• Did you know that emergency physicians spend nearly 1/3 of their handoff time responding to interruptions?
• EPs are interrupted around 7-11 times during handoffs, accounting for 11% of the total adverse events, a third of which are considered preventable.
• This study examined the number of interruptions and perception of collaboration in three different physical spaces in the same ED: an open workstation, an enclosed workstation, and a semi-open workstation (see photos and blueprints below).
• Most EDs have open workstations as they are thought to optimize visibility and opportunities for collaboration among team members of all levels.
• EPs conducting handoffs in open workstations experienced more interruptions (patient care-related or not) as compared to those in the enclosed workstations. 
• Investigators found that enclosure of the physicians’ workstation can decrease the number of times physicians are interrupted during critical tasks like handoffs, therefore decreasing the risk of errors and adverse events.
• EPs perceived a high degree of collaboration with colleagues in the enclosed workstation during handoff and felt less interrupted.
• While the number of documented handoff interruptions in the semi-open plan were lower than the open workstation, EPs still perceived interruptions as frequent. 
• While there are clear benefits of the open workstation in the ED, it may be worth considering a different venue, specifically for handoffs, such as a “No Interruptions Zone” (NIZ) to decrease the perceived and actual frequency of interruptions, while also improving the sense of collaboration between team members during the handoff process.

Show References

Traditional Medicare now covers < 50% of Medicare beneficiaries. It reimburses on a fee-for-service basis. For beneficiaries, it includes deductibles and coinsurance requirements that yield average annual out-of-pocket expenses measured in the thousands of dollars.

Medicare Advantage, the new alternative, has grown quickly. Plans typically promise beneficiaries fewer co-pays and more services. It relies on private insurers (think United, Blue Cross, Kaiser Permanente) to coordinate care and rein in costs. Subsidies to Medicare Advantage have helped spur growth, subsidies that mean costs per beneficiary for Medicare Advantage exceed those for traditional Medicare.

Which means Medicare still needs to figure out how to save money and remain viable while the US population over 65 grows.

When listening to a lecture about Medicare or reading a study that uses Medicare data, take a moment to ask “Which Medicare? Fee-for-service? Or Advantage?”

For a take on the future of Medicare, see McWilliams JM, The Future of Medicare and the Role of Traditional Medicare as Competitor, NEJM, August 22/29, 763-769.

To understand why Medicare Advantage plans are popular, see https://www.kff.org/medicare/issue-brief/10-reasons-why-medicare-advantage-enrollment-is-growing-and-why-it-matters/.

Show References

“I’m not going to the hospital, my father died in a hospital.”

In planning a study it’s a good practice to consider what confounding variables you may need to look out for.

Confounding variables are associated with the predictor (independent) and outcome (dependent) variables, but they are not in the causal chain. In the above example, disease is likely the predictor variable, death is the outcome variable, and going to the hospital is a confounder. Of course, this assumes the death was not iatrogenic; then the hospital would be in the causal chain.

Patients may be selected for interventions based on severity of disease, functional status, education level, and other factors, and these may be confounders.

Confounding can be addressed at the design stage, by:

• Specification – excluding patients with the confounder (often not feasible)
• Matching – selecting cases and controls matched by confounding variable levels
• Randomization – randomly select patients for an intervention and hope confounding variables will balance out

It can be addressed in the analysis stage by:

• Stratification – analyzing data in strata defined by confounding variable levels
• Adjustment – mathematically adjusting for the confounding variable (usually by regression)

Show References

This retrospective study found that while overall rates of antibiotic prescriptions for viral URIs were low (that's good!), patients identified as non Hispanic white were prescribed antibiotics, despite guidelines advising against them,  at a higher rate than non white patients (that's bad).  It also found that in areas of socioeconomic deprivation, the prescribing rates were lower across all races than in more affluent areas (that's good and bad!)

Show References

Participation in meetings is an expected part of most (if not all) of our jobs.  How many of these meetings are necessary?  Could some of the “work” of meetings be accomplished with a few emails or other asynchronous forms of communication?  Are meetings cluttering your schedule and making it impossible to get any real work done?

Some answers to these questions are offered in a Harvard Business Review article from March 2022.  

Key points include:

• 70% of all meetings keep employees from working and completing all their tasks.
• Ineffective meetings that waste our time can negatively impact psychological, physical, and mental wellbeing.

Advantages to fewer meetings:

• Productivity was 71% higher when meetings were reduced by 40%.
• Employees feel empowered and more autonomous, increasing their job satisfaction by 52%.
• Removing 60% of meetings increased cooperation by 55%.

Authors recommend holding meetings only when “absolutely” necessary. That typically includes:

• To review work that’s occurred (what worked or didn’t and why)
• To clarify and validate something (policies, team goals, etc.)
• To distribute work appropriately among your team

Show References

Early administration of antibiotics for open fractures can reduce serious bone and soft tissue infections, with a common goal being antibiotic administration within one hour of injury.

In this study, there were 523 patients treated by EMS who had an open extremity fracture.

