Emergency Department Operating Room

Timing Of Hip Fracture Surgery

How we practice medicine in the United States is often dictated by quality metrics established by Medicare and The Joint Commission. Our hospitals often focus on monitoring these publicly reported metrics but there are others that deserve equal attention, even though they are not publicly reported. One of these is the time between when a person presents to the emergency department with a hip fracture to when they have hip fracture surgery. If the hospital’s expectation is that surgery be done immediately, then there is a substantial expense in maintaining an open operating room and on-call pay for the surgeon, anesthesiologist, and OR staff to do emergency surgeries in the middle of the night. On the other hand, if there is an excessive delay, then the mortality rate goes up.

A 2016 study in the American Journal of Preventive Medicine examined 19.8 million EMS “events” (most of which were 911 calls). Of these, 4.3 million involved people over age 65 years old. 17.5% of all 911 calls in patients over age 65 were for falls, most of which (60%) were in the person’s home. There was a gender difference: 15.0% of 911 calls involving men were for falls but 19.1% of 911 calls involving women were for falls.  The older the person, the more likely a fall was the reason for the 911 call:

  • Age 65-74: 12.7%
  • Age 75-84: 17.4%
  • Age ≥ 85: 22.6%

One of the most important complications of falls in the elderly is hip fracture. Every year in the United States, there are about 250,000 admissions to the hospital for hip fractures and 90% of hip fractures result from falls. Over a lifetime, 6% of American men will sustain a hip fracture but 14% of post-menopausal women will have a hip fracture. Hip fracture is an important cause of death: when women have a hip fracture, 5% will die within 30 days and 20% will die within a year; when men have a hip fracture, 10% will die within 30 days and 30% will die within a year. About half of patients who have a hip fracture are unable to live independently after their fracture.

A study in last month’s JAMA gives us some direction regarding how hospitals should approach the timing of hip fracture repair. The authors examined 42,230 hip fracture patients treated by 522 orthopedic surgeons at 72 hospitals in Ontario from 2009 – 2014. The average age of the patients was 80 years old and 70% of the patients were women. One-third of the patients had surgery within 24 hours of admission and two-thirds had surgery later than 24 hours after admission. The key result was that the mortality rate went up for every hour that surgery was delayed beyond 24 hours from admission to the hospital. Shown in this graph is the 30-day mortality but the 1-year mortality graph had a similar shape (although higher overall mortality rates). The authors further analyzed various complications and found that the percentage of patients having pneumonia, myocardial infarction, deep venous thrombosis, and pulmonary embolism had similar-appearing graphs with the incidence of all of these complications increasing in patients whose surgeries were delayed beyond 24 hours.

So, it appears that there is a “sweet spot” in the timing of hip fracture repair. A wait time of up to 24 hours is acceptable but beyond 24 hours, the risk of complications and death steadily increase.

Because patients with hip fracture are elderly and often have serious medical co-morbidities, having at least a few hours to obtain medical consultation, correct major electrolyte abnormalities, identify and treat unstable angina, correct significant anemia, etc. can be useful to improve a patient’s ability to get through a major operation. On the other had, the sooner the patient has surgery, the sooner they can get out of bed to be started in physical therapy and the less likely they are to get complications of being bedridden such as pneumonia and pulmonary embolism.

So from the hospital’s perspective, what expectations should we be setting for the management of patients with hip fracture?

  • We need to monitor the time from ER presentation to surgery. The goal should be for most patients to be operated on within 24 hours of presentation. 
  • We need to ensure that we have surgeons, anesthesiologists, and OR staff to do hip fracture surgery seven days per week.
  • Most patients presenting with hip fracture at night can wait to have surgery until the next morning. 
  • We need to have availability of medical consultants who can evaluate patients with hip fracture in the first hours of their presentation.
  • We need to set expectations for medical consultants that their evaluation should not delay surgery except in patients with the most serious acute medical problems.
  • For patients with hip fracture and unstable medical problems such as active gastrointestinal bleeding or unstable angina, we need to have seven day per week availability of testing such as endoscopy and cardiac catheterization or have the ability to transfer patients needing these pre-op tests to another hospital that can do them. 
  • We need to have physical therapists available to get patients up and out of bed as soon as possible after surgery – preferably on the same day. This requires having physical therapists available seven days per week.

The good news is that the incidence of hip fracture appears to be decreasing. The best way to improve mortality from hip fractures is to prevent the fractures in the first place by reducing geriatric falls. Community programs designed to screen patients at risk for falls, to improve balance and gait by improving physical conditioning in the elderly, to correct vision impairment, to modify the living environment of the elderly, and to identify and eliminate medications contributing to falls are all effective measures to reduce the incidence of geriatric falls.

However, even though we may be able to reduce the number of hip fractures, we are not going to be able to eliminate them entirely. We should target a “door to OR time” of < 24 hours for hip fracture just like we target a “door to balloon time” of < 90 minutes for patients with acute myocardial infarction.

December 11, 2017

Emergency Department

Shaving 35 Minutes Off Of Door-To-Needle Time With Stroke Patients

  1. When a patient has a stroke, every minute matters. The quicker the stroke is recognized by either the patient or their family, the quicker the emergency squad can get the patient to the emergency department, and the quicker the ER physician can evaluate the patient and administer intravenous t-PA, the better the patient will do.

t-PA has it’s greatest benefit if given within 3 hours of the onset of stroke symptoms. If given between 3 and 4 1/2 hours, it loses some of it’s beneficial effects but patients still do better than if they do not receive t-PA. After 4 1/2 hours, t-PA can actually cause more harm than good by increasing the risk of bleeding into the brain and making a stroke larger.

In the hospital, we only have control over the time between when the patient arrives in the ER until the time that the blood clot dissolving medication, t-PA, is given. For a hospital to be a designated stroke center, that time has to be less than 60 minutes, we call that the “door-to-needle” time. On the surface, 60 minutes seems like a long time and many people would wonder why it would ever take that long to given an IV medication after a patient comes to the ER.

