Thirty-Minute CPR Course as Effective as a Three-Hour One

From Medpage Today:

A 30-minute, video-based cardiopulmonary resuscitation course (CPR) is as effective as a traditional 3-hour course, with possibly better retention at six months, researchers found.

A comparison of the short course with longer versions of CPR training was conducted by a team at the University of Texas Southwestern Medical Center, here, and reported in the August issue of Resuscitation.

Ahamed Idris, M.D., and colleagues randomized 294 volunteers to one of the two training programs; 270 completed the training -- 151 took the short course, adopted recently by the American Heart Association, and 119 took the longer one. Volunteers were all employees of American Airlines and CPR training sessions took place at corporate headquarters in Fort Worth, Tex.

The short course consisted of a 23-minute CPR video, a three-minute discussion on recognition of choking and demonstration of the Heimlich maneuver, and a five-minute demonstration on the use of an automated external defibrillator (AED).

Students each received an inflatable mini-manikin to use during training, a device that provides real-time audio feedback on the depth and rate of chest compressions, knee pads, and alcohol wipes.

In the traditional course didactic lectures on CPR, rescue maneuvers for choking, and AED use are supplemented by videos. Students share full-size manikins, which cuts the amount of hands-on training they received, the researchers noted.

With the short course, "individuals practice while they learn, allowing more time to perform and retain the critical hands-on skills required to provide more effective CPR," said Dr. Lynn Roppolo, assistant professor of emergency medicine and lead author of the study.

Skills evaluation was accomplished by having the student demonstrate CPR and AED use on a life-size manikin. They were videotaped and the manikin recorded compressions/ventilations. The videotapes were evaluated by reviewers blinded as to which of the courses the subjects took.

After evaluation, the researchers found no significant difference between the two groups in ability to provide the correct depth and rate of compressions, the amount of air delivered during ventilations, or other measures of competence.

However, at six months follow-up, more of the students in the short course called 911 appropriately, conducted a more rapid assessment of the victim, began CPR more rapidly, and were more likely to provide adequate ventilations compared with those enrolled in the longer training course.

Report: Average patient spends 4 hours in ED

Source: AHA News Now (http://www.ahanews.com)
Date: June 28, 2007


The average time spent in emergency departments rose in 2006, but so did patient satisfaction, according to a new report by Press Ganey Associates. Based on the firm's patient surveys in 1,500 hospitals, patients spent an average of 4 hours in the ED, 18 minutes more than in 2005. The more patients an ED saw over the year, the longer the average visit, which increased by 30 minutes for every additional 10,000 patients annually. Patient satisfaction dropped as time in the ED increased, with the lowest satisfaction reported from 3-11 p.m. and highest from 7 a.m.-3 p.m.

To view the report, go to:
http://www.pressganey.com/ER-report.pdf

Baghdad ER

Baghdad ER" an excellent documentary originally aired on HBO, is now posted, in its entirety, on Google Video.

Here's a link to a site devoted to the program at HBO.com

New Cervical Collar Design

From Medgadget

"LuboCollar is designed to protect the neck by restricting the movement of the head relative to the rest of the body and to maintain an open airway in a non-invasive, simple and quick to operate way. It does so by using a "jaw-thrust"-like knob to maneuver the mandibles, pushing them forward in the direction of the chin," explains Dr. Omri Lubovsky, developer of the LuboCollar and a physician in the Department of Orthopedic Surgery at Hadassah University Hospital.

Reassurance Workup

From Movin' Meat:

I have devised a simple, cheap and quick "reassurance work-up" for these folks which consists of: an ECG, an i-Stat, a D-dimer, and a troponin. Sometimes I add a chest x-ray if it seems helpful. (We are lucky in that most of these tests can be done in the ED's stat lab with a turn-around-time of about 15 minutes.) Then I sit down with the patient and invest a few minutes telling him or her about all the tests we did and all the Bad Things we ruled out. I list each electrolyte separately, the normal blood sugar (we ruled out diabetes), normal blood counts (rules out anemia), ruled out heart attack, blood clots, aneurysm, etc etc. It's interesting how well patients respond to that. The long list of things "you don't have" seems to really be effective in reassuring patients. Then a quick laugh -- I ask the question for them: "Great, doc, you told me what I don't have, so what do I have? Well, I can't tell you what is causing your symptoms, but there are only x number of Bad Things that can cause symptoms like yours, and you don't have any of those Bad Things, so I know it is safe for you to go home, we will keep an eye on it, and I expect that it will go away on its own."

