Academic Hospital Emergency Department Research Articles

Aesthetic Surgery Complications Disproportionately Burden Economically Disadvantaged Patients and Financially Strain Public Health Insurance: A Single Academic Center Retrospective Analysis

Abstract Goals/Purpose Complications of elective aesthetic surgery performed in private practice pose significant morbidity to patients and resource burden to healthcare systems. We aimed to characterize contemporary demographic and complication patterns among patients presenting to an academic center after aesthetic surgery, as well as the financial and resource burden of their postoperative care on the hospital and payor. Methods/Technique We performed a retrospective review of patients who presented to an urban, academic hospital emergency department in Northern California from September 1, 2020 to September 30, 2023. We included patients with primary complaints related to aesthetic procedures performed at outside centers resulting in a plastic surgery consultation. Demographics, outcomes, hospital charges, and insurance payments were determined. Univariable analyses identified associations with outcomes. Results/Complications We identified 36 patients with aesthetic procedure-related complaints. Mean age was 37.5 ± 9.8 years and all patients were female. Compared with the rest of the patient population presenting to the emergency department over the same time period (n=269,286), the identified patients were more likely to be black (34.3% vs. 20.4%, p=.04), Hispanic (40% vs. 24.6%, p=.03), and on Medicaid (80.6% vs. 31.7%, p<.001). Tobacco/cannabis use and obesity were prevalent in 25% and 47.2% of patients, respectively. Most patients underwent aesthetic procedures in the United States (51.4%), followed by Mexico (37.1%) and the Dominican Republic (11.4%). Body regions intervened upon were the abdomen (52.8%), breasts (52.8%), buttocks (33.3%), and arms (8.3%). In 36.1% of patients, multiple body regions were intervened upon during the index case. Abdominal cases included primary abdominoplasty (84.2%), panniculectomy (10.5%), and revision abdominoplasty (5.3%). Breast cases were primary augmentation (36.8%), revision augmentation (21.1%), augmentation mastopexy (15.8%), mastopexy only (15.8%), and other (10.5%). Buttocks cases were gluteal fat grafting (63.6%) and implant insertion (36.4%). Arm cases were all brachioplasty. Median postoperative day was 21 (Interquartile Range [IQR] 11.5, 36). Reasons for presentation included infection (44.5%), dehiscence (16.7%), pain (16.7%), seroma/drainage (11.1%), drain management (5.6%), and hematoma (2.8%). Nearly half received computed tomographic imaging (47.2%). Half of patients were admitted with a median length of stay of 2.5 days (IQR 1, 3). One-third underwent intervention, including implant removal (58.3%), image-guided aspiration (25%), and incision and drainage (16.7%). Patients using tobacco/cannabis were more likely to present with infection (88.9% vs. 25.9%, p=.001) and undergo intervention (66.7% vs. 22.2%, p=.01). There were recurrent emergency department visits among 22.2%. Overall, 44.4% of patients had outpatient follow-up visits for a median of 3 (IQR 2, 4) visits up to a median of 38 (IQR 21.5, 70.5) days after consultation. For the index hospital encounter and any subsequent outpatient/emergency visits, the total median hospital charge was $43,324.96 (IQR $10,728.12, $80,803.18) and median insurance payment was $3,947 (IQR $404.61, $24,516.00). In the setting of operative intervention, median hospital charge and insurance payments were $125,358.70 (IQR $51,065.52, $152,704.70) and $14,863.52 (IQR $3,947, $49,031.13), respectively. Conclusion In this case series, the majority of patients presenting with complaints related to aesthetic surgery were economically disadvantaged and nearly half received surgery abroad. Their surgical complications often directly and significantly cost the state-funded health insurance and strained inpatient and outpatient resources. Nearly a quarter of patients were offered aesthetic surgery despite active smoking, and they were more likely to develop infection and receive invasive treatments. While future analysis should aim to replicate our findings in a larger sample, providers and government agencies should warn their vulnerable patients of these risks.

