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IC in Care Series The Emergency Department – Infection Control Today

By Kelly M. Pyrek

Competing priorities, life-and-death situations and a vast quantity of unknown variables are the hallmarks of the emergency department (ED), and compliance with infection prevention and control (IPC) principles and practices can be challenging. Katherine West, BSN, MSEd, CIC, points to the directive from the Occupational Health and Safety Administration (OSHA) — CPL 02-02.069 — that indicates that the delivery of healthcare should not be delayed. “Trauma response is more important than infection control compliance, and even OSHA recognizes that fact,” West says. “We have a duty to meet the patient care needs.”

That being said, abdication of IPC is not acceptable, and infection preventionists and ED personnel must work toward a manageable compromise that can still protect patients and healthcare professionals to a reasonable degree. Researchers are currently endeavoring to study the IPC needs of the ED and determine best practices for better outcomes, as well as determine standardized methods and definitions of compliance monitoring in order to be able to compare results across settings.

In their review, Carter, et al. (2014) examined published literature addressing adherence rates among ED personnel to selected infection control practices, including hand hygiene and aseptic technique during the placement of central venous catheters and urinary catheters, as well as rates of ED equipment contamination. Suitable studies revealed that hand hygiene compliance ranged from 7.7 percent to 89.7 percent, while other studies indicated that aseptic technique practices during urinary catheterization was lacking, and equipment contamination in the ED was persistent.

As Carter, et al. (2014) summarize, “The emergency department is an essential component of the healthcare system, and its potential impact continues to grow as more individuals seek care and are admitted to the hospital through the ED. Invasive procedures such as central lines are placed with increased frequency in certain EDs, but adherence to best practices (e.g., maximum barrier precautions) varies. ED clinicians also face numerous workflow challenges that may foster the spread of infections including crowding, frequent interruptions to care delivery, use of nontraditional care areas such as hallways and conference rooms, and close proximity of patients, who are often separated only by curtains. Given that many of these barriers have been identified as infection prevention threats, it is critical to understand the infection prevention practices of ED providers and their potential role in the risk of HAIs.”

West points to a number of factors that complicate IPC in the emergency department. “The ED is a very challenging area for infection control because it is often a contracted services and staff miss many of the laws and procedures that are important. For example, many are not aware of the HIV testing laws in their state or that HIPAA does not prevent the release of source patient test results to the exposed employee. Rapid patient turnover may impede cleaning compliance. So, compliance monitoring is important. In many facilities, staff is temp staff and that adds to the issues.”

She also emphasizes the need to balance healthcare personnel safety with the need to protect patients. “There is a need to protect patients from infection as well as staff,” West says. “For too long the duty to the patient has often been forgotten. With the new healthcare law, patient protection from infection becomes more important. Patient who develop infection two days after admission, that will be termed healthcare-associated and there may be no government reimbursement for the cost of extended stay and treatment. Staff training needs to focus on proper IV site prep, etc. Training is often not in accordance with requirements for infection control. Attendance at training is important and often not deemed as important.”

Additionally, West emphasizes that “Infection preventionists often do not have enough time to do training in person, which is ideal, so there is time for questions to be answered and items clarified. Paperwork seems to take up so much time. Making rounds and observing care rendered in the ED is very important. Compliance monitoring is key to risk and liability reduction and will also identify training needs. Rounds and training are the best way to interact with ED staff and identify problems.” Let’s take a closer look at several key IPC areas in the ED.

Hand hygiene Carter, et al. (2014) found that hand hygiene was the most commonly observed infection prevention practice in the studies they reviewed, and adherence rates varied widely. For example, several studies examined hand hygiene practices before and after interventions; Haas and Larson used WHO guidelines to assess the impact of a wearable alcohol hand sanitizer dispenser among ED personnel in a New York hospital. The researchers observed 757 hand hygiene opportunities; the adherence rate improved from 43 percent to 62 percent during the first intervention month of the study but was not sustained, with a 51 percent adherence rate after the second quarter.

Scheithauer, et al. (2013) acknowledges that the ED “represents an environment with a high density of invasive and thus infection-prone procedures,” and sought to define the number of hand-rubs needed for an individual patient care at the ED and to optimize hand hygiene compliance without increasing workload. In this prospective tri-phase (6-week observation phases interrupted by two six-week interventions) before after study to determine opportunities for and compliance with hand hygiene per WHO protocol, the researchers evaluated 378 patient cases with 5674 opportunities for hand-rubs (HR) and 1664 HR performed. They found that compliance significantly increased from 21 percent (545/2,603) to 29 percent (467/1,607), and finally 45 percent (652/1,464) in phases 1, 2 and 3, respectively. The number of HR needed for one patient care significantly decreased from 22 to 13 for the non-surgical and from 13 to 7 for the surgical patients due to improved workflow practices after implementing standard operating procedures (SOPs). In parallel, the number of HR performed increased from 3 to 5 for non-surgical and from 2 to 3 for surgical patients. Avoidable opportunities as well as glove usage instead of HR decreased by 70 percent and 73 percent, respectively.

