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Ge Bai Gabor D. Kelen Kevin D. Frick Gerard F. Anderson 《The American journal of emergency medicine》2019,37(5):928-932
Objective
As nurse practitioners (NPs) and physician assistants (PAs) become an integral part of delivering emergency medical services, we examined the involvement of NPs and PAs who billed independently in emergency departments (EDs).Methods
We used Medicare provider utilization and payment data from 2012 to 2016 to conduct a retrospective analysis. We examined the changes in the number of each clinician type who billed independently for four common emergency services (CPT codes: 99282-5), the change in their service volume, and the change in their average number of services billed.Results
Between 2012 and 2016, the proportion of NPs and PAs billing independently increased from 18% to 22% for ED visits of low severity (99282), 23% to 29% for visits with moderate severity (99283), 21% to 27% for visits with high severity (99284), 18% to 24% for visit with the highest severity (99285), and 23% to 29% across all four services. The proportion of services provided by emergency physicians decreased from 66% to 63% across all four services, and from 11% to 9% for internists and family physicians. The number of NPs, PAs billing independently, and emergency physicians increased by 65%, 35% and 12% respectively.Conclusions
NPs and PAs are increasingly billing emergency services of all levels of severity, independent of physicians. This trend is driven by a growing number of NPs and PAs independently billing services, despite a relatively stable number of emergency physicians (excepting the decline in rural areas), and diminished involvement of family physicians and internists in EDs. 相似文献3.
Zlata K. Vlodaver Jeffrey P. Anderson Brittney E. Brown Michael D. Zwank 《The American journal of emergency medicine》2019,37(3):478-481
Background
We seek to determine if experienced emergency medicine physicians can accurately predict the likelihood of admission for patients at the time of triage. Such predictions, if proven to be accurate, could decrease the time spent in the ED for patients who will ultimately be admitted by hastening downstream workflow.Methods
This is a prospective cohort study of experienced physicians at a large urban hospital. Physicians were asked to predict the likelihood of admission for patients based only on information available in the EMR at the time of triage. Physicians also predicted the service to which the patients would be admitted. Physicians provided a confidence level of their prediction. Measures of predictive accuracy were calculated, including sensitivity, specificity, and area under the receiver operating characteristic curve.Results
35 physicians evaluated 398 patient charts and made predictions. Sensitivity of determining admission for the entire cohort was 51.8%. The specificity was 89.1%. For those predictions made with a confidence level of >90%, sensitivity was 61.5% and specificity was 95.7%. Among physicians correctly predicting admission, the admitting service was predicted accurately 88.6% of the time.Conclusion
Physicians performed poorly at predicting which patients would be admitted at the time of triage, even when they were confident in their predictions. Conversely, physicians accurately predicted who would be discharged. Physicians predicted with reasonable accuracy the service to which patients were ultimately admitted. More research and operational assessment needs to be performed to determine if these predictions can help improve ED efficiency. 相似文献4.
Ingrid Llovera Kirsten Loscalzo Jia Gao Timmy Li Martina Brave Lance Becker Isabel Barata 《The American journal of emergency medicine》2019,37(3):486-488
Objective
We studied the impact four new urgent care centers (UCCs) had on a hospital emergency department (ED) in terms of overall census and proportion of low acuity diagnoses from 2009 to 2016. We hypothesized that low acuity medical problems frequently seen in UCCs would decrease in the ED population. Since Medicaid was not accepted at these UCCs, we also studied the Medicaid vs non-Medicaid discharged populations to see if there were some differences related to access to urgent care.Methods
We conducted a retrospective review of computerized billing data. We included all patients from 2009 to 2016 who were seen in the ED. We used the Cochran-Armitage Trend Test to examine trends over time.Results
As hypothesized, the proportion of ED patients with a diagnosis of pharyngitis decreased significantly over this time period from 1% to 0.6% (p?<?0.0001). The rate of bronchitis in the total ED population also decreased significantly (0.5% to 0.13%, p?<?0.0001).When we looked at the discharged patients with and without Medicaid, we found that significantly more Medicaid than non-Medicaid patients presented with pharyngitis to the ED with an increasing trend from 2009 to 2016: OR?=?2.33, p?<?0.0001. The overall census of the ED rose over the period 2009 to 2016 (80,478 to 85,278/year). Overall admission rates decreased significantly: 36.9% to 34.5% (p?<?0.0001).Conclusion
With the introduction of four new urgent care centers (UCCs) within 5?miles of the hospital, the ED diagnoses of pharyngitis and bronchitis, two of the most common diagnoses seen in UCCs, decreased significantly. Significantly more Medicaid discharged patients presented to the ED with pharyngitis than in the non-Medicaid discharged group, likely because Medicaid patients had no access to UCCs. 相似文献5.
