Posts (148)

Thu, Aug 2 11:36am · The opioid epidemic

Author: Molly Jeffery PhD @mollyjeffery

Commentary about: Jeffery at al. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ 2018.

With all the attention that is being paid to opioid prescribing over the past few years, we wanted to know whether we’re moving the needle: are fewer people taking opioids now than a few years ago?

Surprisingly, we found that the percentage of people who take opioids hasn’t changed much since the rates started to level off in about 2012. Specifically, among commercially insured people—people who generally get their health insurance from their or a family members’ employer—and people aged 65 and older who have Medicare Advantage insurance, we have seen very little change in the proportion of people taking prescribed opioids.

In the third population we looked at—people with long-term disabilities who have Medicare Advantage—we saw minor changes, but use has been nearly flat since 2012. And in all three groups, use was higher in 2016 than at the beginning of the study in 2007.

What does this mean?  The United States uses opioids in a way no other country does. We use nearly twice as much opioids per person as the next closest countries (Canada and Germany), and about 7 times as much as the UK. We don’t know the ideal level of opioid use that balances risks and benefits to patients and societies, but it seems pretty clear that we in the US are above that ideal level.

To change that, we need to address two different problems. First, we need to do a better job with opioids for acute pain, and there may be a role for emergency medicine in that effort. In earlier work (https://doi.org/10.1016/j.annemergmed.2017.08.042

), we found that first-time opioid prescriptions (that is, prescriptions for people who haven’t taken opioids in at least 6 months) written in the emergency department were for shorter durations and lower doses than first-time prescriptions written in other settings. Still, researchers at UPenn have found substantial national variation (https://doi.org/10.1016/j.annemergmed.2018.06.003) in the proportion of people being treated for ankle sprains in the ED, with state rates as high as 40% and as low as 3%.

Some health systems have had success reducing opioid prescriptions by instituting voluntary prescribing guidelines. Here at Mayo Clinic, the department of orthopedic surgery looked at their data on opioid prescribing after surgery and developed a voluntary guideline that resulted in a nearly 50% reduction in the volume of opioids prescribed after hip and knee replacement surgeries  (doi: 10.1007/s11999.0000000000000292). And this was accomplished without an increase in the proportion of patients requesting refills. In other words, the new lower prescribing does not seem to have negatively impacted patient pain control.

The second problem we need to address is opioid prescribing for chronic pain. Our study found that in the commercially insured population, the 3% of opioid use episodes that represented long-term use were associated with 62% of all opioids dispensed to that group. The scientific evidence suggests that on average, long-term opioid use is not an effective treatment for chronic pain (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm). Some patients are able to achieve improved functioning and pain reduction when using opioids long term, but most are not. We desperately need more effective treatments for chronic pain and better access to non-opioid treatments we already have. For example, multidisciplinary pain programs have been found to help patients with chronic pain improve function and pain management, but they can be expensive and difficult to access, with some insurers reluctant to cover them. (http://americanpainsociety.org/uploads/about/position-statements/interdisciplinary-white-paper.pdf)

Some have suggested that we need laws or policies to cut off access to high dose or long-term opioid therapy. The trouble with that is that there is no such thing as a one-size-fits-all treatment plan for pain. Different types of pain respond to different treatments, and so do different patients. Policies that require the insurance company to sign off on an opioid dose above some level can have an unfair impact on patients with fewer resources. If you have the cash to pay, you can fill that high dose prescription written by your physician. But if you need your insurance company to pay, you may have to leave the pharmacy without your medication. You may have to spend substantial time on the phone to get the treatment approved. You may have to wait until the physician and insurance company contact each other. It’s not the right way to treat people.


Reducing prescribed opioid use is going to take time to do humanely and effectively. It will take partnership between providers and patients, but it can be done.

Thu, Jun 14 11:41am · Blockchain: A new technology for health professions education

Author: Eric Funk, MD @efunkem

 

This is commentary of Funk et al. Blockchain Technology: A Data Framework to Improve Validity, Trust, and Accountability of Information Exchange in Health Professions Education. Academic Medicine. In press.

Since the inception of Bitcoin in 2009, the use of blockchains has steadily gained attention. What began as mild interest from computer scientists has now grown to a fervor pitch. The initial impacts have been seen in the world of finance and are now spreading to many other sectors. More recently, thought leaders and entrepreneurs have begun to explore how the idea of blockchain could be used to improve healthcare. The obvious progression of this idea is to explore how blockchain will influence the education and training of healthcare workers. In our recent paper in Academic Medicine, we have laid out a basic framework for how blockchain could impact healthcare education.

