The American journal of emergency medicine
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The Centers for Medicare and Medicaid Services introduced the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) as a national quality measure in October 2015. The purpose of SEP-1 is to facilitate the efficient, effective, and timely delivery of high-quality care to patients presenting along the spectrum of sepsis severity. ⋯ Overall, there were no clinically or statistically meaningful changes in fluid volume resuscitation strategies for suspected septic shock patients following SEP-1. Broad mandates may not be effective tools for promoting practice change in the ED setting. Further research investigating barrier to changes in practice patterns surrounding fluid administration and other SEP-1 bundle elements is warranted.
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Despite projections of an oversupply of residency-trained emergency medicine physicians by 2030 and amidst intensifying national debate over Nurse Practitioner (NP) qualifications to practice independently and unsupervised, NPs are increasingly staffing Emergency Departments (EDs) as hospitals seek to contain costs while simultaneously expanding services. We sought to characterize NP practice in the ED by examining NP independent billing by level of severity of illness, and relationship to practice authority, State Medicaid expansion status, and rurality. ⋯ As a proportion of the providers independently billing in the ED, NPs are increasingly managing higher acuity patients as evidenced by billing percentage of the highest acuity CPT codes (99284 and 99285). During the same time period, ED MDs decreased their billing in the same categories. Current employment of NPs in the ED may not be fulfilling its original vision to care for the lower acuity patients in order to allow MDs to care for the more acutely and critically ill patients, and to increase the services for underserved populations in rural areas, those over age 65, and those with limited English language proficiency. Future research should investigate ED policies resulting in NPs as opposed to MDs seeing patients with greater severity codes.
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This case demonstrates a complex patient presenting with diagnosis of pulmonary embolism. He received heparin therapy, then subsequently found to have an intracranial hemorrhage, which rapidly progressed, leading to patient demise. Through this case, the reader should better understand the therapeutic conundrums in critical PE patients and complications of anticoagulation.
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Comment Letter Randomized Controlled Trial
Letter to the editor: Transcutaneous electrical nerve stimulation (TENS) for the treatment of renal colic in the ED: A randomized, double-blind, placebo-controlled trial.
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Observational Study
Trauma center designation level and survival of patients with chest wall instability.
Chest wall instability is a potentially life-threatening condition that should be evaluated at a trauma center. While patients with chest wall instability are sent to different trauma center levels, the impact of this on outcomes has not been evaluated yet. This study examines survival to hospital discharge of patients with chest wall instability treated at different trauma center levels. ⋯ Survival rates for patients having chest wall instability were similar when transported to level II or level III versus level I centers. This finding can help guide pre-hospital field triage criteria for this specific type of injury and highlights the need for more outcome research in organized trauma systems.