Emergency Practitioners Research Articles

Ocular Point-of-Care Ultrasonography to Diagnose Posterior Chamber Abnormalities

Diagnosing posterior chamber ocular abnormalities typically requires specialist assessment. Point-of-care ultrasonography (POCUS) performed by nonspecialists, if accurate, could negate the need for urgent ophthalmologist evaluation. This meta-analysis sought to define the diagnostic test characteristics of emergency practitioner-performed ocular POCUS to diagnose multiple posterior chamber abnormalities in adults. PubMed (OVID), MEDLINE, EMBASE, Cochrane, CINAHL, and SCOPUS were searched from inception through June 2019 without restrictions. Conference abstracts and trial registries were also searched. Bibliographies of included studies and relevant reviews were manually searched, and experts in the field were queried. Included studies compared ocular POCUS performed by emergency practitioners with a reference standard of ophthalmologist evaluation. Pediatric studies were excluded. All 116 studies identified during abstract screening as potentially relevant underwent full-text review by multiple authors, and 9 studies were included. In accordance with PRISMA guidelines, multiple authors extracted data from included studies. Results were meta-analyzed for each diagnosis using a bivariate random-effects model. Data analysis was performed in July 2019. The outcomes of interest were diagnostic test characteristics of ocular POCUS for the following diagnoses: retinal detachment, vitreous hemorrhage, vitreous detachment, intraocular foreign body, globe rupture, and lens dislocation. Nine studies (1189 eyes) were included. All studies evaluated retinal detachment, but up to 5 studies assessed each of the other diagnoses of interest. For retinal detachment, sensitivity was 0.94 (95% CI, 0.88-0.97) and specificity was 0.94 (95% CI, 0.85-0.98). Sensitivity and specificity were 0.90 (95% CI, 0.65-0.98) and 0.92 (95% CI, 0.75-0.98), respectively, for vitreous hemorrhage and were 0.67 (95% CI, 0.51-0.81) and 0.89 (95% CI, 0.53-0.98), respectively, for vitreous detachment. Sensitivity and specificity were high for lens dislocation (0.97 [95% CI, 0.83-0.99] and 0.99 [95% CI, 0.97-1.00]), intraocular foreign body (1.00 [95% CI, 0.81-1.00] and 0.99 [95% CI, 0.99-1.00]), and globe rupture (1.00 [95% CI, 0.63-1.00] and 0.99 [95% CI, 0.99-1.00]). Results were generally unchanged in sensitivity analyses of studies with low risk of bias. This study suggests that emergency practitioner-performed ocular POCUS is an accurate test to assess for retinal detachment in adults. Its utility in diagnosing other posterior chamber abnormalities is promising but needs further study.

A Survey of Emergency Providers Regarding the Current Management of Anterior Shoulder Dislocations.

Background:Anterior shoulder dislocations (ASDs) are frequent painful injuries commonly treated in the emergency department. The last decade new potentially less traumatic and painful reduction techniques for ASDs have been introduced. Recent literature comparing best reduction techniques, medication use, and approaches is limited. To better guide future research including the use of these newer techniques, information about the current use of different reduction techniques and medication is needed.Methods:Our primary aim was to survey the techniques used by emergency practitioners to reduce ASDs. Our secondary objective was to gather data on medication usage during reduction. To these ends, we surveyed members of the Netherlands Society of Emergency Physicians.Results:Forty-four percent of respondents reported using a traction-based technique (Hippocrates or Stimson). Biomechanical techniques were used by 40% of respondents. Twelve percent reported using the Kocher leverage-based technique. Five percent of the techniques used could not be classified. A wide variety of procedural sedation and pain management interventions were reported, with an opioid and propofol being used most commonly. Approximately 9% of the reductions were attempted without any medications.Conclusions:To our knowledge, this is the first study of its kind on ASD management by emergency practitioners. Our results indicate that Dutch emergency practitioners employ all three classes of reduction techniques: traction-countertraction most commonly, closely followed by biomechanical techniques. Medication use during repositioning varied widely. Per our survey, emergency practitioners are desirous of an evidence-based guideline for ASD management.

Implementing a Clinical Pathway for Paediatric Mental Health Care in the Emergency Department

Practitioners in emergency departments across Canada are challenged with providing quality mental health (MH) care for children and youth despite increased demand for services. Coordinated service strategies, such as clinical pathways, are needed to effectively manage paediatric MH disorders. Practitioners in a children’s hospital emergency department implemented a pathway to improve the care of children and youth with MH conditions. This paper describes an external evaluation of practitioner and stakeholder experiences of the initiative as well as the implementation process, then explores current state and lessons learned. The paper provides a unique contribution to the practitioner-led implementation literature.