Venkatesh, et al. (2011) conducted an observational study to identify predictors of hand hygiene in the ED. Compliance was 89.7 percent over 5,865 opportunities. The researchers found that observation unit, hallway or high-visibility location, glove use, and worker type predicted worse hand hygiene compliance. Hallway location was the strongest predictor (relative risk, 88.9 percent).

In their study at two university hospital centers, Martel, et al. (2014) found that 53 percent of nurses washed their hands after seeing the patient, and only 40 percent applied recommendation before. However, the researchers note, “given a great turnover of patients, nurses may have just washed their hands after the last patient assessment and be already decontaminated for the next. Some handwashing may have been missed because nurses often left our site of observation immediately before and after seeing the patient.”

Aseptic technique during catheterization In their review, Carter, et al. (2014) identified one study that observed aseptic technique during urinary catheterization. In this study, medical students used standardized observation tools to observe aseptic technique in one ED in the UK and another ED in New Zealand. Procedures observed included urinary catheterization, wound examination or closure, injections or intravascular cannulation, lumbar puncture, and pleural aspiration. Overall, 27 percent (UK) and 58 percent (New Zealand) of invasive procedures were performed using aseptic technique. Adherence to aseptic technique was reported in aggregate and not categorized by procedure type.

Regarding aseptic technique during central venous catheter insertion, Carter, et al. (2014) identified seven studies that examined central venous catheters inserted in the ED or by emergency medicine residents. One study examined the effect of a video review on the sterile technique practices of surgical and emergency medicine residents during the placement of central lines. Compliance to aseptic technique was higher among those who received the video-based online training than those who received paper-based training or no training (74 percent vs 33 percent, respectively). In a separate evaluation, the same research team also assessed maximum barrier precautions among primary and secondary operators through a video recording. Among elective central lines, maximum barrier precautions were used by 88 percent (99/113) of primary operators and 69 percent (31/45) of secondary operators or senior medical staff.

Contact precautions Researchers have found variability of contact precaution policies in U.S. emergency departments. A study published in Infection Control and Hospital Epidemiology in 2014, Daniel J. Pallin, MD, MPH, and Jeremiah D. Schuur, MD, MS, both from Brigham and Women’s Hospital, surveyed a random sample of U.S. EDs confirmed substantial variation in the adoption of policies relating to contact precautions. While most EDs have policies relating to contact precautions when specific organisms are suspected, a minority have such policies for the symptoms often caused by those organisms. This indicated that institutional policies do not mirror consensus recommendations by the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA) and other national bodies. The authors write, “The variation in policy that we observed leads us to recommend that emergency medicine organizations, such as the American College of Emergency Physicians, should enact policies addressing contact precautions in the ED.”

Respiratory hygiene As Rothman, et al. (2006) remind us, “The participation of emergency physicians and nurses is critical for effective responsiveness to respiratory threats in hospitals. ED personnel represent a critical link in the chain of communication and response, along the continuum from the community to the inpatient unit. Policies should anticipate responses to the complex spectrum of possible respiratory illnesses, from highly transmissible and unexpected emerging global diseases such as SARS to yearly influenza epidemics.” They add, “Concerns about the potential spread of respiratory pathogens begin at the point of entry into the healthcare system and continue to the inpatient setting. Emergency personnel need to be aware of the potential for infection, illness, and transmissibility in a variety of potentially high-risk environments, including (1) emergency medical services (EMS) and triage settings (in which historical and clinical information may be limited and risk underestimated), (2) during performance of high-risk invasive airway procedures, and (3) during patient transport to the various inpatient units throughout the hospital.”

Fusco and Puro (2012) observe that “The role of emergency departments in disease transmission dramatically emerged during the outbreak of severe acute respiratory syndrome (SARS). Subsequently, the Centers for Disease Prevention and Control and the World Health Organization issued new infection control guidelines that introduced respiratory hygiene and cough etiquette measures (e.g., covering of nose and mouth possibly with disposable surgical mask, adequate distancing among patients and careful application of hand hygiene) as part of standard precautions to be applied in all health care settings, to all patients with cough and other respiratory symptoms. A rigorous application of this set of infection control measures, including isolation if indicated, may significantly reduce the risk of disease transmission in emergency departments, thus protecting healthcare workers, patients and visitors. Mention about it should be included in all basic sets of indications for the management of community-acquired pneumonia in emergency departments.”

Martel, et al. (2014) sought to determine the compliance with respiratory hygiene of triage nurses at two university hospital centers and to identify factors influencing compliance to the respiratory hygiene principles of emergency healthcare workers. An anonymous observation of compliance with respiratory hygiene by triage emergency nurses was performed, and a self-administered, voluntary questionnaire on attitudes, perceptions, and knowledge of respiratory hygiene guidelines was distributed to the healthcare workers in the ED. The researchers found the average compliance with respiratory hygiene measures of triage nurses was 22 percent; compliance of healthcare workers was 68 percent. Overall, 91.9 percent of respondents believed that a mask was an effective preventive measure. The main barriers to mask use by healthcare workers were tendency to forget (37.8 percent) and discomfort (35.1 percent). Despite clearly visible respiratory hygiene posters in both hospital sites, necessary materials such as masks and tissues were missing in 9.6 percent of the cases. Patient isolation and decontamination measures were rarely or never applied.