Emergency department communication with diverse caregivers and persons living with dementia: A qualitative study.

Research to date has detailed numerous challenges in emergency department (ED) communication with persons living with dementia (PLWD) and their caregivers. However, little is known about communication experiences of individuals belonging to minoritized racial and ethnic groups, who are disproportionately impacted by dementia and less likely to be included in dementia research. We conducted semi-structured interviews with 29 caregivers of PLWD from two urban academic hospital EDs with distinct patient populations. The first site is an ED in the Northeast serving a majority White, English-speaking, and insured population. The second site is an ED in the South serving a majority Black and/or Hispanic, Spanish-speaking, and underinsured population. Interviews lasted an average of 25 min and were digitally recorded and transcribed. We used an inductive approach to analyze interview transcripts for dominant themes and compared themes between sites. Our sample included caregivers of diverse racial and ethnic backgrounds. Caregivers cared for PLWD who spoke English, Spanish, Arabic, Chinese, and Vietnamese. We identified three themes. First, caregiver advocacy was central to experiences of ED communication, particularly when PLWD primarily spoke a non-English language. Second, routine care plans did not address what mattered most to participants and PLWD. Participants felt that care arose from protocols and did not address what mattered most to them. Third, White English-speaking caregivers in Site 1 more commonly expected ED staff to engage them in care decision-making than Black, Hispanic, Asian, and Middle Eastern caregivers in Site 2. Language barriers amplify the higher intensity care needed by PLWD in the ED. Strategies should be developed for communicating with PLWD and caregivers about what matters most in their ED care.

Analysis of 2011-2020 intentional drug poisoning in children and adolescents

Purpose: We aimed to investigate the changing trends in intentional drug poisoning among pediatric and adolescent patients over the past 10 years.Methods: A retrospective study was conducted on patients younger than 20 years who visited an academic hospital emergency department (ED) in Incheon, Korea, from January 2011 through December 2020. The study focused on patients who responded with “self-harm or suicide” in the ED-based Injury In-depth Surveillance, and whose injury mechanism was drug poisoning. Exclusion criteria were unintentional injuries and the ingestion of substances other than drugs. To describe the trend over the decade, we used the number of events/100,000 ED annual visits of the database. Results: A total of 3,388 cases with a median age of 17 years (interquartile range, 15-18 years) were included. The most frequently ingested drugs were acetaminophen (27.8%), followed by benzodiazepines (15.2%), antidepressants (14.1%), other sedatives and hypnotics (13.4%), and antipsychotics (8.3%). As for the events/100,000 ED annual visits, benzodiazepines showed the biggest increase, from 7.6 to 80.2 cases. Similarly, antidepressants increased from 10.2 to 71.1 cases, and antipsychotics from 3.6 to 53.7 cases.Conclusion: Intentional drug poisoning has increased over the past 10 years, particularly in benzodiazepines, antidepressants, and antipsychotics. It is advisable to establish injury prevention strategies according to patients’ characteristics and ingested drugs.

Diagnosis and management of patients who present with narrow complex tachycardia in the emergency department.

While narrow complex tachycardia (NCT) is a common presentation to the emergency department (ED), little is known about its incidence in the ED or about emergency physician expertise in its diagnosis and management. We sought to compare cases of NCT due to primary arrhythmias to those with a rapid heart rate secondary to a medical issue, as well as to determine the accuracy of ED physician diagnosis and appropriateness of treatment. We conducted a health records review at a large academic hospital ED staffed by 95 physicians and included consecutive adult patients over 7months (2020-2021) with NCT (heart rate ≥ 130bpm and QRS < 120ms). Cases were reviewed for accuracy of ECG diagnosis and for correctness of treatment as per guidelines by an adjudication committee. We identified 310 ED visits (0.8% of all ED visits), mean age 65.1years, 52.6% female. Primary arrhythmias accounted for 54.8%. ED physicians correctly interpreted 86.6% of ECGs. The most common arrhythmias and accuracy of ED physician ECG interpretation were atrial fibrillation 44.5% (95.1%), sinus tachycardia 24.2% (90.5%), atrial flutter 15.8% (61.5%), and supraventricular tachycardia (SVT) 12.9% (81.6%). Treatments were judged optimal in 96.5% of primary NCT and 99.3% in secondary NCT. Treatments were suboptimal for failure to reduce heart rate < 100bpm prior to discharge in 2.1% of primary cases and failure to treat underlying cause in 0.7% of secondary cases. NCT was found in 0.8% of all ED visits, with more being primary NCT. ED physicians correctly interpreted 86.6% of ECGs but had difficulty differentiating atrial flutter and SVT. They implemented appropriate care in most cases but sometimes failed to adequately control heart rate or to treat the underlying condition, suggesting opportunities to improve care of NCT in the ED.