Artenimol\u2013piperaquine in children with uncomplicated imported falciparum malaria: experience from a prospective cohort

BackgroundAlthough malaria remains one of the major public health threats in inter-tropical areas, there is limited understanding of imported malaria in children by paediatricians and emergency practitioners in non-endemic countries, often resulting in misdiagnosis and inadequate treatment. Moreover, classical treatments (atovaquone-proguanil, quinine, mefloquine) are limited either by lengthy treatment courses or by side effects. Since 2010, the World Health Organization (WHO) has recommended the use of oral artemisinin-based combination therapy for the treatment of uncomplicated Plasmodium falciparum malaria worldwide. The benefits of artenimol–piperaquine in children have been validated in endemic countries but experience remains limited in cases of imported malaria.MethodsThis prospective observational study in routine paediatric care took place at the Emergency Department, Robert-Debré Hospital (Paris, France) from September 2012 to December 2014. Tolerance and efficacy of artenimol–piperaquine in children presenting with the following inclusion criteria were assessed: P. falciparum positive on thin or thick blood smear; and the absence of WHO-defined features of severity.ResultsAmong 83 children included in this study, treatment with artenimol–piperaquine was successful in 82 children (98.8%). None of the adverse events were severe and all were considered mild with no significant clinical impact. This also applied to cardiological adverse events despite a significant increase of the mean post-treatment QTc interval.ConclusionArtenimol–piperaquine displays a satisfying efficacy and tolerance profile as a first-line treatment for children with imported uncomplicated falciparum malaria and only necessitates three once-daily oral intakes of the medication. Comparative studies versus artemether-lumefantrine or atovaquone-proguanil would be useful to confirm the results of this study.

Highlighting the rules between diagnosis types and laboratory diagnostic tests for patients of an emergency department: Use of association rule mining.

Diagnostic tests are widely used in emergency departments to make detailed investigations on diagnosis and treat patients correctly. However, since these tests are expensive and time-consuming, ordering correct tests for patients is crucial for efficient use of hospital resources. Thus, understanding the relation between diagnosis and diagnostic test requirement becomes an important issue in emergency departments. Association rule mining was used to extract hidden patterns and relation between diagnosis and diagnostic test requirement in real-life medical data received from an emergency department. Apriori was used as an association rule mining algorithm. Diagnosis was grouped into 21 categories based on International Classification of Disease, and laboratory tests were grouped into four main categories (hemogram, biochemistry, cardiac enzyme, urine and human excrement related). Both positive and negative rules were discovered. Since the nature of the data had the dominance of negative values, higher number of negative rules with higher confidences were discovered compared to positive ones. The extracted rules were validated by emergency department experts and practitioners. It was concluded that understanding the association between patient's diagnosis and diagnostic test requirement can improve decision-making and efficient use of resources in emergency departments. Association rules can also be used for supporting physicians to treat patients.

Approach to Male Urologic Emergencies

This review details the evaluation and management of the acute scrotum in the emergency department setting and emergent penile complaints in adults, with an emphasis on the most serious and most common conditions. Other emergent conditions include necrotizing fasciitis of the perineum (Fournier disease), incarcerated or strangulated inguinal hernia, and genitourinary (GU) trauma. Emergency practitioners need to be most concerned with the entities that, if left untreated, can result in ischemia and necrosis of the penis. Basic anatomy and bedside evaluation are reviewed. Acute scrotal and penile pain and GU trauma are discussed in terms of assessment and stabilization, diagnosis, and treatment and disposition. This review contains 5 figures, 19 tables, and 71 references. Keywords: Acute scrotal pain, testicular torsion, priapism, Peyronie disease, paraphimosis, phimosis, balanitis, posthitis, epididymitis

The Compliance of Current Small Animal CPR Practice With RECOVER Guidelines: An Internet-Based Survey.