As Martel, et al. (2014) observe, “The emergency department is the point of entry into the hospital for many patients and as such constitutes a prime location for the propagation of respiratory infections. These communicable diseases can then be further spread into the hospital as well as back into the community, creating a significant societal burden.” Martel, et al. (2014) found that nurses frequently asked about fever and cough (82 percent), which could be explained by the fact that the emergency room evaluation sheet included an inquiry regarding cough and fever, but they rarely informed the patient of the need to wear a mask (18 percent). The researchers say this could be explained by a lack of knowledge regarding the increased transmission risk in the presence of fever and cough. However, despite the fact that the self-applied questionnaire was not completed by the same healthcare workers, 94.1 percent of them reported that they would recommend mask wearing to a patient with fever and cough. Even though hygiene equipment (such as masks) was present 94.4 percent of the time, only 18.3% of patients had applied the mask recommendations prior to triage.

Martel, et al. (2014) also point out that in spite of CDC recommendations, patient handwashing measures were never met. The absence of posters focusing on this measure, in contrast to the importance of wearing a mask by patient, may result in the slightly higher adherence to the mask precaution (18% vs 0%, respectively). The researchers note, “Several factors could explain that only 9% of nurses informed patients about proper mask technique. Some nurses were seen to request isolation precautions instead. Also, when masks were well positioned, nurses did not further address proper application. Moreover, some nurses may have overestimated patient knowledge regarding the need for mask to cover both nose and mouth and be changed when wet. Despite evidence that spatial separation can reduce droplet spread of infection, we showed a very low compliance to patient isolation (12%).We know that implementation of these measures in many crowded waiting rooms remains particularly difficult. However, both hospitals sites had well-identified areas for this purpose.”

Martel, et al. (2014) recommend the following measures to standardize adequate practices: 1. Visual tools specifically designed for the emergency waiting room displayed prominently (e.g., on the door of the room), encouraging the following basic steps: disinfection of hands and wearing of mask by patient with fever and cough. 2. Modification of present visual tools in waiting rooms to mention real indications for mask wearing: coughing, sneezing, and runny nose and not only fever and cough because they are common. 3. Modification of the emergency department sheet, reminding nurses of the association between fever and cough and the need for patients to wear a mask. 4. Positive reinforcement of respiratory hygiene compliance by supervisors and training on respiratory hygiene/respiratory etiquette of emergency personnel with creation of measures such as online courses aimed at facilitating learning and improving accessibility and flexibility as well as reducing costs.

Equipment contamination In their review, Carter, et al. (2014) identified four papers described equipment contamination in the ED: “Of primary focus was contamination with methicillin-resistant Staphylococcus aureus (MRSA). In one large ED from a United States tertiary care hospital, 7 percent (5/69) of environmental surfaces (chairs, keyboards, telephones, and others) were positive for MRSA compared with no positive sites (0/63) in an outpatient clinic. Another research team took 63 samples of computer mice in an ED in over a one-year period and found only normal skin flora, with no MRSA. In a United States ED, Frazee et al took surveillance cultures of ultrasonographic probes used in the ED; approximately two thirds (111/164) were contaminated with skin or environmental flora, eight samples had heavy growth of skin or environmental flora, and 3.7 percent (6/164) grew organisms including methicillin-sensitive S aureus, Aspergillus, Acinetobacter spp, and mixed Gram-negative rods. Finally, a researcher cultured the stethoscopes of ED nurses and physicians in three Canadian EDs. Of the 100 stethoscopes samples, 70 percent were contaminated. A majority of specimens grew coagulase-negative staphylococci (54/100).”

References:

Carter EJ, Pouch SM and Larson EL. Common infection control practices in the emergency department: A literature review. Am J Infect Control. 42 (2014) 957-62.

Fusco FM and Puro V. Infection control in the emergency department. CMAJ. 184(9):1065. Jun 12, 2012.

Martel J, Bui-Xuan EF, Carreau AM, Carrier JD, Larkin E, Vlachos-Mayer H and Dumas ME. Respiratory hygiene in emergency departments: Compliance, beliefs and perceptions. American Journal of Infection Control 42 (2014) 957-62.

Rothman RE, Irvin CB, Moran GJ, et al. Respiratory hygiene in the emergency department. Ann Emerg Med 2006;48:57082

Scheithauer S, Kamerseder V, Petersen P, Brokmann JC, Lopez-Gonzalez LA, Mach C, Schulze-Rbbecke R and Lemmen SW. Improving hand hygiene compliance in the emergency department: getting to the point. BMC Infectious Diseases 2013, 13:367.

Venkatesh AK, Pallin DJ, Kayden S and Schuur JD. Predictors of Hand Hygiene in the Emergency Department. Infect Control Hosp Epidemiol. 2011 Nov;32(11):1120-3.

