Laura Pimentel

Scurvy: historical review and current diagnostic approach

Scurvy, a deficiency of vitamin C, now most often occurs in disadvantaged groups seen frequently in EDs: alcoholics with poor nutrition, the isolated elderly, and the institutionalized. Its prominent clinical features are lethargy; purpuric lesions, especially affecting the legs; myalgia; and, in advancing disease, bleeding from the gums with little provocation. Common misdiagnoses are vasculitis, blood dyscrasias, and ulcerative gingivitis. Untreated, scurvy is inevitably fatal as a result of infection or sudden death. Fortunately, individuals with scurvy, even those with advanced disease, respond favorably to administration of vitamin C.

Amantadine toxicity presenting with complex ventricular ectopy and hallucinations

Amantadine hydrochloride is a commonly prescribed drug with a narrow therapeutic-to-toxic range. Toxicity is related to the anticholinergic properties of the drug and primarily affects the cardiovascular, central nervous, and respiratory systems. We report the case of an adolescent who ingested 1.3 grams of amantadine and developed complex ventricular arrhythmias and altered mental status. The arrhythmias were completely suppressed with intravenous lidocaine. This case supports the hypothesis that lidocaine is effective for treatment of ventricular arrhythmias secondary to amantadine toxicity.

Evaluation and Management of Acute Cervical Spine Trauma

The evaluation and management of cervical spine injuries is a core component of the practice of emergency medicine. This article focuses on evaluation and management of blunt cervical spine trauma by the emergency physician. Pertinent anatomy of the cervical spine and specific cervical spine fractures are discussed, with an emphasis on unstable injuries and associated spinal cord pathology. The association of vertebral artery injury with cervical spine fracture is addressed, followed by a review of the most recent literature on prehospital care. Initial considerations in the emergency department, including cervical spine stabilization and airway management, are reviewed. The most current recommendations for cervical spine imaging with regard to indications and modalities are covered. Finally, emergency department management and disposition of patients with spinal cord injuries are reviewed.

Community-acquired pneumonia in the emergency department: A practical approach to diagnosis and management

Pneumonia is one of the most common conditions for which patients seek emergency care. It is a challenging infection in that the spectrum of illness ranges from the nontoxic patient appropriate for outpatient antibiotics to the critically ill patient requiring intensive care hospitalization. Current data and diagnostic technology provide the emergency physician with the tools for an appropriately rapid evaluation and consideration of the differential diagnosis. Key critical thinking and application of published findings allow for intelligent empirical antibiotic treatment and risk stratification for the best disposition. Although antibiotic-resistant organisms increasingly are being identified, patients continue to benefit from early institution of standard ED treatment. Coverage for atypical organisms improves patient response and outcome. Finally, identification and treatment of the complications of pneumonia and accompanying sepsis must be considered by the ED physician when evaluating critically ill patients.

Statistical Process Control: Separating Signal from Noise in Emergency Department Operations

BACKGROUND Statistical process control (SPC) is a visually appealing and statistically rigorous methodology very suitable to the analysis of emergency department (ED) operations. OBJECTIVE We demonstrate that the control chart is the primary tool of SPC; it is constructed by plotting data measuring the key quality indicators of operational processes in rationally ordered subgroups such as units of time. Control limits are calculated using formulas reflecting the variation in the data points from one another and from the mean. SPC allows managers to determine whether operational processes are controlled and predictable. We review why the moving range chart is most appropriate for use in the complex ED milieu, how to apply SPC to ED operations, and how to determine when performance improvement is needed. DISCUSSION SPC is an excellent tool for operational analysis and quality improvement for these reasons: 1) control charts make large data sets intuitively coherent by integrating statistical and visual descriptions; 2) SPC provides analysis of process stability and capability rather than simple comparison with a benchmark; 3) SPC allows distinction between special cause variation (signal), indicating an unstable process requiring action, and common cause variation (noise), reflecting a stable process; and 4) SPC keeps the focus of quality improvement on process rather than individual performance. CONCLUSION Because data have no meaning apart from their context, and every process generates information that can be used to improve it, we contend that SPC should be seriously considered for driving quality improvement in emergency medicine.

