Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation.

BACKGROUND: Reperfusion of ST elevation myocardial infarction (STEMI) is most effective when performed early. Notification of the cardiac catheterization laboratory (cath lab) prior to hospital arrival based on paramedic-performed ECGs has been proposed as a strategy to decrease time to reperfusion and mortality. The purpose of this study was to compare the effects of cath lab activation prior to patient arrival versus activation after arrival at the emergency department (ED). METHODS: We performed a retrospective cohort study (n = 1933 cases) using Los Angeles County STEMI database from May 1, 2008 through August 31, 2009. The database includes patients arriving at a STEMI Receiving Center (SRC) by ambulance who were diagnosed with STEMI either before or after hospital arrival. We compared the cohort of patients with prehospital cath lab activation to those activated from the ED within 5 minutes of first ED ECG. Outcomes measured were mortality, door-to-balloon time, percent door-to-balloon time <90 min, and percentage of false-positive activations. RESULTS: Prehospital cath lab activations had mean door-to-balloon times 14 minutes shorter (95% CI 11-17), in-hospital mortality 1.5% higher (95% CI -1.0-5.2), and false-positive activation 7.8%, (95% CI 2.7-13.3) higher than ED activation. For prehospital activation, 93% (95% CI 91-94%) met a door-to-balloon target of 90 minutes versus 85% (95% CI 80-88%) for ED activations. CONCLUSION: Prehospital cath lab activation based on the prehospital ECG was associated with decreased door-to-balloon times but did not affect hospital mortality. False-positive activation was common and occurred more often with prehospital STEMI diagnosis.

At-risk populations and the critically ill rely disproportionately on ambulance transport to emergency departments.

STUDY OBJECTIVE: Emergency department (ED) crowding increases ambulance diversion. Ambulance diversion disproportionately affects individuals who rely on ambulance transport. The purpose of this study is to determine which populations rely most on ambulance transport. METHODS: We queried the National Hospital Ambulatory Medical Care Survey database for 1997 to 2000 and 2003 to 2005 for patients who arrived by ambulance or personal transport. We performed bivariate analysis to assess the extent to which all patients and a subset of critically ill patients use ambulance transport relative to self-transport. RESULTS: In our sample, 30,455 (15%; 95% confidence interval [CI] 15% to 16%) patients arrived by ambulance and 162,091 (85%; 95% CI 84% to 85%) arrived by walk-in/self-transport. Overall, patients with Medicare insurance were more likely to rely on ambulance transport, at 34% (95% CI 33% to 35%), than the privately insured, at 11% (95% CI 10% to 11%). Among the critically ill, privately insured patients were less likely to rely on ambulance transport, at 47% (95% CI 42% to 52%), than those with Medicare insurance (61%; 95% CI 58% to 65%), the publicly insured (60%; 95% CI 52% to 67%), or the uninsured (57%; 95% CI 49% to 64%). Among the critically ill, patients aged 15 to 24 years and those older than 74 years were most likely to rely on ambulance transport, at 63% (95% CI 53% to 72%) and 67% (95% CI 62% to 71%), respectively. Fifty-seven percent (95% CI 54% to 59%) of the critically ill used ambulance versus 15% (95% CI 14% to 15%) of noncritical patients. CONCLUSION: Patients with Medicare insurance or public insurance, the uninsured, the elderly, and the critically ill disproportionately rely on ambulance transport to the ED. Ambulance diversion may disproportionately affect these populations.

Griev_Ing: death notification skills and applications for fourth-year medical students.

BACKGROUND AND PURPOSE: Our study examined whether GRIEV_ING improved death notification skills of medical students, whether pretesting with simulated survivors primed learners and improved results of the intervention, and whether feedback on the simulated encounter improved student performance. METHODS: GRIEV_ING training was given to 138 fourth-year medical students divided into three groups: exposure to simulated survivor (SS) with written feedback, exposure to SS but no feedback, and no exposure to SS before the training. Students were tested on self-confidence before and after the intervention and were rated by SSs on interpersonal communication and death notification skills. ANCOVA was performed, with gender and race covariates. RESULTS: All groups improved on death notification competence and confidence at about the same rate. Competence significantly (p =.037) improved for the feedback group. Interpersonal communication scores declined for all groups. CONCLUSIONS: GRIEV_ING provides an effective model medical educators can use to train medical students to provide competent death notifications. Senior medical students are primed to learn death notification and do not require a preexposure.