Healthcare education has a long history of adopting new technological innovations in order to improve student’s learning. This has included MOOCs, digital platforms, and the #FOAMed movement. Using blockchains to improve education is the logical next step.

What is blockchain?

It’s a new way of storing data. Most people don’t think about how their data is stored, but it has a large impact on how the data can be used. In a blockchain, a recording of every transaction between users during a time period is group together in a “block”. These blocks are then “chained” together in chronological order. The recording of transactions and linking of blocks are done with advanced mathematics. Fortunately, it is not necessary for end-users to understand all of the technical concepts in order to benefit from using a blockchain (just as it is not necessary to know how to build an engine in order to drive a car). The chain of blocks is completely open and can be inspected by anyone to see the entire history of interactions. Since every single person involved can inspect the blockchain, it is nearly impossible to change the record of events.

How can blockchain allow educators to better track their impact?

It has traditionally been very difficult for clinical educators to get credit for their work, especially compared to their peers who focus primarily on research output. Recording this information in the blockchain will easily allow educators to track their impact as their students ultimately become educators themselves, and pass along their knowledge to each subsequent class of students. It will also allow for easy tracking of the most utilized and most effective learning modules.

How can blockchain make CBME (competency based medical education) and EPAs (Entrustable Professional Activities) better?

The blockchain can serve as a digital ledger of the behaviors that are critical for assessment. This will allow learners to easily see how they compare to their peers at various other universities or institutions. One significant improvement is that this system allows for asynchronous evaluation of milestones, that are completed independent of location. It better allows learners to progress through the required knowledge at their own pace.

How can blockchain improve credentialing?

Using a blockchain allows for one decentralized database of information. Anyone who has recently applied for medical licenses in multiple states or gone through the process of applying for hospital privileges will be able to appreciate this benefit. Rather than combing through information that is scattered across multiple different sources, a decentralized blockchain will be able to efficiently store this information. There will be easily accessible proof of completing a degree, diplomas, certifications in other states, procedure logs, etc… rather than trusting unverified information coming from various sources.

These ideas represent the potential benefit that blockchain could bring to medical education. They do not represent a prediction of the future or a magical solution for all the problems facing educators and students. Many blockchain platforms already exist that could be used to implement these ideas (Ardor and Ethereum being a few of the more technologically advanced and accessible blockchain platforms), or new ones could be created. The next step in exploring these ideas will be for developers and forward-thinking educators to join forces and begin producing real-life products that allow for implementation of these ideas. The future is bright.

 

 

 

Tue, May 22 7:24am · Addressing the Active Shooter Challenge through In-situ Simulation

Author: Mark Mannenbach, MD. @MMannenbach

Commentary on: Mannenbach et al. An In Situ Simulation-Based Training Approach to Active Shooter Response in the Emergency Department. in Disaster Medicine and Public Health Preparedness

With an increased number of active shooter events in the United States, emergency departments are challenged to ensure preparedness for this low-frequency, but extremely high stakes event.  Engagement of all emergency department personnel can be very challenging due to a variety of barriers including perception of lack of time, likelihood of occurrence, or interference with actual patient care

Our department chose to utilize an in situ simulation training model as a component of active shooter education for our academic emergency medicine practice.  Although a variety of modalities can be utilized for this type of training, we felt that an in situ model allowed for our emergency department personnel to engage actively in the experience.  We did so with some hesitation as we felt that the experience may be “too realistic” for some members of the department.  However, we felt that this approach allowed for the greatest degree of engagement and ownership of the need for awareness and personal decision-making.

We were intentional in our inclusion of as many disciplines as possible for each scenario session.  Leaders from physician, nursing, security, registration, laboratory medicine, and radiology technology were chosen to participate in the planning process.

We utilized both mannequins and live standardized patients to specifically address the need for incorporation of real patients as a factor for emergency department personnel to consider as they processed their reactions and plans for the scenario.

These scenarios were conducted in care areas of our emergency department where actual patients were not present at the time.  The scenarios were also conducted at a time when the attending physicians were present for a mandatory monthly meeting to improve their involvement in the process outside of their usual clinical assignments.

Debriefing occurred after each of the brief 10 minute scenarios and included feedback and direction from physician and security experts in regard to the preferred approach of “RUN, HIDE, FIGHT” when faced with an active shooter situation.  Careful attention was paid by those overseeing the scenarios to allow for identification of the triggering of any emotional or psychological stress as a result of participation.

