Emergency Physician Risk Estimates and Admission Decisions for Chest Pain: A Web-Based Scenario Study

COVID-19 related negative emotions and emotional suppression are associated with greater risk perceptions among emergency nurses: A cross-sectional study

Background

As the COVID-19 pandemic began, frontline nurses experienced many emotions as they faced risks relevant to both patients (e.g., making errors resulting in patient harm) and themselves (e.g., becoming infected with COVID-19). Although emotions are often neglected in the patient safety literature, research in affective science suggests that emotions may significantly impact nurses' perceptions of risk, which can have downstream consequences. Further, the use of chronic emotion regulation strategies that are known to differ in adaptability and effectiveness (i.e., emotional suppression, reappraisal) can impact risk perceptions.

Objective

To investigate the relationship between nurses' emotional experiences in response to the pandemic and their estimates of how likely they would be to experience adverse outcomes related to both patients and themselves within the next six months. Additionally, we investigated the extent to which the use of suppression and reappraisal processes to manage emotions are associated with these risk perceptions.

Design

Cross-sectional survey.

Setting

Online survey distributed via email to emergency nurses at eight hospitals in the northeastern United States during fall 2020.

Participants

132 emergency nurses (M _age = 37.05; 81.1% Female; 89.4% White).

Methods

Nurses reported the extent to which they experienced a variety of positive (e.g., hope, optimism) and negative (e.g., fear, sadness) emotions in response to the COVID-19 pandemic, and reported their perceptions of risk to both patients and themselves. Nurses also completed the Emotion Regulation Questionnaire, a measure of chronic tendencies to engage in emotional suppression and reappraisal. Immediately prior to providing data for this study, nurses completed an unrelated decision-making study.

Results

Nurses' negative emotions in response to COVID-19 were associated with greater perceptions of both patient safety risks (b = 0.31, p < .001) and personal risks (b = 0.34, p < .001). The relationships between positive emotions and risk perceptions were not statistically significant (all p values > 0.66). Greater chronic tendencies to suppress emotions uniquely predicted greater perceptions of patient safety risks (b = 2.91, p = .036) and personal risks (b = 2.87, p = .040) among nurses; however, no statistically significant relationships with reappraisal emerged (all p values > 0.16).

Conclusions

Understanding factors that influence perceptions of risk are important, given that these perceptions can motivate behaviours that may adversely impact patient safety. Such an understanding is essential to inform the development of interventions to mitigate threats to patient safety that emerge from nurses' negative emotional experiences and their use of different emotion regulation strategies.

Tweetable abstract

Covid-related negative emotions and emotional suppression are associated with greater patient and personal risk perceptions among emergency nurses @lindamisbell @Nathan_Huff_1.

Association of physician malpractice claims rates with admissions for low-risk chest pain

Background

Chest pain accounts for 5% of all emergency department visits and accounts for the highest malpractice payout against emergency physicians. To clarify the impact of defensive medicine, we assessed whether admission rates of low-risk chest pain patients are associated with malpractice claims rates.

Methods

A cross-sectional time-series analysis of state-year level malpractice claims rates, admission rates for low-risk chest pain (LRCP; requiring ED physician discretion), and admission rates for acute myocardial infarction (AMI; requiring minimal physician judgment for admission, used as a control) from 2008 to 2017 was performed. Admission rates were derived from Optum's deidentified Clinformatics Data Mart Database. LRCP visits were defined by primary ICD-9 or ICD-10 codes of 786.5, R07.9, or R07.89; length of stay of 2 or fewer days; and no previous major cardiac diagnosis and AMI visits with ICD-9 or ICD-10 codes 410, I21.3, or I121.9. Malpractice claims rates (MPCRs) were derived from the National Practitioner Database (NPD). The association between state-year level MPCR and admission rates for LRCP and AMI was estimated using state fixed-effects models. Standardized costs were inflation adjusted and are expressed in US dollar rate as of 2019.

Results

There were 40,482,813 ED visits during the 10-year study period, of which 2,275,757 (5.6%) were for chest pain, and 1,163,881 met LRCP criteria. Mean age of LRCP patients was 67.8 years, 60.9% were female, and 16.6% were hospitalized, at a mean cost of $17,120. During the same period, 75,266 (0.2%) visits were for AMI, with 87% admitted. The MPCR by state-year varied widely, from 2.6 to 8.6 claims per 100,000 population. A state fixed-effects model showed that an additional physician malpractice claim per 100,000 population was associated with a 3.66% (95% CI 2.02%-5.30%) increase in the admission rate of LRCP. An analogous model showed no association between MPCR and admission rates for AMI (-1.52%, 95% CI -4.06% to 1.02%).

Conclusion

Higher MPCRs are associated with increased admission rates for LRCP, at substantial cost, which may be attributable to defensive medicine in the ED.

