Health-care associated pneumonia (HCAP) is the term used to describe patients presenting with pneumonia who may be at higher risk of multi-drug resistant (MDR) pathogens than other patients presenting from the community due to recent contact with the health care system. What are the criteria for HCAP?
Emergent airway management and severe sepsis are both high-risk situations that are commonly encountered by emergency physicians. It is well known that complications can be high in both situations, which in turn can lead to increased morbidity and mortality. For instance, about 1/4 of patients who are hemodynamically stable prior to intubation get post-intubation hypotension (PIH) after rapid sequence intubation. Also septic patients may not be reliably identified by systemic inflammatory response syndrome (SIRS) markers early in their disease course. The Shock Index (SI) may be an adjunct that is easy to calculate and could predict both PIH and severe sepsis.
For the ALiEM – Annals of EM global journal club on the article “Emergency Department Computed Tomography Utilization in the United States and Canada”, discuss question number 4 on the topic of reimbursements tied to diagnosis:
The Centers for Medicare & Medicaid Services (CMS) proposed instituting a new process metric OP 15 “Use of Brain CT in the Emergency Department of Atraumatic Headache.” OP 15 measures the percentage of ED visits for atraumatic headache (ie, ED billing codes for tension, cluster, migraine, and nonspecific headaches) among Medicare beneficiaries who have a brain CT performed on the same day. ED patients who are admitted to the hospital and those whose secondary diagnoses include codes related to subarachnoid hemorrhage, transient cerebral ischemia, and tumor/mass are excluded from the denominator. The public reporting of OP 15 is presently postponed to allow time for refinement of the measure by a technical expert panel. However, if this indicator is fully instituted, would the threat of decreased reimbursement and public reporting of use decrease your ordering of CTs in patients older than 65 years and with atraumatic headaches?
For the ALiEM – Annals of EM global journal club on the article “Emergency Department Computed Tomography Utilization in the United States and Canada”, discuss question number 3 on the topic of malpractice and CT use:
Discuss some of the important differences between the current health care systems and medical malpractice environments in Canada and the United States. How might these differences affect CT use in the emergency department (ED)? How might the implementation of the Patient Protection and Affordable Care Act in the US affect these differences?
For the ALiEM – Annals of EM global journal club on the article “Emergency Department Computed Tomography Utilization in the United States and Canada”, discuss question number 2 on the topic of estimation on CT counts:
Do you think the National Hospital Ambulatory Medical Care Survey (NHAMCS) method is likely to overcount or undercount CTs? What about the method used for calculating use in Ontario? Would these biases likely make the authors’ estimate of the overall difference between these countries too large or too small? Defend your answer.
For the ALiEM – Annals of EM global journal club on the article “Emergency Department Computed Tomography Utilization in the United States and Canada”, discuss question number 1 on the topic of bias:
The authors use distinct methods for tallying computed tomography (CT) use in the 2 countries. List the biases that could occur in counting CTs by each method.
CT imaging is a powerful tool in diagnosing pathological medical conditions. Despite this, there is appropriate concern about the “magnitude of imaging-related financial costs and radiation induced malignancies.” In this month’s Annals of Emergency Medicine journal publication, Berdachl et al published about “Emergency Department Computed Tomography Utilization in the United States and Canada.” This article was selected by the journal as the featured piece for a Journal Club discussion. In this inaugural global EM journal club, ALiEM and Annals are collaborating to provide a more dynamic discussion of some of the posed questions. The focus is on teaching concepts around HOW to critically appraise a journal article rather than just receive a pre-digested summary statement from social media sites and textbooks.