In 2012 the Reassessment Campaign on Veterinary Resuscitation (RECOVER) published evidence-based treatment recommendations for dogs and cats with cardiopulmonary arrest (CPA), to optimize the clinical practice of small animal CPR and positively impact outcomes. Six years after the release of these guidelines, we aimed to determine the compliance of small animal veterinary CPR practices with these RECOVER guidelines. To identify current CPR practices in clinically active small animal veterinarians and their awareness of the RECOVER guidelines, we conducted an internet-based survey. Survey invitations were disseminated internationally via veterinary professional organizations and their social media outlets. Questions explored respondent demographics, CPR preparedness, BLS and ALS techniques and awareness of RECOVER guidelines. Responding small animal veterinarians (n = 770) in clinical practice were grouped by level of expertise: board-certified specialists (BCS, n = 216) and residents (RES, n = 69) in anesthesia or emergency and critical care, practitioners in emergency (GPE, n = 299) or general practice (GPG, n = 186). Large disparities in preparedness measures, BLS and ALS techniques emerged among levels of expertise. Only 32% (95% CI: 29–36%) of respondents complied with BLS practice guidelines, varying from 49% (95% CI: 42–55%) of BCS to 15% (95% CI: 10–20%) of GPG. While incompliances in BCS, RES, and GPE were predominantly due to knowledge gaps, GPG compliance was further compromised by limitations in the resuscitation environment (e.g., defibrillator availability, team size). Those aware of RECOVER guidelines (100% of BCS and RES; 77% of GPE; 35% of GPG) were more likely to comply with recommended preparedness (OR = 2.4; 95% CI: 1.2–4.8), BLS (OR = 4.5; 95% CI: 2.4–9.1), and ALS techniques (OR = 7.8; 95% CI: 2.4–9.1) independent of age, gender, region of practice or level of expertise. We conclude that awareness of RECOVER guidelines is high in specialists and residents, but incomplete among general practitioners. This awareness positively influenced compliance with CPR guidelines, but CPR practices continue to be variable and largely not in agreement with guidelines. A widely accessible educational strategy is required to broadly improve compliance with best practices in small animal CPR.

Process and findings informing the development of a provincial emergency medicine network.

We describe the process undertaken to inform the development of the recently launched British Columbia (BC) Emergency Medicine Network (EM Network). Five methods were undertaken: (1) a scoping literature review, (2) a survey of BC emergency practitioners and EM residents, (3) key informant interviews, (4) focus groups in sites across BC, and (5) establishment of a brand identity. There were 208 survey respondents: 84% reported consulting Internet resources once or more per emergency department shift; however, 26% reported feeling neutral, somewhat unsatisfied, or very unsatisfied with searching for information on the Internet to support their practice. Enthusiasm was expressed for envisioned EM Network resources, and the key informant interviews and focus group results helped identify and refine key desired components of the EM Network. In describing this, we provide guidance and lessons learned for health leaders and others who aspire to establish similar clinical networks, whether in EM or other medical disciplines.

Nursing patients with acute aortic dissection in emergency departments.

Acute aortic dissection is an emergency condition that is often missed during initial assessment. Delay in diagnosis increases mortality, but the presentation can mimic several more common conditions. Emergency practitioners must maintain a high index of suspicion in patients who present with chest or back pain and ensure timely diagnostic testing and interpretation of results if aortic dissection is suspected.

Medical perspectives regarding goals-of-care consultations in Emergency Departments

ABSTRACTGoals-of-care discussions aim to establish patient values for shared medical decision-making. These discussions are relevant towards end-of-life as patients may receive non-beneficial treatments if they have never discussed preferences for care. End-of-life care is provided in Emergency Departments (EDs) but little is known regarding ED-led goals-of-care discussions. We aimed to explore practitioner perspectives on goals-of-care discussions for adult ED patients nearing end-of-life. We report the qualitative component of a mixed methods study regarding a ‘Goals-of-Care’ form in an Australian ED. Eighteen out of 34 doctors who completed the form were interviewed. We characterised ED-led goals-of-care consultations for the first time. Emergency doctors perceive goals-of-care discussions to be relevant to their practice and occurring frequently. They aim to ensure appropriate care is provided prior to review by the admitting team, focusing on limitations of treatment and clarity in the care process. ED doctors felt they could recognise end-of-life and that ED visits often prompt consideration of end-of-life care planning. They wanted long-term practitioners to initiate discussions prior to patient deterioration. There were numerous interpretations of palliative care concepts. Standardisation of language, education, collaboration and further research is required to ensure Emergency practitioners are equipped to facilitate these challenging conversations.

