Academic Emergency Department Research Articles

Prehospital emergency department care activations during the initial COVID-19 pandemic surge.

To describe trends in prehospital presentations of critical medical and trauma conditions during the COVID-19 pandemic using prehospital and emergency department (ED) care activations. Observational analysis of ED care activations in a tertiary, urban ED between March 10, 2020 and September 1, 2020 was compared to the same time periods in 2018 and 2019. ED care activations for critical medical conditions were classified based on clinical indication: undifferentiated medical, trauma, or stroke. The primary outcomes were the number of patients presenting from the prehospital setting with specified ED activation criteria, total ED volume, ambulance arrival volume, and volume of COVID-19 hospital admissions. Locally weighted scatterplot smoothing curves were used to visually display our results. There were 1,461 undifferentiated medical activations, 905 stroke activations, and 1,478 trauma activations recorded, representing absolute decreases of 11.3, 28.1, and 20.3 percent, respectively, relative to the same period in 2019, coinciding with the declaration of a public health emergency in Connecticut. For all three types of presentation, post-peak spikes in activations were observed in early May, approximately two weeks after our health system in Connecticut reached its peak number of COVID-19 hospitalizations-eg, undifferentiated medical activations: increase in 280 percent, n = 140 from 2019, p < 0.0001-and declined thereafter, reaching a nadir in early June 2020. After the announcement of public health measures to mitigate COVID-19, ED care activations declined in a large Northeast academic ED, followed by post-peak surges in activations as COVID- 19 cases decreased.

Clinician Absences and Contributing Factors During a COVID-19 Surge: Potential Areas for Intervention and Planning.

IntroductionOur goal was to quantify healthcare clinician (HCC) absenteeism in the emergency department (ED) during the coronavirus disease 2019 (COVID-19) surge and to identify potential interventions that may mitigate the number of absences.MethodsThis was a retrospective, descriptive record review that included 82 resident physicians, physician assistants, and staff physicians who were scheduled to work more than three clinical shifts during March 2020 in an urban, academic ED that received a high number of coronavirus disease 2019 (COVID-19) patients. Exposure was defined as a healthcare clinician who was not wearing appropriate personal protective equipment (PPE) having contact with a confirmed COVID-19 positive patient in the ED. The main outcome was the number of HCC absences secondary to exposure to or symptoms concerning for COVID-19.ResultsDuring March 2020, of 82 ED HCCs, 28 (34%) required an absence from clinical duties, totaling 152 absentee calendar days (N = 13 women [46%]; N = 15 men [54%]). Median HCC age was 32 years (interquartile range 28–39), and median number of days absent was four (interquartile range 3–7). While 16 (57%) of the total absences were secondary to a known exposure, 12 (43%) were symptomatic without a known exposure. A total of 25 (89%) absent HCCs received COVID-19 testing (N = 5 positive [20%]; N = 20 negative [80%]) with test results returning in 1–10 days. Eleven (39%) symptomatic HCCs had traveled domestically or internationally in the prior 30 days.ConclusionEmergency departments should anticipate substantial HCC absences during the initial surge of a pandemic. Possible interventions to mitigate absences include early and broad use of PPE, planning for many asymptomatic HCC absences secondary to exposures, prioritizing HCC virus testing, and mandating early travel restrictions.

Health-Related Quality of Life of Patients Presenting to the Emergency Department with a Musculoskeletal Disorder.

