Initial ED Research Articles

The Impact of HIRAID Implementation on the Accuracy of Emergency Nurse Documentation in Australian Rural Emergency Departments: A Multicenter Quasi-Experimental Study.

Documentation templates supported the implementation of HIRAID, a validated framework that supports nurses in assessing and managing patients in emergency departments in rural Australia using a strategy informed by behavior change theory. The study aimed to determine whether the implementation of HIRAID improved the accuracy of nurses' documentation across a large rural health district. A Quasi-experimental pre-post study design was conducted across 10 rural emergency departments between November 2020 and November 2021, with HIRAID implemented in February 2021. Retrospective audit of clinical documentation occurred 3 months pre-implementation and repeated at 6-months post. Based on power analysis and a sampling framework, records that met study inclusion were randomized for audit. Documentation accuracy was evaluated, using a modified D-catch instrument, assessing quality and quantity by an experienced research nurse. Data were analyzed with descriptive and inferential statistics. A review of 222 records (110 pre/112 post), demonstrated an improvement in initial ED nursing assessment documentation. Audit scores increased significantly for quantity of documentation across all areas, in particular history (P < .001) and red flags (P < .001), with a 27.1% increase in all red flags recorded. The quality of documentation also significantly improved across all areas, most notably in history (P < .001) and assessment (P < .001). Implementation of HIRAID demonstrated a sustained improvement in the quantity and quality of emergency nurse documentation. Improved documentation accuracy is key to informing and evaluating ongoing care and supporting communication and continuity of care, and is essential to patient safety.

The ball's in your court: Trends, causes, outcomes, and costs of patient transfer for pediatric testicular torsion

BackgroundThe transfer of pediatric patients with testicular torsion from community hospitals to pediatric centers can be a time and resource-intensive step toward emergent surgical intervention. ObjectiveWe sought to describe trends of patient transfer in our state and compare clinical outcomes and health system costs between patients transferred and treated primarily at a pediatric center. Study DesignThis retrospective cohort study compared patients aged 1-18 years who presented directly to a pediatric center to those transferred for acute testicular torsion from 2018-2023. Exclusion criteria included age <1 year, non-urgent surgery, and admission from clinic. Patient age, BMI, Tanner stage, ASA class, insurance coverage, and presentation time were covariates. Group characteristics and times from symptom onset to initial ED presentation to surgery were compared via two-sided Student’s t-tests. Clinical outcomes (orchiectomy, testicular atrophy) were compared via Fisher’s exact tests. Costs from transferring hospitals were estimated from costs at our institution, and medical transport costs were extrapolated from contract prices between transport agencies and the pediatric center to compare total episode-of-care cost. ResultsA total of 133 cases (37 primaries, 96 transfers) met inclusion criteria. Transfers increased over the study period (67% to 75%). There were no significant differences in age, Tanner stage, ASA score, BMI, or time of day of presentation between groups. Median transfer distance was 12 miles (IQR 7-22) and time was 1 hour (IQR 1-2). More than half of cases (53%) were transferred due to hospital policy regarding surgical treatment of minors, and 25% due to lack of urology coverage. Time from initial ED site to OR was nearly doubled for the transfer group (median 4.5 vs 2.5 hours, p=0.02). Despite a higher rate of orchiectomy in the primary group (43 vs 22%, p=0.01), this difference was not significant after stratification by symptom duration. The estimated average cost of care for patients transferred was twice that of primary patients ($15,082 vs $6,898). DiscussionTransfer of pediatric patients in our state for testicular torsion has increased in recent years. Hospital policies and local urology coverage are primary drivers of patient transfer which nearly doubled time to surgical intervention and more than doubled cost of care. Clinical outcomes were driven by delayed presentation. ConclusionTransfer of pediatric patients for testicular torsion nearly doubles time to surgical intervention and more than doubles cost of care. Restrictive hospital policies and gaps in rural hospital urology coverage present opportunities to improve the quality and efficiency of care for these children.

