Crash Cart: ED influx, the FDA’s drug watch list, EOL forms, and roller coasters for kidney stones

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This week: Huffington Post describes the emerging state of medical care in the ED. Plus, there is a potential new kidney stone remedy – roller coasters. Join in as our editors discuss the week’s headlines.

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Emergency rooms are becoming busier with the influx of patients coming in for routine checkups

Techniques such as “boarding,” where patients are lined up in the ER hallways, as well as “discharge lounges,” where patients are released into a special area to reduce crowding, are used to combat the increasing influx of patients. Original Article by The Huffington Post.

Nicholas Genes, MD, PhD: Dr. Bose advocates some reasonable solutions to boarding – better bed management systems and reports, discharge lounges, sync’d OR schedules – that we’ve been hearing for years. What I’m really looking for is how to convince the hospital that these investments are in their best interest, because HuffPo pieces and peer-reviewed articles haven’t managed this yet. And I wish he didn’t base his whole article on ACEP survey data regarding doctors’ perceptions on rising ED volumes, which probably doesn’t reflect reality as well as actually measuring ED volumes (we discussed this back in March – Seth and I noted that ED visits were rising well before ACA passed, and lately are not rising as much).

Jaime Hope, MD: None of these issues are newly emerging. Reducing boarding is well known to reduce poor outcomes. And anyone who works in an Emergency Dept knows this fact as well – patients don’t like it!! They don’t like being in a gown in a hallway discussing their personal health. They don’t like waiting for hours to be seen. They don’t like waiting around for their discharge paperwork because the nurses are busy acting as floor nurses. The voices of EM docs has not yet changed the problems of boarding and long wait times, perhaps the voice of the almighty dollar might.

Ryan McKennon, DO: This article seems a little disjointed. It starts by talking about non-emergent patient. It then shifts to how volumes are increasing based on doc surveys (I agree with Nick, not that helpful). Finally, it talks about how to decrease ED boarding as a solution to the problem of overcrowding. They are all great ideas that have been discussed before but if the underlying problem is non-emergent visits, the solutions do not address that problem.

William Sullivan, DO, JD: First, Dr. Bose has it wrong in the first paragraph of his article. He states that patients “cannot be turned away regardless of how sick or injured they actually are or whether or not they have insurance. They must be seen and treated.” That’s partially true. While EMTALA requires that all patient receive a screening exam, once that screening exam shows that no emergency medical condition exists, there is no legal requirement that patients receive any further medical evaluation or treatment. Yet emergency physicians are in the business of providing medical care, so we go beyond what the law requires … which is precisely why ED volumes have increased. Patients know that they’ll receive care in the emergency departments when no primary care provider will take them because they have no (or insufficient) insurance or when the next available appointment for their primary care provider is months away. But emergency providers are getting crushed by the costs of providing uncompensated and poorly compensated care. Insurance compensation that is lower than the cost of providing care simply is not a net benefit. Getting to the issue of the article – how to “reduce the volume of patients flooding E.R.s for non-emergency treatments” doesn’t involve a simple answer. ACEP committees have debated this issue for years. Increasing alternate sources of medical care won’t work because those sources require funding to operate and there isn’t a reliable source of funding for uncompensated/poorly compensated care. The “screen and discharge” model of triaging non-emergency patients out of the emergency department goes against our mission of treating patients, but may become a necessary evil if the current system becomes an issue of financial viability for hospitals. Requiring co-pays for ED treatment effectively amounts to a refusal of care to indigent patients. Dr. Bose discusses boarding as a simple solution to reducing patient volumes, but I don’t see that as an issue at any of the facilities in which I work, and reducing boarding improves throughput, it doesn’t decrease volumes. Discharge lounges are a good idea to try – provided that there is a place to privately discuss discharge instructions and there is available staff to provide these services. In effect, Dr. Bose’s article raises some valid issues, but I don’t think it comes up with many workable solutions to those issues.

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FDA is considering the increase in regulation for 27 drugs

The FDA has put up 27 drugs on it’s watch-list, including the direct-acting antivirals for hepatitis C virus (HCV) infections, simeprevir and sofosbuvir. Original Article by Medscape.

Nicholas Genes, MD, PhD: This is the FDA Adverse Reporting System – FAERS – and it’s just a database to support post-marketing surveillance. A lot of these are recently approved drugs that we really should be collecting data on, in a systematic fashion – and if the data show something concerning, of course the FDA should step in. Some of these, like diphenhydramine’s effect on QT interval, are already well-known – further regulatory action here seems kind of annoying (how will practice change, realistically, if Benadryl gets a black box warning?) Finally, there are a few of these, like SSRI’s association with Takotsubo cardiomyopathy, that are new to me. In these cases I think the FDA database is going to really help research on a rare and serious complication – so, kudos to them.

Jaime Hope, MD: It just goes to show the truth in the old axiom ‘any drug can cause any side effect at any time’. We have so many patients with polypharmacy, reactions and interactions are a substantial concern. And a med is started, gives a side effect so new drug is prescribed to combat the side effect, it doesn’t take much to end up with a whole cupboard full of medications! Even though as a practicing EM doc, I don’t prescribe many of the drugs listed, I am charged with caring for whomever walks through my door so having a database is helpful. Many of the interactions are common sense – immune suppressants increase risk for infection, diabetic medications that stimulate the pancreas can lead to inflammation of the stimulated organ, etc. Our EMR gives warnings for potential interactions but we get warning fatigue.  And we are trusting that the host of the EMR is keeping current. Drugs causing transverse myelitis?…ugh!  Forget meds, I think I’m going to eat my vegetables, exercise regularly, and try to sleep more!

