Archive for category ED Management
Sandra Schneider, MD, FACEP, ACEP Past President
I would like to personally invite you to become a member of the Emergency Medicine Practice Research Network – EM-PRN. Becoming a member is simple; just click on this link and answer a brief survey. It will take less than five minutes. We want to know if you are seeing patients with chronic pain, we want to know if you are experiencing medication shortages and how you are coping. We want to know how you practice. YOUR ANSWERS will provide ACEP with essential information for our advocacy in Washington and improving emergency care. To stay a member, all you need TO DO is to agree that you will complete 3-4 surveys, five minutes or less, each year.
Membership at this time is only open to ACEP members, residents, attendings and life members. Sorry, we cannot as yet accommodate non-members or medical students. Many other specialities have built practice research networks. Pediatrics has had one for more than a decade. They started small, like us. They have found that getting data from physicians on the front lines is often very different than getting it from inner city, teaching hospitals. Once you join EM-PRN, you will be able to do much more than just give opinions to survey questions. We want to submit ideas for research projects and survey questions that YOU would be interested in. Our group will pick the more interesting and the most popular IDEAS for the next survey. So you not only will be providing answers, you’ll be designing the questions.
Right now and for the next few years, EM-PRN will be largely surveys. Eventually, we will likely want to grow to collect some data. For example, IN THE FUTURE we might want to monitor the number of patients seen with chronic pain in emergency departments. You would simply count the actual number of patients you see during a single shift (no names, no identifiers) and submit it to ACEP.
We could then monitor this number over time to see if it is increasing, decreasing or staying the same. The members of EM-PRN will help direct what research projects we consider and will be acknowledged on any publication. Members will also receive the results of any project ahead of publication. So in the time it has taken you to read this Blog, YOU could contribute to advancing our knowledge of the real practice of emergency medicine. Join now.
This is Part 2, outlining suggested strategies (dos and don’ts) for providers of emergency care who want to prepare for value based purchasing under health reform. It is primarily aimed at emergency physicians and other hospital-based providers, but also applies to specialists providing on-call backup services to ER patients.
• Don”t assume that because your hospital’s business model is predicated on exploiting the fee-for-service payment system, and avoiding at all costs going ‘at risk’ for the care of managed care enrollees; you should avoid talking to your hospital CEO about future payment models predicated on value based purchasing of hospital and physician services. They all know it’s coming, and they will appreciate that you are thinking about it as well.
Do consider doing your homework, reading up on VBP and payment reform and how it may affect hospital-based providers, and anticipating how you and your group will respond when your hospital begins to align its business model (and its medical staff) to the new reimbursement paradigm.
• Don’t expect to be carved out of bundled payments, utilization risk-pools, and other incentive programs to constrain costs, just because you provide non-elective services. Once payers get a handle on how to bundle payments for more predictable services like knee replacements and cholecystectomys, they will then begin to target episodic unscheduled care for strokes, MIs, and even acute abdominal pain.
Do prepare for these payment reform eventualities by tackling one of the thorniest problems emergency care providers face in the ‘open practice’ of the ED – attribution. Whatever system you use to order up tests, treatments, and services in the ED, you need to be able to identify, and track, whose decision it was to spend that money, and provide that care.
• Don’t assume that, just because your hospital is not involved in an integrated provider network, the CFO isn’t concerned about resource utilization. Just about every hospital depends upon the provision of cost-effective care in order to profit from services to seniors on Medicare, which is paid on a DRG basis.
Do begin, if you haven’t already, to address your approach to the care of the elderly in your department, with particular emphasis on co-ordination of care, reducing re-admissions, communicating with nursing homes, facilitating review of complex medical records during the evaluation phase of care, and other strategies for reducing unnecessary utilization and improving the efficiency of care.
• Don’t wait for health plans or hospital medical directors to tell you how to spend less and give more and better care. They don’t know your patients, your department, or your business as well as you do, and they will likely be less willing to invest in your success than you are.
Do consider developing some strategies for cost-effective care for current or future implementation, so that when you are asked to participate in shared savings programs and other incentives to provide quality care at less cost, you and your hospital can both profit from the opportunity.
