Category: Administration
Keywords: administrative harm, employee, adverse events (PubMed Search)
Posted: 6/26/2024 by Steve Schenkel, MPP, MD
(Updated: 7/16/2024)
Click here to contact Steve Schenkel, MPP, MD
“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.
Category: Administration
Keywords: STI, prophylaxis (PubMed Search)
Posted: 6/24/2024 by Visiting Speaker
(Updated: 7/16/2024)
Click here to contact Visiting Speaker
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.
Bachmann LH, Barbee LA, Chan P, et al. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep. 2024;73(2):1-8. Published 2024 Jun 6. doi:10.15585/mmwr.rr7302a1
Category: Administration
Keywords: pulse oximetry, skin pigmentations (PubMed Search)
Posted: 6/15/2024 by Kevin Semelrath, MD
(Updated: 7/16/2024)
Click here to contact Kevin Semelrath, MD
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.
Low Perfusion and Missed Diagnosis of Hypoxemia by Pulse Oximetry in Darkly Pigmented Skin: A Prospective Study. Anesth Analg. 2024 Mar 1;138(3):552-561. doi: 10.1213/ANE.0000000000006755. Epub 2023 Dec 18. PMID: 38109495
Category: Administration
Keywords: POCUS, musculoskeletal, fingers, water baths (PubMed Search)
Posted: 6/3/2024 by Alexis Salerno, MD
(Updated: 7/16/2024)
Click here to contact Alexis Salerno, MD
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.
Category: Administration
Keywords: Specialty ED, Geriatric ED, Oncologic ED (PubMed Search)
Posted: 5/21/2024 by Mercedes Torres, MD
(Emailed: 5/22/2024)
(Updated: 5/22/2024)
Click here to contact Mercedes Torres, MD
There is a growing trend toward the development of specialty-specific emergency services, such as Geriatric or Oncologic 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.
Brouillette M. Are Specialty Emergency Departments the Future of Emergency Care? Oncology- and Geriatric-Focused Emergency Departments Hope to Improve Care, Lower Costs. Annals of Emergency Medicine. May 2024, 83(5):9A-12A. https://doi.org/10.1016/j.annemergmed.2024.03.015
Category: Administration
Posted: 5/13/2024 by Robert Flint, MD
(Updated: 7/16/2024)
Click here to contact Robert Flint, MD
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.
Mohammed A. Alrashed Stephen J. Perona Mark C. Borgstrom Elias Ramirez-Moreno
JAPhA VOLUME 64, ISSUE 3, 102020, MAY 2024
Published:January 29, 2024DOI:https://doi.org/10.1016/j.japh.2024.01.016
Category: Administration
Keywords: trauma, EMS, hemorrhagic shock (PubMed Search)
Posted: 5/3/2024 by Ben Lawner, MS, DO
Click here to contact Ben Lawner, MS, DO
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:
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.
Duchesne, J. , McLafferty, B. , Broome, J. , Caputo, S. , Ritondale, J. , Tatum, D. , Taghavi, S. , Jackson-Weaver, O. , Tran, S. , McGrew, P. , Harrell, K. , Smith, A. , Nichols, E. , Dransfield, T. , Marino, M. & Piehl, M. (9900). Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care. Journal of Trauma and Acute Care Surgery, Publish Ahead of Print , doi: 10.1097/TA.0000000000004363.
Category: Administration
Keywords: staffing, employment, Teamhealth, Medstar, Edelman (PubMed Search)
Posted: 3/16/2024 by Steve Schenkel, MPP, MD
(Emailed: 4/17/2024)
(Updated: 4/17/2024)
Click here to contact Steve Schenkel, MPP, MD
Emergency Medicine staffing groups can be organized in any number of ways. Here’s Leon Adelman’s take:
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.
Category: Administration
Keywords: Administration, Patient Experience, Microaggression, Discrimination (PubMed Search)
Posted: 3/27/2024 by Mercedes Torres, MD
(Updated: 7/16/2024)
Click here to contact Mercedes Torres, MD
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:
Punches BE, Osuji E, Bischof JJ, et al. Patient perceptions of microaggressions and discrimination toward patients during emergency department care. Acad Emerg Med. 2023; 30: 1192-1200. doi:10.1111/acem.14767
Category: Administration
Keywords: DEI, Ramadan, fasting (PubMed Search)
Posted: 3/16/2024 by Kevin Semelrath, MD
(Updated: 7/16/2024)
Click here to contact Kevin Semelrath, MD
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
Impact of Ramadan on emergency department visits and on medical emergencies. Reem G Al Assaad, Rana Bachir, Mazen J. El Sayed. Europena Journal of Emergency Medicine. 2018, 25:440-444.