BackgroundMusculoskeletal disorders (MSKDs) are among the most disabling and costly non-fatal health conditions. They may lead to long-term consequences such as chronic pain, physical limitations, and poorer quality of life. They also account for a significant proportion of emergency department visits, representing between 18% and 25% of all visits, depending on country.PurposeTo assess the health-related quality of life of patients presenting to the emergency department with a MSKD, to convert their answers to utility scores and to explore the association between diverse socio-demographic and clinical variables and patients’ health-related quality of life.Patients and MethodsThis is an analysis of cross-sectional data obtained during the baseline assessment performed as part of a 6-month pragmatic randomized controlled trial conducted in an academic emergency department. We included patients aged 18–80 years with a minor MSKD. The main outcome measures were health-related quality of life (five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and utility scores (−0.148 – worse than death, 0 – dead, 0.949 – perfect health) measured with the EQ-5D-5L. Possible associations were explored by comparing scores across subgroups based on certain socio-demographic (eg, age, gender, triage score) and clinical factors (eg, pain interference on function, pain intensity) and with reference values using descriptive statistics (mean, median), rankFD ANOVAs, and χ2 tests.ResultsSixty-nine participants completed the EQ-5D-5L. Mean and median utility scores were, respectively, 0.536 (95% CI: 0.479–0.594) and 0.531 (IQR: 0.356–0.760). Participants with higher levels of pain (<4/10: 0.741, 95% CI: 0.501–0.980; 4–7/10: 0.572, 0.500–0.644; >7/10: 0.433, 0.347–0.518) or pain interference on function (<4/10: 0.685, 95% CI: 0.605–0.764; 4–7/10: 0.463, 0.394–0.533; >7/10: 0.294, 0.126–0.463) presented significantly lower utility scores. No significant differences were found for other socio-demographic characteristics.ConclusionIn patients with MSKDs who present to the emergency department, higher levels of pain or pain interference are associated with decreased health-related quality of life. These findings need to be confirmed on a larger scale.

Validating the HELP Survey to Understand Health Disparity Influence on Chronic Pain

BackgroundSocioeconomic deprivation is shown to be linked to chronic lower back pain. However, a comprehensive approach to identify key components contributing to pain outcomes using a biopsychosocial model incorporating social determinants of health is needed to develop and tailor successful strategies for mitigating chronic pain development and persistence. We aimed to develop and validate an instrument (the HELP survey) to assess themes characterized by a combination of social determinants of health and the biopsychosocial model in an underserved population. The HELP survey was developed as part of an observational study determining the influence of health disparities on chronic pain interference, The Neighborhood of Pain: Health Disparity Influence on Level of Chronic Pain Interference study (HELP).MethodsA multidisciplinary group of experts developed the 40-item, 5-domain HELP survey to address Pain Catastrophizing, Pain Motivation, Social Support, Health Care Access, and Physical Environment. After IRB approval, recruitment occurred at an academic pain clinic and emergency department. Survey validation included principal factor analysis, factor loadings of 0.40 or greater, and Cronbach’s alpha of 0.70 or greater.ResultsInitial pilot testing occurred in 48 participants, followed by question revision and retesting in 57 patients. The average age was 57 years old. The majority were female (61.9%), self-reported black (55.2%), and had a high school health literacy level of 60.9%. Nearly half of participants (52.4%) lived in a neighborhood of extreme socioeconomic disadvantage and for 43.4% highest educational attainment was high school. Pilot testing resulted in 5 domains with Cronbach’s alphas: Pain Catastrophizing (0.82), Patient Motivation (0.80), Social Support (0.56), Health Care Access (0.75), and Physical Environment (0.81).ConclusionPilot study validation of the HELP survey demographic data indicated testing was performed in an underserved chronic pain population, and questions supported measurement of social determinants of health and the biopsychosocial model based on the five themes identified.

A pilot mixed-methods randomized controlled trial of verbal versus electronic screening for adverse social determinants of health.

ObjectivesExamining the social risks that influence the health of patients accessing emergency care can inform future efforts to improve health outcomes. The optimal modality for screening in the emergency department (ED) has not yet been identified. We conducted a mixed methods evaluation of the impact of screening modality on patient satisfaction with the screening process.MethodsPatients were enrolled at a large urban academic ED and randomized to verbal versus electronic modalities following informed consent. Participants completed a short demographic survey, a brief validated health literacy test, and a social need and risk screening tool. Participants were purposively sampled to complete qualitative interviews balanced across 4 groups defined by health literacy scores (high vs limited) and screening modality. Quantitative outcomes included screening results and satisfaction with the screening process; qualitative questions focused on experience with the screening process, barriers, and facilitators to screening.ResultsOf 554 patients assessed, 236 were randomized (115 verbal, 121 electronic). Participants were 23% Hispanic, 6% non‐Hispanic Black, 58% non‐Hispanic White, 38% publicly insured, and 57% privately insured. Two‐thirds (67%) identified social needs and risks and the majority (81%) reported satisfaction with the screening. Screening modality was not associated with satisfaction with screening process after adjustment for language, health literacy, and social risk (adjusted odds ratio, 0.74; 95% confidence interval, 0.32, 1.71).ConclusionScreening modality was not associated with overall satisfaction with screening process. Future strategies can consider the advantage of multimodal screening options, including the use of electronic tools to streamline screening and expand scalability and sustainability.

