For many years, Annals of Emergency Medicine has selected two articles every month to make open access to non-subscribers, based on their perceived interest and/or importance. Problem is, we make those choices blind to what our readers really want. You can help us improve this selection if you would review the list of articles that will be in the April 2014 issue, and vote for any articles you’d like to see free full-text. Please vote on your top two choices over the next 2 days and we’ll make them full text open access shortly thereafter. The in-press titles and abstracts are listed below. Thank you for your support!

[polldaddy poll=7658207]

Anticipated Changes in Reimbursements for US Outpatient Emergency Department Encounters After Health Reform

Jessica E. Galarraga, MD, MPH, Jesse M. Pines, MD, MBA

Study objective: We study how reimbursements to emergency departments (EDs) for outpatient visits may be affected by the insurance coverage expansion of the Patient Protection and Affordable Care Act as previously uninsured patients gain coverage either through the Medicaid expansion or through health insurance exchanges.

Methods: We conducted a secondary analysis of data (2005 to 2010) from the Medical Expenditure Panel Survey. We specified multiple linear regression models to examine differences in the payments, charges, and reimbursement ratios by insurance category. Comparisons were made between 2 groups to reflect likely movements in insurance status after the Patient Protection and Affordable Care Act implementation: (1) the uninsured who will be Medicaid eligible afterward versus Medicaid insured, and (2) the uninsured who will be Medicaid ineligible afterward versus the privately insured.

Results: From 2005 to 2010, as a percentage of total ED charges, outpatient ED encounters for Medicaid beneficiaries reimbursed 17% more than for uninsured individuals who will become Medicaid eligible after Patient Protection and Affordable Care Act implementation: 40.0% versus 34.0%, mean absolute difference=5.9%, 95% confidence interval 5.7% to 6.2%. During the same period, the privately insured reimbursed 39% more than for uninsured individuals who will not be Medicaid eligible after Patient Protection and Affordable Care Act implementation: 54.0% versus 38.8%, mean absolute difference=15.2%, 95% confidence interval 12.8% to 17.6%.

Conclusion: Assuming historical reimbursement patterns remain after Patient Protection and Affordable Care Act implementation, outpatient ED encounters could reimburse considerably more for both the previously uninsured patients who will obtain Medicaid insurance and for those who move into private insurance products through health insurance exchanges. Although our study does provide insight into the future, multiple factors will ultimately influence reimbursements after implementation of the act.



Circulatory Death Determination in Uncontrolled Organ Donors: A Panel Viewpoint

James L. Bernat, MD, Thomas P. Bleck, MD, Sandralee A. Blosser, MD, et al.

One barrier for implementing programs of uncontrolled organ donation after the circulatory determination of death is the lack of consensus on the precise moment of death. Our panel was convened to study this question after we performed a similar analysis on the moment of death in controlled organ donation after the circulatory determination of death. We concluded that death could be determined by showing the permanent or irreversible cessation of circulation and respiration. Circulatory irreversibility may be presumed when optimal cardiopulmonary resuscitation efforts have failed to restore circulation and at least a 7-minute period has elapsed thereafter during which autoresuscitation to restored circulation could occur. We advise against the use of postmortem organ support technologies that reestablish circulation of warm oxygenated blood because of their risk of retroactively invalidating the required conditions on which death was declared.


Concordance of Out-of-Hospital and Emergency Department Cardiac Arrest Resuscitation With Documented End-of-Life Choices in Oregon

Derek K. Richardson, MD, MPH, Erik Fromme, MD, MCR; Dana Zive, MPH, Rongwei Fu, PHD; Craig D. Newgard, MD, MPH

Study objective: Resuscitation measures should be guided by previous patient choices about end-of-life care, when they exist; however, documentation of these choices can be unclear or difficult to access. We evaluate the concordance of a statewide registry of actionable resuscitation orders unique to Oregon with out-of-hospital and emergency department (ED) care provided for patients found by emergency medical services (EMS) in out-of-hospital cardiac arrest.