435 Use of Optic Nerve Sheath Diameter in Extraventricular Drain Weaning in Adults With Post-hemorrhagic Hydrocephalus

INTRODUCTION: Optic nerve sheath diameter (ONSD) can be used as a noninvasive measurement of intercranial pressure. Few studies have evaluated the value of ONSD in predicting the need for ventriculoperitoneal shunt (VPS) placement after development of post-hemorrhagic hydrocephalus (PHH) in adults. METHODS: Adult patients 18 years or older, admitted with intracranial hemorrhage and hydrocephalus requiring EVD placement were included in the study. Demographics were recorded. CT imaging of ONSD was measured (mm) upon initial ED visit before EVD placement (pre-EVD), immediately after successful EVD removal (post-EVD), and if applicable, after EVD removal but immediately before VPS placement. Change in ONSD was calculated and groups were stratified by EVD only patients and EVD+VPS patients. RESULTS: Imaging for 30 patients were successfully retrieved and analyzed for bilateral ONSD values at all timepoints. A statistically significant convergence to a normally distributed mean ONSD was found for both groups (EVD and EVD+VPS). Additionally, a statistically significant increase was found in ONSD between the EVD+VPS group compared to the EVD only group. The EVD only group showed a mean EVD placement time of only 14 days (2 weeks) with an average decrease in ONSD (-0.905mm) compared with the EVD+VPS group who had an increase in ONSD at 14-days (+1.089 mm). CONCLUSIONS: Patients with hydrocephalus due to intracranial hemorrhage who went on to require VPS developed an increase in ONSD despite EVD use while patients who were successfully weaned from the EVD developed a decrease in ONSD. ONSD may be a useful adjunct tool to aid in the process of EVD weaning in this patient population.

(288) Trends in Penile Prosthesis Placement in Men with Erectile Dysfunction

Abstract Introduction Erectile Dysfunction (ED) is a common problem impacting 20% of all men. Current treatment options include oral medications, vacuum erection devices, intraurethral suppositories, intracavernosal injections, and penile prosthesis placement (PPP). A shared decision-making framework is increasingly utilized for treatment decisions where an appropriate treatment is selected from all options based on the values and priorities of the patient and their partner. Objective Our objective is to identify trends in PPP, including the proportion of patients who pursue PPP as an initial treatment as well as the time from ED diagnosis to PPP. Methods We retrospectively reviewed all men with an ED diagnosis based on ICD9/ICD10 codes using the IBM MarketScan insurance claims database. The initial treatment option processed through an insurance claim following an ED diagnosis was identified and categorized using ICD, HCPCS, NDC, J, and CPT codes. Time from ED diagnosis to PPP was also recorded. Only patients with at least one year of enrollment pre-ED diagnosis and with at least one year of follow-up were included. Linear regressions were performed to investigate the trends of each year based on the time of initial ED diagnosis. Results We identified a total of 670,096 patients diagnosed with ED between 2012-2019. The mean age was 56 years (47-62). Of those patients, 11% were smokers, 29% had diabetes, 24% had cardiovascular disease, 65% had hypertension, and 29% were obese. Among those who received treatment, the most common initial treatment was oral medications in 26% of patients. PPP was an initial treatment in &amp;lt;1% of patients. The proportion of patients who underwent this surgical intervention as an initial treatment significantly decreased from 2012-2019 (P&amp;lt;0.001) as patients utilized other initial treatment modalities more commonly. Over the same period, the time from ED diagnosis to PPP significantly decreased from approximately 500 days in 2012 to &amp;lt;200 days in 2019 (P=0.001). Conclusions Although the proportion of patients who utilize other ED treatment options prior to PPP is higher, patients diagnosed with ED more recently undergo PPP in a significantly shorter timeframe. Utilization of other treatment modalities as an initial treatment option may stem from changes in insurance coverage. Patients moving more quickly from an ED diagnosis to PPP is likely due to several factors, including improvements in the device leading to less mechanical and infectious complications, familiarity with the device due to marketing, and an earlier discussion with the physician about the device based on a shared decision-making model. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Inherent bio, Paterna bio, Firmtech, Turtle health, Maximus, Carrot.