Catherine A. Marco Robert P. Wahl James D. Thomas Ramon W. Johnson O. John Ma Anne L. Harvey Earl J. Reisdorff 《The American journal of emergency medicine》2019,37(5):859-863
Objective
The ABEM ConCert Examination is a summative examination that ABEM-certified physicians are required to pass once in every 10-year cycle to maintain certification. This study was undertaken to identify practice settings of emergency physicians, and to determine if there was a difference in performance on the 2017 ConCert between physicians of differing practice types and settings.Methods
This was a mixed methods cross sectional-study, using a post-examination survey and test performance data. All physicians taking the 2017 ConCert Examination who completed three survey questions pertaining to practice type, practice locations, and teaching were included. These three questions address different aspects of academia: self-identification, an academic setting, and whether the physician teaches.Results
Among 2796 test administrations of the 2017 ConCert Examination, 2693 (96.3%) completed the three survey questions about practice environment. The majority (N?=?2054; 76.3%) self-identified as primarily being a community physician, 528 (19.6%) as academic, and 111 (4.1%) as other. The average ConCert Examination score for community physicians was 83.5 (95% CI, 83.3–83.8); the academic group was 84.8 (95% CI, 84.3–85.3); and the other group was 82.3 (95% CI, 81.1–83.6). After controlling for initial ability as measured by the Qualifying Examination score, there was no significant difference in performance between academic and community physicians (p?=?.10).Conclusions
Academic emergency physicians and community emergency physicians scored similarly on the ConCert. Working at a community teaching hospital was associated with higher examination performance. Teaching medical learners, especially non-emergency medicine residents, was also associated with better examination performance. 相似文献6.
Eung Nam Kim Min Joung Kim Je Sung You Hye Jung Shin In Cheol Park Sung Phil Chung Ji Hoon Kim 《The American journal of emergency medicine》2019,37(3):395-400
Background
Patients who cannot be stabilized at a lower-level emergency department (ED) should be transferred to an upper-level ED by emergency medical services. However, some patients are subsequently discharged after transfer without any intervention or admission, and this secondary overtriage (SO) wastes the limited resources of upper-level EDs. This study aimed to investigate whether an emergency transfer coordination center (ETCC) could reduce the risk of SO among patients who were transferred to a tertiary ED by emergency medical services.Methods
This retrospective observational study evaluated data from a prospective registry at an urban tertiary ED in Korea (January 2017 to May 2017). The exposure of interest was defined as ETCC approval prior to transfer and the primary outcome was SO. Univariate analyses were used to identify statistically significant variables, which were used for a multivariate logistic regression analysis to estimate the effects of ETCC approval on SO.Results
During the study period, 1270 patients were considered eligible for this study. A total of 291 transfers were approved by the center's ETCC, and the remaining patients were transferred without approval. Compared to cases without ETCC approval, cases with transfer after ETCC approval had a significantly lower risk of SO (odds ratio: 0.624, 95% confidence interval: 0.413–0.944).Conclusion
Transfers that were evaluated by an ETCC had a lower risk of SO, which may improve the appropriateness of transfer. Thus, tertiary EDs that have high proportions of transferred patients should have a transfer coordination system that is similar to an ETCC. 相似文献7.
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Jenna Garlock Leborah Lee Michaelia Cucci Lawrence A. Frazee Chanda Mullen 《The American journal of emergency medicine》2019,37(5):884-889
Background
In the ED, patients are treated empirically for suspected gonorrhea and/or chlamydia (GC). Limited studies have evaluated the treatment of sexually transmitted diseases (STDs) in conjunction with predictor variables. This study will allow providers to better identify patients with potential GC to streamline antibiotic treatment.Objectives
The primary objective was to determine the incidence of positive assay in patients that underwent GC screening. The secondary objectives included the proportion of patients assayed that received empiric therapy and the predictive value of risk factors to identify positive assays.Methods
This retrospective cohort study included adult patients who presented to the health-system EDs and underwent GC screening. Subjects were excluded if they were victims of sexual assault, left AMA or eloped.Results
A total of 490 assayed patients were included, of which 84 (17%) were found to be positive for GC assay. Of the 278 patients treated empirically, 74% had a negative assay. Of the entire sample (n?=?490), risk factors found to predict a positive assay (p?<?0.05) included male, women <25?years of age, concomitant bacterial vaginosis, pelvic inflammatory disease or trichomonas, penile discharge, inconsistent condom use, previous/coexisting STDs, and uninsured.Conclusions
Compared to previous reports, this study found a higher incidence of positive GC assays for patients with suspected infection. This is the first study to evaluate GC testing in both men and women in the ED, and risk factors not previously reported by the CDC were identified. 相似文献10.
