Headed to the emergency room? Bring a book

The stereotype of hospital emergency rooms crowded with patients waiting endlessly to be seen by a doctor is true, according to a new study in Tuesday's edition of Archives of Internal Medicine. The conventional wisdom that throngs of low-income, uninsured people who use the ER as a substitute for primary care visits are to blame, however, is wrong.

First, a few statistics:

• In 1997, the median wait time for ER patients was 22 minutes. By 2006, it was 33 minutes.
• Per capita use of ERs was 40.5 visits per 100 people in 2006, up from 34.2 visits per 100 people a decade earlier.
• The proportion of ER patients deemed to be suffering from a real medical emergency fell from 26.9% in 1997 to 18.3% in 2007.
• The percentage of ER patients who lacked health insurance remained between 16% and 17% between 1997 and 2006.

These and other statistics were gleaned from data on 151,999 patient visits to emergency departments recorded in the National Hospital Ambulatory and Medical Care Survey. The survey includes four triage categories – emergent (patient should be seen within 14 minutes), urgent (15-60 minutes), semiurgent (61 minutes to two hours) and nonurgent (anywhere from two to 24 hours).

Though wait times got longer for everyone, the problem was worst for emergent patients – their median wait times increased by 4.6% per year, the study found. Waits for urgent patients grew 2.8% per year for urgent patients, 3.9% per year for semiurgent patients, and 1.6% for nonurgent patients.

Put another way, only 56.6% of emergent patients saw a doctor within the time recommended by triage staff, compared to 100% of nonurgent patients. Overall, the proportion of patients who got to a doctor within the “triage target time” fell from 80% in 2000 to 75.9% in 2006, the study found.

One theory to account for increased ER wait times is that more people who can’t afford to go to a regular doctor wind up coming to the ER instead, where federal law guarantees they’ll be treated regardless of ability to pay. The survey data corroborated this to an extent, finding that 17% of uninsured patients in the ER were classified as nonurgent, compared to only 13.9% of people who had private insurance. That works out to about 567,000 extra visits each year.

But the researchers, Dr. Leora Horwitz and Elizabeth Bradley of the Yale University School of Medicine, found that all patients – regardless of whether they had private insurance, Medicare,  Medicaid, or nothing – were more likely to use the ER for nonurgent reasons. Overall, the number of patients coming to ERs with true emergencies barely budged between 1997 and 2006, but the number of total visits increased by 3.9% per year, on average.

The use of triage assessments was supposed to reduce waiting times for the most vulnerable patients by allowing ER staff to focus their attention on those most in need of treatment. Instead, the researchers found that “these patients experienced the largest percentage increases in wait time and were consistently the least likely to be seen on time.”

What gives?

NIH terminates emergency resuscitation trials for cardiac arrest

The National Institutes of Health has prematurely terminated a clinical trial testing two techniques designed to improve survival when paramedics treat heart attack victims, concluding that neither one provided any benefit. One trial tested how much CPR paramedics should perform before determining whether the patient needed to be defibrillated (shocked) to restart his or her heart. The second tested the efficacy of a device called an impedance threshold device or ITD that had been shown in animal trials to increase blood flow to the heart during CPR. About 11,500 patients already had been treated during the trial, and the researchers concluded that enrolling more would not change the results.

CPR performed by paramedics is a combination of chest compressions (to pump blood through the body) and rescue breathing. Lay people are encouraged to use only chest compressions until paramedics arrive.

Paramedics treat about 350,000 people with cardiac arrest, in which the heart stops beating, in the United States each year, but fewer than 10% of patients survive. In the majority of cases, the patient's heart had simply stopped beating for too long before paramedics were summoned and arrived. But health officials had hoped the new techniques could provide some improvement in survival rates.

In one arm of the trial, paramedics performed CPR for only 30 to 90 seconds before checking to determine whether defibrillation was indicated. In the other arm, they performed it for at least three minutes before checking. Small trials have given different results, with some showing that a short delay is better and others showing the long delay is preferable. But the new trial's Data and Safety Monitoring Board concluded that neither was more effective than the other. "Both techniques appear to be equally beneficial," said Dr. Ian Stiell of the Ottawa Hospital Research Institute in Canda, the principal investigator.

