Corporate Control of Emergency Departments: Dangers from the Growing Monster.

BACKGROUND: Corporate control in emergency departments (EDs) has increased during the past 20 years through hospital consolidation and the growth of ED contract management groups. OBJECTIVES: To describe the growing corporate influence in the practice of emergency medicine and associated dangers to the public's safety and well-being. DISCUSSION: Hospital systems through mergers and acquisitions have created regional monopolies providing them the power to charge high fees, which can lead to economic hardship for patients. Hospitals have also increasingly employed physicians and can exert influence over their practice to further increase profits. ED contract management groups (CMGs) obtain the exclusive contract for emergency services and gain control over the livelihood of emergency physicians, decreasing their autonomy and inserting the business interest into the physician-patient relationship, and this may result in harm to patients. Safety issues identified by emergency physicians may not be articulated for fear of being fired, and protocols may direct physicians to order unneeded testing and encourage unnecessary hospital admissions to make higher profits. Of additional concern, some CMGs are involved in graduate emergency medicine education, exposing physicians in training to corporate influence during their formative years. CONCLUSIONS: Given the potential harm to patients due to corporate influence, there must be serious consideration for legislative or regulatory solutions regarding the increasing corporate control of emergency medicine in the United States.

Corporate and Hospital Profiteering in Emergency Medicine: Problems of the Past, Present, and Future.

BACKGROUND: Health care delivery in the United States has evolved in many ways over the past century, including the development of the specialty of Emergency Medicine (EM). With the creation of this specialty, many positive changes have occurred within hospital emergency departments (EDs) to improve access and quality of care of the nation's de facto "safety net." The specialty of EM has been further defined and held to high standards with regard to board certification, sub-specialization, maintenance of skills, and research. Despite these advances, problems remain. OBJECTIVE: This review discusses the history and evolution of for-profit corporate influence on EM, emergency physicians, finance, and demise of democratic group practice. The review also explores federal and state health care financing issues pertinent to EM and discusses potential solutions. DISCUSSION: The monopolistic growth of large corporate contract management groups and hospital ownership of vertically integrated physician groups has resulted in the elimination of many local democratic emergency physician groups. Potential downsides of this trend include unfair or unlawful termination of emergency physicians, restrictive covenants, quotas for productivity, admissions, testing, patient satisfaction, and the rising cost of health care. Other problems impact the financial outlook for EM and include falling federal, state, and private insurance reimbursement for emergency care, balance-billing, up-coding, unnecessary testing, and admissions. CONCLUSIONS: Emergency physicians should be aware of the many changes happening to the specialty and practice of EM resulting from corporate control, influence, and changing federal and state health care financing issues.

One-Year Experience with the Institution of a Critical Airway Team at an Academic Medical Center.

BACKGROUND: At our institution, there were a number of adverse patient events related to an unstable airway that led to the formation of a designated critical airway response team (CAT). It was hoped that this would improve patient outcomes in such matters. OBJECTIVE: Our aim was to evaluate the impact of the creation of the CAT. METHODS: A review of the activations of the CAT for 1 year was conducted. RESULTS: We reviewed 51 CAT activations, the majority (71%) occurred in the emergency department (ED) and the most common reasons for activation were angioedema (41%) and epiglottitis (12%). Fiber optic intubation was the most common method used to secure the airway, 22% of the cases were transported to the operating room for management. Only one surgical airway was required and no adverse outcome related to the airway occurred in the studied group. CONCLUSIONS: The creation of a critical airway has been considered a success in terms of patient management at our institution. It has been most commonly used in the management of life-threatening angioedema in the ED.

Impact of an Opioid Prescribing Guideline in the Acute Care Setting.

BACKGROUND: Death from opioid abuse is a major public health issue. The death rate associated with opioid overdose nearly quadrupled from 1999 to 2008. Acute care settings are a major source of opioid prescriptions, often for minor conditions and chronic noncancer pain. OBJECTIVE: Our aim was to determine whether a voluntary opioid prescribing guideline reduces the proportion of patients prescribed opioids for minor and chronic conditions. METHODS: A retrospective chart review was performed on records of adult emergency department visits from January 2012 to July 2014 for dental, neck, back, or unspecified chronic pain, and the proportion of patients receiving opioid prescriptions at discharge was compared before and after the guideline. Attending emergency physicians were surveyed on their perceptions regarding the impact of the guideline on prescribing patterns, patient satisfaction, and physician-patient interactions. RESULTS: In our sample of 13,187 patient visits, there was a significant (p < 0.001) and sustained decrease in rates of opioid prescriptions for dental, neck, back, or unspecified chronic pain. The rate of opioid prescribing decreased from 52.7% before the guideline to 29.8% immediately after its introduction, and to 33.8% at an interval of 12 to 18 months later. The decrease in opioid prescriptions was observed in all of these diagnosis groups and in all age groups. All 31 eligible prescribing physicians completed a survey. The opioid prescribing guideline was supported by 100% of survey respondents. CONCLUSIONS: An opioid prescribing guideline significantly decreased the rates at which opioids were prescribed for minor and chronic complaints in an acute care setting.

