Initial Disposition Research Articles

1278-PUB: Acid-Base Alterations after Isotonic Fluid Resuscitation of Patients in Suspected DKA in the Pediatric Emergency Department

Introduction: Pediatric patients presenting to the emergency department (ED) for diabetic ketoacidosis (DKA) often present with dehydration, with admission to the intensive care unit (ICU) dependent on measures of dehydration and acidosis. Objective: The objective of this study was to assess the effect of fluid resuscitation in the ED on patient disposition to the ICU or floor based on changes in markers of dehydration and acidosis. Methods: This investigation was a single-center, retrospective study of patients 6 to 18 years old presenting to the ED for concern of DKA from 2016-2019. Patients with pre-bolus and post-bolus venous blood gas (VBG) were included. Each pre-bolus and post-bolus VBG was classified as meeting ICU or floor criteria. Based on the protocol developed at Rainbow Babies and Children’s Hospital, ICU criteria were pH < 7.3 and/or bicarbonate (HCO3) < 15 (on VBG or renal function panel). Dehydration was assessed using heart rate and blood urea nitrogen (BUN), adjusted by age. Continuous variables were analyzed using Kruskal-Wallis test, and categorical variables were analyzed with the chi-square test or Fisher’s exact test. Results: In this study, 187 patients met inclusion criteria. Post-bolus pH was increased in 52%, decreased in 41%, and unchanged in 7%. Post-bolus bicarbonate was increased in 44%, decreased in 53%, and unchanged in 2%. Of 145 patients with initial disposition to the ICU, 26 (17.9%) met floor criteria post-bolus, and no marker for dehydration distinguished this cohort (p=0.054 for heart rate, p=0.93 for BUN). Of 40 patients with initial disposition to the floor, 7 (17.5%) met ICU criteria post-bolus, and no marker for dehydration distinguished this cohort (p=0.68 for heart rate and p=1 for BUN). Conclusion: Patients presenting to the ED in DKA may have a decrease in pH or HCO3 following a normal saline bolus. In patients initially meeting criteria for the floor, up to 17.5% may change disposition to the ICU after a normal saline bolus. Disclosure S. Gera: None. S. P. Sheth: None. K. A. Kutney: None. S. Malay: None.

COVID-19-Related Circumstances for Hospital Readmissions: A Case Series From 2 New York City Hospitals.

The aim of the study was to determine the main factors contributing to hospital readmissions and their potential preventability after a coronavirus disease 2019 (COVID-19) hospitalization at 2 New York City hospitals. This was a retrospective study at 2 affiliated New York City hospitals located in the Upper East Side and Lower Manhattan neighborhoods. We performed case reviews using the Hospital Medicine Reengineering Network framework to determine potentially preventable readmissions among patients hospitalized for COVID-19 between March 3, 2020 (date of first case) and April 27, 2020, and readmitted to either of the 2 hospitals within 30 days of discharge. Among 53 readmissions after hospitalization for COVID-19, 44 (83%) were deemed not preventable and 9 (17%) were potentially preventable. Nonpreventable readmissions were mostly due to disease progression or complications of COVID-19 (37/44, 84%). Main factors contributing to potentially preventable readmissions were issues with initial disposition (5/9, 56%), premature discharge (3/9, 33%), and inappropriate readmission (1/9, 11%) for someone who likely did not require rehospitalization. Most readmissions after a COVID-19 hospitalization were not preventable and a consequence of the natural progression of the disease, specifically worsening dyspnea or hypoxemia. Some readmissions were potentially preventable, mostly because of issues with disposition that were directly related to challenges posed by the ongoing COVID-19 pandemic. Clinicians should be aware of challenges with disposition related to circumstances of the COVID-19 pandemic.

Large-Volume Intrathecal Administrations: Impact on CSF Pressure and Safety Implications.

