Correspondence / American Journal of Emergency Medicine 34 (2016) 903-932 915

Table

Manual vs. Lifeline ARM Chest Compressions. Data are presented as median (interquartile range).

Parameter Manual CC ARM CC p Value

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Perkins GD, Handley AJ, Koster RW, Castren M, Smyth MA, Olasveengen T, et al.

Adult basic life support and Automated external defibrillation section Collaborators. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95: 81-99. http://dx.doi.org/10.1016/j.resuscitation.2015.07.015.

Kurowski A, Szarpak L, Bogdanski L, Zasko P, Czyzewski L. Comparison of the effectiveness of cardiopulmonary resuscitation with standard manual chest compressions and the use of TrueCPR and PocketCPR Feedback devices. Kardiol Pol 2015;73(10):924-30. http://dx.doi.org/10.5603/KP.a2015.0084.

Krueger GP. Psychological and performance effects of chemical-biological protec-

tive clothing and equipment. Mil Med 2001;166(12 Suppl.):41-3.

Prior authorization for child and adolescent

Psychiatric patients deemed to be in need of inpatient admission?

To the Editor,

Four million children and adolescents in the US suffer from a serious mental disorder that causes significant functional impairments at home, at school and with peers [1]. In any given year, only 20% of children with Mental disorders are identified and receive mental health services [2]. In youth, many of these disorders can have life-long deleterious effects.

Although obtaining timely care for Young people with psychiatric disorders is vitally important, by requiring prior authorizations before patients are admitted, insurers make obtaining needed care difficult. Previous research has examined the prior authorization process among adult psychiatric patients deemed in need of hospital admission [3]. In the current study we sought to formally examine this process as it pertains to children and adolescents who are deemed in need of inpatient admission. To do so, between the periods of May 2014 and October 2014, licensed social workers employed in the psychiatric consultation service embed- ded in the emergency department at Hasbro Children’s Hospital in Rhode Island, completed paperwork each time they contacted an insurance company on behalf of a child deemed in need of psychiatric admission. For each patient, the social workers recorded the patient’s age, gender, race, chief complaint, insurance company, time on the phone required to obtain authorization, decision and length of stay authorized. The Lifespan

Institutional Review Board approved this study.

We obtained 203 data sheets, and of these individuals, 55.7% (113/207) were female and 44.3% (90/203) were male. They ranged in age from 4 to 19 years old-although only one patient was 19 years of age-and the average age was 13.6. The most common reasons for admission included suicidal ideation or a suicide attempt (114 patients, or 56.2%), aggression (44 patients, or 21.7%), and homicidal ideation (21 patients,

? Disclosures: None.

or 10.4%). Other chief complaints included eating disorder, anger, self-injurious behavior, and Auditory hallucinations.

The average time required to obtain authorization from the insurance company from the time of first contact to authorization was 59.8 min ranging from 3 min to 270 min. There were variations in time required based on Insurance type. Blue Cross Blue Shield, which was used by 18.2% (37/203), required 76.5 min on average to complete the authorization process. United Health Care, which was utilized by 27.6% (56/203) of patients, required 56 min on average and Neighborhood Health Plan, which was the most popular insurance and was utilized by 43.8% (89/203) of patients, required 51.4 min. Forty-eight percent (98/203) of our 203 data sheets had the number of days approved listed on their form, and the average was 2.42 days, which included some patients boarding overnight in the medical hospital before a psychiatric bed was available. All 203 requests for authorization were granted and none were denied.

One study found that the median length of stay (LOS) for emergency department visits for primarily psychiatric reasons was, on average, 61 min longer than the median LOS for other visits [4]. Being between ages 6 and 13 years old, in particular, predicted an extended stay. Extended lengths of stay (EL-LOS) can create safety risks. One study found that patients with EL-LOS’s can “threaten provider safety” [5].

Given that 100% of our attempts to obtain authorization were granted,

the need to obtain prior authorizations appears to function more as an administrative hurdle rather than an effective triage mechanism, because if professionals know they or their colleagues are going to have to spend lengthy amounts of time on the phone with the insurance company, they may think twice prior to trying to admit a given patient.