The problem is that you first have to diagnose a possible stroke and this can be difficult when patients walk in the door with very non-specific symptoms. For example, is the patient’s had numbness from a stroke or did they sleep on their arm wrong, compressing the brachial nerve causing the hand to “feel asleep”? Or is the patient’s slurred speech due to a stroke or are they intoxicated? Second, the doctor has to get a head CT scan to be sure that the stroke is not hemorrhagic, that is bleeding into the brain – if the stroke is hemorrhagic, then t-PA can make it worse, not better. Third, there needs to be an evaluation by a stroke specialist to analyze the patient’s situation and determine if t-PA would be beneficial. In our case, we do this with “tele-stroke” where we have video communication with a stroke specialist available 24 hours a day. This stroke specialist is on-call for many hospitals in Ohio via tele-stroke technology.

In order to get all of this done within 60 minutes, the following are the guidelines for time intervals once a patient comes through the ER door created by the American Heart Association and the American Stroke Association:

  • Evaluation by a physician – 10 minutes
  • Stroke specialist contacted – 5 minutes
  • Head CT scan completed – 10 minutes
  • Head CT scan interpreted – 20 minutes
  • Intravenous t-PA started – 15 minutes
  • TOTAL = 60 minutes

There are several reasons why you would not want to give t-PA to someone having a stroke. For example, if their blood pressure is too high or if you cannot verify that the initial onset of stroke symptoms was < 4.5 hours, then you can make the patient worse with t-PA.

In order to meet these time intervals, the ER has to change the work flow for patients with stroke compared to other patients. Here are our tactics:

  • Nurse activated internal stroke alerts. Rather than waiting for the ER physician to evaluate the patient to determine if there might be a stroke, we have empowered our nurses in the triage area to make that initial assessment. If they suspect stroke based on the patient’s symptoms, then they will activate the stroke process. We anticipate an increase in false alarms but the benefit should be a 10 minute savings.
  • Initiation of the tele-stroke consultation immediately after the non-contrast CT scan. In our hospital, the protocol is for patients with suspected stroke to get a series of 3 CT scans: a non-contrast head CT, a CT angiogram of the brain, and a CT perfusion scan of the brain. The first CT dictates whether t-PA can be given safely and the second two help guide the use of other treatments, such as neurosurgical treatments. The problem is that the patient has to remain in the CT scanner after the first CT scan for 9 minutes while getting the other two CT scans. By not waiting for the second two scans, the benefit should be a 9 minute savings.
  • The ER physician does the tele-stroke consult in the CT scan room. Usually, after the CT scans are completed, the patient is taken off of the CT scan table, transferred to a gurney, and then transported back to a regular ER exam room to do the tele-stroke video consult with the stroke neurologist. By taking the tele-stroke equipment into the CT scan room, we can eliminate the transfer and transportation time – the benefit should be a 5 minute savings.
  • Stock t-PA in the emergency department Pyxis machine. In the past, when there was a stroke alert, our pharmacist would have to go from wherever in the hospital they were at the time, down to the pharmacy in the basement of the hospital to get the t-PA, and then back up to the emergency department. By stocking the t-PA in the ER, the ER nurses can pull the t-PA out of the Pyxis and have it ready at the bedside. This saves the pharmacist from having to first go to the pharmacy to get the drug and so she/he can go directly to the ER to reconstitute the medication for IV administration. The benefit should be a 6 minute savings.
  • All stroke alerts go to the hospital medical director’s pager. Currently, I get receive pages for all STEMI alerts and all code blue alerts, 24-hours a day. If I am in the hospital, I go to all of these to help ensure that the hospital’s response is timely and effective. If I am at home or in the clinic, I can call in or check on-line through our electronic medical record to be sure that everything is running smoothly. The advantage is that it shows an institutional priority for good code blue responses and rapid STEMI “door-to-balloon” times. With this same personal response to all internal stroke alerts, we can emphasize that a stroke alert should activate the same sense of urgency as a code blue or STEMI. The benefit should be a 5 minute time savings.
  • Mock stroke alerts. We do all sorts of drills the hospital: mock code blues, massive transfusion protocol drills, disaster drills, fire drills, etc. The purpose of drills is to be sure that when the real thing happens, everyone knows their role and is able to perform their role efficiently and effectively. By doing stroke drills, my hope is that we can achieve all of the above time savings to shave a total of 35 minutes off our our door-to-needle times.

Completing the evaluation and initiating treatment of patients with a stroke is truly a team effort involving the ER nurses, the ER physician, the tele-stroke neurologist, the radiology technician, the radiologist, and the pharmacist. In order to consistently get the door-to-needle time under 60 minutes, it requires every member of the team to be prepared, to be practiced, and to prioritize the patient.

June 25, 2017

Emergency Department Life In The Hospital

Should Hospital Security Officers Carry Narcan?

Two days ago, I was leaving the hospital and I heard the overhead announcement “Code Blue, front entrance to the hospital”. Nine times out of ten, this is because someone slipped and fell and a panicked visitor will run into the front lobby yelling something about cardiac arrest. But as I’ve mentioned in a previous post, you just don’t know until you know and so we treat every code blue as an emergency, regardless of its location.

Our hospital’s chief of cardiology and I arrived at the same time. There was a minivan at the front entrance of the hospital and an animatedly hysterical woman standing at the side with an unconscious young man in the front seat. We asked a couple of quick questions: “Does he have diabetes?”, “Does he have seizures?”, “Did he take any street drugs?”. The answers were no, no, and he “just smoked a little weed”. I took a quick check of his forearms – no needle marks.

He had a strong pulse and was breathing regularly but the best we could do was to get him to briefly open his eyes with stimulation. His pupils were small. We managed to get him out of his car and onto a patient cart. A quick oximetry check showed his oxygen saturation was 94%. We raced him to the emergency department which meant down a hallway, up one level in an elevator, and down another hallway. While we were in route, I called to the ER and spoke to our emergency department’s medical director, who happened to be on duty that evening. As we were wheeling the guy through the hospital, I told him to have a dose of intranasal Narcan ready when we arrived.

About 7 or 8 minutes after the code blue was first called, we got him into a room in the ER. By that time, he was pretty much unresponsive. Before vital signs, blood draws, or hooking him up to a cardiac monitor, he got a dose of Narcan sprayed into his nose. About a minute later, he sat up asking what was going on. He got opioids somehow – either he was snorting heroin or injecting in some unobtrusive part of the body that wasn’t easily visible. Marijuana laced with fentanyl or carfentanil is always something that we worry about but it is probably pretty uncommon.

