USA Today Op-Ed, 5/30/08: 

By Rich Umbdenstock

The professionals in America’s hospital ERs are working on immediate and long-term solutions to the crowded conditions many patients find when they come to the emergency room. With the number of uninsured people increasing and fewer primary care doctors available, more Americans turn to the emergency room for routine care. But waiting times must be reduced.

Many hospitals, physicians and local emergency medical systems monitor available capacity and direct patients to less crowded hospitals. As hospitals rebuild aging ERs, they are adding multiple levels of care to ensure that emergencies are treated by emergency specialists and that non-emergencies are handled in settings much like a doctor’s office. Better coordination of operating room schedules for emergency and elective surgeries, and efforts to make the daily discharging of patients more efficient, can make beds available more quickly for arrivals. No single solution will work in every hospital. But progress is being made in easing crowded conditions and shortening patient waits.

Today’s ER problems often are the result of greater challenges facing the community at large. We must expand health coverage to the 46 million people without it. And we must increase the number and availability of primary care physicians so that everyone, whether insured or not, has access to primary and preventive care.

From the inner city to rural America, emergency rooms must respond to every imaginable illness, injury and disaster. It is what they do. When it comes to facing these long- and short-term challenges, hospitals aren’t waiting for someone else to come up with a solution. They are making changes according to their community’s needs.

But crowded ERs cannot be relieved solely by changes at the hospital door. They are a symptom of the many serious problems challenging our nation’s health and health care — problems that can be solved only by fundamental reform. That is a task that awaits a new president and Congress.

Rich Umbdenstock is president and CEO of the American Hospital Association.

USA Today Editorial, 5/30/08: On the night of her baby’s seizure in February, Brandy Nannini discovered a harsh reality of today’s overtaxed medical system. The ambulance crew that responded to her 911 call refused to take 23-month-old Bella to a nearby Washington, D.C., hospital where her doctor was waiting. The emergency room was so crowded it was closed to new patients. Despite Nannini’s pleas, the ambulance was diverted to suburban Virginia.

WebMD, 5/29/08:  Emergency room visitors may be exposed to potentially dangerous levels of radiation from X-rays, CT scans, and other tests that may increase their risk of cancer in years to come.Researchers say emergency room physicians do not routinely keep track of the cumulative amount of radiation their patients receive. In fact, until now, they had no way of knowing how much radiation a patient has been exposed to during one or multiple visits.

A new study shows emergency room patients received an average radiation dose of 45 millisieverts. But 12% of patients received 100 or more millisieverts of radiation during the five-year study period — a dose that exceeds the recommended safety limits and may increase the risk of cancer.

“Our research hopefully will affect the habits of physicians who routinely order medical imaging diagnostic studies in their practices,” researcher Timothy Bullard, MD, MBA, of the Orlando Regional Medical Center, says in a news release. “We also hope that our research will further promote the need for electronic medical records with portability and encourage the development of an individual patient cumulative exposure estimate tool.”

In the study, presented this week at the annual meeting of the Society for Academic Emergency Medicine in Washington, D.C., researchers measured the amount of radiation that a random sample of patients at two urban emergency rooms received over the course of five years.

Overall, an average of 10.8 tests involving radiation exposure, such as X-ray, CT scans, and nuclear imaging tests (tests that use small amounts of radioactive material to produce pictures of internal parts of the body not visible on X-rays), were performed on each patient studied.

Nearly two-thirds of these tests were X-rays (63%), 26% were CT scans, 5% were nuclear studies, and 2% were mammography.

Researchers found more than 70% of ER-related radiation exposure came from three primary types of diagnostic imaging tests: CT scans of the abdomen and pelvis, nuclear imaging of the heart, and CT scans of the chest.

They say if these findings apply to the average emergency room visitor nationwide, a substantial number of people may be at increased risk of developing cancer during their lifetime because of excessive radiation exposure from diagnostic ER testing.

They estimate that an additional six cancers above the national average would be attributable to radiation exposure in this population.

In patients with potential acute coronary syndromes, a negative CT angiogram means they can be sent home safely, a researcher said here.

That finding comes from a study of patients considered to be at low risk for heart attack who were treated in a hospital emergency department for chest pain, Anne Marie Chang, M.D., of the University of Pennsylvania, reported at the Society for Academic Emergency Medicine meeting.

Dr. Chang and colleagues assigned the patients to either an immediate coronary computerized tomographic angiography or to CT angiography after a nine- to 12-hour observation period that included tests for coronary biomarkers, Dr. Chang said. 

The bottom line, Dr. Chang said, is that patients whose coronary [CT angiography] is negative are not at risk for cardiovascular death or MI. 

“We have shown in our clinical practice,” she said, “that if they have a negative [CT angiogram], you should be able to safely send patients home.” 

The procedure has “excellent performance characteristics” when it’s compared to standard coronary angiography, as well as to exercise or pharmacological stress tests. 

But it remained unclear if doctors can use the method to stratify low-risk patients, Dr. Chang reported, where low-risk is defined as a Thrombolysis in Myocardial Infarction (TIMI) score of less than two. 

To try to answer the question, she and colleagues conducted a prospective evaluation of 568 consecutive patients, with 285 in the immediate CT angiography arm and 283 in the observation-first arm. 

