Emergency Department Protocol Research Articles

Utilization and extravasation of peripheral norepinephrine in the emergency department.

Vasopressors are typically administered through central venous catheters (CVC) due to a historical risk of extravasation with peripheral administration. However, CVC insertion is a time-consuming process that may delay vasopressor administration and is associated with complications. The Virginia Commonwealth University Health System (VCUHS) Emergency Department (ED) implemented a protocol that recommends peripheral norepinephrine (pNE) be administered through an 18 gauge or larger at or above the antecubital fossa or the external jugular vein with a maximum dose of 20μg/min. This study characterizes the use and incidence of extravasation in all adult patients who received pNE initiated in the VCUHS ED. This was an observational, retrospective cohort study in adult patients from March 2016 to March 2019. Of the 331 patients that were screened, 177 met inclusion criteria. Data were analyzed using descriptive statistics. Patients had a median age of 60years and 59% were male. The median APACHE II score was 25 with an overall hospital mortality of 27%. A majority of patients received pNE for distributive shock (63%). Approximately 69% received pNE through an antecubital infusion site. The median total pNE duration was 62min (IQR 32, 142). Eighty-four percent of patients received a central line. Only 2.3% of patients had confirmed extravasation in addition to another 2.3% where extravasation could not be excluded, for a total rate of 4.5%. None had subsequent extremity injury. Administration of pNE according to the VCUHS ED protocol resulted in a low extravasation rate.

Acute undifferentiated febrile illness: Protocol in emergency department.

Fever accounts for around 15% of emergency visits in elderly age group and around 5% in adults. The spectrum of etiologies ranges from non-infectious to infectious etiologies. There are very few studies done in the past highlighting the approach of patients with acute febrile illness without any localizing signs and symptoms. Objectives:The aim of the study was to formulate a targeted approach for evaluation and treatment of patients with acute undifferentiated febrile illness without evidence of localizing symptoms and signs. The secondary objective was to study the etiology and final outcome of patients with acute undifferentiated febrile illness.Materials and Methods:A protocol was devised for patients aged more than 18 years, who presented in emergency department with complaints of fever without localizing symptoms or signs of sepsis over a period of 6 months from April 2018 to September 2018. Patient's data were collected retrospectively from the hospital record section.Results:A total of 212 patients of undifferentiated acute febrile illness were enrolled in the study. Maximum number of patients [n = 69 (32.5%)], presented on second day of illness. All the patients presenting within 1 or 2 days of fever experienced defervescence. Out of these 69 patients, 35 (36.4%) were investigated of which in 29 (82.2%) investigations were not found to be useful; 75 (78.1%) patients with 1 or 2 days history of fever improved without investigations. Surprisingly, 54 patients (72%) with 1 or 2 days' history of acute febrile illness experienced defervescence without the need of antibiotics.Conclusion:There is an urgent need to devise a standardized protocol for diagnosis and treatment of patients with acute undifferentiated febrile illness in order to avoid unnecessary investigations and antimicrobial use.

Is There a Role for CT Pan-Scans in the Initial Workup of Fragility Fracture Patients?

Introduction:Computed tomography (CT) pan-scans have become increasingly commonplace as part of the initial diagnostic workup for patients sustaining traumatic injuries. They have proven effective in improving diagnostic accuracy in those with high-energy mechanisms of injury. However, the utility of pan-scans in the geriatric population sustaining low-energy traumatic injuries remains unproven.Methods:A retrospective review was conducted of patients who sustained a fragility fracture at a level-1 trauma center over a 15-month period. Radiologist interpretations of any CT pan-scans were reviewed for acute findings, and charts were reviewed for resulting changes in orthopedic and nonorthopedic management. Additionally, mechanism of injury, definitive management, time to surgery, length of stay, level of care at discharge, and demographic data were compared against similar patients who did not receive a pan-scan.Results:Of the 109 patients who underwent a CT pan-scan, 1 (0.92%) had a change in orthopedic treatment. Twelve (11.01%) patients had changes to their nonorthopedic management. In addition, 14 other patients had one or more consultations obtained based on pan-scan results that did not result in any change in management. Discussion: This study found that only 1 of the included patients had a change in orthopedic management and 12 had a change in nonorthopedic management, despite over half of the study population being found to have additional findings. Furthermore, patients who underwent a pan-scan did not have expedited surgical intervention or earlier discharges compared to those who were not pan-scanned. Conclusion:This study demonstrates whole-body CT imaging provides little benefit in geriatric patients who sustain fragility fractures and should be utilized judiciously and in a targeted fashion instead of as a routine part of trauma surgery or emergency department protocol in this patient population.Level of Evidence:Level III Retrospective Study.

