ED Setting Research Articles

Screening for suicide risk in medical settings: From research to implementation

IntroductionSuicide is an international public health problem and a leading cause of death for youth and adults, worldwide. Prevention efforts in health care systems create opportunities for identifying medical patients with occult suicidality. Detecting suicide risk among patients in medical settings can be a challenge, but successful suicide risk screening programs have been demonstrated in hospital settings.ObjectivesThis presentation will discuss how a suicide risk screening tool that was developed for the pediatric emergency department was tested and then implemented in other medical settings in order to leverage healthcare providers as partners in combating the public health crisis of youth suicide..MethodsImplementation and quality improvement projects in various medical settings that have adapted the ASQ will be described. Effective management of pediatric patients that screen positive for suicide risk and how mental health clinicians can best be utilized in efficient ways will also be discussed.ResultsAverage time to administer the ASQ was 20 seconds. Positive screen rates across ED, inpatient and outpatient settings ranging from 2-14% equating to one additional psychiatric consultation per week. The ASQ Toolkit was developed to help medical providers implement screening including scripts for nurses, flyers for parents and a brief suicide safety assessment (ASQ BSSA) to operationalize next steps for patients at risk.ConclusionsThe medical setting is a key venue for youth suicide risk detection and linking patients with effective interventions. Mental health clinicians have a role in guiding non-mental health providers in the identification and management of patients found to be at risk.DisclosureNo significant relationships.

Delirium in Emergency Departments: Is it Recognized?

BackgroundDelirium is a complex neurocognitive manifestation of an underlying medical or surgical abnormality such as substance abuse, infection, sepsis, or organ failure. A recognized risk factor for delirium is advanced age (age >65 years). The projected demographic changes over the next 2 decades suggest that the number of aging adults will grow dramatically, and emergency nurses will see an increasing number of older patients manifesting the wide range of neuropsychiatric symptoms associated with delirium. MethodAn examination of 5 commonly used delirium assessment tools was undertaken specific to clinical features, use, scoring, findings, advantages, and disadvantages. FindingsNumerous factors contribute to the lack of effective delirium recognition. However, emergency nurses, with educational support, can successfully use the delirium assessment tools to recognize delirium. ConclusionEmergency nurses face challenges in recognizing delirium. One key challenge for many of these nurses is the appropriate use of assessment tools suitable for the ED setting.

"I don't have any emotions": An ethnography of emotional labour and feeling rules in the emergency department.

This study aims to apply Hochschild's theory of emotional labour to emergency care, and uncover the 'specialty-specific' feeling rules driving this labour. Despite the importance of positive nurse well-being, the emotional labour of nursing (a great influencer in wellbeing) remains neglected. Ethnography enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nursing team. We undertook first-hand observations at one major trauma centre ED and one district general ED including semi-structured interviews (18). A reflexive and interpretive approach towards thematic analysis was used. We unearthed and conceptualized four feeling rules born from this context and offer extensive insights into the emotional labour of emergency nurses. Understanding the emotional labour and feeling rules of various nursing specialties offers critical insight into the challenges facing staff - fundamental for nursing well-being and associated retention programs. What problem did the study address? What were the main findings? Where and on whom will the research have impact? Academically, this research expands our understanding - we know little of nurses' feeling rules and how specialties influence them. Clinically, (including service managers and policy makers) there are practical implications for nurse well-being.

Design and Implementation of a Curriculum for Emergency Medicine Residents to Address Medications and Treatment Referral for Opioid Use Disorder

Background: Medications for Opioid Use Disorder (MOUD) are recognized as successful treatments for Opioid Use Disorder (OUD). The Emergency Department is well situated to initiate MOUD and begin the referral process. Unfortunately, uptake of this practice among Emergency Medicine (EM) physicians has been slow. EM physicians may feel inadequately prepared to provide MOUD and addiction referral services due to lack of previous training and experience. The goal of this pilot study was to create, implement, and evaluate an OUD management curriculum for EM residents and measure impact on knowledge, practice, and empathy. Methods : A 4.5-hour curriculum was developed, incorporating the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment mission statement as well as the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine resident physician milestones. The curriculum was inserted into an existing EM residency didactic block at an urban, tertiary care, residency program. Surveys were obtained pre- and post-intervention. Results : Post curriculum surveys demonstrated improved knowledge of buprenorphine/naloxone including indications, clinical effects and side-effects (p < 0.05). Surveys also noted increased comfort prescribing buprenorphine/naloxone for opioid withdrawal and misuse and instructing patients on home induction (p < 0.05). Additionally, residents responded positively regarding the impact of the curriculum on their understanding of the topic and their subsequent confidence in managing patients with OUD in the ED setting. Conclusion: A dedicated brief MOUD and referral curriculum can be effectively integrated into EM resident education to provide valuable clinical knowledge that may affect clinical practice.