Use of a Brief Negotiation Interview in the emergency department to reduce high-risk alcohol use among older adults: A randomized trial.

ObjectiveTo determine whether a Brief Negotiation Interview (BNI) performed in the emergency department (ED) can reduce future rates of alcohol use among older adults who are high‐risk drinkers.MethodsAdults aged 65 years and older in a single academic ED were screened for high‐risk alcohol use based on the National Institute for Alcohol Abuse and Alcoholism definition of >7 drinks per week or >3 drinks per occasion. Eligible individuals who were high‐risk drinkers who passed a cognitive impairment screener and who consented to enrollment were randomly assigned to receive the BNI versus usual care. Outcomes were assessed at 3, 6, and 12 months. The primary outcome was the rate of high‐risk alcohol use at 6 months.Results Of 2250 ED patients who were screened, 183 (8%) met the criteria for high‐risk alcohol use. Of those, 98 (53%) patients met full criteria and consented to participation. Of the participants, 67% were men and 83% were non‐Hispanic White. There was no significant difference in the primary outcome of high‐risk alcohol use at 6 months between the BNI at 59.1% (95% confidence interval [CI], 45.5%–76.8%) and the control at 49.1% (95% CI, 36.9%–65.2%). However, there was a significant time‐effect reduction in alcohol consumption and rates of high‐risk alcohol use for both groups.ConclusionAmong older adults who met the criteria for high‐risk alcohol use, the BNI in the ED did not result in a reduction in high‐risk alcohol use at 6 months, although both groups showed significant reductions after their ED visit. Further work is needed to determine the optimal setting and time to use the BNI to impact high‐risk alcohol use in this population.

Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Nurses.

Background: Most older adults visit the emergency department (ED) near the end of life without advance care planning (ACP) and thus are at risk of receiving care that does not align with their wishes and values. ED GOAL is a behavioral intervention administered by ED clinicians, which is designed to engage seriously ill older adults in serious illness conversations in the ED. Seriously ill older adults found it acceptable in the ED. However, its potential to be used by nurses remains unclear. Objective: The aim of this study is to identify refinements to adapt an ED-based ACP intervention by eliciting the perspectives of nurses. Design: This is a qualitative study using semistructured interviews. Data were analyzed using axial coding methods. Setting/Subjects: We recruited a purposeful sample of ED nurses in one urban academic ED and one urban community ED in the northeastern region of the United States. Results: Twenty-five nurses were interviewed (mean age 46 years, 84% female, and mean clinical experience of 16 years). Emerging themes were identified within six domains: (1) nurses' prior experience with serious illness conversations, (2) overall impression of ED GOAL, (3) refinements to ED GOAL, (4) implementation of ED GOAL by ED nurses, (5) specially trained nursing model, and (6) use of telehealth with ED GOAL. Conclusions: ED nurses were generally supportive of using ED GOAL and provided insight into how to best adapt and implement it in their clinical practice. Empirical evidence for adapting ED GOAL to the nursing practice remains to be seen.

Factors Associated With Point-of-Care Ultrasound Use by Recent Pediatric Emergency Medicine Fellowship Graduates.