Accuracy of Diagnosing Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic State (HHS), and DKA-HHS: The Significance for Cardiac Function

BackgroundDiabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) are severe complications of diabetes. DKA is characterized by high blood glucose, low blood bicarbonate, and high BOHB, while HHS is associated with high serum osmolality. DKA-HHS is a combination of both, which can lead to a higher mortality rate due to acidosis, electrolyte imbalances, and suboptimal IVF replacement causing cardiac injury. This study aims to determine the accuracy of the initial ED diagnosis of DKA and identify patients with HHS or DKA-HHS among those initially diagnosed with DKA. MethodsIn this retrospective, single-site study, 20 adult patients who were consecutively admitted in January 2023 with a diagnosis of DKA were re-evaluated using BMP, serum osmolality, and BOHB to determine their actual diagnosis. The diagnostic error rate was calculated, and chi-square analysis was used to compare categorical variables. ResultsUpon re-evaluation of laboratory values, 15 patients (75%) were confirmed to have DKA, 4 patients (20%) had HHS, and 1 patient (5%) had DKA-HHS. The diagnostic error rate was 25% (p<0.05), with 5 of the 20 patients misdiagnosed with DKA. ConclusionThis retrospective, single-site study suggests that the ED admitting diagnosis of DKA was incorrect in 25% of 20 subjects. This finding supports the hypothesis that the ED may fail to properly diagnose HHS or DKA-HHS. Therefore, further research is necessary to evaluate the efficacy of educating diabetic patients and ED staff on DKA, HHS, and DKA-HHS diagnostic criteria in preventing misdiagnosis and cardiac injury with the ultimate goal of improving diabetic patient care.

Are Data Driving Our Ambulances? Liberal Use of Tranexamic Acid in the Prehospital Setting.

Current data on tranexamic acid (TXA) supports early administration for severe hemorrhagic shock. Administration by EMS has been facilitated by developing protocols and standing orders informed by these data. In this study, patterns of TXA use by EMS agencies serving a large level 1 trauma center were examined. We hypothesized that current widespread TXA use often includes administration outside of data-driven indications. The trauma registry at a level 1 trauma center was queried for patients who received TXA. To determine the practice patterns and appropriateness of administration of TXA, patients' physiologic state in the prehospital environment based on EMS records, physiologic state on arrival to hospital, and interventions performed in both settings were examined. Over 20 separately managed EMS systems that administer TXA transport patients to this trauma center, allowing for a broad survey of practices. From 2016 to 2021 1089 patients received TXA, 406 (37.3%) having treatment initiated by EMS services. Of these, the average prehospital systolic blood pressure (SBP) was 108.2mmHg and initial ED SBP was 107.8mmHg. Only 58.4% of these patients received blood transfusion after arrival to this trauma center. Compliance with standard indications was low with only 14.6% of administrations meeting any data-driven SBP indication. Similar levels of compliance were seen across high volume EMS services. Tranexamic acid use has become common in trauma and has been adopted by many EMS systems. These results indicate TXA in the prehospital setting is over-used as administration is not being limited to indications that have shown benefit in prior data.

Repeat Fall Risk in Geriatric Patients After Fall-Induced Head Trauma.

Introduction There are many known risk factors for falls, with poor health and physiologic decreases in function as the major contributors to fall risk in older adults. However, risk factors for repeat falls after initial ED discharge are not well-described. This study seeks to prospectively investigate risk factors for short-term repeat falls in geriatric ED patients with fall-related head trauma who do not require hospital admission. Methods This is a prospective study of patients aged 65 years and older with fall-related head trauma who presented to the EDs of two community level I trauma centers. Patients were excluded for intracerebral hemorrhage, admission during initial ED visit, or death in the hospital. Patients were followed for 14 days. Patient characteristics, repeat ED visits, and reason for returns were noted. Results About 2,143 patients were identified as meeting the inclusion criteria. Within 14 days of the initial presentation, 14.1% of patients returned to the ED, with 8.3% presenting with a complaint related to the initial trauma and 2.6% with a new injury. Patients with comorbidities of dementia (OR 3.02, 95% CI, 1.72-5.33, p<0.001), stroke (OR 2.12, 95% CI, 1.05-4.27, p=0.031), and smoking (OR 4.27, 95% CI,1.76-10.37, p<0.001) were significantly more likely to sustain a new injury leading to a repeat ED visit within 14 days. Conclusions After an ED visit due to a fall, over one in 10 patients will re-present to the ED due to a new injury or sequelae from the initial fall. In the immediate period after a fall, enhanced outpatient follow-up or risk mitigation strategies should be considered to lessen return visits and decrease morbidity.

