Christopher S. Weaver

A Task Analysis of Emergency Physician Activities in Academic and Community Settings

STUDY OBJECTIVE We characterize and compare the work activities, including peak patient loads, associated with the workplace in the academic and community emergency department (ED) settings. This allows assessment of the effect of future ED system operational changes and identifies potential sources contributing to medical error. METHODS This was an observational, time-motion study. Trained observers shadowed physicians, recording activities. Data included total interactions, distances walked, time sitting, patients concurrently treated, interruptions, break in tasks, physical contact with patients, hand washing, diagnostic tests ordered, and therapies rendered. Activities were classified as direct patient care, indirect patient care, or personal time with a priori definitions. RESULTS There were 203 2-hour observation periods of 85 physicians at 2 academic EDs with 100,000 visits per year at each (N=160) and 2 community EDs with annual visits of 19,000 and 21,000 (N=43). Reported data present the median and minimum-maximum values per 2-hour period. Emergency physicians spent the majority of time on indirect care activities (academic 64 minutes, 29 to 91 minutes; community 55 min, 25 to 95 minutes), followed by direct care activities (academic 36 minutes, 6 to 79 minutes; community 41 minutes, 5 to 60 minutes). Personal time differed by location type (academic 6 minutes, 0 to 66 minutes; community 13 minutes, 0 to 69 minutes). All physicians simultaneously cared for multiple patients, with a median number of patients greater than 5 (academic 7 patients, 2 to 16 patients; community 6 patients, 2 to 12 patients). CONCLUSION Emergency physicians spend the majority of their time involved in indirect patient care activities. They are frequently interrupted and interact with a large number of individuals. They care for a wide range of patients simultaneously, with surges in multiple patient care responsibilities. Physicians working in academic settings are interrupted at twice the rate of their community counterparts.

ED Patient Falls and Resulting Injuries

INTRODUCTION Patient falls are the most common adverse events reported in hospitals. There is a growing body of literature on inpatient falls but a lack of data on ED falls. We applied the Hendrich II Fall Risk Model to patients who fell during their ED stays and provided a description of the patients and their injuries. METHODS We retrospectively reviewed the medical records of all patients who fell in the emergency department during a 2-year period. We collected the 8 assessment parameters for high-risk fall identification in the Hendrich II Fall Risk Model. We also collected subject characteristics, circumstances surrounding the falls, fall-related injuries, and ED disposition. RESULTS Fifty-seven falls were recorded, representing a rate of 0.288 falls per 1000 patient visits. The average age was 50 years, and a median of 48. 67% were men. Twenty-one subjects had a Hendrich II Model score of 5 of greater, which represents a sensitivity of 37.5%. Eleven subjects (19.6%) were intoxicated with alcohol. Eleven subjects (19.6%) received a potentially sedating medication prior to the fall. Thirty-six subjects (64.3%) fell in their ED rooms. Six subjects (10.7%) fell in the restroom. Three falls (5.4%) resulted in lacerations and 2 falls (3.6%) resulted in hematomas. DISCUSSION The Hendrich II Fall Risk Model may not reliably identify patients at high risk of falling in the ED setting. It may be necessary to develop an emergency department-specific fall model considering additional factors, such as intoxication and receipt of potentially sedating medications.

Improving specialty care follow-up after an ED visit using a unique referral system

OBJECTIVE Many patients discharged from the emergency department (ED) require urgent follow-up with specialty providers. We hypothesized that a unique specialty referral mechanism that minimized barriers would increase follow-up compliance over reported and historical benchmarks. METHODS Retrospective review of all patients requiring urgent (within 1 month) specialty referrals in 2010 from a safety net hospital ED to dermatology, otolaryngology, neurology, neurosurgery, ophthalmology, urology, plastic surgery, general surgery, or vascular surgery clinics. After specialist input, all patients received a specific follow-up appointment before ED discharge via a specific scheduling service. Necessity for payment at the follow-up visit was waived. RESULTS Of the 1174 receiving referrals, 85.6% of patients scheduled an appointment and 80.1% kept that appointment. After logistic regression analysis, the factors that remained significantly associated (P < .05) with appointment-keeping compliance were the specialty clinic type (dermatology, 61.5%, to ophthalmology, 98.0%), insurance status (other payer, 87.5%; commercial, 82.8%; Medicaid, 77.9%; Medicare, 85.7%; charity care program, 88.1%; self-pay, 73.0%), age (<18 years, 80.1%; 18-34 years, 75.0%; 35-49 years, 79.2%; 50-64 years, 85.9 %; >64 years, 93.9%), and mean length of time between ED visit and clinic appointment (kept, 10.5 days; not kept, 14.3 days). The specialty clinic (neurology, 72.8%, to vascular surgery, 100%; P < .001) was significantly associated with the likelihood of patients to complete the appointment-making process. Race/Ethnicity was not associated with either scheduling or keeping an appointment. CONCLUSION A referral process that minimizes barriers can achieve an 80% follow-up compliance rate. Age, insurance, specialty type, and time to appointment are associated with noncompliance.