The ITD is a small hard-plastic device, about the size of a fist, that is attached to the face mask or breathing tube during CPR. It is designed to improve circulation by enhancing changes in pressure within the chest during CPR. In animal studies and small studies in humans, the device was found to markedly increase blood flow to the heart and raise blood pressure. Researchers had hoped that would improve retention of neurological function in patients who survived. Some patients whose heart stops for prolonged periods have severe neurological impairment that interferes with their quality of life.

In the trial, patients were randomized to receive either the ITD or a nonfunctional device that looked the same. Researchers found that survival was the same in both groups, as was retention of neurological function, suggesting that standard CPR was as effective as CPR with the device.

Patients in both arms of the trial will be studied for another six months to determine if there are any long-term effects.

-- Thomas H. Maugh II

Photo: An instructor teaches CPR. Credit: Los Angeles Times

Alcohol may land you in the ER, but it also may help you survive

Without a doubt, alcohol use can lead to accidents, even fatal ones. And it can screw up the body's ability to recover from traumatic injury, some studies have shown. But it's also been linked to shorter hospital stays and better outcomes after such injuries.

So researchers at the Los Angeles Biomedical Research Institute, on the Harbor-UCLA Medical Center campus, gathered data on the blood alcohol level of almost 8,000 trauma patients -- and compared the death rates of those who had indulged against those who hadn't.

Turns out, the drunken ones fared better. Only about 1% of the intoxicated patients died; compared with 7% of the nonintoxicated patients. 

More study is needed, concludes the study published in the American Surgeon, as to what precisely the protective mechanism might be.  (Here's the press release; the article itself isn't easily accessible.)

Also worth noting is this point in the study's discussion section: "The mortality rate reported here is based on patients who are actually brought to the hospital, and the sample is thus limited by selection bias. It is certainly possible that a higher proportion of those who died in the field were intoxicated and were thus never transported to the hospital."

Ah.

-- Tami Dennis

Photo credit: Associated Press

For a broken arm, give a child ibuprofen -- not codeine, researchers say

The parent of a kid with a newly broken arm -- not to mention the kid himself or herself -- is unlikely to want to leave the emergency department without a prescription for pain relief. A new study suggests that such relief should come from ibuprofen.

Researchers at the Medical College of Wisconsin studied 336 children, ages 4 to 18, with arm fractures, half of whom were prescribed ibuprofen upon their discharge from the emergency department, half of whom were given acetaminopen with codeine. The patients and their family then kept a diary of pain and medication side effects for the next 72 hours.

Not only did the ibuprofen work just fine in controlling pain -- at least as good as the codeine-laced acetaminophen -- the medicine normally associated with relieving headaches and muscle aches also had far fewer downsides.

Among those kids taking ibuprofen, 29.5% reported an adverse effect. Among those taking the codeine-laced drug, however, 50.9% reported an adverse effect. Such reactions included nausea, vomiting, drowsiness, dizziness and constipation.

As for pain and its ability to affect general function, the kids taking ibuprofen were less likely to report effects on their play and eating.

That's not to say side effects can't happen with any drug. Here's information from drugs.com on the medications used in this study -- ibuprofen suspension and acetaminophen with codeine suspension.

The researchers point out that some doctors might not be particularly enamored of the idea of recommending nonsteroidal anti-inflammatory drugs (or NSAIDs), of which ibuprofen is one, for kids who have broken a bone, even if the break is just a fracture. Animal studies have suggested that NSAIDS may negatively affect the way the bone heals.

But considering the lack of research on that possibility -- and the clear findings of this study -- the findings to them seem clear. They conclude: "Ibuprofen is preferable to acetaminophen with codeine for outpatient treatment of children with uncomplicated arm fractures."

The study was published today in the Annals of Emergency Medicine.

-- Tami Dennis

Photo: When good play goes bad, injuries -- and a trip to the local ER -- ensue.

