Impact of Expanding Screening Colonoscopy Interval on Providers Choice of Prescribing Colonoscopy for Colorectal Cancer Screening.

GOALS: We investigated if increasing the colonoscopy screening interval from 10 to 15 years would increase provider preferences for colonoscopy as a screening test. We further examined whether having colonoscopy performed at a 15-year interval by an endoscopist with a high adenoma detection rate would influence preferences. BACKGROUND: Colonoscopy is recommended every 10 years in average risk individuals without polyps for colorectal cancer (CRC) screening. The use of a 15-year interval offers substantial protection, increases cost-effectiveness, and might make colonoscopy more attractive to patients and health care providers who order CRC screening tests. STUDY: An anonymous online survey of health care providers across a health care system that serves a single US state and encompasses both academic and community physicians was conducted. Physicians and nurse practitioners in family medicine, obstetrics-gynecology, and internal medicine were included. Providers were asked to indicate their preference for CRC screening tests as a proportion of tests they prescribe among 5 common screening tools. Responses were compared for current colonoscopy screening intervals and if the screening intervals are increased to 15 years. RESULTS: One hundred and twelve (34%) responded of 326 providers. Colonoscopy was the most frequently ordered test for CRC screening. Increasing screening interval from 10 to 15 years increased the choice of colonoscopy from 75.2% to 78.6% ( P =0.003). CONCLUSIONS: Expanding colonoscopy screening interval to 15 years could produce an increase in physicians and nurse practitioners choice of using colonoscopy for CRC screening, but the clinical impact appears minor. Additional surveys of patients and providers are needed.

Crohn's pericarditis identified with point-of-care ultrasonography: A case report.

We report the case of a 71-year-old male with Crohn's disease, shortness of breath, and chest pain that highlights cardiac involvement in inflammatory bowel disease and the role of point-of-care ultrasonography using an alternate cardiac ultrasound window in making the diagnosis of Crohn's pericarditis. The role of ultrasonography in diagnosis and management of inflammatory bowel disease focuses primarily on intestinal pathology. Cardiac involvement is a rare but clinically impactful extraintestinal manifestation, the diagnosis of which benefits from ultrasonography if the clinician performing and interpreting the exam is aware of the possibility and understands the potential value of whole-body ultrasonography as part of a physical exam.

Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study.

STUDY OBJECTIVE: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding. METHODS: In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). RESULTS: We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability. CONCLUSION: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.

A Multicenter Evaluation of Emergency Department Pain Care Across Different Types of Fractures.

Objectives: To identify differences in emergency department (ED) pain-care based on the type of fracture sustained and to examine whether fracture type may influence the more aggressive analgesic use previously demonstrated in older patients. Design: Secondary analysis of retrospective cohort study. Setting: Five EDs (four academic, one community) in the United States. Participants: Patients (1,664) who presented in January, March, July, and October 2009 with a final diagnosis of fracture (774 long bone [LBF], 890 shorter bone [SBF]). Measurements: Primary-predictor was type of fracture (LBF vs. SBF). Pain-care process outcomes included likelihood of analgesic administration, opioid-dose, and time to first analgesic. General estimating equations were used to control for age, gender, race, baseline pain score, triage acuity, comorbidities and ED crowding. Subgroup analyses were conducted to analyze age-based differences in pain care by fracture type. Results: A larger proportion of patients with LBF (30%) were older (>65 years old) compared to SBF (13%). Compared with SBF, patients with LBF were associated with greater likelihood of analgesic-administration (OR = 2.03; 95 CI = 1.58 to 2.62; P < 0.001) and higher opioid-doses (parameter estimate = 0.268; 95 CI = 0.239 to 0.297; P < 0.001). When LBF were examined separately, older-patients had a trend to longer analgesic wait-times (99 [55-163] vs. 76 [35-149] minutes, P = 0.057), but no other differences in process outcomes were found. Conclusion: Long bone fractures were associated with more aggressive pain care than SBF. When fracture types were examined separately, older patients did not appear to receive more aggressive pain care. This difference should be accounted for in further research.