Asynchronous Testing of 2 Specimen-Diversion Devices to Reduce Blood Culture Contamination: A Single-Site Product Supply Quality Improvement Project

ObjectiveBlood culture contamination above the national threshold has been a consistent clinical issue in the ED setting. Two commercially available devices were examined that divert an initial small volume of the specimen before the collection of blood culture to reduce skin contamination. MethodsProspectively, 2 different blood culture–diversion devices were made available in the unit supplies to ED clinicians at a single site during 2 different periods of time as a follow-up strategy to an ongoing quality improvement project. Blood samples were collected in the emergency department over a period of 16 months. A retrospective record review study was conducted comparing the use of the 2 specimen-diversion devices with no device (control group) for blood culture contamination rates. The main outcome of monthly blood culture contamination per device was tested using a Bayesian Poisson multilevel regression model. ResultsA total of 4030 blood samples were collected and analyzed from November 2017 to February 2019. The model estimated that the mean incidence of contaminated blood draws in the device A group was 0.29 (0.14-0.55) times the incidence of contaminated draws in the control group. The mean incidence of contaminated blood draws in the device B group was 0.23 (0.13-0.37) times the incidence of contaminated draws in the control group, suggesting that initial-diversion methods reduced blood culture contamination. ConclusionInitial specimen–diversion devices supplement present standard phlebotomy protocols to bring down the blood culture contamination rate.

150. the RAPID trial: randomized Controlled Trial assessing point-of-care influenza and Other Respiratory Virus diagnostics in the Pediatric ED Setting

BackgroundRespiratory illnesses represent one of the commonest reasons for pediatric visits to the ED, and over 50% of these children are prescribed antibiotics despite a viral etiology in most cases. Our objectives were to determine whether rapid respiratory pathogen (RRP) testing decreases antibiotic and health care utilization among children evaluated in the ED with a respiratory illness.MethodsWe conducted a randomized controlled trial among children 1 mo-18 yrs of age attending an ED with influenza like illness (ILI). All children received a nasopharyngeal swab for RRP testing, and were randomized to the intervention group (result given to providers and parents) or control group (result not given, routine clinical care). Families were interviewed on enrollment, 1 and 10 days later. The primary outcome was antibiotic use. Secondary outcomes included antiviral use, hospitalization and recurrent medical visits. Intention to treat (ITT) (assigned group) and pragmatic (provider knows test results) analyses were conducted using SAS v 9.4. Pragmatic analyses were adjusted using multivariable Poisson regression.ResultsAmong 920 visits (890 children) with ILI, 795 (85%) were RRP positive. Sociodemographic characteristics between groups were similar; 37% of children in the intervention group were discharged before results were available and 12% of children in the control group underwent clinical testing. The median age was 2.1 yrs (IQR 0.88–5.6); 35% had high-risk comorbidities. In the ITT intervention group, children were more likely to receive antibiotics (RR 1.3, 95% CI 1.0–1.7) (Table 1). In adjusted pragmatic analyses, children with known results were more likely to receive antivirals (RR 2.6 95% CI 1.5–4.3) and be hospitalized (RR 2.0, 95% CI 1.5–2.7); antibiotic use was not significant (Table 2). Children testing negative for a virus were more likely to receive antibiotics than those with a virus (35% vs 23%, p = 0.01).Table 1. Clinical Outcomes by Study Arm, Intention to Treat Analyses Table 2. Clinical Outcomes by Study Arm, Pragmatic Analyses ConclusionKnowledge of testing led to a paradoxical increase in antibiotic prescribing, as well as an increase in appropriate antiviral prescribing, ED length of stay and hospitalization. Further studies are needed to assess whether RRP testing with faster turn around times or coupled with stewardship interventions may impact outcomes.Disclosures Suchitra Rao, MD, BioFire (Grant/Research Support) Molly Lamb, PhD, BioFire (Grant/Research Support) Rakesh Mistry, MD, MSCE, BioFire (Grant/Research Support) Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)

Diagnostic accuracy of inferior vena cava ultrasound for heart failure in patients with acute dyspnoea: a systematic review and meta-analysis

BackgroundDyspnoea is the most common sign of heart failure (HF). Patients accessing the ED for HF-related symptoms require fast diagnosis and early treatment. Transthoracic echocardiography has a crucial role in...