Ketamine for Acute Agitation

This review describes the use of ketamine for acutely agitated patients in the emergency care setting. Evidence for its efficacy will be reviewed and practical suggestions for using ketamine in this scenario will be presented. The available observational literature on the topic of ketamine for agitation was recently summarized in a systematic review. This review found that ketamine effectively and quickly sedates acutely agitated patients. However, it did raise some concerns about an increased intubation rate in patients administered ketamine. In severely agitated patients, particularly those presumed to be caused by stimulant drug use, who need immediate sedation to ensure the safety of the patient and staff, ketamine is a reasonable and safe choice. Emergency practitioners can consider giving ketamine 4-6 mg/kg IM (500 mg for most adults). Once given, it is important to closely monitor the patient for adverse effects and that the examination continue to determine the etiology of the patient’s agitation.

Developing Degree Programs in Emergency Management: Ghana’s Experience

Abstract Training or Educating Emergency Management practitioners and academics are crucial to disaster risk reduction. However, not much is known about higher education program development, specifically, degree program development in Emergency Management. This paper seeks to find factors that help and or hinder Emergency Management higher education program development. An interpretive constructionist perspective method was used to analyze data collected through purposive and snowball sampling. Nineteen emergency management scholars and practitioners who have been involved with Ghana’s efforts, and additional six faculty members who have been involved with developing other new degree programs in four Ghanaian universities were also selected through snowball sampling for the purposes of comparison. Data was collected through in-depth semi-structured face-to-face and telephone interviews. The results suggest six main factors explain why Ghana has not yet established an Emergency Management degree program. The factors include institutional support, partnership, advocacy, funding, program marketing, and cultural factors. In addition to laying theoretical foundation for studies in this area, the relative novelty of Disaster/Emergency Management degree programs, make findings of this study, a checklist for institutions looking into establishing Disaster or Emergency Management degree programs in future.

Practice Standards for the Emergency Nurse Practitioner Specialty.

THE EMERGENCY NURSE PRACTITIONER (ENP) specialty in the United States has grown rapidly since its origins during the 1980s following the establishment of the emergency medicine specialty. Initially, ENPs were prepared on the job with direct mentoring by emergency medicine physicians. Since then, in

More Reform of the English National Health Service: From Competition Back to Planning?

The period of sustained financial austerity since 2009 has led to a shift in competition policy within the English National Health Service. Policymakers have directed their attention away from the preexisting priority to support quicker access to routine and planned hospital care and have focused instead on improving emergency, cancer, and general practitioner services. This has prompted the development of a new policy framework and, in particular, a desire to create collaborative health systems focused on specific populations. In addition, previous policy initiatives to engage the leadership of general practitioners in planning services have been revisited. The overall effect has been to shift emphasis away from competitive markets and back toward a planning approach.

Exploring retention and behavioral intentions when using social robotics to communicate a weather risk

During weather risks and crises, emergency managers and practitioners are often tasked with disseminating messages to individuals or groups of people who are located in a variety of hard-to-reach areas. Social robotics may serve as a useful delivery medium for disseminating some of these messages, if a group is located in an area that is hard to reach. This exploratory study investigated the information retention and behavioral intentions after being disseminated a mock weather risk message. The results provide support for delivery platform being important to consider when disseminating a risk message, such that novel technologies may actually lead to lower retention of message content. Discussion is centered around the implications of using novel technology to communicate risk messages.

A qualitative study of the determinants of adherence to NICE falls guideline in managing older fallers attending an emergency department

BackgroundThe National Institute for Health and Care Excellence (NICE) 2004 Falls guideline was developed to improve the assessment and management of falls and prevention of future falls. However, adherence to the guideline can be poor. As emergency departments (EDs) are usually consulted by older adults (aged 65 and over) who experience a fall, they provide a setting in which assessments can be conducted or referrals made to more appropriate settings.The objective of this study was to investigate how falls are managed in EDs, reasons why guideline recommendations are not always followed, and what happens instead.MethodsThe study involved two EDs. We undertook 27 episodes of observation of healthcare professional interactions with patients aged 65 or over presenting with a fall, supported by review of the clinical records of these interactions, and subsequently, 30 interviews with healthcare professionals. The qualitative analysis used the framework approach.ResultsVarious barriers and enablers (i.e. determinants of practice) influenced adherence at both EDs, including the following: support from senior staff; education; cross-boundary care; definition of falls; communication; organisational factors; and staffing.ConclusionsA variety of factors influence adherence to the Falls guideline within an ED, and it may be difficult to address all of them simultaneously. Simple interventions such as education and pro-formas are unlikely to have substantial effects alone. However, taking advantage of the influence of senior staff on juniors could enhance adherence. In addition, collaborative care with other NHS services offers a potential approach for emergency practitioners to play a part in managing and preventing falls.