Background
Online medical information has transformed the way patients obtain information.Purpose
The present study examined patients' informational needs and the patient- Healthcare Provider (HCP) relationship from the perceptions of both patients and HCP.Methods
The study was a cross-sectional study; data were collected in Israel from100 HCPs (nurses and physicians) and 184 e-patients.Findings
E-patients were comfortable sharing e-information with their HCP and expected them to consider the e-information in treatment decision-making. Physicians thought they provided more information than the patients considered that they received from them, while both nurses and patients were in agreement about their interactions. Patients thought that there was a higher concordance between the e-information and the information they received from the physician/nurse as compared to what physicians and nurses reported.Discussion and Conclusions
E-health information does not disrupt the patient-nurse/physician relationship. To promote compliance to treatment, it is important that HCPs consider information presented by patients when preparing the treatment plan. 相似文献11.
Cheryl Ross Cath Rogers Christine King 《Collegian (Royal College of Nursing, Australia)》2019,26(1):1-7
Background
Nursing workload remains an issue in current health care contexts. The use of quantitative methodologies, methods and tools to measure workload has not produced adequate data to inform workforce policy to resolve workforce concerns about workload.Objective
This study aimed to identify the influence of both culture and climate as factors in nursing workload.Methods
This research used an overall critical ethnographic methodology to investigate the real lifeworkload issues of nurses. Methods included fieldwork observations and informal discussions over a 3 year period and 11 in-depth interviews.Results
The study identifies the impact of safety mandates on nursing workload as an invisible phenomenon within current workload methodologies. Such mandates add to nursing roles and routines, and become a ‘taken-for-granted’ activity that is not always directly related to patient care, nor is a visible factor in workload measurement.Conclusion
Given that workload measurements are formulated on direct patient care activities, indirect and unrecognised activities may create additional nursing workload. 相似文献12.
Itay Zmora Yonit Wiener-Well Evan Avraham Alpert 《The American journal of emergency medicine》2019,37(5):1006.e5-1006.e7
Background
Purulent bacterial pericarditis is a rare and potentially fatal disease. The course may be fulminant, and the presentation may pose a diagnostic challenge.Case report
An otherwise healthy 75-year-old male was brought to the emergency department in a state of general deterioration, confusion, and shock. Bedside ultrasound showed a significant pericardial effusion. His condition quickly deteriorated and the resuscitation included emergent bedside pericardiocentesis. The drainage was purulent and later cultures grew out Streptococcus pneumoniae.Why should an emergency physician be aware of this?
Purulent pericarditis is extremely rare but should be considered in the patient with a fulminant infectious process (particularly pneumonia) and signs of pericardial effusion. Treatment should include appropriate antibiotics and early drainage. 相似文献13.
Jonathan D. Auten John H. Naheedy Nicole D. Hurst Andrew T. Pennock Kathryn A. Hollenbach John T. Kanegaye 《The American journal of emergency medicine》2019,37(5):832-838
Objective
Emergency department (ED) reduction of pediatric fractures occurs most commonly in the forearm and can be challenging if fluoroscopy is not available. We sought to assess the ability of point of-care ultrasonography (POCUS) to predict adequacy of reduction by fluoroscopy.Methods
We prospectively enrolled ED patients 0–17?years of age with radial and/or ulnar fractures requiring reduction under fluoroscopic guidance. Post-reduction POCUS (probe dorsal, volar, and coronal) and fluoroscopic (AP and lateral) fracture images were recorded. Fracture angles were compared between blinded POCUS and fluoroscopic measurements and between POCUS measurements by a blinded emergency physician and a blinded radiologist, reporting mean differences and 95% confidence intervals. We calculated sensitivity, specificity, and likelihood ratios of POCUS in the prediction of fluoroscopically detected post-reduction malalignment, as interpreted by a blinded pediatric orthopaedist.Results
The 58 patients were 7.9?±?3.5?years of age and had 21 radial (36%), 1 ulnar (2%), and 36 radioulnar (62%) fractures. Fluoroscopy and POCUS angles were within a mean of 0.1°–3.2°, depending on the site and surface measured. Radiologist- and emergency physician-interpreted POCUS measurements were within a mean of 1° in all dimensions. POCUS identified inadequate reductions with 100% sensitivity and 92–93% specificity.Conclusions
Blinded emergency medicine and radiology interpretations of post-reduction POCUS fracture images agree closely. Post-reduction POCUS measurements are comparable to those obtained by fluoroscopy and accurately predict adequacy of reduction. POCUS can be used to guide pediatric fracture reduction when bedside fluoroscopy is not available in the ED. 相似文献14.