The influence of the causes and contexts of medical errors on emergency medicine residents' responses to their errors: an exploration.

PURPOSE: To determine emergency medicine residents' emotional and behavioral responses to their medical errors and examine associations between residents' responses to medical error and perceptions of their training. METHOD: In 2003, 55 residents at two U.S. residency programs were asked to complete questionnaires about their errors and responses to their errors in three domains: emotional response, learning behavior, and disclosure. The questions were a mixture of free text, yes/no responses, and some were rated using a five-point Likert scale. Based on a conceptual framework, the authors constructed scales to describe the various domains and associations between the residents' responses to medical error and perceptions of their training were examined using Somers' D. RESULTS: A total of 43 residents returned questionnaires (80%); 40 of these residents described errors. Thirty-three (83%) residents discussed the error with someone; 27 (71%) with the attending and 10 (28%) with the patient/family. Negative emotions were common: 27 (68%) felt remorse, 21 (53%) guilt, 23 (58%) inadequacy, and 22 (55%) frustration. Residents' negative emotional responses were associated with their personal characteristics [26% (95% CI, 5-47%) association with lack of experience] and residents' perceptions of their training environment: 15% association with job overload (95% CI, -8-38%) and 23% association with lack of institutional support (95% CI, 5-41%). While 32 (81%) residents increased attention to detail, only 2 (5%) increased their use of evidence-based medicine. CONCLUSIONS: Errors committed by emergency medicine residents often resulted in negative emotions, limited constructive system-based improvements, and inadequate disclosure. Negative perceptions of the training environment are associated with negative emotional responses.

Inadequate follow-up controller medications among patients with asthma who visit the emergency department.

STUDY OBJECTIVE: The purpose of this study is to determine the frequency with which primary care physicians add inhaled corticosteroids to the regimen of asthmatic patients after a visit to the emergency department (ED) among patients not previously prescribed inhaled corticosteroids and to determine the rate at which inhaled corticosteroids prescribed in the ED were continued by primary care physicians. METHODS: We conducted a structured retrospective cohort study using electronic medical record review of consecutive patients aged 6 to 45 years, treated for acute asthma exacerbation (International Classification of Diseases, Ninth Revision code 493.00 through 493.99) in the ED during a specified 6-month period, and followed up for 1 year. The patients' first ED visit for asthma exacerbation during the study period was considered the index visit for purposes of this study. RESULTS: Six hundred twenty-nine patients met study inclusion criteria, 414 of whom were not previously receiving inhaled corticosteroid therapy. On ED or hospital discharge, 99 (24%) of these 414 patients were prescribed an inhaled corticosteroid. Of these 99 patients, 37 patients had a primary care follow-up visit within 6 months, with 4 receiving an inhaled corticosteroid dose change and no patients having the inhaled corticosteroids discontinued. Of the 315 patients not prescribed an inhaled corticosteroid on ED or hospital discharge, 128 had a primary care follow-up visit within 6 months, with 32 (25%) patients having an inhaled corticosteroid added to their therapeutic regimen. After primary care follow-up, only 69 (42%) of the 165 patients treated in clinic were receiving an inhaled corticosteroid for control of their asthma. Patients without insurance (odds ratio 0.14; 95% confidence interval 0.027 to 0.71) and patients initially discharged home from the ED (odds ratio 0.17; 95% confidence interval 0.05 to 0.53) were much less likely to receive inhaled corticosteroids at follow-up on multivariate logistic regression adjusting for race, sex, insurance status, and initial disposition. CONCLUSION: Primary care physicians infrequently add controller medications (inhaled corticosteroids) at follow-up to the regimen of asthmatic patients after a visit to the ED. Emergency physicians should be encouraged to evaluate chronic asthma burden among patients presenting with exacerbation, educate asthmatic patients, and prescribe controller medications, such as inhaled corticosteroids, for those with persistent symptoms.

Variability in emergency physician decision making about prescribing opioid analgesics.

