- Email: [email protected]
International Sports Nursing Special Interest Group
LETTERS
LETTERS
TO THE
EDITOR
Submit all Letters to the Editor online at http://ees.elsevier.com/jen/
Door-to-ECG Time and Gender Equity
Dear Editor: We have read with interest the article published by Pearlman et al1 regarding the disparities in door-to-ECG time for patients with noncardiac chest pain. They failed to show gender or racial disparities in this time, but they found it was longer for younger patients (aged 18-39 years). Every effort to uncover gender inequities is welcome, especially when it is investigated in patients with a highly prevalent complaint such as chest pain in emergency department.2,3 Although the authors acknowledge several limitations in their study, we would like to underline two that may significantly influence the results. First, the time of patient inclusion (from noon to 8 PM) may explain the very long times elapsed between patient arrival and the ECG recording (around 30 minutes). In nearly all emergency departments,4,5 the afternoon is the most overcrowded time of day, and thus this is when objective markers of ED efficacy, such as door-to-ECG time, are predictably the worst. Therefore the prolonged times found by Pearlman et al probably do not mirror what is happening all day in their emergency department. Second, the low number of patients studied did not yield sufficient statistical power to perform multivariate analysis, thereby making it impossible to raise hard conclusions regarding the presence or absence of a gender bias in the door-to-ECG time. Using a very similar study design, we have recently examined the hypothetical gender bias in 2,111 patients at low risk for acute coronary syndrome who were seen in the chest pain unit of our emergency department.6 Women had a significantly longer door-to-ECG time than men (15 minutes vs 13 minutes, P < .01), although this difference disappeared after consideration of age and Thrombolysis in Myocardial Infarction score in a multivariate analysis. We recognize that improving chest pain care in the emergency department is a true challenge, ranging from an accurate initial assessment to a correct final diagnosis, treatment, and patient disposition.7,8 Our study findings are in agreement with the conclusions of Pearlman J Emerg Nurs 2009;35:279-81.
et al,1 but with the additional advantage that it does not have the previously discussed biases. Accordingly, we believe that the emergency department in general and the chest pain unit in particular respect gender equity in the management of urgent patients.—Òscar Miró, MD, PhD, Alba Riesgo, MD, and Miquel Sánchez, MD, PhD, Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain; E-mail: [email protected] doi:10.1016/j.jen.2009.04.015
REFERENCES 1. Pearlman MK, Tanabe P, Mycyk MB, Zull DN, Stone DB. Evaluating disparities in door-to-EKG time for patients with noncardiac chest pain. J Emerg Nurs 2008;34:414-8. 2. Mayberry RM, Nicewander DA, Qin H, Ballard DJ. Improving quality and reducing inequities: a challenge in achieving best care. World Hosp Health Serv 2008;44:16-31. 3. García-Castrillo L, Recuerda Martínez E, Loma-Osorio A, García-Camarero T, García-Cases C, Epelde Gonzalo F, et al. Nontraumatic chest pain in hospital emergency departments: characteristics and management in the EVICURE II study. Emergencias 2008;20:391-8. 4. Sánchez M, Salgado E, Miró O. Adaptive and survival organization mechanisms in the emergency department. Emergencias 2008;20:48-53. 5. Korn R, Mansfield M. ED overcrowding: an assessment tool to monitor ED registered nurse workload that accounts for admitted patients residing in the emergency department. J Emerg Nurs 2008;34:441-6. 6. Riesgo A, Bragulat E, López-Barbeito B, Sánchez M, Miró O. Diagnosis of chest pain in the emergency room: is the approach different for men and women? Emergencias 2008;20:399-404. 7. Goodacre SW, Angelini K, Arnold J, Revill S, Morris F. Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. QJM 2003;96:893-8. 8. Brady WJ, Ghaemmaghami CA. The significant challenge of chest pain in the Emergency department. Emergencias 2008;20: 374-6. International Sports Nursing Special Interest Group
0099-1767/$36.00 Copyright © 2009 Emergency Nurses Association. Published by Elsevier. All rights reserved.