But from an emergency response standpoint, it was pretty clear that the guy was going to die if nothing was done. In patient care areas, we keep a “crash cart” that is stocked with all of the medications that are needed to treat a patient during a cardiorespiratory arrest. But carts are not immediately available everywhere in the hospital, for example, in the driveway in front of the entrance to the building. Panicked people don’t always know to take someone with an urgent medical condition to the hospital’s emergency room, they may not even know where the emergency room is – they just drive up to the front of the hospital and yell for help. When someone has an opioid overdose, intranasal naloxone (Narcan) is life-saving and even a couple minutes delay can mean the difference between life and death. Narcan is the drug overdose equivalent of bystander CPR for cardiac arrests. So, it behooves us to have it immediately available to hospital first responders to “code blues”.

Ohio started Project DAWN as a way of getting naloxone into people who overdose on opioids as quickly as possible. In 2016, the Columbus EMS personnel administered intranasal naloxone 2,300 times. In a 6-month pilot program, 125 Columbus police officers were given intranasal naloxone to carry – they administered it 58 times and all but one of the people survived. So if city police carry intranasal Narcan, should hospital security staff carry it also?

Our hospital is currently debating this. On the one hand, a security officer responds to every code blue and they also patrol the hospital grounds, including the parking lot, where a lot of drug overdoses arrive. On the other hand, there are a lot of security officers that would need to be trained and it would require us to buy a lot of doses of intranasal naloxone to supply them all. The other option would be our nursing supervisors – there is only one of them on duty at any given time and they also respond to all code blue calls. Because of their nursing background, they would require a lot less training in administration and would likely be a lot more comfortable administering the medication. With fewer of them, it wold require a lot fewer doses to supply them. I’m not sure what the final decision will be but it is clear that we need to make intranasal naloxone more widely available, even in the hospital.

In cities, there has to be a fire hydrant every 400 feet. There has to be a smoke detector in every bedroom of your house. There should be one fire extinguisher for every 200 square feet of building space. We go to great efforts to prevent people from dying of fires. Last year, 104 Ohioans died from fire. But last year, 4,149 Ohioans died of unintentional drug overdose. That means that in Ohio, you are 40 times more likely to die of an accidental drug overdose than from a fire. How many lives could we save if intranasal Narcan was as easily available as fire hydrants and fire extinguishers?

The simplistic answer is that you get people to stop using heroin and other opioids. But as I’ve stated in a previous post, humans have a 5,000 year history with opioids and if history teaches us anything, it is that you can’t make heroin and other opioids go away by education, legislation, or moralization.

It is time to look at intranasal Narcan the way we look at automated electronic defibrillators (AEDs). Get them to where the people are who need them.

May 26, 2017

Emergency Department Inpatient Practice

Disaster Drill Management

This week, our city staged a mass-casualty disaster drill. In preparing for it, I found that there is very little written about the medical director’s responsibilities in disaster preparation. The scenario was this: terrorists explode bombs at Mapfre stadium (home to the Columbus Crew professional soccer team) and John Glenn Airport then attack civilians with guns. At the same time, a truck runs into a crowd at Otterbein University and then the driver gets out and starts shooting into the crowd. In this year’s mock disaster, there are 500 trauma victims that are then dispersed to hospitals throughout Central Ohio.

The Joint Commission requires U.S. hospitals to do at least 2 disaster drills per year and each one is a little different. For example, we’ve had a simulated plane crash at the airport and a simulated super-flu epidemic in the past. The hospital sets up a command center and everyone wears a vest with a tag identifying that person’s role – incident commander, medical director, logistics director, communications director, public relations, etc. The medical director’s job can be summarized in two words: inventory and coordinate. Inventory available physician resources and coordinate to direct those resources to where they are needed. Here is how I approach it:

Designate on-site physician leaders in key areas. They don’t necessarily have to be specialists in those areas but they need to be knowledgable about those particular physicians and their needs. So, for example, a hospitalist could coordinate for the ICU and an anesthesiologist could coordinate the surgeons. The key physician areas are:

  • Emergency department
  • Intensive care unit and critical care
  • Surgery
  • Anesthesia
  • Hospitalists and medical specialists

Inventory physician assets. Find out who you have currently on-site in the hospital and who can be called in from home or outpatient locations. Don’t forget about residents or fellows. Start by paging all of the physicians who are scheduled to be working in the hospital that day and tally who you have from what specialties. Then page all of the physicians from specialties that you anticipate needing to determine who could come in to the hospital immediately if it was a real disaster. It is a good idea to use administrative staff to do this because it can be time consuming for you if 100 doctors are trying to respond to your pages. Also, do not have physicians call in to a phone number to confirm their availability because with a lot of physicians all trying to call in at the same time, they will just get a busy signal. Instead use text messaging and/or email. Because normal transportation routes may be impassable in a disaster, be prepared to give physicians that are driving to the hospital advice on the best routes to take to get in. The highest priority include:

  • ER physicians
  • General surgeons
  • Critical care physicians
  • Anesthesiologists
  • Orthopedic surgeons

Depending on the specific disaster, you may also need hospitalists, radiologists, oral maxillofacial/ENT surgeons, ophthalmologists, or infectious disease

Inventory dischargable/transferable patients.

  • Contact each admitting service/hospitalist to determine how many patients could be discharged immediately in order to free up bed capacity.
  • Determine how many patients can be transferred out of the ICU and PCU immediately to lower acuity hospital units.
  • Inventory emergency department patients who could be moved to other locations immediately (medical boarders waiting for an inpatient bed, psychiatric holds, etc.).
  • Determine number of level 1, 2, 3, 4. & 5 patients in the ED and how many of the low acuity patients could be moved out of ED bays immediately to create ED capacity.
  • Determine how many operating rooms you currently have open and how many you would have if you canceled all of the day’s elective surgical cases. For those operating rooms that currently have a surgery taking place, how long will the surgery take to complete so that you can use that OR for disaster victims?