Again, If any of you have additional do and don’t suggestions, please comment through the link below. The Fickle Finger
Boondoggle – a scheme that wastes time and money. Perhaps this is not the best way to describe the many efforts that are being made to try to keep patients with non-urgent problems from using the emergency department, but from where I sit, deferral of ED care is a cost-saving tactic that not only fails to deliver much in the way of cost savings, it also is a strategy that can be both risky and unethical. More importantly, the focus on deferral of care and ‘unnecessary ED visits’ as a cost-containment tactic is a distraction from efforts that would yield far more savings at far less risk to patients, and to our fragile emergency care safety net.
Recently, I worked with one of the major health plans to look at over 637,000 consecutive commercial and Medicaid California ED patient visits over a one-year period (excluding ED patients who were admitted to the hospital). Based on the data below, it is clear that those 20% of patient visits that represented the least costly visits (facility plus professional ‘allowable payments’) accounted for less than 4% of the total cost for all non-admitted ED patient visits.
Rank Total Allowed % of Total Allowed
1 $520,314,096 54%
2 $195,156,385 20%
3 $129,376,962 13%
4 $84,949,393 9%
5 $33,929,559 4%
Remember, this data just represents patients who were not admitted (facility costs for ED care of admitted patients are bundled into inpatient payments). Thus, it is likely that the bottom 20% of admitted, discharged, and transferred ED patient visits likely represented between 2 and 3% of the total cost of care for all ED visits. ACEP has been saying for a while now that (depending on the source of the data) ED care accounts for around 2% of the $2.4 trillion spent on all health care costs. Now the estimates of the percentage of ED patients who ‘don’t need to be there’ or have ‘non-urgent’ or ‘non-emergency’ problems is a bit more wide-ranging, depending on the agenda of the estimator; and numbers as low as 10% and as high as 50% get thrown around all the time. The Rand Corporation put the number at 17%, the CDC at 8%, and HCA Gulf Coast Hospitals put the number at 40% !!! Clearly, no one seems to be able to define this group in a standardized way, but it is clear that as the poster child for unnecessary and expensive care, the ED has become the target of many attempts to reduce costs by keeping patients out of the ED, or sending them away, based on screening criteria that may, or may not, meet EMTALA standards. Much has been written about the down-sides of the deferral of ED care strategy, and ACEP has a policy that opposes deferral of care, especially when it is not accompanied by adequate access to alternative care venues and carefully designed programs to arrange for timely and appropriate care for those whose care in the ED is deferred. Most ED physicians agree that the way to reduce unnecessary visits to the ED is by improving access for non-urgent care in clinics and primary care offices. However, my issue with all the hubbub about cost-containment through deferral (or denial) of ED care goes beyond the ethical and risk issues: it simply is not a cost-effective strategy.
Let’s assume that it is possible to accurately identify and screen the patients that do not need ED care without missing the patients who really do have an impending medical emergency in the early stages of presentation, and that we could reasonably eliminate the 20% of ED visits that use the least amount of ED resources. I don’t actually believe this is possible, but let’s make this assumption. If it were, we could reduce the US health care budget by something like 3% x 2%, or 0.06%. But wait- surely some money would have to be spent caring for most of these patients in the clinic or PCP’s office. So perhaps the actual savings from deferral of ED care might amount to 0.05% of the health care budget (50 cents for every $1,000). Probably, the number is even lower. Yes, I know, it is real money, but in relative terms, they call this ‘budget dust’.