Dear Editor: Given the ever-broadening horizon of nursing and the increasing acknowledgement of nurses’ skills, expertise, and
July 2009 35:4
JOURNAL OF EMERGENCY NURSING
279
LETTERS
knowledge, I would like to provide interested Journal readers with the opportunity to form an international special interest group in sports nursing. Sports take all forms, and involvement in sports has inherent risks and benefits. As a retired contact sport participant, I have been exposed to these various risks and benefits and have found, over time, that varying levels of care are provided to injured participants. In my own profession I have found that the knowledge of management of sports injuries is sparse and fragmented and, unfortunately, often incorrect, resulting in inadequate rehabilitation. Having completed postgraduate qualifications in sports medicine, I find that I am now being approached by other nurses who also have an active interest in caring for people who take part in sporting activities. These nurses have questions about the opportunities that are available to enable learning, how to facilitate information sharing, and how to develop the role of nurses involved in the sports medicine arena. As well, several internationally recognized sports physicians have commented that nurses have a very important part to play in sports medicine, and should they define that role, they could be formally recognized as a professional specialization. It is hoped that if members who have an active interest in sports medicine join together from around the world, they can develop and foster growth in the sports nursing perspective, which in turn will naturally further expand the roles and perspective of the nurse that we currently see. Any Journal readers who are interested in formulating an international sports nursing special interest group can contact me by e-mail.—Doug King, RCpN, BN, Lead Clinical Nurse Specialist, Emergency Department, Hutt Valley District Health Board, Lower Hutt 5010, New Zealand; E-mail: [email protected] doi: 10.1016/j.jen.2009.05.008
Screening Out Does Little to Address ED Overcrowding
Dear Editor: I agree with the authors that ED overcrowding is a major barrier to providing high-quality emergency care services.1 Overcrowding also contributes to the increasing number of ED patients who leave without being seen, and the sooner these problems are addressed, the better. However, I was disappointed to read that the authors proposed “screening out” as a potential solution. Screening out is really a form of ED diversion. Under diversion plans, patients are triaged, and based on their triage assessment,
280
they may receive a medical screening examination (MSE). The MSE is less comprehensive and less time-consuming than a full ED examination. Patients chosen to receive the MSE can elect to pay an additional fee for a complete evaluation if they choose. After the MSE, patients deemed as having a low level of acuity are referred to alternate sites of care with no guarantee that care actually will be delivered. The authors note that patients who are diverted out of emergency departments are not routinely seen as planned, and this holds true for both insured and uninsured patients. Diversion schemes do little to provide the services that patients require; they simply move individuals from one location to another. These plans could be disastrous when patients fail to get the help they need, and they might be a liability for providers if patients suffer harm. Contrary to suggestions that patients visit the emergency department out of convenience, the 2004 Emergency Department Summary of the National Hospital Ambulatory Medical Care Survey found otherwise. Of the 110 million ED visits recorded in 2004, only 12.5% were classified as non-urgent. By contrast, 13% of ED visits that year were emergent and 38% were listed as urgent, meaning that more than half of the patients needed treatment within a brief time frame. For adults older than 65 years, the number of emergent and urgent visits climbed to 63% of the total. The overall rate of return visits and subsequent hospital admissions at the Galveston facility is likely higher than reported because patients who are screened out will simply seek care at another site. I suggest that screening out will not reduce health care expenditures but cause expenditures to rise by shifting costs to other institutions and forcing patients to pay additional out-of-pocket ED co-pays. To propose that screening patients out of the emergency department will reduce overcrowding is like putting a bandage on a gunshot wound. Diverting patients away from the ED safety net is a potentially dangerous practice and one that I cannot endorse as a caring professional.— Denise Dunford, DNS, FNP-C, RN, Member, ENA of Western New York, Assistant Professor of Nursing, D’Youville College, and Emergency Nurse Practitioner, Department of Emergency Medicine, Buffalo General Hospital; E-mail: [email protected] doi: 10.1016/j.jen.2009.05.005
REFERENCE 1. Nash K, Nguyen H, Tillman M. Using medical screening examinations to reduce emergency department overcrowding. J Emerg Nurs 2009;35:109-13.
