Northwestern University Feinberg School of Medicine

Department of Emergency Medicine

Research Publications

Following is information on recent faculty publications. For more information on our research, see the Emergency Medicine section on Northwestern Scholars.

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The Weekend Effect for Patients with Sepsis Presenting to the Emergency Department.

Powell ES, Khare RK, Courtney DM, Feinglass J

J Emerg Med. 2013 Aug 29. pii: S0736-4679(13)00598-2. doi: 10.1016/j.jemermed.2013.04.042. [Epub ahead of print]

BACKGROUND:

Mortality differences in weekend and weekday admissions have been observed for a variety of conditions that require aggressive early intervention. It is unknown if there is a mortality difference that exists for patients presenting to the Emergency Department (ED) with sepsis on the weekend.

STUDY OBJECTIVES:

We hypothesized that there is an increase in early inpatient mortality (death on day 1 or day 2 of hospitalization) among patients with sepsis who present to the ED on the weekend vs. weekdays.

METHODS:

We performed a cross-sectional analysis of 114,611 ED admissions with a principal diagnosis consistent with sepsis from 576 hospitals in the 2008 Nationwide Inpatient Sample. Adjusted analyses controlled for patient and hospital characteristics, and examined the likelihood of either early (day 1 or day 2 of hospitalization) or overall inpatient mortality.

RESULTS:

A greater proportion of patients admitted on the weekend died on day 1 and day 2 of hospitalization (5.4% vs. 4.0%, p < 0.001; and 7.5% vs. 6.9%, p = 0.001), the difference for overall inpatient mortality was not significant (17.9% vs. 17.5%, p = 0.08). The risk-adjusted odds ratio (OR) of day 1 and day 2 early inpatient mortality of weekend vs. weekday admissions was 1.10 (95% confidence interval [CI] 1.04-1.17) and 1.08 (95% CI 1.03-1.14), respectively; the association with overall inpatient mortality was not significant (OR 1.03, 95% CI 1.00-1.07).

CONCLUSIONS:

Patients admitted through the ED with sepsis on the weekend had a greater likelihood of early mortality, but not overall mortality, when compared to patients admitted on weekdays.

Copyright © 2013 Elsevier Inc. All rights reserved.

What patients think doctors know: Beliefs about provider knowledge as barriers to safe medication use.

Serper M, McCarthy DM, Patzer RE, King JP, Bailey SC, Smith SG, Parker RM, Davis TC, Ladner DP, Wolf MS

Patient Educ Couns. 2013 Jul 25. pii: S0738-3991(13)00275-9. doi: 10.1016/j.pec.2013.06.030. [Epub ahead of print]

OBJECTIVE:

We examined patient beliefs about provider awareness of medication use, patient-reported prevalence and nature of provider counseling about medications, and the impact of health literacy on these outcomes.

METHODS:

Structured interviews were conducted at academic general internal medicine clinics and federally qualified health centers with 500 adult patients. Interviewer-administered surveys assessed patients' beliefs, self-reported prevalence and nature of provider counseling for new prescriptions, and medication review.

RESULTS:

Most patients believed their physician was aware of all their prescription and over the counter medications, and all medications prescribed by other doctors; while a minority reported disclosing over the counter and supplement use. Among those receiving new prescriptions (n=190): 51.3% reported physician medication review, 77.4% reported receiving instructions on use from physicians and 43.3% from pharmacists. Side effects were discussed 42.9% of the time by physicians and 25.8% by pharmacists. Significant differences in outcomes were observed by health literacy, age, and clinic type.

CONCLUSIONS:

There is a sizable gap between what patients believe physicians know about their medication regimen and what they report to the physician.

PRACTICE IMPLICATIONS:

Discordance between patient beliefs and physician knowledge of medication regimens could negatively impact patient safety and healthcare quality.

Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Video Self-instruction for Police Officers in Cardiopulmonary Resuscitation and Automated External Defibrillators.

Aldeen AZ, Hartman ND, Segura A, Phull A, Shaw DM, Chiampas GT, Courtney DM

Prehosp Disaster Med. 2013 Jul 26:1-6. [Epub ahead of print]

Introduction Police officers often serve as first responders during out-of-hospital cardiac arrests (OHCA). Current knowledge and attitudes about resuscitation techniques among police officers are unknown. Hypothesis/problem This study evaluated knowledge and attitudes about cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) among urban police officers and quantified the effect of video self-instruction (VSI) on these outcomes.