The increasing number of studies demonstrates the high potency of the intrathecal (IT) route for the delivery of biopharmaceuticals to the central nervous system (CNS). Our earlier data exhibited that both the infused volume and the infusion rate can regulate the initial disposition of the administered solute within the cerebrospinal fluid (CSF). This disposition is one of key factors in defining the subsequent transport of the solute to its intended target. On the other hand, fast additions of large volumes of liquid to the CSF inevitably raise the CSF pressure [a.k.a. intracranial pressure (ICP)], which may in turn lead to adverse reactions if the physiologically delimited threshold is exceeded. While long-term biological effects of elevated ICP (hydrocephalus) are known, the safety thresholds pertaining to short-term ICP elevations caused by IT administrations have not yet been characterized. This study aimed to investigate the dynamics of ICP in rats and non-human primates (NHPs) with respect to IT infusion rates and volumes. The safety regimes were estimated and analyzed across species to facilitate the development of translational large-volume IT therapies. The data revealed that the addition of a liquid to the CSF raised the ICP in a rate and volume-dependent manner. At low infusion rates (<0.12 ml/min in rats and <2 ml/min in NHPs), NHPs and rats displayed similar tolerance patterns. Specifically, safe accommodations of such added volumes were mainly facilitated by the accelerated pressure-dependent CSF drainage into the blood, with I stabilizing at different levels below the safety threshold of 28 ± 4 mm Hg in rats and 50 ± 5 mm Hg in NHPs. These ICPs were safely tolerated for extended durations (of at least 2–25 min). High infusion rates (including boluses) caused uncompensated exponential ICP elevations rapidly exceeding the safety thresholds. Their tolerance was species-dependent and was facilitated by the compensatory role of the varied components of craniospinal compliance while not excluding the possibility of other contributing factors. In conclusion, large volumes of liquids can safely be delivered via IT routes provided that ICP is monitored as a safety factor and cross-species physiological differences are accounted for.

Bigger is Still Better: A Step Forward in Reperfusion With React 71.

While multiple new larger-bore aspiration catheters have been introduced for stroke thrombectomy, sizeable cohort outcome studies are lacking along with meaningful comparative studies to evaluate whether they represent a clinically relevant improvement compared to predecessors. To evaluate comparative angiographic and clinical outcomes between an 071 and 068 aspiration catheter. The authors reviewed an institutional thrombectomy database extracting the first 150 consecutive cases utilizing React 71 (Medtronic, Dublin, Ireland) with a comparison of background/demographic, procedural, angiographic, and clinical outcome variables to a cohort of patients treated with our previously most frequently utilized 0.068-inch aspiration catheter. In our React 71 cohort, successful reperfusion (thrombolysis in cerebral infarction [TICI] 2b-3) was achieved in 95% of cases. In comparison to a prior cohort of 96 patients treated with a 0.068-inch catheter, there was no statistically significant difference in rates of successful reperfusion (TICI 2b-3), initial disposition, and 90-d outcome. However, the frequency of single pass cases was significantly higher in the React 71 cohort (47%vs 35%, P=.019 on multivariate analysis) along with the rate of TICI 2c-3 reperfusion after the first pass (26%vs 14%, P=.019 on multivariate analysis), and final TICI 2c-3 reperfusion (39%vs 28%, P=.04 on multivariate analysis). While rates of TICI 2b-3 reperfusion and clinical outcome results were similar, our study suggests that a newer, larger bore aspiration catheter may be associated with a greater frequency of single pass cases and higher quality reperfusion, judged as TICI 2c-3 frequency after the first and final pass.

What is the Impact of the 2020 Coronavirus Lockdown on Maxillofacial Trauma?