With this approach and planning, we were able to include nearly all of the attending physicians as well as many resident physicians, nursing staff, and other emergency department personnel over the course of several months.

The feedback from the participants was overwhelmingly positive in terms of increased awareness, educational value, and planning for an actual event.  Those involved felt that the scenarios created realism without undue stress.

Although our approach may not be translated exactly to other emergency departments, we hope that our approach and lessons learned can be applied by others and they are planning and preparation for these potentially devastating events.

As recent as this week, several reports have emerged about US emergency departments are not ready for “mass tragedy”. Our article highlights the need to develop explicit training about events potentially leading to mass casualties.

 

Further details of our work can be found in an upcoming issue of Disaster Medicine and Public Health Preparedness.

Thu, Mar 1 9:25am · We all make mistakes

Author: Laura Walker, M.D. @dortzus

This post is a comment on Walker et al. Clinical care review systems in healthcare: a systematic review. Int J Emerg Med. 2018

 

We all make mistakes.

 

Most errors are avoidable in some way or another, the trick is figuring out how to do it.  To avoid repeating a mistake, you need to understand why it happened.  To understand why it happened, you need to talk about it.  And talking about it can be very hard to do.

 

Despite reports on the extent of medical errors1 and the need for increased transparency2 there is not a lot of literature out there exploring what review of a perceived medical error (care review) really looks like, or what it should look like.

 

Recognizing this gap, we undertook to perform a qualitative systematic review of the current literature on review of adverse events.  We performed a massive search of peer-reviewed literature and identified over 1300 articles that seemed to fit the bill.  In the end this was winnowed down to only 46 articles that were addressing what we were looking for – a description of what the process of exploring errors looks like.

 

We read through these articles and identified 16 common domains among them:

  • Systems analysis
  • Functional department
  • Educational output
  • Standardized process
  • Structured case classification
  • Feedback from and to the team
  • Human factors assessment
  • Outcome consideration
  • Non-punitive
  • Recognition of excellence
  • Referral process
  • Multidisciplinary
  • Process leadership
  • Reviewer training
  • Case blinding
  • Implementation of improvement recommendations

 

Wading my way through all these articles helped me better understand the concept of care review, and there are two groupings that I would call out as fundamentally important to understand.

 

First, there is the systems and processes aspect – the components of review that are very analytical and focus on the facts of the case and guide toward an objective evaluation and recommendations to decrease the chance of the error occurring again.  Second, there are those aspects that lead us to consider the role of human nature both in error and our response to it, in addition to the biases we have when we approach a situation.

 

The work that I do reviewing care often leads me to consider second-victim phenomenon – the psychological stress that affects the care provider after an error occurs.  Hearing that there are concerns about care you provided strikes fear in to all our hearts.  We need to continue to take care of our own, even as we strive to improve the care we provide for our patients.   Talking about our mistakes can be difficult, but it can also be educational, and from personal perspective and when done well – therapeutic.  And it can make a difference as we implement practice changes in response to concerning events – maybe we develop a process to improve checks on high risk medication doses, or implement a tool to aim for a safer care handoff, or we develop learning modules to highlight high-risk patient presentations.

 

Systems improvement and education are the goal outcomes after an event, and when a review incorporates the domains we identified in our review, we think that the downstream effect could be a process that fosters engagement and positive change.

 

(There is always the medico-legal aspect to consider when engaging in care review, check with your local legal team before setting out to make sure you are protected.)

 

References

  1. Makary, Martin A and Daniel, Michael, Medical error – the third leading cause of death in the US.  BMJ 2016 May 3; 353:i2139
  2. Kohn L T, Corrigan J M, Donaldson MS (Institute of Medicine) To err is human: building a safer health system. Washington, DC: National Academy Press, 2000

Fri, Feb 2 10:23am · Intravenous Lidocaine for pain in the ED: what the evidence shows?

Author: Lucas Oliveira J. e Silva (@lucasojesilva12)

 

Lidocaine is a local anesthetic agent of the amide type that has been described as containing analgesic (1), anti-hyperalgesic (2) and anti-inflammatory properties (3,4). It has a short half-life (60 to 120 minutes) and its side effects are often predictable. Due to its short half-life, toxicity symptoms at lower doses are generally transient, although its analgesic effect might last more than expected (5). Lidocaine for pain control, administered by intravenous (IV) injection, has been studied in various settings, including the operating room for management of perioperative pain (5) and outpatient clinics for treatment of neuropathic pain. Its use in the Emergency Department (ED), however, has only recently gained attention after emerging evidence for the management of pain of renal colic patients in the ED (6,7).