The aims of this study were to describe point-of-care ultrasound (POCUS) use by recent pediatric emergency medicine (PEM) fellowship graduates and identify associations between frequency and breadth of POCUS use with variations in POCUS training and current clinical practice environment. This was a cross-sectional online survey of recent PEM fellowship graduates. Chi-square and nonparametric tests were used to compare POCUS use among physicians with varying types of POCUS training and varying clinical practice environments. Eighty-two percent of 143 respondents reported using POCUS in their past 10 shifts. There was no association between the methods of POCUS education and frequency or breadth of POCUS use. Pediatric emergency medicine fellowship graduates with additional POCUS fellowship training performed more scans and used more applications than those who completed a pediatrics or medicine-pediatrics residency before PEM fellowship only [median 15 (9, 20) vs 2 (1, 5) (P < 0.01) and median 11 (6.5, 13) vs 2 (1, 3) (P < 0.01), respectively]. Participants who worked in academic emergency departments performed more ultrasounds than those who did not [3.5 (1, 8) vs 1 (0, 2), P < 0.01] and used a greater breadth of applications [3 (1, 5) vs 1 (0, 3), P < 0.01]. Physicians who billed for POCUS studies were more likely to use POCUS (odds ratio, 2.8; 95% confidence interval, 1.1-7.3) with greater frequency [5 (2.3, 10) vs 2 (0.8, 5), P < 0.01] and use a broader range of applications [3 (2,6) vs 2 (0.8, 3.3), P < 0.01]. Most respondents report recent POCUS use in practice. Point-of-care ultrasound fellowship training, working in an academic emergency department, and having the ability to bill were associated with increased POCUS use.

Effect of resident complement on timeliness of stroke team activation in an academic emergency department.

ObjectivesInvestigations of the impact of residents on emergency department (ED) timeliness of care typically focus only on global ED flow metrics. We sought to describe the association between resident complement/supervisory ratios and timeliness of ED care of a specific time‐sensitive condition, acute stroke.MethodsWe matched ED stroke patient arrivals at 1 academic stroke center against resident and attending staffing and constructed a Cox proportional hazards model of door‐to‐activation (DTA) time (ie, ED arrival [“door”] to stroke team activation). We considered multiple predictors, including calculated ratios of residents supervised by each attending physician.ResultsAmong 462 stroke activation patients in 2014–2015, DTA ranged from 1 to 217 minutes, 72% within 15 minutes. The median number of emergency and off‐service residents supervised per attending were 1.7 (interquartile range [IQR], 1.3–2.3) and 0.7 (IQR, 0–1), respectively. A 1‐resident increase in off‐service residents was associated with a 24% decrease (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.64–0.90) in the probability of stroke team activation at any given time. An independent 1‐resident increase in the number of emergency residents was associated with a 13% increase (HR, 1.13; 95% CI, 1.01–1.25) in timely activation.ConclusionTimeliness of care for acute stroke may be impacted by how academic EDs configure the complement and supervisory structures of residents. Higher supervisory demands imposed by increasing the proportion of rotating off‐service residents may be associated with slower stroke recognition and DTA times, but this effect may be offset when more emergency residents are present.

Costs Without Value When Treating Pediatric Behavioral Patients in the ED

Summary The demand on pediatric EDs to provide behavioral health care has increased over the past decade. Thus, an accurate cost analysis of providing this care in pediatric ED settings could inform the design of the most appropriate care model for these patients and identify opportunities to deliver the same quality care at a lower cost. Leaders at an academic pediatric ED with a yearly behavioral health census of approximately 1,000 conducted a study to assess the true cost of caring for nonacute behavioral health patients. Since traditional costing strategies often neglect to consider unreimbursed or undocumented care activities, this study utilized time-driven activity-based costing to capture these hidden costs. The study showed that the cost of caring for one behavioral health patient in a pediatric ED is approximately $219 an hour, with most activities offering little to no value to the patient. This article further discusses potential reasons for this low-value care and solutions to overcome the regulatory burdens and bottlenecks in the care processes that prevent optimal care in an ED setting.

Advance Care Planning for Emergency Department Patients With COVID-19 Infection: An Assessment of a Physician Training Program.

Coronavirus Disease 2019 (COVID-19) has heightened the importance of advance care planning (ACP), particularly in the emergency department (ED). The objective of this study was to determine the effect of an educational program for emergency physicians on ACP conversations in the ED during the COVID-19 pandemic. This was an observational pre-/post-interventional study. This study was conducted at a Southeastern U.S. academic ED. 143 patients with confirmed COVID-19 infection in the 2 weeks up to and including the ED encounter of interest (between March 26 and May 25, 2020) were included. The primary intervention was an ACP training toolkit with three components: (1) an evidence-based guide to COVID-19 risk stratification, (2) education on language to initiate ACP conversations, and (3) modification of the electronic health record (EHR) to facilitate ACP documentation. Palliative care physicians also delivered a 60-minute ACP educational session for emergency medicine physicians. The primary outcome was a composite of ACP activities including: (1) identification of a healthcare decision-maker (HCDM), (2) an order for a code status, or (3) a documented goals of care conversation. There was a 25.4% (95% CI: 7.0-43.9) increase in the composite outcome of ED-based ACP. After adjustment for patient demographics and triage score, there was a non-statistically significant increase in ACP activity (OR = 2.71, 95% CI: 0.93-8.64; P = .08). A rapid and simple physician-facing educational intervention demonstrated a trend, though lacking in statistical significance, towards increased ED-based ACP activities for patients with COVID-19.

