First EDition: News for and about the practice of Emergency Medicine
CDC updates guidance on protecting health care workers from Ebola; Malpractice reform failed to curb defensive medicine in the ED; New test will speed enterovirus D68 case confirmation from weeks to days; ED visits by young patients trended up in California; Pit bull bites are worse by several measures;Doubling of US heroin deaths spurs call for increased naloxone access; Opioid-poisoning deaths rose fastest in 55- to 64-year-olds.
CDC updates guidance on protecting health care workers from Ebola
By: Jennie Smith
The new guidance, issued Oct. 20, closely mirrors the Ebola personal protective equipment (PPE) guidance issued by Médecins Sans Frontières (Doctors Without Borders).
The CDC’s recommendations update the PPE guidance that was issued Aug. 1 and is now widely considered to be inadequate. The new recommendations advise that health care workers have no skin exposed, that they be supervised while donning and removing PPE, and that rigorous training and practice accompany any use of PPE in the treatment of patients with Ebola infections.
Specific equipment recommendations include double gloves, waterproof boot covers to mid-calf or higher, and a disposable fluid-resistant or impermeable gown that extends to at least mid-calf, or an coverall without a hood. The agency also recommends the use of respirators (N95 or powered air purifying), disposable single-use full-face shields in lieu of goggles, surgical hoods for complete coverage of the head and neck, and a waterproof apron extending from torso to mid-calf if patients have vomiting or diarrhea.
The guidance specifies that hospitals must have designated areas for putting on and taking off PPE and that trained observers monitor all donning and removal. The guidance also contains instructions for disinfecting PPE prior to its removal.
The agency emphasized that training, not merely having the correct equipment in place, was key to the successful use of PPE. “Focusing only on PPE gives a false sense of security of safe care and worker safety,” the CDC stated. “Training is a critical aspect of ensuring infection control.”
Facilities must make sure all health care providers practice “numerous times” until they understand how to properly and safely use the equipment, the CDC advised.
Malpractice reform failed to curb defensive medicine in the ED
By: Mary Ann Moon
Vitals Key clinical point: Changing the liability standard for emergency care did not reduce the practice of defensive medicine. Major finding: Malpractice reform failed to decrease intensity of practice in the ED, so eight of nine expected benefits never materialized. Data source: An analysis of all 3,868,110 ED visits to 1,166 hospitals from 1997 through 2011 in three states where malpractice reform was enacted. Disclosures: This study was supported by the Veterans Affairs Office of Academic Affiliations, RAND Health, and the RAND Institute for Civil Justice. Dr Waxman reported having no financial conflicts of interest; one of his associates reported receiving grant support unrelated to this study from The Doctors Company, CAP-MPT, Norcal, Physicians Insurance, and COPIC. |
Malpractice reforms enacted in three states approximately 10 years ago failed to reduce defensive medicine in the emergency department, according to a report published Oct. 16 in the New England Journal of Medicine.
The reforms changed the liability standard for emergency care from ordinary negligence to gross negligence, providing exceptionally broad protection to emergency physicians so they could feel safe from litigation if they stopped ordering unnecessary (and expensive) tests and stopped admitting patients who didn’t truly need inpatient care. The legal community in the three reform states – Texas, Georgia, and South Carolina – “characterizes the gross negligence standard as providing ‘virtual immunity’ to emergency physicians,” said Dr Daniel A. Waxman of RAND Health and the University of California, Los Angeles, and his associates.
“Our findings suggest that physicians are less motivated by legal risk than they believe themselves to be. Although a practice culture of abundant caution clearly exists, it seems likely than aversion to legal risk exists in parallel with a more general risk aversion and with other behavioral, cultural, and economic motivations that might affect decision making. “When legal risk decreases, the ‘path of least resistance’ may still favor resource-intensive care. Our results suggest that malpractice reform may have less effect on costs than has been projected,” they noted.
The researchers examined database information on 3,868,110 emergency department (ED) visits by Medicare patients to 1,166 hospitals across the 3 reform states, as well as to 10 neighboring control states, from 1997 through 2011. They found that the proportion of patients who underwent CT or MRI increased each year in both the reform states and the control states, and per-visit costs increased as well.
In a regression analysis, malpractice reform was not associated with a decline in CT or MRI use in any of the reform states. And in an analysis of ED costs, per-visit ED charges were not reduced after malpractice reform was enacted in either Texas or South Carolina; in Georgia, reforms were associated with a 3.6% reduction.