Patients with negative tests were sent home. The main outcome was cardiovascular death or myocardial infarction within 30 days, Dr. Chang said. 

All told, 476 patients (84%) had a negative coronary CT angiogram and were sent home. 

During the 30-day follow-up period, none of them died of a cardiovascular event or had a nonfatal MI, she said, implying that the negative scan is sufficient to rule out any danger. 

The study was one of two evaluating aspects of coronary CT angiography presented by Dr. Chang. 

The other was a retrospective look at four strategies for evaluating low-risk patients after a doctor determined they should be admitted and tested to rule out acute coronary syndrome. 

The four strategies were: 

• Immediate coronary CT angiography in the emergency room for 98 patients, without serial cardiac biomarkers. 
• Coronary CT angiography and clinical decision unit evaluation with serial cardiac biomarkers for 102 patients. 
• Clinical decision unit evaluation with serial cardiac biomarkers and stress testing, for 154 patients. 
• Usual care, defined as admission with serial cardiac biomarkers and hospitalist-directed evaluation, for 289 patients. 

The outcomes were actual cost of care, length of stay, diagnosis of coronary disease, and cardiovascular death or MI within 30 days, Dr. Chang said. 

Analysis found that the median cost for immediate CT angiography was $1,240 compared with $2,318 for clinical decision unit evaluation with CT angiography, $4,024 for clinical decision unit evaluation and stress testing, and $2, 913 for usual care. The differences were significant at P<0.01, Dr. Chang reported. 

Length of stay was 8.1 hours for immediate CT angiography, compared with 20.9 hours for clinical decision unit evaluation with CT angiography, 26.2 for clinical decision unit evaluation and stress testing, and 30.2 for usual care. The differences were, again, significant at P<0.01. 

The rate of diagnosis of coronary disease was similar in all four arms, ranging from 5.1% to 6.6%. 

However, there were no cardiovascular deaths or MIs within 30 days in the immediate CT angiography arm, compared with 0% and 3.2% for clinical decision unit evaluation with CT angiography, 0.7% and 2.3% for clinical decision unit evaluation and stress testing, and 3.1% and 12.2% for usual care. The differences were significant at P=0.04 for cardiovascular death and P<0.01 for MI. 

The cohorts for the two studies overlapped, Dr. Chang said, with some of the patients in the prospective analysis also used in the cost-benefit analysis. Primary source: Society for Academic Emergency Medicine meeting
Source reference:
Chang AM, et al “Coronary computerized tomography for rapid discharge of low risk patients with potential acute coronary syndromes” SAEM Meeting 2008; Abstract 11. 

Additional source: Society for Academic Emergency Medicine meeting
Source reference:
Chang AM, et al “Actual financial comparison of four strategies to evaluate patients with potential acute coronary syndromes” SAEM Meeting 2008; Abstract 12. 

The Lancet 2008; 371:1854-1860 

Summary

 

The Lancet 2008; 371:1848-1853

Summary

Background

The cause and mechanism of most cases of sudden unexpected death in infancy (SUDI) remain unknown, despite specialist autopsy examination. We reviewed autopsy results to determine whether infection was a cause of SUDI.

Methods

We did a systematic retrospective case review of autopsies, done at one specialist centre between 1996 and 2005, of 546 infants (aged 7–365 days) who died suddenly and unexpectedly. Cases of SUDI were categorised as unexplained, explained with histological evidence of bacterial infection, or explained by non-infective causes. Microbial isolates gathered at autopsy were classified as non-pathogens, group 1 pathogens (organisms usually associated with an identifiable focus of infection), or group 2 pathogens (organisms known to cause septicaemia without an obvious focus of infection).

Findings

Of 546 SUDI cases, 39 autopsies were excluded because of viral or pneumocystis infection or secondary bacterial infection after initial collapse and resuscitation. Bacteriological sampling was done in 470 (93%) of the remaining 507 autopsies. 2079 bacteriological samples were taken, of which 571 (27%) were sterile. Positive cultures yielded 2871 separate isolates, 484 (32%) of which showed pure growth and 1024 (68%) mixed growth. Significantly more isolates from infants whose deaths were explained by bacterial infection (78/322, 24%) and from those whose death was unexplained (440/2306, 19%) contained group 2 pathogens than did those from infants whose death was explained by a non-infective cause (27/243, 11%; difference 13·1%, 95% CI 6·9–19·2, p<0·0001 vs bacterial infection; and 8·0%, 3·2–11·8, p=0·001 vs unexplained). Significantly more cultures from infants whose deaths were unexplained contained Staphylococcus aureus (262/1628, 16%) or Escherichia coli (93/1628; 6%) than did those from infants whose deaths were of non-infective cause (S aureus: 19/211, 9%; difference 7·1%, 95% CI 2·2–10·8, p=0·005; E coli: 3/211, 1%, difference 4·3%, 1·5–5·9, p=0·003).

Interpretation

Although many post-mortem bacteriological cultures in SUDI yield organisms, most seem to be unrelated to the cause of death. The high rate of detection of group 2 pathogens, particularly S aureus and E coli, in otherwise unexplained cases of SUDI suggests that these bacteria could be associated with this condition.