ART AND SCIENCE OF
CONDUCTING RESEARCH IN THE EMERGENCY DEPARTMENT
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The environment is chaotic and uncontrolled, but a
gateway for admission to every specialty in the hospital. Did you know the
emergency department is taking a lead in clinical research? You are listening
to ReachMD, The Channel for Medical Professionals.
Welcome to the Clinician's Roundtable. I am Dr. Shira
Johnson, your host, and with me today is Dr. Arthur Kellerman, professor of
emergency medicine and associate dean for health policy at Emory University.
Dr. Kellerman works clinically in the ER at Grady Memorial Hospital, Atalanta's
only public hospital and level 1 trauma center. He is considered to be one of
the nation's leading emergency care researchers, and he is a member of the
Institute of Medicine, the IOM, of the National Academy.
Today, we are discussing emergency medicine research, the
state of the art.
DR. SHIRA JOHNSON:
Welcome, Dr. Kellerman.
DR. ARTHUR KELLERMAN:
Hi, it's good to be here.
DR. SHIRA JOHNSON:
Can you tell us a little bit about your career path and some
of the things you have accomplished and why you are going to talk about
emergency room research today?
DR. ARTHUR KELLERMAN:
I have spent my career in emergency medicine from residency
to research fellowship and have largely practiced in public intercity hospitals
but in academic settings since the mid 1980s and a lot of my own personal
research has been clinically based or looked at issues involving how we deliver
emergency care in a populations that use emergency department and I have always
found that combining teaching at the bedside, patient care and asking and
answering academic questions is just an incredibly energizing, rewarding way to
pursue a medical career, and in fact the emergency department has increasingly
become a pivotal arena for not just inpatient care, but outpatient care in the
United States and it's a very rich environment for tackling some of the most
difficult and challenging dilemmas facing not only emergency physicians, but
any acute care clinician.
DR. SHIRA JOHNSON:
We know that the emergency department is the gateway to the
rest of the hospital and as a research pathway it has got so many
opportunities. It's got great historical data and you've got a fairly captive audience.
How have you seen this area explode in the last 20 years?
DR. ARTHUR KELLERMAN:
The key issues are first of all, more and more Americans,
for better or for worse, had had to turn to the emergency department as the
strains and challenges of our primary care system had become more evident.
Also many more patients today lack health insurance than 20 years ago, and for
them, the emergency department sometimes is their only source of care or their
last resort. Third, we've had major developments in biomedical research that
have given us new diagnostic tools and new treatment technologies to make a
difference in conditions with timely intervention that weren’t able to really
effect in the past. For example, use of thrombolytics or prompt admission to a
cath lab in the case of an acute MI or aborting stroke and evolution with
thrombolytic therapy or using advanced biomarkers to detect certain clinical
diseases so this combination of need and of increasingly powerful technologies
have allowed us to really make a difference in the lives of patients in a way
that is again both challenging, but very rewarding in emergency care settings.
DR. SHIRA JOHNSON:
Yeah, you know, and I know and some of our listeners do
too. It's really a very exciting place to be right now. There have been so
many studies that have been done at the ER in the last 10 or 15 years. I am
just going to pick out a few of them. Can you tell us a little about the study
out of Hopkins on HIV testing and what whole medical community can learn from
that?
DR. ARTHUR KELLERMAN:
The papers that we are discussing came out of the scientific
forum of the American College of Emergency Physicians, which is broadly
considered one of the two top academic meetings for emergency medicine
researchers each year in the country, the other being in the spring at the
Society for Academic Emergency Medicine that this particular session was really
sort of the greatest hits or the highlights of literally hundreds of research
papers that were presented at scientific assembly and one that stood out was a
study that looked back at 20 years of experience with HIV testing among
emergency department patients at the Johns Hopkins Hospital, and this is
important because Hopkins was a very influential research ground in the early
days of understanding the prevalence of HIV infection, particularly in patients,
who came in and did not know that they were infected and were one of the major
driving forces in developing the concept of universal precautions. In other
words, assuming that every patient might have HIV and therefore we should take
appropriate protection from fluid and blood borne pathogens in every case. In
the beginning, we were saying "Gee, this person might have AIDS, I will
glove, I will be more careful. This person doesn’t, I don’t need to worry, and
obviously today we assume every patient is HIV positive just to make sure that
we don’t get burned in the patient, who is in fact infected and not aware.
Well, what this paper did was essentially looked at their most recent data on
serial prevalence in their emergency department population and really kind of
look back historically to see how things had changed over this 20-year period
of time when enormous changes in the epidemiology, and then the treatment of
HIV had occurred in the United States. The bottom line was that they found
that their overall prevalence rate was about 7.4% in males and in those ages
35-64 and not accounted for the majority of infections that they found in their
emergency department. This was down a bit from 1992 and from 2000, but still
an impressive amount, one that would certainly justify continued universal
precautions. They also found that while there had been a sharp decrease in the
number of patients coming in the door with unrecognized infections, once as
high as 3 out of every 4 in 1987, hit a low of 20% in 2003, but now is trending
back upwards; 42% of their patients were unaware that they were HIV positive.
DR. SHIRA JOHNSON:
So this would have been patients that came in for whatever
reason, thought they were negative, testing was done.