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IC in Care Series The Emergency Department – Infection Control Today

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A big health insurer is planning to punish patients for ‘unnecessary’ ER visits – Los Angeles Times

Anthem is the nations second-largest health insurer, with thousands of medical professionals on its payroll. Yet its Blue Cross and Blue Shield of Georgia subsidiary has just informed its members that if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their claim wont be paid.

Its a new wrinkle in the age-old problem of how to keep patients from showing up at the ER for just anything. But medical experts say the Georgia insurer is playing with fire. By requiring patients to self-diagnose at the risk of being stuck with a big bill, it may discourage even those with genuine emergencies from seeking necessary care. And its asking them to take on a task that often confounds even experienced doctors and nurses.

Patients dont come with a sticker on their forehead saying what the diagnosis is, said Renee Hsia of the Institute for Health Policy Studies at UC San Francisco, who has studied the difficulty of making snap diagnoses at the ER. We as physicians cant always distinguish necessary from unnecessary visits.

Blue Cross Blue Shield of Georgia, the only insurer offering individual insurance plans in 96 of the states 159 counties, sent letters to its enrollees in late May stating that it would refuse to cover non-emergency ER visits starting July 1. It defined inappropriate visits as any but those that a prudent layperson, possessing an average knowledge of medicine and health, would believe needed immediate treatment. It hoped to encourage patients with non-emergency conditions to seek help instead at an urgent care clinic or a doctors office.

The prudent layperson language was written into the Affordable Care Act to protect patients, not subject them to retroactive second-guessing. The idea was to require insurers to base their claims payments on what an average person would consider an emergency, not on the ultimate diagnosis reached by doctors after examinations and tests at the ER.

The policy of Blue Cross Blue Shield of Georgia, however, could allow the insurer to decide for itself after a claim is submitted whether the patient actually acted prudently.

A spokesperson for Anthem didnt respond to my query about the new policy. A spokeswoman for the Georgia insurer, Debbie Diamond, told us its goal was to control costs by steering patients away from expensive ER services and toward doctor offices or urgent care clinics when those are more appropriate settings for treatment. People who have a cold or use the ER as their primary physician thats got to stop, she said. This really is a question of getting healthcare more affordable.

She said the policy wouldnt apply when the patient is 14 or younger, an urgent care clinic isnt located within 15 miles, or the visit occurs on a Sunday or holiday. She said its aimed at manifestly minor ailments If you had cold symptoms; if you have a sore throat. Symptoms of potentially more serious conditions, such as chest pains, could be seen at the ER even if they turn out to be indigestion.

Diamond said similar policies have been implemented with Anthem plans in New York, Missouri and Kentucky. What isnt known is whether Anthem plans to roll out the policy in other states. The company offers insurance in 14 states, including California.

Insurers and government authorities have pondered for years how to stem unnecessary ER visits. Washington states Medicaid program, for instance, tried to impose an annual three-visit limit on its enrollees. After a court rejected the proposal, the program developed a list of 500 diagnoses for which it would deem ER visits unnecessary and wouldnt pay.

But doctors argued that many symptoms on the list, which included headaches, earaches and bronchitis, could be indicators of genuinely serious conditions. Bronchitis, for example, often cant be distinguished from pneumonia without a chest x-ray. Headaches could be symptoms of meningitis, encephalitis or hemorrhage.

Gov. Christine Gregoire quashed the plan in 2012, on the day it was to begin. Washington later instituted a program encouraging hospitals to develop systems to weed out unnecessary visits more effectively, in part through patient education and by identifying frequent visitors or patients presenting at the ER chiefly to obtain drugs.

Hsias research, published last year in the Journal of the American Medical Assn., found that ER doctors and triage nurses often were unable to distinguish urgent from non-urgent visits without examining the patient. Six of the 10 top reasons for unnecessary visits, including back, abdominal and chest pain and sore throats and headaches, were also among the top 10 symptoms of real emergencies. Many visits that were later deemed unnecessary arrived by ambulance had procedures performed, and were admitted to the hospital, including critical care units, her groups study found.

Everyone in insurance, everyone in emergency medicine has stories to tell about wildly inappropriate emergency room presentations, observed David Anderson, an insurance expert at Duke University. The problem is that the decision to go to the emergency room is fraught with uncertainty. Most people know that something is wrong and they dont know if it is really, really wrong or mildly wrong. Retrospective claims review with denials is too blunt of a tool to deal with a scenario with explicit uncertainty and information gaps.

Nor is it clear how much money could be saved by really cracking down. The caricature is of a patient blindly visiting the ER [for no reason], but thats relatively uncommon, said Ari Friedman, a physician who collaborated on Hsias research. Policies aimed at cutting down on inappropriate visits are all based on judgments made after final diagnoses, which obviously arent available to patients before they decide to go to the ER.

ER services come to only 2% to 6% of total U.S. healthcare spending, Friedman said, and most of that is spending on sick patients, not healthy ones.