Category: Administration
Keywords: employee, independent contractor, employment, job market (PubMed Search)
Posted: 1/12/2024 by Steve Schenkel, MPP, MD
(Emailed: 2/28/2024)
(Updated: 2/28/2024)
Click here to contact Steve Schenkel, MPP, MD
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
Category: Administration
Posted: 2/22/2024 by Robert Flint, MD
(Updated: 7/16/2024)
Click here to contact Robert Flint, MD
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.
https://doi.org/10.1016/j.annemergmed.2023.08.492
RESEARCH LETTER| VOLUME 83, ISSUE 2, P177-180, FEBRUARY 2024
Category: Administration
Keywords: Transfer, surgery, scoping review, further research (PubMed Search)
Posted: 1/28/2024 by Robert Flint, MD
(Emailed: 2/11/2024)
(Updated: 2/11/2024)
Click here to contact Robert Flint, MD
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.
Silver, David S. MD, MPH; Teng, Cindy MD; Brown, Joshua B. MD, MSc. Timing, triage, and mode of emergency general surgery interfacility transfers in the United States: A scoping review. Journal of Trauma and Acute Care Surgery 95(6):p 969-974, December 2023. | DOI: 10.1097/TA.0000000000004011
Category: Administration
Keywords: Medicare advantage, insurance, payor (PubMed Search)
Posted: 1/12/2024 by Steve Schenkel, MPP, MD
(Emailed: 1/30/2024)
(Updated: 1/30/2024)
Click here to contact Steve Schenkel, MPP, MD
Approximately half of all Medicare beneficiaries are now enrolled in Medicare Advantage plans. Why does this matter?
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/.
Category: Administration
Keywords: Risk, diagnostic error (PubMed Search)
Posted: 1/21/2024 by Robert Flint, MD
(Updated: 7/16/2024)
Click here to contact Robert Flint, MD
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.
Published November 2023
Category: Administration
Keywords: restraint use (PubMed Search)
Posted: 1/21/2024 by Kevin Semelrath, MD
(Updated: 7/16/2024)
Click here to contact Kevin Semelrath, MD
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:
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
Published:September 19, 2023DOI:https://doi.org/10.1016/j.annemergmed.2023.08.009
Category: Administration
Posted: 1/6/2024 by Robert Flint, MD
(Updated: 7/16/2024)
Click here to contact Robert Flint, MD
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.
Jakob Emerson - Updated Friday, December 29th, 2023 Becker’s Payer Issues
Category: Administration
Keywords: Personal growth. (PubMed Search)
Posted: 12/31/2023 by Robert Flint, MD
(Updated: 7/16/2024)
Click here to contact Robert Flint, MD
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!
Category: Administration
Keywords: boarding, administration, crowding (PubMed Search)
Posted: 11/22/2023 by Mercedes Torres, MD
(Updated: 7/16/2024)
Click here to contact Mercedes Torres, MD
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:
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.
Loke D, et al. Clinicians’ Insights on Emergency Department Boarding: An Explanatory Mixed Methods Study Evaluating Patient Care and Clinician Well-Being. The Joint Commission Journal on Quality and Patient Safety 2023; 000:1-8.
Category: Administration
Keywords: DEI, sexual harassment (PubMed Search)
Posted: 10/29/2023 by Kevin Semelrath, MD
(Emailed: 11/18/2023)
(Updated: 11/18/2023)
Click here to contact Kevin Semelrath, MD
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.
Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights Christopher T. Begeny1,* , Homa Arshad2, Tamzin Cuming3, Daljit K. Dhariwal4, Rebecca A. Fisher5, Marieta D. Franklin6, Philippa M. Jackson7, Greta M. McLachlan8, Rosalind H. Searle9 and Carrie Newlands10
BJS, 2023, 110, 1518–1526