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Emergency Medicine

Emergency Medicine, Health Costs, Research, Technology

Can sharing patient records among hospitals eliminate duplicate tests and cut costs?

566748316_7b72d5b777A recent analysis of the impact of health information exchanges, which allow health-care providers to share patient records electronically and securely, shows the systems hold promise for reducing health costs and unnecessary care in emergency departments.

For the study (subscription required), University of Michigan researchers examined information on hospital health information exchange participation and affiliation from the Health Information Management Systems Society’s annual survey as well as data the  California and Florida state emergency department databases from 2007 through 2010. Both states were early adopters of health information exchanges. According to a university release:

The findings show that the use of repeat CT scans, chest X-rays and ultrasound scans was significantly lower when patients had both their emergency visits at two unaffiliated hospitals that took part in a [health information exchange]. The data come from two large states that were among the early adopters of [health information exchanges]: California and Florida.

Patients were 59 percent less likely to have a redundant CT scan, 44 percent less likely to get a duplicate ultrasound, and 67 percent less likely to have a repeated chest X-ray when both their emergency visits were at hospitals that shared information across an [health information exchange].

More research is needed to determine the value of health information exchanges on patient care and health-care costs. But in order to conduct future analysis, said study authors, more states need to report relevant data to the Healthcare Cost and Utilization Project system  to allow researchers to view the activity of individual patients across their different medical encounters, while preserving patient privacy.

Previously: Experts brainstorm ways to safely reduce health-care costs, U.S. Olympic team switches to electronic health records and A new view of patient data: Using electronic medical records to guide treatment
Photo by Tabitha Kaylee Hawk

Cardiovascular Medicine, Emergency Medicine, Patient Care, Pediatrics, Research

New approach to resuscitation training saves more kids

New approach to resuscitation training saves more kids

Heart-2014Children whose hearts stop while they are in the hospital need fast, well-coordinated resuscitation to give them the best chance of surviving their cardiac arrest. But because pediatric cardiac arrests are (fortunately) rare, pediatric physicians, nurses and other caregivers have few opportunities to experience a real response to this life-threatening emergency. And rehearsing what to do in educational settings outside the hospital may not give responders the chance to practice for unexpected problems that can arise in real life.

To solve this problem, a team at Lucile Packard Children’s Hospital Stanford implemented a new training approach. Lynda Knight, RN, MSN, the hospital’s pediatric resuscitation program educator, wanted to make sure that every person responding to emergency “codes” broadcast through the hospital when a patient’s heart stops – from attending physicians to security guards – had regular opportunities to practice working together. Knight and Deborah Franzon, MD, led a group that staged mock “codes” to simulate cardiac arrests in many locations throughout the hospital.

After the new training was implemented, the hospital’s survival rate for cardiac arrest patients jumped from 40 percent (a figure similar to the national average for children’s hospitals) to 60 percent. The findings were published this week in Critical Care Medicine.

From our press release about the study:

One key goal of the training package was for one person to quickly assume the role of the code team leader, and for others to take on specific, pre-defined roles in the team’s response. The roles were based on American Heart Association guidelines about best practices for resuscitation.

“It’s sort of like an orchestra,” Franzon said. “Everyone has a really important part to play.” For instance, one physician or nurse stood at the code cart, distributing equipment. A social worker comforted the patient’s parents. Security guards directed unnecessary foot traffic away from the area. A nursing supervisor made sure all essential roles were filled quickly.

“With this training in place, responding to codes becomes muscle memory for the whole team,” Knight said. “That’s what’s going to save lives.”

Photo by dev null

Emergency Medicine, Stanford News, Videos

“I’m glad that we were there”: Stanford emergency-response team returns home from the Philippines

"I'm glad that we were there": Stanford emergency-response team returns home from the Philippines

Time for another (feel-good) video? The SEMPER team that’s been in the Philippines for the last few weeks made it home safely yesterday; in this piece, the group is greeted at the airport by friends and family. “We saw [about] 200 patients a day. It was very difficult – I have to tell you that,” said one of the returnees, later adding, “Our presence actually made them feel good, and they’re very grateful for that. And I’m glad that we were there.”