PurposeThe novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) or COVID-19 pandemic first arrived in Nashville, Tennessee, in early March 2020. Soon after, stay-at-home orders were initiated. The purpose of this study is to evaluate the impact of a 7-week lockdown on maxillofacial trauma volume at TriStar Skyline Medical Center, a level II trauma center in Nashville, Tennessee.Patients and MethodsThe investigator designed a retrospective cohort study and enrolled a sample of patients who presented for evaluation of maxillofacial trauma between March 23 and May 11 in the years 2019 and 2020. The primary predictor variable was evaluation of injures during the 2020 lockdown period or the same control period in 2019. The primary outcome variable was injury volume. Additional variables including demographic information, etiology, anatomic location, and initial disposition were evaluated. Descriptive and bivariate statistics were computed, with statistical significance set at P < .05.ResultsThe study sample showed a 35.6% reduction in patients seen during the 2020 lockdown (n = 38) compared with 2019 (n = 59, P = .15). The proportion of male to female trauma patients increased during the lockdown period from 6.6:1 (n = 33 male, n = 5 female) in 2020 compared with 2.3:1 (n = 41 male, n = 18 female) in 2019 (P = .049). The number of assaults decreased by 65.2% (P = .22). The percentage of patients seen on an outpatient basis decreased from 27.1% (n = 16) to 5.3% (n = 2, P = .007) during the lockdown period.ConclusionsThe initial 7-week lockdown during the COVID-19 pandemic was associated with a decrease in patients with maxillofacial trauma. The effect of the stay-at-home orders with resultant social distancing, has shown a decrease in maxillofacial trauma due to interpersonal violence.

For Homeless People with Serious Mental Illness, Can a State Transitional Shelter Promote Racial Equity in Housing Outcomes?

To examine the role of race, sex, arrest history, and psychiatric diagnoses in duration of shelter tenure and housing outcomes for patients in transitional shelters. The authors performed a three-year retrospective chart review of Massachusetts Department of Mental Health (DMH) records for individuals residing in three DMH transitional homeless shelters from 2013 to 2015. Race was not predictive of length of stay, initial disposition, or housing status at three to five-year follow-up. Arrest history negatively predicted initial housing placement, and diagnosis of substance use disorder predicted homelessness at follow-up. There were no differences by race in arrest history or diagnosis of substance use disorder. Race was not a factor in duration of shelter tenure, or in securing or maintaining housing following shelter stay. Arrest history and lifetime substance use disorder were associated with more negative outcomes following transitional shelter stay.

Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism.

While guidelines recommend outpatient management of patients with low-risk pulmonary embolism (PE), little is known about the disposition of patients with PE diagnosed in United States emergency departments (EDs). We sought to determine disposition practices and subsequent health care utilization in patients with acute PE in U.S. EDs. This was a retrospective cohort study of adult ED patients with a new diagnosis of acute PE treated at 740 U.S. acute care hospitals from July 1, 2016, through June 30, 2018. The primary outcome was the initial disposition following an ED visit for acute PE. Additional measures included hospital cost and 30-day revisit rate to the ED. A total of 61,070 cases were included in the overall cohort, of which 4.1% of new cases of PE were discharged from the ED. The median hospital-specific proportion of patients discharged was 3.1% (interquartile range= 0.8%-6.8%). The median odds ratio, representing the importance of the hospital in initial disposition decisions, was 2.21 (95% confidence interval= 2.05 to 2.37), which was greater than any patient-level factor with the exception of concurrent ED diagnosis of hypoxemia/respiratory failure, shock, or hypotension. Within 30days of discharge, 17.9% of discharged cases had an ED return visit to the ED only and 10.3% of patients were hospitalized. Of the 30-day ED return visits in patients initially managed as outpatients, 1.3% had a bleeding-associated diagnosis. Despite guidelines promoting outpatient management, few patients are currently discharged home in the United States; however, practice varies widely across hospitals. Return visit rates were high but most did not result in hospitalization.

Pediatric Seizures and Status Epilepticus

Seizures represent a common neurologic complaint among pediatric patients in the emergency department (ED). They can be classified as generalized or focal. In terms of etiology, seizures are most basically broken down into “acute symptomatic” seizures, which are due to another primary medical cause, and unprovoked seizures which occur as a primary pathology. Febrile seizures are the most common types of seizures in children, which themselves can be simple or complex. The most concerning seizures are those which associate with meningismus, encephalitis, metabolic derangements, intracranial mass, and, of course those which progress to status epilepticus. Significantly, it is appropriate and even critical to assume status epilepticus and intervene accordingly whenever a child arrives to the ED seizing for an unspecified period of time. This review covers the initial evaluation, resuscitation, management, work-up, and disposition of pediatric patients who present to the emergency room with seizures. Figures in this chapter illustrate stepwise and algorithmic approaches to initial management, expanded differential, systematic diagnostic approach, and disposition for pediatric patients presenting with seizures and status epilepticus. Tables list important physical exam components for evaluating children with seizures, classifications of seizures, common seizure look-alikes in children, features of febrile seizures, etiologies of pediatric seizures. This review contains 5 figures, 11 tables, and 22 references. Key Words: pediatric seizures, febrile seizures, pediatric neurologic emergencies, pediatric emergency medicine, status epilepticus

