Category Archives: happenings

Disclosure of Adverse Events and Medical Errors

Authors: Allison Moyes, MD (EM Resident Physician, University of Washington / Harborview Medical Center, Seattle, WA) and Amy E. Betz, MD (Clinical Assistant Professor, Harborview Medical Center, University of Washington Division of Emergency Medicine, Seattle, WA) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) & Justin Bright, MD (@JBright2021)

The Institute of Medicine’s 1999 report “To Err is Human: Building a Safer Health System” drew attention to medical errors and the need for improving quality and safety in medicine.1  Since then, a body of literature has emerged suggesting that transparency around adverse events and medical errors benefits both providers and patients.  However, the actual rate of disclosing medical errors has lagged behind popular support for the concept.2-5

Benefits of error disclosure

  1. Provides support for patients and enhances patient-provider communication.2, 6-8
  1. Improves institutional awareness of errors which might otherwise go unreported. Analyses of why errors occur can lead to system-wide improvements in quality and safety.5
  1. Open disclosure of medical errors may make lawsuits less likely.2-3,6
  • In 2001, the University of Michigan adopted a program of full disclosure, which also offers compensation to patients for medical errors. Retrospective reviews have demonstrated a reduction in claims and liability costs since the program began.9
  • Disclosure policies in other isolated institutions and insurance networks have yielded inconsistent results.10
  • Nondisclosure of errors has been shown to decrease patient satisfaction and increase the likelihood of seeking legal advice.8
  • The cumulative effect of error disclosure on legal claims remains difficult to determine and largely unclear.

The disclosure gap

Patients and providers agree that errors resulting in otherwise preventable adverse events should be disclosed; however, actual rates of disclosure remain variable.2-6

  • Patient surveys often indicate a desire for disclosure of errors wherein minimal or no harm occurs as well.7
  • Whether to disclose these “near misses” appears to be more controversial among physicians and may account for a portion of nondisclosure cases.7

pic1

Uncertainty over which errors need to be disclosed, and how much information to share, may negatively impact rates of error disclosure.2,4,5,7

  • Mixed messaging within institutions can compound provider uncertainty. Surveys of risk managers, for instance, demonstrate strong support for the disclosure of errors but less support for apologizing for errors.9
  • Reducing conflict over error disclosure within institutions, through broad institutional support and policies, appears to improve disclosure rates.5,7

Concern exists over the possible legal repercussions of disclosure.

  • Some states have adopted “apology laws” which prevent portions of disclosure from being used in lawsuits.2
  • The protection provided by those laws varies significantly between states, however, and many states remain without any legal protection.
  • The net effect of error disclosure on legal claims remains unclear.

Steps for the disclosure process

  1. Plan for the conversation
  • Attempt to determine whether an error occurred and whether the error had an adverse impact on the patient. It can be difficult to say whether an error resulted in an otherwise preventable adverse event immediately.  Do your best to assemble the facts through discussion with all of the involved personnel, and acknowledge ambiguity if it exists.
  • Consult risk management at your institution before disclosing an error. Consider talking with your department’s quality improvement team as well.
  • Plan your wording carefully. Be careful not to speculate or place blame.  An admission of regret can be distinct from an admission of liability.
  • Be aware of your own emotions and how they may impact communication. Patients often perceive rationalizations or defensiveness negatively.  Aim for accountability and empathy.
  1. Set up for optimal communication
  • Choose a quiet location with minimal distractions.
  • Silence your pager and phone.
  • Sit down.
  • Arrange for an interpreter, if needed.
  • Have the appropriate personnel present.
    • Essential physicians – don’t overcrowd the meeting.
    • Include a nurse manager or pharmacist if involved in the incident.
  1. Essential components of disclosure

Based on patient preference studies, disclosing an error should include the following core components.2-4,6-7

  1. An apology.
  2. An explicit statement that an error occurred.
  3. A factual description of what the error was, why it occurred, and its clinical implications.
  • Acknowledge that the outcome of an error may be ambiguous at the time of disclosure.
  • Discuss the possible repercussions and how the medical team will monitor for and manage adverse effects, and plan for subsequent conversations.
  1. An opportunity for the patient to relate his/her experience.
  2. A description of steps being taken to prevent recurrence of similar errors.

Summary

Benefits of error disclosure include enhanced patient-provider communication, opportunity for system-wide improvements in quality and safety, and possibly fewer lawsuits.  Patients and providers agree that errors resulting in otherwise preventable adverse events should be disclosed; however, actual rates of disclosure remain variable.  Approach the disclosure process with a few key steps in mind: 1. Plan for the conversation by assembling the facts and consulting with risk management ahead of time, 2. Set up for optimal communication, and 3. Include each of the core components in the discussion (see above).

References / Further Reading:

  1. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 2000.
  2. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289(8):1001-7.
  3. Gallagher, TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients.  New England Journal of Medicine 2007; 356(26): 2713-2719.
  4. Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Disclosure of “Nonharmful” Medical Errors and Other Events: Duty to Disclose. Arch Surg. 2012;147(3):282-286.
  5. King ES, Moyer DV, Couturie MJ, Gaughan JP, Shulkin DJ. Getting Doctors to Report Medical Errors: Project DISCLOSE.  The Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 7, July 2006, pp. 382-392(11).
  6. “Teaching Module: Talking about harmful medical errors with patients”. Tough talk: a toolbox for medical https://depts.washington.edu/toolbox/errors.html.  Accessed: 06 March 2016.
  7. Fein S, Hilborne L, Kagawa-Singer M, et al. A Conceptual Model for Disclosure of Medical Errors. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb. Available from: http://www.ncbi.nlm.nih.gov/books/NBK20500/
  8. Mazor KM, Reed GW, Yood RA, Fischer MA, Baril J, Gurwitz JH. Disclosure of Medical Errors: What Factors Influence How Patients Respond? Journal of General Internal Medicine. 2006;21(7):704-710. doi:10.1111/j.1525-1497.2006.00465.
  9. Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, et al. Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. Ann Intern Med. 2010;153:213-221.
  10. Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? The jury is still out. Jt Comm J Qual Saf. 2003;29:503-11.
  11. Loren DJ, Garbutt J, Dunagan WC, Bommarito KM, Ebers AG, Levinson W, Waterman AD, Fraser VJ, Summy EA, Gallagher TH. Risk managers, physicians, and disclosure of harmful medical errors.  Jt Comm J Qual Patient Saf. 2010 Mar;36(3):101-8.