Medical Management of Pain in the Emergency Setting Without Narcotics: Current Status and Future Options

Relief of pain and discomfort is a critical component of the mission of every health care provider to reduce suffering. Pain management is of paramount importance in the provision of care at every level. This is an era of increasing patient expectations of care, yet also there exists an ongoing scourge of opiate abuse. ED visits for opioid overdoses rose 30% in all parts of the USA from July 2016 through September 2017. Deaths from narcotic overdose in the USA now exceed those from motor vehicle crashes. The concept of an “opiate-free” emergency department has been posited. The emergency practitioner is presented with clinical and political challenges which did not exist in the past. This article elucidates current pharmacologic options regarding analgesia in the emergency setting, with some possible future options.

LO83: Relevance of international opioid prescribing guidelines for emergency department practice

Introduction: The opioid crisis in North America has led to more rigorous prescribing guidelines in various practice settings. Recent studies suggest that the Emergency Department is an environment with increased opioid prescribing, leading to increased rates of long-term use and dependence in opioid naive patients. Prior reviews of international opioid prescribing guidelines have demonstrated overall congruence of practice recommendations, although these are focused on primary care prescribers. The goal of this study was to review international opioid prescribing guidelines for recommendations relevant to emergency department practitioners. Methods: The search strategies of prior congruence studies were reproduced, updated and supplemented by electronic database and specialty organization searches. Only the most recent iteration of a published guideline was included, unless it was a limited update of a prior more comprehensive guideline, in which case both were assessed. Prescribing guidelines were included if they represented national practice statements, national or international specialty organizations generating guidelines. Sub-national or regional guidelines were excluded due to local practice bias tendency. Included guidelines were independently reviewed for evidence evaluation and recommendation formulation frameworks, relevance of recommendations for emergency medicine (EM) practice (and supporting levels of evidence), inclusion of EM authors (and corresponding conflict of interest statements), and involvement of EM-relevant stakeholders in reviewing guideline publications. Results: Sixteen international and specialty organization guidelines were included in the review. Evidence evaluation and recommendation formulation frameworks were incompletely reported (12/16), and used a multitude of evaluation processes when reported. Two guidelines included EM-relevant recommendations based on weak evidence. Three guidelines included EM authors, one of which reported a conflict of interest. None of the included guidelines were reviewed by EM-relevant stakeholder organizations prior to publication. Conclusion: International and specialty organization opioid prescribing guidelines virtually ignore relevant recommendations for EM practice, and any supporting evidence is weak. Emergency practitioners are nearly absent from authorship groups, and are excluded from external review of draft documents prior to final publication. This study reinforces the urgent need for EM organizations to create guidance documents around opioid prescribing for their own practitioners, and involving appropriate EM stakeholders.

The British Columbia Emergency Medicine Network: A Paradigm Shift in a Provincial System of Emergency Care.

As generalists, emergency practitioners face challenges in providing state-of-the-art care owing to the broad spectrum of practice and the rapid rate of new knowledge generation. Networks have become increasingly prevalent in health care, and it was in this backdrop, and the resulting opportunity to advance evidence-informed emergency care in the Canadian province of British Columbia (BC), that a new “Emergency Medicine Network” (EM Network) was launched in 2017. The EM Network consists of four programs, each led by a physician with expertise and a track record in the domain: (1) Clinical Resources; (2) Innovation; (3) Continuing Professional Development; and (4) Real-time Support. This paper provides an overview of the EM Network, including its background, purpose, programs, anticipated evolution, and impact on the BC health care system.

Ascariasis and hyperosmolar hyperglycemic state: a surprising ultrasound finding in the emergency department

BackgroundWe report the ultrasound finding of ascariasis in a patient with hyperosmolar hyperglycemic state (HHS). Although ascariasis is common in low-resource settings, there has been no previous report associating ascariasis with HHS.Case presentationA 26-year-old Rwandan man was admitted to the emergency department in coma, with a glycemia of 600 mg/dl. He was resuscitated with fluids, intubated and ventilated, and treated with insulin and antibiotics. On day 3, an ascaris worm was passed via his nasogastric tube, and abdominal ultrasound revealed a heavy worm load. He was treated with albendazole and eventually made a full recovery.ConclusionsThis is the first report of ascariasis as a potential cause of HHS, and we recommend that emergency practitioners consider early abdominal ultrasound in patients with hyperglycemic emergencies in areas with a high prevalence of ascariasis.