Previously: On the ground in post-typhoon Philippines, Post-typhoon Philippines: “It is all becoming real and sinking in”, Providing medical care to typhoon survivors in the Philippines and Stanford emergency-response team heads to the Philippines

Emergency Medicine, In the News, Pediatrics, Pregnancy, Stanford News, Women's Health

Russian doctors visit Packard Children’s Hospital for childbirth-crisis training

Russian doctors visit Packard Children's Hospital for childbirth-crisis training

operationSome believe “The Trauma of Birth” is part of the human condition even during a healthy delivery. But sometimes entry into the world comes with unexpected medical complications – for mother as well as baby. Stanford’s Center for Advanced Pediatric and Perinatal Education at Lucile Packard Children’s Hospital trains health professionals on best practices for handling childbirth emergencies. An article in the San Francisco Chronicle spotlights experiences of the first Russian visitors to the center, which has been training medical experts from all over the world since 2002.

From the piece:

The simulation room looked a lot like a hospital room, with a couple of significant differences. Behind a two-way mirror, technicians sat in a control room video-recording the doctors’ every movement on seven cameras. They manipulated the vital signs shown on the bedside monitor of the mother, who was played by a hospital employee. They controlled the pumping lungs and warm breath of the baby mannequin.

After the childbirth simulation, the four Russian doctors involved in the scenario sat before a television and watched themselves on instant replay. Cringing a bit, the obstetricians admitted that they could have worked more efficiently by splitting up, with one monitoring the woman’s vital signs and the other guiding the delivery. One of the neonatologists who assisted with the newborn remarked that she should have called for help from a colleague sooner.

One of the participating doctors, Yulia Vorontsova, a neonatologist, said with the assistance of an interpreter, “When you look at a situation from the outside, it gives you a richer experience.”

Previously: “Preparation is everything:” More on how Stanford and Packard got ready for the Asiana crash, Whiz Kids: Research looks at handling pediatric crises effectively and Improving treatment for infant respiratory distress in developing countries
Photo by phalinn

Emergency Medicine, Global Health, Patient Care, Stanford News

Providing medical care to typhoon survivors in the Philippines

Providing medical care to typhoon survivors in the Philippines

SEMPER - smallYesterday we wrote about a Stanford team who had traveled to the Philippines to provide medical assistance to survivors of Typhoon Haiyan. Members of SEMPER, each carrying an average of 160 lbs of equipment, arrived on Saturday and completed their first full day of providing medical care on Monday.

The team, pictured to the right, reports that there are “clear signs of recovery” but says the devastation from the typhoon is enormous. They’re chronicling their experiences on a blog, which you can read here.

Previously: Stanford emergency-response team heads to the Philippines
Photo courtesy of SEMPER

Emergency Medicine, Global Health, Patient Care, Stanford News, Videos

Stanford emergency-response team heads to the Philippines

Stanford emergency-response team heads to the Philippines

On Friday, several members of Stanford’s emergency-response team headed to the Philippines to provide medical assistance in the aftermath of Typhoon Haiyan. Stanford Hospital videographer Todd Holland was on the scene as the team prepared, and he captured the beginning of their journey in the video above.

Previously: New Stanford Hospital team ready to mobilize for disaster relief, Treating the injured amid the apocalypse of Haiti, Reports from Stanford medical team in Haiti and Stanford sends medical team to Haiti

Emergency Medicine, Health Disparities, Public Health, Research

Texts may help people with diabetes manage care

flipphoneWhat if a doctor’s orders were as simple as two text messages a day to keep the ER at bay? A recent study published in Annals of Emergency Medicine used an automated mobile health (mHealth) program to reach low-income inner-city patients with type 2 diabetes and engage them in their own health and disease management outside of emergency facilities.