METHODS:

Urban police officers were enrolled in this online, prospective, educational study conducted over one month. Demographics, prior CPR-AED experience, and baseline attitudes were queried. Subjects were randomized into two groups. Each group received a slightly different multiple-choice test of knowledge and crossed to the alternate test after the intervention, a 10-minute VSI on CPR and AEDs. Knowledge and attitudes were assessed immediately before and after the intervention. The primary attitude outcome was entering "very likely" (5-point Likert) to do chest compressions (CC) and use an AED on a stranger. The primary knowledge outcomes were identification of the correct rate of CC, depth of CC, and action in an OHCA scenario.

RESULTS:

A total of 1616 subjects responded with complete data (63.6% of all electronic entries). Randomization produced 819 participants in group 1, and 797 in group 2. Groups 1 and 2 did not differ significantly in any background variable. After the intervention, subjects "very likely" to do CC on a stranger increased by 17.2% (95% CI, 12.5%-21.8%) in group 1 and 21.2% (95% CI, 16.4%-25.9%) in group 2. Subjects "very likely" to use an AED on a stranger increased by 20.0% (95% CI, 15.3%-24.7%) in group 1 and 25.0% (95% CI, 20.2%-29.6%) in group 2. Knowledge of correct CC rate increased by 59.0% (95% CI, 55.0%-62.8%) in group 1 and 64.8% (95% CI, 60.8%-68.3%) in group 2. Knowledge of correct CC depth increased by 44.8% (95% CI, 40.5%-48.8%) in group 1 and 54.4% (95% CI, 50.3%-58.3%) in group 2. Knowledge of correct action in an OHCA scenario increased by 27.4% (95% CI, 23.4%-31.4%) in group 1 and 27.2% (95% CI, 23.3%-31.1%) in group 2.

CONCLUSION:

Video self-instruction can significantly improve attitudes toward and knowledge of CPR and AEDs among police officers. Future studies can assess the impact of VSI on actual rates of CPR and AED use during real out-of-hospital cardiac arrests. Aldeen AZ , Hartman ND , Sequra A , Phull A , Shaw DM , Chiampas GT , Courtney DM . Video self-instruction for police officers in cardiopulmonary resuscitation and automated external defibrillators. Prehosp Disaster Med. 2013;28(5):1-6.

Understanding patient-provider conversations: what are we talking about?

McCarthy DM, Buckley BA, Engel KG, Forth VE, Adams JG, Cameron KA

Acad Emerg Med. 2013 May;20(5):441-8. doi: 10.1111/acem.12138.

OBJECTIVES:

Effective patient-provider communication is a critical aspect of the delivery of high-quality patient care; however, research regarding the conversational dynamics of an overall emergency department (ED) visit remains unexplored. Identifying both patterns and relative frequency of utterances within these interactions will help guide future efforts to improve the communication between patients and providers within the ED setting. The objective of this study was to analyze complete audio recordings of ED visits to characterize these conversations and to determine the proportion of the conversation spent on different functional categories of communication.

METHODS:

Patients at an urban academic ED with four diagnoses (ankle sprain, back pain, head injury, and laceration) were recruited to have their ED visits audio recorded from the time of room placement until discharge. Patients were excluded if they were age < 18 years, were non-English-speaking, had significant history of psychiatric disease or cognitive impairment, or were medically unstable. Audio editing was performed to remove all silent downtime and non-patient-provider conversations. Audiotapes were analyzed using the Roter Interaction Analysis System (RIAS). RIAS is the most widely used medical interaction analysis system; coders assign each "utterance" (or complete thought) spoken by the patient or provider to one of 41 mutually exclusive and exhaustive categories. Descriptive statistics were calculated for all 41 categories and then grouped according to RIAS standards for "functional groupings." The percentage of total utterances in each functional grouping is reported.

