Tag Archives: emergency department

Extubating Trauma Patients In The ED

Many patients are intubated in the emergency department who need brief control of their airway or behavior. In some cases, the condition requiring intubation resolves while they are still in the department. Most of the time these patients are admitted, typically to an ICU bed, for extubation. This is expensive and uses valuable resources. Is it possible to safely extubate these patients and possibly send them home?

Maryland Shock Trauma and Mount Sinai Medical Center looked at their experience in extubating selected patients in the ED. They looked at a series of 50 patients who were intubated for combativeness, sedation, or seizures. A specific protocol was followed to gauge whether or not extubation should be attempted.

None of the patients who were extubated per protocol required unplanned reintubation. One patient underwent planned reintubation when taken to the OR for an orthopedic procedure. 16% of patients were able to be discharged home from the ED.

Bottom line: A subset of patients who are intubated in the emergency department can be extubated once the inciting factor has resolved. These factors include sedation for painful procedures and combativeness. Following this protocol can reduce admission rates and reduce the use of scarce intensive care unit resources.

Click here to download a copy of the ED extubation protocol.

Related post: Trauma 20 years ago: ED intubation for head injury

Reference: Trauma patients can be safely extubated in the emergency department. J Emerg Med 40(2):235-239, 2011.

NOTE: The EMCrit blog, written by Scott Weingart, covered this topic in November 2010. He is the first author on the paper and has created a nice podcast on the topic. You can find his blog here, and you can download the podcast here.

Extubation in the Emergency Department

Many patients are intubated in the emergency department who need brief control of their airway or behavior. In some cases, the condition requiring intubation resolves while they are still in the department. Most of the time these patients are admitted, typically to an ICU bed, for extubation. This is expensive and uses valuable resources. Is it possible to safely extubate these patients and possibly send them home?

Maryland Shock Trauma and Mount Sinai Medical Center looked at their experience in extubating selected patients in the ED. They looked at a series of 50 patients who were intubated for combativeness, sedation, or seizures. A specific protocol was followed to gauge whether or not extubation should be attempted.

None of the patients who were extubated per protocol required unplanned reintubation. One patient underwent planned reintubation when taken to the OR for an orthopedic procedure. 16% of patients were able to be discharged home from the ED.

Bottom line: A subset of patients who are intubated in the emergency department can be extubated once the inciting factor has resolved. These factors include sedation for painful procedures and combativeness. Following this protocol can reduce admission rates and reduce the use of scarce intensive care unit resources.

Click here to download a copy of the ED extubation protocol.

Related post: Trauma 20 years ago: ED intubation for head injury

Reference: Trauma patients can be safely extubated in the emergency department. J Emerg Med 40(2):235-239, 2011.

NOTE: The EMCrit blog, written by Scott Weingart, covered this topic last November. He is the first author on the paper and has created a nice podcast on the topic. You can find his blog here, and you can download the podcast here.

Frequent Flyers in the Emergency Department

We’re all aware of the patients that are seen in the ED so frequently that the ER staff know their names, medical histories, and sometimes family members very well. They are the so-called “frequent flyers.” These patients have been characterized as uninsured and on occasion, undesirable.

A recent study analyzed 25 studies done in the last decade detailing the characteristics of these patients. As usual, reality is different that perception.

The study examined data from a variety of sources. The bulk of these studies examined patients being treated at university of public hospitals. Some highlights:

  • 1 in 20 ED patients were “frequent fliers”, and they accounted for more than a quarter of all ED visits. Many go on to become a frequent flyer the following year, too.
  • Half of frequent flyers presented to multiple EDs
  • The majority (60%) were middle-aged and white
  • Almost two-thirds had Medicare or Medicaid coverage. Only 15% were uninsured.
  • Frequent users were more likely to have seen a primary care physician in the year before their visits. They were also 6 times more likely to have been hospitalized after a visit.
  • Use of ambulances was more frequent, and mortality was higher.
  • Children were frequent flyers, too. Parents stated that access to a pediatrician was the major factor, but 95% of kids had a primary care provider.

Hopefully, this study will stimulate more scrutiny of this patient group. The research may give some insight into some of the unintended consequences of healthcare reform.

Reference: LaCalle, Rabin. Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications. Ann Emerg Med, in press, March 2010.