The requirement to obtain prior authorization is common across the country. One national survey of the time that physicians and other practice administrators spend interacting with insurance companies calculated that the annual cost to our health care system for all physicians nationwide to engage in these non-reimbursable interac- tions was at least between $23 billion and $31 billion [6]. If physicians and social workers doing psychiatric consultations in the emergency department are spending significant amounts of time obtaining authoriza- tion rather than seeing patients, the costs could also be astoundingly high. Insurance reviews and pre-authorization requests are just a part of what makes accessing needed psychiatric care difficult for children and adolescents, given that finding comprehensive services for children is only possible in certain parts of the country. Adding prior authorization to an already difficult process, especially for psychiatric patients who are deemed to be of “imminent risk” to themselves or others,

seems both dangerous and predatory.

Onerous prior authorization requirements that single out the most severely ill psychiatric patients should be halted. It burdens our psychiatric clinicians and functions to limit care by placing time consuming bureaucratic burdens on clinicians rather than meaningfully evaluating patient’s needs. Insurance companies need to stop requiring prior authorizations so that our patients receive the safest and most timely care possible.

Amy Funkenstein, MD

Department of Psychiatry, Tufts Medical Center, Boston, MA

Stephanie Hartselle, MD

Department of Psychiatry and Human Behavior, Warren Alpert School of

Medicine, Brown University, Providence, RI

J. Wesley Boyd, MD, PhD Center for Bioethics, Harvard Medical School 26 Central Street, Somerville, MA, 02143

Department of Psychiatry, Cambridge Health Alliance/Harvard Medical School

26 Central Street, Somerville, MA, 02143 Corresponding author. Tel./fax: +1 781 449 1995 E-mail addresses: [email protected]

http://dx.doi.org/10.1016/j.ajem.2016.02.027

916 Correspondence / American Journal of Emergency Medicine 34 (2016) 903-932

References

1. National Research Council and Institute of Medicine. Preventing Mental, Emotional, and Behavioral Disorders Among Young People. Available at http:// iom.nationalacademies.org/Reports/2009/Preventing-Mental-Emotional-and- Behavioral-Disorders-Among-Young-People-Progress-and-Possibilities.aspx. [Accessed July 21, 2015].
2. U.S. Public Health Service. Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. Washington, DC: Department of Health and Human Services; 2000 .
3. Funkenstein A, Malowney M, Boyd JW. Insurance prior authorization approval does not substantially lengthen the emergency department length of stay for patients with psychiatric conditions. Ann Emerg Med 2013;61(5):596-7.
4. Case SD, Case BG, Olfson M, Linakis JG, Laska EM. Length of stay of pediatric Mental Health Emergency Department visits in the United States. J Am Acad Child Adolesc Psychiatry 2011;50(11):1110-9.
5. Stephens RJ, White SE, Cudnik M, Patterson ES. Factors associated with longer length of

   stay for Mental Health Emergency Department patients. J Emerg Med 2014;47(4):412-9.

   Casalino LP, Nicholson S, Gans DN, Hammons T, Morra D, Karrison T, et al. What does it cost physician practices To interact with Health insurance plans? Health Aff 2009;28(4):w533-43.

   Which out-of-hospital cardiac arrest patients should be thrombolysed?

   

   To the Editor,

   It appears that there is benefit with thrombolysis in ST-elevation myocardial infarction and hemodynamically unstable pulmo- nary embolism (PE) [1,2]. In cardiac arrest the evidence is inconclusive although there is a robust biological rationale [1,2]. TROICA (Thrombolysis for Out of Hospital Cardiac Arrest), a large double-blinded randomized placebo controlled trial showed no difference in 30-day mortality between thrombolysis and placebo group [3]. However, anti-thrombotics and salicylates weren’t given with the fibrinolytic agent in the TROICA trial, and multiple case reports and animal studies in the literature did show benefit in return of spontaneous circulation and neurological outcome in subjects given thrombolysis [4,5]. This dilemma was illustrated in a young patient in cardiac arrest we recently treated.

   A 36-year-old lady complained of cough, chest pain, and general malaise, and collapsed pulseless with ventricular fibrillation (VF) en route to hospital. She had a past medical history of pulmonary embolus (PE) complicated by stroke. She underwent prolonged cardiopulmonary resuscitation (CPR) (90 minutes) during which she was repeatedly defibrillated, intubated, received multiple boluses of adrenaline, Amiodarone, electrolytes, and finally Lidocaine whereupon she regained sinus rhythm. Throughout resuscitation thrombolysis was considered, ultimately being decided against. Following return of spontaneous circulation a computerised tomography pulmonary angiogram showed no PE, and electrocardiogram showed inferior ST elevation. A Right to left shunt with paradoxical Coronary embolism was suspected. She underwent urgent coronary angiography and a clot aspiration of a coronary embolus was performed. Subsequent bubble echocardiography confirmed a patent foramen ovale (PFO) suggesting paradoxical coronary embolism as the cause of cardiac arrest.