It's a Hard Knock Life: How Kids With Mild Traumatic Brain Injuries Are Treated.

The diagnosis and treatment of mild traumatic brain injuries (mTBIs) by emergency medicine providers is greatly varied. Because of the frequency and long-term consequences associated with pediatric head injuries, it is crucial that adequate counseling is provided in acute care settings. The purpose of our study is to evaluate existing practices at Loyola University Medical Center emergency department to address inconsistencies in diagnostic or discharge practices and determine future quality improvement measures. A retrospective cohort study was conducted at an academic hospital emergency department of patient records from 2017 to 2020. Demographic, diagnostic, and discharge data were summarized, and Pearson χ2 tests and Fisher exact tests were performed to determine associations among patient characteristics and provider practices. A total of 1160 patients met inclusion criteria for analysis. In terms of diagnostic procedure, 31.6% of providers did not uniformly use existing screening criteria, such as PECARN, to determine if CT scans were needed for mTBI evaluation. Most discharge instructions were based on a generalized template on epic (91.9%). Only a minority of providers prepared patient-specific instructions through written, verbal, or other supplemental materials. The most common formats included epic only (46.1%), epic and personalized written instructions (20.2%), and epic and verbal instructions (12.4%). Follow-up care instructions were provided to 93% of patients who received discharged instructions, mainly for primary care (96.7%), sports medicine (1.58%), neurology (0.65%), or other providers (1.11%). There is a lack of consistency in the evaluation and education of mTBI in pediatric patients. There is a need for personalized discharge instructions to ensure adequate patient and parent understanding and compliance. Further studies looking at long-term outcomes in these patients would also be beneficial.

Targeted Temperature Management Experience of an Academic Emergency Department: A 5-Year Retrospective Study.

Targeted temperature management (TTM) for postcardiac arrest syndrome patients is a cornerstone therapy to reduce mortality and neurological morbidity. The care of critical patients is provided in the emergency department (ED) when intensive care units (ICUs) are unavailable. This study aimed to determine the characteristics and mortality outcomes of postcardiac arrest patients who underwent TTM in an academic ED. Postcardiac arrest patients who underwent TTM between January 1, 2014, to November 1, 2018, at a tertiary care academic ED in Turkey were examined retrospectively. The mean age of 24 patients in whom TTM was initiated in the ED was 60.7 ± 19.2 years. Five (20.8%) of the patients who underwent TTM were discharged. Four (80%) of the discharged patients were in out-of-hospital cardiac arrest (OHCA). All patients with a total cardiopulmonary resuscitation duration of >25 minutes died. Mortality was significantly higher in patients without light reflexes (p = 0.006). Two patients who underwent TTM in the ED became organ donors after neurological determination of death. If the ICU cannot meet the needs, early initiation of TTM in the ED may contribute to good neurological outcomes. In this study, 80% of the patients who have positive neurological outcomes are OHCA. Lack of light reflex may be an evidence of poor neurological outcomes in postcardiac arrest patients. Emergency physicians should be encouraged to apply TTM.