The median time from EMS dispatch until antibiotic administration was 31 minutes.  99% of the patients who received antibiotics received them within one hour of EMS dispatch.  Prehospital times were on average 10 minutes longer for those patients who received antibiotics.  The majority of these patients received cefazolin, followed by ceftriaxone, ampicillin, gentamicin and piperacillin/tazobactam.  None of these patients required management for an allergic reaction or anaphylaxis.  Five patients (1%) who received prehospital antibiotics and 159 patients who did not (1.4%) had a subsequent infection based on ICD codes.

Bottom line: In this small group, it was safe to administer antibiotics to a patient with an isolated open extremity fracture and the medication was able to be delivered earlier.  Larger studies will be needed to see the impact of this practice on the development of osteomyelitis or soft tissue infections.

Show References

“Administrative harm” (defined as “the adverse consequences of administrative decisions within health care”) is a relatively new term for challenges that arise in complex health care work environments. 

41 mostly hospitalists participating in interviews and focus groups found that the concept resonated, and that administrative harms could arise at all levels of leadership, negatively impacted both workforce and patients, were challenging to measure, and pointed to a lack of leadership responsibility and accountability. The group also suggested many approaches and solutions for prevention.

The article is here, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2820266. If interested, take a look at the thematic tables 2 and 3.

There is a brief editorial comment here, https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2820275.

Author:

Gabriella Miller (She/Her)

Clinical Instructor

Department of Emergency Medicine

University of Maryland School of Medicine

Doxycycline PEP for the prevention of bacterial STIs.

The CDC now recommends “doxy PEP” for high-risk individuals. Doxycycline post-exposure prophylaxis (doxy PEP) is a prescription for patients to self-administer 200 mg doxycycline by mouth within 72 hours after anal, oral, or vaginal sex to prevent the transmission of chlamydia, gonorrhea, and syphilis. The CDC defines “high-risk” as men who have sex with men (MSM) and transgender women (TGW) who have been diagnosed with a bacterial STI within the past 12 months. They summarize the findings of the French IPERGAY and ANRS DOXYVAC studies, as well as the US DoxyPEP study, which all show promising reductions in risk ratios or hazard ratios of decreasing bacterial STI transmission on high-risk populations, including those who are taking PrEP for HIV. No significant adverse events related to doxy PEP have been reported.

Conclusion:

Counsel patients at high risk for bacterial STIs regarding the prescription of doxy-PEP for patient self-administration within 72 hours after sex.

Show References

This article shows us that even things we think of as objective measures in medicine may actually perpetuate systemic biases.  

The study evaluated controlled hypoxemia in a group of volunteers.  Traditional pulse ox devices measured falsely elevated pulse ox readings in participants with dark skin pigmentation and low tissue perfusion.  It suggested different types of devices that may have improved accuracy in patients with darker skin pigmentation, but the underlying problem still exists.

Bottom line, this goes to prove what we have taught, never rely on a single value to reassure yourself of the patient's status, always take into account the bigger picture.

Show References

Do you have a patient with a finger injury or infection, or possibly a retained foreign body?

Try placing the hand in a water bath and use a linear ultrasound probe for evaluation. If there is an open wound, use a sterile ultrasound probe cover.

With ultrasound guidance, you can observe dynamic finger movements and identify areas that may require abscess drainage.

There is a growing trend toward the development of specialty-specific emergency services, such as Geriatric or Oncologic EDs.

• Supporters of this trend argue that:
  • They provide better care at lower cost.
  • They reduce the overall burden of patients in the general ED.
  • They prevent hospitalizations and improve discharge rates due to specialty services and outpatient resources not otherwise available in the general ED (especially with complex patient populations like geriatrics or oncology).
  • They streamline care for vulnerable populations and decrease ED LOS.
• On the other hand:
  • Their establishment requires a substantial financial investment.
  • Patients are less likely to use them because they don’t know that they exist.
  • One of the largest studies of Geriatric EDs in the country did not show significantly different discharge rates or 72-hour revisit rates when compared with general EDs.

Will this trend continue? Is the segmentation of emergency care in our future?  The author of this article opines that the answer depends on future outcomes research in this area.

Show References

This retrospective study looked at patients diagnosed with urinary tract infections receiving an IV dose of antibiotics  prior to discharge and compared ED length of stay and return visit rate. They found:

“Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours”

Appears no benefit to the practice of IV antibiotics prior to discharge in UTI patients.

Show References

BACKGROUND:
Prehospital administration of whole blood involves some areas of controversy. Though theoretical benefits are clear, concerns about logistics and timing of blood often dominates the discussion. This study was a retrospective analysis of prehospital blood administration within an urban EMS system from 2021-2023. Primary endpoints included: time to administration and in hospital mortality. 

PATIENTS/METHODS:
The study population included patients presenting to the EMS system with signs and symptoms of hemorrhagic shock (SBP<70 or SBP<90 + HR> 100, n=61) and who received at least 1 unit of prehospital blood (PHB).  The EMS system administered blood in conjunction with an advanced resuscitative bundle (calcium, TXA, blood). Isolated head injuries and blunt trauma patients were excluded from the analysis.  The control group (n=82) was comprised of patients in the system's trauma registry presenting to EMS PRIOR to the initiation of whole blood and who exhibited similar clinical crtieria. 