Who provides what care? An analysis of clinical focus among the national emergency care workforce.

Clinician expertise has been associated with improved patient outcomes, yet ED clinicians often work in various clinical settings beyond the ED and, therefore, may risk expertise by having less clinical focus. We sought to describe clinical focus among the emergency care workforce nationally. Using the 2017 Medicare Public Use Files (PUF), we performed a cross-sectional analysis of clinicians receiving reimbursement for emergency care Evaluation & Management (E/M) services from Medicare fee-for-service Part B. Clinicians were categorized by type as EM physicians, non-EM physicians, and advanced practice providers (APPs). The primary outcome was the clinical focus of the individual clinician, defined as the proportion of E/M services within the ED setting relative to a clinician's total E/M services across all practice settings. Of 65,710 unique clinicians providing care to Medicare fee-for-service beneficiaries in the ED setting, 39,016 (59.4%) were classified as EM physicians, 8123 (12.4%) as non-EM physicians, and 18,571 (28.5%) as APPs. The individual clinician median focus was 92.8% (interquartile range [IQR]: 87.0, 100.0) for EM physicians, 45.2% (IQR: 5.1, 97.0) for non-EM physicians, and 100.0% (IQR: 96.3, 100.0) for APPs. EM physicians have twice as much clinical focus in comparison to non-EM physicians providing emergency care to Medicare fee-for-service beneficiaries. These findings underscore the importance of diverse training and certification programs to ensure access to clinically focused ED clinicians.

Impact of clinical decision support on oritavancin prescribing in the emergency department

BackgroundEmergency department (ED) visits and hospitalizations from skin and soft tissue infections (SSTIs) have been on the rise and have led to an increased clinical and economic burden. Owing to their single-dose regimen, recently approved lipoglycopeptides such as oritavancin have the potential to shift the management of SSTIs from an inpatient to outpatient setting. Limited data exist regarding the use of these drugs in the ED setting. ObjectivesThe purpose of this study was to describe the impact that clinical decision support (CDS) incorporation into the computerized physician order entry (CPOE) system had on oritavancin use and to assess compliance with appropriate use guidelines in the ED. MethodsThis was a retrospective cohort study evaluating patients who received oritavancin from September 2016 to May 2018. The patients were assigned to the pre-CDS–implementation group if oritavancin was used between September 13, 2016, and June 28, 2017 and to the post-CDS–implementation group if oritavancin was used between August 28, 2017, and May 25, 2018. There was a 2-month transition period between the 2 study time periods. Patients were excluded if the administration occurred outside of the ED or during the transition period. The primary endpoints were oritavancin use and compliance with the appropriate use guidelines after the implementation. ResultsThere were 169 oritavancin orders in total, of which 119 met the inclusion criteria. There was a marked decrease in use post-CDS implementation (9.2 orders/mo vs. 3 orders/mo). Among those who were prescribed oritavancin, compliance with the appropriate use guidelines increased; however, this did not reach statistical significance. ConclusionThe implementation of the appropriate use guidelines with CDS integration into the CPOE system decreased overall oritavancin use but did not have an impact on compliance with the appropriate use guidelines.

A CLIMATE: A Tool for Assessment of Climate-Change–Related Health Consequences in the Emergency Department

Climate change is an urgent public health problem that has looming implications and associated deleterious health consequences. The intersection of climate change and health has broad implications for health professionals in a variety of settings but especially for ED settings. Climate change is already affecting human health and health systems—which includes impacts on ED care. Disaster response and emergency preparedness are critically important public health interventions in our climate-changing world, and the contributions of emergency nurses are essential. Disaster preparedness, environmental emergency response, and health emergency management are important elements of emergency nursing and are explicated in Sheehy’s Emergency Nursing Principles and Practices, 7th Edition. The purpose of this article is to present an overview of a clinical tool and mnemonic, A CLIMATE, developed by the authors with application to a case review. It is imperative that the nursing profession—particularly emergency clinicians—address the intersection of climate and health to engage in the assessment, intervention, management, evaluation, education, and referral of those who present to emergency departments with potential climate-related health impacts.

