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Monday, September 22, 2014

Hospital administrators need to implement stricter policies and guidelines to improve ED timeliness and crowding, according to a commentary published in JAMA Internal Medicine. (


Jeremiah D. Schuur, MD, an emergency physician at Brigham & Women’s Hospital in Boston and an assistant professor of medicine at Harvard Medical School, wrote that many U.S. EDs remain crowded, citing that one quarter had median wait times in excess of 41 minutes, the longest being 14 hours, and that these facilities are likely to be large, urban, public, or teaching hospitals.


Hospitals with shorter ED lengths of stay (LOS) have higher admission rates, according to another JAMA study on the association between LOS and rate of admission, and researchers theorized that it creates a risk that patients will be inappropriately admitted or discharged just to stay within guidelines if physicians are encouraged to keep visits to a certain length of time. ( Another factor researchers considered was that ED patients require a variety of services, and an LOS that is adequate for one patient may not be sufficient for another’s evaluation.


Dr. Schuur discussed three strategies to solve crowding, and said policymakers and administrators should promote proven solutions. “Smoothing the surgical census streamlined patient flow throughout [Cincinnati Children’s Hospital], increasing occupancy while decreasing wait times for emergency surgical procedures. The State University of New York at Stony Brook Hospital uses a full-capacity protocol, in which boarding patients are moved to an inpatient unit hallway when the ED is full. According to a study in Annals of Emergency Medicine in 2009, the protocol has reduced ED waiting and walkouts without increasing detrimental events.”


He also suggested that the Joint Commission enforce a standard that requires hospitals to have processes that support patient flow from ED arrival to discharge. A new element of this standard, which took effect at the beginning of the year, requires hospitals to measure and address boarding of inpatients for longer than four hours, according to his commentary.


Lastly, researchers of a third JAMA study said the payment policy should discourage boarding. ( Hospital payments should be adjusted to reduce the financial disparity against emergency admissions, and payers could penalize hospitals when an admitted patient boards for a set extended time before being placed in an inpatient bed, creating an incentive against boarding. Researchers who recently studied the timeliness of care in the EDs, however, pointed out that the pay-for-performance model may result in hurried admissions or unintended consequences in an EP’s pursuit of a short LOS.


The goal, then, Dr. Schuur concluded, is to motivate hospitals to improve while watching for these unplanned penalties.

Thursday, September 18, 2014

By Leon Gussow, MD


Four years ago in this column I wrote that I had seen the future of medicine, and its name was Twitter. Nowhere is that truer than in medical toxicology, where the future has arrived with a vengeance.


More and more of the best-known names in the field have joined the 140-character colloquy that is the Twittersphere. The members on my toxicology Twitter list have snowballed from 31 to 122 in the past year alone.


The following are some of the newer additions to my list. Those interested in toxicology will want to consider adding them to their Twitter feed.


Lewis Nelson (@LNelsonMD) is the director of the medical toxicology fellowship program at NYU/Bellevue and the current president of the American College of Medical Toxicology. He frequently tweets links to tox-related news stories.


Jeanmarie Perrone (@JMPerroneMD) is the director of medical toxicology at the University of Pennsylvania. Her tweets focus on prescription drug abuse and the epidemic of prescription opioid overuse and addiction.


Martin Caravati (@emcaravati), the editor-in-chief of Clinical Toxicology, tweets about the journal’s content and developments from international toxicology conferences.


Nadia Awad (@Nadia_EMPharmD), a prolific tweeter, is an emergency medicine pharmacist at the Robert Woods Johnson University Hospital in New Jersey and a contributor to the Emergency Medicine PharmD blog. She covers all aspects of emergency pharmacy and toxicology.


Justin Brower (@NaturesPoisons) is a forensic toxicologist in the department of pathology and laboratory medicine at the University of North Carolina. His blog, Nature’s Poisons, is an amazing compendium of toxicology history and science. A recent post: “The Exciting True Story of Blowing Smoke Up One’s Arse.”


The University of Massachusetts Toxicology Fellowship (@UMassTox) is a powerful presence on social media, producing the superb ToxTalk podcast. Their tweets provide links to important medical literature and pearls from their conferences.


Kavita Babu (@kavitababu) is the captain of the UMass toxicology social media juggernaut and the director of the medical toxicology fellowship program. Her tweets are witty and informative.


Michael Downes (@ToxTalks) is an emergency physician and clinical toxicologist in Newcastle, NSW, associated with the Hunter Area Toxicology Service.


Doug Borys (@DougBorys) is a clinical toxicologist at the Wisconsin Poison Center who tweets about interesting clinical cases and conundrums.