Reversal of Anticoagulation in a True Emergency – An Update

Author: Erica Simon, DO, MHA (EM Resident Physician, SAUSHEC) // Edited by: Alex Koyfman, MD (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital, @EMHighAK) & Justin Bright, MD (@JBright2021)

Please see prior post here: http://www.emdocs.net/reversal-of-anticoagulation/

On October 16, 2015 the FDA granted accelerated approval of idarucizumab (Praxbind), a novel reversal agent of the direct thrombin inhibitor Dabigatran (Pradaxa), for utilization in life-threatening bleeding emergencies.1

Idarucizumab is a humanized monoclonal antibody (Fab) fragment designed specifically to bind dabigatran.  It has an affinity for dabigatran that is approximately 350 times greater than that of thrombin.2,3

Human Studies

Glund, et al. performed a phase 1, single-rising-dose, randomized, double-blinded, placebo-controlled trial of 110 healthy male volunteers (ages 18-45) to assess the pharmacokinetics and safety of idarucizumab.4  Randomization (designed to occur in a 3:1 ratio) assigned 27 participants to receive placebo and 83 to receive idarucizumab.  For those enrolled in the idarucizumab study arm, dosing was randomly assigned with individuals receiving between 20 mg – 8 g of idarucizumab as a 1-hour intravenous infusion in 10 sequential dose groups, versus 1, 2 or 4 g of idarucizumab as a 5-minute infusion.  Results of the phase 1 trial revealed that idarucizumab attained peak plasma levels rapidly, but that its concentration decreased to 5 % or less of the peak level within 4 h secondary to renal elimination.  It was noted that idarucizumab required a 1:1 dosing ratio with dabigatran for complete efficacy, and of significance, idarucizumab demonstrated no impact on the coagulation profile of subjects who received placebo.4

Pollack et al. are currently conducting a phase 3 prospective cohort study to determine the safety of 5 g of IV idarucizumab and its capacity to reverse the anticoagulant effects of dabigatran in patient with serious bleeding (Group A) or requiring an urgent procedure (Group B).  A preliminary report including data from 90 patients (51 Group A, 39 Group B) assessed the primary end point of maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours of idarucizumab administration (utilizing dilute thrombin time or ecarin clotting time).  Among patients with an elevated dilute thrombin time and or an elevated ecarin clotting time, the median maximum percentage reversal was 100% (95% confidence interval, 100-100). Idarucizumab normalized the test results in 88 to 98% of the patients, an effect that was evident within minutes.  Concentrations of unbound dabigatran remained below 20 ng per milliliter (steady-state) at 24 hours in 79% of the patients.   Preliminary data on the secondary end point of hemostasis was also published: among 35 patients in Group A who could be assessed, hemostasis, as determined by local investigators, was restored at a median of 11.4 hours.  Among 36 patients in Group B who underwent a procedure, normal intraoperative hemostasis was reported in 33, and mildly or moderately abnormal hemostasis was reported in 2 patients and 1 patient, respectively.  One thrombotic event occurred within 72 hours after idarucizumab administration in a patient in whom anticoagulants had not been reinitiated.5,6

Administration

Praxbind is currently marketed as an IV formulated solution for injection, with dosing recommendations of 5 g (administered as 2 separate 2.5 g doses no more than 15 minutes apart).  Per the manufacturer (Boehringer Ingelheim Pharmaceuticals, Inc), if coagulation parameters (eg, aPTT) re-elevate and clinically relevant bleeding occurs, or if a second emergency surgery/urgent procedure is required and patient has elevated coagulation parameters, the physician may consider administration of an additional 5 g (few studies to support).5,7

Additional Up and Coming Novel Reversal Agents for Factor Xa Inhibitors

Andexanet Alfa (PRT064445) – Previously introduced in the Factor Xa Inhibitor Section

Andexanet alfa (PRT064445, r-Antidote; Portola Pharmaceuticals) is a recombinant modified human factor Xa decoy protein designed to reverse the effects of direct and indirect factor Xa inhibitors.  Andexanet binds and sequesters factor Xa inhibitors within the vascular space, thereby restoring the activity of endogenous factor Xa and reducing levels of anticoagulant activity.2,9

Human Studies

In phase 2 proof-of-concept and dose-ranging studies, Crowther et al. demonstrated that the administration of andexanet resulted in dose-dependent, reproducible reversal of anticoagulation in cohorts of healthy volunteers receiving one of four factor Xa inhibitors (apixaban, rivaroxaban, edoxaban, or enoxaparin).  Reversal was assessed as the reduction in anti–factor Xa activity and unbound factor Xa inhibitor concentrations, as well as the restoration of thrombin generation.11-13 No serious adverse reactions were reported, and no antibodies against factor Xa or factor X were detected.11-13

ANNEXA-A (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of FXA Inhibitors – Apixaban) and ANNEXA-R (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of FXA Inhibitors – Rivaroxaban) – Results published November 11, 2015:

ANNEXA-A and ANNEXA-R were conducted as parallel, randomized, double-blind, placebo-controlled studies to evaluate the ability of andexanet to reverse anticoagulation with apixaban or rivaroxaban and to evaluate the safety of andexanet in healthy older volunteers (ages 50-75).  To review study methods, reference the Siegel article cited below.

Bottom Line: In participants anticoagulated with apixaban, anti–factor Xa activity was reduced by 94% among those who received andexanet (24 individuals), as compared with 21% among those who received placebo (9 individuals) (P<0.001).  As a secondary end point, thrombin generation was fully restored in 100% versus 11% of the participants (P<0.001) within 2 to 5 minutes. In study subjects anticoagulated with rivaroxaban, anti–factor Xa activity was reduced by 92% among those who received andexanet (27 individuals), as compared with 18% among those who received placebo (14 individuals) (P<0.001), and thrombin generation was fully restored in 96% versus 7% of the participants (P<0.001). In a subgroup of participants, transient increases in levels of d-dimer and prothrombin fragments 1 and 2 were observed, which resolved within 24 to 72 hours, and no serious adverse or thrombotic events were reported.8

Arapazine/Cirapantag (PER977)

PER977 is a synthetic water-soluble molecule that binds to direct inhibitors of factor Xa and IIa as well as to heparin-based anticoagulants through non-covalent hydrogen bonding and charge interactions.

Human Studies

In the first double-blinded, placebo controlled trial of PER977 (NCT01826266), pharmacokinetics and pharmacodynamics were evaluated in 80 healthy volunteers utilizing escalating doses of PER977 (100–300 mg) administered alone and after a 60mg PO dose of edoxaban.  Whole-blood clotting time was employed to assess the anticoagulant effect of edoxaban and its reversal by PER977.