Silver Trauma Review Clinic: a novel model of care to manage non-operative injuries in older patients

BackgroundIncreasing numbers of older patients are presenting to the ED following trauma. These patients require multidisciplinary care that the traditional trauma model fails to provide. A Silver Trauma Review Clinic...

Comparison of Professionally and Parentally Administered Analgesia Before Emergency Department Admission

BackgroundPediatric patients frequently present to emergency departments in pain. AimA cross-sectional prospective study was conducted to investigate the prevalence of acute pain in children attending the ED and arriving by ambulance, as well as the initial ED management of pain. We describe pediatric pain management practices in the pediatric ED, as well as parental pain relief. MethodDemographic data, medications, and type of transport to hospital were noted. Pain was assessed upon admission and 30 minutes after administration of analgesia. To standardize pain evaluations, only children aged 4 years or older were included in the study. A numeric rating scale was used to assess pain intensity. ResultsThe study group consisted of 124 patients. More than 80% of the patients suffered from trauma, injuries to the extremities were the most common cause of admission, and the patient population showed male predominance (62.1%). Over half of the patients (64.51%) were transported by ambulance. Analgesia was administered in 63.5% of the ambulance cases in contrast to only 13.3% of children brought by their parents. Treatment was significantly related to severity of pain. ConclusionsBoth medical emergency teams and parents administered prehospital analgesia insufficiently and without previous assessment. However, medical emergency teams used medications more often than parents. Analgesic therapy used in the emergency department resulted in significant pain reduction.

Malpractice

FigureFigureA man presented to the ED with sudden onset flank pain. He was afebrile, and his vital signs were normal except for tachycardia of 105 bpm. A urinalysis was positive for nitrite and 15 WBC, and a urine sample was sent for culture. A CT scan showed a ureteral stone and minimal hydronephrosis. His pain was treated, he said he felt better, and he was discharged with instructions about treatment and follow-up for a kidney stone. The culture was reported the next day to the PA in the ED as growing Klebsiella. The PA called the patient and left a voicemail advising him of the culture result and the need for an antibiotic. He asked the patient to call the ED to obtain a prescription for Macrobid. The patient didn't return the call, but returned to the ED two days later. He was septic with significant hydronephrosis and was admitted. Despite aggressive treatment, including a nephrostomy to reduce urinary back pressure and drain infected urine, he decompensated rapidly and died. His family filed a lawsuit. The Plaintiff's Case The plaintiff's counsel believed that his client should have been treated with an antibiotic based on the urinalysis, but he could not find an expert who would support his claim that failure to do so was negligent. The survivors of the deceased lost interest in pursuing the claim. The Defense's Case The defense counsel had no difficulty securing strong expert opinions that the patient's care was within acceptable standards and not negligent, that is, that failure to treat with an antibiotic at the initial visit did not cause the patient's death. The Verdict The care at the initial ED visit was considered within the standard, given the lack of fever and the presence of only mildly abnormal urine findings. Despite the lack of medical decision-making addressing the possibility of a serious complication, expert review of the case felt this was a judgment call rather than negligence. The case was dismissed without prejudice, meaning that it could be refiled should circumstances change. Takeaways Pyelonephrosis is a serious complication of ureteral stones, aggravating an existing ureteral blockage due to viscous pus that cannot easily pass through the ureter. If a urinalysis shows sufficient evidence of concurrent infection in the presence of ureteral obstruction, antibiotics should be given and the patient admitted. This patient had minimal if any evidence of impending pyonephrosis. (Medscape eMedicine. March 23, 2021; https://bit.ly/3ViNnS4.) As often mentioned, physicians are not prophets. We cannot predict with certainty which patients will deteriorate and which will improve. We can only treat each patient according to the standard of care. We depend on patients to follow instructions. The PA in this case had no reason to assume that the patient was any worse than he was 24 hours earlier, and he had no reason to have him return to the ED emergently. We depend on patients to assess themselves and respond if things are worse.