ACEP Comment on CDC Data

ED Visits Jump to Record 115 Million

Visits to emergency departments increased to an all-time high of 115 million in 2005, 5 million more than in 2004, according to a [new report from the Centers for Disease Control and Prevention. ACEP leaders said the increase in visits combined with closures of emergency departments threaten the safety of patients and will further endanger an already fragile system.

"With 315,000 people visiting emergency departments every day, the alarm bells are sounding and policymakers should heed the alert and respond," said ACEP President Brian Keaton, MD.

ACEP supports legislation, the Access to Emergency Medical Services Act (H.R. 882 and S.1003), that calls for the creation of a national bipartisan commission on access to emergency medical services that will examine factors that affect and may impede the delivery of care in U.S. emergency departments.

CMS Proposes Big Cuts for 2008 Medicare Payments

From ACEP:

The now yearly controversy over cuts to Medicare payments has started again, and without congressional action, emergency physicians could see a 12% decrease in Medicare payments starting in 2008. The 2007 Medicare Trustees report predicts total cuts of approximately 40% for all physician payments by 2016.

Key policy makers on Capitol Hill expressed concern about the cuts and are working with ACEP, the AMA, and others in the physician community to develop a legislative solution for the next several years. The temporary fix would also allow Congress time to develop a comprehensive plan to change the sustainable growth rate (SGR) formula, the flawed metric used to set payment rates.

The legislation could reach the floor of the House before the August recess or sometime in September. Rural legislators are also considering extensions of physician payment bonuses that expire at the end of this year.

National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary

Available as a PDF on the CDC website

Here's one graph (courtesy of GruntDoc)

Pay for Specialist Coverage for the ED

From the American Hospital Association

More than one-third of hospitals now pay for some physician specialty emergency department call coverage, according to results from AHA's survey of hospital leaders. The 2007 State of America's Hospitals - Taking the Pulse also found 55% of hospitals experienced gaps in physician specialty coverage with coverage issues most prevalent in orthopedics and neurosurgery. In addition, nearly half of EDs are "at" or "over" capacity, with a majority of urban hospitals experiencing time on diversion. Hospital leaders cited a lack of staffed critical care beds as the most common reason for diversion. The survey also found that hospital workforce shortages, including an estimated 116,000 registered nurse vacancies as of December 2006, are affecting patient care. Regarding disaster readiness, hospitals are taking a variety of actions to bolster preparedness, including participating in large scale drills, establishing back-up communication plans and developing resource plans with other hospitals. The survey, which had a 17% response rate, was sent to about 5,000 ommunity hospital CEOs in late February 2007 via fax and email.

Physicain Drain in (Rural) Upstate New York

It's similar in other rural areas, I'd wager...

From The New York Times

While newly licensed doctors flock to New York City, Long Island and Westchester County, where there is already a glut, far fewer choose to practice in the vast upstate region. For instance, during the years the study was conducted, Essex County in the Adirondacks lost 22 percent of its doctors, while there was a 19 percent increase in Nassau County, on Long Island.

And as doctors upstate retire — one-third of the physicians in Binghamton are 55 or older — recruiting replacements is becoming more difficult. “I worry that new physicians may not see certain areas in the state as viable or attractive,” Ms. Moore said.

There is little question why, since statistics show a steady exodus of jobs and a decline in prosperity in upstate New York. In the last three decades, the population drain has contributed to New York’s loss of Congressional seats, to 29 today from 39, and state figures show that the number of 20- to 34-year-olds in the region decreased by 22 percent in the 1990s.

Newsweek Article on Resuscitation

This week's cover article.
The focus of the article is on the use of therapeudic post resuscitation hypothermia.
http://www.msnbc.msn.com/id/19751440/site/newsweek/

CMS Memo on EMTALA

The Centers for Medicare & Medicaid Services (CMS) recently sent out a memo regarding EMTALA On-Call Requirements and Remote Consultation Utilizing Telecommunications Media.


Memorandum Summary
*The treating physician in a hospital’s or critical access hospital’s (CAH) dedicated emergency department (DED) who is conducting the medical screening examination and/or providing stabilizing treatment of an individual required by the EMTALA regulations at 42 CFR 489.24 may, without violating EMTALA, consult on the individual’s case with a physician who is not present in the DED by means of any telecommunications medium that the physicians choose to use.
*This does not change the obligation under EMTALA of a physician who is on-call to make an in-person appearance in the DED when requested to do so by the treating physician.
*This guidance does not affect policy by any health care third party payer, including Medicare, governing the circumstances under which it will or will not pay for remote consultation services.
*The portions of the interpretative guidelines for 42 CFR 489.20(r) and _489.24(j) that discuss telemedicine or telehealth are superseded by this guidance.