Bottom Line:  After the administration of edoxaban, the mean whole-blood clotting time increased by 37% over the baseline value in study participants.  In patients receiving a single intravenous dose of PER977 three hours after the administration of edoxaban, the whole-blood clotting time decreased to within 10% above the baseline value in 10 minutes or less, whereas in patients receiving placebo, the time to reach that level was approximately 12 to 15 h. The whole-blood clotting time remained within 10% above or below the baseline value for 24 hours after the administration of a single dose of PER977.  Researchers discovered no evidence of pro-coagulant activity after administration of PER977, as assessed by measurement of levels of D-dimer, prothrombin fragments 1 and 2, and tissue factor pathway inhibitor, and by whole-blood clotting time.  Additional phase 2 clinical studies are ongoing.14

 

References / Further Reading

  1. “Press Announcements: FDA approves Praxbind, the first reversal agent for the anticoagulant Pradaxa.” FDA News Release. U.S. Food and Drug Administration, 2015. Web. 16 Nov. 2015 <http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm467300.htm>.
  2. Das A, Liu D. Novel antidotes for target specific oral anticoagulants. Exp Hematol Oncol. 2015;4:25.
  3. Schiele F, van Ryn J, Canada K, et al. A specific antidote for dabigatran: functional and structural characterization. Blood. 2013;121(18):3554-3562.
  4. Glund S, Stangier J, Schmohl M, et al. Safety, tolerability, and efficacy of idarucizumab for the reversal of the anticoagulant effect of dabigatran in healthy male volunteers: a randomised, placebo-controlled, double-blind phase 1 trial. Lancet. 2015;386(9994):680-690.
  5. Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015;373(6):511-520.
  6. Pollack CV, Reilly PA, Bernstein R, Dubiel R, Eikelboom J, Glund S, et al. Design and rationale for RE-VERSE AD: a phase 3 study of idarucizumab, a specific reversal agent for dabigatran. Thromb Haemost. 2015;114(1):198–205.
  7. Praxbind injection (idarucizumab) [prescribing information]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc; 2015.
  8. Siegal D, Curnutte J, Connolly S, et al. Andexanet alpha for the reversal of factor Xa inhibitor activity. N Engl J Med. 2015
  9. Gomez-Outes A, Suarez-Gea ML, Lecumberri R, Terleira-Fernandez AI, Vargas-Castrillon E. Specific antidotes in development for reversal of novel anticoagulants: a review. Recent Pat Cardiovasc Drug Discov. 2014;9(1):2–10
  10. Crowther M KM, Lorenz T, Mathur V, Lu G, Hutchaleelaha A, et al. A phase 2 randomized, double-blind, placebo-controlled trial of PRT064445, a novel, universal antidote for direct and indirect factor Xa inhibitors. J Thromb Haemost. 2013;11(Suppl 2): AS20.1.
  11. Crowther M LG, Lu G, Conley PB, Castillo J, Hollenbach S, et al. Reversal of enoxaparin-induced anticoagulation in healthy subjects by andexanet alfa (PRT064445), an antidote for direct and indirect FXa inhibitors—a phase 2 randomized, double-blind, placebo- controlled trial. J Thromb Haemost. 2014;12(Suppl 1): COA01 (abstract).
  12. Crowther M LG, Conley P, Hollenbach S, Castillo J, Lawrence, J, et al. Sustained reversal of apixaban anticoagulation with andexanet alfa using a bolus plus infusion regimen in a phase 2 placebo controlled trial. Eur Heart J. 2014;35(Suppl.1): P738 (abstract).
  13. Crowther MMV, Kitt M, Lu G, Conley PB, Hollenbach S, et al. A phase 2 randomized, double blind, placebo-controlled trial demonstrating reversal of rivaroxaban-induced anticoagulation in healthy subjects by andexanet alfa (PRT064445), an antidote for FXa inhibitors. Blood. 2013;122(21):3636.
  14. Ansell JE, Bakhru SH, Laulicht BE, Steiner SS, Grosso M, Brown K, et al. Use of PER977 to reverse the anticoagulant effect of edoxaban. N Engl J Med. 2014;371(22):2141–2142.

The Patient Experience: Why Is It Important? Why Do We Hate It So Much? What Can We Do To Improve?

Author: Justin Bright, MD (Senior Staff Physician, Henry Ford Hospital, Department of Emergency Medicine, Detroit, MI (@JBright2021)) // Editor: Alex Koyfman, MD (@EMHighAK)

To start, I have a few disclosures to make.  I have no financial relationship with any patient satisfaction survey company.  I have been practicing emergency medicine as an attending physician since July 2010.  I presently work as a hospital employee and core academic faculty in a massive level 1 trauma center in inner city Detroit which has a large emergency medicine residency program.  I formerly worked in the community for a private physician group in Toledo, OH that owned the contract for 4 emergency departments within a larger health care system.  Between residency, moonlighting, and attending jobs, I have pulled shifts in 12 different emergency departments.  Some departments paid very little attention to patient satisfaction scores, and others had a near fanatical obsession with them.  I have been asked to hand out cards to patients on discharge and say to them, “remember, we strive for 5!”  AIDET scripting has been forced down my throat, and subsequently fallen to the wayside when nobody bought into the process.  I have had to have a meeting with my medical director over a poor Press Ganey survey that was an n = 1.  I am certain I have treated thousands of very happy patients relative to the incredibly small sample of Press Ganey surveys returned.  I have grown to hate the term “patient satisfaction.”

But, this is perhaps the biggest disclosure of all: I HAVE BECOME INFATUATED WITH THE PATIENT CARE EXPERIENCE.  I believe the term “patient care experience” is a more inclusive term that describes our technical expertise while also including everything else, such as communication, department ambience, throughput, and the behavior of everyone a patient comes into contact with while in the department. 

My goals with this post are the following:

1) Get to the crux of why providers dislike patient satisfaction

2) Review the literature out there

3) Debunk those articles which we use as a rally cry against patient satisfaction surveys

4) Discuss the key variables associated with survey scores

5) Suggest some very simple tips to bring back to your department that could help you tremendously

Before we move forward, I think we need to accept the following things.  First and foremost, an emphasis on the patient care experience is not going to go away, no matter how much we wish it would, and no matter how much we complain about it.  Instead of continuing to fight against it, we can focus on ways to proactively become part of the solution.  Our job is incredibly specialized and unique, so I understand the resentment that occurs when the experience of our patients is treated the same way a restaurant or retailer would treat the experience of their customers.  But I also know this; none of us out there would do this job for free.  Our compensation is important to us, and the money has to come from somewhere.  That money comes from seeing patients, and having them select our health care system over another one.  In the coming years, group and hospital reimbursement will become increasingly tied to the patient care experience, so I think it makes sense that the sooner we get on board with it the sooner we can come up with departmental solutions that are ready to maximize financial gains from this link.

We also need to wipe a few things from our mindset.  Our patients are not drug seeking, free-loading, non-paying, abusers of our system.  An overwhelming majority are normal people who are sick, injured, scared, or have nowhere else to turn. One of the noblest things we do is take care of patients when they have no other alternative.  Our patients have better places to be than in our emergency department, and they want to know that you recognize that.  Also, we need to stop internally thinking, or worse, saying out loud, “this is not an emergency, you shouldn’t have come here for this.”  Your patient does not have the medical knowledge or experience you have.  The average health care literacy in America is that of a 5th grader.  They believe they need to see a doctor, and it’s our job to reassure them and make them better.  From a business standpoint, you need to change your state of mind.  These patients tend to be lower acuity, relatively easy dispositions, and are within the pool of patients most likely to get a Press Ganey survey.  As one of my partners used to say, “You don’t open a restaurant and hope nobody shows up.”