8445 Surgical Management of Urethral Prolapse: A Case Report

<h3>Study Objective</h3> To describe a case of acute urethral prolapse presenting with refractory pain and urinary retention, and to demonstrate surgical management, delineating key surgical steps using a surgical video. <h3>Design</h3> Case report demonstrated in a narrated surgical video <h3>Setting</h3> Patient presented to an academic hospital emergency department and required emergent surgical management in the operating room. In the operating room, patient is positioned in dorsal lithotomy with LoneStar retractor in place. <h3>Patients or Participants</h3> This surgical video describes a case report of a 45-year-old perimenopausal female who presented with acute onset refractory pain and urinary retention, as well as inability to tolerate catheterization, secondary to acute urethral prolapse with thrombosis and necrosis. <h3>Interventions</h3> After appropriate patient positioning, healthy urothelium was identified with cystourethroscopy above the prolapsed tissue. Next, normal appearing urothelium was tagged proximal to the prolapse at 3 o'clock, 6 o'clock and 9 o'clock using interrupted 4-0 Vicryl sutures so that this healthy tissue would not retract once the prolapse was excised. The base of the prolapsed portion of the urethral was injected with 1% lidocaine with epinephrine. The prolapsed portion was excised with Bovie electrocautery in quadrants around the urethra. A 16 French transurethral Foley catheter was placed, and the balloon inflated. Normal healthy appearing urothelium was re-approximated to the external urethral meatus epithelium using interrupted 4-0 Vicryl sutures with repair of one quadrant at a time. This was performed over the Foley catheter to ensure patency and prevent stricture. <h3>Measurements and Main Results</h3> The patient presented in this surgical video had immediate and complete resolution of symptoms. <h3>Conclusion</h3> Urethral prolapse rarely requires surgical intervention; however, when surgical treatment of urethral prolapse is necessary, it can be effective with appropriate surgical technique.

How do people think about the implementation of speech and video recognition technology in emergency medical practice?

BackgroundRecently, speech and video information recognition technology (SVRT) has developed rapidly. Introducing SVRT into the emergency medical practice process may lead to improvements in health care. The purpose of this study was to evaluate the level of acceptance of SVRT among patients, caregivers and emergency medical staff.MethodsStructured questionnaires were developed for the patient or caregiver group and the emergency medical staff group. The survey was performed in one tertiary academic hospital emergency department. Questions were optimized for each specific group, and responses were provided mostly using Likert 5-scales. Additional multivariable logistic regression analyses for the whole cohort and subgroups were conducted to calculate odds ratios (OR) and confidence intervals (CI) to examine the association between individual characteristics and SVRT acceptance.ResultsOf 264 participants, respondents demonstrated a positive attitude and acceptance toward SVRT and artificial intelligence (AI) in future; 179 (67.8%) for video recordings, and 190 (72.0%) for speech recordings. A multivariable logistic regression model revealed that several factors were associated with acceptance of SVRT in emergency medical practice: belief in health care improvement by signal analysis technology (OR, 95% CIs: 2.48 (1.15–5.42)) and AI (OR, 95% CIs: 1.70 (0.91–3.17)), reliability of AI application in emergency medicine (OR, 95% CIs: 2.36 (1.28–4.35)) and the security of personal information (OR, 95% CIs: 1.98 (1.10–3.63)).ConclusionA high level of acceptance toward SVRT has been shown in patients or caregivers, and it also appears to be associated with positive attitudes toward new technology, AI and security of personal information.

