Preferences for EMS Transport andPediatric Emergency Department Care

Objectives. To characterize the reasons pediatric emergency department (PED), patients access emergency medical services (EMS) for transport to the pediatric ED. To describe the acceptability of other modes of transport andalternative sites of care. Methods. We included a convenience sample of the responsible adults accompanying pediatric patients who arrived via EMS to the PED of an academic medical center. We administered a survey to evaluate why they chose EMS andtheir feelings about alternative modes of transport (e.g., medical van, taxi) or alternative sites of care (e.g., urgent care center, primary care physician's office, or getting an appointment within 24 hours). Results. One hundred thirthy-eight surveys were completed. Pediatric patients averaged eight years of age. Trauma (44%) andseizures (17%) were the chief complaints. The primary reasons for EMS use were perceived medical necessity (54%) andsecurity of transport by EMS (17%). Only transport by EMS was found to be acceptable. The responsible adults expressed acceptance of the PED (median = 7, 1 = not acceptable, 7 = very acceptable) as a destination, more than their child's primary care doctor's (median = 4), urgent care centers (median = 3), or no transport anda physician appointment within 24 hours (median = 1). Conclusions. Adults access the EMS system for children because of concerns regarding the acuity of illness andfor the security of EMS transport. They were generally uninterested in transport by any mode other than EMS. However, they would accept transport to alternative sites for immediate care.     

Academic Departments of Emergency Medicine: The Effects of Managed Care

Abstract. Objective: To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice. Methods: A 38-question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994–1995 and 1995–1996. Results: Forty-seven ADEMs (90.3%) responded. When comparing the 1995–1996 and 1994–1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two-thirds of ADEMs used mid-level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast-track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety-eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty-eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9-1-1 services and 16% reporting HMOs provided 9-1-1 services to take patients only to participating hospital EDs. Conclusion: ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.     

The Impact of Two Freestanding Emergency Departments on a Tertiary Care Center

Background

Freestanding emergency departments (FEDs) have become increasingly popular as the need for emergency care continues to grow.

Objective

To analyze the impact of two FEDs on a local tertiary care center’s patient volume and admission rates.

Methods

A retrospective analysis examined monthly volume and admission rates for the main ED and two FEDs located 9.6 and 12 miles away. Main ED census records were divided into three distinct time frames: period A (control) was January 2007 through June 2007. Period B was July 2007 through July 2009 when one FED was open. Period C was August 2009 through June 2010 when both FEDs were open. A two-factor analysis of variance was used to analyze admission rates while adjusting for monthly variation.

Results

The mean monthly patient volume for the main ED was 4709 for period A, but dropped significantly (p < 0.01) to 4447 for period B, and again dropped significantly (p < 0.01) to 4242 during period C. The volume for all facilities increased throughout the study period. A combined monthly volume increase to 5642 occurred in Period B, and increased to 6808 in Period C. The adjusted mean admission rate at the main ED for period A was 0.221, which dropped somewhat, though not significantly (p = 0.3505) to 0.213 for period B, and then significantly (p < 0.01) to 0.189 for period C.

Conclusion

Opening two FEDs decreased the volume and admission rates for the main ED and increased the overall ED volume for the health care system.     

Specialty Coverage at Non-Tertiary Care Centers

The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. Although most injuries are minor or moderate andcan be managed at local community hospitals, a significant minority of injured patients require extensive andexpensive care to survive or minimize injury. Most prehospital trauma triage criteria address a combination of factors to consider, but this approach sometimes fails to identify patients with severe injuries andoften burdens trauma centers with patients suffering minor injuries. It is critical to utilize a method to differentiate those injury victims who need the specialized expertise andresources available in trauma centers from those who can be adequately cared for locally. Although trauma centers assume the leadership role, in a truly inclusive system, all health care providers (prehospital, community hospitals, andtrauma centers) have a defined role in providing care to patients with trauma. All these institutions should establish andmaintain transfer agreements for the transfer of patients meeting system trauma triage criteria. Because prehospital triage criteria are not 100% sensitive, there should be a mechanism in place for the secondary triage of patients. Initial management of patients should continue while efforts are made to transfer the patient.     