Association Between Patient and Emergency Department Operational Characteristics and Patient Satisfaction Scores in a Pediatric Population.

BACKGROUND: Emergency departments (EDs) are seeing an increase in the importance of patient satisfaction scores, yet little is known about their association with patient and operational characteristics. OBJECTIVES: This study aimed to identify patient and operational characteristics associated with patient satisfaction scores. METHODS: This was a retrospective analysis of data from Press Ganey patient satisfaction surveys of pediatric patients (<18 years) and their families, discharged from the ED of a single, academic, pediatric ED from December 2009 to May 2013. A linear mixed-effects regression model was used to identify significant associations while taking the clustering within patients and physicians into account. Outcome variables included scores for overall experience (0-10), wait time to be seen by a provider (0-100), and likelihood to recommend (0-100). The ED characteristics considered included daily census, proportion of left without being seen, average length of stay (LOS), and total boarding hours, as well as time of day by shift, door-to-room time, and discharge LOS. Patient characteristics included patient age, sex, race, person completing survey, survey language, survey method (mailed or online), payer type, mode of arrival, distance to hospital, weekend or weekday visit, and difference of patient-reported LOS to actual LOS. Only statistically significant variables were included in the final model. RESULTS: A total of 810 pediatric surveys were included for analysis. The overall mean (SD) was 8.7 (2.0) for overall experience, 84.0 (23.5) for waiting time to be seen by a provider, and 90.1 (22.2) for likelihood to recommend. The score for overall experience was highly correlated with likelihood to recommend (r = 0.90) and less strongly correlated with score for waiting time (r = 0.58). In the final models, increased door-to-room time was associated with a significant decrease in scores for all 3 outcome variables. In addition, a difference between perceived and actual LOS (>2 hours) was significantly associated with lower scores in overall experience and likelihood to recommend, whereas surveys completed online had higher scores for waiting time to see a provider compared with mailed. CONCLUSIONS: Emergency departments looking to increase satisfaction scores should focus efforts on decreasing door-to-room times.

A Multicenter Evaluation of the Impact of Sex on Abdominal and Fracture Pain Care.

BACKGROUND: Previous studies examining sex-based disparities in emergency department (ED) pain care have been limited to a single pain condition, a single study site, and lack rigorous control for confounders. OBJECTIVE: A multicenter evaluation of the effect of sex on abdominal pain (AP) and fracture pain (FP) care outcomes. RESEARCH DESIGN: A retrospective cohort review of ED visits at 5 US hospitals in January, April, July, and October 2009. SUBJECTS: A total of 6931 patients with a final ED diagnosis of FP (n=1682) or AP (n=5249) were included. MEASURES: The primary predictor was sex. The primary outcome was time to analgesic administration. Secondary outcomes included time to medication order, and the likelihood of receiving an analgesic and change in pain scores 360 minutes after triage: Multivariable models, clustered by study site, were conducted to adjust for race, age, comorbidities, initial pain score, ED crowding, and triage acuity. RESULTS: On adjusted analyses, compared with men, women with AP waited longer for analgesic administration [AP women: 112 (65-187) minutes, men: 96 (52-167) minutes, P<0.001] and ordering [women: 84 (41-160) minutes, men: 71 (32-137) minutes, P<0.001], whereas women with FP did not (Administration: P=0.360; Order: P=0.133). Compared with men, women with AP were less likely to receive analgesics in the first 90 minutes (OR=0.766; 95% CI, 0.670-0.875; P<0.001), whereas women with FP were not (P=0.357). DISCUSSION: In this multicenter study, we found that women experienced delays in analgesic administration for AP, but not for FP. Future research and interventions to decrease sex disparities in pain care should take type of pain into account.

Associations between patient and emergency department operational characteristics and patient satisfaction scores in an adult population.