Identify and inventory alternative treatment locations. What areas in the hospital could be converted to ICU-level care? For an ICU bed you basically have to have medical gases, monitoring equipment, and enough room to fit the patient plus equipment such as a ventilator. The PACU (surgical pre-op/post-op area) is a natural fit but it will likely be used for operating room support so other hospital locations may be more prudent. In our hospital, 2 areas that could be converted to ICU areas include the cath lab recovery rooms and the endoscopy suite recovery rooms.

What locations could be converted to non-surgical treatment areas? In a mass casualty event, there will be a lot of minor injuries, the so-called “walking wounded”. You will want to direct those victims to other locations so that you don’t clog up the emergency department and the operating room. Think “outside the box” to determine what units could be used for caring for minor injuries. For example, ambulatory clinic space can be used for treatment of minor abrasions and burns. At our hospital, we have a outpatient wound center and it can be converted to a temporary burn unit.

Work with the rest of the disaster center leaders to inventory equipment and supplies that your physicians will need. As the physician lead in the disaster command center, you will often be the one most knowledgable about needed resources:

  • Mechanical ventilators will be needed to support victims needing to go the ICU; if there are a lot of surgical casualties, you may also need additional ventilators in the PACU because the anesthesiologists may not have sufficient time to extubate patients in the OR in order to expedite patient flow in and out of the OR. If you don’t have enough ventilators and BiPAP units in the hospital, how many can your medical supply vendor get you on short notice? Many communities (including Columbus) have emergency depot supplies of gas-powered ventilators that are not very fancy but will work in a pinch.
  • IV fluids will be needed and often in large amounts. How many bags of lactated Ringers, saline, and plasmalyte do you have in stock?
  • What is your current supply of blood for transfusions including number of units of O negative blood?
  • Tetanus toxoid supplies in the pharmacy?
  • Trauma tourniquets – how many do you have and where are they located?
  • Central line kits – how many do you have in your hospital’s inventory?

Coordinate patient flow from ED triage physicians to appropriate inpatient/OR locations. In a true disaster, there will inevitably be some degree of unanticipated chaos. You will need to ensure adequate physician staffing at hospital locations managing victims and re-direct physicians to needed locations. The most effective way to do this is to use your various physician site/specialty leaders to give you on-site reports. Make sure you have their cell phone numbers loaded into your cell phone and use group texting so all of your physicians are getting up to date information.

Do a debriefing with your physicians. Find out what went well and what you can improve on the next time.

A great reference for disaster management is: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. October 2014:

April 6, 2017

Emergency Department

Should Emergency Department Wait Times Be Publicly Posted?

Currently in our medical center, there is a running debate about whether the emergency department wait times should be posted on the internet. This is a polarizing question and there are very strong opinions on both sides of the issue. What most people don’t realize is that your local hospital’s ER wait times are already posted on the internet at Medicare’s hospital compare website where you can find the average number of minutes you will wait:

  • Total wait to be admitted to the hospital (national average is 5.6 hours)
  • Wait to be admitted to the hospital after a doctor decides you need to be admitted (national average is 2.2 hours)
  • Total time spent in the ER for non-admitted patients (national average is 2.9 hours)
  • Time in the ER before you are evaluated by a healthcare professional (national average is 30 minutes)

If you don’t want to go to the Medicare website, you can go to the Yelp website and search your local hospital and find the same information.

Many hospitals have responded by putting their current wait times on-line or even on billboards outside of the hospital, updated every 5-15 minutes.

But if you read the fine print, it turns out that the ER wait time can mean different things. For example, at HCA Virginia hospitals, the on-line ER wait time is defined as “…the time of patient arrival until the time the patient is greeted by a qualified medical professional” (physician, nurse practitioner, or physician assistant). On the other hand, at the INOVA hospitals in Virginia, the on-line ER wait time is defined as the “…period from registration to assignment of provider (doctor, nurse practitioner or physician assistant)”. At WakeMed in North Carolina, the on-line ER wait time is defined as “…check-in to care being initiated by a doctor, nurse practitioner or physician assistant”. At Middlesex Hospital in Connecticut, the on-line ER wait time is defined as the time “…from registration to having a physician assigned to the case”. When I checked their website this morning, The Mountain States Health Alliance in eastern Tennessee/western Virginia boasted that 8 of their 11 hospitals had an ER wait time of zero minutes but they define their ER wait time as “…amount of time people have been in the waiting room”.

If you read these words carefully, you can see how it would be easy for hospitals to game the system. If I was the medical director at any of these hospital systems, here’s how I would make my ER wait times look better:

  • HCA Virginia. I would put a physician assistant behind the registration desk so that each patient would be “greeted by a qualified medical professional” as soon as they walked in the door.
  • INOVA Hospitals and Middlesex Hospital. I would have the registration staff “assign a provider” when the patient first registers at the front desk of the ER and then the patient can go wait in the waiting room until an ER bed is available.
  • WakeMed Hospital. I would have each patient go straight from the registration desk to a triage area where a nurse practitioner would check that patient’s vital signs, thus minimizing the time from “check-in to care being initiated by a nurse practitioner”.
  • Mountain States Health Alliance Hospitals. I would build out a 25-bay triage ward where patients would be taken as soon as they register so that they don’t have to wait in the “waiting area”.

So what are the advantages of publicly reporting your emergency department wait times?

  1. It is great advertising. A low posted ER wait time is a great marketing tool to attract insured patients to your hospital.
  2. Motivate your staff. If the doctors and nurses all see a big clock on the ER wall with the current wait time, it gets them motivated to move a little faster.
  3. Better allocation of resources. If the ER wait time is getting excessively high, then the hospital’s nursing director may be able to re-assign nurses from slow units to the ER and the medical director may be able to bring in additional ER doctors to help out or hospitalists to reduce inpatients “boarding” in the ER.
  4. Improve patient satisfaction. If you know that the ER wait time is 90 minutes, you’re less likely to be angry if you sit in the waiting room for 90 minutes than if you were expecting to be seen right away.
  5. Discourage low-acuity patients when the ER is busy. When your ER is full of patients with heart attacks and broken legs, you don’t want to take up precious rooms with a patient who comes in just because he has a cold. Presumably, that patient with a cold will either stay home, go elsewhere, or come back to your ER another time if he sees that he is going to have to wait a long time.
  6. You control the message. As can be seen from the examples above, there are many ways to define “ER wait time” and you can pick the number that makes your ER look best or that best suits your purposes for posting the ER wait time.
  7. Even out the work load among different hospitals. If your hospital is part of a larger health system with multiple hospitals in a single geographic area, then this is a way of insuring that the patient distribution among the different hospitals stays even. This makes staffing easier and improves staff satisfaction. This is particularly the case when office-based physicians have to send a patient to the emergency room – knowing which ER has the shortest wait time can best match the health system’s resources with the health system’s physicians’ needs at any given moment.
  8. Improve timeliness of care in the community. If the EMS squads know that one hospital has an unusually long wait time, then they can re-direct squads to another hospital in the community that is less busy thus ensuring that the entire geographic area’s health needs are being optimized. This has the potential to decrease ER overcrowding and is more proactive than waiting until an ER goes on “divert” status because they can’t take any more patients.