Diagnostic Discordance in Pediatric Critical Care Transport: A Single-Center Experience.

The aims of the study were to describe diagnostic discordance rates at our pediatric tertiary care center between the reason for transfer of critically ill/injured children (determined by the referring institution) and the inpatient admission diagnosis (determined by our accepting institution), to identify potential factors associated with discordance, and to determine its impact on patient outcomes. We conducted a retrospective chart review of all critically ill/injured children transferred to the Johns Hopkins Children's Center between July 1, 2017, and June 30, 2018. All patients whose initial inpatient disposition was the pediatric intensive care unit were included. Six hundred forty-three children (median age, 51 months) from 57 institutions (median pediatric capability level: 3) met inclusion criteria: 46.8% were transported during nighttime, 86.5% by ground, and 21.2% accompanied by a physician. Nearly half (43.4%) had respiratory admission diagnoses. The rest included surgical/neurosurgical (14.2%), neurologic (11.2%), cardiovascular/shock (8.7%), endocrine (8.2%), infectious disease (6.8%), poisoning (3.1%), hematology-oncology (2.2%), gastrointestinal/metabolic (1.9%), and renal (0.3%). Forty-six (7.2%) had referral-to-admission diagnostic discordance: 25 of 46 had discordance across different diagnostic groups and 21 of 46 had clinically significant discordance within the same diagnostic group. The discordant group had higher need for respiratory support titration in transport (43.9% vs 27.9%, p = 0.02); more invasive procedures and vasopressor needs during the day of admission (26.1% vs 11.6%, P = 0.008; 19.6% vs 7%, P = 0.006); and longer intensive care unit (ICU) and hospital stays (5 vs 2 days; 11 vs 3 days, P < 0.001). When compared with respiratory admission diagnoses, patients with cardiovascular/shock and neurologic diagnoses were more likely to have discordant diagnoses (odds ratio [95% confidence interval], 13.24 [5.41-35.05]; 6.47 [2.48-17.75], P < 0.001). Seven percent of our critically ill/injured pediatric cohort had clinically significant referral-to-admission diagnostic discordance. Patients with cardiovascular/shock and neurologic diagnoses were particularly at risk. Those with discordant diagnoses had more in-transit events; a higher need for ICU interventions postadmission; and significantly longer ICU stays and hospitalizations, deserving further investigation.

Utilization of a Resuscitative Care Unit for Initial Triage, Management, and Disposition of Minor Intracranial Hemorrhage.

Objectives:Management of minor intracranial hemorrhage typically involves ICU admission. ICU capacity is increasingly strained, resulting in increased emergency department boarding of critically ill patients. Our objectives were to implement a novel protocol using our emergency department–based resuscitative care unit for management of management of minor intracranial hemorrhage patients in the emergency department setting, to provide timely and appropriate critical care, and to decrease inpatient ICU utilization.Design:Retrospective analysis of prospectively collected data.Setting:Single large academic medical center in the United StatesPatients:Adult patients presenting to the emergency department with management of minor intracranial hemorrhage managed via our resuscitative care unit-management of minor intracranial hemorrhage protocol from September 2017 to April 2019.Intervention:Implementation of a resuscitative care unit-management of minor intracranial hemorrhage protocol.Measurements and Main Results:Demographic data, need for vasoactive infusions in the emergency department, emergency department and hospital length of stay, emergency department disposition, and 30-day outcomes (readmission, mortality, need for neurosurgical procedure) were collected. Fifty-five patients were identified, with mean age 67.1 ± 20.0 years. Mean Glasgow Coma Scale on presentation was 14.8 ± 0.5, and 66% had a history of trauma. Locations of hemorrhage were subdural (42%), intraparenchymal (35%), subarachnoid (15%), intratumoral (7%), and intraventricular (2%). Nineteen patients (35%) were discharged from the emergency department, 22 (40%) were admitted to general care, and 14 (26%) were admitted to intensive care. In discharged patients, there was no mortality or neurosurgical interventions at 30 days. In a subgroup analysis of 36 patients with a traumatic mechanism, 18 (50%) were able to be discharged from the emergency department after management in the resuscitative care unit.Conclusions:Initial management of emergency department patients with minor intracranial hemorrhage in a resuscitative care unit appears safe and feasible and was associated with a substantial rate of discharge from the emergency department (35%) and a low rate of admission to an inpatient ICU (26%). Use of this strategy was associated with rapid initiation of ICU-level care, which may help alleviate the challenge of increasing emergency department boarding time of critically ill patients facing many institutions.