RESULTS:

• PHB patients had significantly higher BP upon arrival to hospital
• Following multivariate regression analysis, each minute delay to blood administration was linked to an independent increase in mortality of 11%
• PHB group demonstrated lower in hospital mortality 
• PHB group linked to longer prehospital time interval (increased scene times) 

BOTTOM LINE:
In this prospective study conducted within an urban EMS system, patients receiving prehospital whole blood demonstrated improved vital signs and reduced mortality when compared to a control group. Slightly extended prehospital time intervals for patients receiving PHB may be offset by the measured benefits of whole blood therapy.

Show References

Emergency Medicine staffing groups can be organized in any number of ways. Here’s Leon Adelman’s take:

• There are EDs staffed by non-physician-owned corporations. The two largest of these are Teamhealth and the restructured Envision, owned by Blackstone and a consortium of investors, respectively.
• Then there are physician-owned groups. The largest of these is USACS, but these range in size from staffing for a single ED to USACS’ 297 EDs.
• A third of EDs are staffed directly by health systems, think Medstar locally. This is probably also the category Edelman uses for academic centers, though physicians may be employed by a separate faculty practice or by the medical school instead of the hospital.

Read more at https://emworkforce.substack.com/p/state-of-the-us-emergency-medicine-677. Read closely and you’ll find a reference to Maryland.

Do microaggressions and discrimination impact the patient experience in your ED?  How can we address this?

This article is one of few studies to address this topic specifically in the ED. Authors used quantitative (discrimination scale) and qualitative (follow-up interviews) methods to answer this question in two urban academic EDs.  

Common themes from patient responses provide food for thought and action in this regard:

• Clinician behaviors: Positive behaviors included frequent communication, reassurance, privacy, respect, and validation of concerns. Empathy and eye contact were also mentioned.
• Healthcare team actions: Positive interactions with clinicians reassured confidence in the emergency care visit and willingness to return for future health care.
• Environmental pressures in the ED: Participants often noted long wait times and busy staff when describing negative ED experiences.
• Hesitancy to Complain: Patients were hesitant to identify staff members, did not feel that the complaint would be acted on, and worried that their medical care would suffer if they brought up their concerns.

Show References

This study is out of the American University of Beirut, Lebanon, and courtesy of our own Mazen El Sayed!

Many patients of Muslim faith will observe fasting during the month of Ramadan, with no food, water, oral of IV medication taken from sunrise to sunset

This study showed a lower daily ED volume than during non Ramadan months, however did show a higher length of stay during Ramadan.

It also found an increase in mortality rates during Ramadan (OR 2.88) and 72 hour ED bounce-backs (OR 1.34)

Be sensitive and aware of the needs of your patients of Muslim faith during this holy month of fasting.

Ramadan Kareem

Show References

The relationship between an Emergency Physician and the hiring group (whether large or small) may be one of employer-employee or contactor-independent contractor. There are legal job protections for employees that don’t exist for independent contractors. There are also regulations that define an independent contractor. Enforcement of these regulations varies but may be increasing. This has implications for the Emergency Medicine job market. We have the highest percentage of independent contractors of any medical specialty. 

See more at Leon Adelman’s Emergency Medicine Workforce Newsletter, here https://emworkforce.substack.com/p/thousands-of-employed-emergency-physicians

This research letter notes: “The Rural Emergency Hospital is a new Medicare payment model available to hospitals with 50 or fewer beds in rural areas. Rural hospitals converting to this model will have emergency department (ED), observation, and outpatient services.”. Their study concludes that the majority of these hospitals already transfer the vast majority of their admissions to larger hospitals and this designation is a recognition of already established practices.

Show References

These authors performed a scoping review of English language studies involving United States general surgery patients that required transfer to another facility looking at timing of transfer, triage guidelines, and mode of transport . They concluded: “There were mixed results for the impact of transfer timing on outcomes with heterogeneous definitions of delay and populations. Triage guidelines for EGS transfer were consensus or expert opinion. No studies were identified addressing the mode of interfacility EGS transfer.”  More research is needed in the area concerning timing, triage and mode of transport for these patients.

Show References

Approximately half of all Medicare beneficiaries are now enrolled in Medicare Advantage plans. Why does this matter?

• Traditional insurers (for example, United & Blue Cross) run Medicare Advantage (MA) plans. The federal government pays the insurers. This is different from Traditional Medicare which the Federal Government both funds and runs.
• MA plans may include prescription drug, vision, and dental care. They also often include out-of-pocket caps.
• MA plans may limit flexibility in provider choice with in-network and out-of-network provisions.
• So far, MA costs the federal government more than traditional Medicare.

Intrigued? Learn more at https://www.nejm.org/doi/full/10.1056/NEJMhpr2302315 or https://www.kff.org/medicare/issue-brief/medicare-advantage-2024-spotlight-first-look/.