OK, what about the disadvantages of publicly reporting your emergency department wait times?

  1. “Self-triaging” can be dangerous to patients. A patient with a potentially serious condition may choose to stay home rather than go to the ER if the posted wait time is too long.
  2. They are not accurate. The ER wait time is inevitably going to be an average for all patients. However, an ER does not work on a  “first come, first served” basis. A patient with chest pain suspicious for a heart attack is always going to be taken back first, no matter how long the less acute patients have been waiting. So, an average wait time of 30 minutes may mean 0 minutes if you are having a stroke but 60 minutes if you have poison ivy.
  3. Increase stress level of the ER staff. If the doctors and nurses feel like they can’t keep up with the hospital’s wait time goal, (often because of patient surges that they can’t control), then they are at risk for getting burned out.
  4. You may look bad compared to the hospital a few miles away. Particularly if the other hospital chooses a different definition of ER wait time that is more easily achieved than your hospital does.
  5. You may discourage business. ER charges can be very lucrative, particularly for patients paying out of pocket or patients with commercial insurance. You hate to turn away paying customers.
  6. Risk patient satisfaction. If you define your ER wait time as “time to assignment of provider” but it still takes 2 hours before the patient actually sees that provider after the provider is assigned, the patient is going to be pretty unhappy if she expected the wait time to mean the time from walking in the door until a physician lays eyes on her.

So, what is the right answer? Well… there isn’t one. You first have to decide what your hospital’s motivation is for posting ER wait times – is it a marketing tool or a resource allocation tool? Next, you have to decide where you want to post waiting times – you will have vastly different effects (and different audiences) if you publicly post times on-line versus on a sign in the ER lobby versus on the hospital’s non-public website. Lastly, you have to decide how you are going to define your ER wait time.

My recommendation is to start by just reporting your ER wait time internally to hospital staff where you can trend the data and determine how you are going to use it to improve patient flow. Then pick a definition of wait time that is meaningful from an administrative standpoint, such as time from registration to actually being seen a physician/NP/PA in an ER room. Once you are internally comfortable with the information and what it actually means, then make it publicly available.

Publicly posted ER wait times should be a part of overall hospital strategy, not a means of hospital self-flagellation.

March 19, 2017

Emergency Department Intensive Care Unit

What Do You Do If You Can’t Intubate The Patient?

At our larger, tertiary care, University Hospital, we have a “difficult airway team” with an experienced anesthesiologist with a surgeon for back-up available in the hospital 24-hours a day. At University Hospital East, we don’t have a difficult airway team in the hospital at night and the anesthesiologist and surgeon have to be called in from home when a difficult-to-intubate patient develops respiratory failure. In the operating room, the percentage of patients with a difficult airway is 1-4% but in the ICU or ER, it is as high as 20%. So what can the hospitalist or emergency room doctor do to ventilate the patient for the 20 minutes it takes before help arrives? 15 years ago… not much. But now, we have a lot of devices that we can use when an endotracheal tube cannot be placed. Here are some of the more common ones:

  1. The video laryngoscope. One of the first of these to come to market was the Glidescope®. Similar devices include the McGrath, the King Vision®, the IntuBrite®, the APA™, the C-MAC®, and the Marshall Video Laryngoscope®. These laryngoscopes have largely replaced the rigid steel Macintosh and Miller laryngoscopes in many hospitals. They are easier to use and improve intubation success for less-experienced physicians. Many EMS units now carry them in their emergency squads. In our hospital, we have Glidscopes available in our ICU, OR, and ER. We still use standard laryngoscopes in our intubation kits that are in our crash carts but the respiratory therapists can get a Glidescope to the bedside on very short notice. They have been shown to double the likelihood of a successful intubation on the first pass of the endotracheal tube and can reduce the time of intubation to one-third the time it takes with a standard laryngoscope. Watch a video of how to use the Glidescope here.
  2. The bougie. Think of this as a guide wire for an endotracheal tube. Many times, when looking at an airway with a laryngoscope, you can see part of the vocal cords but not enough to confidently pass an endotracheal tube. Or, you may be able to get a good look at the vocal cords but as soon as you introduce the endotracheal tube, you obliterate your view. The bougie can solve this problem by being being small and semi-rigid. Also, it is colored blue so it is easy to see the tip of it, even if the is a lot of blood, fluid, or floppy laryngeal tissues covering up the vocal cords. Once you pass the bougie into the trachea, you then simply slide an endotracheal tube over the bougie and into the airway. If you can’t slide an endotracheal tube over the bougie, you can put an adaptor on the end of it and at least blow oxygen through it. Watch a video of how to use a bougie to facilitate intubation here.
  3. The laryngeal mask airway (LMA). These are very simple to insert and in fact, anesthesiologists will often use them during short duration surgeries to ventilate patients in the operating room. They require little skill to place and can ventilate patients sufficiently until you can get someone with advanced airway skills into the hospital to place an endotracheal tube. The LMA consists of an elliptical inflatable cuff that is inserted into the mouth (after lubricating it) and over the top of the tongue, along the hard palate until you meet resistance. You then inflate the cuff. In the middle of the cuff, is an opening that leads to the ventilation tube. When the cuff is inflated, it occludes the esophagus so that air coming out of the port can only go one way – down through the vocal cords into the trachea. They do need to be secured, particularly when transporting a patient, because if they migrate out of the mouth, air may not go into the trachea properly. Watch a video of insertion of an LMA here.
  4. The Combitube. This is somewhat similar to the King airway (see below). It is a fool-proof tube that you place into the mouth so that it can either go into the esophagus or the trachea – it will usually go into the esophagus. Either way, you can ventilate the patient. Inside the Combitube, there are two tubes – one with an opening at the distal tip of the tube and one with an opening on the side of the tube about a third of the way back from the distal tip. There are two balloons on the Combitube – one at the tip and one about half way back from the tip. So, if the tube goes into the esophagus, then you blow both the proximal and the distal balloon up and ventilate through holes on the side of the Combitube. The distal balloon prevents air from going into the stomach and the proximal balloon prevents air from going back out of the mouth. If the Combitube ends up going into the trachea, then you can ventilate the patient through the distal tip of the tube. If you are not sure where the tube is, you can use an end-tidal CO2 detector connected to each of the two ports of the Combitube to determine if you are in the esophagus or the trachea. Watch a video of how to place a Combitube here.
  5. The King airway. This looks a lot like a Combitube but it is designed to only go into the esophagus. Although there is a hole at the distal tip, it is only there in order to pass an NG/OG tube through it into the stomach and not designed to ventilate through it. Ventilation is through the side ports. Like the Combitube, the ventilation holes in the King airway are on the side of the tube, in between the two balloons. In a study of 27 emergency medical responders comparing the King airway to the Combitube, the King airway insertion time was 24 seconds and the Combitube insertion time was 38 seconds; the King airway was perceived by the responders to be easier to place and was preferred over the Combitube by 26/27 of the participants. Watch a video of how to place a King airway here.
  6. The nasal intubation. OK, so this is not exactly a new device. This is an old-school approach that I was taught to use for difficult airways back in the early 80’s, before LMAs, King airways, and Glidescopes were invented. You simply liberally lubricate a small (#7 or #6) endotracheal tube and insert it into the nares like you would a nasogastric tube. A little neosynephrine in the nose will open things up and make passage of the tube easier. Once the endotracheal tube makes the curve in the back of the pharynx, you listen over the end of the tube (or, better yet, place an end-tidal CO2 monitor on the end of the tube). If you position the patient’s head in the “sniffing position” (as opposed to bending the neck forward like you would when inserting a nasogastric tube) then you will have more success getting the tube to go into the trachea instead of the esophagus. Insert following the breath sounds (or end-tidal CO2 waveform) until you are in the trachea. This is a particularly useful approach when you can’t open the patient’s mouth fully to insert an endotracheal tube orally and can also be useful in the patient with angioedema. Watch a video of how to place a nasotracheal tube here.

The whole idea of using any of these techniques is to be able to ventilate the patient as quickly as possible. So when should they be used in the hospital? First, if the physician is not trained or proficient in performing endotracheal intubation with a standard laryngoscope – there is just too much that can go wrong such as placing the endotracheal tube in the esophagus or causing airway trauma that can create difficulty even for the skilled operator who performs an attempt later. Second, if the physician cannot get the patient intubated quickly using a standard laryngoscope – my rule is that if it takes 3 tries, you need to go to another option. If all else fails, then the cricothyroidotomy is the procedure of last resort. The last time I did one of these was on a dog during an Advanced Trauma Life Support course in 1983 and I hope that I never have to do one again.

If you are on call by yourself in the hospital at night, make sure you know what is available because when you are responding to a cardiorespiratory arrest and you encounter a difficult airway, you’re not going to have time to go to a computer and search the internet for advice.

February 28, 2017

Emergency Department

Found Down With A Needle In The Arm

“39 yo female presented in cardiac arrest after being found down with needle in her arm. Multiple epinephrine and Narcan given prior to arrival with no ROSC. Resuscitation continued briefly with PEA on monitor and patient was pronounced dead.” Every week, we review all deaths in the hospital. One of our quality nurses summarizes each case in a couple of sentences. Every 2-3 weeks, there is one similar to this one from last week. The perpetrators: heroin and fentanyl.

We often consider heroin abuse as a problem of modern times. But opioid use has been with us for at least 5,000 years and heroin abuse has been a plague on humanity for more than 100 years. It all started with the ancient Sumerians. They migrated from what is now Iran to settle between the Tigris and Euphrates rivers around 5,000 BC. They had one key advantage over all of the other tribes in the area, in that they learned irrigation techniques to keep their crops from dying during periods of drought. They flourished and by 3,000 BC, they had invented writing and from their writing, we can learn about what crops they grew. For example, we know that they grew barley and about 40% of it went to the brewing of beer. They also grew poppies that they called the “plant of joy”.

By 500 BC, the secret of opium poppy cultivation spread to the Akkadians, the Assyrians, the Egyptians, and then the Greeks. Two thousand years later in 1,500 AD, Europeans had figured out that you can get a stronger effect of opium by smoking it rather than by drinking it and from this was born the opium dens. With fast and sturdy sailing ships, the Europeans were eager trade with China for spice, porcelain, and silk. But Europe needed something to take to China in return and that something was opium.

In 1720, the British East India Company shipped 15 metric tons of opium to China and by 1840, that had increased to 2,555 metric tons. In 1804, morphine was first extracted from opium and it rapidly gained commercial success as an analgesic. In 1874, a chemist in London was experimenting with morphine by mixing it with various acids and he created diacetylmorphine. His work was forgotten and then in 1897, Felix Hoffman, working for the Bayer chemical company accidentally synthesized diacetylmorphine when he was trying to produce codeine. Scientists at Bayer had just invented another drug that they called aspirin and the head of Bayer decided to move forward with diacetylmorphine first because it was felt to have more commercial potential than aspirin. They called their new product heroin and said that it was 10 times more effective then codeine as a cough medicine and more effective than morphine as a pain reliever. They also pushed it as a treatment for asthma, bronchitis, and tuberculosis. In its first year, Bayer produced 1 ton of heroin. It was initially claimed to be completely non-addictive but soon there were heroin addicts world-wide and by 1913, Bayer decided to stop producing the drug.