Drivers of ED efficiency: a statistical and cluster analysis of volume, staffing, and operations

STUDY OBJECTIVE The percentage of patients leaving before treatment is completed (LBTC) is an important indicator of emergency department performance. The objective of this study is to identify characteristics of hospital operations that correlate with LBTC rates. METHODS The Emergency Department Benchmarking Alliance 2012 and 2013 cross-sectional national data sets were analyzed using multiple regression and k-means clustering. Significant operational variables affecting LBTC including annual patient volume, percentage of high-acuity patients, percentage of patients admitted to the hospital, number of beds, academic status, waiting times to see a physician, length of stay (LOS), registered nurse (RN) staffing, and physician staffing were identified. LBTC was regressed onto these variables. Because of the strong correlation between waiting times measured as door to first provider (DTFP), we regressed DTFP onto the remaining predictors. Cluster analysis was applied to the data sets to further analyze the impact of individual predictors on LBTC and DTFP. RESULTS LOS and the time from DTFP were both strongly associated with LBTC rate (P<.001). Patient volume is not significantly associated with LBTC rate (P=.16). Cluster analysis demonstrates that physician and RN staffing ratios correlate with shorter DTFP and lower LBTC. CONCLUSION Volume is not the main driver of LBTC. DTFP and LOS are much more strongly associated. We show that operational factors including LOS and physician and RN staffing decisions, factors under the control of hospital and physician executives, correlate with waiting time and, thus, in determining the LBTC rate.

Prognostic Value of the Emergency Department for In-Hospital Complications of Acute Myocardial Infarction

Study objective: To identify patients who are admitted from the emergency department with chest discomfort who are at low risk for life-threatening complications. Design: Retrospective chart review. Setting: A 450-bed military medical center providing active duty and military beneficiaries. Type of participants: Six hundred twenty-one patients admitted to an ICU from the ED with the chief complaint of chest discomfort. Measurements and main results: Study participants were placed into low- and high-risk groups based on clinical criteria and ECGs. The groups were compared with respect to occurrence of life-threatening complications during the hospital course. Three of the 262 patients in the low-risk group experienced life-threatening events; two died. Twenty-nine of the 224 high-risk patients experienced life-threatening events; 17 died. Results were statistically evaluated using Fishers exact test. Significance was achieved at a value of P Conclusion: Patients who meet low-risk group criteria have a low likelihood of immediate life-threatening events and could be admitted to an intermediate care unit.

The impact of a freestanding ED on a regional emergency medical services system

OBJECTIVE The objective of the study is to examine the effect of the opening of a freestanding emergency department (FED) on the surrounding emergency medical services (EMS) system through an examination of EMS system metrics such as ambulance call volume, ambulance response times, and turnaround times. METHODS This study is based on data from the countys computer-aided dispatch center, the FED, and the Maryland Health Services Cost Review Commission. The analysis involved a pre/post design, with a 6-month washout period. The preintervention period was April to October 2010, and the postintervention period was April to October 2011. Data were analyzed using standard t tests. RESULTS The average daily number of EMS-related calls received in the computer-aided dispatch center was lower after the FED opened (16.3 [95% confidence interval {CI}, 15.7-16.9] vs 15.8 [95% CI, 14.9-16.9]). One-fourth of all patients were transported by ambulance to the FED after it opened. Use of the FED and adjacent hospitals increased by 8647 visits (15.8%) during the study period. Turnaround time for the countys ALS units decreased from 26.8 (95% CI, 26.2-27.5) to 25.1 (95% CI, 24.3-25.8) minutes. The ambulance out-of-service interval decreased from 87.3 (95% CI, 86.0-88.5) to 81.1 (95% CI, 79.7-82.4) minutes. Based on change in out-of-service this study had a small effect size (Cohens d = 0.33). CONCLUSIONS The opening of an FED was associated with a modest improvement in time-specific EMS system metrics: a decrease in ambulance turnaround time and shorter out-of-service intervals.

The Maryland Medicare waiver and emergency care: mixed experiences deserve close scrutiny.