Emergency Dispatcher Stroke Recognition: Associations with Downstream Care

Objective: As the first point of contact for patients activating emergency medical services (EMS), emergency dispatchers have the earliest opportunity to recognize stroke. We sought to quantify dispatcher stroke recognition and its relationships with EMS stroke recognition and response speed. Methods: We assembled a cohort of consecutive EMS-transported patients with a dispatcher suspected stroke or a hospital discharge diagnosis of stroke or transient ischemic attack (TIA). Dispatcher sensitivity and positive predictive value (PPV) for stroke recognition were calculated. Multivariable logistic regression analysis was used to determine predictors of dispatcher recognition and relationships between dispatcher recognition and downstream care. Results: During a 12-month period, 601 patients met inclusion criteria. Dispatchers suspected stroke in 229/324 (sensitivity = 70.7% [65.5 to 75.4%]) confirmed stroke/TIA cases and correctly assigned a suspected stroke label in 229/506 cases (PPV = 45.3% [41.0 to 49.6%]). Dispatchers had higher odds of recognizing ischemic strokes (aOR 3.4 [1.4 to 8.5]) and lower odds of recognizing patients with visual deficits (aOR = 0.4 [0.2 to 0.9]) or vomiting (aOR = 0.3 [0.1 to 0.9]). Dispatcher suspected stroke cases received more on-scene stroke screens (79.0% vs. 54.7%, p < 0.0001) and were more often recognized by EMS as strokes (77.7% vs. 57.9%, p = 0.0005). Dispatcher recognition was independently associated with EMS stroke recognition (aOR = 3.8 [1.9 to 7.7]), but not with transportation times, door-to-CT times, or t-PA delivery. Conclusions: Emergency dispatcher stroke recognition is associated with higher rates of on-scene stroke scale performance and EMS ischemic stroke recognition but not with reduced transport times, door-to-CT times, or t-PA treatment.     

End-of-life Models and Emergency Department Care

Many people die in emergency departments (EDs) across the United States from sudden illnesses or injuries, an exacerbation of a chronic disease, or a terminal illness. Frequently, patients and families come to the ED seeking lifesaving or life-prolonging treatment. In addition, the ED is a place of transition-patients usually are transferred to an inpatient unit, transferred to another hospital, or discharged home. Rarely are patients supposed to remain in the ED. Currently, there is an increasing amount of literature related to end-of-life care. However, these end-of-life care models are based on chronic disease trajectories and have difficulty accommodating sudden-death trajectories common in the ED. There is very little information about end-of-life care in the ED. This article explores ED culture and characteristics, and examines the applicability of current end-of-life care models.     

Adverse Outcomes of Managed Care Gatekeeping

Objectives : To determine whether telephone preauthorization for reimbursement of ED care (medical “gate-keeping”) by managed care organizations (MCOs) is associated with adverse outcomes. Methods : A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on-call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) “near miss” (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above. Results : Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococcal meningitis in immuno-compromised host, endocarditis, incarcerated inguinal hernia, meningococcemia, meningococcal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina. Conclusion : Adverse outcomes occur with MCO gatekeeping. Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study.     

Knowledge Translation in the Emergency Medical Services: A Research Agenda for Advancing Prehospital Care

Little is known about knowledge translation in the practice of out-of-hospital medicine. It is generally accepted that much work is needed regarding "getting the evidence straight" in emergency medical services, given the substantial number of interventions that are performed regularly in the field but lack meaningful scientific support. Additional attention also needs to be given to "getting the evidence used," because there is some evidence that evidence-based practices are being incompletely or incorrectly applied in the field. In an effort to help advance a research agenda for knowledge translation in emergency medical services, nine recommendations are put forth to help address the problems identified.     

Resident Field Response in an Emergency Medicine Prehospital Care Rotation

Abstract

Background. Emergency medical services (EMS) is an important component of emergency medicine residency curricula. For over 20 years, residents at a university-affiliated program have staffed a physician response vehicle and responded to selected calls in an urban EMS system with online faculty backup. Objectives. To describe the prehospital educational experience and patient care provided through this unique program and to assess residents’ perceptions. Methods. This was a three-year retrospective study of patient care records for all prehospital resident responses. Information obtained included complaint, disposition, procedures performed, and medications administered. The number of EMS radio consultations provided by residents during this rotation was also sought. We surveyed 43 current and recently graduated residents to assess their perceptions of this experience. Results. Residents treated 1,434 patients during 1,381 scene responses (16.7 field patient contacts per resident-year). Complaints included cardiac arrest (788, 55.0%) and neurologic (230, 16.0%), traumatic (194, 13.5%), respiratory (144, 10.0%), and other cardiac (40, 2.8%) emergencies. Most patients (1,022; 71.3%) were transported to the hospital, including 82 of 143 patients (57.3%) who initially refused EMS transport. Residents performed procedures on 546 responses (39.5%), including 123 successful intubations, 115 central lines, 43 peripheral (IV) lines, and 10 intraosseous lines. EMS radio consultation records were available for only the second half of the study period. Residents provided 11,583 consultations during this one-and-a-half-year period (264 radio consultations per resident-year). Of the 40 returned surveys (93.0%), autonomy (n = 21), medical decision making (n = 10), and management of high-acuity patients (n = 7) were the most important perceived benefits of this program. Conclusion. Our prehospital training program incorporates emergency medicine residents as in-field physicians and allows hands-on opportunity to provide patient care for a variety of conditions in the EMS environment, as well as extensive experience in online medical direction. The trainees believed it had a strong positive impact on their acquisition of important emergency medicine abilities.     

Patient Refusal of Care in the Out-of-hospital Setting

A case vignette of out-of-hospital refusal of emergency care is reported with accompanying discussion. This case illustrates the challenges faced by out-of-hospital emergency care personnel in these scenarios and provides guidance to the emergency physician and emergency medical technician. Recommendations are provided for preparing the emergency medical services system to handle these cases.     