So why do providers hate this so much?  I think we all want to have happy patients and to be liked by them.  The biggest criticism is that patient satisfaction surveys are a poor attempt to measure a patient’s subjective perception of care with objective number scores.  As people of science, we are accustomed to critically reading research articles looking for bias and poor methodology.  It is natural to be frustrated when contract stability, financial incentive, and even individual job security is tied to poorly designed surveys with dreadfully small sample sizes.  Further disgust over the surveys lies in the fact that surveys only go to discharged patients – who are theoretically “less sick” – while leaving out admitted patients who we theoretically spent more time taking care of using the very skills we got into emergency medicine for.

There are other reasons I believe health care providers dislike such a heavy emphasis on patient satisfaction.  Some believe there are many factors beyond their control – experience with triage staff, transport, security guards, etc. are all going to affect a patient’s perception of their overall experience.  Attempts at scripting seem forced and sometimes condescending to the provider.  Perhaps the biggest complaint outside the poor survey design is a feeling that providers have to pander to their patients or even do things detrimental to a patient’s health in order to get strong scores – prescribing medication and ordering tests that are not medically indicated.

As my interest in the patient care experience has grown, I have read obsessively about it. Almost universally, opinion articles arguing and complaining about the use of patient satisfaction scores mention opiate prescriptions and harming patients within the first few paragraphs.  It is a crutch that providers lean on without actually knowing the literature. So let’s discuss the most important article on patient satisfaction.  It is important because I believe it is misunderstood, misquoted, and is not even a study on satisfaction in the emergency department.  However, it has a lot of buzzwords that can serve as a battle cry for those that are anti-patient satisfaction.  The article in question: The Cost of Satisfaction, published in the Archives of Internal Medicine in 2012 (Journal is now called JAMA of Internal Medicine).  In this study, they reviewed a prospective cohort of over 50,000 patients.  Medical data was extracted from the Medical Expenditure Panel Survey (MEPS) database, and these patients were asked customer satisfaction questions from the HCAHPS surveys.  When corrected for a number of potential confounding patient characteristics, the study found the following things to be statistically significant in patients that rated higher levels of satisfaction:

1) Emergency department visits dropped

2) Inpatient admissions increased (the correlation between this and #1 believed to be that more direct admits were done rather than sending patients through the ED or less satisfied patients bypassed their own doctors to go to the ED)

3) Higher health care and prescription drug expenditures (perhaps related to the increased hospital admission)

4) Increased patient mortality (the article states a 26% difference)

This study does raise very interesting points, but also has design flaws that make their conclusions suspect.  The study only evaluated patient satisfaction in the year 2000 (time 0 for the study).  They tracked mortality in years 1-6, but never actually rated a patient’s satisfaction during those times.  So, while they raise interesting points and topics for further debate, those that clutch to this study as a reason why patient satisfaction does not matter are foolishly doing so.  There are countless studies essentially refuting their points.  Physicians who have better communication and rapport with their patients typically have better patient compliance, lower malpractice suit risk, and report higher job satisfaction.

A second point that those who still resist patient satisfaction efforts rally around is the perception that to achieve higher scores, a provider must freely and recklessly dispense opiates.  I do not for a single second believe this to be accurate.  The perception that all of our ED patients are drug seeking is simply not true.  I have never felt pressured to give patient prescriptions for opiates (or any other medication for that matter) at the risk of poor scores if I did not.  No patient has ever threatened to give me a bad score if I did not give in to their demands.  A study out of UMass published in the 2014 Annals of Emergency Medicine suggests the same – that patient satisfaction lacks an association with dispensing opiates.  I will not deny that I have had patients come in with certain expectations – be it medications, testing, or consultations.  Instead of casting them off, I clearly communicated with them, managed expectations, and involved them in the decision making.  Not every encounter left either of us with a warm and fuzzy feeling inside, but we had a mutual respect for each other and they understood why I could not give them what they wanted on that day.

Simply put, patients care about the following things during their experience in the Emergency Department:

1) Communication

2) Perceived wait instead of actual wait

3) Feeling better – either reassurance or symptom relief

So what are some easy, incredibly effective, no cost ways that you the provider can take control of the patient care experience in your emergency department?

  • Diffuse the wait – apologize for the delay and tell the patient their issue is important to you. Even if the door to doc time is 5 minutes, they will appreciate it and it will make your life easier.  If the LOS is significantly longer, it will relieve a lot of tension if they have been laying on a cot scared and feeling ill for a long period of time.
  • SIT DOWN!! Multiple studies demonstrate that the patient and family think the physician was in the room twice as long as they actually were when they sit down
  • Introduce yourself, including your role. Try to lay out why multiple people will come and ask the same things.  Think about how many times your patient may tell the same story – at a minimum they will speak to triage, nursing intake, med student, resident, and attending.
  • Acknowledge the other people in the room – they know the patient much better than you do and often have valuable information for you. They want to be heard and they deserve to be heard.
  • Give the patient time to state their issue. Ask an open ended question – and actually listen to the response.  Emergency medicine physicians take an average of 7 seconds to interrupt their patients.
  • Give anticipated time frames – if you think a patient needs admission, tell them up front so they can plan accordingly. Overestimate times for diagnostic testing to return so when they come back sooner they are happy.  If a consultant is going to be involved and you know they are busy elsewhere, explain this to your patient.
  • Round on your patients – if you’re walking by to another room, pop in real quick and remind them you have not forgotten about them. See if they need anything.  A MASSIVE DISSATISFIER IS NOT BEING KEPT IN THE LOOP ABOUT DELAYS AND ANTICIPATED DURATION OF STAY IN THE ED.
  • Close the deal – when a patient is ready to be discharged, you need to go to the room to tell them they are being discharged. Do not print out a discharge and have the nurse walk into the room without the patient knowing the encounter is over.  It is very bad form, and will dissatisfy nursing staff and patient alike. This is an opportunity to make sure everything has been addressed and to remind them that your department is always here for them.  Make sure male patients and children have passed the “wife test” or the “mom test” and they are comfortable with discharge plan.  Trust me on this one!
  • If you think it’s not fair to only include discharged patients in your surveys, create your own survey using an online survey tool, and place the link on a business card. Hand it to families of admitted patients. Now you have all encompassing data, and in my experience, you will get a larger sample size.  Administrators may not see this data regularly, but you will have access to it if you ever need to prove that you are doing better than Press Ganey suggests.

Everything I suggested is completely free.  It does not take an excessive amount of time.  All of them are likely to improve your interaction with the patient and make their experience in the ED better.  As a result, they will be more likely to comply with a treatment regimen that you lay out, and they are less likely to complain.  Shift your focus from a disdain for patient satisfaction, and instead focus on delivering a great patient care experience in your emergency department.  If you do so, the patient satisfaction scores will take care of themselves.  Excellent care and an excellent experience can and should go hand-in-hand.  We all need to strive to deliver a great patient experience every shift, every patient, every time.  As the provider, you set the tone for the rest of the department team.  The decision to change needs to start with you.