External Female Urinary Catheter: Implementation in the Emergency Department

The emergency department is a care environment in which indwelling urinary catheters are placed frequently; however, the significance of the role of the emergency department in catheter-associated urinary tract infection prevention has been overlooked. The use of an external female urinary catheter is an alternative to placing an indwelling urinary catheter for female patients in the emergency department who are incontinent of urine or are immobile. The purpose was to describe the implementation of an initiative to decrease the number of indwelling urinary catheters and increase the use of external urinary female catheters in non–critically ill women who visited the emergency department at a 451-bed Magnet-designated community hospital in the Southeast. For this clinical implementation project, the Plan, Do, Check, Act framework was used to develop the initiative, and outcome data were collected retrospectively and included an indirect calculation of the number of indwelling urinary catheters placed in the emergency department. A total of 187 external catheters were used in place of indwelling catheters in female patients over a 3-month period. No skin irritation or breakdown was observed. This project demonstrated the initial staff acceptability and feasibility of external female urinary catheter use in the ED setting.

Implementation of a Medication for Addiction Treatment (MAT) and Linkage Program by Leveraging Community Partnerships and Medical Toxicology Expertise.

Implementing a hospital medication for addiction treatment (MAT) and a linkage program can improve care for patients with substance use disorder (SUD); however, lack of hospital funding and brick and mortar SUD resources are potential barriers to feasibility. This study assesses the feasibility of implementation of a SUD linkage program. Components of the program include a county-funded hospital opioid support team (HOST), a hospital-employed addiction recovery specialist (ARS), and a medical toxicology MAT induction service and maintenance program. Data for linkage by HOST, ARS, and MAT program were tracked from July 2018 to December 2019. From July 2018 through December 2019, 1834 patients were linked to treatment: 1536 by HOST and 298 by the ARS. The most common disposition categories for patients linked by HOST were 16.73% to medically monitored detoxification, 9.38% to intensive outpatient, and 8.59% to short-term residential treatment. Among patients linked by the ARS, 65.66% were linked to outpatient treatment and 9.43% were linked directly to inpatient treatment. A total of 223 patients managed by the ARS were started on MAT by medical toxicology and linked to outpatient MAT clinic: 72.68% on buprenorphine/naloxone, 24.59% on naltrexone, 1.09% buprenorphine, and 0.55% acamprosate. Implementing a MAT and linkage program in the ED and hospital setting was feasible. Leveraging medical toxicology expertise as well as community and funding partnerships was crucial to successful implementation.

Analgesic Efficacy of MSIR/Acetaminophen vs. Oxycodone/Acetaminophen (Percocet) for Pain

Several research papers demonstrated that administration of Morphine Sulfate Immediate Release (MSIR) results in similar analgesic efficacy to Oxycodone but with significantly lesser degree of euphoria and reward. By identifying a safer alternative to oxycodone, our study may influence opioid prescribing practices nationwide, which has the potential to reduce the considerable morbidity and mortality related to misuse and abuse of prescription opioids. The purpose of this study is to investigate if Morphine Sulfate Immediate Release (MSIR) combined with Acetaminophen can serve as an opioid analgesic alternative to Oxycodone combined with acetaminophen (Percocet) for acute pain in the ED setting.

Evidence for Age-Adjusted D-Dimer to Rule out Pulmonary Embolism: An Institutional Study