Methods: This was a retrospective cohort study of patients found by EMS providers in out-of-hospital cardiac arrest in 5 counties in 2010. We used probabilistic linkage to match patients found in out-of-hospital cardiac arrest with previously signed documentation of end-of-life decisions in the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. We evaluated resuscitation interventions in the field and ED.

Results: There were 1,577 patients found in out-of-hospital cardiac arrest, of whom 82 had a previously signed POLST form. Patients with POLST do-not-resuscitate orders for whom EMS was called had resuscitation withheld or ceased before hospital admission in 94% of cases (95% confidence interval [CI] 83% to 99%). Compared with patients with no POLST or known do-not-resuscitate orders, more patients with attempt resuscitation POLST orders had field resuscitation attempted (84% versus 60%; difference 25%; 95% CI 12% to 37%) and were admitted to hospitals (38% versus 17%; difference 20%; 95% CI 3% to 37%), with no documented misinterpretations of the form once CPR was initiated.

Conclusion: In this sample of patients in out-of-hospital cardiac arrest, out-of-hospital and ED care was generally concordant with previously documented end-of-life orders in the setting of critical illness. Further research is needed to compare the effectiveness of Oregon’s POLST system to other methods of end-of-life order documentation.

Demystifying Maintenance of Certification

Richard N. Nelson, MD

Board certification for a medical specialty was first proposed in 1908. Subsequently, the American Board of Medical Specialties (ABMS) was formed in 1933. The ABMS approved emergency medicine as the 23rd medical specialty in 1979. Since its inception, the American Board of Emergency Medicine (ABEM) has always had time-limited certification requiring a recertification examination every 10 years. The notion of recertification has since evolved into maintenance of certification (MOC). I define the various components of the ABEM MOC program. The MOC axioms of continuous professional development and adherence to quality development are discussed. Finally, physician participation in the ABEM MOC is reviewed.


Derivation of a Clinical Decision Instrument to Identify Adult Patients With Mild Traumatic Intracranial Hemorrhage at Low Risk for Requiring ICU Admission

Daniel K. Nishijima, MD, MAS, Matthew Sena, MD, Joseph M. Galante, MD, Kiarash Shahlaie, MD, PhD, Jason London, MD, Joy Melnikow, MD, MPH, James F. Holmes, MD, MPH

Study objective: The objective of this study is to derive a clinical decision instrument with a sensitivity of at least 95% (with upper and lower bounds of the 95% confidence intervals [CIs] within a 5% range) to identify adult emergency department patients with mild traumatic intracranial hemorrhage who are at low risk for requiring critical care resources during hospitalization and thus may not need admission to the ICU.

Methods: This was a prospective, observational study of adult patients with mild traumatic intracranial hemorrhage (initial Glasgow Coma Scale [GCS] score 13 to 15, with traumatic intracranial hemorrhage) presenting to a Level I trauma center from July 2009 to February 2013. The need for ICU admission was defined as the presence of an acute critical care intervention (intubation, neurosurgical intervention, blood product transfusion, vasopressor or inotrope administration, invasive monitoring for hemodynamic instability, urgent treatment for arrhythmia or cardiopulmonary resuscitation, and therapeutic angiography). We derived the clinical decision instrument with binary recursive partitioning (with a misclassification cost of 20 to 1). The accuracy of the decision instrument was compared with the treating physician’s (emergency medicine faculty) clinical impression.

Results: A total of 600 patients with mild traumatic intracranial hemorrhage were enrolled; 116 patients (19%) had a critical care intervention. The derived instrument consisted of 4 predictor variables: admission GCS score less than 15, nonisolated head injury, aged 65 years or older, and evidence of swelling or shift on initial cranial computed tomography scan. The decision instrument identified 114 of 116 patients requiring an acute critical care intervention (sensitivity 98.3%; 95% CI 93.9% to 99.5%) if at least 1 variable was present and 192 of 484 patients who did not have an acute critical care intervention (specificity 39.7%; 95% CI 35.4% to 44.1%) if no variables were present. Physician clinical impression was slightly less sensitive (90.1%; 95% CI 83.1% to 94.4%) but overall similar to the clinical decision instrument.