The profile of patients presenting with intentional self-poisoning to the Charlotte Maxeke Johannesburg Academic Hospital emergency department, South Africa

Background. With 23.5 suicide-related deaths per 100 000 population, South Africa (SA) has the eighth-highest age-standardised suicide rate in the world. Intentional self-poisoning is associated with significant morbidity, mortality and cost. In SA, self-poisoning is the leading method of suicide in females and the second leading method in males. Objectives. To determine the profile of patients presenting with intentional self-poisoning to the Charlotte Maxeke Johannesburg Academic Hospital emergency department. Methods. The study was a cross-sectional, retrospective audit of the medical records of patients who presented over a 12-month period with intentional self-poisoning. Results. Of the 288 patients included, 62.8% were female, 62.1% were aged 18 - 30 years, 22.2% were foreign nationals, 88.9% were single, 62.8% were unemployed, 82.3% reported that the episode was precipitated by an acute stressful event, 5.6% required intensive care unit (ICU) admission, and 4.5% died prior to hospital discharge. Organophosphate/carbamate pesticide ingestion was the most common method of self-poisoning (25.3%) and was responsible for the majority of ICU admissions (81.3%), cases requiring hospitalisation for &gt;6 days (56.5%) and deaths (69.2%). Conclusion. A large proportion of patients were female, 18 - 30 years of age, single, unemployed, and reported an acute stressful event as a precipitant. Organophosphate/carbamate pesticide ingestion was the most common method of self-poisoning and accounted for the majority of deaths and ICU admissions. Nationwide efforts should be aimed at enhancing awareness and implementing strategies to identify those at increased risk of suicidal behaviour.

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.

Stroke: A retrospective review of the incidence and epidemiology in a South African academic hospital emergency department.

Stroke is a leading cause of morbidity and mortality. Most deaths occur in low- and middle-income countries, with the incidence predicted to increase as populations undergo socioeconomic and epidemiological changes. Knowledge of contributing factors in a South African (SA) population can be used to drive healthcare initiatives to modify this burden of disease. To analyse epidemiological data on patients with stroke presenting to an emergency department in Johannesburg, SA. The study was a 12-month descriptive, retrospective review of medical records, undertaken at a tertiary-level hospital. Patients' records were selected based on the presumptive diagnosis of stroke. Data collected included ethnicity, age, gender, risk factors, signs and symptoms at presentation, and computed tomography (CT) brain scan findings. Of 312 records reviewed, 160 were eligible for inclusion. The mean age of the patients included was 57.7 years, and 64 patients (40%) had CT-confirmed haemorrhagic strokes. Hypertension was the most common comorbidity/risk factor identified, in the sample as a whole (n=93; 58%) and in both patients with haemorrhagic (n=33; 52%) and ischaemic strokes (n=56; 61%). Diabetes was the second most common comorbidity/risk factor (n=23; 14%), and was three times more likely in patients with ischaemic strokes (n=19; 20%) compared with haemorrhagic strokes (n=4; 6%). Stroke is an important healthcare concern for SA. Our study demonstrated a lower mean age of patients presenting with stroke compared with high- and upper middle-income countries, and a higher proportion of haemorrhagic strokes. Several modifiable risk factors such as hypertension and diabetes were identified. Data collection on a regional and national level is important to drive targeted healthcare initiatives.