It has been brought to the attention of the Centers for Medicare & Medicaid Services (CMS) that the interpretative guidelines for 42 CFR 489.20(r) and _489.24(j), concerning hospital/CAH on-call physician requirements under EMTALA, are being interpreted by some parties as prohibiting emergency department physicians from utilizing modern telecommunications to facilitate consultation with specialists who are not present in the hospital/CAH. There is no such prohibition under EMTALA. It is necessary to distinguish among:

*a hospital’s/CAH’s obligation under EMTALA to maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of its patients;
*the obligation of an on-call physician to make an in-person appearance when requested to do so by the physician who is treating an individual who has come to the emergency department of the hospital/CAH; and
*remote consultation on the individual’s case by the treating physician with another physician, who may or may not be on the hospital’s/CAH’s on-call list.

The EMTALA statute at Sections 1866 and 1867 of the Social Security Act and EMTALA regulations at 42 CFR 489.20(r) and _489.24(j) establish requirements regarding hospital/CAH on-call lists and the obligations of on-call physicians to make in-person appearances. These provisions apply to hospitals/CAHs participating in Medicare. Section 1866(a)(1)(I)(iii) and 42 CFR section 489.20(r)(2) require hospitals/CAHs to _maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition._ Each hospital/CAH must maintain its on-call list in a manner that best meets the needs of the hospital’s patients who receive services required under EMTALA. The resources available to a hospital/CAH, including the availability of on-call physicians, are taken into account when assessing the adequacy of its on-call list.

There is no EMTALA prohibition against the treating physician consulting on a case with another physician, who may or may not be on the hospital’s or CAH’s on-call list, by telephone, video conferencing, transmission of test results, or any other means of communication. CMS is aware that it is increasingly common for hospitals/CAHs to use telecommunications to exchange imaging studies, laboratory results, EKG’s, real-time audio and video images of patients, and/or other clinical information with a consulting physician not on the hospital/CAH premises. Such practices may contribute to improved patient safety and efficiency of care. In some cases it may be understood by the hospitals/CAHs and physicians who establish such remote consulting arrangements that the physician consultant is not available for an in-person assessment of the individual at the treating physician’s hospital/CAH.

However, if a physician:
*is on a hospital’s or CAH’s on-call list; and
*has been requested by the treating physician to appear at the hospital; and
*fails or refuses to appear within a reasonable period of time,
then the on-call physician may be subject to sanctions for violation of the EMTALA statutory requirements.

It is only when the treating physician requests an in-person appearance by the on-call physician that a failure by the latter to appear in person may constitute an EMTALA violation.

It is an entirely separate issue, outside the scope of EMTALA enforcement, whether or not insurers or other third party payers, including Medicare, will provide reimbursement to physicians who provide remote consultation services.

This clarification of existing policy will be incorporated into the SOM, Appendix V the next time it is revised.

Violence in the (Hospital) Workplace

From CNN

BOSTON, Massachusetts (CNN) -- Nurses understand that they have a tough job, but getting attacked and abused is not what former Boston area emergency room nurse Ellen MacInnis says she signed up for.

"It was very frightening," said the 18-year veteran. An angry and frustrated patient had grabbed MacInnis' hand, dug her nails in and made a chilling threat. "If you have children, I'll find them and I'll kill them."

This was not the only time MacInnis was assaulted on the job. Last summer, an intoxicated, H.I.V.-infected female patient tried to hit her and wound up covering her in blood.

MacInnis said the thought that her life was in danger never occurred to her until after the situation was under control. "Then it sort of hit me," she said, "And I fell apart."

Nurses are often on the receiving end of physical assaults, because they are typically the first and most frequent medical personnel by the bedside of ill and sometimes angry or frustrated patients.

Emergency rooms seem to be the hot spots for violent assaults, according to experts interviewed for this article, but general practice nurses are not immune.

Fifty percent of nurses surveyed by the Massachusetts Nurses Association (MNA) -- a union of registered nurses -- and the University of Massachusetts said they had been punched at least once in a two-year period. Some reported being strangled, sexually assaulted or stuck with contaminated needles.