Patients' experiences and reasons for unplanned return visits to the emergency department: A qualitative study.

The aim of this study was to explore the reasons for and experiences of patients who make an unplanned return visit to the emergency department. This study forms the qualitative phase of a larger explanatory sequential mixed methods study and is informed by interpretive description. The paper was prepared using the consolidated criteria for reporting qualitative research. Semi-structured patient interviews were conducted over a 3-month period (July-September 2021). Data were analysed using reflexive thematic analysis. Interviews from 13 participants generated findings related to experiences at and following their initial visit that contributed to their decision to return to the emergency department. Four themes were developed: (1) Patients experience barriers to feeling heard and having their concerns addressed; (2) Patients have little choice but to place their trust in clinicians; (3) Patients unexpectedly experience persistent symptoms which cannot be managed at home; and (4) Patients develop a sense of urgency about having their condition treated. A negative experience at the initial ED visit may have dual conflicting impacts. It can contribute to patients' perceived need for a return visit because they are ill-equipped to manage their condition at home, and it can also contribute to their initial reluctance to return to the ED when symptoms persist. Nurses and other clinicians working in ED need to actively build patient's experiential trust through clear communication, timely consultation and shared decision-making at discharge, which in turn can increase patient's confidence and capability to self-manage their condition. This study adds to the current body of literature about return visits by highlighting that a more positive experience of ED may assist patients to make better-informed decisions about when and how to seek treatment and minimize unnecessary and unplanned return visits. Whilst not an intended topic for exploration in this study, the COVID-19 pandemic influenced patients' experiences at both initial and return ED visits and limited their ability to access primary healthcare options. These experiences contributed to patients' decisions to make a return visit.

Paediatric acute non-traumatic limp presenting to the emergency department: a retrospective observational study

BackgroundAcute non-traumatic limp in children has many causes, ranging from common benign and self-limiting disease to serious time-sensitive emergencies such as septic arthritis. We aimed to (1) describe the epidemiology...

Comparison of efficacy and frequency of akathisia and dystonia between olanzapine, metoclopramide and prochlorperazine in ED headache patients

Study objectiveTo compare the efficacy and frequency of akathisia and dystonia between the dopamine antagonist headache medications olanzapine, metoclopramide and prochlorperazine. MethodsThis was a retrospective observational cohort study of patients presenting to a large urban level one trauma center between 2010 and 2018. Inclusion criteria was age ≥ 18 who presented to the emergency department with a chief complaint of headache who received either olanzapine, metoclopramide or prochlorperazine. The primary outcome was need for rescue medication. Secondary outcomes were receiving medication for either akathisia or dystonia. Logistic regression was used to identify differences between the three cohorts up to 72 h from initial presentation. ResultsThere were 5643 patients who met inclusion criteria. Olanzapine was the most commonly used drug (n = 2994, 53%) followed by prochlorperazine (n = 2100, 37%) and metoclopramide (n = 549, 10%). After adjusting for age and gender, there were no differences in risk for receiving rescue therapy or developing akathisia or dystonia. ConclusionDuring initial ED visit and up to 72 h after receiving olanzapine, metoclopramide or prochlorperazine, we found no difference in risk for requiring rescue medication or developing akathisia or dystonia.

Abstract 168: Hypoxia On Arrival At The Hospital Among Major Traumatic Brain Injury Patients Who Were Non-Hypoxic In The Field: Support For “Hyper-oxic” Prehospital Treatment?

