UMEM Educational Pearls - Administration

“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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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/.

From the Canadian Medical Protective Association looking at  5 years of closed medical legal cases.  This fits with previous risk management data and should give us pause when treating these conditions.

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This study was a retrospective review of restraint use at a level 1 trauma center in the Midwest.

It found the following were factors in a patient encounter associated with an increased risk of restraint usage:

• drug or alcohol intoxication (highest OR)
• American Indian race
• male gender
• Medicaid or self pay insurance
• dx of bipolar disorder, psychosis

This study found a decreased OR of restraint use with Black or Hispanic race, which was in contrast to other studies

This was a single center, retrospective study, so it was already limited in what it could tell us.  In addition, they didn't see  the reason for the restraints being ordered in the first place. Nonetheless, it does show that people in certain marginalized groups have a higher likelihood of ending up in restraints.  Please think twice when ordering restraints in the ED, especially for behavioral reasons

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Since 2014, Medicare has payed for inpatient services for Medicare patients who’s admitting physician noted that hospital stay required at least 48 hours (measured as 2 midnights) or required specialty care that could not be performed as an out patient.  This rule now will apply to Medicare Advantage insurance patients as well. Physicians will need to document their reasoning why a patient’s stay will likely require two midnights.

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As the calendar flips to a new year, consider not setting goals or resolutions. Studies show unmet goals or having too many half finished projects leads to increased stress, anxiety and depression. Instead, consider approaching the new year looking for growth, introspection, and  striving to achieve excellence.  Understanding the why and what motivates you will lead to the correct what and how. Here are some questions to get you thinking about the why.  May your New Year be filled with growth and excellence!  

A recently published study of ED APPs, residents, attendings, and nurses attempted to assess clinician's perspectives on how ED boarding impacts ED staff and patients.  Authors performed a survey followed by focus group sessions to obtain qualitative insignts from participants. 

All respondents associated boarding with feelings of burnout and self-reported poor satisfaction with communication and the process of boarding care.

Several key themes emerged which are outlined below:

1. Clinicians perceived that boarding leads to increased patient safety events.
2. Clinicians desired standardization for the boarding care process.
3. Clinicians felt they had a lack of knowledge, resources, and training to care for boarding patients.
4. Clinicians desired proactive bed and resource planning for boarding patients.
5. Clinicians advocated for improved communication among the team and to patients.
6. Clinicians identified a need for culture change regarding boarding care.

This publication highlights the negative workforce and patient safety effects of ED boarding.  It amplifies the voices of our colleagues who work towards change to improve both the health of our wrokforce as well as that of our patients and the communities that we serve.

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This disturbing study out of the UK details the prevelance of sexual harassment, sexual assault and rape within the hospital environment.  

Overall it's clear that women surgeons in this study were the victims and witnesses of sexual violcence at a substantially higher rate than men.  89% on women report being witnesses of sexual harassment and 63% being the victim of it; 30% of women report being the victim of sexual assault, and 35% report being witness to it; and most concerning 0.8% of women report being raped by a colleague, with 1.9% being witness to it.

The study also asked respondents about their faith in higher organizations' (the Royal Colleges and the General Medical Council) ability to respond to these issues.  For women, the percentage of people who felt that there was an adequate response was only between 15-30 percent.

There is a huge and persistent gap between men and women both witnessing and experiencing sexual harassment and assault at work.  Everyone has a responsibility to immediately interrupt any form of sexual harassment or assault, no matter how inocuous it may seem to the perpertrator, in order to provide an environment we can all thrive in.

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