The study on ED visits in CA that I mentioned above also looked at costs by procedure and costs by diagnosis for those 637,000 patients. I was surprised to learn that renal and ureteral stones accounted for $25 million of the $963 million spent on all these patients. So, roughly, the same amount of money was spent taking care of 7,900 patients with kidney stones as was spent on taking care of the 127,000 patients who might have qualified for deferral of ED care. In fact, the data from the Anthem study suggested that we could save as much money by reducing the number of CT scans done in the ED by 1 out of 12 scans as we could by barring the door of the ED to every single one of the 127,000 patients in this study who accounted for the lowest 20% of ED costs. My point is that all sorts of legislators and health plan executives and government regulators are screaming about, and scheming about, reducing unnecessary ED visits, and distracting us all from focusing on where the real money gets spent, and the real savings could be achieved. You want to talk about saving health care dollars: let’s look at back surgery, depression, end of life care, obesity. But no, the focus of TENCare and HCA and the Dr. Thompson’s in Washington State and elsewhere is on the ‘imprudent’ parent who takes their screaming, vomiting, febrile 2 year old child into the ED at 3 AM, only to be diagnosed with a lowly ear infection. And to top it off, the solution to this problem that many Medicaid program directors and legislators have lit upon, the best way to keep these patients out of the ED, is simply to decide, after the fact, not to pay the ED physician for having provided this care. Yep, that makes a lot of sense.
Dr. Centor is at it again, with more bashing of the Emergency Department, this time because we order too many CTs. He cites this great study, by my friends/colleagues Jarone and Jonathan at my own institution, showing that CT imaging has risen in our own ED over time. And why has use of CT gone up? According to Dr. Centor, an academic hospitalist, it’s due to (his words, not mine):
- Emergency physicians practice in the “fog of war”.
- It appears that too often CT scanning takes the place of a careful history and physical examination. This can occur when the emergency physician is drowning in patients.
- I believe that emergency physicians need more inpatient experiences to better understand the natural history of disease.
Okay, first, Fog of War. I like this. I agree. We are, I’d argue, the only physicians who are really comfortable managing the acutely ill undifferentiated patient. You never know which way a case is going to go, you never know what the labs are going to show, so you make sure you have that 2nd line, and you change your pathway as things develop. The Fog of War is lifted once you get your workup done (that’s called hindsight bias).
But these two other points? Wowzers. Just so everyone knows–Emergency Physicians actually do go to the same medical schools as Internists, before we get turned to the dark side. We learn how to take a history and physical–really, we do! Despite what my colleagues may think, I am not a scan-ordering, button-pushing monkey.* I actually care deeply about radiation risk–and do not scan when I think it’s safe not to–and it’s a little offensive to assume that I simply scan because it’s easier. Yes, it’s really difficult when it’s busy. But just because a patient has, say, chest pain, and it’s busy, that doesn’t mean I just start CTing willy-nilly. Just because it’s busy and you have a headache, you still get evaluated for your type of headache; if I’m not worried about mass, subarachnoid, bleed, or tumor–you get my regular headache meds, not a scan. (The scan doesn’t fix the headache!)
Here’s a sampling of the patients I’ve CT’d recently:
- Seizing AIDS patient
- Elderly woman on coumadin, minor head injury, GCS 15, neuro exam normal
- 3rd-visit bounceback with back pain radiating to the right lower quadrant, tender to palpation, vomiting, no prior CT
- New onset facial droop 1 hour ago
- Demented man with a head injury, two sycopal episodes with head injury
- 75 year-old lady with a good story for kidney stones and a family history of them, but never had them before
And a few who I haven’t:
- Hypotensive guy who I resuscitated, had been complaining of epigastric abdominal pain, but never tender on exam. (I instead performed my own bedside ultrasound of his gallbladder, aorta, heart, IVC, and FAST exam.)
- 24 year-old woman with on-and-off tension headaches associated with stress and her cigarette smoking, who wanted one “just to be sure”
- 23 year-old guy with a classic story for kidney stones and blood in his urine
It’s funny that Dr. Centor would want me to have more internal medicine training; he states that “In the late 70s I spent a couple of years working in emergency rooms,” which, I gotta say, would make me argue that he needs more recent Emergency Medicine training, not the other way around. Sounds like he has no idea how EPs practice, besides knowing there’s a lot of crowding in our departments. I’d love to hear how more internal medicine training would make me image less as an Emergency Physician.
Some thoughts on CT: Just like the fog of war, hindsight bias is 20/20. When that CT comes back negative, and you have to continue your hunt, then it’s really easy to say “Wow, the dumb ER doctor scanned another patient for no reason.” (The patients with the head bleeds don’t go to medicine, they go to neurosurgery, that’s why medicine teams see patients with negative head CTs all the time. Selection bias.)