 

References / Further Reading

– “Patient Satisfaction.” An ACEP Emergency Medicine Practice Committee review paper.  June 2011.  www.acep.org/patientsatisfaction

– “Patient Satisfaction in Emergency Medicine.” Emergency Medicine Journal, 2004. 21:528-532; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726409/pdf/v021p00528.pdf

– “Emergency Department Patient Satisfaction.” Family Practice Notebook, December 2014. http://www.fpnotebook.com/Manage/Cmnctn/EmrgncyDprtmntPtntStsfctn.htm

“Patient Satisfaction – Why Should We Care?” AAEM Young Physician Section article. May 2012. http://www.ypsaaem.org/yps-articles/past-yps-articles/2010/patient-satisfaction–why-should-we-care

– “AAEM Position Statement on Patient Satisfaction Surveys in the Emergency Department. May 2006. http://www.aaem.org/em-resources/position-statements/quality/patient-surveys

– “10 Easy Ways to Improve Customer Service in the Emergency Department.” ECI Healthcare Partners. http://www.ecihealthcarepartners.com/blog/patient-satisfaction-title-here/

– “Twenty Years of Patient Satisfaction Research Applied to the Emergency Department: A Qualitative Review.” American Journal of Medical Quality. Jan 2010 25:64-72 http://www.ncbi.nlm.nih.gov/pubmed/19966114

– “Boosting Patient Satisfaction in the Emergency Department: What Hospitals Should and Shouldn’t Do.” Becker’s Hospital Review. September 20, 2013. http://www.beckershospitalreview.com/hospital-management-administration/boosting-patient-satisfaction-in-the-ed-what-hospitals-should-and-shouldn-t-do.html

– “Patient Satisfaction in the Emergency Department. A Review of Literature and Implications For Practice.” Journal of Emergency Medicine. Jan 2004 vol 26 issue 1:13-26 http://www.ncbi.nlm.nih.gov/pubmed/14751474

– “Dying For Satisfaction.” Emergency Physicians Monthly. March 20, 2012. http://www.epmonthly.com/departments/columns/in-my-opinion/dying-for-satisfaction/

– “The Cost of Satisfaction.” Archives of Internal Medicine 2012; 172 (5): 405-411 http://archinte.jamanetwork.com/article.aspx?articleid=1108766

– “Lack of Association Between Press Ganey Emergency Department Patient Satisfaction Scores and Emergency Department Administration of Analgesic Medications.” Annals of Emergency Medicine. November 2014. Volume 64, (5): 469-481  http://www.annemergmed.com/article/S0196-0644(14)00120-6/abstract

http://www.pressganey.com

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html

emDocs Teams Up with Access EM / Tintinalli

Dear Colleagues,

When we set out to start emDocs part of our vision was to create a regularly updated source on everyday / cutting-edge topics; “the supplement to the authoritative EM texts”.  We are happy to announce another step in this direction. For the past two years, Tintinalli chapters have been updated online to keep up with the latest clinical standards.  We are going to be linking up with Access Emergency Medicine (http://accessemergencymedicine.mhmedical.com/). As they release an updated chapter, we will publish a write-up on a component of the chapter to be used as supplemental reading / next-level thinking. The full Tintinalli chapter will be available for a week thru a link on our site and in limited view after that.  We hope this adds what we provide to our readership.

Best,
Alex, Adaira, Manny, and Baker

Yellowstone Advanced Airway Course Pearls

Thanks to Twitter I was privileged to attend a free advanced airway course hosted by Dr. Richard Levitan a few weeks ago.  This is an incredible 3-day course set in the beautiful Tetons near Yellowstone National Park. The course features lectures, Q&As, and hands-on stations to improve your airway assessment and intubation skills.

Instead of summarizing the entire course, because you really have to experience it yourself to get the full effect, I’m writing down the top 10 pearls I took away from this phenomenal experience.

  1. Intubate one step at a time. Instead of ramming the blade in the airway, take a deep breath and approach the airway in a step-wise fashion. First, find the uvula. Second, perform epiglottoscopy! Track down the uvula until you find the epiglottis. Third, remove the epiglottis off the posterior wall (suction may help remove that sticky film keeping the epiglottis on the posterior wall). Then laryngoscopy, to find a landmark (cords, notch, arytenoids). Finally, place the tube.
  2. Take time to position your patients. Everyone, regardless of age or size, should have ear-to-sternal notch. Want to avoid laundry? Try this.
    yellowstone1
  3. Learn the airway anatomy. Don’t rely on 2D pictures to understand the airway. Look at the CT imaging of your patients and learn how the turbinates are positioned and where the epiglottis rests in comparison to the hyoid. Understanding positioning and location will improve your skills.
  4. The floor of the nose is flat, when inserting anything into the nose, always stay flat and go straight back.yellowstone2
  5. Levitan has amazing recommendations for performing a cricothyrotomy. He emphasizes making a vertical incision BEFORE going horizontal. This procedure is a bloody mess and very tactile, you want to feel your landmarks before making each cut.
  6. When it comes to a cricothyrotomy, don’t rely on fine motor skills to find the landmarks. You will be too nervous and your hands won’t stay still. Avoid using only one fingertip to palpate and use your entire hand with the laryngeal handshake.
  7. Sedate your patients before invasive procedures to attenuate recall and PTSD.
  8. Learn how to manage yourself, a team, and a patient in a crisis and avoid fixation error. Biggest lesson was his focus on what to do after an unsuccessful intubation attempt; do not try the same method twice. Use bougie, use new blade size, or different operator. But don’t get stuck on stupid.
  9. The DOPE acronym is backwards, if a patient is on a ventilator with signs of hypoxia, you start with (E) equipment first and disconnect the patient from the ventilator and bag them manually.
  10. The Shaka

I recommend everyone try to make it out to the next Yellowstone Advanced Airway Course in 2015. It was honestly a game-changer in how I will now approach the airway.

Edited by Alex Koyfman

All NYC EM Chief Resident Conference 2014

On April 28th, 2014 I was privileged to take part in the ALL NYC EM Chief Resident Conference. This experience was incredibly high-yield and filled with a range of pearls on working with department administration to attaining better leadership skills. It served as an excellent think-tank and networking experience for residents. Below is a brief overview of the salient points from some of the lectures.

Introduction

The day began with Kaushal Shah giving a concise but thoughtful introduction on what it takes to be selected as chief resident. He says chief residents require the right ingredients; they must be responsible, hard working, and approachable. Faculty and residents see a chief resident as a leader who is trustworthy, clinically strong and ready to make departmental changes.

The introduction had the expected intimidating comments such as “next year will be the hardest year of your life.” But there was an overwhelming amount of encouragement that left the room thinking, “I will survive this year and leave a positive mark.” It was the perfect opening to describe the themes of the lectures and breakout sessions of the day.