Abstract The diagnostic approach for ruling out suspected acute pulmonary embolism (PE) in the ED setting includes several tests: ultrasound, plasma d-dimer assays, ventilation-perfusion scans and computed tomography pulmonary angiography (CTPA). Importantly, a pretest probability scoring algorithm is highly recommended to triage high risk cases while also preventing unnecessary testing and harm to low/moderate risk patients. The d-dimer assay (both ELISA and immunoturbidometric) has been shown to be extremely sensitive to rule out PE in conjunction with clinical probability. In particularly, d-dimer testing is recommended for low/moderate risk patients, in whom a negative d-dimer essentially rules out PE sparing these patients from CTPA radiation exposure, longer hospital stay and anticoagulation. However, an unspecific increase in fibrin-degradation related products has been seen with increase in age, resulting in higher false positive rate in the older population. This study analyzed patient visits to the ED of a large academic institution for five years and looked at the relationship between d-dimer values, age and CTPA results to better understand the value of age-adjusted d-dimer cut-offs in ruling out PE in the older population. A total of 7660 ED visits had a CTPA done to rule out PE; out of which 1875 cases had a d-dimer done in conjunction with the CT and 5875 had only CTPA done. Out of the 1875 cases, 1591 had positive d-dimer results (&amp;gt;0.50 µg/ml (FEU)), of which 910 (57%) were from patients older than or equal to fifty years of age. In these older patients, 779 (86%) had a negative CT result. The following were the statistical measures of the d-dimer test before adjusting for age: sensitivity (98%), specificity (12%); negative predictive value (98%) and false positive rate (88%). After adjusting for age in people older than 50 years (d-dimer cut off = age/100), 138 patients eventually turned out to be d-dimer negative and every case but four had a CT result that was also negative for a PE. The four cases included two non-diagnostic results and two with subacute/chronic/subsegmental PE on imaging. None of these four patients were prescribed anticoagulation. The statistical measures of the d-dimer test after adjusting for age showed: sensitivity (96%), specificity (20%); negative predictive value (98%) and a decrease in the false positive rate (80%). Therefore, imaging could have been potentially avoided in 138/779 (18%) of the patients who were part of this older population and had eventual negative or not clinically significant findings on CTPA if age-adjusted d-dimers were used. This data very strongly advocates for the clinical usefulness of an age-adjusted cut-off of d-dimer to rule out PE.

Review article: Rapid review of the emergency department‐initiated buprenorphine for opioid use disorder

AbstractOpioid‐related harms have been increasing in Australia over the last 5 years. Patients with opioid use disorder are over‐represented in ED presentations. Opioid agonist treatment is the most effective community‐based treatment. Buprenorphine is considered the safest of these treatments to use in the ED setting. This rapid review investigated the effectiveness of initiating buprenorphine in the ED setting. Medline, Embase, Emcare, PSYCinfo, CINAHL and Cochrane Central Register of Controlled Trials databases were searched. Randomised and non‐randomised studies published in peer‐reviewed journals that involved the initiation of buprenorphine in the ED setting were considered eligible. The search revealed 350 articles of which 11 were included in the review; three articles representing two randomised controlled trials (RCTs) and eight observational studies. Data were extracted from included papers and risk of bias assessed on the RCTs. One well‐conducted RCT showed that buprenorphine initiated in the ED does improve treatment engagement up to 2 months after an ED visit. Eight observational studies, one with a comparator group reported positive results for this intervention. There is strong evidence that clinicians should consider commencing buprenorphine in the ED for patients with opioid use disorder when combined with a direct and supported referral or ‘warm handover’ to community care. Further implementation studies and investigation of long‐acting injectable buprenorphine treatment are required.

Review article: Systematic literature review of leadership in emergency departments.

Emergency medicine (EM) is a discipline with complex leadership demands. However, studies of EM physician leadership and ED leadership are in their infancy. As such, there is a lack of clarity about the forms, antecedents, enablers, barriers and consequences of EM physician leadership. A systematic review of the scientific literature was conducted to reveal the different conceptualisations of EM physician leadership, the activities involved in the practice of leadership, and the knowledge and skills of effective ED leaders. Seven databases were systematically searched for peer-reviewed empirical studies on the topic of EM physicians carrying out a manager or leadership role in an ED setting. Finally, 26 articles were included, and their findings were synthesised and analysed narratively. Two conceptualisations of EM physician leadership were found, reflecting clinical leadership and medical leadership, respectively. Clinical leadership is performed by all EM physicians, often informally, within their daily clinical practice, whereas medical leadership is performed by EM physicians who work at the management level within a hospital, in addition to or instead of their clinical practice. The focus of EM physician leadership and ED leadership research is team leadership, with much less attention given to wider organisation leadership. Consistent with the focus on team leadership, clinical knowledge and skill in orchestrating teams, especially trauma and resuscitation teams, emerged as the most important factors underpinning leadership effectiveness. Future research and training should make better use of existing leadership theory and research designs to illuminate the forms, dynamics, antecedents, moderators and consequences of EM physician leadership.