Background: Prehospital and early hospital hypoxia powerfully affect traumatic brain injury (TBI) outcomes. However, the correlations between EMS and hospital O2 saturations are unknown. Using the EPIC Study data (NIH-1R01NS071049; DOD-W81XWH-19-C-0058), we assessed correlations between EMS SpO2 and the risk of major TBI patients arriving at the trauma center (TC) with hypoxia (initial ED SpO2&lt;90%). Methods: Subjects meeting EPIC Study criteria, age ≥10 years, and transported directly to the TC were included. Basic statistics were determined by Kruskal-Wallis, Chi-square or Fisher’s exact test. Adjusted odds (aOR) were assessed using logistic regression, controlling for significant confounders. Results: A total of 10,370 subjects were included. Compared to no hypoxia, aORs for death were: EMS, but no TC hypoxia: 2.1 (1.7-2.6), TC, but no EMS hypoxia: 2.5 (1.7-3.8), both EMS/TC hypoxia: 3.2 (2.1-4.8; p&lt;0.0001). Among the 9,243 cases with no EMS hypoxia, only 242 [2.6% (2.3%-3.0%) were hypoxic at TC arrival, compared to 215 of 1127 cases that had EMS hypoxia [19.1% (16.8%, 21.5%); OR: 8.8 (7.2, 10.7); aOR: 4.6 (3.7, 5.7); p&lt;0.0001]. The Figure shows the odds of arriving hypoxic at the TC, based upon the lowest recorded EMS SpO2 (whether hypoxic or not). Conclusion: As expected, hypoxia upon TC arrival was highly correlated with EMS hypoxia (OR 8.8, aOR 4.6). However, it is remarkable that even a single EMS SpO2 below 100% was associated with 2.4 greater odds of TC hypoxia (&lt;90%). Given our recent findings that the optimal odds of survival occurs in patients whose recorded EMS SpO2s were always 100%, these findings argue against the popular concept of preventing “ hyper -oxia” by titrating O2 to maintain SpO2 in the mid/upper 90s. Our results imply that keeping EMS SpO2 as high as possible prevents subsequent hypoxic episodes (i.e., “pre-oxygenation” for unexpected deterioration) and supports maintaining an SpO2 of 100% during the prehospital interval in major TBI.

Factors Associated With Dermatologic Follow-up vs Emergency Department Return in Patients With Hidradenitis Suppurativa After an Initial Emergency Department Visit

Emergency department (ED) visitation is common for the treatment of hidradenitis suppurativa (HS), whereas dermatology outpatient care is low. The reasons underlying this differential follow-up have not been elucidated. To assess the interventions and patient factors associated with ED return following an initial ED visit for HS. This retrospective cohort study used data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases (trademark symbols retained per database owner requirement). An HS cohort was formed from patients who had 2 or more claims for HS during the study period of 2010 to 2019 and with at least 1 ED visit for their HS or a defined proxy. Data were analyzed from November 2021 to May 2022. Factors analyzed included those associated with the ED visit and patient characteristics. Primary outcomes were return to the ED or dermatology outpatient follow-up for HS or related proxy within 30 or 180 days of index ED visit. This retrospective cohort study included 20 269 patients with HS (median [IQR] age, 32 [25-41] years; 16 804 [82.9%] female patients), of which 7455 (36.8%) had commercial insurance and 12 814 (63.2%) had Medicaid. A total of 9737 (48.0%) patients had incision and drainage performed at the index ED visit, 14 725 (72.6%) received an oral antibiotic prescription, and 9913 (48.9%) received an opioid medication prescription. A total of 3484 (17.2%) patients had at least 1 return ED visit for HS or proxy within 30 days, in contrast with 483 (2.4%) who had a dermatology visit (P < .001). Likewise, 6893 (34.0%) patients had a return ED visit for HS or proxy within 180 days, as opposed to 1374 (6.8%) with a dermatology visit (P < .001). Patients with Medicaid and patients who had an opioid prescribed were more likely to return to the ED for treatment of their disease (odds ratio [OR], 1.48; 95% CI, 1.38-1.58; and OR, 1.48; 95% CI, 1.39-1.58, respectively, within 180 days) and, conversely, less likely to have dermatology follow-up (OR, 0.16; 95% CI, 0.14-0.18; and OR, 0.81; 95% CI, 0.71-0.91, respectively, within 180 days). This cohort study suggests that many patients with HS frequent the ED for their disease but are not subsequently seen in the dermatology clinic for ongoing care. The findings in this study raise the opportunity for cross-specialty interventions that could be implemented to better connect patients with HS to longitudinal care.

