Utilizing an emergency medicine stabilization team to provide critical care in a rural health system.

INTRODUCTION: Over the past decade, Emergency Department (ED) patient volumes have increased more than available hospital ICU capacity. This has led to increased boarding and crowding in EDs, requiring new methods of providing intensive care. Many hospitals nationwide have developed ICU boarding mitigation strategies at the hospital and ED level or implemented ED-based resuscitative care units to improve patient care and disposition. However, these have been described in the setting of larger medical centers without broader application to rural, community ED environments. The authors herein have created an ED model utilizing a physician and nurse on-call team to provide improved care to critically ill patients requiring resuscitation when an ICU bed is not immediately available. GOALS: The goal of this paper is to describe a novel approach to providing critical care in a rural health system. A community health system-based resuscitation team named Emergency Medicine Stabilization Team, or EMSTAT, was developed as a mobile team consisting of one emergency physician and one emergency or critical care nurse. The authors present data from the first 12 months of the program including diagnoses, procedures, temporal trends, and lengths of stay. RESULTS: Over the course of twelve months, EMSTAT was contacted for 195 patients and ultimately traveled to bedside for 131 cases. The three most common diagnoses seen were sepsis, respiratory failure, and diabetic emergencies. 99 documented procedures were performed; the most common were central venous catheters, arterial lines, and intubations. 104 patients were admitted to the intensive care unit, while the other 27 were either downgraded to a lower level of care, discharged, transitioned to palliative care, or died. DISCUSSION: Over a twelve-month period, the authors describe a novel rural community-based mobile critical care team. This team demonstrated the ability to quickly arrive at bedside, continue resuscitation, acquire a disposition, and provide individualized critical are. This model serves as a roadmap for developing similar community based-resuscitation programs.

Does providing prescription information or services improve medication adherence among patients discharged from the emergency department? A randomized controlled trial.

STUDY OBJECTIVE: We determine whether prescription information or services improve the medication adherence of emergency department (ED) patients. METHODS: Adult patients treated at one of 3 EDs between November 2010 and September 2011 and prescribed an antibiotic, central nervous system, gastrointestinal, cardiac, or respiratory drug at discharge were eligible. Subjects were randomly assigned to usual care or one of 3 prescription information or services intervention groups: (1) practical services to reduce barriers to prescription filling (practical prescription information or services); (2) consumer drug information from MedlinePlus (MedlinePlus prescription information or services); or (3) both services and information (combination prescription information or services). Self-reported medication adherence, measured by primary adherence (prescription filling) and persistence (receiving medicine as prescribed) rates, was determined during a telephone interview 1 week postdischarge. RESULTS: Of the 3,940 subjects enrolled and randomly allocated to treatment, 86% (N=3,386) completed the follow-up interview. Overall, primary adherence was 88% and persistence was 48%. Across the sites, primary adherence and persistence did not differ significantly between usual care and the prescription information or services groups. However, at site C, subjects who received the practical prescription information or services (odds ratio [OR]=2.4; 95% confidence interval [CI] 1.4 to 4.3) or combination prescription information or services (OR=1.8; 95% CI 1.1 to 3.1) were more likely to fill their prescription compared with usual care. Among subjects prescribed a drug that treats an underlying condition, subjects who received the practical prescription information or services were more likely to fill their prescription (OR=1.8; 95% CI 1.0 to 3.1) compared with subjects who received usual care. CONCLUSION: Prescription filling and receiving medications as prescribed was not meaningfully improved by offering patients patient-centered prescription information and services.

Heat-related illness.

Environmental exposure to high temperatures can result in abnormalities ranging from mild heat exhaustion to heat stroke with multiorgan system failure. An understanding of the mechanisms of thermoregulation and how those mechanisms fail with extreme heat stress is critical for management of the patient with elevated body temperature in the emergency department.