Hsia called the Blue Cross Blue Shield of Georgia rule a well-intentioned policy with dangerous consequences for patients. Studies have shown that efforts to use financial incentives to reduce healthcare usage often lead patients to cut down on necessary as well as unnecessary care. That was the finding of a classic Rand Corp. study in the 1970s, which found that patients subjected to co-pays did indeed use fewer healthcare services than those who got the services for free but that they reduced the use of both highly effective and less effective services in roughly equal proportions.

Diamond said that Blue Cross Blue Shield of Georgia patients have access to telehealth services via smartphones and other connected gadgets, which will allow them to get a basic judgment about the seriousness of their symptoms remotely. But its questionable whether thats an adequate substitute for an ER visit in all cases. Not all patients will have access to smartphones or connectivity, for one thing. For another, when even trained triage nurses cant flawlessly judge the urgency of a patients condition when meeting face-to-face, a phone consultation may not be very reliable.

As Hsia said, the impetus underlying the Georgia policy is understandable in economic terms. But this Anthem subsidiary and its cousins in New York, Missouri and Kentucky have chosen a crude and counterproductive way to cut costs by putting the onus on patients to know just how serious their condition may be, at risk of what could be hundreds of dollars or more in unpaid claims. If this is the healthcare world of the future, its a perilous and costly place.

Keep up to date with Michael Hiltzik. Follow @hiltzikm on Twitter, see his Facebook page, or email michael.hiltzik@latimes.com.

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A big health insurer is planning to punish patients for ‘unnecessary’ ER visits – Los Angeles Times

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Can Comfort Care At The ER Help Older People Live Longer And … – NPR

As baby boomers age, more older Americans are visiting the emergency room, which can be an overcrowded, disorienting and even traumatic place. Heidi de Marco/Kaiser Health News hide caption

As baby boomers age, more older Americans are visiting the emergency room, which can be an overcrowded, disorienting and even traumatic place.

A man sobbed in a New York emergency room. His elderly wife, who suffered from advanced dementia, had just had a breathing tube stuck down her throat. He knew she never would have wanted that. Now he had to decide whether to reverse the life-sustaining treatment that medics had begun.

When Dr. Kei Ouchi faced this family as a young resident at Long Island Jewish Medical Center, he had no idea what to say. The husband, who had cared for his wife for the past 10 years, knew her condition had declined so much that she wouldn’t want to be rescued. But when Ouchi offered to take out the tube, the man cried more: “She’s breathing. How can we stop that?”

Ouchi had pursued emergency medicine to rescue victims of gunshot wounds and car crashes. He was unprepared, he says, for what he encountered: a stream of older patients with serious illnesses like dementia, cancer and heart disease patients for whom the life-saving techniques he was trained to perform often only prolonged the suffering.

As baby boomers age, more of them are visiting the emergency room, which can be an overcrowded, disorienting and even traumatic place. Adults 65 and older made 20.8 million emergency room visits in 2013, up from 16.2 million in 2000, according to the most recent hospital survey by the Centers for Disease Control and Prevention. The survey found 1 in 6 visits to the ER were made by an older patient, a proportion that’s expected to rise.

Half of adults in this age group visit the ER in their last month of life, according to a study in the journal Health Affairs. Of those, half die in the hospital, even though most people say they’d prefer to die at home.

Some states on board

The influx is prompting more clinicians to rethink what happens in the fast-paced emergency room, where the default is to do everything possible to extend life. Hospitals across the country including in Ohio, Texas, Virginia and New Jersey are bringing palliative care, which focuses on improving quality of life for patients with advanced illness, into the emergency department.

Interest is growing among doctors: 149 emergency physicians have become certified in palliative care since that option became available just over a decade ago, and others are working closely with palliative care teams. But efforts to transform the ER face significant challenges, including a lack of time, staffing and expertise, not to mention a culture clash.

Researchers who interviewed emergency room staff at two Boston hospitals, for instance, found resistance to palliative care. ER doctors questioned how they could handle delicate end-of-life conversations for patients they barely knew. Others argued that the ER, with its “cold, simple rooms” and drunken patients screaming, is not an appropriate place to provide palliative care, which tends to physical, psychological and spiritual needs.

Ouchi saw some of these challenges during his residency in New York, when he visited the homes of older patients who frequently visited the emergency room. He saw how obstacles like transportation, frailty and poor vision made it difficult for them to leave the house to see a doctor.

“So what do they do?” Ouchi asks. “They call 911.”

When these patients arrive at the emergency room, doctors treat their acute symptoms, but not their underlying needs, Ouchi says. In more severe cases, when the patient can’t talk and doesn’t have an advanced directive or a medical decision-maker available, doctors pursue the most aggressive care possible to keep them alive: CPR, intravenous fluids, breathing tubes.

“Our default in the ER is pedal to the metal,” says Dr. Corita Grudzen, an emergency physician at NYU Langone Medical Center who studies palliative care in the ER. But when doctors learn after the fact that the patient would not have wanted that, the emergency rescue forces families to choose whether to remove life support.

When older adults are very ill if they need an IV drip to maintain blood pressure, a ventilator to breathe, or medication to restart the heart they are most likely to end up in an intensive care unit, where the risk of developing hospital-acquired infections and delirium is increased, Grudzen says. Meanwhile, it’s not clear whether these aggressive interventions really extend their lives, she adds.

