Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States.

BACKGROUND: Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. METHODS: This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. RESULTS: Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. CONCLUSION: Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.

Predictors of patient adherence to follow-up recommendations after an ED visit.

BACKGROUND: It is unclear whether factors identified during the emergency department (ED) visit predict noncompliance with ED recommendations. STUDY OBJECTIVE: We sought to determine predictors of adherence to medical recommendations after an ED visit. METHODS: We conducted a prospective, observational study at a single urban medical center. Eligible ED patients provided baseline demographic data as well as information regarding insurance status, whether they had a primary care physician (PCP), and the impact of cost of care on their ability to follow medical recommendations. Patients were contacted at least 1 week after the ED visit and answered questions regarding adherence to medical recommendations. RESULTS: Four hundred twenty-two patients agreed to participate in the study. At follow-up, 89.7% of patients reported that they had complied with recommendations made during the ED visit. Patients who were adherent to follow-up recommendations were more likely to have a primary care provider (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.1-6.1), have an annual income of greater than $35000 (OR, 2.9; 95% CI, 1.2-7.2), and report a non-Hispanic ethnicity or race (OR, 2.8; 95% CI, 1.1-7.1). Individuals who reported that cost "sometimes" or "always" impacts their ability to follow their physician's recommendations were significantly less likely to comply with ED recommendations (OR, 2.7; 95% CI, 1.3-5.6). CONCLUSION: Individuals who reported that cost affects their ability to follow their physician's recommendations and those who did not have a PCP were less likely to follow ED recommendations. Identification of predictors of noncompliance during the ED visit may aid in ensuring compliance with ED recommendations.

Emergency physician knowledge of reimbursement rates associated with emergency medical care.

STUDY OBJECTIVE: We investigated emergency physician knowledge of the Centers for Medicare & Medicaid Services (CMS) reimbursement for common tests ordered and procedures performed in the emergency department (ED), determined the relative accuracy of their estimation, and reported the impact of perceived costs on physicians' ordering and prescribing behavior. METHODS: We distributed an online survey to 189 emergency physicians in 11 EDs across multiple institutions. The survey asked respondents to estimate reimbursement rates for a limited set of medical tests and procedures, rate their level of current cost knowledge, and determine the effect of health expenditures on their medical decision making. We calculated relative accuracy of cost knowledge as a percent difference of participant estimation of cost from the CMS reimbursement rate. RESULTS: Ninety-seven physicians participated in the study. Most respondents (65%) perceived their knowledge of costs as inadequate, and 39.3% indicated that beliefs about cost impacted their ordering behavior. Eighty percent of physicians surveyed were unable to estimate 25% of the costs within ±25%, and no physicians estimated at least 50% of costs within 25% of the CMS reimbursement and only 17.3% of medical services were estimated correctly within ±25% by 1 or more physicians. CONCLUSION: Most emergency physicians indicated they should consider cost in their decision making but have a limited knowledge of cost estimates used by CMS to calculate reimbursement rates. Interventions that are easily accessible and applicable in the ED setting are needed to educate physicians about costs, reimbursement, and charges associated with the care they deliver.

Web-based emergency department patient satisfaction surveys may introduce potential for bias.

BACKGROUND: Emergency departments (ED) have proposed utilizing a Web-based format to distribute patient satisfaction surveys, but the potential for bias in this distribution method has not been assessed. OBJECTIVE: The aim of this study was to evaluate the characteristics of ED patients who have access to the Internet to better understand potential bias in Web-based patient satisfaction surveys. METHODS: We distributed a 20-question survey to consenting, English-speaking adult patients presenting to the ED from December 2010 to March 2012. Patients reported demographic information and answered questions related to their access and use of the Internet. RESULTS: Seven hundred four patients participated in the study; 90% of Whites reported Internet access, vs. 82% of Hispanics (p = 0.034). Ninety-two percent of patients with at least some college education had Internet access, compared to 79% of those with a high school education level or lower (p ≤ 0.001). Of households reporting an income of > $22,000/year, 95% had Internet access, compared to 77% of those reporting a household income < $22,000/year (p ≤ 0.001). Ninety-four percent of participants < 40 years of age had Internet access, compared to 83% between the ages of 40 and 56 years, and 77% for those over 56 years of age (p < 0.001). CONCLUSION: A Web-based distribution of ED patient satisfaction surveys may underrepresent minorities, patients without college education, those with lower income, and patients older than 40 years. This information may provide guidance in interpreting results of Web-based patient satisfaction surveys and may suggest the need for multiple sampling methods.