Emergency department crowding and loss of medical licensure: a new risk of patient care in hallways.

We report the case of a 32-year-old male recently diagnosed with type 2 diabetes treated at an urban university emergency department (ED) crowded to 250% over capacity. His initial symptoms of shortness of breath and feeling ill for several days were evaluated with chest radiograph, electrocardiogram (EKG), and laboratory studies, which suggested mild diabetic ketoacidosis. His medical care in the ED was conducted in a crowded hallway. After correction of his metabolic abnormalities he felt improved and was discharged with arrangements made for outpatient follow-up. Two days later he returned in cardiac arrest, and resuscitation efforts failed. The autopsy was significant for multiple acute and chronic pulmonary emboli but no coronary artery disease. The hospital settled the case for $1 million and allocated major responsibility to the treating emergency physician (EP). As a result the state medical board named the EP in a disciplinary action, claiming negligence because the EKG had not been personally interpreted by that physician. A formal hearing was conducted with the EP's medical license placed in jeopardy. This case illustrates the risk to EPs who treat patients in crowded hallways, where it is difficult to provide the highest level of care. This case also demonstrates the failure of hospital administration to accept responsibility and provide resources to the ED to ensure patient safety.

A survey of emergency physicians regarding due process, financial pressures, and the ability to advocate for patients.

BACKGROUND: A 1998 survey of emergency physicians indicated that many were threatened with adverse actions when advocating regarding the quality of care or raising concerns about financial issues. STUDY OBJECTIVES: To assess the current state of these issues. METHODS: An anonymous electronic survey of emergency physicians was conducted using the American Medical Association's database. RESULTS: Of the 1035 emergency physicians who received the survey, 389 (37.6%) answered the questions. Over half had been in practice for 16 or more years and 86% were board certified. Of those who knew the answer to the question, 62% (197 of 317) reported that their employer could terminate them without full due process and 76% (216 of 284) reported that the hospital administration could order their removal from the clinical schedule. Nearly 20% reported a possible or real threat to their employment if they raised quality-of-care concerns. Financial pressures related to admission, discharge, and transfer of patients were also noted by a number of respondents. Physicians who worked for contract management companies reported a higher incidence of impaired practice rights. CONCLUSION: Practicing emergency physicians continue to report substantial concerns regarding their ability to speak up about the quality of care and pressure regarding financial matters related to patient care.

Evaluation and management of acute abdominal pain in the emergency department.

Evaluation of the emergency department patient with acute abdominal pain is sometimes difficult. Various factors can obscure the presentation, delaying or preventing the correct diagnosis, with subsequent adverse patient outcomes. Clinicians must consider multiple diagnoses, especially those life-threatening conditions that require timely intervention to limit morbidity and mortality. This article will review general information on abdominal pain and discuss the clinical approach by review of the history and the physical examination. Additionally, this article will discuss the approach to unstable patients with abdominal pain.

A screening tool to medically clear psychiatric patients in the emergency department.

BACKGROUND: Emergency physicians are frequently called on to medically clear patients presenting with a psychiatric complaint. There is limited guidance on how to conduct this clearance. OBJECTIVE: This study evaluated the usefulness of a screening tool in ruling out serious organic disease in emergency department (ED) patients with psychiatric complaints. METHODS: A retrospective chart review was performed on 500 consecutive adult ED patients with primarily psychiatric complaints who were evaluated using the tool, and then subsequently transferred to a psychiatric crisis center. The screening tool consists of a series of historical and physical examination criteria derived from the literature intended to identify patients who have a psychiatric manifestation of an organic disease. The physician filled out the screening form and if the proper conditions were met, the patient was transferred to Psychiatry without further laboratory or imaging studies. We reviewed the charts of both the ED visit and the psychiatric crisis center visit to determine if any of the patients required further medical treatment or a medical admission rather than a psychiatric admission. RESULTS: Five hundred consecutive ED patient charts were reviewed. Fifteen of the corresponding charts from the psychiatric center could not be found. Of the remaining 485 patients, 6 patients were sent back to the ED for further evaluation. After laboratory work and imaging, none of these 6 patients required more than an outpatient prescription. CONCLUSION: The screening tool proved useful in determining if a psychiatric patient needed further medical evaluation beyond a history and physical examination before transfer for a psychiatric evaluation.