Some have sought to address these problems by creating separate, quieter emergency rooms for older patients. Others say bringing palliative care consultations into regular emergency rooms could reduce hospitalization, drive down costs and even extend life.

There’s no hard evidence that this approach will live up to its promise. The only major randomized controlled trial, which Grudzen led at Mount Sinai Hospital in New York City, found that palliative care consultations in the emergency room improved quality of life for cancer patients. It did not find statistically significant evidence that the consultations improved rates of survival, depression, ICU admission or discharge to hospice.

Trying to avert suffering

But frontline doctors say they’re seeing how palliative care in the ER can avert suffering. For instance, Ouchi recalls one patient a man, in his late 60s who showed up at the emergency room for the fifth time in six months with fever and back pain. Previous visits hadn’t addressed the underlying problem: The man was dying of cancer.

This time, a nurse and social worker called in a palliative care team, who talked to the patient about his goals.

“All he wanted was to be comfortable at home,” Ouchi says. The man enrolled in hospice, a form of palliative care for terminally ill patients. He died about six months later, at home.

Now Ouchi and others are trying to come up with systematic ways to identify which patients could benefit from palliative care.

One such screening tool, dubbed P-CaRES, developed at Brown University in Providence, R.I., gives ER doctors a list of questions. Does the patient have life-limiting conditions such as advanced dementia or sepsis? How often does the patient visit the ER? Would the doctor be surprised if the patient died within 12 months?

Doctors are using the tool to refer patients at the University of California-San Francisco Medical Center at Parnassus to palliative care doctors, says Dr. Kalie Dove-Maguire, a clinical instructor there. The questions pop up automatically on the electronic medical record for every ER patient who is about to be admitted to the hospital.

Dove-Maguire says UCSF hasn’t published results, but the tool has helped individual patients, including a middle-aged man with widespread cancer who showed up at the ER with low blood pressure. The man “would have been admitted to the ICU with lines and tubes and invasive procedures,” she says, but staff talked to his family, learned his wishes and sent him to home hospice.

“Having that conversation in the ER, which is the entry point to the hospital, is vital,” Dove-Maguire says.

Measured in minutes

But time is scarce in ERs. Doctors’ performance is measured in minutes, Grudzen notes, and the longer they stop to make calls to refer one patient to hospice, the more patients line up waiting for a bed.

Finding someone to have conversations about a patient’s goals of care can be difficult, too. Ouchi enlisted ER doctors to use the screening tool for 207 older ER patients at Brigham and Women’s Hospital in Boston, where he now works as an emergency physician. They found a third of the patients would have benefited from a palliative care consultation. But there aren’t nearly enough palliative care doctors to provide that level of care, Ouchi says.

“The workforce for specialty palliative care is tiny, and the need is growing,” says Grudzen.

Palliative care is a relatively new specialty, and there’s a national shortfall of as many as 18,000 palliative care doctors, according to one estimate.

“We’ve got to teach cardiologists, intensivists, emergency physicians, how to do palliative care,” she said. “We really have to teach ourselves the skills.”

Kaiser Health News is an editorially independent part of the Kaiser Family Foundation.

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Can Comfort Care At The ER Help Older People Live Longer And … – NPR

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‘Do-not-hospitalize’ orders reduce hospital or emergency room visits, but few patients have them – Medical Xpress

May 18, 2017 Only a small percentage of patients with ‘Do Not Resuscitate’ orders also have ‘Do Not Hospitalize’ orders, according to a new study led by researchers at UAlbany’s School of Public Health. Credit: University at Albany

Do-not-hospitalize orders help reduce the number of hospital stays and emergency department visits for nursing home residents, but they are used by only a small percentage of patients, according to a new study led by researchers at UAlbany.

Publishing in the May issue of JAMDA, the authors conducted a cross-sectional study of patients in skilled nursing facilities. They found that while 61 percent of nursing home residents have ‘do-not-resuscitate’ orders, only six percent have ‘do-not-hospitalize’ orders in place. Twelve percent of patients had feeding restrictions. The findings suggest that nursing home residents may be subjected to unwanted hospital or emergency room visits that are contrary to their expressed values and goals for end-of-life care.

“We set out with the goal of examining whether an advanced ‘Do Not Hospitalize’ directive would be effective in reducing hospital/emergency department transfers,” said Taeko Nakashima, a visiting assistant professor in the department of Health Policy Management and Behavior at UAlbany’s School of Public Health. “The results show that for residents without DNH orders, the odds of being transferred to a hospital was significantly higher.”

The findings suggest skilled nursing providers should encourage residents to complete DNH orders, so that their end-of-life health care wishes are respected, Nakashima said.

“Residents with DNH orders had significantly fewer transfers,” said Nakashima. “This suggests that residents’ end-of-life care decisions were respected and honored. Efforts should be made to encourage nursing home residents to complete DNH orders to promote integration of the resident’s values and goals in guiding care provision toward the end of life.”