A bold new chapter commenced this year in Maryland’s 40-year experiment in hospital cost control through an all-payer reimbursement system. The foundation, Maryland’s Health Services Cost Review Commission (HSCRC), is an independent agency that establishes hospital rates for all insurance companies, excluding professional services. Hospital rates vary based on service complexity, payer mix, and provision of medical education. In 1977, Maryland received a federal waiver aligning Medicare payments with HSCRC rates. For 36 years, the system controlled costs per hospital admission. As care for all but the sickest moved to outpatient settings, this program became less effective in controlling costs as hospital incentives to increase admission volumes remained. A revision of the Medicare waiver became necessary. The new waiver is a population-based model that transitions nearly all Maryland hospitals to global budgets over 5 years: a statewide expansion of the Total Patient Revenue (TPR) pilot initiated in July 2010 in 10 rural hospitals. In TPR, hospitals are assured a fixed revenue each year, independent of patient volume and services delivered. The goals are cost reduction, improved outcomes and patient experience, and healthier communities. Policy makers believe this new model may be the future of US health care, emphasizing preventive care, improved transitions, and greater coordination among hospitals, primary care physicians, and other outpatient providers. Although global hospital budgets are intended to improve care and reduce costs, hospital-based emergency departments (EDs) in Maryland have had mixed experiences with TPR. EDs are a good barometer for payment reform as the epicenter for unscheduled illness and injury. They serve as a last resort when care is unavailable elsewhere and are the gateway for more than 50% of US hospital admissions. TPR had several positive effects on EDs, such as expanded resources to shift some care to outpatient settings. Yet access to timely outpatient follow-up after ED care was a major problem and was a cause for many lowacuity admissions. Global budgets spurred investments in ED case managers to facilitate access to newly established discharge clinics. Case managers also facilitated home health services and obtained durable medical equipment—services not typically available through an ED. There also has been increased use of observation units. In lieu of admission, patients can be observed safely for a short time for conditions such as chest pain, heart failure, and transient ischemic attack. Through a combination of state and federal funding, Maryland also formed a health information exchange, the Chesapeake Regional Information System for our Patients (CRISP). All acute care hospitals and many imaging centers and laboratories participate with CRISP, allowing clinicians access to patient records across settings. ED physicians are among CRISP’s largest user group. At the same time, aggressive efforts to displace care from hospitals has resulted in several unintended consequences, such as a proliferation of urgent care centers near hospital EDs—unregulated facilities paid under fee for service (FFS). Although TPR constrains hospital payments, it does not impose cost controls on outpatient settings. As hospital-based EDs shift from revenue centers to cost centers, urgent care centers and freestanding EDs may replace downsized hospital-based acute care capacity. Whether moving emergency care out of hospitals benefits patients or reduces cost remains to be seen. TPR has spurred some hospitals to heavily scrutinize admission decisions, further lengthening ED stays in an already overcrowded system while case managers search for alternatives. Disposition delays consume scarce ED resources while new, undifferentiated patients wait longer to be seen. Admission criteria are promulgated by proprietary groups based on expert consensus, and are not 546182 AJMXXX10.1177/1062860614546182American Journal of Medical QualityPines et al research-article2014

Development of a University-based Emergency Department Network: Lessons Learned

BACKGROUND As part of the growth of emergency medical care in our state, our university-based emergency medicine practice developed a network of affiliated emergency department (ED) practices. The original practices were academic and based on a faculty practice model; more recent network development incorporated a community practice model less focused on academics. OBJECTIVE This article discusses the growth of that network, with a focus on the recent addition of a county-wide two-hospital emergency medicine practice. During the transition of the two EDs from a contract management group to the university network, six critical areas in need of restructuring were identified: 1) departmental leadership, 2) recruitment and retention of clinical staff members, 3) staffing strategies, 4) relationships with key constituents, 5) clinical operations, supplies, and equipment, and 6) compensation structure. The impact of changes was measured by comparison of core measures, efficiency metrics, patient volumes, admissions, and transfers to the academic medical center before and after the implementation of our practice model. CONCLUSION Our review and modification of these components significantly improved the quality and efficiency of care at the community hospital system. The consistent presence of board certified emergency physicians optimized utilization of clinical resources in the community hospital and the academic health system. This dynamic led to a mutually beneficial merger of these major state healthcare systems.