RESULTS:

Twenty-six audio recordings were analyzed. Patient participants had a mean (±SD) age of 38.8 (±16.0) years, and 30.8% were male. Intercoder reliability was good, with mean intercoder correlations of 0.76 and 0.67 for all categories of provider and patient talk, respectively. Providers accounted for the majority of the conversation in the tapes (median = 239 utterances, interquartile range [IQR] = 168 to 308) compared to patients (median = 145 utterances, IQR = 80 to 198). Providers' utterances focused most on patient education and counseling (34%), followed by patient facilitation and activation (e.g., orienting the patient to the next steps in the ED or asking if the patient understood; 30%). Approximately 15% of the provider talk was spent on data gathering, with the majority (86%) focusing on biomedical topics rather than psychosocial topics (14%). Building a relationship with the patient (e.g., social talk, jokes/laughter, showing approval, or empathetic statements) constituted 22% of providers' talk. Patients' conversation was mainly focused in two areas: information giving (47% of patient utterances: 83% biomedical, 17% psychosocial) and building a relationship (45% of patient utterances). Only 5% of patients' utterances were devoted to question asking. Patient-centeredness scores were low.

CONCLUSIONS:

In this sample, both providers and patients spent a significant portion of their talk time providing information to one another, as might be expected in the fast-paced ED setting. Less expected was the result that a large percentage of both provider and patient utterances focused on relationship building, despite the lack of traditional, longitudinal provider-patient relationships.

© 2013 by the Society for Academic Emergency Medicine.

Management of hemorrhage complicated by novel oral anticoagulants in the emergency department: case report from the northwesternemergency medicine residency.

Kiraly A, Lyden A, Periyanayagam U, Chan J, Pang PS

Am J Ther. 2013 May-Jun;20(3):300-6. doi: 10.1097/MJT.0b013e3182878d18.

Anticoagulation has long complicated the care of hemorrhage in the emergency department and other acute care settings. With the advent of novel anticoagulants such as direct thrombin inhibitors and direct factor Xa inhibitors, the absence of any direct antidote for these medications presents new and difficult challenges in the management of hemorrhagic complications in these patients. We present 2 cases of patients with hemorrhagic complications taking novel oral anticoagulants, their management, and outcomes.

Results from the first decade of Research Conducted by the Research on Adverse Drug Events and Reports (RADAR) project.

McKoy JM, Fisher MJ, Courtney DM, Raisch DW, Edwards BJ, Scheetz MH, Belknap SM, Trifilio SM, Samaras AT, Liebling DB, Nardone B, Tulas KM, West DP

Drug Saf. 2013 May;36(5):335-47. doi: 10.1007/s40264-013-0042-x.

INTRODUCTION:

In 1998, a multidisciplinary team of investigators initiated the Research on Adverse Drug events And Reports (RADAR) project, a post-marketing surveillance effort that systematically investigates and disseminates information describing serious and previously unrecognized serious adverse drug and device reactions (sADRs).

OBJECTIVE:

Herein, we describe the findings, dissemination efforts, and lessons learned from the first decade of the RADAR project.

METHODS:

After identifying serious and unexpected clinical events suitable for further investigation, RADAR collaborators derived case information from physician queries, published and unpublished clinical trials, case reports, US FDA databases and manufacturer sales figures.

STUDY SELECTION:

All major RADAR publications from 1998 to the present are included in this analysis.

DATA EXTRACTION:

For each RADAR publication, data were abstracted on data source, correlative basic science findings, dissemination and resultant safety information.

RESULTS:

RADAR investigators reported 43 serious ADRs. Data sources included case reports (17 sADRs), registries (5 sADRs), referral centers (8 sADRs) and clinical trial reports (13 sADRs). Correlative basic science findings were reported for ten sADRs. Thirty-seven sADRS were described as published case reports (5 sADRs) or published case-series (32 sADRs). Related safety information was disseminated as warnings or boxed warnings in the package insert (17 sADRs) and/or 'Dear Healthcare Professional' letters (14 sADRs).

CONCLUSION:

An independent National Institutes of Health-funded post-marketing surveillance programme can supplement existing regulatory and pharmaceutical manufacturer-supported drug safety initiatives.

Use of Risk Assessment Analysis by Failure Mode, Effects, and Criticality to Reduce Door-to-Balloon Time.

Khare RK, Nannicelli AP, Powell ES, Seivert NP, Adams JG, Holl JL

Ann Emerg Med. 2013 Mar 28. pii: S0196-0644(13)00095-4. doi: 10.1016/j.annemergmed.2013.01.023. [Epub ahead of print]

STUDY OBJECTIVE:

The Centers for Medicare & Medicaid Services currently endorses a door-to-balloon time of 90 minutes or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction. Recent evidence shows that a door-to-balloon time of 60 minutes significantly decreases inhospital mortality. We seek to use a proactive risk assessment method of failure mode, effects, and criticality analysis (FMECA) to evaluate door-to-balloon time process, to investigate how each component failure may affect the performance of a system, and to evaluate the frequency and the potential severity of harm of each failure.