The relationship between adverse childhood experiences, the frequency and acuity of emergency department utilization and primary care engagement

IntroductionA history of adverse child experiences (ACEs) is associated with increased high-risk adult behaviors, morbidity, mortality, and use of the emergency department. This study was designed to understand the relationship between ACEs and the characteristics of emergency department use and primary care engagement. MethodsAn in-person survey was conducted at an academic emergency department (ED) assessing ACE score, emergency department utilization and acuity, and primary care engagement. ResultsThe prevalence of ACEs was 71.1% with 1+ ACE and 32.5% with 4+ ACE. ACE scores of four or more were associated with three or more ED visits in the past year compared those with an ACE score of zero (OR 3.22; p < 0.05) and when adjusted for sociodemographic factors (OR 3.22; p < 0.10). Higher ACE scores were associated with lower acuity presentations as indicated by the Emergency Severity Index before (ACE score 1 OR 3.91 p < 0.05; ACE score 2–3 OR 2.35 p < 0.05; ACE score 4+ OR 3.95 p < 0.05) and after adjustment (ACE score 1 OR 3.80 p < 0.10; ACE 2–3 OR 3.50 p < 0.10; ACE 4+ OR 4.36 p < 0.05). There was no association between ACE score and having a primary care provider (PCP), frequency of PCP visits, or PCP rating. ConclusionHigher ACE scores were associated with higher emergency department utilization and lower acuity presentations but not associated with levels of primary care engagement. Additional investigations are needed to adequately characterize the discrete causal mechanisms behind these current findings.

Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework.

delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol. we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients. we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified. a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture. this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.

Comparison of PECARN clinical decision rule and clinician suspicion in predicting intra-abdominal injury in children with blunt torso trauma in the emergency department.

The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule to identify children at low risk for intra-abdominal injury requiring acute intervention (IAI-I) for reducing unnecessary radiation exposure of ab-dominal computed tomography (CT) after blunt torso trauma. This study aimed to compare the PECARN decision rule with clinician suspicion in identifying children at low risk of intra-abdominal injuries that an abdominal CT scan can be safely avoided. This study is a retrospective review of children with blunt torso trauma in an academic emergency department (ED) between 2011 and 2019. Patients were considered positive for the PECARN rule if they exhibited any of the variables. Clinician suspi-cion was defined as actual CT ordering of the treating physician. The primary outcome was IAI-I detected by imaging or surgery within 1 month after the trauma, and the secondary outcome was any intra-abdominal injury (IAI) presence. Among the 768 children included, 48 (6.25%) had intra-abdominal injuries and 21 (2.73%) of whom underwent acute in-tervention. Four hundred and fifty-three (59%) children underwent abdominal CT scanning. If the PECARN rule had been applied, 232 patients would have undergone abdominal CT. The rule revealed 90.48% (95% CI=68.17-98.33%) sensitivity for IAI-I and 81.25% (95% CI=66.9-90.56%) for IAI. Clinician suspicion revealed sensitivities of 100% (95% CI=80.76-00%) and 93.75% (95% CI=81.79-98.37%) for IAI-I and IAI, respectively. Sensitivities of the rule and clinician suspicion were statistically similar for both IAI-I (p=0.5) and IAI (p=0.146). In this study, the PECARN abdominal rule and clinician suspicion performed similarly in identifying intra-abdominal injuries in children with blunt torso trauma. However, our study supports the use of PECARN abdominal rule in addition to clinical judgment to limit unnecessary abdominal CT use in pediatric patients with blunt torso trauma in the ED.

Evaluation of Insulin Infusion Rates for the Treatment of Diabetic Ketoacidosis in the Emergency Department.

Introduction:There is minimal literature to support the appropriate dosing for the initiation of IV regular insulin therapy in DKA patients. A 0.1 unit/kg bolus followed by 0.1 units/kg/hour or 0.14 units/kg/hour is commonly utilized and recommended in guidelines.Objective:We sought to assess clinical and safety outcomes associated with various insulin infusion starting doses in patients diagnosed with DKA in the emergency department in an effort to help guide prescribing.Methods:A retrospective cohort study was conducted within an academic emergency department and included patients who received continuous infusion regular insulin with an ICD-10 code for DKA between January 2016 and January 2019. A predictive regression model was applied to test if predefined lab values influenced the starting insulin infusion rates. Clinical and safety outcomes were evaluated by starting insulin infusion rate. Data was analyzed based on starting insulin infusion rates.Results:347 patients met inclusion criteria with 92 (26.5%) patients receiving <0.07 units/kg/hr, 123 (35.4%) patients receiving 0.07 to 0.099 units/kg/hr, 123 (35.4%) patients receiving 0.10 to 0.139 units/kg/hr, and 9 (2.6%) patients receiving ≥0.14 units/kg/hr. After adjusting for baseline labs, glucose was the only significant predictor of the initial infusion rate (p < 0.001). For every 100 mg/dL increase in the baseline glucose value, the initial infusion rate increased by 0.005 units/kg/hr. There was no difference between insulin starting infusion rates and length of stay, rates of hypoglycemia, hypokalemia, or dysrhythmias.Conclusion:Glucose levels significantly influenced the insulin starting infusion rate, with no identified differences in adverse effects or clinical outcomes.