Ice Breaker

This was a unique idea for unifying a group of strangers. The goal was for each group to create a logo that defines who we are as NYC EM chief residents. In the end, everyone voted for the best design. Groups were formed randomly and we all got to talk briefly about experiences being new chiefs. The logo ideas were a bit insane, mildly inappropriate and incredibly hilarious. The room was definitely having a blast! The winning logo will be placed on buttons for all NYC EM chiefs to wear at SAEM 2014. You’ll have to look out for the winning design of this competition in Dallas at the resident leadership forum.

Be a Great Leader

Dr. Mark Silverberg opened his talk with a dose of inspiration saying that “those of you sitting here will be the next generation of program directors.” One of the best take away messages from this lecture is that to be chief resident, “many people must have believed in you” and now we must live up to those expectations.

The key concepts Dr. Silverberg addressed are below and applicable to all physicians, especially those in leadership positions.

Agreements versus Disagreements

At some point we will disagree with the directors of our department or residency on an important decision. This is expected as everyone is entitled to an opinion. The steps to address this disagreement are crucial. First, as chiefs, we must think about our opinion in detail (all the pros and cons). Then we discuss the topic with all relevant parties—this meeting should be in private. Finally, as a group of leaders representing all sides of the discussion, we must come to a consensus that unifies all parties involved. The final verdict may not be the opinions of the chiefs, but to outside parties we will all share that one opinion. This helps avoid division among the leadership groups.

Become an Inspiring Leader

This is not a position where we can project the mantra of “do what I say, not as I do.” People can recognize a sham and we should avoid anything that resembles one. We must be good listeners, compassionate, trustworthy, consistent, and ultimately, someone who others consistently want to follow. We should always have the best interests of the residency and department in mind. A big pearl he gave was to come to work passionate about our job and what we do. We should set the tone for our shift to be “I love my job. Let’s go take care of patients together.”

Choice and Timing of Words

“Better to remain silent and be thought a fool than to speak and to remove all doubt.” -Lincoln

Main lesson here is to think before we speak. Being chief is in many ways a political role where our word choice can be later used against us. Take 1-2 days to respond to even the most borderline controversial situations. This will give time to truly analyze the situation, decide the best wordage for a response and have another responsible person give input, if needed.

Continue to Be a Good Physician

Remember, we are doctors first and everything else second. We must continue to improve our medical fund of knowledge because that is the primary goal during residency. We were given this responsibility because someone believed we could handle it in addition to clinical responsibilities.

Look the Part

Words of the day by Silverberg, “No one likes B.O.” So shower, dress business casual at important meetings, and go to conference appearing groomed. When speaking, have a positive attitude, good posture, and make eye contact. Everyone is looking at us so be on time and form a positive reputation of using admirable habits. If we are on time, happy to be at work, willing to work hard, people will look forward to shifts with us.

Be Consistent and Fair

The most valuable lesson I have learned from this conference is to be consistent and fair. The main idea is to never ask of others what you are unwilling to do yourself. If you look out for the well being of others it will be appreciated. Never give yourself the best schedule, do not play favorites, and do not break promises, because it will be noticed. Know your policies and continue to revisit and improve them, because you can always reference them when you make a decision that is not warmly accepted by another resident.

Promote Others

This was an interesting approach that is worth considering. If we acknowledge and publicize accomplishments in the department it will tell residents that we care about their success. We should encourage creativity and give good constructive feedback. If we continue to back our residents they will feel empowered to accomplish more. No good leader wants to do all the work and take all the credit for doing it.

Conflicting Agendas-Residency versus Administration

This was a creative activity where the room of residents was split in half. One portion represented residency leadership and the other portion represented residency administration. The objective was for all chief residents to try to understand the perspectives of each group so they can make better collaborative decisions later in the year. Each group was given a few frequently seen scenarios and told to find a resolution from their perspective.

Scenario One—Funding for Residency Retreat

Every year a residency wants to have a residency retreat and that is usually paid for by the department at $90/person for 60 residents. This year the cost of the retreat increased to $125/person. How can this cost be obtained?

Administration Responses

  1. The retreat could alternate each year between inexpensive and expensive locations
  2. Residents could fundraise the money themselves
  3. Attendings could help subsidize the cost via donations
  4. Invite attendings to the retreat and charge them $200/person to help offset the cost of residents
  5. Simply find a cheaper location

Residency Leadership Responses

  1. Cut costs elsewhere to shift funds to cover retreat (less money on conference food, less money on graduation, etc…)
  2. Ask attendings for help to fund the retreat
  3. Contact the alumni fund or larger organizations like CIR to help subsidize cost.

Scenario Two—Send Residents to ACEP/SAEM with Financial and Shift Coverage

Every year residents want to be sponsored to go to national conferences like ACEP or SAEM. How do you decide which residents are financially covered?

Administration Responses

  1. Need to have an application process where residents submit a reason for financial sponsorship
  2. Cover the cost of all residents given oral or poster presentations
  3. Make residents find their own shift coverage

Resident Leadership Responses

  1. Select a particular PGY class to go to one conference on an annual basis (i.e. PGY3s go to SAEM each year with PGY4s covering shifts and PGY4s go to ACEP with PGY3s covering shifts)
  2. Split the conference in half where some residents go to the first few days and the remaining go to the last few days
  3. Pay for costs if presenting or accepting an award or given oral or poster presentation

Concluding Thoughts

Again, these are only a few of the highlights of this very impactful conference. Overall, it was a great success and full of helpful tips and tricks for all chiefs residents. Truly worthwhile for other regions to consider hosting their own regional chief resident conference!

#dontgetleftbehind: FOAMed and Social Media for EM Educators

On March 30th, 2014 at the CORD Academic Assembly, the first FOAMed and Social Media for EM Educators workshop was held. The goal of this half-day workshop was to introduce learners to the concepts of social media through interactive workshops.

I was privileged to take part in a FOAMed workshop at CORD 2014 along with innovators such as Joe Lex, Jan Shoenberger, Steve Carroll, and Michelle Lin. Instead of exclusively focusing on the importance of social media and education this workshop delivered a highly informative lecture and hands-on workshop describing how each of us can get involved with this digital movement.  It was very clever and very awesome. If you missed out, fret not; I’m here to give you the details.

It began with Dara Kass showing the audience that she is a #boss of social media. The short story is that she has used social media to spread word about her husband’s recent experience at a local movie theater in Brooklyn. Her husband, a Type 2 Diabetic, tried to watch a movie with a basket of strawberries purchased elsewhere. Despite his preference for healthy food options he was escorted out of the theater by NYPD. The story spread with the help of Dara Kass and her use of Facebook and Twitter, showing the power of social media to spread a message. (For more details on history go here, here, here, here, or here.)

bond


Joe Lex then took the stage and, as always, rocked the house. He opened up explaining how FOAM is not a generational experience as much as it is an educational experience.