METHODS:

We conducted a 2-part study: FMECA of the door-to-balloon time system and process of care, and evaluation of a single institution's door-to-balloon time operational data using a retrospective observational cohort design. A multidisciplinary group of FMECA participants described the door-to-balloon time process to then create a comprehensive map and table listing all process steps and identified process failures, including their frequency, consequence, and causes. Door-to-balloon time operational data were assessed by "on" versus "off" hours.

RESULTS:

Fifty-one failure points were identified across 4 door-to-balloon time phases. Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. Total door-to-balloon time during on hours had a median time of 55 minutes (95% confidence interval 46 to 60 minutes) compared with 77 minutes (95% confidence interval 68 to 83 minutes) during off hours.

CONCLUSION:

The FMECA revealed clear areas of potential delay and vulnerability that can be addressed to decrease door-to-balloon time from 90 to 60 minutes. FMECAs can provide a robust assessment of potential risks and can serve as the platform for significant process improvement and system redesign for door-to-balloon time.

Copyright © 2013. Published by Mosby, Inc.

An early look at performance on the emergency care measures included in Medicare's hospital inpatient Value-Based Purchasing Program.

McHugh M, Neimeyer J, Powell E, Khare RK, Adams JG

Ann Emerg Med. 2013 Jun;61(6):616-623.e2. doi: 10.1016/j.annemergmed.2013.01.012. Epub 2013 Mar 13.

STUDY OBJECTIVE:

Medicare's new, mandatory Hospital Inpatient Value-Based Purchasing Program introduces financial rewards or penalties to hospitals according to achievement or improvement on several publicly reported quality measures. Our objective was to describe hospital reporting on the 4 emergency department (ED)-related program measures, variation in performance on the ED measures across hospital characteristics, and the characteristics of hospitals that were more likely to receive performance scores based on improvement versus achievement.

METHODS:

This was an exploratory, descriptive analysis. We merged 2008 to 2010 performance data from Hospital Compare with the 2009 American Hospital Association Annual Survey. We calculated a composite score for the 4 ED measures and used Kruskal-Wallis tests to examine differences in performance across hospital characteristics. We also examined differences in the percentage of scores that were awarded according to improvement versus achievement.

RESULTS:

There were 2,927 hospitals that qualified for the value-based purchasing program and were included in the analysis. For-profit hospitals received the highest scores; public hospitals and hospitals lacking The Joint Commission (TJC) accreditation received the lowest scores. Public hospitals had the largest share of scores awarded according to improvement (39.8%); for-profit hospitals had the lowest (27.8%).

CONCLUSION:

We found variation in performance by hospital characteristics on the ED-related program measures. Although public and non-TJC-accredited hospitals trailed in performance, they showed strong signs of improvement, signaling that performance gaps by ownership and accreditation may decrease. Considering the increasing scope of the value-based purchasing program, ED leaders should monitor both achievement and improvement on the 4 ED-related program measures.

Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Large-volume hypertonic saline therapy in endurance athlete with exercise-associated hyponatremic encephalopathy.

Elsaesser TF, Pang PS, Malik S, Chiampas GT

J Emerg Med. 2013 Jun;44(6):1132-5. doi: 10.1016/j.jemermed.2012.11.048. Epub 2013 Feb 26.

BACKGROUND:

Small-volume boluses of intravenous hypertonic saline are the recommended therapy for exercise-associated hyponatremic encephalopathy (EAHE). Failure to properly diagnose and treat EAHE has been associated with significant morbidity and death. To prevent this, current consensus statement guidelines recommend up to three 100-mL boluses of 3% NaCl spaced at 10-min intervals to correct symptoms. Due to lack of evidence, however, guidelines are vague regarding the maximal volume that can be safely administered in a given time period beyond these initial boluses.

OBJECTIVES:

This case report will review the underlying pathophysiology, clinical presentation, diagnosis, and management of EAHE in a patient refractory to initial treatment.

CASE REPORT:

We report a case of EAHE in an experienced marathon runner requiring large-volume infusion (950 mL) of 3% NaCl therapy for resolution of symptoms without any adverse events.