CT changes disposition frequently–and frequently from “admit” to “discharge.” CT takes many-a-patient who, in the 70s, when Dr. Centor was practicing in the ED, would have been admitted for observation or more testing, and allows us to safely discharge a patient. The tender belly now gets a CT instead of serial abdominal exams; the patient on coumadin with a fall gets a CT instead of serial neuro exams and close observation; the trauma patient gets their liver laceration visualized and gets serial hematocrits in the SICU instead of being taken to the operating room. Or the stable patient with a penetrating neck injury, who gets a CT angiogram instead of an angiogram, EGD, bronchoscopy, barium swallow, and SICU admission. Inpatient teams don’t frequently see these benefits, because we frequently discharge the patients who would have otherwise been admitted. Again, selection bias.
Finally, I actually find that it’s the inpatient medicine teams and consulting services that won’t see or accept a patient on their service without a CT. They want the patient completely tucked away; they want the diagnostics completed before admission; they want all the answers when we don’t even have them, either. Some examples:
- Ortho patients with comminuted fractures: CT for “pre-op planning”
- Mid-face cellulitis patients with a small amount of fluctuance, ENT Consult doesn’t want a CT: medicine asks “What’s the CT show? Why didn’t you CT them yet?”
- Short of breath patient, I don’t think it’s a PE: Medicine asks, “Can you just do a CTA of their chest before they go upstairs?”
- Kids with chronic nosebleeds, per ENT: “Can you CT them and we’ll follow-up in clinic? We don’t need to see the patient today.”
- Altered, blown pupil, per Neurosurgery: “We’ll come down after we review the CT.”
- Urology, on kidney stones: “How big is the stone on CT? Where is it? Can you re-CT them, their stent may have migrated.”
- Neurology, acute onset stroke patient: “Are they at CT yet?”
- Surgery, 22 year-old female, great story for appendicitis, but without peritonitis: “It might be gyn-related, not appendicitis.”
Similarly, many more patients are coming through the Emergency Department now than before, frequently referred by another service. While yes, the patient is getting the CT in the Emergency Department, it’s due to a request from another service.
If anyone (including Dr. Centor) could diagnose these patients with just a “careful history and physical,” or if anyone would be willing to take the above patients on their service without some sort of imaging–please, come work here! We’d love to have you! But my guess is that no one would touch them with a 10-foot pole.
* Funny enough, we had a medicine resident rotate with us for a month, and at the end of the month, she told us, “Wow, you guys have a really physically exhausting job. Before this, my entire time on the wards, I thought you guys just sat at the computer and ordered tests and checked your email. But now I realize the reason I always saw you at the computer is because you were giving me signout while I was sitting there.”
Update: Dr. Centor responds.
In The Hitchhiker’s Guide to the Galaxy, the Babel Fish was a fish you stuck in your ear that allowed you to understand any language spoken to you. We’re not far off.
Google just yesterday released a new version of their (free!) Google Translate app for Android phones, featuring conversation mode, which allows you to have a back and forth conversation with someone who speaks another language (currently just English/Spanish is supported). Translation companies should be shaking in their boots.
I created a quick little demo below, on how you could actually use this (or a future version) in your clinical practice. It’s pretty incredible. (Also, a quick shout out to the web version of Google Translate, which will allow to translate any text or website into your native language (not just English/Spanish). Very useful for typing up basic discharge instructions for languages with which you’re not familiar.)
Or a forensic examiner? Got into a little debate with one of our trauma surgeons about the cause of cardiac arrest in a patient with a gunshot wound to the head. I said they respiratory arrest from herniation and this causes a hypoxemic cardiac arrest: ie, destroying the brain doesn’t make the heart stop beating. Would love to get a medical examiner’s perspective, if you know of one. Thanks!
It’s funny how you can walk into a room, think you have a pretty clear history of what’s going on with the patient, and 30 minutes later your attending comes up saying, “No, he’s telling me it was crushing substernal chest pain with trouble breathing, NOT 2 seconds of pain when he moves his left arm.” Yessirree Bob, the attending effect is real: but I’d like to challenge its origin.
