Dr. Hevesi is a consultant at Mayo Clinic in Rochester, MN. Dr. Kaisler is a PGY-3 and chief resident at Mayo Clinic Emergency Medicine Residency in Rochester, MN.
The inaugural Mayo EM residency journal club met for the first time on July 13th, hosted by Dr. Sara Hevesi and her husband Mario (an Orthopedic Surgery resident at Mayo). We reviewed an Academic Emergency Medicine paper titled “Out-of-Hospital Spinal Immobilization: Its Effect on Neurologic Injury” from 1998 and an EM:RAP chapter from April 2020 titled “Pediatric Pearls – Pediatric C-Spine Clearance.” Due to COVID, a small group met at Dr. Hevesi’s house and the rest of the participants joined via Zoom. In addition to the residents and faculty from Mayo Rochester we also had several EMS faculty join from Mayo Arizona.
The bottom line from the AEM paper was that spinal immobilization did not affect outcomes in the only large-scale study of its kind to date. This was a unique paper in that it compared patient outcomes from a country where immobilization is not used (Malaysia) with a country where immobilization is used. Highlights from the EM:RAP lecture were that in pediatric patients, their C spine can often be cleared with plain films alone as long as there is a low clinical suspicion (adequately restrained in a car seat, moving neck without pain, no neurologic deficits). They also gave good clinical pearls about allowing the child to “clear themselves” by keeping the (often ill-fitting) C collar on until they are moved out of the trauma bay, warm and calm near parents and watch to see if they move their neck on their own.
Mario grilled a large selection of brats and burgers from Greg’s Meats and Ricky and Maria were able to put aside their extreme hatred of the other’s college football team to emerge victorious at corn hole. Look for another post covering August journal club where we reviewed the evidence behind using tPA for ischemic strokes with the involvement of our Pharmacy colleagues..
Special thanks to Dr. Joe Walter and the crew over at Regions Rap (https://regionsrap.com/) who were gracious enough to share the scoring tool they use for their Journal Club!
Dr. Woods is an emergency physician at Mayo Clinic in Rochester MN and SE MN.
This study was recently published in the American Journal of Emergency Medicine. The objective was to evaluate Mayo Clinic Emergency Department’s already established scribe program on throughput and revenue capture while Mayo Clinic underwent EMR transition.
We used a prospective cohort design to compare patients that were managed with and without scribes in an academic ED. Multiple throughput metrics and RVUs were collected and data was analyzed over 3 months during out go live period (immediate 2 weeks) and adoption of the EMR (two weeks post implementation to the end of the study period).
We found there was no significant difference in throughput metrics or RVUS during this three month period, although in some specific instances improvements were noted.
A scribe’s ability to mitigate operational inefficiencies during EMR transition does seem to be limited in an academic institution. We were unable to replicate prior research that highlighted to impact of scribes on revenue.
Dr. Woods is an Emergency Physician at Mayo Clinic in Rochester and South-East Minnesota
Palliative care has been identified as an area of low outpatient referral from our emergency department, yet palliative care has been shown to improve the quality of patient’s lives.
This study investigates both provider and patient perspectives on palliative care for the purpose of identifying barriers to increased palliative care utilization within our healthcare system.
Two surveys were developed, one for patients and/or their caregivers and one for healthcare providers, including attending physicians, resident physicians and advanced practice providers.
This was a single-center study completed at a quaternary academic emergency department. A survey was sent to emergency medicine providers with 47% response rate. Research staff approached Emergency Department patients who had been identified to be high risk to fill out paper surveys with 76% response rate.
Only 28% of patients had already undergone palliative care, with an additional 25% interested in palliative care. Nearly half of the patients felt that they needed more resources to prevent hospital visits. Patients identified low understanding of palliative care and difficulty accessing appointments as barriers to consultation. Among providers, 98% indicated that they had patients who would benefit from palliative care. A majority of providers highlighted patient understanding of palliative care and access to appointments as barriers to palliative care. Notably, 52% of providers reported that emergency medicine provider knowledge was a barrier to palliative care consultation.
Despite emergency department patients’ self-identified need for resources and emergency medicine providers’ recognition of patients who would benefit from palliative care, few patients receive palliative care consultation.
Dr. Brown and Dr. Mattson are pharmacists at Mayo Clinic in the Emergency Department.
With the rapidly increasing population of individuals aged 65 years and older, pain management in the emergency department (ED) has become much more complex. Many of the medications we use to treat pain in the ED are on the American Geriatrics Society Beers Criteria, including nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. According to this list there is a strong recommendation to avoid ketorolac; however, there is no guidance on whether a single dose is acceptable and safe. In order to find safe ways to treat pain in our geriatric patients we assessed whether a single dose of ketorolac in the ED contributed to adverse cardiovascular, gastrointestinal, and renal outcomes.
This was a single-center retrospective study including patients 65 years of age and older who received intramuscular or intravenous ketorolac for analgesia management prior to being discharged home. We directly matched patients 3:1 who did not receive ketorolac. The primary outcome was the occurrence of any of the following events within 30 days of the ED visit: gastrointestinal bleeding, intracranial bleeding, acute decompensated heart failure, acute coronary syndrome, dialysis, transfusion, and death. The secondary outcome was the occurrence of an increase in serum creatinine of ≥1.5 times baseline within 7 and 30 days of the ED visit.
We found the primary outcome occurred in 14 of 360 patients who did not receive ketorolac and 2 of 120 patients who received parental ketorolac (3.9% vs 1.7%, p=0.38; OR 2.39, 95% CI 0.54-10.66). Both events in the ketorolac group were GI bleeds. We also did not find a significant number of patients with an increase in serum creatinine who received ketorolac.