Co-infection of COVID-19 and Monkeypox: A Case Report from Florida, USA, 2022

Monkeypox is a re-emerging zoonotic disease of the orthopoxvirus genus presenting with myocutaneous symptoms similar to those caused by smallpox. Patients infected with monkeypox may experience a prodromal period with flulike symptoms lasting between 1-4 days, an asymptomatic incubation period lasting 7-17 days and a symptomatic rash period lasting 14-28 days between the appearance of widespread vesiculopapular lesions and desquamation. Specific risk factors for the current monkeypox outbreak include HIV infection, prior STI infection, male sex, young-adult age (specifically being in the 20’s-30’s age group), engaging in risky behaviors (such as unprotected sex) and men having sex with other men. We report the case of a 38-year old HIV+ patient testing positive for monkeypox, COVID-19 and herpes who presented to the emergency department with widespread vesiculopapular lesions. One week prior to ED presentation, the patient experienced flu-like symptoms including fever and, two days later, developed a vesiculopapular rash beginning on his face and spreading downwards to his extremities, trunk and genitalia. The flu-like symptoms developed twelve days after attending an event where the patient reported having sex with multiple other men. The patient was treated with intravenous fluids and supportive care alongside his HIV medications. Nine days after initial ED presentation, all skin lesions were desquamated and the patient was discharged from the hospital. To our knowledge, this is one of the first reported cases of co-infection with COVID-19 and monkeypox in Florida and the United States more broadly. Despite our patient’s several risk factors for monkeypox infection, and immunosuppressed status, he experienced an uncomplicated clinical course. As vaccination and antiviral treatments become more available for monkeypox patients, our case suggests supportive care with airborne and contact precautions may be adequate in the treatment of future monkeypox patients where these treatments are unavailable.

Transient synovitis of the hip: Current practice and risk of misdiagnosis

IntroductionTransient synovitis (TS) is a common and benign cause of hip pain in children, but must be distinguished from more serious entities such as septic arthritis, osteomyelitis, and pyomyositis. Our objectives were to determine the risk of missed bacterial musculoskeletal infection and rates of diagnostic testing in children diagnosed with TS. MethodsWe performed a cohort study using the Pediatric Heath Information System of children 1–10 years diagnosed with TS in the ED. We determined rates of missed bacterial musculoskeletal infection (defined as a new diagnosis of septic arthritis, osteomyelitis, or pyomyositis within 14 days of initial ED visit). We described the initial diagnostic evaluation and ED management of children diagnosed with TS and variability between sites. ResultsWe analyzed 6419 encounters from 37 hospitals. 62 (1.0%, 95%CI: 0.7–1.2%) children were diagnosed with a missed bacterial musculoskeletal infection. Children with missed infection were younger than those without (median age 2.6 vs. 4.6 years, p < 0.01). Serum laboratory testing was performed in 76% of encounters with minimal variation across sites. There was significant variation in the rates of hip ultrasound by site (2 to 92%), which has increased in use over time (from 42% in 2016 to 62% in 2021). ConclusionIn this large observational study, missed bacterial musculoskeletal infection in children diagnosed with TS was rare but more common in younger children. The optimal combination of bloodwork and radiographic testing, especially ultrasound, to distinguish TS from more serious disease remains unclear.

Comparison of Time-to-Surgery and Outcomes in Transferred Vs Non-Transferred Open Globe Injuries.