CONCLUSION:

Although further research is needed, this case may provide helpful information for acute care and sports medicine physicians who encounter patients with EAHE refractory to initial therapy.

Published by Elsevier Inc.

Literacy and race as risk factors for low rates of advance directives in older adults.

Waite KR, Federman AD, McCarthy DM, Sudore R, Curtis LM, Baker DW, Wilson EA, Hasnain-Wynia R, Wolf MS, Paasche-Orlow MK

J Am Geriatr Soc. 2013 Mar;61(3):403-6. doi: 10.1111/jgs.12134. Epub 2013 Feb 4.

OBJECTIVES:

To examine the effect of the relationship between literacy and other individual-level factors on having an advance directive (AD).

DESIGN:

Face-to-face structured interview.

SETTING:

Participants were recruited from an academic general internal medicine clinic and one of four federally qualified health centers in Chicago.

PARTICIPANTS:

Seven hundred eighty-four adults aged 55 to 74.

MEASUREMENTS:

Assessment of participant literacy, sociodemographic factors, and having an AD for medical care.

RESULTS:

One-eighth (12.4%) of participants with low literacy, 26.6% of those with marginal literacy, and 49.5% of those with adequate literacy reported having an AD (P < .001). In multivariable analyses, literacy and race were independently associated with less likelihood of having an AD. Specifically, participants with limited literacy (risk ratio (RR) = 0.45, 95% confidence interval (CI) = 0.22-0.95) and African Americans (RR = 0.64, 95% CI = 0.47-0.88) were less likely to have an AD. Exploratory analyses showed that there was not a significant interaction between the effect of literacy and race.

CONCLUSION:

Limited literacy and African-American race were significant risk factors for not having an AD in this cohort of older adults. Literacy and race probably represent two separate but important causal pathways that need to be understood to improve how the healthcare system ascertains and protects individuals' advance care preferences.

© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Approaches to improving healthcare delivery by multi-stakeholder alliances.

McHugh MC, Harvey JB, Aseyev D, Alexander JA, Beich J, Scanlon DP

Am J Manag Care. 2012 Sep;18(6 Suppl):s156-62.

OBJECTIVE:

Our purposes were: (1) to describe how 14 multi-stakeholder alliances participating in the Aligning Forces for Quality (AF4Q) initiative approached the charge of improving healthcare delivery at the community level between 2006 and 2010; and (2) to offer insights to policy makers and program planners seeking to promote or establish community-wide quality improvement (QI).

STUDY DESIGN:

This was a qualitative study.

METHODS:

A total of 84 semi-structured interviews were conducted with AF4Q alliance leaders between 2006 and 2010, and an iterative coding process was used to identify salient themes. Program documents supplemented the interview data and were used to develop an inventory of the alliances' QI activities using the Leatherman and Sutherland taxonomy of quality-enhancing interventions.

RESULTS:

Alliances spent years planning their QI approaches and activities. Initial selection of QI activities was driven by the availability of local expertise and resources, rather than alignment with a community-wide vision for quality. Alliances were just as likely to rely on local partners to lead QI activities as they were to establish their own activities. The most commonly adopted QI activities were collaboratives aimed at producing organizational-level changes.

CONCLUSIONS:

Policy makers and program planners seeking to promote community-wide QI should consider developing clear expectations, offering technical assistance at the start of the program, providing information on the evidence base for QI activities, and highlighting additional funding opportunities that could support QI activities. Alliances may need a stronger push to move beyond coordinated, organizational-level activities to more community-focused, cross-organizational QI activities.

Assessing practice-based learning and improvement.

Salzman DH, Franzen DS, Leone KA, Kessler CS

Acad Emerg Med. 2012 Dec;19(12):1403-10. doi: 10.1111/acem.12026.

Assessment of practice-based learning and improvement (PBLI) is a core concept identified in several competency frameworks. This paper summarizes the current state of PBLI assessment as presented at the 2012 Academic Emergency Medicine consensus conference on education research in emergency medicine. Based on these findings and consensus achieved at the conference, seven recommendations have been identified for future research.

© 2012 by the Society for Academic Emergency Medicine.

Severe sepsis in do-not-resuscitate patients: intervention and mortality rates.

Powell ES, Sauser K, Cheema N, Pirotte MJ, Quattromani E, Avula U, Khare RK, Courtney DM

J Emerg Med. 2013 Apr;44(4):742-9. doi: 10.1016/j.jemermed.2012.09.034. Epub 2012 Dec 21.