STUDY OBJECTIVE: Our primary aim is to identify patient and emergency department (ED) characteristics that are associated with patient satisfaction scores. METHODS: This retrospective study reviewed Press Ganey patient satisfaction surveys completed between December 2009 and May 2013 in a single academic ED for all patients aged 21 years and older. Patient and ED operational characteristics were included in the analysis. The outcomes were satisfaction scores for overall experience, likelihood to recommend, and wait time before consulting provider. A linear mixed-effects regression model was used while taking the clustering within patients and physicians into account. RESULTS: Two thousand eighty-three patients were included in the analysis, representing all responses to the survey. A total response rate could not be calculated because Press Ganey does not report the total number of surveys sent out. During this period, 119,244 patients were treated in the ED. The overall mean score was 7.7 (SD 2.7) for overall experience, 78.0 (SD 31.8) for likelihood to recommend, and 70.9 (SD 30.7) for wait time before consulting provider. For all 3 outcomes, white older patients with low door-to-room times had higher scores. Additionally, survey language and payer type were significantly associated with overall experience score, discharge length of stay and time of day by shift were significantly associated with wait time scores, and patients who arrive by ambulance were less likely to recommend the ED. CONCLUSION: Both ED and patient characteristics were associated with satisfaction with care. EDs seeking to increase patient satisfaction scores may consider working on reducing door-to-room times.

Is outpatient emergency department care profitable? Hourly contribution margins by insurance for patients discharged from an emergency department.

STUDY OBJECTIVE: We determine the contribution margin per hour (ie, profit) by facility evaluation and management (E&M) billing level and insurance type for patients treated and discharged from an urban, academic emergency department (ED). METHODS: Billing and demographic data for patients treated and discharged from an ED with greater than 100,000 annual visits between 2003 and 2009 were collected from hospital databases. The primary outcome was contribution margin per patient per hour. Contribution margin by insurance type (excluding self-pay) was determined at the patient level by subtracting direct clinical costs from contractual revenue. Hospital overhead and physician expenses and revenue were not included. RESULTS: In 523,882 outpatient ED encounters, contribution margin per hour increased with increasingly higher facility billing level for patients with commercial insurance ($70 for E&M level 1 to $177 at E&M level 5) but decreased for patients with Medicare ($44 for E&M level 1 to $29 at E&M level 5) and Medicaid ($73 for E&M level 1 to -$16 at E&M level 5). During the study years, cost, charge, revenue, and length of stay increased for each billing level. CONCLUSION: In our hospital, contribution margin per hour in ED outpatient encounters varied significantly by insurance type and billing level; commercially insured patients were most profitable and Medicaid patients were least profitable. Contribution margin per hour for patients commercially insured increased with higher billing levels. In contrast, for Medicare and Medicaid patients, contribution margin per hour decreased with higher billing levels, indicating that publicly insured ED outpatients with higher acuity (billing level) are less profitable than similar, commercially insured patients.

Association of emergency department and hospital characteristics with elopements and length of stay.

BACKGROUND: As the Centers for Medicare & Medicaid Services (CMS) core measures in 2013 compare Emergency Department (ED) treatment time intervals, it is important to identify ED and hospital characteristics associated with these metrics to facilitate accurate comparisons. STUDY OBJECTIVES: The objective of this study is to assess differences in operational metrics by ED and hospital characteristics. ED-level characteristics included annual ED volume, percentage of patients admitted, percentage of patients presenting by ambulance, and percentage of pediatric patients. Hospital-level characteristics included teaching hospital status, trauma center status, hospital ownership (nonprofit or for-profit), inpatient bed capacity, critical access status, inpatient bed occupancy, and rural vs. urban location area. METHODS: Data from the ED Benchmarking Alliance from 2004 to 2009 were merged with the American Hospital Association's Annual Survey Database to include hospital characteristics that may impact ED throughput. Overall median length of stay (LOS) and left before treatment is complete (LBTC) were the primary outcome variables, and a linear mixed model was used to assess the association between outcome variables and ED and hospital characteristics, while accounting for correlations among multiple observations within each hospital. All data were at the hospital level on a yearly basis. RESULTS: There were 445 EDs included in the analysis, from 2004 to 2009, with 850 observations over 6 years. Higher-volume EDs were associated with higher rates of LBTC and LOS. For-profit hospitals had lower LBTC and LOS. Higher inpatient bed occupancies were associated with a higher LOS. Increasing admission percentages were positively associated with overall LOS for EDs, but not with rates of LBTC. CONCLUSIONS: Higher-volume EDs are associated with higher LBTC and LOS, and for-profit hospitals appear more favorably in these metrics compared with their nonprofit counterparts. It is important to appreciate that hospitals have different baselines for performance that may be more tied to volume and capacity, and less to quality of care.