   The majority (50%-70%) of out of hospital cardiac arrests are due to MI or massive PE [3] suggesting that thrombolysis would be therapeutic. This woman had a history of Factor V Leiden mutation, PE, and cerebrovascular accident, which prompted consideration of veno-arterial shunt such as a PFO. The prevalence of PFO is quoted as 10% to 25% [6]. Paradoxical embolism is rarer [7] and paradoxical embolism causing MI is particularly rare [8] compared with CVA and extremity embolism. Valsava-type maneuvers can reverse flow across the shunt, as may have been the case with this woman’s cough.

   The management of this lady included the considered decision not to thrombolyse despite the background, in view of the uncertainty of the mechanism of the arrest.

   The following factors may be considered when contemplating thrombolysis during cardiac arrest.

   Underlying pathology. Thrombolysis in acutely hemodynamically unstable PE is supported [9].

   Timing of the lysis. Fifty percent of sudden deaths from MI occur within the first hour of symptom onset and are predominantly attributable to VF. Trials comparing pre-hospital thrombolysis to inhospital thrombolysis in highly selected patients suggest improve- ment in 30-day mortality [10].

   Consequence of decision. The half-life of Tenecteplase is 20 minutes, committing carers to prolonged CPR.

   Age. The most feared complication is intracranial hemorrhage (0.4% to 0.8%), with older patients making up the majority of the cohort, with a third dying. The relevance of fibrinolysis in younger smoking patients where acute obstruction is composed of fibrin and thrombin rather than atheromatous plaques is demonstrated by a study in India showing increased benefit of fibrinolytic agents in younger patients in with suspected STEMI compared with older non-smoking patients [11].

   Contraindications. The evidence for the relative contra-indications to lysis is very scant. CPR was once a relative contra-indication due to perceived risk of hemorrhage secondary to chest trauma [12].

   Access to alternative interventions. extracorporeal membrane oxygenation, cardiac bypass, percutaneous interventions and surgery have been successfully used [13].

   Overall, currently the risk to benefit ratio of thrombolysis in cardiac arrest remains poorly understood but review of the literature suggests it tips in favor in out of hospital cardiac arrest from suspected PE, and in younger patients with suspected STEMI if given early, with heparin and aspirin, where alternative interventions are not imme- diately available, although further trials are required to confirm this.

   Ben McCartney Noosa Hospital, ICU, Queensland, Australia Corresponding author. Tel.: +61 353834821359 E-mail addresses: [email protected]

   [email protected]

   Paula McQuail

   Royal College of Surgeons, Ireland E-mail address: [email protected]

   Peter Garrett Noosa Hospital, ICU, Queensland, Australia E-mail address: [email protected]

   http://dx.doi.org/10.1016/j.ajem.2016.02.018

   References

   Marshall PS, Mathews KS, Siegel MD. Diagnosis and management of life-threatening pulmonary embolism. J Intensive Care Med 2011;26(5):275-94.

6. Sura AC, Kelenmen MD. Early management of ST-segment elevation myocardial

   infarction. Cardiol Clin 2006;24(1):37-51 [Available from http://www.ncbi.nlm. nih.gov/pubmed/16326255].

   Bottiger BW, Arntz H-R, Chamberlain DA, Bluhmki E, Belmans A, Danays T, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 2008;359(25):2651-62.

7. Archan S, Prause G, Kugler B, Gumpert R, Giacomini G. Successful prolonged resuscitation involving the use of tenecteplase without Neurological sequelae. Am J Emerg Med 2008;26(9):7-9.
8. Lederer W, Lichtenberger C, Pechlaner C, Kinzl J, Kroesen G, Baubin M. Long-term Survival and neurological outcome of patients who received recom- binant tissue plasminogen activator during out-of-hospital cardiac arrest. Resuscitation 2004;61(2):123-9 [Available from http://www.ncbi.nlm.nih.gov/ pubmed/15135188].
9. Purvis JA, Morgan DR, Hughes SM. Prevalence of patent foramen ovale in a consecutive cohort of 261 patients undergoing routine “coronary” 64-multi-detector cardiac computed tomography. Ulster Med J 2011;80(2):72-5 [Available from: http://www.pubmedcentral.nih.gov/articlerender. fcgi?artid=3229849&tool=pmcentrez&rendertype=abstract].