Improving patient flow in acute coronary syndromes in the face of hospital crowding.

BACKGROUND: The current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease. OBJECTIVE: To measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS. METHODS: Primary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post-availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death. RESULTS: In the post-implementation period there was a 30% (95% confidence interval [CI] 36-44%) reduction in admissions to telemetry with a 33% (95% CI 26-39%) reduction in ED LOS and a 20% (95% CI 7-34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p=0.001). CONCLUSION: The focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS.

Hepatic dysfunction and neurotoxicity in a patient receiving long-term low-dose amiodarone therapy.

BACKGROUND: Amiodarone is commonly used in the treatment of refractory paroxysmal atrial fibrillation. Much of the literature focuses on the toxic effects of this medication in the setting of rapid loading or long-term therapy with high maintenance doses. However, patients have been known to develop multi-organ toxicities with long-term low-dose therapy. CASE REPORT: We present a 90-year-old man with paroxysmal atrial fibrillation undergoing low-dose amiodarone therapy for a period of 18 months without medical follow-up who developed signs and symptoms consistent with neurotoxicity and hepatotoxicity in association with hyperammonemia. Upon discontinuation of the medication and treatment of the hyperammonemia, the patient had a rapid decline in symptoms and a return to his baseline status. CONCLUSION: Identifying toxicity early and correcting it rapidly may prevent life-threatening sequelae associated with amiodarone toxicity.

Academic emergency medicine faculty and industry relationships.

OBJECTIVES: The authors surveyed the membership of the Society for Academic Emergency Medicine (SAEM) about their associations with industry and predictors of those associations. METHODS: A national Web-based survey inviting faculty from the active member list of SAEM was conducted. Follow-up requests for participation were sent weekly for 3 weeks. Information was collected on respondents' personal and practice characteristics, industry interactions, and personal opinions regarding these interactions. Raw response rates were reported and a logistic regression was used to generate descriptive statistics. RESULTS: Responses were received from 430 members, representing 14% of the 3,183 active members. Respondents were 83% male and 86% white, with 96% holding an MD degree (24% with an additional postdoctoral degree). Most were at the assistant (37%) or associate (25%) professor rank, with 51% holding at least one leadership position. Most respondents (82%) reported some type of industry interaction, most commonly the acceptance of food or beverages (67%). Respondents at the associate professor rank or higher were more likely to receive payments from industry (51% vs. 22%, odds ratio [OR] = 3.7). CONCLUSIONS: This survey suggests that interactions between industry and academic EM faculty are common and increase with academic rank, but not with years in practice or leadership influence. The number and type of interactions are consistent with those reported by a national sampling of other physician specialties.

Emergency department crowding: factors influencing flow.

BACKGROUND: THE OBJECTIVE OF THIS STUDY WAS TO EVALUATE THOSE FACTORS, BOTH INTRINSIC AND EXTRINSIC TO THE EMERGENCY DEPARTMENT (ED) THAT INFLUENCE TWO SPECIFIC COMPONENTS OF THROUGHPUT: "door-to-doctor" time and dwell time. METHODS: We used a prospective observational study design to determine the variables that played a significant role in determining ED flow. All adult patients seen or waiting to be seen in the ED were observed at 8pm (Monday-Friday) during a three-month period. Variables measured included daily ED volume, patient acuity, staffing, ED occupancy, daily admissions, ED boarder volume, hospital volume, and intensive care unit volume. Both log-rank tests and time-to-wait (survival) proportional-hazard regression models were fitted to determine which variables were most significant in predicting "door-to-doctor" and dwell times, with full account of the censoring for some patients. RESULTS: We captured 1,543 patients during our study period, representing 27% of total daily volume. The ED operated at an average of 85% capacity (61-102%) with an average of 27% boarding. Median "door-to-doctor" time was 1.8 hours, with the biggest influence being triage category, day of the week, and ED occupancy. Median dwell time was 5.5 hours with similar variable influences. CONCLUSION: The largest contributors to decreased patient flow through the ED at our institution were triage category, ED occupancy, and day of the week. Although the statistically significant factors influencing patient throughput at our institution involve problems with inflow, an increase in ED occupancy could be due to substantial outflow obstruction and may indicate the necessity for increased capacity both within the ED and hospital.

The association between money and opinion in academic emergency medicine.

OBJECTIVES: Financial conflicts of interest have come under increasing scrutiny in medicine, but their impact has not been quantified. Our objective was to use the results of a national survey of academic emergency medicine (EM) faculty to determine if an association between money and personal opinion exists. METHODS: We conducted a web-based survey of EM faculty. Opinion questions were analyzed with regard to whether the respondent had either 1) received research grant money or 2) received money from industry as a speaker, consultant, or advisor. Responses were unweighted, and tests of differences in proportions were made using Chi-squared tests, with p<0.05 set for significance. RESULTS: We received responses from 430 members; 98 (23%) received research grants from industry, while 145 (34%) reported fee-for-service money. Respondents with research money were more likely to be comfortable accepting gifts (40% vs. 29%) and acting as paid consultants (50% vs. 37%). They had a more favorable attitude with regard to societal interactions with industry and felt that industry-sponsored lectures could be fair and unbiased (52% vs. 29%). Faculty with fee-for-service money mirrored those with research money. They were also more likely to believe that industry-sponsored research produces fair and unbiased results (61% vs. 45%) and less likely to believe that honoraria biased speakers (49% vs. 69%). CONCLUSION: Accepting money for either service or research identified a distinct population defined by their opinions. Faculty engaged in industry-sponsored research benefitted socially (collaborations), academically (publications), and financially from the relationship.