Family Medicine and Emergency Redeployment: Unrealized Potential

Background and Objectives: Discussions of scope of practice among family physicians has become a crucial topic amidst the COVID-19 pandemic, coupled with new attention to residency training requirements. Family medicine has seen a gradual narrowing of practice due to a host of issues, including physician choice, expanding scope of practice from physician assistants and nurses, an increased emphasis on patient volume, clinical revenue, and residency training competency requirements. We sought to demonstrate the flexibility of the family medicine workforce as shown through their scopes of practice, and argue that this is indication of their potential for redeployment during emergencies. Methods: This study computes scopes of practice for 78,416 family physicians who treat Medicare beneficiaries. We used Evaluation and Management (E/M) codes in Medicare’s 2017 Part-B public use file to calculate volumes of services done across six sites of service per physician. We aggregated counts and proportions of physicians and the E/M services they provided across sites of practice to characterize scope, and performed a separate analysis on rural physicians. Results: The study found most family physicians practicing at a single site, namely, the ambulatory clinic. However, family physicians in rural areas, where need is greater, exhibit broader scope. This suggests that a significant number of family physicians have capacity for COVID-19 deployment into other settings, such as emergency rooms or hospitals. Conclusions: Family physicians are a potential resource for emergency redeployment, however the current breadth of scope for most family physicians is not aligned with current residency training requirements and raises questions about the future of family medicine scope of practice.

Comparison of Blunt Abdominal Trauma Scoring System (BATSS) versus FAST in assessment of Blunt Trauma Abdomen

Trauma is the second largest cause of disease worldwide accounting for more than 16 % of global burden 1. By the next decade, the World Health Organization (WHO) estimates that trauma will be the leading cause of Years of Potential Life Lost (YPLL) amongst the world population. With advancement in infrastructure and economic prosperity, accidental trauma due to vehicular accidents has become more commonplace. A majority of victims of motor vehicular accidents present with Blunt abdominal trauma, which due to the complexity in diagnosis and management, presents with significant morbidity and mortality2. Introduced in the 1970s in Europe, point of care Ultrasonographic examination of the abdomen in trauma called as FAST (Focussed Assessment with Sonography for Trauma) has become a routine in emergency rooms worldwide 3. The Blunt Abdominal Trauma scoring system was developed to better diagnose intra-abdominal injury after blunt abdominal trauma 4. This study is aimed in comparing the findings of FAST and BATSS in predicting intra-abdominal injury accurately.

Computed tomography in intestinal obstruction: a tertiary care perspective from Northern India

Background: Intestinal obstruction is a very common surgical emergency faced today in surgical ERs (emergency rooms) all around the globe. With the advent of newer technology, management of intestinal obstruction has changed significantly. Today computed tomography (CT) employs both intravenous as well as oral contrast for determining the cause and the level of obstruction. It also gives additional information regarding any malignancy causing the obstruction, its staging and status of vessels. Thus, a surgeon can go in the procedure with a plan already in mind which can be discussed in detail with experienced surgeons beforehand.Methods: This was a prospective observational study that was done in department of surgery at GMC Jammu over a period of two years. Patients of intestinal obstruction who presented to our department were enrolled in this study. They were subjected to a contrast enhanced CT after due preparation and managed accordingly. Data was recorded in a tabulated fashion and evaluated.Results: After implementing the exclusion criteria’s, a total of 163 patients were included in this study, majority being males in the age group of 20-40 years. Major cause of intestinal obstruction was attributed to post-operative adhesions followed by band obstruction due to various cause. CT findings were seen to be quite significant in evaluation and management of intestinal obstruction. About 30 % of the patients enrolled in our study were treated conservatively while 70 % required operative intervention in form of exploratory laparotomy.Conclusions: Computed tomography is widely available now a days at a cheaper cost. It greatly increases the armamentarium of the surgeon in dealing with this condition. A lot many cases today are dealt conservatively due to high utilisation of CT scan. It also helps the surgeon to preoperatively plan a proper surgical approach

The Emergency Rooms and Emergency Medicine should not be the answer to the weakness of the Italian National Health System

Dear Editors, The COVID-19 pandemic has highlighted several and wellknown limits of the Italian national health system, including the weakness of the territorial medical services and the absence of dedicated structures for patients affected by chronic or end-stage diseases in need of long hospitalization, or with social difficulties. [...]

Comparing the first and second waves of COVID-19 in a tertiary university hospital in Barcelona

Background: Hospitals have constituted the limiting resource of the healthcare systems for the management of the COVID-19 pandemic. As the pandemic progressed, knowledge of the disease improved, and healthcare systems were expected to be more adapted to provide a more efficient response. The objective of this research was to compare the flow of COVID-19 patients in emergency rooms and hospital wards, between the pandemic's first and second waves at the University Hospital of Vall d’Hebron (Barcelona, Spain), and to compare the profiles, severity and mortality of COVID-19 patients between the two waves. Methods: A retrospective observational analysis of COVID-19 patients attending the hospital from February 24 to April 26, 2020 (first wave) and from July 24, 2020, to May 18, 2021 (second wave) was carried out. We analysed the data of the electronic medical records on patient demographics, comorbidity, severity, and mortality. Results: The daily number of COVID-19 patients entering the emergency rooms (ER) dropped by 65% during the second wave compared to the first wave. During the second wave, patients entering the ER were significantly younger (61 against 63 years old p<0.001) and less severely affected (39% against 48% with a triage level of resuscitation or emergency; p<0.001). ER mortality declined during the second wave (1% against 2%; p<0.000). The daily number of hospitalised COVID-19 patients dropped by 75% during the second wave. Those hospitalised during the second wave were more severely affected (20% against 10%; p<0.001) and were referred to the intensive care unit (ICU) more frequently (21% against 15%; p<0.001). Inpatient mortality showed no significant difference between the two waves. Conclusions: Changes in the flow, severity and mortality of COVID-19 patients entering this tertiary hospital during the two waves may reflect a better adaptation of the health care system and the improvement of knowledge on the disease.