Conclusion: We derived a clinical decision instrument that identifies a subset of patients with mild traumatic intracranial hemorrhage who are at low risk for acute critical care intervention and thus may not require ICU admission. Physician clinical impression had test characteristics similar to those of the decision instrument. Because the results are based on single-center data without a validation cohort, external validation is required.


Does the Use of Tranexamic Acid Improve Trauma Mortality? [review article]

Virginia Harvey, MD, JeanMarie Perrone, MD, Patrick Kim, MD


Donation After Circulatory Determination of Death: Time for Transparency [editorial]

Scott D. Halpern


Identifying Emergency-Sensitive Conditions for the Calculation of an Emergency Care Inhospital Standardized Mortality Ratio

Simon Berthelot, MD, Eddy S. Lang, MD, Hude Quan, MD, PhD, Henry T. Stelfox, MD, PhD, Panel on Emergency-Sensitive Conditions (PESC)

Study objective: Hospital standardized mortality ratios are used for hospital performance assessment. As a first step to develop a ratio variant sensitive to the outcome of patients admitted from the emergency department (ED), we identified International Classification of Diseases, 10th Revision, Canada diagnosis groups in which high-quality ED care would be expected to reduce inhospital mortality (emergency-sensitive conditions).

Methods: To identify emergency-sensitive conditions, we assembled a multidisciplinary panel of emergency care providers and managers (n=14). Using a modified RAND/University of California, Los Angeles Appropriateness Method, 3 rounds of independent ratings including a teleconference were conducted from May to October 2012. Panelists serially rated diagnosis groups included in the Canadian hospital standardized mortality ratio (n=72) according to the extent ED management influences mortality.

Results: The panel rated ED care as potentially reducing patient mortality for 37 diagnosis groups (eg, sepsis) and morbidity for 43 diagnosis groups (eg, atrial fibrillation) and rated timely ED care as critical for 40 diagnosis groups (eg, stroke). Panelists also identified 47 diagnosis groups (eg, asthma) not included in the Canadian hospital standardized mortality ratio in which mortality could potentially be decreased by ED care.

Conclusion: We identified 37 diagnosis groups representing emergency-sensitive conditions that will enable the calculation of a hospital standardized mortality ratio relevant to emergency care.


Is Outpatient Emergency Department Care Profitable? Hourly Contribution Margins by Insurance for Patients Discharged From an Emergency Department

Philip L. Henneman, MDemail address, Brian H. Nathanson, PhD, Haiping Li, MD, Andrew Tomaszewski, AB, Jesse M. Pines, MD, MBA, Daniel A. Handel, MD, MPH, Michael J. Lemanski, MD

Study objective: We determine the contribution margin per hour (ie, profit) by facility evaluation and management (E&M) billing level and insurance type for patients treated and discharged from an urban, academic emergency department (ED).

Methods: Billing and demographic data for patients treated and discharged from an ED with greater than 100,000 annual visits between 2003 and 2009 were collected from hospital databases. The primary outcome was contribution margin per patient per hour. Contribution margin by insurance type (excluding self-pay) was determined at the patient level by subtracting direct clinical costs from contractual revenue. Hospital overhead and physician expenses and revenue were not included.

Results: In 523,882 outpatient ED encounters, contribution margin per hour increased with increasingly higher facility billing level for patients with commercial insurance ($70 for E&M level 1 to $177 at E&M level 5) but decreased for patients with Medicare ($44 for E&M level 1 to $29 at E&M level 5) and Medicaid ($73 for E&M level 1 to –$16 at E&M level 5). During the study years, cost, charge, revenue, and length of stay increased for each billing level.

Conclusion: In our hospital, contribution margin per hour in ED outpatient encounters varied significantly by insurance type and billing level; commercially insured patients were most profitable and Medicaid patients were least profitable. Contribution margin per hour for patients commercially insured increased with higher billing levels. In contrast, for Medicare and Medicaid patients, contribution margin per hour decreased with higher billing levels, indicating that publicly insured ED outpatients with higher acuity (billing level) are less profitable than similar, commercially insured patients.


