AEM Early Access 27: Capturing Emergency Department Discharge Quality with the Care Transitions Measure: A Pilot Study

Welcome to the twenty-seventh episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON LINK FOR FULL TEXT, OPEN ACCESS THROUGH JUNE 30):

Capturing Emergency Department Discharge Quality with the Care Transitions Measure: A Pilot Study. Amber K. Sabbatini MD, MPH, Fiona Gallahue MD, Joshua Newson MD, Stephanie White, Thomas Gallagher MD

LISTEN NOW: AUTHOR INTERVIEW WITH Amber K. Sabbatini MD, MPH



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Amber K. Sabbatini MD, MPH

Assistant Professor

Department of Emergency Medicine

University of Washington



Abstract

Background: Recent attention has been given to developing measures to capture the quality of ED transitions of care. We examined the utility of a patient-reported measure of transitional care, the Care Transitions Measure - 3 (CTM-3) in the ED setting and its association with outcomes of care after ED discharge.

Methods: Telephone survey of a convenience sample of patients 14 days after discharge from 2 emergency departments in an academic health system. Patients responded to 3 statements using a 4-point agreement scale (Strongly Disagree, Disagree, Agree, Strongly Agree): 1) "The hospital staff took my preferences and those of my family or caregiver into account when deciding what my healthcare needs would be" 2) " When I left the ER, I had a good understanding of the things I was responsible for in managing my health, and 3) "When I left the hospital, I clearly understood the purpose for taking each of my medications." Patients were also queried about outcomes after ED discharge that are known to be related to ED care transitions including medication adherence, completion of recommended follow-up and return visits to the ED. Multivariable logistic regression was used to determine the association between the CTM-3 score (on a 100-point scale) and outcomes of interest.

Results: Among 1832 patients called, 576 were reached by phone, and 410 consented and completed our survey, representing a 22.4% response rate of patients we attempted to call. A 10-point increase in the CTM-3 score (better care experiences) was associated with a 12% decrease in the odds of having an ED return visit (AOR 0.88, 95% CI 0.77-1.00) and a 45% increase in the odds of taking prescribed medications as recommended (AOR 1.45; 95% CI 1.12-1.87). There was no association between CTM-3 score and completion of follow-up.

Conclusions: The CTM-3 is associated with outcomes of care after an ED visit, including ED return visits and medication adherence, and may have utility as a patient-reported measure of ED transitions of care. This article is protected by copyright. All rights reserved.

Money Minutes for Doctors #15 - Income Protection and Disability Insurance

Major catastrophes in life generally do not telegraph their impending arrival…but there are ways to protect yourself and your family, as well as your income. In this month’s edition of Money Minutes, Katherine Vessenes discusses with us the three major catastrophes that typically present themselves to individuals and families ~ premature death, job loss, and too sick or injured to work ~ and the various ways to protect oneself following those events.

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About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

Quick Summary:

Three major catastrophes (1) premature death – mitigated w life insurance (2) job loss – protected by physician shortage (3) too sick or injured to work – mitigated by disability insurance

  • Best to purchase disability insurance while you are young and healthy. 

  • If possible try to purchase within physician group as often way to get best rates. 

  • Level premium and level death benefit is preferred

  • Variable companies offer different quality of coverage – price is not the only decision point

Level of Income protection policies:

  1. Only pay claim if too sick to do any work at all. Really does not apply to physicians

  2. Own Occupation (vast majority) – applies or so long as you are not earning income or earning benefits elsewhere.  Some polices deduct additional income that you get from outside sources from your benefit but most will deny coverage.  For example too sick or injured to be a neurologist but if you do any teaching or lecturing would void the policy.   If had multiple employment sources at the time of injury, application of policy would depend on what your primary income source was at the time of the disability.  

  3. Double dip own occupation (considered the gold standard) – if too sick to work in your own occupation but can function in other capacities can get full disability benefit but then allowed to keep income for alternate employment

 ** polices should be reviewed w some frequency to make sure information is up to date

FYI - As long as paying the premiums on the policy the insurance company cannot cancel policy and can’t raise the rates, but be sure to read the fine print.  

Tax implications of receiving a disability benefit – (1) if employer is paying the premium then the benefit is fully taxable as income (2) if you pay for the benefit then the benefit is not taxable income

Having an agent/advisor that you trust is key to choosing the right product so you know what is covered and what is not as well as getting the best priced package. 

Pre-existing conditions – this makes it difficult if not impossible to get coverage so pursue coverage early in life when healthy and/or optimize your health when you apply to get best rates and best policy (i.e. stop smoking, delay less emergent health needs so that they don’t appear on your record)

Ultrasound Case of the Month: A Silent Killer

The Case:

A 72 year old male with no PMH presents to the emergency department (ED) for vague abdominal discomfort and fullness. The patient is hemodynamically stable on arrival and received a point of care ultrasound (POCUS) for evaluation of his abdominal pain. FAST performed was negative for free fluid, however, the renal ultrasound showed unilateral mild hydronephrosis on the right side. POCUS was then performed to evaluate the aorta, and a large abdominal aortic aneurysm (AAA) was seen, measuring 14cm at its largest diameter.