“HIGH sensitivity Troponins In Patients With Elevated Pro BNP and Acute Heart Failure”. (HIGH-TRIP Trial)

Background:In patients presented to emergency rooms NT-Pro BNP essay is overly sensitive test to rule out heart failure but less specific in predicting outcomes in follow-ups, in this study we ought to find the added value of HS-Troponin I, in patients presented acutely with heart failure and its impact on mortality when Pro BNP is highly elevated.Methods:Prospective cohort study, inclusion criteria were age above 18 and clearly positive NT Pro BNP > 1000 pg/ml, with 12 months follow up period, primary end point was mortality from heart failure, secondary endpoint was need for rehospitalization.Results:95 patients were enrolled, divided into overt and non-overt pulmonary edema groups. Mean (NT-Pro BNP) was 6184 and 5927 pg/ml and mean (Hs-c Trop I) were 19.27 and 0.17ng/ml respectively, Mean Ejection fraction was 48+/-7 and 47+/-7 for each group sequentially. Mortality rate was 4 (13%) in the higher Hs-c Troponin I group, and 1 (1.6%) in the low troponin level group p=.03, odd ratio was 8.5, 95% CI (0.9-80). Need for re-hospitalization was present in 12 (38%) Vs 7 (8%) patients, p=.0081, odd ratio 4.8, 95% CI (1.7-14.2). In COX proportional hazard analysis, only Hs-cTN was a significant predictor of poor outcome in this high-risk cohort with p=0.0001.Conclusion: Adding (Hs-cTroponin I) assay to the panel of laboratory testing, in patients presented to ER with acute heart failure and with high Pro-BNP>1000, may further predicts mortality and rehospitalization rate.

Impact of profession and wards on moral distress in a community hospital

Background: Recently, a singular survey titled “Measure of Moral Distress—Healthcare Professionals,” which addresses shortcomings of previous instruments, has been validated. Aim: To determine how moral distress affects nurses and physicians differently across the various wards of a community hospital. Participant and research context: We distributed a self-administered, validated survey titled “Measure of Moral Distress—Healthcare Professionals” to all nurses and physicians in the medical/surgical ward, telemetry ward, intensive care units, and emergency rooms of a community hospital. Findings: A total of 101 surveys were included in the study. The mean Measure of Moral Distress—Healthcare Professionals score for all respondents was 143.0 (standard deviation = 79.8). The mean Measure of Moral Distress—Healthcare Professionals score was 1.75 greater for nurses than for physicians (92.5 vs 161.5, p < .001), and nurses were 2.52 times more likely to consider leaving their position due to moral distress (68% vs 27%). The mean Measure of Moral Distress—Healthcare Professionals score for moral distress was least prevalent in the medical/surgical ward (92.5, SD = 38.2) and highest in the telemetry ward (197.7, SD = 83.6). The intensive care unit ward had a mean Measure of Moral Distress—Healthcare Professionals score mildly greater than the emergency room. Ethical considerations: No participant identifying information or information connecting a survey response to an individual was collected. This study was approved by the Raritan Bay Medical Center’s Institutional Review Board. Discussion: This study provides insight into the level of moral distress in the community hospital setting. Telemetry nurses experience significantly more than nurses in other wards. Telemetry nurses typically manage patients sicker than medical/surgical wards, however do not have the resources of the critical care units. This scenario presents challenges for telemetry nurses and may explain their elevated moral distress. Conclusion: In community hospitals, telemetry nurses experience a considerably greater amount of moral distress compared to their colleagues in other wards. As measured by the Measure of Moral Distress—Healthcare Professionals questionnaire, moral distress continues to be higher among nurses compared to physicians.

Reduction in Pediatric Emergency Department Admissions during Lockdown: Just Fear of COVID-19?

Objective: Italy was the first European nation to undergo a general lockdown as a means of containing the COVID-19 pandemic. In that period, a significant reduction in pediatric accesses to emergency rooms (ERs) was reported. In this study, we evaluated whether, in addition to the fear of infection, the reduced ER visits were also an indirect indicator of reduced incidence of common seasonal viruses. Methods: Sales data for pediatric formulations of antipyretics and probiotics from 27 pharmacies were evaluated, during March-May 2020, and compared to sales during the same period in 2019. Pediatric accesses in the emergency department (ED) also were evaluated. Results: The median number of antipyretics and probiotics sold per pharmacy was respectively 152 (IQR = 144) and 55 (IQR = 52) in 2019; during the same period of 2020 it was 77.5 (IQR = 60) (p < .001) and 27 (IQR = 44) (p < .05). In the March-May period of 2019, the number of pediatric accesses was 1004, whereas in the same period of 2020 it was 143, a reduction of 85.76% (p < .001). Conclusions: We found a statistically significant reduction in pediatric admissions to the ED during the lockdown, but that this reduction could largely be due to a reduction in seasonal viral disease as an effect of social distancing, mask use, and frequent hand-washing, as mandated by healthcare dispositions.