DR. ARTHUR KELLERMAN:
They were tested and turned out to be seropositive. So it
looks like we may be seeing an increase in people, who have not been getting
screened and therefore unaware that they are infected. They also found a
little more than 60% of patients, who reported having sex with an HIV infected
partner also had a positive serostatus. So basically the bottom line for this
study was that rates of unknown HIV infection, which had decreased steadily
over the first 15 years now look like they are trending upward. They have also
seen an overall decrease in HIV prevalence in their population over the last 5
years. Most of that is due to a decrease in people with diagnosed HIV and may
in fact reflect improvements in treatment, heart therapy and the like, but
clearly this is a disease that continues to be a common challenge in emergency
departments and one that requires ongoing vigilance.
DR. SHIRA JOHNSON:
What is the take-home message for the rest of the practicing
clinicians in the community?
DR. ARTHUR KELLERMAN:
Well, I think #1 it's that we have to continue to be careful
about assuming that every patient we deal with might be HIV positive and
therefore universal precautions are as relevant today as they ever were.
Second, it's important for patients who are at risk for HIV to be tested. The
fact that we are seeing an increase or at least the folks of Hopkins are seeing
an increase in the number of patients through the percentage that didn’t know
they were infected, suggests that both they and us need to be more alert to
making sure that people get tested because we do know that if people are aware
of their status, by and large they will change their behavior and tend to be
more careful and if people don’t know they are infected, they are more likely
to pass the infection on to a partner. Third it's clear that we have to make
sure that people don’t become complacent and that in an era where we now have a
lot of treatment options that people take prevention less seriously. So we
need to redouble our efforts on prevention, redouble our efforts on advising
and when appropriate testing and continue to practice universal precautions to
control this deadly disease.
DR. SHIRA JOHNSON:
And those are some great lessons to come out of emergency
room research. Let's talk about the study in Stony Brook, admitted patients
not having a bed, we see this as an almost everyday occurrence in larger
hospitals. How was this study and what did they find?
DR. ARTHUR KELLERMAN:
The group at Stony Brook has really championed a
straightforward, but for some radical notion, and that is that when the
hospital is full and admitted patients are backing up in the emergency
department, and this is in fact the #1 contributor to ER crowding across the
country. They basically challenged the notion why do we do this, why is it
okay that admitted patients, who've been hours for a bed can stay in an ER
hallway or top in exam room when the hallways upstairs are completely empty and
so they were a very early adopter of what they call a full capacity protocol,
which is essentially when there are more than three admitted patients boarding
in the ED waiting for a vacant bed and there is no space to see incoming
emergency department patients, they will pick the most stable admitted patients
and moved them to selected inpatient units where they are put in the bed in the
hallway under the observation of inpatient nursing until their room is
available, but they did more than that. Rather than simply changing the
practice, very properly they studied it and over a multi-year period they
compared the patients, who did go to the hallway, and there were over 2000 such
admissions who spent some time in the inpatient hallway before they got in
their bed compared to over 50,000 patients, who were admitted to a standard
floor bed. What they found first of all were that the two groups while they
were very similar in general characteristics they were different in a couple of
important ways. The patients who ended up going to the floor waited an average
of 7 hours for a bed. That tells you how busy this 65,000 visit a year
emergency department is and how long people had to wait to get admitted. The
hallway admissions actually didn’t go until over 10 hours, so they really only
moved people to inpatient hallways when the place was absolutely packed and
people were terribly backed up. Despite that, they found that the in-hospital
death rates were lower for patients, who ended up going to the hallway for a
period of time than the ones, who went straight to a bed, 2.5% for those who
went straight to the floor versus 1.1% for those who spent time in the
inpatient hallway. They also found that patients, who went to a regular bed,
but spent a long time in the ER or more likely ended up in the ICU. So in
other words, putting a person in an inpatient hallway for a few hours while
their room gets opened up, so that you can up your ER to take more incoming
patients and reduce ambulance diversion, is a safe practice.
DR. SHIRA JOHNSON:
And again and again we have seen we have to be our own
champions. We need to take this data back to your own hospital and make your
own case for a different way of doing things.
DR. ARTHUR KELLERMAN:
Right, and the issue we have to make sure people understand,
this is about quality and about patient safety. It is very difficult for an
emergency department nurse caring for two or three times the number of patients
that she or he should be to deliver safe and adequate care and most of the time
if you give families the choice or you give patients the choice, they would
much rather be on a quiet inpatient hallway close to a nurse's station waiting
for their bed than be in the middle of a noisy, brightly lit non-private
emergency department and so this is actually good for customer relations, it's
good for patient satisfaction and it's good for the institution and
interestingly when Stony Brook implemented this protocol, their patient
satisfaction scores, their Press Ganey scores skyrocketed. Patients were far
happier under this arrangement and it actually reflected well on the entire
institution. So this isn't just good practice, it's probably good business for
hospitals.
DR. SHIRA JOHNSON:
Dr. Kellerman, thank you for being our guest.
DR. ARTHUR KELLERMAN:
You're welcome.
DR. SHIRA JOHNSON:
We've been talking today to Dr. Arthur Kellerman. We've
been discussing the art and the science of conducting research in the emergency
department. Dr. Kellerman is from Emory University. I am Dr. Shira Johnson.
You've been listening to the Clinician's Roundtable from ReachMD, The Channel for
Medical Professionals. Please visit our website at www.reachmd.com, which
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