Intranasal sufentanil provides adequate analgesia for emergency department patients with extremity injuries.

BACKGROUND: In emergency medicine, the ability to provide rapid, adequate pain control without high resource utilization is ideal. In this study, the efficacy of intranasal sufentanil in emergency department (ED) patients with acute distal extremity injury was evaluated. METHODS: A nonrandomized, open-label dose trial to determine safety and efficacy of intranasal sufentanil in patients with a distal extremity injury who presented to the ED with moderate to severe pain was conducted. Vital signs, pain scores, Ramsay sedation score, and any side effects during a 30-minute observation period after medication administration were recorded. Patients, nurses, and physicians completed satisfaction surveys. RESULTS: Fifteen ED patients with acute extremity injuries agreed to participate in the study and received a dose of 0.5 mcg/kg of sufentanil intranasally. The average pain score decreased 4.3 points (from 7.8 to 3.5). Eight patients reported a final pain score of #3. The most common side effect was mild dysphoria. Patients, physicians, and nurses reported high average satisfaction scores. CONCLUSION: Intranasal sufentanil resulted in a significant clinical reduction in patients' reported pain without serious side effects. This medication and administration route demonstrated promise for potential use in the ED.

Folic acid use in pregnant patients presenting to the emergency department.

BACKGROUND: The US Preventive Services Task Force has recommended daily folic acid supplementation for women planning on becoming pregnant in an effort to prevent fetal neural tube defects. We evaluated pregnant patients presenting to the emergency department to determine rates of folic acid supplementation. METHODS: We surveyed a convenience sample of pregnant patients who presented to the University of Utah Emergency Department (ED) between 1 January 2008, and 30 April 2009, regarding pregnancy history and prior medical care. RESULTS: One hundred thirty-five patients participated in the study. Eighty-four patients (62.2%) reported current folic acid supplementation. Sixty-six patients identified themselves as Caucasian and 69 as non-Caucasian race. There was a significant difference in folic acid use between Caucasian and non-Caucasian women (p = 0.035). The majority of Caucasian women (71.2%) reported daily folic acid use versus approximately one-half of non-Caucasian women (53.6%). Both groups were similar in accessing a primary care provider (PCP) for pregnancy care prior to the ED visit (53% vs. 49.3%, p = 0.663), and rates of folic acid use were similar in those who had seen a PCP (85.7% vs. 76.5%, p = 0.326). Language did not have a significant association with folic acid use. CONCLUSION: A large percentage of pregnant ED patients did not report current folic use, and there was a significant difference between Caucasian and non-Caucasian women in rates of folic acid supplementation. This study highlights the potential role of the ED in screening patients for folic acid supplementation.

A fibril-specific, conformation-dependent antibody recognizes a subset of Abeta plaques in Alzheimer disease, Down syndrome and Tg2576 transgenic mouse brain.

Beta-amyloid (Abeta) is thought to be a key contributor to the pathogenesis of Alzheimer disease (AD) in the general population and in adults with Down syndrome (DS). Different assembly states of Abeta have been identified that may be neurotoxic. Abeta oligomers can assemble into soluble prefibrillar oligomers, soluble fibrillar oligomers and insoluble fibrils. Using a novel antibody, OC, recognizing fibrils and soluble fibrillar oligomers, we characterized fibrillar Abeta deposits in AD and DS cases. We further compared human specimens to those obtained from the Tg2576 mouse model of AD. Our results show that accumulation of fibrillar immunoreactivity is significantly increased in AD relative to nondemented aged subjects and those with select cognitive impairments (p < 0.0001). Further, there was a significant correlation between the extent of frontal cortex fibrillar deposit accumulation and dementia severity (MMSE r = -0.72). In DS, we observe an early age of onset and age-dependent accumulation of fibrillar OC immunoreactivity with little pathology in similarly aged non-DS individuals. Tg2576 mice show fibrillar accumulation that can be detected as young as 6 months. Interestingly, fibril-specific immunoreactivity was observed in diffuse, thioflavine S-negative Abeta deposits in addition to more mature neuritic plaques. These results suggest that fibrillar deposits are associated with disease in both AD and in adults with DS and their distribution within early Abeta pathology associated with diffuse plaques and correlation with MMSE suggest that these deposits may not be as benign as previously thought.