According to the findings, residents with DNH orders had significantly fewer unnecessary hospital stays and emergency department visits in their last 90 days of life than residents without them, the researchers reported. The orders also helped reduce hospital stays for residents with dementia.

Explore further: Nursing home residents need more activities to help them thrive

More information: Taeko Nakashima et al. Are Hospital/ED Transfers Less Likely Among Nursing Home Residents With Do-Not-Hospitalize Orders?, Journal of the American Medical Directors Association (2017). DOI: 10.1016/j.jamda.2016.12.004

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‘Do-not-hospitalize’ orders reduce hospital or emergency room visits, but few patients have them – Medical Xpress

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Study: ER docs using smartphones to receive test results can … – MobiHealthNews

Smartphones can make a lot of things faster, like getting a cab, ordering food or finding a date. But they can also shave down waiting time in a situation where every minute can feel like an eternity: getting out of the hospital.

Specifically, patients who came to the emergency room in the University of Torontos system with chest pain could spend nearly a half hour less waiting to be discharged if their doctor received lab results on their smartphone rather than on the hospitals electronic health record system, a new study published in the journal Annals of Emergency Medicine found.

Normally, all patients who come to the emergency room with chest pain must have their blood drawn to test for troponin levels, which, if elevated, can indicate a heart attack. In the study population of 1,554 patients, the median time from result to discharge is nearly 80 minutes. Doctors were randomly selected to receive results on their smartphone (the intervention) versus those who relied on the customary electronic health record notifications via the hospitals computer system. The control group of 551 patients waited more than 94 minutes to be discharged, whereas the smartphone group was out of the emergency room in 68.5 minutes.

For patients waiting for lab results, 26 minutes is significant, even if the smartphone process did not shorten overall length of stay significantly, lead author Dr. Aikta Verma said in a statement. For many patients, waiting for lab results that determine if they stay in the hospital or go home is the hardest part of the ER visit. Physicians who received troponin results on their smartphones made the decision to discharge their patients with chest pain a median of 26 minutes faster than physicians without troponin push-alert notifications.

As the authors point out, reducing wait times in the emergency room is an ongoing challenge, as prolonged stays in the ER are associated with an increased risk of death even for patients who are well enough to be discharged. While the study didnt find the total length of emergency department stays to change much, getting faster results from other tests via smartphones could perhaps bring the total time down someday.

Our study demonstrated reduced time to discharge decision for chest pain patients by pushing troponin results to smartphones. However, there are many other results that could also be pushed: other critical laboratory results, radiology reports, vital signs, etc., the authors write. Future studies could evaluate a combination of these push alerts to determine whether it leads to improvement in length of stay in the broader group of ED patients.

For now, the researchers recommend using the smartphone method to deliver troponin results, but did caution against using smartphones in the hospital without careful consideration.

Discussions with physicians revealed that too many alerts can be problematic, they write. Thus, future studies should aim to elucidate the ideal number and type of alerts that would optimize use of the push-alert program.

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Study: ER docs using smartphones to receive test results can … – MobiHealthNews

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Cotton swabs send children to emergency rooms each day, study – WSYR

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(CNN) – The advice from doctors is clear: Don’t use cotton swabs to clean your ears.

But people continue to use a soft-tipped plastic or paper stick to dig out the wax from their ear canals — and it’s a problem.

Authors of a new study in the Journal of Pediatrics, conducted by researchers at Nationwide Children’s Hospital, warn that using cotton-tip applicators to clean the ear can be dangerous, especially in the hands of little ones.

Each year, about 12,500 children under the age of 18 are treated in US emergency departments for ear injuries related to cotton swabs, the study says. That breaks down to about 34 visits per day.

“This is not like brushing your teeth every day. Children and adults do not need to clean out the ear canal of wax as part of a routine hygiene practice,” said Dr. Kris Jatana, assistant professor of otolaryngology-head and neck surgery at the Ohio State University and the lead author of the study.

The researchers looked at hospital visits between 1990 and 2010 and discovered that an estimated 260,000 children ended up in the emergency room with ear injuries. Of those visits, tears in the tissue that separates the ear canal from the middle ear, called the tympanic membrane or simply the eardrum, were the most common.

The largest portion of those injuries occurred when children were using the applicators themselves to clean their ears, a practice that doctors have unanimously denounced.

Cotton swabs can cause cuts in our ear canals, perforate our eardrums and dislocate our hearing bones. And any of these things could lead to hearing loss, dizziness, ringing or other symptoms of ear injury.

Instead of potentially pushing the wax farther into the ear, Jatana says, we should let nature do the job.

“The ear canal is self-cleaning, and the cotton-tip applicator actually works against your ear’s natural cleaning mechanism by pushing the earwax deeper toward the eardrum, where it essentially gets trapped and can’t get out on its own,” he said.

Dr. Seth Schwartz of the American Academy of Otolaryngology-Head and Neck Surgery said “it’s cultural” to want clear ears, but “wiping away any excess wax when it comes to the outside of the ear is enough to keep it clean.”