Modafinil and zolpidem use by emergency medicine residents.

OBJECTIVES: The objective was to assess the prevalence and patterns of modafinil and zolpidem use among emergency medicine (EM) residents and describe side effects resulting from use. METHODS: A voluntary, anonymous survey was distributed in February 2006 to EM residents nationally in the context of the national American Board of Emergency Medicine in-training examination. Data regarding frequency and timing of modafinil and zolpidem use were collected, as well as demographic information, reasons for use, side effects, and perceived dependence. RESULTS: A total of 133 of 134 residency programs distributed the surveys (99%). The response rate was 56% of the total number of EM residents who took the in-training examination (2,397/4,281). Past modafinil use was reported by 2.4% (57/2,372) of EM residents, with 66.7% (38/57) of those using modafinil having initiated their use during residency. Past zolpidem use was reported by 21.8% (516/2,367) of EM residents, with 15.3% (362/2,367) reporting use in the past year and 9.3% (221/2,367) in the past month. A total of 324 of 516 (62.8%) of zolpidem users initiated use during residency. Side effects were commonly reported by modafinil users (31.0%)-most frequent were palpitations, insomnia, agitation, and restlessness. Zolpidem users reported side effects (22.6%) including drowsiness, dizziness, headache, hallucinations, depression/mood lability, and amnesia. CONCLUSIONS: Zolpidem use is common among EM residents, with most users initiating use during residency. Modafinil use is relatively uncommon, although most residents using have also initiated use during residency. Side effects are commonly reported for both of these agents, and long-term safety remains unclear.

Follow-up after asymptomatic penetrating thoracic injury: 3 hours is enough.

BACKGROUND: Patients with asymptomatic penetrating thoracic injuries routinely undergo chest radiographs (CXRs) upon emergency department (ED) arrival, and then 6 hours later to exclude delayed pneumothorax (PTX) or hemothorax (HTX). Although previous reports indicate that up to 12% (mean, 3%) of asymptomatic penetrating thoracic injuries are complicated by delayed PTX or HTX, we hypothesized that these events would be detectable after only 3 hours of observation. The purpose of this study was to compare the incidence of delayed thoracic injury at 3 hours and 6 hours using standard CXR. METHODS: A prospective trial of asymptomatic patients with penetrating thoracic injuries was conducted during 36 months. CXRs were performed upon arrival (supine, AP), and at 3 hours (upright, PA/lateral) and 6 hours (upright, PA/lateral). Patients with either injuries detected on initial CXR or cardiopulmonary symptoms were excluded. Findings from 3 hour and 6 hour CXRs were compared. Assuming a delayed PTX or HTX rate of 3%, the probability of detecting at least one delayed event between 3 hours and 6 hours in 100 patients is 95.25%. RESULTS: Of 648 patients with penetrating thoracic injuries, 100 patients both met inclusion criteria and completed the study. Patients were predominantly young (32.5 years +/- 13.3 years [mean +/- SD]) men (75% men) with stab wounds (75% stab wounds, 25% gunshot wounds). The mean length of stay for patients discharged from the ED was 8.8 hours +/- 2.6 hours. Although two patients developed a PTX between arrival and 3 hours, none developed after 3 hours. Patient charges, hospital costs, and radiation exposure were calculated for patients in our proposed study protocol, totaling $2802, $189, and 0.08 mSv, respectively. CONCLUSIONS: No patient in our study population developed a delayed PTX or HTX after 3 hours. Our results suggest that shortening the observation period after asymptomatic penetrating thoracic injuries to 3 hours is safe, cost-effective, minimizes radiation exposure, and may help relieve congested urban EDs.

Substance use in emergency medicine training programs.