Credit: Los Angeles Times

'ER' and intubation: Everyone's a critic!

In its 14 seasons on the air, NBC's path-blazing medical drama, "ER," may have taught you the signs of stroke, the importance of wearing seat belts and an appreciation for the perils of workplace romance. But if you were watching the show -- or any other TV medical drama -- for tips on proper intubation technique, a new study suggests you should have looked elsewhere. (And no, I do NOT mean "St. Elsewhere.")

Among physicians-in-training in Canada, a study published recently in the journal Resuscitation found that fewer than half positioned a patient's head and neck properly to prepare for the introduction of an emergency airway. A survey prepared for the Canadian Resuscitation Institute set out to explore why so many patients were positioned poorly prior to intubation. Many trainees reported they had received limited supervision or had effectively taught themselves how to intubate a patient, reports Dr. Peter G. Brindley of the University of Alberta Medical Center's Critical Care Division.

So how did physician trainees learn this skill, which can spell the difference between life and death? After "trial and error," Brindley and his colleagues were shocked to learn that medical dramas on TV were the second most often cited source of training of intubation skills. And the good docs at Chicago's County General -- the cast of "ER" -- were "by far the most common source," Brindley reports in a letter to the editors of Resuscitation.

And did "ER" -- hailed for tackling many medical problems with earnest verisimilitude -- do a good job?

Well, no, according to Dr. Brindley. In the 42 episodes that made up the 12th and 13th seasons of "ER," Brindley counted 41 intubation attempts. Of those, 22 were conducted on "patients" with no sign of neck or spinal injury and could be seen and assessed in video by resuscitation specialists (thank goodness you can now watch back episodes on your computer). Of those, none were done correctly -- which, by the way, involves flexion of the lower cervical spine, extension of the atlanto-occipital joint, and raising the ears anterior to the sternum. A few met one of those three criteria, but none met all three.

That "ER" showcases such poor technique, in spite of the fact that the show "retains numerous medical experts," suggests to Brindley and colleagues that optimal airway positioning for intubation is "poorly appreciated" among those who train emergency department physicians. The audit "highlighted the perils of leaving pulmonary resuscitation to the inexperienced or the unsupervised."

Or to people glued to their TVs on Thursday nights hoping, as this blogger has, for Dr. Ross to come back. (I'll bet HE knew how to put an emergency airway in correctly!)

-- Melissa Healy

 

The face of domestic violence

Domestic violence is believed to be vastly under-reported, and emergency and other physicians have long been urged to be on the alert for patients with unexplained injuries. The right questions can help identify victims -- the  majority of them women -- and secure referrals to community service agencies.

Now doctors have a new clue. Rather than trying to read injured patients' faces for signs of fear or shame, physicians can read their facial injuries.

Women who had been assaulted by intimate partners generally sustained different patterns of facial injuries than women who were injured in car crashes, falls or assaults by strangers, according to a study published today in Archives of Facial Plastic Surgery.

Women who were assaulted by a husband or boyfriend had higher than expected numbers of orbital blow-out fractures (breaks or cracks in the bones surrounding the eye) and traumatic brain injuries.

Previous studies of facial injuries in men and women from car accidents and assaults had found that mandible and nasal fractures -- broken jaws and noses -- were the most frequent injuries, followed by zygomatic complex fractures, or cracks in the cheekbones and the bones that adjoin them.

Researchers had expected to find similar results in women who were victims of domestic violence. They looked at medical records of women age 18 years and older who went to the University of Kentucky Medical Center to be treated for trauma to the face.

The most common cause of facial injury was car accidents, followed by falls, then assaults. Of 45 assault victims identified, 19 were documented victims of domestic violence.

Women who were in motor vehicle crash or had suffered falls had higher than expected numbers of fractures to the alveolar ridge fractures (the horseshoe of bone directly beneath the teeth) and facial cuts. Women who were assaulted by a stranger were more likely to have broken jaw bones and zygomatic complex fractures.

In addition to distinctive patterns of injury, domestic violence victims also differed in presentation: They were more likely to delay seeking care for their injuries.