BACKGROUND:

Severe sepsis is a high-mortality disease, and early resuscitation decreases mortality. Do-not-resuscitate (DNR) status may influence physician decisions beyond cardiopulmonary resuscitation, but this has not been investigated in sepsis.

OBJECTIVE:

Among Emergency Department (ED) severe sepsis patients, define the incidence of DNR status, prevalence of central venous catheter placement, and vasopressor administration (invasive measures), and mortality.

METHODS:

Retrospective observational cohort of consecutive severe sepsis patients to single ED in 2009-2010. Charts abstracted for DNR status on presentation, demographics, vitals, Sequential Organ Failure Assessment (SOFA) score, inpatient and 60-day mortality, and discharge disposition. Primary outcomes were mortality, discharge to skilled nursing facility (SNF), and invasive measure compliance. Chi-squared test was used for univariate association of DNR status and outcome variables; multivariate logistic regression analyses for outcome variables controlling for age, gender, SOFA score, and DNR status.

RESULTS:

In 376 severe sepsis patients, 50 (13.3%) had DNR status. DNR patients were older (79.2 vs 60.3 years, p < 0.001) and trended toward higher SOFA scores (7 vs. 6, p = 0.07). DNR inpatient and 60-day mortalities were higher (50.5% vs. 19.6%, 95% confidence interval [CI] 15.9-44.9%; 64.0% vs. 24.9%, 95% CI 25.1-53.3%, respectively), and remained higher in multivariate logistic regression analysis (odds ratio [OR] 3.01, 95% CI 1.48-6.17; OR 3.80, 95% CI 1.88-7.69, respectively). The groups had similar rates of discharge to SNF, and in persistently hypotensive patients (n = 326) had similar rates of invasive measures in univariate and multivariate analyses (OR 1.19, 95% CI 0.45-3.15).

CONCLUSION:

In this sample, 13.3% of severe sepsis patients had DNR status, and 50% of DNR patients survived to hospital discharge. DNR patients received invasive measures at a rate similar to patients without DNR status.

Published by Elsevier Inc.

Patients with acute heart failure in the emergency department: do they all need to be admitted?

Pang PS, Jesse R, Collins SP, Maisel A

J Card Fail. 2012 Dec;18(12):900-3. doi: 10.1016/j.cardfail.2012.10.014.

Hospitalization for acute heart failure (AHF) is associated with a high rate of postdischarge mortality and readmissions, as well as high financial costs. Reducing 30-day readmissions after AHF hospitalization is a major national quality goal intended to both improve patient outcomes and reduce costs. Although the decision threshold for the vast majority of hospitalized AHF patients lies in the emergency department (ED), the role of the ED in reducing preventable admissions has largely been ignored. While admissions for AHF also originate from outpatient clinics, the greatest opportunity to reduce inpatient admissions lies with the cohort of patients who present to the ED with AHF. Safe discharge mandates interdisciplinary collaboration, close follow-up, careful scrutiny of psychosocial and socioeconomic factors, and a shared definition of risk stratification. Although additional research is needed, strategies for lower risk patients can and should be initiated to safely discharge AHF patients from the ED.

Copyright © 2012 Elsevier Inc. All rights reserved.

The role of natriuretic peptides: from the emergency department throughout hospitalization.

Pang PS, Xue Y, Defilippi C, Silver M, Januzzi J, Maisel A

Congest Heart Fail. 2012 Sep-Oct;18 Suppl 1:S5-8. doi: 10.1111/j.1751-7133.2012.00307.x.

Assessment of natriuretic peptide (NP) levels has a well-established role in the diagnosis and prognosis of acute heart failure (AHF) patients. Current guidelines recommend assessment of NPs when the diagnosis is in question, yet multiple studies suggest a broader value of NP assessment. Measurement of NP levels results in more efficient treatment, resource utilization (ie, reduced costs), and possibly improved short- and long-term outcomes. Given the large number of patients hospitalized every year with heart failure, combined with the high post-discharge mortality, rehospitalization rates, and subsequent large financial costs, improving outcomes for hospitalized HF patients remains an unmet need. In this review, we highlight the value of NP assessment, starting in the emergency department and throughout hospitalization. The contents of this review were generated from a roundtable discussion of AHF and biomarker experts held in Chicago in April 2012 and focused on addressing the burden of AHF and readmission.