Today, 80% of the world’s heroin comes from poppies grown in Afghanistan. Here in the United States, most heroin comes from Mexico and Colombia. Mexican heroin production has significantly increased over the past decade, rising from 26 tons in 2013 to an estimated 70 tons in 2015. The reason for the increase is the economics of capitalism in its purest form. First, Drug cartels previously were primarily in the business of cocaine and marijuana importation but with the increase of legalized marijuana production in the United States for recreational and medicinal purposes, the demand for illegal Mexican marijuana fell significantly. Second, coincident with this was the burgeoning appetite of Americans for opioid prescription pain pills resulting in a rather dramatic increase in the American demand for opioids. With a recent nation-wide crackdown on excessive opioid prescriptions, the supply of pills dried up. The reduction in the demand for Mexican marijuana and the increase in demand for opioids resulted in a ramped up production in Mexican heroin as business shifted from cannabinoids to opioids. It is simple supply and demand – the heart of capitalism.

A big part of the cost of heroin is the transportation costs – getting it across the U.S. border. As with any transportation cost, if you can decrease the size of your product, you can reduce your cost to get it to the market. Enter fentanyl. In medicine, we’ve used it as an intravenous anesthetic for many years. It is 50-100 times more potent than heroin. Therefore, by adding fentanyl to heroin, you can dramatically decrease the size and weight of the opioid, thus significantly decreasing transportation costs. So now, we have heroin that is often more than just heroin and will additionally contain fentanyl and its many derivatives, such as carfentanil (which is 100 times more potent than fentanyl)

The net effect of this is that we now have heroin available on the street that is more potent and cheaper than ever before. A single dose of heroin costs about $10-$15 dollars. In comparison, to buy a 40 mg oxycontin tablet on the street will cost about $25-$40. So, heroin is now usually cheaper than prescription pain pills when purchased illegally. As “pill mills” declined, street sales of heroin exploded.

In 2014, 1 out of every 300 Americans used heroin and more than 10,000 Americans died from heroin overdose. And the number keep going up. In 2015, 1,424 Ohioans died from a heroin overdose, an increase from 1,196 in 2014. Fentanyl overdose deaths in Ohio increased from 503 in 2014 to 1,155 in 2015. Last year, Franklin County (Columbus, OH) had 279 drug overdose deaths. Heroin and fentanyl have emerged as the top overdose killers in our state. At the same time, deaths from prescription opioids has fallen.

The Sumerians didn’t die of overdoses from sipping tea made from poppies 5,000 years ago. The Europeans didn’t die from overdoses from smoking opium 300 years ago. And people didn’t die from drinking Felix Hoffman’s newly invented heroin 100 years ago. But today, we have cheap and incredibly powerful heroin and fentanyl derivatives that make it all too easy to overdose and die, for as little as $15 or $20. So, for the near future, a chief complaint of “Found down with needle in her arm” will continue to be a common first line in the emergency room chart and a common epitaph on our nation’s gravestones. Opioid deaths come down to the principles of Economics 101.

January 3, 2017

Emergency Department

Diversion Is Deadly

Every day, I get an email with all of the statistics from the previous day’s emergency department activity. The one statistic that can drive me crazy is the emergency department diversion hours. These occur when the ER goes on “divert” status which means that emergency squads are told to bypass our emergency department and take patients to some other hospital’s emergency department. We never close the emergency department and patients can still walk-in to the ER normally.

There are several reasons that the ER can go on divert:

  1. The ER itself is overwhelmed (for example, multiple critically ill patients arrive at the same time)
  2. We don’t have any empty beds on the nursing units to admit patients to from the ER
  3. We don’t have any ICU beds to admit patients to from the ER
  4. We don’t have enough inpatient nurses to take care of more admissions

Diversion is bad news for several reasons. First, and most importantly, it means that our hospital does not have the resources to care for the patients in our community at that particular time. A patient who lives 5 blocks away should not have to be taken to another hospital 15 miles away where their family and friends cannot easily visit. Second, it disrupts continuity of care. Patients who always get their care in one hospital and whose physicians practice at that hospital are best served by being taken care of by the doctors who know them the best. Third, it is bad business. Hospital admissions are the fuel that keeps the hospital running and patients arriving by squad are far more likely to be admitted to the hospital than those who walk in through the front door who are more likely to be treated and released.

Last year, our ER diversion hours reached record highs. Rather than being a rarity as it had been for more than a decade, it was becoming a regular occurrence, at least once a week. Our initial solution was to open up 4 new ER beds and 5 new inpatient beds to avoid the “no room at the inn” phenomenon. That helped but didn’t solve the entire problem entirely. So next, we asked the 5 whys.

The 5 whys was a concept developed by the founder of the Toyota Corporation, Sakichi Toyoda. His idea was that if you identify a problem, then you keep asking why it occurred through 5 layers of inquiry in order to get to the root of the problem and solve it. So, for example, you identify a problem that your medical students are passing out when holding retractors during pancreatic surgeries.

  1. Why are the medical students passing out? Because they are hypoglycemic.
  2. Why are they hypoglycemic? Because pancreas surgeries go on for 5 hours and the medical students haven’t had anything to eat.
  3. Why don’t they get something to eat before the start of surgeries? Because they are pre-rounding on their patients until 8:00 AM and all of the donuts in the physician lounge are gone by 7:00 AM.
  4. Why are all of the donuts gone by 7:00 AM? Because the donut company only brings 3 boxes of donuts even though the administrator in charge of donuts always orders 8 boxes of donuts.
  5. Why do they only bring 3 boxes rather than 8 boxes of donuts? Because the donut administrator always fills the donut order out in blue ink and faxes the order to the donut company and since the blue ink doesn’t fax well, the “8’s” look like “3’s”.

So, what is the solution to the syncopal medical students? Buy the donut administrator a pen with black ink.

We applied this principle to our emergency squad diversion problem. First, we looked at the what days of the week we were going on divert and found that over the course of a year, diversion hours peaked on Wednesdays, pretty regularly and pretty dramatically on Wednesdays. In contrast, diversion was very rare on Fridays, Saturdays, or Sundays. Next, we looked at when our emergency department admissions peaked and it was on Mondays, again, pretty regularly and dramatically peaked on Mondays. Next we looked at when our elective surgery admissions peaked and it was on Tuesdays, very consistently on Tuesdays.

