All posts tagged study

Emergency room patients shouldn’t have to worry about coverage – STLtoday.com

In the wake of Anthem Blue Cross/Blue Shield notifying Missouri plan participants that non-urgent emergency room visits would no longer be covered, the Post-Dispatch published an article (June 23) asserting that St. Louis residents use the ER too often for unnecessary care. Unfortunately, there were serious methodological flaws in their study. This policy from Blue Cross/Blue Shield may violate federal law regarding the national “prudent layperson” standard.

This standard requires insurance coverage be based on a patients symptoms, not final diagnosis. Anyone seeking emergency care suffering from symptoms that appear to be an emergency should not be denied coverage.

Burning in the chest may be heartburn; however as emergency physicians, we know not infrequently it actually ends up being a heart attack.

If you have an Anthem Blue Cross/Blue Shield health insurance plan in Missouri, be aware that nearly 2,000 diagnoses which the company consider to be non-urgent would not be covered in the emergency room. Heart disease, cancer, asthma, stroke, diabetes, influenza and pneumonia are among the top eight causes of death in the United States. All of these illnesses can cause life-threatening conditions that require emergency care.

Missouri participants need to fight for their right to have access to emergency care as protected by the “prudent layperson” standard.

Patients should be able to seek emergency care immediately without wondering if insurance will cover the ER visit. The vast majority of patients who come to the emergency department seek care appropriately.

Dr. Kristen Mueller St. Louis

Member, Missouri College of Emergency Physicians

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Shasta County sees increase in opiod-related emergency room visits – KRCRTV.COM

Shasta County sees increase in…

REDDING, Calif. – The nationwide opioid epidemic is seriously impacting Shasta County.

Shasta CountyHealth and Human Services said they have seen a dramatic increase in hospital and emergency room visits in recent years due to these drugs.

In Shasta County between 2007 and 2015, there were 150 emergency department visits that were heroin related.

Those visits dramatically increased in the most recent years, going from eight heroin related emergency visits per 100,000 residents from 2009 to 2011, to 42 visits from 2012 to 2014 for heroin related incidents alone.

For visits related to all opioids per 100,000 residents between 2007 and 2015, the number spiked from 37 visits in 2009 to a high of 121 in 2015.

Their study also notes that 40 percent of opioids are distributed in emergency departments, so patients should be screened for history of abuse before being given opioids.

Based on these statistics, the Health and Human Services report warns that intervention is critical from the Federal Government to local health providers.

A link to the study can be found under fact file.

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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.

Return to Michael Hiltzik’s blog.

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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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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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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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More patients can avoid hospital admissions after emergency room visits for diverticulitis – Medical Xpress

April 25, 2017

About 150,000 people are admitted to hospitals each year for diverticulitis,1 an inflammation of an outgrowth or pouching in the colon that can cause severe abdominal pain. Furthermore, emergency room (ER) visits for diverticulitis have increased 21 percent in recent years.2 However, these ER visits don’t have to land patients in the hospital as frequently as they do, according to new findings published as an “article in press” on the Journal of the American College of Surgeons website in advance of print publication. A study of patients with diverticulitis who went to emergency rooms in a Minnesota health system found that about half of those admitted could have been sent home at significant savings to not only the health care system, but to the individual patients as well.

Researchers at the University of Minnesota, Minneapolis, reported that most patients with uncomplicated diverticulitis could safely go home with a prescription for oral antibiotics after their ER visits with a very low risk of returning to the hospital. “While that finding may not seem surprising to most surgeons, it is a poorly studied topic in the United States, and gathering some data on this occurrence is important to clarify in terms of whether there are even more people seen in the emergency room who could be safely managed at home,” said lead study author Mary Kwaan, MD, MPH, FACS, assistant professor of surgery, division of colon and rectal surgery, department of surgery, University of Minnesota. National statistics have shown that only 15 percent of patients with diverticulitis who go to the emergency room need an operation right away.1

Complicated diverticulitis involves a small perforation of the pouching or outgrowth of the colon that is visible on a computerized tomography (CT) scan, whereas uncomplicated diverticulitis is defined as no identifiable perforation on a CT scan. Extreme cases involve a large perforation of the colon with peritonitis, which is inflammation of the abdomen. The goal of treatment is to relieve symptoms, typically of abdominal pain and inflammation, and to restore normal bowel function. Severe cases often require surgery. CT scanning is essential in the diagnosis of diverticulitis. “The CT scan provides us with a surrogate for determining the severity of perforation one has suffered,” Dr. Kwaan said.