Researchers recruited 128 participants who had sought care for diabetes at the Los Angeles County Hospital of the University of Southern California ED. The study reported that the largest safety-net hospital in the county’s public care system annually serves 170,000 patients, 70 percent of them Latino. Study participants could choose English or Spanish versions of the messages, which offered tips on healthy behavior and disease management and did not require a smartphone to receive.

From a release:

For patients who received the text messages, blood glucose levels decreased by 1.05 percent and self-reported medication adherence improved from 4.5 to 5.4 (on an eight-point scale). Effects were even larger among Spanish speakers for both medication adherence and blood glucose levels. The proportion of patients who visited the emergency department was lower in the text messaging group (35.9 percent) than in the control group (51.6 percent). Almost all (93.6 percent) patients enrolled in the program reported enjoying it and 100 percent reported that they would recommend it to family and friends.

“Our goal is to transition our patients from crisis management to long-term diabetes management,” study lead author Sanjay Arora, MD, of USC’s Keck School of Medicine, said in a release. “The absence of other health care options, reaching our patients by text message makes us partners in handling their disease and improves their quality of life.”

Previously: Help from a virtual friend goes a long way in boosting older adults’ physical activityA look at the “Wild West” of medical apps and Mobile phone app helps manage diabetes
Photo by kiwanja

Emergency Medicine, In the News, Patient Care

Patient advocacy and staff courtesy in the ER

waitingroomOne morning during a ballet class I did an extra-large backbend, fainted, flipped, fell and hit my head on the bottom of the metal barre I had been holding onto, awoke on the floor and stared at my colleagues, who hovered above. The company manager insisted I go to the emergency room. A friend who wanted to get out of her Nutcracker rehearsals that day volunteered to take me. We sat in rigid chairs and waited for seven-and-a-half hours in a seemingly not very busy ER before I was seen and told that I probably did not have a concussion. While I didn’t mind waiting all that much (I was also getting out of back-to-back runs of the Snow Scene), I wondered how the experience could have gone differently. Were symptoms missed in the time that elapsed? Should I have gone to urgent care instead, to make space for more acutely ill or injured people in the ER?

I found resonance in a recent post on by Abigail Schildcrout, MD, who describes a frustrating experience navigating the ER as the parent of a young patient. In it, the physician and mother emphasizes the need for patients to be assertive and hospital staff to be attentive, but also for both parties to be respectful of the other.

From the post:

We waited far longer than we should have for the test that determined whether a surgical emergency existed.

Yes, there are people who use emergency room resources when they’re not needed. But most of us go out of our way to avoid emergency rooms. When we’re there, it means we’re really concerned about something.

When I tell my clients and my readers to advocate for themselves and their loved ones, I know it’s hard. I know it’s a delicate balance between making sure you get what you need and not annoying people in the process. But it has to be done. And hospitals are working on seeing things from the patients’ side.

Previously: Speed it up: Two programs help reduce length of stay for emergency-room visitors and Decreasing demand on emergency department resources with “ankle hotline”
Photo by cinemich

Emergency Medicine, Health Disparities, LGBT, Patient Care, Research

Study finds ER avoidance in transgender individuals needing care

ER2Past reports have found high levels of postponing medical care in transgender and non-gender-conforming people, owing to experiences including refusal of care, harassment and violence in medical settings, and lack of provider knowledge. A 2011 committee opinion from the American Colleges of Obstetricians and Gynecologists called the consequences of inadequate treatment among this population “staggering.”

Now, Canadian research on an Ontario transgender population shows levels of emergency-room avoidance by trans people. Published online in the Annals of Emergency Medicine, the study (subscription required) examined data from surveys in 408 transgender, transsexual, or transitioned people, many of them young (16-24 years); approximately half were male-to-female and half were female-to-male.