So the solution wasn’t to bring in extra ER physicians on Wednesdays or open additional inpatient beds on Wednesdays. The solution was to move one of our busiest orthopedic surgeons from operating on Tuesdays to operating on Thursdays. What had been happening was that we would get a bolus of emergency department visits on Mondays followed by a bolus of joint replacement surgery admissions  on Tuesdays and then by Wednesdays, we’d be out of inpatient beds. By Fridays, the Monday and Tuesday admissions would be ready for discharge and then we’d have excess inpatient capacity through the weekend. By moving the orthopedic surgeon to Thursdays, we evened out the admissions over the course of the week and presto, the ER diversion hours plummeted.

The 5 whys can keep you from making stupid decisions. Getting back to our medical students who were passing out in the OR, if we had stopped with the first why, we may have banned medical students from holding retractors. If we had stopped with the second why, we may have told the surgeon that he needs to finish his pancreas surgeries in 4 hours. If we had stopped with the third why, we may have required the medical students to come in an hour earlier to do their rounding. If we had stopped with the fourth why, we may have fired the donut company. It was only after the fifth why that the solution of buying a 99¢ black ballpoint pen to fix the problem became apparent.

December 17, 2016


Emergency Department

America’s Increasing Suicide Rate

suicide-in-the-usSuicide in the U.S. is increasing. It is the second leading cause of death for people age 10-34 and the tenth leading cause of death overall. Americans favorite method of suicide: firearms. One of the reasons for our country’s increasing suicide rate is the declining number of psychiatric beds compared to other nations. The Organisation for Economic Cooperation and Development (OECD) is a group of the top 35 industrialized countries in the world. A recent study analyzing the U.S. suicide rate found that it correlates perfectly with our declining psychiatric bed availability. Since 1998, we have had a 35% drop in the number of psychiatric beds. At the same time, we have seen a 24% increase in suicides.

In the U.S., there are 22 psychiatric beds per 100,000 population. The average world-wide is 72 per 100,000. Only 4 other countries have fewer psychiatric beds per capita than the United States: Italy, Chile, Turkey, and Mexico. Our annual suicide rate is 13 per 100,000 population which is high compared to the global average of 11.4 per 100,000.

It is not because we are psychiatrically healthier. Here in Central Ohio, our psychiatric beds are almost always full. This results in psychiatric patients backing up in our emergency departments, waiting to be admitted. Last week, for example, when I got in to work, we had 11 patients in the ER who were “psych holds”, that is patients who were determined to be at too high of risk of causing harm to themselves or others to release. They occupied 38% of all of our ER beds. Because each of these patients requires a “sitter” to watch them to ensure that they do not harm themselves or leave the ER, it ends up being an enormous use of hospital staff and resources.

The time suicidal patients spend in the emergency department is often wasted time. There are usually not psychiatrists, counselors, and social workers who can initiate the psychiatric care that the patients need. The patients are psychiatry purgatory, waiting to go somewhere that they can get their treatment.

As a society, we are under a constant demand to increase emergency department beds in order to meet the needs of our communities. Perhaps our first step should not be increasing ER beds but instead, increasing psychiatric beds. Surely the greatest economic powerhouse nation in the world can at least strive to be average in psychiatric care.

November 9, 2016

Emergency Department

Guns, Guns, Guns

gunYesterday, a man was shot a couple of miles from our hospital. Not an unusual event, people get shot every day in America’s large cities. Our hospital is not a designated trauma center but we still have gunshot victims dropped off at our front lobby by their friends – either they die in our ER or we stabilize them and send them to one of the regional trauma centers in Columbus. Guns are a way of life in our city, as they are in all cities in the U.S. We require all patients to go through metal detectors to get into the emergency department – as do all hospitals in town – and finding guns is not uncommon at the metal detector. We require anyone with a weapon to hand it over to our security personnel until they leave – a lot like an old west saloon.

Shootings and murder are commonplace in the United States. We kill each other more than any other first world nation and we are right up there with third world countries where a murder doesn’t even make headlines. We’re pretty good at the detective work that goes into solving those murders, our problem is that we just have too many of them.



To kill a person, two things have to happen. There has to be someone who wants to kill someone else and they have to have an effective way of killing. So, if killing another person requires both intent and an available method, which of these is the reason for the United State’s exceptionally high murder rate compared to peer countries? I’d like to think that it is not because Americans are full of more hatred than other industrialized nations.

A gun is a highly effective way to kill someone and we have too many of them. Guns are everywhere in the United States. We have more guns per capita than any other country on earth. In fact, we have more guns than we have people in our country.


What is the answer? I’m not any smarter than anyone else. But solutions need to start with what we agree on instead of starting with what we disagree on.

I think everyone in the U.S. would agree that a person shouldn’t be able to walk into a sporting goods store and by a nuclear weapon. But almost everyone would agree that a person who wants to go duck hunting should be able to buy a shotgun.

Everyone would agree that someone who was previously convicted of felony armed robbery and is also a card-carrying member of a terrorist group should not be allowed to buy guns. But almost everyone would agree that a law abiding citizen with no criminal record should be allowed to buy a gun.

We agree with the extremes of gun control. What we disagree with is where the line needs to be drawn in the middle. By spending all of our political energy on fighting each other in courts and legislatures about exactly where that middle line is for gun control, we’ve accomplished almost nothing. If we instead started with the fringes of the gun control debate and tried to figure out on what we can agree on, we might actually get something accomplished.

Don’t get me wrong. I’m not a raging liberal out to pry guns from everyone’s hands. I used to be a member of the NRA (when I perceived it as being an organization primarily dedicated to gun safety and recreational hunting rather than a lobby group for gun ownership). Some of my fondest memories from childhood were bird hunting with my father in early winter in rural Southern Ohio. And I’ve personally annihilated hundreds of clay pigeons over the decades (with permanent tinnitus as evidence).

But having too many guns and putting them in the hands of the wrong people just creates a lot more work for all of us who keep America’s hospitals working. As it is right now, we just make it too easy to kill each other in our country. For most of Americans, the topic of gun control is polarizing. But if you work in an emergency department or a trauma operating room, the lack of gun control is just exhausting.

Sorry to be up on a soap box about this. But we have to make steps to stop our country from being the murder capital of the Western World. I would much prefer my hospital to focus on treating disease than treating the consequences of motive + opportunity.

October 18, 2016