The researchers evaluated 240 patients treated in five hospital emergency rooms in the Fairview Health System, which includes University of Minnesota Health, from September 2010 through January 2012; 144 (60 percent) were admitted to the hospital and 96 (40 percent) were discharged to their homes on oral antibiotics.

Admitted patients were more likely to be age 65 years or older, have other health problems, take steroids to treat inflammation or agents that suppressed their immune system, have excess air in the digestive system, or have an abscess or perforation in the diverticular area as seen on a CT scan. Among those patients discharged from the emergency room, 12.5 percent returned to the ER or were admitted to the hospital within 30 days, and only one patient required emergency surgery, but not until 20 months later. “That [finding] didn’t seem to be a high rate,” Dr. Kwaan said. For the patients who were admitted from their emergency room visit, the hospital readmission rate was slightly higher, at 15 percent.

Dr. Kwaan and coauthors found that 53 percent of the admitted patients in their study could be safely discharged home. They used a standard that Margaret Greenwood-Ericksen, MD,2 and colleagues at Brigham and Women’s Hospital, Boston, had developed for determining low-risk diverticulitis.

Two key factors the researchers found that determined the severity of diverticulitis were high fever and high white blood cell counts. In low-risk patients, “we found that few patients had high fevers and most patients had normal or mildly elevated white blood cell counts,” Dr. Kwaan said.

While the study is relatively small, Dr. Kwaan noted it is significant because it involved several emergency rooms across one health system. It also confirms findings of an earlier randomized clinical trial in Spain that concluded outpatient treatment is safe in selected cases of uncomplicated diverticulitis.3

Dr. Kwaan said physicians and hospitals could use the Minnesota study findings to develop protocols for emergency room doctors to better treat diverticulitis. “As a result of this study, a checklist approach to patient and CT characteristics can prompt a protocol that allows an emergency room doctor to quickly sort out whether or not the patient needs a surgical consult or whether they need to be admitted to the hospital, and then whether they can be safely discharged home,” she said. She and her colleagues are collaborating with ER physicians to develop such protocols in their health system. The next step would be to create a feedback loop to monitor the effectiveness of the protocol.

Avoiding unnecessary hospitalizations is important for reducing health care costs and applying hospital resources more effectively. “Diverticulitis is quite a common disease, and there is a general movement among hospitals toward being more strategic with their resources,” Dr. Kwaan said. “Unnecessary hospital admissions cost the system and potentially expose patients to hospital-acquired infections.”

Explore further: Antibiotics may be inappropriate for uncomplicated diverticulitis

More information: Diverticulitis diagnosed in the emergency room: is it safe to discharge home? Journal of the American College of Surgeons. DOI: dx.doi.org/10.1016/j.jamcollsurg.2017.02.016

1. Etzioni DA, Mack TM, Beart RW, Kaiser AM. Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Ann Surg. 2009 Feb;249(2):210-17.

2. Greenwood-Ericksen MB, Havens JM, Ma J, et al. Trends in hospital admission and surgical procedures following ED visits for diverticulitis. W J Emerg Med. 2016 Jul;17(4):409-17.

3. Biondo S, Golda T, Kreisler E, et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: A prospective, multicenter randomized clinical trial (DIVER trial). Ann Surg. 2014 Jan;259(1):38-44.

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More patients can avoid hospital admissions after emergency room visits for diverticulitis – Medical Xpress

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