Digital health screening tool for identification of elder mistreatment.

It is estimated that 15.7% of people aged 60 years and older were subjected to some form of Elder Mistreatment (EM) globally (Yon et al., 2017). In the USA, as many as 1 in 24 EM cases are left unidentified by professionals, with a 300% increased mortality risk for older adults who do not receive help (National Center on Elder Abuse, n.d.; Dong, 2009). Current methods of screening tend to miss less obvious signs of EM and may discourage older adults from disclosing EM, due to either a lack of understanding of what constitutes mistreatment or fear of retaliation from the perpetrator. Our approach shifts the focus of EM identification to the older adults themselves through an automated tablet-based tool. The Virtual cOaching in making Informed Choices on Elder Mistreatment Self-Disclosure (VOICES) tool includes various multimedia components such as videos, audio, and animations designed to educate and enhance screening. Patients screened as positive are guided through a Brief Negotiated Interview (BNI) utilizing motivational interviewing to assist in self-identification (recognize that they are experiencing elder mistreatment) or self-disclosure (inform others about their elder mistreatment experiences). During tool development, we conducted a qualitative study to evaluate the perceived value and likelihood of adopting a tablet-based approach to facilitate screening and self-disclosure of EM in the ED. We held 3 focus groups with stakeholders, including 24 adults 60 years or over, 2 social workers, 2 caregivers, and 2 ED clinicians. We used the findings from the focus groups and User-Centered Design approach (UCD) to develop the tablet-based screening tool. Once the tool was ready, we tested its usability and acceptability with 14 older adults. Focus group participants supported use of a tablet-based tool to screen for EM, indicating that digital screening benefits from feelings of privacy and anonymity. On a 7-point Likert scale ranging from "1=Very Comfortable" to "7=Very Uncomfortable", older adults scored 2.8 on average for whether they would feel comfortable using a tablet device to screen for EM. Prominent suggestions made by older adults included using a female voice for the tool narrator, larger font size, more multimedia, headphones for privacy; and having someone available during screening for assistance if needed. Participants indicated that it is difficult for older adults experiencing EM to ask for help and that any type of mistreatment screening would be helpful. They also highlighted the need to explain community resources available to older adults once EM is disclosed, especially resources offering help to the caregiver. Participants of the usability evaluation rated the tool a mean score of 86.6 (median= 88.8, iQR =18.1) on the System Usability Scale (SUS), far above the benchmark SUS score of 68, which indicates that the system is "good" or "acceptable" (Bangor et al., 2008). Shifting the focus from the provider to the older adult may encourage self-disclosure of EM by addressing major barriers to traditional screening processes. In summary, this study supported the use of self-administered automated tablet-based screening for EM. Participants generally believed that the use of digital health tools to facilitate the screening process would be beneficial in the ED setting.

Cost Savings of Frequent, Concise Skills Competency Training in the Emergency Department

Nurse educators are confronted with ensuring skills competency and staff compliance to support the provision of safe and quality care. The ED setting presents additional challenges when conducting skills competency training. One military hospital’s emergency department implemented a method of frequent, concise skills training sessions to overcome barriers unique to the ED setting; the same method was then implemented at a second military organization owing to the effectiveness of the training approach to increase staff compliance. This article outlines the methods for the implementation of frequent, concise skills training sessions, and it displays the cost savings and increased compliance experienced by the 2 health care organizations after the implementation of this frequent, concise skills training method.