 

Introduction:

When performing a POCUS it is important to remember the differential diagnosis for hydronephrosis is broad, and not limited to renal colic. The ureter can be obstructed either internally from a stone, or externally from surrounding structures.  When renal colic is on your differential, and you find hydronephrosis, be sure to also consider alternative diagnosis such as a AAA. In older patients, consider performing a AAA evaluation in all patients with suspected renal colic, and/or hydronephrosis. 

In this case, the patient had compression of the ureter from the large AAA resulting in hydronephrosis, but if the aorta had not been evaluated, we may have missed the more dangerous diagnosis. In addition, please remember that a patient may have leaking or rupture from the AAA which is located retroperitoneally and may not be seen on POCUS.

A ruptured abdominal aortic aneurysm (AAA) is a vascular catastrophe responsible for 1-3% of deaths in men from the age 65-85 in developed countries. Rupture from an AAA is the 10th leading cause of death in males over 50, the mortality rate of a ruptured AAA approaches 90% and the incidence of AAA continues to increase. Therefore, it is essential for the EM physician to diagnose a AAA in a timely manner. (1) The minority of patients with a ruptured AAA (<25%) will present with the classic triad of hypotension, back pain and a pulsatile abdominal mass.  This results in a delay in diagnosis, or misdiagnosis. Patients may present with referred pain to the scrotum, buttocks, thighs, shoulders, and/or chest and can be misdiagnosed as having renal colic, diverticulitis or MSK pain.

Indications:

The current indications by ACEP for obtaining POCUS to detect AAA include:

Presence of syncope, shock, hypotension, abdominal pain, abdominal mass, flank pain or back pain- especially in patients >50 years old.(3) Currently, the U.S. Preventive Service Task Force recommends that men from the age of 65-75 years who have ever smoked be screened for an AAA sonography.(4)

Utility of bedside ultrasound for AAA in the ED?

While CTA is considered the surveillance study of choice(5),  research suggests that the sensitivity of point of care bedside ultrasound approaches 99% for abdominal aortic aneurysm (AAA). With such a excellent sensitivity and a high prevalence of AAA in specific patient populations (10-15% in men who smoke >65), providers should consider performing this scan at the bedside for an expedited diagnosis.(6)

Performing the scan:

  • The probe of choice is the 3.5 MHz curvilinear probe

  • Start just caudal to xyphoid process

  • Measure the aorta proximally, mid and distally in the transverse plane with the probe marker to the patient’s right (should be <3cm from outer to outer wall)

  • Measure the iliac arteries after the bifurcation in transverse (should be <1.5cm)

  • Evaluate the aorta distally in the longitudinal view with the probe marker to patient’s head as most aneurysms will be located infrarenally

  • Identify vertebral body as relevant landmark

  • Aorta is anterior to vertebral body

  • IVC is anterior & right (patient’s right) of vertebral body

Vertebral body: horseshoe shaped with hyperechoic anterior &amp; posterior shadowing

Vertebral body: horseshoe shaped with hyperechoic anterior & posterior shadowing

Tips and Tricks

  • Aorta and IVC can be confused in longitudinal view:

    • Aorta is rounder, less compressible, & has brighter thicker walls

  • Bowel gas & body habitus can make imaging difficult:

    • Apply steady pressure to move gas

    • Jiggle the probe to move bowel aside

    • Flex patients hips & knees to relax abdominal muscles

    • Lower probe frequency to improve sound wave penetration

Conclusion

POCUS scanning for AAA enables timely diagnosis of a condition with high mortality which is frequently misdiagnosed, or suffers a delay in diagnosis. AAA POCUS has high sensitivity and specificity that can be easily learned and performed in ED. In a patient with hydronephrosis, consider also AAA evaluation, even if renal colic is high on your differential diagnosis.

Faculty Reviewer: Dr. Kristin Dwyer

References:

  1. Sakalihasan N, Limet R, Defawe OD. Abdominal Aortic Aneurysm. Lancet 2005;365:15577-89.

  2. Fink HA, Lederle FA, Roth CS, Bowels CA, Nelson DB, Haa MA. The Accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med.2000;160(6):833-6.

  3. American College of Emergency Physicians. Policy Statement. 2001: Emergency Ultrasound Guidelines.

  4. U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Inter med. 2005;142(3):198-202.

  5. Cantisani V, Ricci P, Grazhdani H, et al. Prospective comparative analysis of colour-doppler ultrasound, contrast-enhanced ultrasound, computed tomography and magnetic resonance in detection endoleak after endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2011;41:(2)186-92.

  6. Rubano, Elizabeth, Ninfa Mehta, William Caputo, Lorenzo Paladino, and Richard Sinert. Systematic Review: Emergency Department Bedside Ultrasonography for Diagnostic suspected Abdominal Aortic Aneurysm. Acad Emerg Med Academic Emergency Medicine 20.2 (2013): 128-38.