Crash Cart: Nurse-driven protocols, autopilot cars, troponin, and FSEDs in high-income areas

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This week: Did this autopilot Tesla save this man’s life by taking him to the ER. Plus, the debate on whether FSEDs are chasing the money by being in high-income areas? Join in as our editors discuss the week’s headlines.

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Nurse-driven protocols can decrease ED overcrowding and reduce the length of stay for patients

An Annals of EM study surveyed doctors and nurses to determine the effects and benefits of the potential overcrowding solution. Original Article by Fierce Healthcare.

William Sullivan, DO, JD: Standing orders improve ED throughput. In other news … the sun is hot and water is wet. Several other studies already demonstrate this benefit (example 1, example 2, example 3). The thing that caught my eye was that by implementing standing orders, this busy Canadian emergency department was able to decrease length of stay by 3.5 hours for patients who had hip fractures and vaginal bleeding. They also decreased the time that patients had to wait to receive Tylenol by more than 3 hours. Those must have been some serious wait times. As the US moves to ACOs and there becomes more of an emphasis on saving money, it makes me wonder whether there will still be as much of an emphasis on throughput times. Too bad the study didn’t look at whether costs of care increased after standing order sets were implemented.

Judith Tintinalli, MD, MS: I am in favor, but there are unanticipated things from RN standing orders. Mostly, getting unnecessary labs. Also on the other side, not getting a lab that is needed after MD evaluation.

Seth Trueger, MD, MPH: There are patients who can get stuff started up front and it’s helpful; other times it certainly slows things down. To steal from Reuben Strayer, a patient with gastro gets a line to IV hydrate quickly. Might as well send some labs while we’re already poking, just in case we need them. WBC comes back at 13… someone convinces themselves the patient needs a CT abdomen now. And the whole time, the fluids are barely trickling in because the patient’s elbow is bent. When I’ve worked in triage, I’ve had to purposely stop myself from ordering labs & imaging. Many patients will be much better off getting a few minutes of H&P instead of labs, and when they get back to the doc who can actually talk to them, now they end up waiting for the labs to result when they didn’t need them in the first place.
And let’s remember the most important part: EDs are not crowded because EDs are slow. ED crowding is a symptom of a larger hospital flow problem. Fixing ED crowding with nurse orders in triage is like taking my jacket off because I’m hot when the real problem is that my house is on fire.

Ryan McKennon, DO: As usual the devil is in the details. Tylenol for fevers, albuterol treatments for asthmatics, extremity x-rays, UA and U-preg tests ordered at triage can all speed up a department. I think where you get in to problems is when it expands into blood work and my personal pet peeve, AAS and L/S x-rays. This leads to unnecessary tests much of the time which then leads to more unnecessary tests.

Jaime Hope, MD: When used judiciously! We had a nurse advance triaging D-dimers on all chest pain and dyspnea patients, regardless of indications, comorbidities, etc. The benefit to having a nurse order is speed. The benefit to having a doctor order is accuracy. Love Seth’s analogy!!

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Autopilot car drives man to emergency room

As cars implement new technology that can hurt people, it can also save. Original Article by Slate.

William Sullivan, DO, JD: First of all, the guy in the article wouldn’t have died if he had driven himself to the ED. If he was well enough to go home the same evening after being diagnosed with a pulmonary embolism, they didn’t do any life-saving procedures in the ED after he arrived. Second, the short video clip in the article is why I’ve been using dashboard cams in my vehicles for a couple of years now. Had there been an accident, the video would have instantly resolved any issues of who was at fault. You can get a cheap dashcam for 25 bucks. Finally, from a legal standpoint, this scenario is giving me fits. Who is liable if an autonomous car crashes? If the driver isn’t “driving” because the car is on autopilot, can the driver be at fault? Or would Tesla liable for “substandard” software? Does Tesla make owners sign a waiver of liability? If so, shouldn’t drivers be able to review the computer code (or have the code reviewed) to assess for appropriateness and coding errors (like that would ever happen)? Should we have more “Tesla-control” regulation due to accidents and deaths? Not sure that we’re quite there yet for autonomous driving.