Jui-Yuan Chung Chien-Chin Hsu Jiann-Hwa Chen Wei-Lung Chen Hung-Jung Lin How-Ran Guo Chien-Cheng Huang 《The American journal of emergency medicine》2019,37(3):391-394
Background
The shock index is a rapid and simple tool used to predict mortality in patients with acute illnesses including sepsis, multiple trauma, and postpartum hemorrhage. However, its ability to predict mortality in geriatric patients with influenza in the emergency department (ED) remains unclear. This study was conducted to clarify this issue.Methods
We conducted a retrospective case-control study, recruiting geriatric patients (≥ 65?years) with influenza visiting the ED of a medical center between January 01, 2010 and December 31, 2015. Demographic data, vital signs, shock index, past histories, subtypes of influenza, and outcomes were included for the analysis. We investigated the association between shock index ≥1 and 30-day mortality.Results
In total, 409 geriatric ED patients with mean age of 79.5?years and nearly equal sex ratio were recruited. The mean shock index?±?standard deviation was 0.7?±?0.22 and shock index ≥1 was accounted for in 7.1% of the total patients. Logistic regression showed that shock index ≥1 predicted mortality (odds ratio: 6.80; 95% confidence interval: 2.39–19.39). The area under the receiver operating characteristic was 0.62 and the result of the Hosmer–Lemeshow goodness-of-fit test was 0.23. The sensitivity, specificity, positive predictive value, and negative predictive value of a shock index ≥1 were 30.0%, 94.1%, 20.0%, and 96.4%.Conclusions
A shock index ≥1 has a high specificity, negative predictive value, and good reliability to predict 30-day mortality in geriatric ED patients with influenza. 相似文献15.
Edmond A. Hooker Peter J. Mallow Michelle M. Oglesby 《The Journal of emergency medicine》2019,56(3):344-351
Background
It is important that policy makers, health administrators, and emergency physicians have up-to-date statistics on the most common diagnoses of patients seen in the emergency department (ED).Objectives
We sought to describe the changes that occurred in ED visits from 2010 through 2014 and to describe the frequency of different ED diagnoses.Methods
This is a retrospective analysis of ED visit data from the National Emergency Department Sample from 2010 through 2014. Visits were stratified by age, sex, insurance status, disposition, diagnosis, and diagnostic category. We calculated the total annual ED visits and the ED visit rates by diagnoses and diagnostic categories.Results
Between 2010 and 2014, the number of U.S. ED visits increased from 128.9 million to 137.8 million. The rate of ED Visits per 1000 persons increased from 416.92 (95% confidence interval [CI] 399.47–434.37) in 2010 to 432.51 (95% CI 411.51–453.61) in 2014 (p = 0.0136). ED visits grew twice as quickly (1.7%) as the overall population (0.7%). The most common reason for an ED visit was abdominal pain (11.75% [95% CI 11.61–11.89]). This was followed by mental health problems (4.45% [95% CI 4.19–4.72]).Conclusion
The number of ED visits in the United States continues to increase faster than the rate of population growth. Abdominal problems and mental health issues, including substance abuse, were the most common reasons for an ED visit in 2014. 相似文献16.