ED procedural sedation of elderly patients: is it safe?

OBJECTIVE Emergency physicians routinely perform emergency department procedural sedation (EDPS), and its safety is well established. We are unaware of any published reports directly evaluating the safety of EDPS in older patients (≥65 years old). Many EDPS experts consider seniors to be at higher risk. The objective was to evaluate the complication rate of EDPS in elderly adults. METHODS This was a prospective, observational study of EDPS patients at least 65 years old, as compared with patients aged 18 to 49 and 50 to 64 years. Physicians were blind to the objectives of this research. The study protocol required an ED nurse trained in data collection to be present to record vital signs and assess for any prospectively defined complications. We used American Society of Anesthesiologists (ASA) physical status classification for systemic disease to evaluate and account for the comorbidities of patients. We used the Fisher exact test for the difference in proportions across age groups and analysis of variance for the differences in dosing across age and ASA categories. RESULTS During the 4-year study, we enrolled 50 patients at least 65 years old, 149 patients aged 50 to 64 years, and 665 patients aged 18 to 49 years. Adverse event rates were 8%, 5.4%, and 5.2%, respectively (P = .563). The at least 65 years age group represented a greater percentage of those with higher ASA scores (P < .001). The average total sedative dose in the at least 65 years group was significantly lower than the comparisons (P < .001). CONCLUSIONS This study demonstrated no statistically significant difference in complication rate for patients 65 years or older. There was a significant decrease in mean sedation dosing with increased age and ASA score.

Healthcare outcomes in undocumented immigrants undergoing two emergency dialysis approaches

Background: Current estimates suggest 6,500 undocumented end-stage renal disease (ESRD) patients in the United States are ineligible for scheduled hemodialysis and require emergent dialysis. In order to remain in compliance with Emergency Medicaid, an academic health center altered its emergency dialysis criteria from those emphasizing interdialytic interval to a set emphasizing numerical thresholds. We report the impact of this administrative change on the biochemical parameters, utilization, and adverse outcomes in an undocumented patient cohort. Methods: This retrospective case series examines 19 undocumented ESRD patients during a 6-month transition divided into three 2-month periods (P1, P2, P3). In P1, patients received emergent dialysis based on interdialytic interval and clinical judgment. In P2 (early transition) and P3 (equilibrium), patients were dialyzed according to strict numerical criteria coupled with clinical judgment. Results: Emergent criteria-based dialysis (P2 and P3) was associated with increased potassium, blood urea nitrogen (BUN), and acidosis as compared to P1 (p < 0.05). Overnight hospitalizations were more common in P2 and P3 (p < 0.05). More frequent adverse events were noted in P2 as compared to P1 and P3, with an odds ratio (OR) for the composite endpoint (intubation, bacteremia, myocardial infarction, intensive care unit admission) of 48 (5.9 – 391.2) and 16.5 (2.5 – 108.6), respectively. Per-patient reimbursement-to-cost ratios increased during criteria-based dialysis periods (P1: 1.49, P2: 2.3, P3: 2.49). Discussion: Strict adherence to criteria-based dialysis models increases biochemical abnormalities while improving Medicaid reimbursement for undocumented immigrants. Alternatives to emergent dialysis are required which minimize cost, while maintaining dignity, safety, and quality of life.

Mobile integrated health to reduce post-discharge acute care visits: A pilot study

Background: Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery. Study objective: To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization. Methods: This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90 days before MIH intervention to 90 days after. Results: Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre‐MIH to 26 post‐MIH (83% reduction, p = 0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p = 0.98; observation stays 95 to 106, p = 0.30) Primary care visits increased 15% (p = 0.11). Conclusion: In this pilot before/after study, MIH significantly reduces acute care hospitalizations.