© 2012 Wiley Periodicals, Inc.

Language use in the informed consent discussion for emergency procedures.

McCarthy DM, Leone KA, Salzman DH, Vozenilek JA, Cameron KA

Teach Learn Med. 2012;24(4):315-20. doi: 10.1080/10401334.2012.715257.

BACKGROUND:

The field of health literacy has closely examined the readability of written health materials to optimize patient comprehension. Few studies have examined spoken communication in a way that is comparable to analyses of written communication.

PURPOSE:

The study objective was to characterize the structural elements of residents' spoken words while obtaining informed consent.

METHODS:

Twenty-six resident physicians participated in a simulated informed consent discussion with a standardized patient. Audio recordings of the discussions were transcribed and analyzed to assess grammar statistics for evaluating language complexity (e.g., reading grade level). Transcripts and time values were used to assess structural characteristics of the dialogue (e.g., interactivity).

RESULTS:

Discussions were characterized by physician verbal dominance. The discussions were interactive but showed significant differences between the physician and patient speech patterns for all language complexity metrics.

CONCLUSIONS:

In this study, physicians spoke significantly more and used more complex language than the patients.

Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach.

Beach C, Cheung DS, Apker J, Horwitz LI, Howell EE, O'Leary KJ, Patterson ES, Schuur JD, Wears R, Williams M

Acad Emerg Med. 2012 Oct;19(10):1188-95. doi: 10.1111/j.1553-2712.2012.01448.x. Epub 2012 Oct 4.

Patient care transitions across specialties involve more complexity than those within the same specialty, yet the unique social and technical features remain underexplored. Further, little consensus exists among researchers and practitioners about strategies to improve interspecialty communication. This concept article addresses these gaps by focusing on the hand-off process between emergency and hospital medicine physicians. Sensitivity to cultural and operational differences and a common set of expectations pertaining to hand-off content will more effectively prepare the next provider to act safely and efficiently when caring for the patient. Through a consensus decision-making process of experienced and published authorities in health care transitions, including physicians in both specialties as well as in communication studies, the authors propose content and style principles clinicians may use to improve transition communication. With representation from both community and academic settings, similarities and differences between emergency medicine and internal medicine are highlighted to heighten appreciation of the values, attitudes, and goals of each specialty, particularly pertaining to communication. The authors also examine different communication media, social and cultural behaviors, and tools that practitioners use to share patient care information. Quality measures are proposed within the structure, process, and outcome framework for institutions seeking to evaluate and monitor improvement strategies in hand-off performance. Validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes will be necessary. By exploring the dynamics of transition communication between specialties and suggesting best practices, the authors hope to strengthen hand-off skills and contribute to improved continuity of care.

© 2012 by the Society for Academic Emergency Medicine.

Emergency Department Team Communication with the Patient: The Patient's Perspective.

McCarthy DM, Ellison EP, Venkatesh AK, Engel KG, Cameron KA, Makoul G, Adams JG

J Emerg Med. 2013 Aug;45(2):262-70. doi: 10.1016/j.jemermed.2012.07.052. Epub 2012 Sep 16.

BACKGROUND:

Effective communication is important for the delivery of quality care. The Emergency Department (ED) environment poses significant challenges to effective communication.

OBJECTIVES:

The objective of this study was to determine patients' perceptions of their ED team's communication skills.

METHODS:

This was a cross-sectional study in an urban, academic ED. Patients completed the Communication Assessment Tool for Teams (CAT-T) survey upon ED exit. The CAT-T was adapted from the psychometrically validated Communication Assessment Tool (CAT) to measure patient perceptions of communication with a medical team. The 14 core CAT-T items are associated with a 5-point scale (5 = excellent); results are reported as the percent of participants who responded "excellent." Responses were analyzed for differences based on age, sex, race, and operational metrics (wait time, ED daily census).

RESULTS:

There were 346 patients identified; the final sample for analysis was 226 patients (53.5% female, 48.2% Caucasian), representing a response rate of 65.3%. The scores on CAT-T items (reported as % "excellent") ranged from 50.0% to 76.1%. The highest-scoring items were "let me talk without interruptions" (76.1%), "talked in terms I could understand" (75.2%), and "treated me with respect" (74.3%). The lowest-scoring item was "encouraged me to ask questions" (50.0%). No differences were noted based on patient sex, race, age, wait time, or daily census of the ED.