“It’s not a bad thing to have wax in your ears. Everybody does and should. It’s more of an issue when it becomes too much,” he said.

If someone is concerned about their earwax or other problems, Jatana recommends seeing a pediatrician, a primary care physician or a specialist. “People do not generally need to clean out their ear canal in the home setting, and certainly, a cotton-tip applicator should not be the product used to do so,” he said.

As for irrigators, candles and other home remedies, Jatana sticks to the medical community’s basic advice: Stay out of the ear.

In the study, 99% of the ER patients were treated and did not suffer permanent damage. In some severe cases, however, damage sustained from injuries resulted in a permanent loss of hearing.

The ear is sensitive, Jatana said, and the risk of harm is too high. “We need to dispel the idea of cleaning ears in the home setting and the use of any products to do so,” he said.

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Cotton swabs send children to emergency rooms each day, study – WSYR

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Here’s How Many People End Up in the ER Due to Cotton Swabs – Health.com

They may look harmless, but cotton-tip applicators send an estimated 34 kids to the ER every day, according to a new study in The Journal of Pediatrics. The authors say theirfindings debunk the myth that we need to clean our ears regularlyand serve as a reminder that doing so may cause more harm than good.

The Q-tip, the original cotton-tip applicator, was invented in 1923 after the companys founder watched his wife clean their babys ears with cotton wads and a toothpick. The ready-made swabs may have been a more convenient alternative at the timebut since the 1970s, doctors have cautioned against using them for the purpose of ear cleaning, noting that they can push wax deeper into the canal (causing impaction) and increase injury risk to the eardrum.

Today, research shows that the use of cotton-tip applicators is the most common cause of accidental penetrating ear injury in children. But despite doctors and manufactures warnings not to use the bathroom staple for ear hygiene, many people still do, says Kris Jatana, MD, an otolaryngologist at Nationwide Children’s Hospital and associate professor at The Ohio State University Wexner Medical Center.

For the new study, Dr. Jatana and his colleagues looked at reports of cotton swab-related ear injuries at hospitals across the country between 1990 and 2010. (Because the National Electronic Injury Surveillance System stopped coding hospital reports for these specific injuries after 2010, more recent info was not available.)

In that 21-year period, an estimated 263,000 patients under age 18 were treated in emergency departments for complaints like ear blockage, pain, and bleedingmore than 1,000 a month, or about 34 a day. Most of these injuries77%occurred while children used cotton-tip applicators themselves. Parental and sibling use accounted for 16% and 6% of injuries, respectively. Overall, 73% of the injuries occurred during ear cleaning; other causes included children playing with the swabs or falling down while a swab was in their ear.

RELATED: 8 Things ER Doctors Refuse to Have in Their Homes

The most common injuries were foreign body sensation (the feeling that something is stuck in the ear), perforated eardrum, and soft-tissue injury. (While cotton swabs have also been associated with ear infections and earwax impaction, these conditions were excluded from the study because it wasnt possible to know if they developed before or after a swab was used.)

Two-thirds of patients were under 8 years of age, and 40% were younger than 3. Fortunately, 99% of patients were treated and releasedbut the authors note that some of these injuries still could have been serious. Damage to the eardrum or inner ear can lead to dizziness, problems with balance, facial nerve paralysis, and permanent hearing loss, they write.

Injury rates did decline over the course of the study, but more than 12,000 children were still treated in 2010a number that Dr. Jatana says is unacceptably high.

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So how are people supposed to clean their ears?

In short, theyre notat least not on a regular basis. The ear is actually self-cleaning, says Dr. Jatana. Wax serves a function, to trap dirt and debris and bring it toward the outside of the ear. It also humidifies the ear canal, he adds, and has antimicrobial properties.

When visible wax is seen in the outer part of the ear, that can be wiped away with a small wet towel or baby wipe, he continues. But sticking any object into the canal itself is completely unnecessary and very dangerous.

In January, the American Academy of OtolaryngologyHead and Neck Surgery Foundation released updated guidelines on this topic, including a new list of dos and donts for patients. They include Do know that ear wax is normal, Dont over-clean your ears, and Dont put cotton swabs, hair pins, car keys, toothpicks or other things in your ear.

RELATED: 5 Mistakes You’re Making Cleaning Your Ears

There are effective ways to treat bothersome earwax impaction, including irrigation devices, wax-softeningdrops, or in-office procedures. But the Academy recommends that people speak with their doctors before trying any treatments at home, since they arent safe for everyone.

You should also see a doctor if you experience drainage or bleeding from the ears, hearing loss, or feelings of pain or fullness in the ears, the guidelines state.

The study authors recommend that cotton-tip applicators be stored out of reach of children, that stronger warning labels be added to their boxes, and that parents be advisedas soon as babies are bornnever to use them for ear cleaning. And just as importantly, they recommend more public education about the myths and facts of ear hygiene.

I think some parents instill in their children that cleaning out the ear canal is similar to brushing their teeth, says Dr. Jatana. That misconception needs to be dispelled in order to help prevent these injuries from occurring.

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Here’s How Many People End Up in the ER Due to Cotton Swabs – Health.com

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