"For more than a decade, we have known that when healthcare providers assess patients for domestic violence and refer those who need help to local domestic violence programs, it can save victims' lives," said Esta Soler, president of the San Francisco-based Family Violence Prevention Fund. "But not nearly enough doctors, nurses and other providers are doing this. This study  makes it even easier for surgeons and other providers to recognize when patients are victims of violence -- and creates an even more urgent mandate for them to intervene."

-- Mary Engel

Credit: Myung J. Chun/Los Angeles Times

Care in a hallway is better than a crowded emergency room

Boarding patients -- keeping them in the emergency room while they await admission to the hospital -- is a key reason that emergency rooms are so crowded. Many ERs have to stop accepting new patients until the backlog clears. But a new study suggests it's safer to move patients out of the emergency room to an in-patient hallway while awaiting a hospital bed.

Researchers from Stony Brook University in Stony Brook, N.Y., studied 57,487 patients who were admitted to the hospital from the emergency department. Admitted patients were moved to in-patient hallways if they were stable, there were more than three admitted patients already boarded in the emergency department and there was no space to see incoming emergency patients. The study found that while patients admitted to in-patient hallways had longer wait times overall to admission, their death rate was 1.1% compared with 2.5% for patients admitted to normal rooms from the emergency room. Moreover, their rate of admission to the intensive care unit was much lower: 2.6% compared with 6.9%.

Though lying on a gurney in a hallway isn't ideal, it appears to be safer than waiting in the chaotic and crowded emergency room, the study authors concluded. "Boarding admitted patients in the emergency department has been established as harmful for both the patients who are boarded and new patients coming to the emergency department who suffer long delays in care because emergency physicians are still monitoring the boarded patients," said Dr. Peter Viccellio, the lead author of the study. Viccellio presented the research today in Chicago at the annual meeting of the American College of Emergency Physicians.

-- Shari Roan

Photo: A patient reads a newspaper on his bed in the hallway of Stony Brook University Hospital in Stony Brook, N.Y. Credit: Seth Wenig / AP

Crowded ER? Don't blame the uninsured

Emergency rooms, known for chaos and life-saving heroics, have become just as well known for crowding and long waits.

Often, people without medical insurance are blamed. Because they don't have regular medical care, they simply go to the ER when illness strikes -- or so the thinking goes. And so the thinking goes wrong.

The uninsured actually don't account for more than their fair share of ER visits, finds a study published this week in the Journal of the American Medical Assn. Anyone who's ever gotten a bill from an ER might understand why. The uninsured don't have someone else to cover the cost of such a visit, which isn't cheap by anyone's standards.

Rather, people with insurance are more likely to turn up at the hospital for minor ailments, the report finds.

The researchers, led by University of Michigan doctors, reviewed 127 medical research papers on emergency care for uninsured patients, searching for unsupported statements -- and then trying to establish whether or not such statements could be backed up by data.

Often, they couldn't.

Says first author Dr. Manya Newton in a news release:

"The rise in ED [emergency department] use has much more to do with the aging of the population, the increase in chronic diseases, and the decrease in available primary care than with the uninsured. Policies based on false assumptions risk diverting energy and money from confronting the true drivers of emergency department crowding."

As the blog Pure Pedantry notes:

"This article is a compelling evidence for the idea that insurance coverage and health care access -- while similar -- are not the same thing. You cannot simply will access into existence by providing everyone with insurance. Rather, I think the solution to ED crowding is that we need more -- many more -- primary care providers. Only an excess in the supply of primary care will bring the prices down and increase access for both the insured and uninsured public."

With the ER situation growing more grim (ERs fail as the nation's safety net), it's a topic worth discussing further -- but with perhaps more facts than have been used thus far.

Observes the author of the Pure Pedantry post: "Whenever you are having a debate -- particularly a policy debate -- it is always important to check your premises."

-- Tami Dennis

Photo: A patient is loaded into an ambulance in 2006 at Huntington Memorial Hospital in Pasadena after the hospital declared itself full and unable to accept new emergency patients. Other area hospitals were in the same condition.

Credit: Jamie Rector / For The Times