STUDY OBJECTIVE: The purpose of this study is to determine what factors influence emergency physicians' decisions to prescribe an opioid analgesic for 3 common, painful conditions. METHODS: We developed items thought to influence the decision to prescribe an opioid analgesic through a review of the literature, expert consultation, and interviews with practicing emergency physicians. We developed a baseline vignette and items expected to influence the decision for each of the 3 conditions: migraine, back pain, and ankle fracture. We surveyed 650 physicians randomly selected from the American College of Emergency Physicians. The influence of individual items was explored through a univariate analysis of the response distribution. Patterns were assessed by analytically creating scales. RESULTS: We received responses from 398 (63%) of the 634 eligible physicians. Physicians' likelihoods of prescribing an opioid showed marked variability, with at least 10% of physicians saying they were unlikely and 10% of physicians saying they were likely to prescribe for each condition. Physician responses to individual pieces of clinical information, such as the patient requesting "something strong" for the pain, were also highly variable, with at least 10% of physicians saying they would be negatively influenced by this request and at least 10% saying they would be positively influenced by it. CONCLUSION: Even when faced with identical case scenarios, physicians' decisions to prescribe opioid analgesics are highly variable. Moreover, the same clinical information, such as a patient requesting a strong analgesic, changes the likelihood of prescribing opioids in opposite directions for different physicians.

Comparison of responses to a US 2 dollar bill versus a chance to win 250 US dollars in a mail survey of emergency physicians.

OBJECTIVES: To evaluate whether small monetary incentives improve physicians' responses to surveys. To the best of the authors' knowledge, no one has evaluated emergency physicians' response rate and cost per participant of a small monetary incentive relative to a chance to win a more substantial sum. The authors compared emergency physicians' responses and per-participant costs between a US 2 dollar bill and a 250 US dollars lottery. METHODS: Two groups of 288 emergency physicians were randomly selected and mailed a survey. Within each group of 288, half received a US 2 dollar bill and the other half received an offer that respondents would be entered into a drawing to win 250 US dollars. Nonresponders received a reminder postcard one week later, and persistent nonresponders received a second mailing of the survey three weeks after the initial mailing. RESULTS: Of the 576 surveys that were mailed, nine (2%) subjects were ineligible or undeliverable, leaving 567 eligible subjects, of whom 301 (53%) participated in the survey. The US 2 dollar bill had a substantially higher response rate: 170 (56%) of those receiving a US 2 dollar bill participated versus 131 (44%) of those receiving a chance to win 250 US dollars (95% confidence interval = 5% to 22%; p < 0.001). The US 2 dollar bill offer was less expensive per participant than the 250 US dollars offer. The cost of postage and incentives was 997.33 US dollars for 170 participants, or 5.87 US dollars per participant, for the US 2 dollar bill and 979.29 US dollars for 131 participants, or 7.48 US dollars per participant, for the chance to win 250 US dollars. CONCLUSIONS: Mailing a US 2 dollar bill incentive produces a better response rate with lower cost per participant than offering a chance to win 250 US dollars.

Racial and ethnic disparities in the clinical practice of emergency medicine.

There is convincing evidence that racial and ethnic disparities exist in the provision of health care, including the provision of emergency care; and that stereotyping, biases, and uncertainty on the part of health care providers all contribute to unequal treatment. Situations, such as the emergency department (ED), that are characterized by time pressure, incomplete information, and high demands on attention and cognitive resources increase the likelihood that stereotypes and bias will affect diagnostic and treatment decisions. It is likely that there are many as-yet-undocumented disparities in clinical emergency practice. Racial and ethnic disparities may arise in decisions made by out-of-hospital personnel regarding ambulance destination, triage assessments made by nursing personnel, diagnostic testing ordered by physicians or physician-extenders, and in disposition decisions. The potential for disparate treatment includes the timing and intensity of ED therapy as well as patterns of referral, prescription choices, and priority for hospital admission and bed assignment. At a national roundtable discussion, strategies suggested to address these disparities included: increased use of evidence-based clinical guidelines; use of continuous quality improvement methods to document individual and institutional disparities in performance; zero tolerance for stereotypical remarks in the workplace; cultural competence training for emergency providers; increased workforce diversity; and increased epidemiologic, clinical, and services research. Careful scrutiny of the clinical practice of emergency medicine and diligent implementation of strategies to prevent disparities will be required to eliminate the individual behaviors and systemic processes that result in the delivery of disparate care in EDs.

The effect of race/ethnicity and desirable social characteristics on physicians' decisions to prescribe opioid analgesics.