Providing Patient Mobilization With a Mobility Technician Improves Staff Efficiency and Constrains Cost in Primary Total Hip Arthroplasty

BackgroundMobility technicians (MTs) demonstrate value in constraining the cost of total joint replacement procedures. MTs are certified medical assistants with specialized ambulation/gait training who work under the direction of the nursing staff to meet patient mobilization demands in hospital wards. This study analyzed their impact on primary total hip arthroplasty (THA). MethodsData were retrospectively reviewed from both the time before and the time after MTs were introduced to the hospital for demographic information (ie, age, gender, race, and payer) and clinical measures (ie, length of stay and discharge disposition). The control group was treated and mobilized according to standard physical therapy and nursing staff protocols. Study group subjects had access to the MTs at the direction of their registered nurse. Included subjects underwent a primary THA procedure for arthritic conditions or hip fractures, or for conversion from a previous hip surgery. Excluded were subjects who underwent procedures for revision, bilateral, or hip resurfacing procedures. ResultsThe study and control groups included 542 and 1297 subjects, respectively. They shared a median length of stay of 2 days (P = .121). More study group subjects were discharged home than were their control group counterparts (91.51%-87.43%, P = .012). Cost analysis revealed an annual savings of $119,794.50 in total first post-acute care (ie, the period spent at a patient’s initial discharge disposition level) costs to the institution. Therefore, MTs would need to successfully treat only 5 patients annually to recoup a savings equivalent to their salary. ConclusionMTs support the recovery of THA patients in the hospital, in turn optimizing their discharge disposition. Institutions may experience a financial benefit in a bundled payment system, in which avoiding costly rehab facilities may result in savings over the episode.

Longevity Aspects of Potable Water Disinfected by Ionic Silver: Kinetic Experiments and Modeling

In the International Space Station (ISS), Russian and European cosmonauts drink water disinfected by dissolved silver. For this to be effective, the concentration of silver should remain above a certain threshold from the moment of its initial disposition in storage tanks on earth until its final consumption in ISS. Unfortunately, during water tanks transportation to ISS and during storage in ISS, silver concentration has been reported to decrease intensively beyond any reason. This work examines the effect of different materials used in ISS water storage and distribution systems on the reduction of silver concentration. An experimental campaign has been organized where passivated stainless steel (SS), passivated and electropolished SS and titanium alloy coupons (official ISS grades) are exposed to simulated ISS potable water at different silver concentrations, different surface to volume ratios, and at stagnant or flow conditions. The evolution of silver concentration remaining in the bulk water is recorded with respect to the exposure time. A reaction engineering model for the Ag loss to the coupons is developed. The model is fitted to the experimental data in order to derive the reaction rate expression and the corresponding parameters. For passivated SS and electropolished SS the silver deposition rate depends on the initial silver concentration in water but is rather unaffected by the progress of silver deposition on the surface. On the other hand, for Ti alloy, while silver deposition rate still depends on initial silver concentration, it decreases continuously as silver deposition on the surface advances, implying that Ti alloy surface becomes gradually saturated and so prevents further silver deposition. Such a model can be useful for material selection and design of water storage and distribution facilities for ISS.