First, some disclaimers: some patients are, simply, crazy. (And I’m not talking psychiatrically crazy, I’m talking dramatic, emotional, over-the-top, and hard to pin down on a clear story. Okay, maybe psychiatrically Axis 2.) And some doctors are, simply, bad listeners. They will never get a good history, because they don’t know what questions to ask, or how to ask them, or how to tease out the important parts of the story from the rest. But besides these caveats, I’d like to hypothesize this: the attending effect is primarily due to pain, or prompting.
Pain’s an easy one. We see this all the time. You have a patient in pain, or nauseous, or angry, or — in any way, emotional — and you might as well kiss most of your history-taking goodbye for the time being. This is no Mt. Everest for us in the ED. This is just how it goes. You get a little story, you treat the pain, you start your workup, you go back once the morphine’s kicked in, and you get some more story. The more calm and rational the patient is able to be, the better history you’re going to get. I find this to be the case all the time when I’m admitting patients: the history of present illness I’ve initially written has evolved over the course of the stay. I’d like to also posit that this is why the medicine resident comes down and thinks I’m an idiot: the story they get from the patient sounds nothing like the one I documented in the chart. (Other possibility: I am actually an idiot.)
“Prompting” is the other big cause (in psychology, they call it “priming“): when you do the initial history and ask the initial questions, the patient may not remember every detail of his or her history. You zip in, get your story, do your exam, zip out, and start writing your orders, while the patient in the mean time has a chance for those questions you’ve asked to simmer a bit in their cranial Crock Pot. Case in point: 28 year-old guy in the ED last night with urinary obstruction. Said he’s never had an STD that might predispose him to this. Urology comes in after multiple failed attempts to Coudé the poor guy, and he freely acknowledges having chlamydia a few years back. So thank you, Urology, for the consult, but I swear we’re not lying: we just primed his brain to remember!
So there’s no reason to be ashamed if you get a different history from someone else — especially if their history comes later than yours.
That is, of course, unless you’re an Axis 2, crazy, dramatic, bad-listening doctor.
The iPhone Alarm Bug has been decimating our department for the past few days — anyone else? Attendings who say they’ve never been late once in “20 years” are oversleeping now, on two consecutive shifts!
There’s a lot of things to like about being an Emergency Physician: the hours, the healthy sarcasm and joke-cracking during a shift, acute pathology, procedures, helping patients; and there’s a lot of things to dislike about being an Emergency Physician, too (you can name your own).
But there’s one thing medically that I can’t stand more than anything else: the NG lavage for upper (or “undifferentiated”) GI bleeds. To me, there’s really no worse test, and here are my reasons:
- It’s a poor screening test. We’re looking for the presence of blood in the stomach. Screening tests should have a high sensitivity, since you want to rule-out disease. And NG lavage simply doesn’t. It has tons of false negatives and tons of false positives.
- It’s brutal. The adage is that we do no other procedure without sedation that is more uncomfortable than the NG tube placement.
- It doesn’t change my management or practice. I find that if patients are continuing to have an active upper GI bleed, I know it by looking at them and their vital signs. They are persistently tachycardic. They are diaphoretic. They pass large clots or melenic stool. They vomit bright red blood or coffee grounds.
Similarly, if a stable, well-appearing patient is pooping bright red blood, odds are it’s probably a lower GI bleed. Have I seen a massive upper GI bleed present as just lower GI bleeding? Yes, in an unstable, tachycardic, hypotensive demented 85 year old woman.
I’m hoping I’m not the only one here who feels this way–but I wonder what’s the bee in the bonnet for everyone else? The CT/LP for subarachnoid? New left bundles with no prior EKG? Renal failure who desperately really needs a CT scan? Looking forward to your thoughts on the NG tube or any other acronym that drives you
to drink mad during a shift.
You know, I like the new New England Journal of Medicine web design, but some of their recent EM-related reviews and summaries have driven me crazy.