OBJECTIVE: Racial/ethnic disparities in physician treatment have been documented in multiple areas, including emergency department (ED) analgesia. The purpose of this study was to determine if physicians were predisposed to different treatment decisions based on patient race/ethnicity and if physicians' treatment predispositions changed when socially desirable information about the patient (occupation, socioeconomic status, and relationship with a primary care physician) was made explicit. METHODS: The authors developed three clinical vignettes designed to engage physicians' decision-making processes. The patient's race/ethnicity was included. Each vignette randomly included or omitted explicit socially desirable information. The authors mailed 5,750 practicing emergency physicians three clinical vignettes and a one-page questionnaire about demographic and practice characteristics. Chi-square tests of significance for bivariate analyses and multiple logistic regression were used for multivariate analyses. RESULTS: A total of 2,872 (53%) of the 5,398 potential physician subjects participated. Patient race/ethnicity had no effect on physician prescription of opioids at discharge for African Americans, Hispanics, and whites: absolute differences in rates of prescribing opioids at discharge were less than 2% for all three conditions presented. Making socially desirable information explicit increased the prescribing rates by 4% (95% CI = 0.1% to 8%) for the migraine vignette and 6% (95% CI = 3% to 8%) for the back pain vignette. CONCLUSIONS: Patient race/ethnicity did not influence physicians' predispositions to treatment plans in clinical vignettes. Even knowing that the patient had a high-prestige occupation and a primary care provider only minimally increased prescribing of opioid analgesics for conditions with few objective findings.

Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?

OBJECTIVES: To determine if the three types of emergency medicine providers--physicians, nurses, and out-of-hospital providers (emergency medical technicians [EMTs])--differ in their identification, disclosure, and reporting of medical error. METHODS: A convenience sample of providers in an academic emergency department evaluated ten case vignettes that represented two error types (medication and cognitive) and three severity levels. For each vignette, providers were asked the following: 1) Is this an error? 2) Would you tell the patient? 3) Would you report this to a hospital committee? To assess differences in identification, disclosure, and reporting by provider type, error type, and error severity, the authors constructed three-way tables with the nonparametric Somers' D clustered on participant. To assess the contribution of disclosure instruction and environmental variables, fixed-effects regression stratified by provider type was used. RESULTS: Of the 116 providers who were eligible, 103 (40 physicians, 26 nurses, and 35 EMTs) had complete data. Physicians were more likely to classify an event as an error (78%) than nurses (71%; p = 0.04) or EMTs (68%; p < 0.01). Nurses were less likely to disclose an error to the patient (59%) than physicians (71%; p = 0.04). Physicians were the least likely to report the error (54%) compared with nurses (68%; p = 0.02) or EMTs (78%; p < 0.01). For all provider and error types, identification, disclosure, and reporting increased with increasing severity. CONCLUSIONS: Improving patient safety hinges on the ability of health care providers to accurately identify, disclose, and report medical errors. Interventions must account for differences in error identification, disclosure, and reporting by provider type.

Do EMS personnel identify, report, and disclose medical errors?

OBJECTIVE: To evaluate self-reports of prehospital providers' error frequency, disclosure, and reporting in their actual practice and in hypothetical scenarios. METHODS: The authors surveyed a convenience sample of prehospital providers attending a statewide emergency medical services conference using a two-part instrument. Part 1 evaluated respondent demographics and actual practice patterns. Part 2 used hypothetic scenarios to assess error identification, disclosure, and reporting patterns. Descriptive statistics and Fisher's exact tests were used to characterize demographics and practice patterns. For hypothetical scenarios, the authors calculated mean responses with 95% confidence intervals (CIs) to assess error identification, anticipated disclosure, and reporting patterns. RESULTS: The response rate was 88% (372/425). Analysis was limited to 283 (75% of 372) respondents who were emergency medical technicians and had complete data. In the previous year, 157 (55%) providers identified no errors in practice, 100 (35%) reported one or two errors, and 26 (9%) identified more than two errors. In approximately half of cases, identified errors were reported to the receiving provider, or supervisor. In hypothetical cases, severe errors were identified 93% (95% CI 92-94) of the time, but the ability of providers to identify mild errors significantly varied. In all scenarios, respondents were much more likely to report errors to the receiving hospital, their supervisor, and their medical director than to patients. CONCLUSIONS: Prehospital providers demonstrate the capacity to identify, report, and, to a lesser extent, disclose errors in hypothetical scenarios but may not apply these skills uniformly in their own practices. Enhancing error management skills in prehospital clinical practice will require focused education and training.

Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children.