OBJECTIVES: To explore the prevalence of substance use among emergency medicine (EM) residents and compare to a prior study conducted in 1992. METHODS: A voluntary, anonymous survey was distributed in February 2006 to EM residents nationally in the context of the national in-service examination. Data regarding 13 substances, demographics, and perceptions of personal patterns of substance use were collected. RESULTS: A total of 133 of 134 residencies distributed the surveys (99%). The response rate was 56% of the total EM residents who took the in-service examination (2,397/4,281). The reported prevalence of most illicit drug use, including cocaine, heroin, amphetamines, and other opioids, among EM residents are low. Although residents reporting past marijuana use has declined (52.3% in 1992 to 45.0% in 2006; p < 0.001), past-year use (8.8%-11.8%; p < 0.001) and past-month use (2.5%-4.0%; p < 0.001) have increased. Alcohol use appears to be increasing, including an increase in reported daily drinkers from 3.3% to 4.9% (p < 0.001) and an increase in number of residents who indicate that their consumption of alcohol has increased during residency (from 4% to 12.6%; p < 0.001). CONCLUSIONS: Self-reported use of most street drugs remains uncommon among EM residents. Marijuana and alcohol use, however, do appear to be increasing. Educators should be aware of these trends, and this may allow them to target resources for impaired and at-risk residents.

Abdominal pain.

Evaluation of the elderly patient with acute abdominal pain is sometimes difficult. Various factors can obscure the presentation, delaying or preventing the correct diagnosis and leading to adverse patient outcomes. Clinicians must consider multiple diagnoses, especially those life-threatening conditions that require timely intervention to limit morbidity and mortality. This article reviews abdominal pain in the elderly, discusses the clinical approach, and highlights key diagnostic considerations.

Femoral phlebotomy: the vacuum tube method is preferable over needle syringe.

A syringe needle (SN) is commonly used to obtain blood specimens from the femoral vein. The vacuum tube (VT) method avoids the needle stick potential of the SN technique during transfer of blood from the syringe to the collection tubes. We compared the perceived safety, patient pain, and efficacy of SN and VT for femoral phlebotomy in a prospective trial. Of 64 patients entered, 38 (59%) had the VT technique and 26 (41%) had the SN technique. There was no significant difference in the success rate between VT and SN (100% vs. 95%, respectively). The VT method was somewhat faster than the SN method (104 +/- 109 vs. 181 +/- 149 s, respectively, p = 0.06). Complications were infrequent and not different between the groups. The mean patient pain score +/- SD on a 10-cm visual analog scale for the VT and SN techniques were 2.6 +/- 2.2 and 3.7 +/- 2.7, respectively (p < 0.001). Physicians subjectively rated the safety of the procedure higher for the VT method than for the SN method. Medical personnel should consider use of the VT method instead of the traditional SN technique for femoral phlebotomy.

Clinical decision rules and cervical spine injury in an elderly patient: a word of caution.

We report a case of a clinically significant cervical spine fracture in an elderly patient without midline cervical tenderness. Application of the NEXUS rule by the treating physicians ruled out the need for radiography. However, knowledge of the Canadian C-spine rule and clinical judgment prompted obtaining a three-view trauma series of the cervical spine and, when the patient's pain increased, a computed tomography scan of the cervical spine. A type III fracture of the dens was found. In review of the case it was recognized that application of the NEXUS rule for this patient was problematic regarding the assessment of mental status. Specifically, the treating physicians did not strictly adhere to the detailed explanations attached to the NEXUS criteria regarding mental status. Clinicians may wish to preferentially apply the Canadian rule for patients over the age of 64 years.

Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients.

A number of cardiopulmonary and neurological symptoms are presumed to be associated with hypertension. We examined the prevalence of these symptoms in ED patients with elevated blood pressure (BP) and studied the relationship between symptom prevalence and BP value. We enrolled consecutive adult ED patients with sustained BP elevation (systolic BP>or=140 mm Hg, diastolic BP>or=90 mm Hg). BP values were categorized according to Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure, 6th Report criteria. Elevated BP was noted in 551 (29%) of 1908 patients. Unprompted complaints of hypertension-associated symptoms were noted in 26%, and there was no association between BP category and complaints other than dyspnea. Symptom interviews were conducted in 294 (56%) patients; 68% of this subset noted >or=1 current hypertension-associated symptom with no relationship between symptom prevalence and BP category. We conclude that symptoms putatively associated with hypertension are common among ED patients with elevated BP, and their prevalence appears unrelated to BP value.