 

The current public health crisis of opioid addiction driven by increased prescribing of these medications, and increased number of overdose-related deaths, further emphasizes the need for alternative approaches for pain control.

 

In order to better understand the whole body of evidence, we conducted a systematic review to evaluate the safety and efficacy of IV lidocaine for adult patients undergoing pain management in the ED through the outcomes of reduction in pain scores, need for rescue analgesia, and incidence of adverse drug reactions.

 

Here the link to the paper (Annals of EM):

 

We found 1947 titles and abstracts and 61 potentially relevant studies were identified. After full-text review, a total of 8 studies met our inclusion criteria. Standard guidelines for systematic reviews were followed (PRISMA and GRADE). Qualitative analysis was done for all studies, and a meta-analysis was not possible given the low quality and significant clinical heterogeneity across the studies.

 

We found that the value of intravenous lidocaine as an analgesic modality and option for pain relief in the ED is promising, but yet to be determined. Four of six randomized controlled trials found comparable or superior reduction in pain scores using IV lidocaine when compared to active controls (ie: morphine). Lidocaine appeared to be effective in patients with renal colic and critical limb ischemia, and did not appear to be beneficial for migraine headaches.

The evidence for safety of IV lidocaine in the ED is also limited, with only 6 studies reporting the adverse drug reactions. One case-series reported a cardiac arrest secondary to the use of the wrong dose of IV lidocaine in the ED.

 

Main findings (Table 2 of the paper):

 

Outcome Effect Number of studies Certainty in the evidence
Reduction in pain scores Only 2 trials found significant reduction and most trials, especially for renal colic pain, failed to compare to standard of care and typical medications. 6 randomized controlled trials and 2 case-series VERY LOW ⨁◯◯◯

(due to methodological limitations, imprecision and inconsistency)

Need for rescue analgesia Most studies did not describe in detail which agent or doses were used after the use of IV lidocaine and controls. 5 randomized controlled trials and 2 case-series VERY LOW ⨁◯◯◯

(due to methodological limitations, imprecision and inconsistency)

Incidence of adverse events 20 adverse events reported across the studies, being 19 non-serious and 1 serious. 4 randomized controlled trials and 2 case-series VERY LOW ⨁◯◯◯

(due to methodological limitations, imprecision, inconsistency and potential publication bias)

 

In summary, this systematic review found limited evidence to support the efficacy and safety of IV lidocaine as a single agent and/or as an adjunct to other parenteral analgesics for short-term pain relief in the ED. Intravenous lidocaine may be effective for conditions like visceral, neuropathic and ischemic pain. Further well-designed studies are needed to address the role of IV lidocaine for different causes of pain in the ED, the most appropriate dose and timing for administration, and confirm its safety in different age groups and clinical populations.

 

Bottom-line: Although promising, the current body of evidence is limited and intravenous lidocaine for pain management needs further well-designed studies to determine its safety and efficacy before the routine use for analgesia in the ED.

 

Link to article

 

REFERENCES

  1. Lauretti GR. Mechanisms of analgesia of intravenous lidocaine. Rev Bras Anestesiol. 2008;58:280-286.
  2. Koppert W, Ostermeier N, Sittl R, Weidner C, Schmelz M. Low-dose lidocaine reduces secondary hyperalgesia by a central mode of action. Pain. 2000;85:217-224.
  3. Hollmann MW, Durieux ME. Local anesthetics and the inflammatory response: a new therapeutic indication? Anesthesiology. 2000;93:858-875.
  4. van der Wal SE, van den Heuvel SA, Radema SA, et al. The in vitro mechanisms and in vivo efficacy of intravenous lidocaine on the neuroinflammatory response in acute and chronic pain. Eur J Pain. 2016;20:655-674.
  5. Dunn LK, Durieux ME. Perioperative Use of Intravenous Lidocaine. Anesthesiology. 2017;126:729-737.
  6. Firouzian A, Alipour A, Rashidian Dezfouli H, et al. Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial. Am J Emerg Med. 2016;34:443-448.
  7. Soleimanpour H, Hassanzadeh K, Vaezi H, Golzari SE, Esfanjani RM, Soleimanpour M. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol. 2012;12:13.

 

Dec 20, 2017 · Thomas R. Hellmich M.D., named new chair of Emergency Medicine at Mayo Clinic Rochester

 

Thomas R. Hellmich, M.D. has been named the new chair of the Department of Emergency Medicine at Mayo Clinic Rochester. Dr. Hellmich follows Annie T. Sadosty, M.D. who recently became the Mayo Clinic Health System Vice president for Southeast Minnesota.