Potential Misdiagnoses of Bell’s Palsy in the Emergency Department

Jahan Fahimi, MD, MPH, Babak B. Navi, MD, Hooman Kamel, MD

Study objective: We evaluate the incidence of potentially incorrect emergency department (ED) diagnoses of Bell’s palsy and identify factors associated with identification of a serious alternative diagnosis on follow-up.

Methods: We performed a retrospective cohort study from California’s Office of Statewide Health Planning and Development for 2005 to 2011. Subjects were adult patients discharged from the ED with a diagnosis of Bell’s palsy. Information related to demographics, imaging use, and comorbidities was collected. Our outcome was one of the following diagnoses made within 90 days of the index ED visit: stroke, intracranial hemorrhage, subarachnoid hemorrhage, brain tumor, central nervous system infection, Guillain-Barré syndrome, Lyme disease, otitis media/mastoiditis, or herpes zoster. We report hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with misdiagnosis.

Results: A total of 43,979 patients were discharged with a diagnosis of Bell’s palsy. Median age was 45 years. On 90-day follow-up, 356 patients (0.8%) received an outcome diagnosis, and 39.9% were made within 7 days. Factors associated with the outcome included increasing age (HR 1.11, 95% CI 1.01 to 1.21, every 10 years), black race (HR 1.68; 95% CI 1.13 to 2.48), diabetes (HR 1.46; 95% CI 1.10 to 1.95), and computed tomography or magnetic resonance imaging use (HR 1.43; 95% CI 1.10 to 1.85). Private insurance was negatively associated with an alternative diagnosis (HR 0.65; 95% CI 0.46 to 0.93). Stroke, herpes zoster, Guillain-Barré, and otitis media accounted for 85.4% of all alternative diagnoses.

Conclusion: Emergency providers have a very low rate of misdiagnosing Bell’s palsy. The association between imaging use and misdiagnosis is likely confounded by patient acuity. Increasing age and diabetes are modest risk factors for misdiagnosis.


Uncontrolled Organ Donation After Circulatory Determination of Death: US Policy Failures and Call to Action

Stephen P. Wall, MD, MSc, Kevin G. Munjal, MD, MPH, Nancy N. Dubler, LLB, Lewis R. Goldfrank, MD, NYC uDCDD Study Group

In the United States, more than 115,000 patients are wait-listed for organ transplants despite that there are 12,000 patients each year who die or become too ill for transplantation. One reason for the organ shortage is that candidates for donation must die in the hospital, not the emergency department (ED), either from neurologic or circulatory-respiratory death under controlled circumstances. Evidence from Spain and France suggests that a substantial number of deaths from cardiac arrest may qualify for organ donation using uncontrolled donation after circulatory determination of death (uDCDD) protocols that rapidly initiate organ preservation in out-of-hospital and ED settings. Despite its potential, uDCDD has been criticized by panels of experts that included neurologists, intensivists, attorneys, and ethicists who suggest that organ preservation strategies that reestablish oxygenated circulation to the brain retroactively negate previous death determination based on circulatory-respiratory criteria and hence violate the dead donor rule. In this article, we assert that in uDCDD, all efforts at saving lives are exhausted before organ donation is considered, and death is determined according to “irreversible cessation of circulatory and respiratory functions” evidenced by “persistent cessation of functions during an appropriate period of observation and/or trial of therapy.” Therefore, postmortem in vivo organ preservation with chest compressions, mechanical ventilation, and extracorporeal membrane oxygenation is legally and ethically appropriate. As frontline providers for patients presenting with unexpected cardiac arrest, emergency medicine practitioners need be included in the uDCDD debate to advocate for patients and honor the wishes of the deceased.




Michael Callaham, MD

Michael Callaham, MD

Editor-in-Chief, Annals of Emergency Medicine
Member, Institute of Medicine
Founding Chair and Professor of Emergency Medicine
University of California, San Francisco
Michael Callaham, MD

Latest posts by Michael Callaham, MD (see all)