“Everyone should have a Twitter Account.”
-Joe Lex, a 66 year-old-M with Social Security, Medicare and Twitter

The idea of FOAM actually is not a new revelation. The Hippocratic Oath, over 2,000 years old, states that we should “teach them this art, if they require to learn it, without fee or indenture.” The idea of spreading knowledge without any price is not truly a modern principal.  However, it became a more digital process when Joe Lex first started Free Emergency Talks by recording lectures from conferences and posting them for free on his website. From there, blogs by Cliff Reid, Chris Nickson, David Newman, Scott Weingart, Mike Cadogan and Michelle Lin began to dominate social media. FOAM however became popularized as a concept in 2012, over a Guinness in Ireland. A detailed history of FOAM evolution can be found here.

During this CORD2014 workshop a discussion among participants was focused around the value of the peer-reviewing process of journals and textbooks versus FOAM. There are obviously arguments for and against the utility of pre-publication versus post-publication peer review. However the recurring conclusions were that there is no evidence that pre-publication peer-review eliminates errors.  The goal of FOAM is not to disregard the role of journals or textbooks. Those sources are still necessary as FOAM is less helpful in the earliest stages of a physician’s career. Early training still should incorporate reading a textbook from cover to cover. As one develops a skill set, FOAM becomes a more valued tool fine-tuning your already engrained knowledge.

So why use social media? Well, you are likely already doing the work required to become involved every time you prepare a lecture, workshop, or write a paper. Now, all you have to do is share that knowledge.

joshi

So how does one share? This workshop was divided into smaller focus groups on blog, podcasts, twitter, and wiki pages. For information on blogs, check out ALiEM’s summary page. Anand Swaminathan, John Greenwood and Rob Cooney had some amazing tips on podcasting, Twitter and wikis, which are found below.


Podcasting

Why create a podcast?

  • Residency programs should consider creating podcasts – this is a podcast not limited to individuals but rather to better development of program.
  • Lectures have inherent weaknesses – dictate “when to learn” to the learner, lectures reach few people and are dead after given.
  • Podcasting is lecture 2.0 – can reach thousands, consumed by learners when they are ready, immortalized and always available.

How to create and shape the theme?

  • Think about why you want to podcast and what unique message or viewpoint you have.
  • Develop a theme (critical care, pediatrics, education etc) for your podcast – the panel noted that there are very few EM pediatrics podcasts.
  • Along with theme you have to consider the layout (single voice, multiple voice and interview style) and the frequency.
  • While you don’t want to replicate another podcast, there’s always room for multiple podcasts with the same theme (i.e. the existence of EMCrit doesn’t obviate the need for other critical care podcasts).

What do you need?

  • Computer – nothing fancy needed here.
  • Microphone – We recommend the Blue Yetti ($97) or the Blue Nessi ($70).
  • Editing software – Audacity (free) or Garage Band.
  • Podcast host – We recommend Libsyn ($5/month for basic package, $20/month for advanced package).
  • Blog Host – We recommend WordPress but there are many out there.

What do you talk about?

  • The most important part of a podcast is the content. If the content is good, you will get listeners.
  • Speech/Voice is the second most important concept. The speaker should be clear, confident and expressive.
  • Select content that fits with the podcast’s theme and format.
  • The majority of time goes into creating the script/outline. Depending on the length of the podcast, this can take up to 10 hours. The time investment will pay off.

The most important thing with deciding to do a podcast is figuring out how much time you have to put in. This will dictate the theme, content, format, frequency etc.


Twitter

What is Twitter?

It is a real-time social networking venue and educational exchange platform.  To understand it you must speak the language. Some basic terms are:

Tweet
A 140 character or less message posted to Twitter. Tip: It gets tricky regarding who can see your tweet. Therefore the basic rule of thumb is to tweet as if the entire world is reading. You cannot edit a tweet. But you can delete them (this may take time to be deleted from Twitter’s servers).
Handle
Your name; begins with the “@” sign. Any individual, organization, journal or department can have a handle. For example:

Tips: If you begin a tweet that begins with a handle, it will only be seen by people who follow you AND that other person. If you want your tweet seen by everyone, start with anything BUT the handle.

  • Ex 1: “@MprizzleER how are you?” –Seen by only followers of @MprizzleER and my followers.
  • Ex 2: “.@MprizzleER how are you?” —Seen by everyone b/c of the “.” Placed before the “@” sign.
Hashtag (#)
Used as a topic label. There are two ways to use a hashtag (#):

  1. To tag a large conversation between multiple people.
    • Ex: If I type “#CordAA14” into the search bar (as below)—All of the Tweets are grouped because each person typed #CORDAA14 using part of their 140 characters.cordaa
  2. To give a category to a particular tweet.
    • Ex: For topics related to critical care you end tweet with #FOAMcc.salim
Retweet (RT)
An action that sends someone else’s tweets to all of your followers.
Modified Tweet (MT)
Means that you changed the original tweet in some fashion.
Hat-tip (HT)
A form of appreciation. Used to give credit to someone else’s tweet that may be helpful to you in some way.
Direct Message
Send a private message to only one individual. Cannot be seen by others.

How to get followers?

You choose your range of Twitter followers; some prefer an intimate group while others prefer to be known internationally. Probably the best advice is to keep your posts interesting and relevant to the topic at hand. Occasionally following others will help you get more followers.  Also, re-tweeting someone else’s comments can’t hurt, right?

Along the same token, follow people who post comments interesting to you. You have the control to decide which posts you want to read in your feed.

How much time does it take?

Up to you! Some people tweet when they are at national conferences, weekly residency conferences, or every ten minutes. Tweeting for the sake of accumulating followers will probably remove all the fun of using this medium. Try not to get overwhelmed and use it as an educational tool and not as the only means to build your career.

Wikis

What is a Wiki?

While blogs are great platform to build your personal brand and are quite sexy in appearance, and podcasts play to our technophile geekiness, if you really want to build a collaborative online learning environment, you want to learn how wikis work.

The term “wiki” is derived from the Hawaiian term “wiki wiki” which means quick or fast. It’s an ample description of how wikis work. If you want a simplistic view of a wiki, consider it an online Word document linked to hundreds of other online Word documents.

How do I set one up?

What wikis lack in sexiness, they make up for in functionality. First, they are incredibly easy to use. Simply set up a wiki at one of the popular wiki hosts: PB works, Google sites, or Wikispaces. Once you’ve created your account, you’ll be taken to a homepage. To get started, you only need to know to buttons: edit and save.

The edit button opens up a world of possibilities. Click it, and the wiki takes on the appearance of a document editor. Just like a document, you can type, change fonts, alignment, and colors. You can also embed videos, other online documents, add photos, and all manner of widgets. Once you have the page looking somewhat like you would like it, click the save button in the page will turn back into a plain Jane wiki site.

So how is this different from a blog?