Implementation and evaluation of sepsis surveillance and decision support in medical ICU and emergency department.

To improve the timely diagnosis and treatment of sepsis many institutions implemented automated sepsis alerts. Poor specificity, time delays, and a lack of actionable information lead to limited adoption by bedside clinicians and no change in practice or clinical outcomes. We aimed to compare sepsis care compliance before and after a multi-year implementation of a sepsis surveillance coupled with decision support in a tertiary care center. Single center before and after study. Large academic Medical Intensive Care Unit (MICU) and Emergency Department (ED). Patients 18years of age or older admitted to *** Hospital MICU and ED from 09/4/2011 to 05/01/2018 with severe sepsis or septic shock. Electronic medical record-based sepsis surveillance system augmented by clinical decision support and completion feedback. There were 1950 patients admitted to the MICU with the diagnosis of severe sepsis or septic shock during the study period. The baseline characteristics were similar before (N=854) and after (N=1096) implementation of sepsis surveillance. The performance of the alert was modest with a sensitivity of 79.9%, specificity of 76.9%, positive predictive value (PPV) 27.9%, and negative predictive value (NPV) 97.2%. There were 3424 unique alerts and 1131 confirmed sepsis patients after the sniffer implementation. During the study period average care bundle compliance was higher; however after taking into account improvements in compliance leading up to the intervention, there was no association between intervention and improved care bundle compliance (Odds ratio: 1.16; 95% CI: 0.71 to 1.89; p-value 0.554). Similarly, the intervention was not associated with improvement in hospital mortality (Odds ratio: 1.55; 95% CI: 0.95 to 2.52; p-value: 0.078). A sepsis surveillance system incorporating decision support or completion feedback was not associated with improved sepsis care and patient outcomes.

A Review of Complications Associated with Cricothyrotomy

<h3>Introduction</h3> Airway management is a requisite skill set for emergency medical service (EMS) providers. Cricothyrotomy is a potentially lifesaving skill that is used when other airway maneuvers fail. The authors reviewed all patients (>14 years of age) transported to a Level I trauma/academic medical center that had cricothyrotomy performed to assess the success, complications and technique used. <h3>Methods</h3> This was a retrospective chart review of patient records from an electronic medical record system over a 151-month period. <h3>Results</h3> During the study period, 407,765 patients were transported to an academic medical center emergency department, 32 (.008%) of whom underwent cricothyrotomy. The typical patient was a white (90% 29/32) male (84% 27/32) trauma (78% 25/32) victim with a mean age of 40 (range 14-71) transported by helicopter (96% 31/32) from a referring hospital (53% 17/32). 63% (20/32) of the patient group were alive at 24 hours post procedure. Of the clinicians performing the procedure 68% (22/32) were helicopter EMS team members; 19% (6/32) were hospital-based physicians and 12% (4/32) ground EMS personnel. Of the procedures 78% (25/32) were surgical cricothyrotomies (scalpel and endotracheal tube) inserted thru the cricothyroid membrane; the remaining were done with a percutaneous device. None of the percutaneous procedures were associated with complications. Of the surgical cricothyrotomy group four patients (16%) had bleeding that required surgical hemostasis; 72% (18/25) had mainstem intubation confirmed by chest x-ray. <h3>Conclusion</h3> This study demonstrates that emergent cricothyrotomy is a rarely performed airway skill that has a high success rate. In this retrospective review, the surgical method demonstrated more complications than the percutaneous approach (mainstem intubation and bleeding); however, none were immediately life threatening.

Abstracts for the 40th emergencies in medicine conference

Abstracts for the 40^th emergencies in medicine conference