Let’s start with Acute Pulmonary Embolism, which I view as a pretty good emergency medicine topic. We’re obviously not the only physicians who evaluate patients for pulmonary embolism, but we’re pretty much the only ones that evaluate outpatients for them. Maybe it’s just specialty pride (and lack of understanding of the Italian health care system), but it seems strange to have a review on “Acute Pulmonary Embolism” written by physicians who hail from the “Internal and Cardiovascular Medicine and Stroke Unit” in Italy. (Especially when Harvard itself has its own PE expert, Chris Kabrhel.)
A couple things rub me the wrong way (and luckily, the comments to the journal say similar things):
- There’s no mention of the PERC rule. The authors presume anyone who is short of breath without any other identifiable cause should get a D-Dimer, which, based on the number of short of breath patients I have, would increase my CT angiograms exponentially. (In a patient with pre-test probability less than 15%, the PERC can get your patient down to a <2% risk of PE.)
- It’s surprising to me that there’s discussion of the data on thrombolysis and thrombectomy but that no high-quality data exists in favor of anticoagulation. Sure, there’s ethical issues (“it’s the standard of care”), but I think it’s at least worth mentioning.
- Finally, fondaparinux is thrown into the treatment mix prominently (“subcutaneous low-molecular-weight heparin or fondaparinux or intravenous unfractionated heparin”) and I’m not completely sure why. Perhaps it’s used much more in Europe than in the US (I have never ordered it here in my community hospital in New York). Also concerning is the fact that the lead author, Giancarlo Agnelli, was both advisor/consultant and member of the Speaker’s Bureau of GlaxoSmithKline, maker of fondaparinux. This is not mentioned in his disclosures.
Next up is Emergency Treatment of Asthma, which, even more than PE, is the bread and butter of Emergency Medicine. Again, it’s not written by an emergency physician, but by Dr. Lazarus from UCSF’s Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute. Just seems a bit strange that “Emergency Treatment of Asthma” is written by a pulmonologist, when their population bias is probably either the intubated asthmatic or the outpatient asthmatic, but not the range of “acute asthma” we see in the ED.
- First is FEV1/peak flow. I know some of my colleagues like to use this for their asthmatics, but I personally don’t. I find that I can typically see which way my asthmatics are going just by listening to them, looking at them, and speaking to them. That is: clinically.
- Second is the workup:
Laboratory and imaging studies should be performed selectively, to assess patients for impending respiratory failure (e.g., by measuring the partial pressure of arterial carbon dioxide [PaCO2]), suspected pneumonia (e.g., by obtaining a complete blood count or a chest radiograph), or certain coexisting conditions such as heart disease (e.g., by obtaining an electrocardiogram).
Where to start: who is still getting ABGs on these patients for hypercapnia? Obviously in the intubated asthmatic, or the asthmatic who looks like they’re tiring out or getting sleepy, but an arterial stick is nowhere near my list of priorities for a tight asthmatic. Next up: the chest x-ray. I typically only get it when the patient is not improving (“maybe it’s not asthma”) or the story is concerning for pneumonia. I won’t even mention getting a CBC to evaluate for suspected pneumonia.)
- I can’t even believe this is really in the table in the New England Journal of Medicine, but it actually suggests that we should be measuring for pulsus paradoxicus to determine who’s a severe asthmatic. If someone could explain this to me, I’d really like to understand its usefulness.
- I’m also unsure as to why inhaled steroids are recommended in this article, when the Cochrane Review did not find any benefit to these (and the Cochrane review includes the cited paper).
- Next, the paper recommends reassessing the patient after an hour of treatment. In my severe asthmatics, this would get many of them intubated.
- Finally, IV magnesium is discussed as an area of uncertainty, but I will typically give it to any severe asthmatic. In subgroup analysis of severe asthmatics, it was beneficial at preventing admission. I find I’m typically throwing the kitchen sink at the bad asthmatic (including BiPAP, occasionally terbutaline) to prevent them from getting intubated.
In summary: New England Journal of Medicine: either cover the diseases emergency physicians see adequately, or I’ll just keep reading our own journals instead.