OBJECTIVE: No data exist on parental preferences for disclosure, reporting, and seeking legal action after errors in the care of their children are disclosed. This study examined parental preferences for error disclosure and reporting; responses to error disclosure; and preferences and responses by race/ethnicity, gender, age, and insurance. METHODS: A 4-scenario survey instrument portraying a range of medical error was provided to a convenience sample of parents who presented with children to an emergency department. Parents were asked to categorize the error, express preferences for disclosure and reporting, and then report how they expected to respond with and without disclosure. Basic demographics were collected also. Bivariate analyses of demographics were performed with Fisher's exact tests, analysis of scenario responses was performed with Somers' D, and the independent effects of the study variables were assessed with a generalized estimating equation. RESULTS: Research assistants approached 661 parents; 499 participated (75% response rate). Of all scenarios presented to the parents, they judged 54% of the scenarios as severe, 99% wanted disclosure, 39% wanted the error reported to a disciplinary body, and 36% were less likely to seek legal action if the error was disclosed by the physician. In multivariate modeling, severity was associated with desire for disclosure, reporting, and change in likelihood of legal action with disclosure. CONCLUSIONS: Regardless of severity, parents want to be informed of error. Educational interventions to improve error disclosure should emphasize the uniformity of parental preferences for disclosure, reporting, and the decreased likelihood of legal action when errors are disclosed than if discovered through other means.

Advanced statistics: how to determine whether your intervention is different, at least as effective as, or equivalent: a basic introduction.

The majority of studies published in the emergency medicine literature attempt to show a difference between two interventions, but often fail to do so. Failing to detect a difference, however, is not the same as demonstrating that one intervention is at least as effective as or better than the other intervention, or that the two interventions are equivalent--a fine point that is often overlooked. The purpose of this paper is to review classical hypothesis testing and then introduce the methodology to determine whether one intervention is at least as effective as another intervention, or whether two interventions are equivalent. Appreciating the conceptual differences between failing to find a difference, demonstrating that one intervention is at least as effective as another, and demonstrating equivalence may lead to a better understanding of the true significance or potential significance of study results.

Declining payments for emergency department care, 1996-1998.

STUDY OBJECTIVE: We describe recent trends in payments from different payer classes and assess their relative importance to the financial solvency of emergency departments. METHODS: We used Medical Expenditure Panel Survey data from 1996 and 1998. The unit of analysis was the ED visit. Primary outcome measures were ED charges and payments. The independent variable of interest was payer class, and therefore, we limited our analysis to those either uninsured or covered by Medicare, Medicaid, or private insurance. RESULTS: From 1996 to 1998, a declining percentage of total charges were paid, from 60.3% to 53.0% (difference -7.3%; 95% confidence interval [CI] -11.3% to -3.5%). Although the percentage of total charges paid by Medicaid, Medicare, and the uninsured remained constant, the percentage of total charges paid by the privately insured declined from 75.1% to 63.4% (difference -11.7%; 95% CI -16.6% to -6.7%). Overall, adjusted mean ED charge increased from 695 dollars to 798 dollars (difference 103 dollars; 95% CI 61 dollars to 146 dollars). Two payer classes experienced statistically significant increases in adjusted mean charge: the uninsured, from 544 dollars to 740 dollars (difference 196 dollars; 95% CI 62 dollars to 330 dollars), and the privately insured, from 658 dollars to 813 dollars (difference 151 dollars; 95% CI 103 dollars to 199 dollars). Although the adjusted mean payment rate for the uninsured remained stable, the adjusted mean payment rate for the privately insured declined from 77.7% to 65.7% (difference -12.0%; 95% CI -13.4% to -10.7%). CONCLUSION: The ability of EDs to provide emergency care to all regardless of ability to pay is increasingly threatened by declining overall payment rates. Cost shifting to fund care for the uninsured is an increasingly untenable financing strategy.

Racial and ethnic disparities in emergency department analgesic prescription.

OBJECTIVES: We examined racial and ethnic disparities in analgesic prescription among a national sample of emergency department patients. METHODS: We analyzed Black, Latino, and White patients in the 1997-1999 National Hospital Ambulatory Medical Care Surveys to compare prescription of any analgesics and opioid analgesics by race/ethnicity. RESULTS: For any analgesic, no association was found between race and prescription; opioids, however, were less likely to be prescribed to Blacks than to Whites with migraines and back pain, though race was not significant for patients with long bone fracture. Differences in opioid use between Latinos and Whites with the same conditions were less and nonsignificant. CONCLUSIONS: Physicians were less likely to prescribe opioids to Blacks; this disparity appears greatest for conditions with fewer objective findings (e.g., migraine).