JOURNAL OF EMERGENCY NURSING
35:4 July 2009
LETTERS
TO THE
EDITOR
Submit all Letters to the Editor online at http://ees.elsevier.com/jen/
Door-to-ECG Time and Gender Equity
Dear Editor: We have read with interest the article published by Pearlman et al1 regarding the disparities in door-to-ECG time for patients with noncardiac chest pain. They failed to show gender or racial disparities in this time, but they found it was longer for younger patients (aged 18-39 years). Every effort to uncover gender inequities is welcome, especially when it is investigated in patients with a highly prevalent complaint such as chest pain in emergency department.2,3 Although the authors acknowledge several limitations in their study, we would like to underline two that may significantly influence the results. First, the time of patient inclusion (from noon to 8 PM) may explain the very long times elapsed between patient arrival and the ECG recording (around 30 minutes). In nearly all emergency departments,4,5 the afternoon is the most overcrowded time of day, and thus this is when objective markers of ED efficacy, such as door-to-ECG time, are predictably the worst. Therefore the prolonged times found by Pearlman et al probably do not mirror what is happening all day in their emergency department. Second, the low number of patients studied did not yield sufficient statistical power to perform multivariate analysis, thereby making it impossible to raise hard conclusions regarding the presence or absence of a gender bias in the door-to-ECG time. Using a very similar study design, we have recently examined the hypothetical gender bias in 2,111 patients at low risk for acute coronary syndrome who were seen in the chest pain unit of our emergency department.6 Women had a significantly longer door-to-ECG time than men (15 minutes vs 13 minutes, P < .01), although this difference disappeared after consideration of age and Thrombolysis in Myocardial Infarction score in a multivariate analysis. We recognize that improving chest pain care in the emergency department is a true challenge, ranging from an accurate initial assessment to a correct final diagnosis, treatment, and patient disposition.7,8 Our study findings are in agreement with the conclusions of Pearlman J Emerg Nurs 2009;35:279-81.
et al,1 but with the additional advantage that it does not have the previously discussed biases. Accordingly, we believe that the emergency department in general and the chest pain unit in particular respect gender equity in the management of urgent patients.—Òscar Miró, MD, PhD, Alba Riesgo, MD, and Miquel Sánchez, MD, PhD, Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain; E-mail: [email protected] doi:10.1016/j.jen.2009.04.015
REFERENCES 1. Pearlman MK, Tanabe P, Mycyk MB, Zull DN, Stone DB. Evaluating disparities in door-to-EKG time for patients with noncardiac chest pain. J Emerg Nurs 2008;34:414-8. 2. Mayberry RM, Nicewander DA, Qin H, Ballard DJ. Improving quality and reducing inequities: a challenge in achieving best care. World Hosp Health Serv 2008;44:16-31. 3. García-Castrillo L, Recuerda Martínez E, Loma-Osorio A, García-Camarero T, García-Cases C, Epelde Gonzalo F, et al. Nontraumatic chest pain in hospital emergency departments: characteristics and management in the EVICURE II study. Emergencias 2008;20:391-8. 4. Sánchez M, Salgado E, Miró O. Adaptive and survival organization mechanisms in the emergency department. Emergencias 2008;20:48-53. 5. Korn R, Mansfield M. ED overcrowding: an assessment tool to monitor ED registered nurse workload that accounts for admitted patients residing in the emergency department. J Emerg Nurs 2008;34:441-6. 6. Riesgo A, Bragulat E, López-Barbeito B, Sánchez M, Miró O. Diagnosis of chest pain in the emergency room: is the approach different for men and women? Emergencias 2008;20:399-404. 7. Goodacre SW, Angelini K, Arnold J, Revill S, Morris F. Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. QJM 2003;96:893-8. 8. Brady WJ, Ghaemmaghami CA. The significant challenge of chest pain in the Emergency department. Emergencias 2008;20: 374-6. International Sports Nursing Special Interest Group
0099-1767/$36.00 Copyright © 2009 Emergency Nurses Association. Published by Elsevier. All rights reserved.