Ryan McKennon, DO: This article may be a bit sensationalized but this technology is amazing. While its not there yet, I think in 20 years or so autonomous driving will probably be significantly safer than human driving. I can think of several people for whom it probably already is. Potential for EMS rigs?

Jaime Hope, MD: I was distracted by the part about the “potentially fatal” PE making that guy too sick to drive but he was discharged the same day. Are we doing tPA and then discharging people? I must have missed that protocol. As for the self driving technology, it definitely cool but not ready for prime time. There are enough distracted drivers out there! According to the National Highway Traffic Safety Administration, in 1 year, “over 3,331 people were killed and over 387,000 injured in motor vehicle accidents connected to distracted driving”. Autopilot driving may be intended to help improve safety and eliminate human error but what it seems actually happens is that people feel that they have time to text and do other tasks. Driving a heavy machine at high speeds really should be taken more seriously. If people can afford a $100k car, why not just hire a chauffer?

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Assessing chest pain with high-sensitivity troponin needs more research

In the first study to evaluate unguided troponin, researchers found it had little impact on admission and needs more protocols. Original Article by Medscape.

William Sullivan, DO, JD: Sorry, but a study that looks at 12 month end points doesn’t interest me that much in an emergency medicine setting. As an emergency physician, I want to know whether it will be safe to discharge the patient for outpatient follow up, not whether my decision will have any bearing on the patient’s likelihood of death or recurrent ischemia 12 months from discharge. The long term outcomes are why patients get referred to a cardiologist for follow up and have outpatient testing done. The study did note that likelihood of death or acute coronary syndrome at 30 days increases substantially with higher peak troponin levels, but few of the endpoints were even close to meeting statistical significance when comparing normal versus high-sensitivity troponin measurements.

Judith Tintinalli, MD, MS: I have not seen any studies on these, but from my own experience, several times a shift we see patients on whom a troponin has been ordered, is hemolyzed, requires repeating; or labs/CXRay are ordered when absolutely none are needed. Or an ankle film is ordered, but the foot is missed. Or an LS spine is ordered when none is needed… Lots of examples.

Ryan McKennon, DO: I agree with Bill, twelve month endpoint is too far out. Thirty days would be more relevant. As there was no change in the number of d/c from the ED, doesn’t look like much of a benefit from this study.

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New findings show freestanding EDs follow the money

Researchers looked at the states with the greatest number of freestanding EDs and found they are located in areas with higher incomes, private health insurance and high population growth. Original Article by Reuters.

Jyoti Mahapatra, MD: My name is Jyoti, and I work in a freestanding ED. It is the only one in my state and is hospital owned. We are not the money gremblins multiplying overnight in all the best neighborhoods. We are not a Dr. Suess cautionary tale, mass-producing FSEDs until there is nothing left but barren trees and dried up ponds. I am not even part of the We. My ED is owned by a specialty hospital, and none of the EPs are owners. There is no personal financial incentive for us if our ED is successful. But I choose to work there because patients want to come to us, whether they can afford to or not, and because it improves my career longevity. I still see Medicaid and uninsured patients on a daily basis. I still argue about narcotics and antibiotics daily. I am still called a racist bitch when someone doesn’t get their way. But people from all walks of life come here because it is simply a better experience. They are seen almost immediately, by courteous staff who are not carrying four other patients on pressors. Labs and radiology results return in the same amount of time patients would normally spend in triage in many other EDs. Their laceration will be sutured within a half hour of walking in and their aortic dissection CTA will be done with a zero likelihood someone needs it more than you. I am able to interact with my patients without worrying that each additional minute I spend with them is one less minute I have to spend with the 12 people in triage. I have plenty of time to ask the unscripted questions I have become so fond of, and truly have time to go over results and answer questions without one hand on the door, trying to escape. I rarely walk into a mess and typically leave my shift on time. Most importantly, I can be a better mother to my kids because I don’t feel like spending the rest of night in a padded room. I also enjoy the different perspective I can offer residents when I work at our main ED. One of the more difficult transitions into attendinghood is the sudden loss of every in-house consultant and radiology-read imaging study. It is very rewarding to give residents a glimpse into community EM where ortho doesn’t come in for every fracture and you will be the only one to catch the subtle STEMI. I could have never imagined this practice environment when I was in residency, I didn’t even know what a FSED was. But it maintains my family and professional well-being.FSEDs offer a change of pace for a specialty with the worst burnout rates in medicine. Ps are leaving EM and medicine all together because of the grueling, unforgiving work environment. Some have found that working just one or two of their scheduled shifts at a FSED helps them recover from the rigors of an overcrowded, under-resourced ED. FSEDs may be accused of siphoning off the ‘best’ patients from a challenging population, but if money talks, maybe it will speak to hospital administrators and leadership to invest in their own ED rather than making it so easy for some patients to go elsewhere.