Delay in Seeking Emergency Care

OBJECTIVE: To determine whether patient clinical and socioeconomic characteristics predict patient delay in coming to the emergency department (ED). METHODS: Adult ED patients at five urban teaching hospitals were surveyed regarding self-reported delay in coming to the ED. Delay was measured by self-perception as well as by the number of days ill and unable to work. Patient socioeconomic and clinical characteristics were obtained by survey questionnaire and chart review. Cross-sectional analysis within a prospective study of 4,094 consecutive patients was performed using a subset of 1,920 patients (84% eligible rate) to whom questionnaires were administered. RESULTS: Overall, 32% of the patients completing the survey reported delay in seeking ED care. Of these patients reporting delay, 71% thought their problem would go away or was not serious. Patients who were older, had higher acuity, or were frequent ED users reported less delay in coming to the ED, while patients without a regular physician or who were African American reported more delay. Perception of increased number of days ill prior to visiting the ED was reported by frequent ED users and those with worse baseline physical function, while patients who had higher acuity reported fewer days ill prior to coming to the ED. CONCLUSIONS: A patient's decision to delay coming to the ED often reflects a belief that his or her illness is either self-limited or not serious. The decision to delay correlates with patient characteristics and access to a regular physician. The correlates of delay in seeking ED care may depend on the delay measure used. Better understanding of patients at risk for delaying care may influence interventions to reduce delay.     

Paramedic-Initiated Home Care Referrals and Use of Home Care and Emergency Medical Services

Objective: We examined the association between paramedic-initiated home care referrals and utilization of home care, 9-1-1, and Emergency Department (ED) services. Methods: This was a retrospective cohort study of individuals who received a paramedic-initiated home care referral after a 9-1-1 call between January 1, 2011 and December 31, 2012 in Toronto, Ontario, Canada. Home care, 9-1-1, and ED utilization were compared in the 6 months before and after home care referral. Nonparametric longitudinal regression was performed to assess changes in hours of home care service use and zero-inflated Poisson regression was performed to assess changes in the number of 9-1-1 calls and ambulance transports to ED. Results: During the 24-month study period, 2,382 individuals received a paramedic-initiated home care referral. After excluding individuals who died, were hospitalized, or were admitted to a nursing home, the final study cohort was 1,851. The proportion of the study population receiving home care services increased from 18.2% to 42.5% after referral, representing 450 additional people receiving services. In longitudinal regression analysis, there was an increase of 17.4 hours in total services per person in the six months after referral (95% CI: 1.7–33.1, p = 0.03). The mean number of 9-1-1 calls per person was 1.44 (SD 9.58) before home care referral and 1.20 (SD 7.04) after home care referral in the overall study cohort. This represented a 10% reduction in 9-1-1 calls (95% CI: 7–13%, p < 0.001) in Poisson regression analysis. The mean number of ambulance transports to ED per person was 0.91 (SD 8.90) before home care referral and 0.79 (SD 6.27) after home care referral, representing a 7% reduction (95% CI: 3–11%, p < 0.001) in Poisson regression analysis. When only the participants with complete paramedic and home care records were included in the analysis, the reductions in 9-1-1 calls and ambulance transports to ED were attenuated but remained statistically significant. Conclusions: Paramedic-initiated home care referrals in Toronto were associated with improved access to and use of home care services and may have been associated with reduced 9-1-1 calls and ambulance transports to ED.     

Planning Recommendations for International Emergency Medicine and Out-of-hospital Care System Development

OBJECTIVES: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM. METHODS: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. CONCLUSIONS: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts.     

Patient and Primary Care Physician Satisfaction with Chest Pain Unit and Routine Care

OBJECTIVES: The chest pain unit (CPU) has been developed to improve care for patients with acute, undifferentiated chest pain. The authors aimed to measure patient and primary care physician (PCP) satisfaction with CPU care and routine care and to determine whether patient satisfaction predicted PCP satisfaction. METHODS: A CPU was established, and 442 days were randomly allocated to either CPU care or routine care. Consenting patients presenting with acute, undifferentiated chest pain were recruited and followed at two days and one month. All were given a self-completed patient satisfaction questionnaire two days after attendance (N = 972). Each patient's PCP was sent a self-completed satisfaction questionnaire during days 171-442 of the trial (N = 601). Analysis determined whether CPU care was associated with improved patient or PCP satisfaction and whether patient satisfaction predicted PCP satisfaction for three questions relating to diagnosis, treatment, and overall care. RESULTS: CPU care was consistently associated with higher scores across all patient satisfaction questions, from the perceived thoroughness of examination to care received to an overall assessment of the service received. However, CPU care achieved small improvements in only two of ten PCP satisfaction questions, concerning overall management of the patient and the amount of information about investigations performed. Furthermore, patient satisfaction did not predict PCP satisfaction in relation to diagnosis (p = 0.456), treatment (p = 0.256), or overall care (p = 0.085). CONCLUSIONS: CPU care is associated with substantial improvements in all dimensions of patient satisfaction but only minimal improvements in PCP satisfaction. Patient satisfaction was not a strong predictor of PCP satisfaction with emergency care.