As described in a release:

“Patients who have had trans-specific negative experiences in other parts of the health care system may defer care until they are desperate and need the ER,” said lead study author Greta Bauer, PhD, MPH, of the Schulich School of Medicine & Dentistry in London, Ontario, Canada. “The good news is that nearly three-quarters of those who needed emergency care were able to get it in the ER. The bad news is that so many still were not.”

Almost one-quarter (21 percent) of trans patients reported ever avoiding the ER due to a perception that their trans status would negatively affect such an encounter. Negative experiences specifically related to being transgender were reported by 52 percent of trans patients.

Approximately 54 percent of trans patients reported having to educate their providers “some” or “a lot” regarding trans issues.

Bauer and her colleagues noted in the paper that their work “represents a first contribution on trans experiences within emergency medicine.” More research is needed, they said, “to better understand reasons for ED avoidance and to develop strategies to overcome this.”

Previously: Documentary on LGBT veterans’ PTSD, trauma and recovery premieres tomorrowDistinction with a difference: Transgender neurobiologist picked for National Academy of Science membershipA call for more training on LGBT health issues and Affordable Care Act prohibits discrimination against transgender patients 
Photo by robnguyen01

Emergency Medicine, Patient Care, Stanford News

More than a manual: Stanford’s crisis checklist helps those working in the OR

More than a manual: Stanford's crisis checklist helps those working in the OR

emergency manualI hate forgetting things, so when I have a bit of information that I absolutely must remember, I write it down. Many people employ the same strategy, yet as my colleague Sara Wykes explains in this edition of Inside Stanford Medicine, medical professionals are often held to unrealistic standards where a list, such as mine, could be mistaken as a sign of weakness.

As David Gaba, MD, associate dean for immersive and simulation-based learning at Stanford, explains in the story, this faulty perception of medical manuals couldn’t be further from the truth. “Many of us strive to emphasize to students, trainees and experienced clinicians that their use is actually a sign of strength and wisdom and that failing to use them is a sign of weakness and perhaps hubris,” said Gaba.

That’s why a team of medical experts from the Stanford Anesthesia Cognitive Aid Group developed an emergency manual for use at Stanford hospitals and other medical facilities. From the story:

It covers protocols for 24 conditions and circumstances. Some, like how to deal with a patient’s bradycardia (a slow and unstable heartbeat), will be familiar only to medical professionals. Others, like how to handle a hospital-wide power failure, address what to do first, and thereafter, in such circumstances.

The development group examined every aspect of the emergency manual, down to details whose importance might not seem immediately obvious, including the colors, typefaces, boldfacing of words, size of pages, binding and physical placement within a working space. Over and over, the implementation team tested the manual in simulation with a full medical team, refining elements based on feedback from its users.

This iterative process provided the Stanford team with critical information that helped them make their manual more effective in an emergency setting. “We learned from simulation testing that it is not enough just to put the manual in the OR… we need to train people to use it,” said Sara Goldhaber-Fiebert, MD, lead author of an Anesthesia & Analgesia paper (subscription required) detailing the work.

“Just the act of training to use the manual promotes team building and communication, which is critical not just in emergencies, but all the time,” agreed Bryan Bohman, MD, the former chief of staff at Stanford Hospital and an anesthesiologist who contributed to the implementation of the Stanford manual.

As Wykes outlines, tangible signs of success emerged after the Stanford team finished training medical professionals to use the manual:

OR nurses requested a second copy be hung near the nursing phone. Computer and anesthesia technicians wanted copies where they work to help them anticipate equipment that might be needed during specific emergencies.

“Having the manual is reassuring, especially when you’re going through these catastrophic events… There’s always a certain part of you that wonders, ‘Have I thought of everything?” said second-year resident at Stanford Jason Johns.

The Stanford emergency manual can be downloaded for free here.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: What health-care providers can learn from the nuclear industrySully Sullenberger talks about patient safety and A closer look at Stanford’s simulation technology
Photo by Norbert von der Groeben

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