Dear Editor: Given the ever-broadening horizon of nursing and the increasing acknowledgement of nurses’ skills, expertise, and
July 2009 35:4
JOURNAL OF EMERGENCY NURSING
279
LETTERS
knowledge, I would like to provide interested Journal readers with the opportunity to form an international special interest group in sports nursing. Sports take all forms, and involvement in sports has inherent risks and benefits. As a retired contact sport participant, I have been exposed to these various risks and benefits and have found, over time, that varying levels of care are provided to injured participants. In my own profession I have found that the knowledge of management of sports injuries is sparse and fragmented and, unfortunately, often incorrect, resulting in inadequate rehabilitation. Having completed postgraduate qualifications in sports medicine, I find that I am now being approached by other nurses who also have an active interest in caring for people who take part in sporting activities. These nurses have questions about the opportunities that are available to enable learning, how to facilitate information sharing, and how to develop the role of nurses involved in the sports medicine arena. As well, several internationally recognized sports physicians have commented that nurses have a very important part to play in sports medicine, and should they define that role, they could be formally recognized as a professional specialization. It is hoped that if members who have an active interest in sports medicine join together from around the world, they can develop and foster growth in the sports nursing perspective, which in turn will naturally further expand the roles and perspective of the nurse that we currently see. Any Journal readers who are interested in formulating an international sports nursing special interest group can contact me by e-mail.—Doug King, RCpN, BN, Lead Clinical Nurse Specialist, Emergency Department, Hutt Valley District Health Board, Lower Hutt 5010, New Zealand; E-mail: [email protected] doi: 10.1016/j.jen.2009.05.008
Screening Out Does Little to Address ED Overcrowding
Dear Editor: I agree with the authors that ED overcrowding is a major barrier to providing high-quality emergency care services.1 Overcrowding also contributes to the increasing number of ED patients who leave without being seen, and the sooner these problems are addressed, the better. However, I was disappointed to read that the authors proposed “screening out” as a potential solution. Screening out is really a form of ED diversion. Under diversion plans, patients are triaged, and based on their triage assessment,
280
they may receive a medical screening examination (MSE). The MSE is less comprehensive and less time-consuming than a full ED examination. Patients chosen to receive the MSE can elect to pay an additional fee for a complete evaluation if they choose. After the MSE, patients deemed as having a low level of acuity are referred to alternate sites of care with no guarantee that care actually will be delivered. The authors note that patients who are diverted out of emergency departments are not routinely seen as planned, and this holds true for both insured and uninsured patients. Diversion schemes do little to provide the services that patients require; they simply move individuals from one location to another. These plans could be disastrous when patients fail to get the help they need, and they might be a liability for providers if patients suffer harm. Contrary to suggestions that patients visit the emergency department out of convenience, the 2004 Emergency Department Summary of the National Hospital Ambulatory Medical Care Survey found otherwise. Of the 110 million ED visits recorded in 2004, only 12.5% were classified as non-urgent. By contrast, 13% of ED visits that year were emergent and 38% were listed as urgent, meaning that more than half of the patients needed treatment within a brief time frame. For adults older than 65 years, the number of emergent and urgent visits climbed to 63% of the total. The overall rate of return visits and subsequent hospital admissions at the Galveston facility is likely higher than reported because patients who are screened out will simply seek care at another site. I suggest that screening out will not reduce health care expenditures but cause expenditures to rise by shifting costs to other institutions and forcing patients to pay additional out-of-pocket ED co-pays. To propose that screening patients out of the emergency department will reduce overcrowding is like putting a bandage on a gunshot wound. Diverting patients away from the ED safety net is a potentially dangerous practice and one that I cannot endorse as a caring professional.— Denise Dunford, DNS, FNP-C, RN, Member, ENA of Western New York, Assistant Professor of Nursing, D’Youville College, and Emergency Nurse Practitioner, Department of Emergency Medicine, Buffalo General Hospital; E-mail: [email protected] doi: 10.1016/j.jen.2009.05.005
REFERENCE 1. Nash K, Nguyen H, Tillman M. Using medical screening examinations to reduce emergency department overcrowding. J Emerg Nurs 2009;35:109-13.
JOURNAL OF EMERGENCY NURSING
35:4 July 2009