Risk Factors for Unplanned Admission to the Pediatric Intensive Care Unit in Pediatric Trauma Patients

Background and Hypothesis: A number of risk factors for unplanned pediatric intensive care unit (PICU) admission and readmission have been identified. However, little is known of the risk factors associated with unplanned admission to the PICU in pediatric trauma populations. We hypothesize specific risk factors can be identified which may be associated with unplanned admission to the PICU following traumatic injury.&#x0D; Methods: For this national retrospective study, we queried the 2016 National Trauma Data Bank for patients younger than 18 years experiencing a traumatic injury requiring hospital admission from the Emergency Department (ED). We excluded patients who had experienced burn injuries. Statistically significant (p&lt;.05) risk factors for unplanned PICU admission were identified in bivariate analysis and used to build a multiple logistic regression model.&#x0D; Results: Patients experiencing unplanned admission to the PICU had lower ED Glasgow Coma Scale (11.83 vs. 14.31; p&lt;0.001), higher Injury Severity Scores (ISS) (17.96 vs. 7.32; p&lt;0.001), and were older (age 11.35 vs. 9.60; p&lt;0.001). Initial ED disposition to the PICU was significantly associated with unplanned admission to the PICU (p&lt;0.001). Initial ED disposition to the OR was significantly associated with unplanned admission to the PICU (p=.018). After multiple logistic regression, ISS (p&lt;0.001), initial ED disposition to the PICU (p=0.002), initial ED disposition to the OR (p=0.005), and older age (p=0.005) remained statistically significant risk factors for unplanned admission to the PICU.&#x0D; Conclusion: ISS and ED disposition to the PICU, OR disposition to the PICU and age are significant risk factors for unplanned admission to the PICU in pediatric trauma. These findings will assist in identifying patients at risk for unplanned admission to the PICU, thereby reducing the adverse effects of unplanned PICU admission and ultimately improving the quality of care for pediatric trauma populations.

Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease.

To examine loss of community-dwelling status 9 months after hospitalization for high-acuity emergency general surgery (HA-EGS) disease among older Americans. Retrospective analysis of claims data. US communities with Medicare beneficiaries. Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ threat (necrotizing soft tissue infections, hernias with gangrene, ischemic enteritis, perforated viscus, toxic colitis or gastroenteritis, peritonitis, intra-abdominal hemorrhage) and an operation of interest on hospital days 1 or 2 (N = 3319). Demographic characteristics (age, race, and sex), comorbidities, principal diagnosis, complications, and index hospitalization disposition (died; discharged to skilled nursing facility [SNF], long-term acute care [LTAC], rehabilitation, hospice, home (with or without services), or acute care hospital; other) were measured. Survivors of index hospitalization were followed until December 31, 2015, on mortality and community-dwelling status (SNF/LTAC vs not). Descriptive statistics, Kaplan-Meier plots, and χ2 tests were used to describe and compare the cohort based on disposition. A multivariable logistic regression model, adjusted for age, sex, comorbidities, complications, and discharge disposition, determined independent predictors of loss of community-dwelling status at 9 months. A total of 2922 (88%) survived index hospitalization. Likelihood of discharge to home decreased with increasing age, baseline comorbidities, and in-hospital complications. Overall, 418 (14.3%) HA-EGS survivors died during the follow-up period. Among those alive at 9 months, 10.3% were no longer community dwelling. Initial discharge disposition to any location other than home and three or more surgical complications during index hospitalization were independent predictors of residing in a SNF/LTAC 9 months after surviving HA-EGS. Older Americans, known to prioritize living in the community, will experience substantial loss of independence due to HA-EGS. Long-term expectations after surviving HA-EGS must be framed from the perspective of the outcomes that older patients value the most. Further research is needed to examine the quality-of-life burden of EGS survivorship prospectively. J Am Geriatr Soc 67:2289-2297, 2019.