PurposeIt is widely accepted in the field of ophthalmology that closure of open globes within 24 hours of the injury results in the best visual outcomes. This study investigates the time-to-surgery and visual outcomes of open globe injury patients in North Carolina that were transferred to our institution before receiving surgical intervention as compared to those that were not transferred.Patients and methodsThis is a retrospective cohort study using data from UNC Hospitals trauma registry. Demographics, time of injury, final clinical outcomes, time to surgical intervention, and transfer history were extracted and analyzed. The study population includes open globe injury patients of all ages that were seen and treated at our institution from 2005 to 2020. Patients were divided based on transfer history. The transfer group consisted of patients who were transferred from an outside hospital to our tertiary care facility for surgical treatment. The non-transfer group consisted of patients who arrived at our tertiary care facility directly after injury.ResultsIn total, 238 open globe injuries were evaluated. Of those, 197 were transferred and 41 were not transferred. Compared to non-transfer patients, transfer patients had longer delays between injury and surgery, between presentation at the initial ED and surgery, and between injury and arrival at the tertiary care center. On average, the delay between injury and surgical intervention was 3 hours and 51 minutes longer for transfer patients compared to non-transfer patients. Eight patients in the transfer group were delayed >24 hours due to inter-hospital transfer. Additionally, transfer patients on average suffered from poorer final visual acuities, with an average final visual acuity of 1.84 logMAR in the transfer group and 1.35 logMAR in the non-transfer group.ConclusionOur study found that inter-hospital transfer leads to significant delays in primary closure of open globe injuries. Injuries that were transferred to a tertiary care center before receiving surgical intervention on average resulted in worse final visual acuities.

Return visits to the paediatric emergency department.

To determine the rate of unplanned return visits (uRVs) within 48 h to a paediatric ED over a 12-month period and describe the factors associated with these uRV. Retrospective review of electronic data regarding the initial and follow-up visit at a tertiary paediatric hospital ED in Western Australia. The primary outcome was the number of patients who presented for uRV within 48 h of their initial ED visit. Between August 2018 and July 2019, 2322 patients returned to the ED for a uRV comprising 3.4% of 68 352 ED presentations with more than 53% returning with infectious causes. Triage category 3 patients were most likely to represent (OR 1.11, P= 0.029) with 3-month to 1-year old (OR 1.37, P< 0.00001) and 1-5-year old (OR 1.32, P< 0.00001) the commonest age groups. There was seasonal variation in uRVs demonstrating a greater number in the winter months. The percentage of uRVs to overall ED presentations was greater in the summer months (3.8-4.1%). There was a significant increase in uRVs occurring up to 2 weeks after the changeovers in middle-grade ED doctors only. The present study has demonstrated associations between uRV and initial-visit triage category 3, age between 3months and 5 years, and presentations because of infectious illness. Middle-grade doctor changeover was also associated with an increase in uRVs.

Ultrasound to facilitate passage of distal ureteral stones

Feasibility of ultrasonic propulsion and burst wave lithotripsy (BWL) to noninvasively reposition distal ureteral stones to facilitate passage and relieve pain was tested. Patients presenting to the clinic or emergency department were recruited. Thirteen subjects underwent ultrasonic propulsion (lower amplitude, longer duration pulses) alone, and 10 subjects also received intermittent BWL (higher amplitude, shorter duration pulses). All participants were awake and underwent a pain assessment pre- and post-procedure. For analysis, subjects were sub-categorized based on whether their stone was acute or chronic (present for ≤10 days or &gt;10 days from their initial ED or symptomatic presentation, respectively). Seventeen subjects were enrolled in the acute study population and 6 subjects were enrolled in the chronic population. Overall, 94% of acute stones passed in an average of 3.4 days post-procedure relative to 54% in 7.5 days in the American Urological Association guidelines. 67% of chronic cases passed stones or fragments, and two surgeries were cancelled. Pain reduction was statistically significant ( p = 0.0215). Adverse events were limited to hematuria on initial urination post-procedure (BWL only, n = 3) and a mild sensation, akin to a pinprick, associated with fewer than 10 of 620 propulsion bursts ( n = 3). [Work supported by NIH-P01-DK04331.]