CONCLUSIONS:

The patients in this study perceived that the ED teams were respectful and allowed them to talk without interruptions; however, lower ratings were given for items related to actively engaging the patient in decision-making and asking questions.

Copyright © 2013 Elsevier Inc. All rights reserved.

Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest?

Engel KG, Buckley BA, Forth VE, McCarthy DM, Ellison EP, Schmidt MJ, Adams JG

Acad Emerg Med. 2012 Sep;19(9):E1035-44. doi: 10.1111/j.1553-2712.2012.01425.x.

OBJECTIVES:

Many patients are discharged from the emergency department (ED) with an incomplete understanding of the information needed to safely care for themselves at home. Patients have demonstrated particular difficulty in understanding post-ED care instructions (including medications, home care, and follow-up). The objective of this study was to further characterize these deficits and identify gaps in knowledge that may place the patient at risk for complications or poor outcomes.

METHODS:

This was a prospective cohort, phone interview-based study of 159 adult English-speaking patients within 24 to 36 hours of ED discharge. Patient knowledge was assessed for five diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the following five domains: diagnosis, medications, home care, follow-up, and return instructions. Knowledge was determined based on the concordance between direct patient recall and diagnosis-specific discharge instructions combined with chart review. Two authors scored each case independently and discussed discrepancies before providing a final score for each domain (no, minimal, partial, or complete comprehension). Descriptive statistics were used for the analyses.

RESULTS:

The study population was 50% female with a median age of 41 years (interquartile range [IQR] = 29 to 53 years). Knowledge deficits were demonstrated by the majority of patients in the domain of home care instructions (80%) and return instructions (79%). Less frequent deficits were found for the domains of follow-up (39%), medications (22%), and diagnosis (14%). Minimal or no understanding in at least one domain was demonstrated by greater than two-thirds of patients and was found in 40% of cases for home care and 51% for return instructions. These deficits occurred less frequently for domains of follow-up (18%), diagnosis (3%), and medications (3%).

CONCLUSIONS:

Patients demonstrate the most frequent knowledge deficits for home care and return instructions, raising significant concerns for adherence and outcomes.

© 2012 by the Society for Academic Emergency Medicine.

Cost-effectiveness comparison of response strategies to a large-scale anthrax attack on the chicago metropolitan area: impact of timing and surge capacity.

Kyriacou DN, Dobrez D, Parada JP, Steinberg JM, Kahn A, Bennett CL, Schmitt BP

Biosecur Bioterror. 2012 Sep;10(3):264-79. Epub 2012 Jul 30.

Rapid public health response to a large-scale anthrax attack would reduce overall morbidity and mortality. However, there is uncertainty about the optimal cost-effective response strategy based on timing of intervention, public health resources, and critical care facilities. We conducted a decision analytic study to compare response strategies to a theoretical large-scale anthrax attack on the Chicago metropolitan area beginning either Day 2 or Day 5 after the attack. These strategies correspond to the policy options set forth by the Anthrax Modeling Working Group for population-wide responses to a large-scale anthrax attack: (1) postattack antibiotic prophylaxis, (2) postattack antibiotic prophylaxis and vaccination, (3) preattack vaccination with postattack antibiotic prophylaxis, and (4) preattack vaccination with postattack antibiotic prophylaxis and vaccination. Outcomes were measured in costs, lives saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We estimated that postattack antibiotic prophylaxis of all 1,390,000 anthrax-exposed people beginning on Day 2 after attack would result in 205,835 infected victims, 35,049 fulminant victims, and 28,612 deaths. Only 6,437 (18.5%) of the fulminant victims could be saved with the existing critical care facilities in the Chicago metropolitan area. Mortality would increase to 69,136 if the response strategy began on Day 5. Including postattack vaccination with antibiotic prophylaxis of all exposed people reduces mortality and is cost-effective for both Day 2 (ICER=$182/QALY) and Day 5 (ICER=$1,088/QALY) response strategies. Increasing ICU bed availability significantly reduces mortality for all response strategies. We conclude that postattack antibiotic prophylaxis and vaccination of all exposed people is the optimal cost-effective response strategy for a large-scale anthrax attack. Our findings support the US government's plan to provide antibiotic prophylaxis and vaccination for all exposed people within 48 hours of the recognition of a large-scale anthrax attack. Future policies should consider expanding critical care capacity to allow for the rescue of more victims.