Is there no “I” in “Team”? Interindividual-intergroup discontinuity effect in a Cournot competition experiment

• We study individual versus team decisions in a Cournot duopoly experiment. • In a “standard” experiment individuals’ and teams’ decisions are indistinguishable. • Outputs decisions of individuals and teams are both around the Cournot-Nash outcome. • We conducted a second experiment with arguably a recommendation to collude. • Now we find that individuals choose lower outputs and collude more than teams. Even though firms consist of teams of individuals, industrial organization experiments are typically conducted under the unitary player assumption with individuals representing firms. Against this practice, there is evidence that individuals’ decisions differ from those made by teams, and also from individuals’ decisions which affect both oneself and others. This study examines the empirical scope of the unitary player assumption (alternatively the “interindividual-intergroup discontinuity effect”) in the context of a Cournot competition experiment. In the first, standard, experiment (216 participants), we find no evidence for the discontinuity effect. Output choices of both individuals and teams are around the Cournot outcome. In a second experiment (198 participants), we use a recommendation to shift participants’ initial disposition towards the (off-equilibrium) collusive output. This triggers the discontinuity effect; individuals choose lower outputs and collude more than teams. This effect is persistent in the second half of the experiment, and is not caused by team-member discussion or by seating team members together. We discuss the interpretations and implications of our results.

A Simulated Mass Casualty Incident Triage Exercise: SimWars.

This multipatient simulation exercise encompasses triage by hospital medical providers during a mass casualty incident (MCI) involving gas line explosion with building collapse. The SimWars format allows two teams to participate in identical simulations coupled with active audience observation, followed by facilitated group discussion. The exercise requires real-time knowledge application of MCI management and helps learners develop a framework for rapidly classifying and dispositioning MCI patients. Two teams of provider pairs completed MCI triage of 12 simulated patients in 8 minutes with an objective of quickly and accurately dispositioning within hospital bed availability. Participants included emergency medicine and surgery physicians, with active observation by mixed provider audiences. Observers completed a checklist per patient (category: urgent/emergent/not emergent, disposition: bed type/location). At simulation conclusion, a 45-minute facilitated discussion compared observers' self-assessment of MCI patient management with the simulation teams' decisions. Finally, an expert panel discussed management decisions and MCI triage pearls. Team performances (N = 4) and audience responses (N = 164) were similar on seven of 12 patients, allowing robust discussion. Participants completed an evaluation at exercise conclusion; 37% reported good/excellent ability to accomplish MCI initial triage and disposition before this exercise compared to 100% after, a statistically significant 63% increase. All postsurvey respondents agreed or strongly agreed that the exercise would change their MCI clinical practice. The two-team format allows comparison of how different teams handle MCI triage, and active observation allows comparison of audience and team decision making.

Malingering in the Psychiatric Emergency Department: Prevalence, Predictors, and Outcomes.

Malingering is commonly encountered in the psychiatric emergency department, yet little is known about its prevalence, objectives, or effect on patient management. This study analyzed characteristics of malingering and patient disposition in a 24/7-staffed comprehensive psychiatric emergency program (CPEP) and created predictive models to understand malingering and its effect on physician decision making. Attending psychiatrists completed questionnaires after comprehensive assessments of 405 patients presenting to the CPEP during the 1-month study, recording suspicion of malingering, symptoms malingered, associated secondary gains, demographic characteristics, and initial disposition decision. Analyses examined characteristics associated with degree of malingering suspicion and disposition. Malingering was suspected among one-third of patients, and 20% were strongly or definitely suspected of malingering. High suspicion was associated with malingering of multiple symptoms and was likely to result in immediate discharge. Lower suspicion was associated with being held for further observation. Among patients for whom suspicion of malingering was high, malingering was most frequent for suicidal ideation (58%) and depression (39%); malingering was often used to seek hospital admission (54%) and to stay in the CPEP (35%); malingering was sometimes used to seek multiple secondary gains (25%); and malingering often involved multiple symptoms (44%). Patients for whom suspicion was high had an admission rate of 4%. Among patients suspected of malingering, three variables each independently increased the likelihood of hospital admission: seeking social work or housing services, seeking admission, and malingering of suicidal ideation. Malingering was prevalent in the psychiatric emergency department, and suspicion of malingering was associated with disposition differences. Disposition was significantly influenced by both suspicion of malingering and the gains sought by patients.