This study found one time doses of ketorolac to be safe in low-risk geriatric patients. Given this study’s retrospective design, there is risk for selection bias. The patients in this study, although advanced in age, are likely low risk. Ketorolac can be considered for analgesia in the emergency department to help limit exposure to opioids and suboptimal pain management.
Check out our full study in the American Journal of Emergency Medicine for more information!
Authors: Jana L. Anderson, MD and Lucas Oliveira J. e Silva, MD
Dr. Anderson is a pediatric emergency physician in the Department of Emergency Medicine at Mayo Clinic, Rochester, MN.
Dr. Silva is a research fellow in the Department of Emergency Medicine at Mayo Clinic, Rochester, MN.
The emergency department is the front line for pain control for acute and many times chronic issues. Given the current climate of opioid use and abuse, alternatives to opioids are being sought. Recently, the EM research division of Mayo Clinic reviewed and analyzed the current evidence of intranasal (IN) ketamine for pain control in children presenting to the emergency department. IN ketamine was found to be equally efficacious as IN fentanyl for pain control. No serious side-effects were found with IN ketamine. The next step is to determine if the benefit of avoiding opioids is worth the non-serious side effects that are higher with IN ketamine.
Overall summary of our systematic review and meta-analysis:
Doses used in the studies: 1 mg/kg to 1.5mg/kg IN ketamine vs. 1.5 mcg/kg to 2 mcg/kg IN fentanyl.
No treatment difference was found at 10 to 15 minutes, 30 minutes and 60 minutes.
Overall, minor side effects were less common with IN fentanyl.
No serious side effects occurred with IN ketamine.
It is unclear whether IN ketamine reduce the rates of rescue analgesia or whether there is benefit in terms of avoiding opioids. This is the area where the next research studies should focus on.
Please read our article in The American Journal of Emergency Medicine in order to obtain more details about the use of IN ketamine as an alternative to opioids in children having significant pain in the emergency department.
Lucas is a research fellow in the Department of Emergency at Mayo Clinic, Rochester, MN.
The number of emergency department (ED) visits by older adults continuously increases. Older patients have unique needs, and strategies to optimize their individual care are have to be developed.
Since 2014, the Geriatric Emergency Department Guidelines have been leading the way “geriatricizing” emergency care. The development of geriatric-friendly EDs will rely upon buy-in from administrative stakeholders who will require compelling associations between specific interventions and improved patient satisfaction and overall experience of care. Patient experience is by definition patient-centered, and is a metric of hospital reimbursement with potentially significant impact on profitability.
With our team, we conducted a systematic review in order to summarize the literature on interventions that may impact on the experience of older adults in the ED as measured by patient experience instruments (e.g. satisfaction and experience surveys).
After an extensive literature search by a librarian, we found 992 studies from which 21 studies met eligibility criteria. Six studies were randomized controlled trials and 15 were quasi-experimental or observational. The included studies involved 3,162 older adults (age 65 or older) receiving an intervention strategy aimed at improving patient experience in the ED.
There was significant heterogeneity in the tools used to measure patient experience and although several studies claimed to use “validated” questionnaires, none of the studies provided a reference for validation in the ED setting (ie: Press Ganey®). This highlights the need for future studies to use adequately validated tools to measure ED patient experience.
Overall the quality of the evidence on the patient experience topic had several limitations such as high risk of bias and inconsistencies across the literature.
We found improved patient experience in department-wide interventions like a geriatric ED and comprehensive geratric assessment unit, for example. See table below with the main findings of the review. We separated interventions by themes related to geriatric patient experience in the ED.
Summary of Interventions Associated with Enhanced Experience
General Elder Care Needs
o Department-wide interventions aimed to provide comprehensive geriatric-friendly acute care. Most effective interventions involved the following: geriatric-trained healthcare professionals, screening for common geriatric conditions, and environmental enhancements such as non-slip floors. o Volunteers to offer social support, anxiety-reducing techniques, and cognitive stimulation interventions
Care Transitions (pre-ED discharge coordination)
o Specialized role for conducting pre-discharge assessment and referrals. This was performed by a geriatric social worker, geriatric advanced practice nurse, nurse discharge plan coordinator, or interdisciplinary team.
Care Transitions (post-ED discharge care coordination)
o Care coordination teams focused on promoting smooth transition following discharge. These teams involved physiotherapy, occupational therapy, speech pathology, nursing, and social work. Home visits were conducted if needed.
Role of Health Care Provider
o Aged care pharmacist to provide patient education, medication reconciliation, and referrals.
Physical Needs in Emergency Care Setting
o Reclining hospital chair rather than standard gurney to enhance comfort.
Barriers to Communication
o Hearing loss screen upon arrival to the ED and assistive listening device for patients who screened positive.
o “No Wait” Policy where older adults are brought to a private room or care area immediately following check-in.
Content of Communication and Patient Education
o Patient Liaison within a Geriatric Emergency Department to address non-medical needs and communicate updates to patients.
Bottom-line for clinicians and administrative stakeholders: This systematic review highlights potential interventions that could be used to improve geriatric patient experience in the ED. Effective interventions were department-wide interventions aimed to provide comprehensive geriatric-friendly acute care.
Bottom-line for researchers: This review highlights the need for validation of patient experience questionnaires as well as the need for providing detailed descriptions of intervention strategies, with special attention to intervention fidelity.
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Richter JP, Muhlestein DB. Patient experience and hospital profitability: Is there a link? Health Care Manag Rev 2017;42(3):247–57. https://doi.org/10.1097/HMR. 0000000000000105.