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Sameer Sharif Michelle Eventov Clive Kearon Sameer Parpia Meirui Li River Jiang Paula Sneath Carmen Otero Fuentes Christopher Marriott Kerstin de Wit 《The American journal of emergency medicine》2019,37(5):845-850
Background
Diagnosing pulmonary embolism (PE) in the emergency department (ED) can be challenging because its signs and symptoms are non-specific.Objective
We compared the efficacy and safety of using age-adjusted D-dimer interpretation, clinical probability-adjusted D-dimer interpretation and standard D-dimer approach to exclude PE in ED patients.Design/methods
We performed a health records review at two emergency departments over a two-year period. We reviewed all cases where patients had a D-dimer ordered to test for PE or underwent CT or VQ scanning for PE. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30?days. We applied the three D-dimer approaches to the low and moderate probability patients. The primary outcome was exclusion of PE with each rule. Secondary objective was to estimate the negative predictive value (NPV) for each rule.Results
1163 emergency patients were tested for PE and 1075 patients were eligible for inclusion in our analysis. PE was excluded in 70.4% (95% CI 67.6–73.0%), 80.3% (95% CI 77.9–82.6%) and 68.9%; (95% CI 65.7–71.3%) with the age-adjusted, clinical probability-adjusted and standard D-dimer approach. The NPVs were 99.7% (95% CI 99.0–99.9%), 99.1% (95% CI 98.3–99.5%) and 100% (95% CI 99.4–100.0%) respectively.Conclusion
The clinical probability-adjusted rule appears to exclude PE in a greater proportion of patients, with a very small reduction in the negative predictive value. 相似文献18.
Charles W. Hwang Desmond E. Fitzpatrick Torben K. Becker Jason M. Jones 《The American journal of emergency medicine》2019,37(3):482-485
Background
Freestanding emergency departments (FSED) are equipped to care for most emergencies, but do not have all the resources that hospital-based emergency departments (ED) offer. As the number of FSEDs grows rapidly, emergency medical services (EMS) must routinely determine whether a FSED is an appropriate destination. Inappropriate triage may delay definitive care, potentially increasing morbidity, mortality, and resource utilization. We sought to evaluate paramedics' ability in determining whether a FSED is the most appropriate destination.Methods
We conducted a retrospective study of two county EMS agencies and two FSEDs over a 25-month period in Alachua and Levy County, Florida, USA. Both EMS agencies allow paramedic discretion in determining transport destination. To determine whether paramedics can correctly identify patients that can be cared for fully at a FSED, our primary outcome was the percentage of patients transported to FSEDs by EMS that were discharged without additional hospital-based resources.Results
We identified 1247 EMS patients that had a selected destination of FSED. We excluded patients that did not arrive at their selected FSED destination, left before FSED disposition, or were transferred from the FSED to unaffiliated hospitals. A total of 1184 patients were included for analysis, and 885 (74.7%) did not require additional hospital resources. Comparing the two EMS agencies yielded similar results.Conclusion
In this study, involving two EMS agencies over a 25-month period, we found that 3 out of 4 patients deemed appropriate for transport to a FSED by a paramedic did not require additional hospital-based services. 相似文献19.
Nalan Kozaci Mustafa Avcı Ertan Ararat Tansu Pinarbasili Muharrem Ozkaya Ibrahim Etli Eda Donertas Omer F. Karakoyun 《The American journal of emergency medicine》2019,37(5):864-868
Objective
In this study, the accuracy of bedside thoracic ultrasonography (TUSG) performed by emergency physicians with patients in the supine position was compared with that of thoracic computed tomography (TCT) for the determination of thoracic injuries due to trauma.Methods
Patients who suffered the multiple traumas, whose thoracic trauma was identified on physical examination or TCT imaging were included in the study. TUSG was performed following a physical examination by the emergency physician who managed the trauma patient. Subcutaneous emphysema, pneumothorax, pulmonary contusions (PCs), hemothorax, pericardial effusion and tamponade, sternal and clavicular fractures and rib fractures were identified by TUSG. TCT imaging was performed after the ultrasonography examination was completed.Results
Eighty-one patients were included in the study. TCT scans showed subcutaneous emphysema in 16 (19.8%) patients, pneumothorax in 21 (25.9%), PCs in 27 (33.3%), hemothorax in 20 (24.7%), sternum and clavicular fractures in 6 (7.4%) and rib fractures in 21 (25.9%). The sensitivity and specificity of ultrasonography varied for detecting the following pathologies: subcutaneous emphysema (56% and 95%), pneumothorax (86% and 97%), hemothorax (45% and 98%), PCs (63% and 91%), sternal fractures (83% and 97%), clavicular fractures (83% and 100%) and rib fractures (67% and 98%), respectively.Conclusion
In conclusion, ultrasound was found to be highly specific but only moderately sensitive for the identification of thoracic injuries. 相似文献20.
Shabana Yusuf Audrey C. Wassef Alan Schlesinger 《The Journal of emergency medicine》2019,56(4):e51-e54