Validation of the screening test for at-risk drinking in an emergency department using a tablet computer

BackgroundThe Alcohol Use Disorder Identification Test (AUDIT) is widely used and validated in primary care settings for alcohol screening, yet practical challenges in conducting it in crowded clinics exist. Recently, a new abbreviated version of the AUDIT, was presented: the Screening Test for At-risk Drinking (STAD). This study aimed to evaluate the performance of STAD compared to other abbreviated versions of AUDIT for patients visiting the emergency department (ED). MethodsThis cross-sectional survey was conducted with 543 patients in the urban tertiary academic hospital ED in South Korea We diagnosed at-risk drinking using the entire AUDIT score. The optimal cut-off values, sensitivity, specificity, and the area under the receiver operating characteristics (AUROC) of the STAD were analyzed. We compared the AUROC with AUDIT-C and AUDIT-QF, which are previously abbreviated versions of AUDIT. ResultsFor males, the optimal cut-off value in the STAD test was 3 points with 83.1% sensitivity (95% CI: 75.3–89.2) and 95.9% specificity (95% CI: 91.2–98.5). For females, the optimal cut-off value was 2 points with 95.9% sensitivity (95% CI: 88.5–99.1) and 89.1% specificity (95% CI: 83.9–93.0). The AUROC curves for STAD were 0.964 (95% CI: 0.934–0.983) for males and 0.980 (95% CI: 0.965–0.993) for females. ConclusionsThe STAD is a simple and useful test to screen at-risk drinking in the ED, and its assisted applications will enable faster and more efficient screening and management of at-risk drinking.

Best Practices Identified in an Academic Hospital Emergency Department to Reduce Transmission of COVID-19.

Emergency departments (EDs) are the point of entry for infectious diseases, making it necessary to reevaluate current practices and make adjustments to decrease transmission when presented with a novel viral infection. This article discusses strategies implemented in the ED to prevent transmission of coronavirus disease-2019 (COVID-19) while identifying areas of needed change in creating a safe environment for patients, health care workers, and ancillary staff. A team approach is ultimately necessary for success; therefore, development of interprofessional teams was formed to mitigate any obstacles. Dissemination of the most current information regarding proper personal protective equipment use, triaging, patient flow, and treatment areas were implemented with weekly emails, videoconferencing, and daily huddles. Developing an efficient triage screening process, redesigning patient flow, and cohorting of patients and staff to a geographical location are essential to minimize transmission. Constant reevaluation of processes is necessary to meet all the needs of patients and health care staff to prevent the spread of COVID-19.

Compliance with hygiene practices among healthcare workers at an academic hospital emergency department.

IntroductionHealthcare-associated infections (HCAIs) are an important contributor to patient morbidity and mortality. Healthcare workers (HCWs) hands are the chief mode of transmission of HCAIs. The emergency centre (EC) is frequently the first point of contact for patients within the health care system. The aim of this study is to determine compliance with hygiene practices among healthcare workers at a tertiary hospital EC.MethodsHygiene practices of staff were observed over a six-week period. Data pertaining to compliance rates with hand cleansing and other hygiene practices was collected. Consent was obtained retrospectively to avoid influencing participant behaviour.ResultsFrom a total of 477 potential hygiene opportunities, compliance with hand hygiene was only 34.4% (n = 164). Hand cleansing with an alcohol-based hand rub was observed in 87 (26.7%) of the 326 (68.3%) opportunities where it was indicated, while handwashing with soap and water was observed in 35 (23.2%) of the 151 opportunities where this was indicated. Compliance to each of the six steps of handwashing ranged between 62.2% and 83.5%, with there being a gradual deterioration in compliance from step one through to step six. Compliance with ‘bare below the elbows’ was observed in 242 (50.7%) opportunities while disposable surgical gloves were worn on 85 (44.7%) of the 190 opportunities where this was indicated.ConclusionCompliance with hygiene practices among EC HCWs is suboptimal. Various strategies including ongoing systematic training and regular audits may improve overall hygiene practices among EC staff.