William Sullivan, DO, JD: Jyoti’s answer is perfect. Many of the benefits she sees with FSEDs are similar to ones that I see working in a rural ED. Of course FSEDs follow the money. That’s the point. FSEDs have come about because they are profitable and because they fill a niche. If it takes patients several days to get an appointment (or if they can’t get an appointment at all because they don’t have the proper insurance), then the immediate and comprehensive care provided at FSEDs will address that problem.

Seth Trueger, MD, MPH: FSEDs may be a wonderful place for the docs who work there and the patients who go there, but that’s only because they are basically the ED version of concierge medicine. FSEDs won’t help the patients who can’t get a specialty appointment if they’re only built in areas with well-insured patients who can get specialty appointments.

Ryan McKennon, DO: Right on Jyoti! I also work at a hospital owned free-standing emergency department. We saw over 70,000 patients last year. It’s a busy place. Our shop as been around for a while and maybe isn’t quite on point with the article. The article argues that new freestanding EDs are only being build “in areas with population growth, higher incomes, a higher proportion of people with private health insurance,” as if this only applied to FSEDs. They compared this expansion to hospitals already in existance; I bet if you looked to see where new hospitals are being built, you would find the same thing.  Is anyone shocked that new medical buildings are being offered in areas with population growth and higher income?  FSEDs are a great way to allocate resources. Sometimes states will not allow a hospital to be built (denial of CON). Its also a great way to keep inner city hospitals open by admitting people from the FSED to the main hospital to keep the beds full and the lights on. FSED don’t “siphon off” the paying patients as much as they increase downstream revenue in many situations, at least for the hospital owned EDs. I have to disagree with Seth’s assertion that FSEDS are EDs version of concierge medicine, we still see patients with government insurance or no insurance as does every other FSED as required by EMTALA. It’s not like any FSED can turn a patient away who can’t pay like an urgent care can. Anyone who needs a specialty consult gets transferred to the main hospital for consult, well insured or not. While not being built in the poorest areas, they are generally following population growth and providing a service currently lacking in that area.

Jaime Hope, MD: Love Jyoti’s response! Agree with Bill and Ryan, of course a business will follow the money, that’s the point of a business. Just because they make money doesn’t make them inherently evil. Also, it’s a good idea to revisit new service models to improve the delivery of patient care.

Seth Trueger, MD, MPH: There are 2 types of FSEDs: those connected to hospitals (classified as hospital outpatient departments, like traditional EDs) and independent freestanding emergency centers. Many IFECs don’t take Medicare/Medicaid and EMTALA does not apply, and they can turn away anyone.

Ryan McKennon, DO: True, except that many states, Texas included where most of the IFECs are located, have state laws similar to EMTALA that require evaluation and stabilization regardless of ability to pay (Texas Administrative Code Title 25 Part 1 Section 131.46).

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  1. It is pretty clear that FSEDs are good for the owners and the docs that work in them: but is it good for the health and welfare of the overall community and for emergency medicine? The answer likely depends on the location and the regulatory environment and other considerations, but what are those considerations and which regulatory constraints mitigate the potential downsides? The profit motive doesn’t necessarily address the welfare of an entire community, and legislators often have no clue. These are population health questions requiring big data analysis, and thus far there are few real answers, and those with the INDEPENDENT resources to investigate appear to have little motivation to make the effort. A key set of unanswered questions for the specialty and for policy makers.

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