Creating critical palliative hypnotic adjustments: temporality, hope, and meaning.

When cure is not possible, suffering often takes form as pain and distressing symptoms, death anxiety, existential distress, and meaninglessness. This paper describes important elements connecting palliative care principles with hypnotic approaches designed to provide support, palliate symptoms, foster hope, and address existential and spiritual distress. We offer a developmental process for and examples of hypnotic suggestions customized to simultaneously ameliorate physical symptoms and address profound distress arising from physical, social, psychological, existential, and spiritual challenges commonly encountered in terminal illness. This process necessarily requires use of the patient's vernacular to hypnotically deepen inwardly focused attention in order to explore and access internal resources, reframe negative automatic thoughts, and create positive meanings for experiences that disinvite suffering. Effective delivery utilizes cognitive tools such as clinical and scientific principles, artistic forms such as poetry and haiku, and a thorough assessment of needs. This approach strategically addresses an overarching dimension of temporality through suggestions that sequentially address multiple sources of suffering that are layered throughout the various dimensions of self. This requires focus and presence in the present moment; it ultimately fosters a therapeutic relationship that can safely hold past painful experience as helpful new meanings emerge that build resiliency for that experience. This work benefits from inwardly focused concentration and a holding environment to identify and access helpful inner resources, which include an increasingly malleable relationship with temporal memories.

The digital rectal examination: a multicenter survey of physicians' and students' perceptions and practice patterns.

OBJECTIVES: The digital rectal examination (DRE) may be underutilized. We assessed the frequency of DREs among a variety of providers and explored factors affecting its performance and utilization. METHODS: A total of 652 faculty, fellows, medical residents, and final-year medical students completed a questionnaire about their use of DREs. RESULTS: On average, 41 DREs per year were performed. The yearly number of examinations was associated with years of experience and specialty type. Patient refusal rates were lowest among gastroenterology (GI) faculty and highest among primary-care doctors. Refusal rates were negatively correlated with comfort level of the physician in performing a DRE. More gastroenterologists used sophisticated methods to detect anorectal conditions, and gastroenterologists were more confident in diagnosing them. Confidence in making a diagnosis with a DRE was strongly associated with the number of DREs performed annually. CONCLUSIONS: The higher frequencies of performing a DRE, lower refusal rate, degree of comfort, diagnostic confidence, and training adequacy were directly related to level of experience with the examination. Training in DRE technique has diminished and may be lost. The DRE's role in medical school and advanced training curricula needs to be re-established.

Palliative care outcomes in surgical oncology patients with advanced malignancies: a mixed methods approach.

PURPOSE: To prospectively compare outcomes and processes of hospital-based early palliative care with standard care in surgical oncology patients (N = 152). METHODS: A randomized, mixed methods, longitudinal study evaluated the effectiveness of a hospital-based Pain and Palliative Care Service (PPCS). Interviews were conducted presurgically and at follow-up visits up to 1 year. Primary outcome measures included the Gracely Pain Intensity and Unpleasantness Scales and the Symptom Distress Scale. Qualitative interviews assessed social support, satisfaction with care, and communication with providers. Survival analysis methods explored factors related to treatment crossover and study discontinuation. Models for repeated measures within subjects over time explored treatment and covariate effects on patient-reported pain and symptom distress. RESULTS: None of the estimated differences achieved statistical significance; however, for those who remained on study for 12 months, the PPCS group performed better than their standard of care counterparts. Patients identified consistent communication, emotional support, and pain and symptom management as positive contributions delivered by the PPCS. CONCLUSIONS: It is unclear whether lower pain perceptions despite greater symptom distress were clinically meaningful; however, when coupled with the patients' perceptions of their increased resources and alternatives for pain control, one begins to see the value of an integrated PPCS.