  • Security: There are three basic degrees of security:
    1. First, the security architecture of wiki will allow you to publish the wiki in an open format inviting anyone on the World Wide Web to help edit your “document.”
    2. Second, you can also publish in read-only format, yet allow a select group of editors to edit the document.
    3. Third, you can set the security high enough that people can only access the wiki with a password. This allows you to create a home base for your residency program behind lock and key, incredibly important when discussing sharing materials with copyright protection.
  • Collaborative work: easy incorporation of large groups of learners into the creation and editing process. If you are looking for a platform that allows true online collaboration, wikis are your tool. The ability to edit and quickly link to other existing pages or create new pages is a boon to those doing collaborative writing. The next time you have a scholarly article to write with the team of people, consider creating a wiki. Each section can have its own page and all of your references can be stored on the wiki for easy access.
  • Revert button: Wikis are programmed to store all prior revisions of itself for a preset number of days. This allows you, the administrator, the ability to go back and undo any mistakes that your collaborative learners may make. Simply click the prior version, ensure that it is the version that you want, and hit revert. Suddenly, all changes are undone. This feature alone should give peace of mind to anyone considering acting as administrator to a wiki. I will warn you, however, that you are more likely to need this feature when working with faculty members than learners!

As you can see, wikis offer a wide array of powerful tools. They are also incredibly easy to learn how to use. For your residency program, consider hosting all manner of information including flipped curriculum, journal clubs, residency handbook, quality improvement team projects, and a significant amount of reference material.


Special thanks to Drs. Rob Cooney, John Greenwood, Nikita Joshi, Dara Kass, and Anand Swaminathan for organizing this workshop. Be sure to check out ALiEM’s post on the blogging section of this session.

Edited by Alex Koyfman

Pregnant and Sick: Haney Mallemat (AllNYCEM6)

Pregnant and Sick: Management of the Critically Ill and Expectant

Haney Mallemat (@CriticalCareNow)
*Graduate from SUNY Downstate/Kings County; Critical Care Fellowship Dartmouth Hitchcock Medical Center, Currently Assistant Professor at University of Maryland.

Dr. Mallemat opens the lecture with a case of a 36 year old pregnant female with HR of 112, BP 100/65 and O2Sat of 92% and asks, “What vital sign should we be most concerned about?” The oxygen saturation! Hypoxia will hurt the mother and developing fetus.

He then rapidly enters into a high-yield lecture on the general approach to the sick pregnant patient.

We know that trauma is the #1 killer in pregnant women and that critical medical illness is rare. Most of our pregnant patients are young with great physiologic reserve and good outpatient follow-up. However, with growing trends of older pregnant patients, mortality can be higher due to concomitant disease like diabetes and hypertension. We must remember that fetal mortality is 100% dependent on maternal mortality.

EVERY single organ system is affected in pregnant body. If you want a general review of all the normal physiologic changes in pregnancy check out http://www.ncbi.nlm.nih.gov/pubmed/15388191.  But during this lecture we focused mostly on the cardiac (perfusion) and pulmonary (diffusion) changes that normally occur.

clip1

Cardiac: 50% increase in CO by 3rd trimester and patients are more tachycardic, with higher stroke volume and increase in red cell volume and mass. About 25% of that CO goes to placenta alone. Most of the data on objective hemodynamic goals are from the OR, ICU or animal studies. Best evidence is to keep MAP >65 and SBP>100.

Pulmonary: Mother has increased respiratory rate, increased minute ventilation, and tidal volume to keep PaO2 normal. FRV gives us all reserve but patients lose this with big fetus. These patients can desaturate QUICKLY! Objective respiratory goals are PaO2>70 or peripheral oxygen saturation > 95%. PaO2 < 60mmHg is dangerous for the fetus. PaCO2 goes down during normal pregnancy and this respiratory alkalosis is expected. You should see PaCO2 of 30-32; if greater than 40mmHg your patient is tired and uterine flow is decreasing. This is bad news.

So your patient comes in and looks sick, do you have to change your workup? He suggests to order the same fluids, labs, most medications (except amiodarone, for instance) and give blood just as you would any other patient. CT the patient, if needed, because a sick mother implies a sick fetus. You must weigh cost benefit of all these interventions to favor mother’s survival.

clip2

How do you save a life in these critically ill patients immediately? Use this mnemonic, TOLD!

  • Tilt the patient in left lateral decubitus
  • Oxygen
  • Lines
  • Dates/delivery

Tilt: After 20 weeks the uterus large and compresses IVC, this can cause a reduction of CO by about 30%. Put towels under right hip and tilt that patient quickly!

Oxygen: Try to avoid BiPAP and CPAP.  These patients have increased progesterone, which means a weak lower esophageal sphincter. This translates to aspiration risk. You can try high flow humidified nasal cannula. This can go up to 60L of flow and give a baby dose of positive pressure (…a diet CPAP).

Lines: Avoid all femoral lines because a large uterus can compress those femoral and iliac veins. Place central lines above the diaphragm.

Dates/Delivery:  Key date to remember is 24 weeks gestational age. This is a critical time for management of mother. Hypotension from compression of IVC starts here AND you have a potentially viable fetus. You can use the poor man’s method (fundal height at umbilicus=20 weeks, fundal height four fingers above umbilicus=24 weeks) or ultrasound to determine dates.

clip3

Don’t forget to call Ob/Gyn MD and RN for fetal monitoring and Pediatrics for care of the newborn.

So now you know the basics, what do you do with the patient literally ABOUT to crash?

Pulmonary (Diffusion)

Address the airway first. Everything that can go wrong with these patients will. No offense to interns, but this is not your intubation. Pregnant women have lower oxygen reserve from that diaphragm being compressed inferiorly. This will be a potentially difficult airway. So be prepared and get everything laid out.

  1. Do your preoxygenation if time permits and apneic oxygenation for everyone (15L nasal cannula free flow).
  2. Treat them like you do the obese airway. This is not meant to be offensive, but an obese patient the most similar anatomical equivalent The pregnant woman also has fat deposition in the neck, large breasts, limited neck mobility, and more mucosal edema. The ear must be at the sternal notch. Pillow and sheets will be your friend in this case.
  3. Load up the small tubes, move down to the 6.0 ETT and have a plan B-D.
  4. Vent settings still require Tidal Volumes to use IBW based on height, PEEP might be higher than standard 5 since you are fighting against the fundus on the diaphragm; but use oxygenation to dictate PEEP.

Cardiac (Perfusion)

When your pregnant patient has a cardiac arrest focus on circulation: The ACLS algorithm is the same in regards to compression, defibrillation, and meds (except amiodarone which crosses fetal-maternal barrier and can cause iodine toxicity.

clip4

Tilting the mother makes it difficult to do adequate compressions. Instead, lay the patient on her back and push the uterus over.

pregnant

Start the clock – you have 4 minutes once the mother arrests to perform a peri-mortem c-section (PMCS). Mother regains up to 80% CO back by removing fetus.  Once you decide you must commit. There are case reports of people doing procedure after more than 4 minutes of CPR. During the procedure CPR must continue.  Don’t forget to deliver the placenta and close the uterus and peritoneum. To recap on how to do PMCS, watch this video at emcrit.org.