Thomas Hellmich, M.D., is a Pediatric Emergency Medicine physician, Assistant Professor in Emergency Medicine and Pediatrics at Mayo Clinic Hospital – Rochester (MN).  He attended DePauw University and received a B.A. degree in Zoology. He then attended Indiana University School of Medicine and completed his residency and fellowship at the Children’s Hospital of Wisconsin.  In 2004, he received a MBA in Health Care Management from the University of St. Thomas.  His past leadership roles at Children’s Hospital and Clinics in Minneapolis, MN include Pediatric Emergency Medicine Fellowship Director, Medical Director of Simulation Program, Medical Director of Emergency Services and Chief of Staff. In 2012, he joined Mayo Clinic and serves as the Medical Director of Mayo Clinic’s first Clinical Engineering Learning Laboratory. His interests include physician leadership, quality, and health system engineering.

Dec 18, 2017 · Better informed consent in the ED: going through the research to practice continuum

Author: Lucas Oliveira J. e Silva (@lucasojesilva12)

Few years ago when consenting patients for procedural sedation in the Emergency Department (ED), we realized that the risks were unclear and communicating those risks to the patients was a challenge.

To solve the problem of risk communication, we knew that knowing the evidence would not be enough, however the first step would be find the best information available regarding the adverse events of procedural sedation in the ED. We looked at the literature and one study was not enough, meaning that a summary of the evidence was needed to make the large amount of information comprehensible for clinicians and patients. Two years later, we published two systematic reviews and meta-analyses (1, 2) evaluating the risks of performing procedural sedation in the ED among both the pediatric and adult populations. However, despite having summarized the literature, we found ourselves empty handed when communicating with patients. We were not filling the gap and improving the communication process, which was the main reason we spent two years working on the systematic reviews. In a 5-step framework (Figure 1) of the research to practice continuum, we were clogged in a gap between the best evidence available and good informed consent in the ED (step 4 of the framework, Figure 1).

Figure 1. 5-step framework of the research to practice continuum.

In the last few years, constant efforts have been made to put together the Evidence-Based Medicine core concepts with translation of evidence into practice, especially in terms of patient-centered perspectives (3). The need for more knowledge translation has emerged essentially from a gap between what is known from high-quality evidence and what is consistently done in clinical practice (4).

Systematic reviews offer multiple benefits but are often written in technical language, are long, and do not contain contextual details, making them hard to translate into practice (5). After the two publications, we then decided to ask for help of implementation scientists, patient education specialists, nurses, providers, caregivers, patients and professional designers, to transform the meta-analyses information into a visual aid tool (step 5 of the framework, Figure 1). An evidence-based visual aid tool was developed to help the translation of complex numbers into meaningful and straightforward information.

Here the link to the paper (open access!): link to the paper here

In this study, we described how we went through the research to practice continuum in order to better translate our research findings to the bedside. Publishing and disseminating research findings with its large amount of information are not enough within this continuum, and efforts should be made to better translate the evidence into practice. The problem of risk communication before informed consent for procedural sedation could not be solved only finding the best evidence available.

Bottom-line: The research to practice continuum in EM can go above the expectations of researchers, and efforts should be made to implement and translate the evidence into practice, taking into consideration that evidence users, including both clinicians and patients, may benefit from easy and straightforward visual aid tools for translation of research findings.

 

FULL-ARTICLE: (open access)

 

REFERENCES

  1. Bellolio MF, Gilani WI, Barrionuevo P, et al. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2016;23:119-134.
  2. Bellolio MF, Puls HA, Anderson JL, et al. Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis. BMJ open. 2016;6:e011384.
  3. Lang E. Finding One’s Way In Translating Evidence Into Practice. Annals of Emergency Medicine.51:791-792.
  4. Lang ES, Wyer PC, Eskin B. Executive summary: Knowledge translation in emergency medicine: establishing a research agenda and guide map for evidence uptake. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2007;14:915-918.
  5. Rowe BH, Wyer PC, Cordell WH. Evidence-based emergency medicine. Improving the dissemination of systematic reviews in emergency medicine. Annals of  Emergency Medicine. 2002 Mar;39(3):293-5.

 

Oct 12, 2017 · Social Media Scholarship as a Criterion for Academic Promotion

This is crosspost from the Mayo Clinic Social Media network. Below a video with our webinar on Social Media and Academic Promotion.

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