The impact of an ED-only full-capacity protocol.

OBJECTIVE: The objective of this study was to assess the impact of an emergency department (ED)-only full-capacity protocol and diversion, controlling for patient volumes and other potential confounding factors. METHODS: This was a preintervention and postintervention cohort study using data 12 months before and 12 months after the implementation of the protocol. During the implementation period, attending physicians and charge nurses were educated with clear and simple figures on the criteria for the initiation of the new protocol. A multiple logistic regression model was used to compare ambulance diversion between the 2 periods. RESULTS: The proportion of days when the ED went on diversion at least once during a 24-hour period was 60.4% during the preimplementation period and 20% in the postimplementation periods (P < .001). In the multivariate logistic regression model, the use of the new protocol was significantly associated with decreased odds of diversion rate in the postimplementation period (odds ratio, 0.32; 95% confidence interval, 0.21-0.48). CONCLUSION: Our predivert/full-capacity protocol is a simple and generalizable strategy that can be implemented within the boundaries of the ED and is significantly associated with a decreased diversion rate.

Predictors of patient length of stay in 9 emergency departments.

OBJECTIVES: Prolonged emergency department (ED) length of stay (LOS) is linked to adverse outcomes, decreased patient satisfaction, and ED crowding. This multicenter study identified factors associated with increased LOS. METHODS: This retrospective study included 9 EDs from across the United States. Emergency department daily operational metrics were collected from calendar year 2009. A multivariable linear population average model was used with log-transformed LOS as the dependent variable to identify which ED operational variables are predictors of LOS for ED discharged, admitted, and overall ED patient categories. RESULTS: Annual ED census ranged from 43,000 to 101,000 patients. The number of ED treatment beds ranged from 27 to 95. Median overall LOS for all sites was 5.4 hours. Daily percentage of admitted patients was found to be a significant predictor of discharged and admitted patient LOS. Higher daily percentage of discharged and eloped patients, more hours on ambulance diversion, and weekday (vs weekend) of patient presentation were significantly associated with prolonged LOS for discharged and admitted patients (P < .05). For each percentage of increase in discharged patients, there was a 1% associated decrease in overall LOS, whereas each percentage of increase in eloped patients was associated with a 1.2% increase in LOS. CONCLUSIONS: Length of stay was increased on days with higher percentage daily admissions, higher elopements, higher periods of ambulance diversion, and during weekdays, whereas LOS was decreased on days with higher numbers of discharges and weekends. This is the first study to demonstrate this association across a broad group of hospitals.

Efficacy and safety of EMR to completely remove Barrett's esophagus: experience in 41 patients.

BACKGROUND: EMR is typically used to remove focal abnormalities of the esophageal mucosa. However, larger areas of Barrett's esophagus (BE) can be resected through side-by-side resections. OBJECTIVE: To assess the efficacy and safety of EMR to completely remove BE. DESIGN: Retrospective, single-center study. SETTING: University of Iowa Hospitals and Clinics. PATIENTS: Between January 2006 and December 2010, 46 patients underwent EMR for complete removal of BE. Three were lost to follow-up, one died of unrelated causes before completion, and one was still undergoing EMR treatment at the conclusion of the study. The remaining 41 patients were included for analysis. The worst histologic grade was low-grade dysplasia in 4 patients, high-grade dysplasia without cancer in 26 patients, and high-grade dysplasia with superficial adenocarcinoma in 11 patients. BE was circumferential in 65.9% of cases, and the mean (± SD) length was 3.3 ± 2.3 cm. INTERVENTION: EMR was performed by using a cap (n = 4), a multiband ligator device (n = 31), or both (n = 6), with a mean (± SD) of 2.4 ± 1.2 sessions per patient. MAIN OUTCOME MEASUREMENTS: Remission rates and complications. RESULTS: Remission of high-grade dysplasia and cancer, all dysplasia, and all BE was achieved in 94.6%, 85.4%, and 78.0%, respectively. Complications included minor bleeding (31.7%), perforations (4.9%), and strictures (43.9%). All complications were managed conservatively. LIMITATIONS: Retrospective design. CONCLUSION: Complete removal of BE with EMR is effective but associated with a high complication rate, which is mainly related to stricture formation. This needs to be considered when choosing between available treatment modalities.