RAFF-3 Trial: A Stepped-Wedge Cluster Randomised Trial to Improve Care of Acute Atrial Fibrillation and Flutter in the Emergency Department

We sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the Canadian Association of Emergency Physicians (CAEP) Acute AF/AFL Best Practices Checklist. We conducted a stepped-wedge cluster randomised trial at 11 large community and academic hospital EDs in 5 Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was introduction of the CAEP Checklist with the use of a knowledge translation-implementation approach that included behaviour change techniques and organisation/system-level strategies. The primary outcome was length of stay in ED, and secondary outcomes were discharge home, use of rhythm control, adverse events, and 30-day status. Analysis used mixed-effects regression adjusting for covariates. Patient visits in the control (n = 314) and intervention (n = 404) periods were similar with mean age 62.9 years, 54% male, 71% onset < 12 hours, and 86% AF, 14% AFL. We observed a reduction in length of stay of 20.9% (95% confidence interval [CI] 5.5%-33.8%; P = 0.01), an increase in use of rhythm control (adjusted odds ratio [OR] 4.5, 95% CI 1.8-11.6; P = 0.002), and a decrease in use of rate-control medications (OR 0.5, 95% CI 0.2-0.9; P = 0.02). There was no change in adverse events and no strokes or deaths by 30 days. The RAFF-3 trial led to optimised care of AF/AFL patients with decreased ED lengths of stay, increased ED rhythm control by drug or electricity, and no increase in adverse events. Early cardioversion allows AF/AFL patients to quickly resume normal activities.

Using body temperature and variables commonly available in the EHR to predict acute infection: a proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients.

Obtaining body temperature is a quick and easy method to screen for acute infection such as COVID-19. Currently, the predictive value of body temperature for acute infection is inhibited by failure to account for other readily available variables that affect temperature values. In this proof-of-concept study, we sought to improve COVID-19 pretest probability estimation by incorporating covariates known to be associated with body temperature, including patient age, sex, comorbidities, month, and time of day. For patients discharged from an academic hospital emergency department after testing for COVID-19 in March and April of 2020, we abstracted clinical data. We reviewed physician documentation to retrospectively generate estimates of pretest probability for COVID-19. Using patients' COVID-19 PCR test results as a gold standard, we compared AUCs of logistic regression models predicting COVID-19 positivity that used: (1) body temperature alone; (2) body temperature and pretest probability; (3) body temperature, pretest probability, and body temperature-relevant covariates. Calibration plots and bootstrap validation were used to assess predictive performance for model #3. Data from 117 patients were included. The models' AUCs were: (1) 0.69 (2) 0.72, and (3) 0.76, respectively. The absolute difference in AUC was 0.029 (95% CI-0.057 to 0.114, p=0.25) between model 2 and 1 and 0.038 (95% CI-0.021 to 0.097, p=0.10) between model 3 and 2. By incorporating covariates known to affect body temperature, we demonstrated improved pretest probability estimates of acute COVID-19 infection. Future work should be undertaken to further develop and validate our model in a larger, multi-institutional sample.

Characteristics of frequent users of the emergency department with chronic pain.

To identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain. We reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details - number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either "chronic pain" or "not chronic pain" related. We analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain. Chronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.

Emergency Department Clinician Perceptions of Implementing High-Sensitivity Troponin T Assay in an Academic Hospital Emergency Department

PurposeA newly approved, high-sensitivity troponin T (hsTnT) assay may offer opportunities to more rapidly assess for acute coronary syndrome and identify lower thresholds of myocardial injury. As more emergency departments begin to use the hsTnT assay, anticipating barriers to hsTnT implementation success are critical to realizing potential benefits in rapid, accurate patient assessment. MethodsAt a tertiary health system emergency department, hsTnT was implemented along with a diagnostic algorithm and a decision tree to aid in utilization. Qualitative interviews with 18 physicians and advance practice providers were conducted 2 months’ postimplementation and again 4 to 6 months postimplementation to capture clinician perceptions to hsTnT implementation efforts. Deductive coding was performed using implementation science determinants frameworks to identify emerging themes related to this topic. ResultsFour themes emerged from the interviews: 1) the need for additional clinician education, 2) challenges with care handoffs, 3) lack of buy-in from the hospital community, and 4) key successes. ConclusionInterviews demonstrated that implementation of hsTnT was associated with several implementation barriers from the perspective of emergency department clinicians. Future implementation efforts should focus on diverse and sustained staff educational efforts, models that address challenges with care handoffs between emergency department clinicians and inpatient clinicians, and operational teams that include inpatient clinicians to facilitate buy-in.

Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial

Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion. We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058. Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68). Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes. Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.

An Audit of Patients with Dog-bite Wounds Presenting to a Tertiary Level Hospital Emergency Department in South Africa.

BackgroundDog-bite wounds are a common emergency department (ED) presentation, accounting for approximately 5% of traumatic wounds in the US. However, only 20-50% of patients actually present to the ED for medical attention following a dog-bite wound.MethodsThis was a transverse, retrospective audit of medical records of patients that had presented to the Tembisa Provincial Academic Hospital ED with dog-bite wounds during the 2014 calendar year.ResultsOf the 269 patients that were included in the study, 148 (55%) were male. The median age of all study patients was 27 years (range: 3-77 years). Most patients presented between 18h00-24h00 (n = 111, 41.3%). Most wounds were sustained on the lower limbs (n = 80, 68.18%), followed by the upper limbs (n = 74, 28.03%). Patients who were ≤12 years of age had a higher prevalence of buttock/perineum (p = 0.0002) and head/face/neck (p = 0.009) wounds, whereas patients who were >12 years of age had a higher prevalence of lower limb wounds (p = 0.0006). Only 15 (5.6%) wounds were sutured, and antibiotics were prescribed to 120 (45.1%) patients. Tetanus toxoid vaccine (TTV) and the first dose of the rabies vaccine (RV) were administered to 152 (57.4%) and 240 (89.1%) patients, respectively.ConclusionChildren are more likely to present with wounds to the head/face/neck or buttock/perineum regions, while adults are more likely to present with wounds to the lower limbs. Proper strategies should be implemented to ensure that clinicians adhere to the current antibiotics protocols as well as rabies and tetanus post-exposure prophylaxis (PEP)-prescribing guidelines.

First-episode Seizures amongst Adult Patients Presenting to an Academic Hospital Emergency Department – A Preliminary Report

Abstract Background: First-onset seizures are not a diagnosis per se but may be a harbinger of a potentially life-threatening underlying illness. The aim of this pilot study was to describe the pattern of presentation of adults presenting with a first-onset seizure to the emergency department (ED). Methods: Medical records of patients &gt;18 years who presented over a 6-month period (November 2016 to May 2017) to the study centre with a first-episode seizure were retrospectively reviewed. Results: A total of 60 patients, with a median age of 37.4 years (IQR; 29.3–47.7 years) presented with first-onset seizures over the study period. The median time to ED presentation after a seizure episode was 120 min (IQR; 51–244 min). More than half the number of subjects (58.3%) were male, 28.3% were HIV positive, 84.2% had a generalized tonic-clonic seizure and 56.7% required admission. A decrease in the level of consciousness, foaming around the mouth, tongue biting and urinary incontinence were evident in 76.7%, 36.7%, 31.7% and 33.3% of subjects, respectively. Hypoglycaemia (26.7%), ring-enhancing space occupying lesion/s (16.7%) and cerebrovascular infarction (11.7%) accounted for approximately two-thirds of causes of first-episode seizures. Long-acting anticonvulsants were administered to 66.7% of subjects in the ED and prescribed to 53.3% of subjects upon hospital discharge. Conclusion: Hypoglycaemia and intracranial pathologies are common causes of first-episode seizures that must be considered in all patients. The late presentation of patients to the ED in this pilot study is a major concern. Due to the high prevalence of HIV in South Africa, there is a need to develop local guidelines on the management of first-presentation seizures in HIV-positive as well as HIV-negative patients.

Improving timely analgesia administration for musculoskeletal pain in the emergency department

Delays to adequate analgesia result in worse patient care, decreased patient and provider satisfaction and increased patient complaints. The leading presenting symptom to emergency departments (EDs) is pain, with approximately...