Who Stays and Who Goes: Predictors of Admission among Patients Presenting with Febrile Illness and a Positive Malaria Rapid Diagnostic Test in a Rural Ugandan Health Center.

Not much is known about clinical decision-making in rural, low-resource settings regarding fever, a common reason for presentation to care. In this prospective cohort study of patients presenting with febrile illness to a rural Ugandan health center, we examined demographic and clinical factors predictive of an initial disposition of inpatient admission after clinical evaluation, but before laboratory testing. We then assessed the association of laboratory results and system factors with a change between initial and final disposition plans. Four thousand nine hundred twenty-four patients with suspected febrile illness were included in the primary analysis. The strongest predictors for an initial disposition of admission after clinical examination were impaired consciousness (adjusted risk ratio [aRR], 3.21; 95% confidence interval [CI]: 2.44-4.21) and fever on examination (aRR, 2.27; 95% CI: 1.79-2.87). Providers initially planned to discharge patients with significant vital sign abnormalities, including tachypnea (3.6%) and hypotension (1.3%). Anemia strongly predicted a final disposition of admission after an initial disposition of discharge (aRR, 48.34; 95% CI: 24.22-96.49); other laboratory abnormalities, including hypoglycemia and acidosis, did not change disposition planning. In those with an initial disposition of admission, living farther than the two neighboring villages was associated with a final disposition of discharge (aRR, 2.12; 95% CI: 1.10-4.12). A concerning number of patients with abnormal vital signs and laboratory results were not admitted for inpatient care. Geographic factors may influence a patient's final disposition contrary to a provider's initial disposition plan. Future work should assess longer term outcomes after discharge and a broader study population.

Pediatric Seizures and Status Epilepticus

Seizures represent a common neurologic complaint among pediatric patients in the emergency department (ED). They can be classified as generalized or focal. In terms of etiology, seizures are most basically broken down into “acute symptomatic” seizures, which are due to another primary medical cause, and unprovoked seizures which occur as a primary pathology. Febrile seizures are the most common types of seizures in children, which themselves can be simple or complex. The most concerning seizures are those which associate with meningismus, encephalitis, metabolic derangements, intracranial mass, and, of course those which progress to status epilepticus. Significantly, it is appropriate and even critical to assume status epilepticus and intervene accordingly whenever a child arrives to the ED seizing for an unspecified period of time. This review covers the initial evaluation, resuscitation, management, work-up, and disposition of pediatric patients who present to the emergency room with seizures. Figures in this chapter illustrate stepwise and algorithmic approaches to initial management, expanded differential, systematic diagnostic approach, and disposition for pediatric patients presenting with seizures and status epilepticus. Tables list important physical exam components for evaluating children with seizures, classifications of seizures, common seizure look-alikes in children, features of febrile seizures, etiologies of pediatric seizures. Key Words: Pediatric seizures, febrile seizures, pediatric neurologic emergencies, pediatric emergency medicine, status epilepticus

Comparison of outcome of very-low-birth-weight babies with developed countries: A prospective longitudinal observational study

Objective: The objective of this study was to compare the immediate outcome of very-low-birth-weight (VLBW) babies with developed countries. Materials and Methods: Design: This was a prospective observational longitudinal study. Setting: This study was conducted in Level II neonatal intensive care unit at a tertiary care center. Subjects: All live-born inborn babies with birth weight 401–1499 g or gestational age between 22 weeks 0 days and 31 weeks 9 days. Outcome: The key outcome was survival to discharge for VLBW babies. Results were compared to data from both developing and developed countries. Results: Of 183 babies enrolled in the study, 73.2% of babies were alive at initial disposition. The outcome (mortality and morbidity) was compared to data from Vermont Oxford Network, the National Institute of Child Health and Human Development as well as mortality data from developing countries. Mortality rates were lower or comparable to the data from developing countries (P > 0.05) but significantly higher than developed countries (P