Fixed-wing medical transport crashes: characteristics associated with fatal outcomes.

INTRODUCTION: Previous studies within the aeromedical literature have looked at factors associated with fatal outcomes in helicopter medical transport, but no analysis has been conducted on fixed-wing aeromedical flights. The purpose of this study was to look at fatality rates in fixed-wing aeromedical transport and compare them with general aviation and helicopter aeromedical flights. METHODS: This study looked at factors associated with fatal outcomes in fixed-wing aeromedical flights, using the National Transportation Safety Board Aviation Accident Incident Database from 1984 to 2009. RESULTS: Fatal outcomes were significantly higher in medical flights (35.6 vs. 19.7%), with more aircraft fires (20.3 vs. 10.5%) and on-ground collisions (5.1 vs. 2.0%) compared with commercial flights. Aircraft fires occurred in 12 of the 21 fatal crashes (57.1%), compared with only 2 of the 38 nonfatal crashes (5.3%) (P < .001). In the multiple logistic regression model, the only factor with increased odds of a fatal outcome was the presence of a fire (56.89; 95% CI, 4.28-808.23). CONCLUSIONS: Similar to published studies in helicopter medical transport, postcrash fires are the primary factor associated with fatal outcomes in fixed-wing aeromedical flights.

Spiritual well-being in long-term survivors with chronic graft-versus-host disease after hematopoietic stem cell transplantation.

Spiritual well-being (Sp-WB) is a resource that supports adaptation and resilience, strengthening quality of life (QOL) in patients with cancer or other chronic illnesses. However, the relationship between Sp-WB and QOL in patients with chronic graft-versus-host disease (cGVHD) remains unexamined. Fifty-two participants completed the Functional Assessment of Chronic Illness Therapy-Spiritual WellBeing (FACIT-Sp) questionnaire as part of a multidisciplinary study of cGVHD. Sp-WB was generally high. Those with the lowest Sp-WB had a significantly longer time since diagnosis of cGVHD (P = 0.05) than those with higher Sp-WB. There were no associations between Sp-WB and demographics, cGVHD severity, or intensity of immunosuppression. Participants with the lowest Sp-WB reported inferior physical (P = 0.0009), emotional (P = 0.003), social (P = 0.027), and functional well-being (P < 0.0001) as well as lower overall QOL (P < 0.0001) compared with those with higher Sp-WB. They also had inferior QOL relative to population norms. Differences between the group reporting the lowest Sp-WB and those groups who reported the highest Sp-WB scores consistently demonstrated a significant difference for all QOL subscales and for overall QOL. Controlling for physical, emotional, and social well-being, Sp-WB was a significant independent predictor of contentment with QOL. Our results suggest that Sp-WB is an important factor contributing to the QOL of patients with cGVHD. Research is needed to identify factors that diminish Sp-WB and to test interventions designed to strengthen this coping resource in patients experiencing the late effects of treatment.

Implementing electronic health records in the emergency department.

BACKGROUND: The increasing presence of electronic health records (EHRs) in health care presents interesting and unique challenges in the Emergency Department (ED) setting. Unfortunately, scant literature exists addressing the implementation of EHRs in this setting. OBJECTIVES: The authors, both involved in the implementation of such systems at their respective institutions, review the challenges and benefits that exist with such implementation, and the steps that EDs can take to facilitate this process. DISCUSSION: Unlike ambulatory and inpatient settings, where patient volume can be adjusted to help with this transition, EDs are unable to alter their volume and must maximize their efficiency during this process. CONCLUSIONS: Understanding and anticipating the EHR's impact on workflow is critical to successful implementation.