparison to previous pain (31%), and comparison to hypothetical pain (12%). The number of previous ED visits was positively correlated with current pain score (Spearman correlation R = 0.28; P < .001). The chief complaints associated with the highest pain scores included dental pain (mean pain score, 8.5) and back pain (mean pain score, 7.6). Chief complaints associated with the lowest pain scores included chest pain (mean pain score, 5.2) and other medical conditions (mean pain score, 5.3). Factors associated with higher pain scores included younger age (P < .001, Kruskal-Wallis), Medicaid insurance (P = .02), and lower educational status (P = .01). There was not a statistically significant association between current pain score and sex, race, previous painful experiences, or number of hospital admissions. CONCLUSION Emergency department patients with acute painful conditions report a wide range of self-reported pain scores. Participants rated pain based on current feeling of pain or comparison to previous or hypothetical pain. Chief complaints with highest pain scores included dental pain and back pain. Factors associated with higher pain scores included younger age, Medicaid insurance, lower educational status, and higher number of previous ED visits.

ETHICAL ISSUES OF RESUSCITATION

There is a wide variety of ethical issues and dilemmas involving resuscitation, the act of restoring life to a patient in cardiorespiratory arrest. Decisions must be made rapidly and often must be based on suboptimal levels of information available at the time. Certain issues should be considered when one is making decisions in the resuscitation arena, including positive-aspects of resuscitation, not only the possibility of restoring life to the patient but also providing a sense of closure and resolution of guilt for the survivors. During and following resuscitative efforts, the psychologic and emotional well-being of the survivors should also be given close attention.