Ryan McKennon, DO: I don’t know what to do with this. It lists potential drug side effects/interactions that the FDA is going to investigate. “The appearance of a drug together with an adverse event on a quarterly FAERS watch list normally doesn’t mean that the FDA has concluded there is a causal relationship, but rather that the FDA intends to investigate whether one exists.” I’m glad they are looking into these concerns and if the FDA proves or is concerned enough that there is causation, great let me know. Otherwise I’m not sure I change my practice based on the fact that the FDA is going to look into whether or not a connection exists.

William Sullivan, DO, JD: I read about this elsewhere. I don’t have much confidence in the FDA. They’ve black boxed quite a few medications in which the literature showed little risk of side effects. Now they’re just getting around to investigating Benadryl for adverse effects? As in the same Benadryl discovered 73 years ago by George Rieveschl? The same Benadryl that’s probably been taken billions of times by billions of patients? THAT Benadryl? Must be some company developing a new antihistamine that made a large donation to the FDA…

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Confusion of elderly patients while filling out their end-of-life forms leads to more emergency care than desired by the patient

Elderly patients don’t know how to fill out medical forms – out of 100 forms in this study, 69 percent were left incomplete. This leads the hospital to increase life-prolonging care and emergency medicines administered to the patient. Original Article by Science Daily.

Nicholas Genes, MD, PhD: Understanding the options on these end-of-life forms would be a lot easier, if the patient toured a typical ICU first. I’d bet the patient’s wishes would be a lot clearer, too.

Jaime Hope, MD: Love that idea, Nick! Patients really have no idea what these interventions look like. I fully respect patient autonomy to choose what they want done, as long as it doesn’t clash with medical futility. “Do everything” sometimes includes things that we know aren’t helpful. We need to get better about presenting the patient with clear options that are consistent with medical benefit so they have the opportunity to choose what is consistent with their wishes and NOT offer medically inappropriate treatments. These decisions can be overwhelming and emotional for patients, let’s focus on what is indicated to make the process as easy for them as possible.

Ryan McKennon, DO: It seems like we could come up with a standard two or three options that don’t require multiple check boxes and confusion contradictions. The fact that a form can be filled out that allows for intubation but not mechanical ventilation (I’ve seen this) is ridiculous. It is incumbent on us as physicians to do a better job explaining and assisting in filling out these forms. Unfortunately, in the ER when someone takes a turn for the worse is not the idea setting to have these conversations.

William Sullivan, DO, JD: Agree with Ryan. The choices for end of life are sometimes a parody. I’ve seen arguments about antibiotics vs no antibiotics, pressors vs. no pressors, chest compressions vs no compressions. Just last night we had a discussion about what was and was not included in “comfort care only.” The more complex that the forms become, the less likely that they are to be followed. It would be a big help to come up with a standard form. Then we can work on showing patients what is involved in resuscitation.

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New study suggests that riding roller-coasters may help pass small kidney stones

A study by David Wartinger, a professor emeritus at Michigan State University, used a 3-D printed version of a kidney to see the correlation between roller-coaster riding and passing kidney stones.  Original Article by The New York Times.

Nicholas Genes, MD, PhD: The author of this NYTimes piece on kidney stones deserves a lot of credit for the “killing two birds” line at the end. But the researchers deserve more –  they address a real void in the literature, and I think a lot people will get the urge to read this paper. In their acknowledgements section, they even get to thank Walt Disney World. I’m still wondering whether Big Thunder Mountain has some special characteristics (like its name?), or other roller coasters would facilitate passage (did the index case report urinating after each run, when he passed three stones after 3 consecutive rides?) Also, whose urine went into the model? Finally, the data was collected in 2008 – what blocked the release of this golden research?

Jaime Hope, MD: I love that they funded and did this study. I loved roller coasters in my youth; now after having suffered through an episode of vertigo, I think I’d rather pass a kidney stone than go on Big Thunder Mountain 20 times in a row. If I’m reading this study correctly, the stones in question are stones innocently and painlessly chilling in the kidneys that are being propelled into the ureters for subsequent passage during the coaster ride. Maybe they would have gotten bigger or maybe would have stayed the same and never caused a problem. It doesn’t say anything about increased passage time once in the ureter, which is the time that is actually painful. Interesting that the stone movement was greater in the back of the coaster compared to the front, which they postulate is due to the bumpiness. If it’s just the bumps, there are plenty of pothole-ridden roads near me, perhaps patients should try this cheaper version. Otherwise, patients will be hitting us for Roller Coaster Cards, like Marijuana cards, and trying to get insurance to cover their amusement park trips.

Ryan McKennon, DO: I need to see if I can get Blue Cross to pay for this. It has got to be cheaper to send me to Cedar Point a couple of times a year then to pay for lithotripsy even once.

William Sullivan, DO, JD: Personally, I’d probably puke more from riding the roller coaster than I would from the kidney stones. I’ll stick with fluids and IV Toradol, thanks.

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