Emergency Physicians Monthly

The Emergency Physicians Monthly website is new and improved - and includes a blog.

ACEP "Focus On" Series

More Podcasts...

The American College of Emergency Medicine's "Focus On" Series:

Each "Focus On" article has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). ACEP is accredited by the ACCME to provide continuing medical education for physicians, and designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physician's Recognition Award and 1 ACEP Category 1 credit.

University of Iowa Department of Emergency Medicine Podcast

Dr Weiss’ presentations to the UIHC EM residency have been recorded as podcasts and are available for download from our itunes site.  A link to the podcast can be found at out department webpage

Lawsuit: Timing in the ED

From NY Emergency Medicine, via Kevin MD:

. . . a patient presented to an Emergency Department having cut off two fingers with a table saw. The injury occurred at 6:30 p.m. The patient was triaged at 7:19 p.m. The emergency medicine physician saw the patient at 7:42 p.m. X-rays were performed at 11:33 p.m. Orthopedics was finally consulted at 1:00 a.m., more than five-and-a-half hours after the patient presented to the Emergency Department. Orthopedics arrived at 1:30 a.m. The wounds were stitched closed by orthopedics at 2:00 a.m. Reimplantation of the saved digits could not be performed within eight hours from the time of injury as an operating room would not have been available that quickly.

The emergency medicine physician was found negligent for not contacting orthopedics sooner. Due to this prolonged period of time, among other negligent acts by orthopedics, the patient and his wife were awarded $525,000.00.

Increase in Visits Combined with ER Closures Threaten Patient Safety and Will Lead to System Collapse

A press release from the American College of Emergency Physicians:

Washington, DC - Visits to emergency departments increased to an all-time high of 115 million in 2005, 5 million more than in 2004, according to a new report from the Centers for Disease Control and Prevention. The American College of Emergency Physicians (ACEP) said the increase in visits combined with closures of emergency departments threaten the safety of patients and will further endanger an already fragile system.

"With 315,000 people visiting emergency departments every day, the alarm bells are sounding and policymakers should heed the alert and respond," said Brian Keaton, MD, president of ACEP. "Emergency physicians are dedicated to saving lives. We want to provide quality care to all of our patients, but we need additional resources to be able to deliver that care. That's why we are asking Congress to pass the Access to Emergency Medical Services Act. This urgently needed legislation will help reduce the dangerous trends that are limiting the public's access to high-quality, lifesaving medical care and stripping emergency departments of their ability to respond to disasters."

The Access to Emergency Medical Services Act (H.R. 882 and S.1003) calls for the creation of a national bipartisan commission on access to emergency medical services which will examine factors that affect and may impede the delivery of care in U.S. emergency departments. The proposed legislation also recognizes the need for additional resources in support of care delivery. The Senate bill directs that a working group within the Centers for Medicare and Medicaid Services be convened to develop boarding and diversion standards, as well as guidelines and incentives for implementation of those standards. The House bill requires hospitals to report to the Department of Health and Human Services statistics on how many patients are boarded and for how long. The legislation is sponsored by Reps. Bart Gordon (D-TN) and Pete Sessions (R-TX) and U.S. Senators Debbie Stabenow (D-MI) and Arlen Specter (R-PA).

According to the new report, nearly 42 million visits to emergency rooms were because of injuries. The leading patient complaints, accounting for nearly one-fifth of all visits, were abdominal pain, chest pain and fever. Only 13.9 percent of visits were for nonurgent medical reasons - conditions that can still need medical attention soon, such as bladder infections, high fevers, and extremity injuries that could be fractures.

The new report said the closure of emergency departments combined with the overall increase in visits resulted in a 31-percent increase in visits per emergency department since 1995. There were 30,388 visits per emergency department in 2005 compared with 23,119 visits per emergency department in 1995. Medicaid recipients had the highest rate of emergency visits (88/100 persons) of all groups including Medicare enrollees and the uninsured, which indicates severe health care access problems by Medicaid patients.

"Emergency departments are the nation's health care safety net for everyone, not just the uninsured," said Dr. Keaton. "But that safety net is breaking under the load, and we are asking the public to contact their members of Congress today - by logging onto ACEP's website at www.acep.org. Given the struggles we face day-to-day, how can we be ready to respond to disasters and acts of terrorism? As citizens, we all need to let Congress know that we are deeply concerned about the alarming findings of the CDC report, and this urgently needed legislation must be passed."