Medical journalism used to be a process by which press releases from medical researchers, drug companies, and big-name journals were transcribed into the pages of daily newspapers without critical analysis. Fortunately, superb reporters now work the medical and pharmaceutical beats at some newspapers, and following their work has become essential. Some of the best of this valuable breed write about issues of interest to toxicologists.


John Fauber (@fauber_mjs) and his team have made the Milwaukee Journal-Sentinel and the website MedPage Today ( absolutely crucial reading. Mr. Fauber specializes in analyzing conflicts of interest in medical research and pharmaceutical marketing. Among the stories he has covered recently is the FDA approval of the opiate ZohydroER, even though the agency’s own advisory panel voted overwhelmingly against releasing it onto the market. His colleague at MedPage Today, Kristina Fiore (@KristinaMFiore), is also worth following.


Barry Meier (@BarryMeier) covers business and medicine for the New York Times. He has recently written excellent pieces on the tendency of some metal-on-metal hips to deteriorate and cause cobalt and chromium toxicity and a series on the epidemic of chronic opioid analgesic addiction.


Carl Zimmer (@carlzimmer), a science writer at the New York Times, recently wrote about microcystin, the bacterial toxin that closed down the water supply to Toledo, OH.


When Ed Silverman (@pharmalot) announced in 2009 that he was folding his influential drug-industry blog Pharmalot, long-time followers were distraught. Fortunately, Pharmlot has been resurrected at the Wall Street Journal. A fascinating recent post, linked to a longer article in the Journal, discussed how the ability of research-study patients to contact one another using social media could become a major impediment to the integrity of large blinded clinical trials.


This list just scratches the surface of Twitter accounts that toxicology aficionados should consider following. View all of the 122 accounts I follow on my Twitter profile (, click “More,” then “Lists,” and subscribe to the “Toxicology” list.


Dr. Gussow is a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago, an assistant professor of emergency medicine at Rush Medical College, a consultant to the Illinois Poison Center, and a lecturer in emergency medicine at the University of Illinois Medical Center in Chicago. Read his blog at, follow him @poisonreview, and read his past columns at

Wednesday, September 17, 2014

About one of every 15 family physicians (FPs) spends at least 80 percent of his time in EDs or urgent care centers, according to researchers. The findings were published in the July/August issue of Journal of the American Board of Family Medicine. (


The study also found that those who work in rural areas are seeing more patients than FPs in urban areas. The researchers used data from Maintenance of Certification for Family Physicians exam applications completed between 2008 and 2012, categorizing physicians according to the geographic setting in which they worked, ranging from urban to small rural to frontier.


Researchers also realized that FPs are most likely filling a needed gap in care because the ED often sees uninsured and underinsured women, children, and minorities, who face barriers to other sources of care, including primary care.

Tuesday, September 16, 2014

A new report from the Medicaid and CHIP Payment and Access Commission (MACPAC) found that Medicaid enrollees have generally more complex health needs than their privately insured counterparts, and those needs can only be addressed in the emergency department.


Nearly all Medicaid enrollees reported having a regular care center other than the ED, but about one-third of adult and 13 percent of child enrollees said they encountered barriers to finding a physician or delays in receiving care. The lack of access to primary care was even more acute for Medicaid patients with disabilities, who are disproportionately represented on Medicaid rolls. The lack of access to primary care contributes to Medicaid patients’ use of the ED, but even having a primary care physician is no bar against emergency department use for those patients with serious mental illness, multiple illnesses, and homelessness, the study said.


MACPAC found that nonurgent visits accounted for just 10 percent of Medicaid visits to the ED, which is close to the general population’s eight percent. A report from the Centers for Studying Health System Change in 2012 also found that most emergency visits by Medicaid patients are for urgent or serious symptoms.

Monday, September 15, 2014

A study funded by the National Institute on Drug Abuse (NIDA) shows that one-third of ED patients who initially declined to be tested for HIV changed their minds after watching a short video.


Researchers showed the 16-minute video to 160 patients who declined testing in a high volume, urban ED. It outlined the importance of testing, and demonstrated how an HIV test can be done orally instead of through blood work, and can yield results in about 20 minutes.


Participants were randomly put into four groups and shown different videos. Patients saw either a white health care provider speaking with a white patient about the importance of HIV testing, or a black health care provider speaking with a black patient. The study also randomized participants to see health care providers describing the benefits of testing and dangers of not testing.


Differences in treatment groups emerged based on the race of participants. The study found significantly greater increases in knowledge and intent to use a condom during vaginal sex among black participants who watched videos depicting white people, compared with black participants randomly assigned to see black people onscreen. The study also found white participants were significantly more likely to accept an HIV test after viewing videos with positive emotional content, compared with white participants who watched negative emotional content.


Interviews with 40 of the patients found that many were unaware that HIV testing could be done without drawing blood or that results could be delivered within 20 minutes. Read the full study at