Reassessing Risk of Severe Anaphylaxis and History of Asthma

Research Article| September 01 2020 Reassessing Risk of Severe Anaphylaxis and History of Asthma AAP Grand Rounds (2020) 44 (3): 28. https://doi.org/10.1542/gr.44-3-28 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Reassessing Risk of Severe Anaphylaxis and History of Asthma. AAP Grand Rounds September 2020; 44 (3): 28. https://doi.org/10.1542/gr.44-3-28 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: anaphylaxis, asthma Source: Dribin TE, Michelson KA, Zhang Y, et al. Are children with a history of asthma more likely to have severe anaphylactic reactions? A retrospective cohort study. J Pediatr. 2020; 220: 159– 164.e2; doi: https://doi.org/10.1016/j.jpeds.2019.12.019Google Scholar Investigators from Cincinnati Children’s Hospital Medical Center, OH, and Boston Children’s Hospital, MA, conducted a retrospective cohort study to assess whether a history of asthma was associated with anaphylaxis severity. Children were eligible if they were 6 months to 18 years old, presented to the study ED with anaphylaxis between 2009–2016, and were hospitalized. Eligible children were identified through chart review using a combination of ICD-9 and ICD-10 codes for allergic reactions, anaphylaxis, or adverse drug reactions followed by manual review to confirm that diagnostic criteria for anaphylaxis were met as defined by the National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network. Children transferred from outside facilities or who were on oral corticosteroids were excluded. Demographics and clinical characteristics were obtained from the medical chart. The primary predictor was a history of asthma, as obtained from review of provider documentation in the medical chart. The primary outcome was severe anaphylactic reaction, obtained from the medical chart and defined as the presence of at least one examination finding (stridor, hypotension, or respiratory distress) during the first 4 hours of ED care or receipt of at least one acute therapy (≥2 doses of IM epinephrine, use of continuous albuterol, initiation of positive pressure ventilation, or use of vasopressors) in the prehospital, ED, or inpatient setting. The investigators used multivariable logistic regression to determine the association of the predictor and outcome after adjusting for demographics and other clinical characteristics. There were 603 children included in analysis, 231 (38.3%) of whom had a history of asthma. Overall, 38 (6%) participants had stridor during the first 4 hours of ED care, 246 (41%) had respiratory distress, and 26 (4%) had hypotension. In addition, 139 (23%) received ≥2 doses of IM epinephrine in the prehospital and ED setting, while 3 (0.5%) received ≥2 doses of IM epinephrine in the inpatient setting. There were 12 (2%) participants who received vasopressors in the prehospital and ED setting and 11 (1.8%) participants who received vasopressors in the inpatient setting. In multivariable analyses, there was no association between a history of asthma and a severe anaphylactic reaction (adjusted odds ratio 0.97; 95% CI, 0.67, 1.39). The authors conclude that children with a history of asthma who are hospitalized with anaphylaxis do not have more severe anaphylactic reactions than those without a history of asthma. Dr Doolittle has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. The American Academy of Allergy, Asthma, and Immunology and the European Academy of Allergy and Clinical Immunology both recommend a prolonged period of observation for children with asthma who experience a severe anaphylactic reaction.1,2 This... You do not currently have access to this content.

Development and Implementation of a Community Paramedicine Program in Rural United States.

IntroductionCommunity paramedicine (CP) is an innovative care model focused on medical management for patients suffering from chronic diseases or other conditions that result in over-utilization of healthcare services. Despite their value, CP care models are not widely used in United States healthcare settings. More research is needed to understand the feasibility and effectiveness of implementing CP programs. Our objective was to develop a CP program to better meet the needs of complex, high-utilizer patients in a rural setting.MethodsWe conducted an observational descriptive case series in a community, 25-bed, critical access hospital and primary care clinic in a rural Wisconsin county. Multiple stakeholders from the local health system and associated ambulance service were active participants in program development and implementation. Eligible patients receiving the intervention were identified as complex or high need by a referring physician. Primary outcomes included measures of emergency department, hospital, and clinic utilization. Secondary measures included provider and patient satisfaction.ResultsWe characterized 32 unique patients as high utilizers requiring assistance in medical management. These patients were enrolled into the program and categorized as high utilizers requiring assistance in medical management. The median age was 76 years, and 68.8% were female. After six months, we found a statistically significant decline in patient utilization for primary care (53.3%, p = .006) and ED visits (59.3%, p = .007), but not for hospitalizations (60%, p = .13, non-significant (NS), compared to the six months preceding enrollment. Overall, the total number of healthcare contacts was increased after implementation (623 before vs 790 after, + 167, +26.8%). Implementation of the CP program resulted in increased overall use of local healthcare resources in patients referred by physicians as high utilizers.ConclusionThe implementation of an in-home CP program targeting high users of healthcare resources resulted in a decrease in utilization in the hospital, ED, and primary care settings; however, it was balanced and exceeded by the number of CP visits. CP programs align well with population health strategies and could be better leveraged to fill gaps in care and promote appropriate access to healthcare services. Further study is required to determine whether the shift in type of healthcare access reduces or increases cost.