Clinical Decision Rules in the Evaluation and Management of Adult Gastrointestinal Emergencies

Although abdominal pain is a common chief complaint in the emergency department, only 1 in 6 patients with abdominal pain are diagnosed with a gastrointestinal (GI) emergency. These patients often undergo extensive testing as well as hospitalizations to rule out an acute GI emergency and there is evidence that not all patients benefit from such management. Several clinical decision rules (CDRs) have been developed for the diagnosis and management of patients with suspected acute appendicitis and upper GI bleeding to identify those patients who may safely forgo further testing or hospital admission. Further validation studies demonstrating the superiority of these CDRs over contemporary practice are needed.

Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes

BACKGROUND

Wide variation exists for hospital admission rates for the evaluation of possible acute coronary syndrome, but there are limited data on physician-level variation. Our aim is to describe physicians' rates of admission for suspected acute coronary syndrome and associated 30-day major adverse events.

METHODS

We conducted a retrospective analysis of adult emergency department chest pain encounters from January 2016 to December 2017 across 15 community emergency departments within an integrated health system in Southern California. The unit of analysis was the Emergency physician. The primary outcome was the proportion of patients admitted/observed in the hospital. Secondary analysis described the 30-day incidence of death or acute myocardial infarction.

RESULTS

Thirty-eight thousand seven hundred seventy-eight patients encounters were included among 327 managing physicians. The median number of encounters per physician was 123 (interquartile range, 82-157) with an overall admission/observation rate of 14.0%. Wide variation in individual physician admission rates were observed (unadjusted, 1.5%-68.9%) and persisted after case-mix adjustments (adjusted, 5.5%-27.8%). More clinical experience was associated with a higher likelihood of hospital care. There was no difference in 30-day death or acute myocardial infarction between high- and low-admitting physician quartiles (unadjusted, 1.70% versus 0.82% and adjusted, 1.33% versus 1.29%).

CONCLUSIONS

Wide variation persists in physician-level admission rates for emergency department chest pain evaluation, even in a well-integrated health system. There was no associated benefit in 30-day death or acute myocardial infarction for patients evaluated by high-admitting physicians. This suggests an additional opportunity to investigate the safe reduction of physician-level variation in the use of hospital care.

Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain

OBJECTIVE

We compare utilization of diagnostic resources and admissions in emergency department (ED) patients with chest pain and abdominal pain when managed by advanced practice providers (APPs) and physicians.

METHODS

We used 2016 to 2019 data from a national emergency medicine group. We compared visits managed by physicians and APPs based on demographics and observed resource utilization (labs, radiography, computed tomography) use and hospital admission/transfer, stratified by patient age. To reduce selection bias, we created inverse propensity score weights (IPWs). To estimate the average treatment effect for APP visits for each outcome, we included IPWs in a multivariable linear probability model with a dummy variable indicating treatment by an APP and used a facility fixed effect. We then estimated the average treatment effect comparing physician to APP visit for all visits and for discharged visits separately, stratified by the study outcomes. Sensitivity analyses were performed using different cohort definitions and adjusting for past medical history.

RESULTS

In chest pain, we included 77,568 visits seen by 1,011 APPs and 586,031 visits seen by 1,588 physicians. In abdominal pain, we included 184,812 ED visits seen by 1,080 APPs and 761,230 visits seen by 1,689 physicians. For both chest pain and abdominal pain visits, physicians saw more older adult patients (55+ years) and admitted a higher percentage of visits than APPs. For chest pain, physicians saw more circulatory system diseases (70.7% vs. 58.6%); APPs saw more respiratory system diseases (17.1% vs. 9.8%). In abdominal pain, emergency physicians saw more digestive system diseases (28.5% vs. 23.3%); APPs saw more genitourinary system diseases. After matching with IPW, predicted probabilities of laboratory, radiology, and admissions either did not vary or were slightly lower for APPs compared to physicians for all outcomes. Sensitivity analyses showed similar results, including controlling for past medical history.

CONCLUSION

Diagnostic testing and hospitalization rates for chest pain and abdominal pain between APPs and physicians is largely similar after matching for severity and complexity. This suggests that APPs do not have observably higher use of ED and hospital resources in these conditions in this national group.

How the Availability of Observation Status Affects Emergency Physician Decisionmaking

STUDY OBJECTIVE

This study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians' subsequent decisionmaking.

METHODS

We conducted detailed semistructured interviews with 24 emergency physicians, including 10 from a hospital in the US Midwest, and 14 from 2 hospitals in central and northern England. Data were extracted from the interview transcripts with open coding and analyzed with axial coding.

RESULTS

We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients, depending on the physician's individual level of risk aversion. Placing patients under observation made some physicians more systematic, whereas others cautioned against overreliance on observation services in the face of uncertainty.

CONCLUSION

Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder, rather than facilitate, decisionmaking.