308. Slow Adoption of a Nurse-Driven Protocol for Universal Hepatitis C Virus Screening in a Hospital Emergency Department: Lessons Learned

BackgroundIn areas with a high prevalence of hepatitis C virus (HCV) infection, emergency department (ED) visits may provide unique opportunities for screening. The catchment area for Hahnemann University Hospital (HUH) has an HCV seroprevalence rate of >20%. However, limited data exist addressing HCV testing strategies in the ED. This study describes the experience of piloting a nurse-driven HCV screening protocol in an urban hospital ED.MethodsA nurse-driven HCV screening protocol was developed and implemented on August 1, 2018. We performed a retrospective analysis of the protocol’s performance from July 1, 2018, through December 31, 2018. Patients who were evaluated in the ED and had blood collected were analyzed. We provided universal HCV screening regardless of age or risk factors. If HCV-positive by antibody screen and viral load confirmation, an attempt was made to link patients to care. Linkage was defined as having received an inpatient evaluation by either infectious diseases or hepatology physician.ResultsAmong 20,705 unique patients seen in the ED, 7841 (38%) had blood work collected. 821 (10.5%) patients had HCV antibody testing. After the implementation of the nurse-driven protocol, the testing rate increased from 68/1340 (5.1%) to 753/6501 (11.6%). 260 Baby Boomers (born between 1945–1965) were screened, of which 60 (23.1%) had positive screens. 561 non-Baby Boomers were screened, of which 30 (5.4%) had positive screens. Barriers of implementing nurse-driven protocol were: (1) multiple steps of the ordering process in the electronic medical record (EMR), (2) the complexity of staff schedules, and (3) staff concerns regarding the disclosure of HCV test results. Among the patients who were diagnosed with chronic HCV, 60 % were linked to care for treatment.ConclusionWe piloted a nurse-driven universal HCV testing protocol in the ED of a hospital with high HCV prevalence. Though the screening rate doubled, it was still low. We identified barriers that may be addressed to improve future screening rates. In areas with a high seroprevalence of HCV, universal screening may be an excellent public health intervention to identify asymptomatic HCV-infected patients.Disclosures All authors: No reported disclosures.

Acute Management of Pediatric Cyclic Vomiting Syndrome: A Systematic Review

To synthesize quantitative and qualitative data on pharmacologic interventions of pediatric cyclic vomiting syndrome and their effectiveness in disease management in the acute care setting. Using keywords, 799 studies published up from December 1954 to February 2018 were extracted from MEDLINE via Pubmed, Embase via OVID, CINAHL via EBSCO, and Cochrane Controlled Trials Registry. Studies were evaluated for inclusion and exclusion by 2 independent reviewers using predetermined inclusion and exclusion criteria. The search yielded 84 studies for full review, of which 54 were included in the systematic review. Studies were subsequently separated into 1 group of 6 case series studies containing quantitative data on sumatriptan, ondansetron, phenothiazines, prokinetic agents, carbohydrate, isometheptene, and aprepitant; 1 one group consisting only of qualitative studies containing expert recommendations. Ondansetron has the most quantitative and qualitative evidence to support its inclusion in pediatric emergency department protocols as a rescue therapy. Sumatriptan and aprepitant are potential candidates for inclusion as abortive therapies. Qualitative data from retrospective studies and case reports are not applicable to a larger patient population. This report informs a need for controlled, prospective cohort studies and randomized, controlled trials to optimize current management protocols and to develop new medical interventions.

Abstract 212: What are the Imaging Capabilities at Referring Hospitals for Large Vessel Occlusion Triage? Results from the Massachusetts Statewide Survey

Introduction: We assessed availability/ feasibility of computed tomography angiography (CTA) acquisition and its potential for screening stroke patients for large-vessel occlusion (LVO) at referring hospitals (RH) (hospitals without endovascular capabilities) in Massachusetts (MA). Methods: The MA CTA Stroke Workgroup (a statewide committee of stroke neurologists, neurointerventionalists, and radiologists) developed a CTA capability survey with 28 questions on logistics, protocols and CT scanner availability. The survey was sent to all 62 RH to be completed by interdisciplinary stroke teams. Results: Response rate was 100 % (62/62 RH); 96.8% have protocols for acute stroke care; 77.4% have protocols for transferring patients to a receiving center; only 35.5% have revised protocols reflecting the extended thrombectomy window. Regarding CTA availability, 95.2% have 24-hour CTA imaging available all year, with 64.5% having two or more scanners. CTA technologist availability is high with 95.2% having a technologist available 24/7. Just over half (53.2%) report protocols where CTA head and neck are obtained immediately after non-contrast head CT, while patient remains in scanner; 29.0 % report non- contrast head CT with patient removed from scanner for further clinical evaluation, followed by CTA head and neck as indicated. For CTA interpretation, 36.9% use emergent reads by local radiology; 31.5% use Nighthawk (remote) radiology; 14.6 % transmit scans for interpretation by the receiving hospital; the remainder use a combination of scan interpretation options. The majority (90.3%) have capability to share images through the cloud. The most challenging element of the CTA process was changing emergency department protocols (45.2%); availability of scanners and technology was identified as least challenging. The majority of RH (88. 7%) prefer to retain patients not in need of transfer to a receiving hospital if no LVO is present on CTA. Conclusion: There is wide spread availability of CTA across MA. Improving LVO detection and triage to thrombectomy capable centers with a focus on RH CTA acquisition is a clear opportunity for intervention. The methods and survey tool developed may prove useful for other states/regions working to enhance stroke systems.

Effects of a standardized emergency department protocol on after-hours use of venous duplex ultrasound

ObjectiveVascular laboratory (VL) venous duplex ultrasound is the “gold standard” for diagnosis of lower extremity deep venous thrombosis (DVT), which is linked to many morbid conditions. Decreasing night and weekend use of VL services in the emergency department (ED) represents a potentially viable means of reducing costs as skilled personnel must remain on call and receive a wage premium when activated. We investigated the effects of workflow changes that required ED providers to use a computerized decision-making tool, integrated into the electronic medical record, to calculate a Wells score for each patient considered for an after-hours venous duplex ultrasound study for suspected DVT. MethodsThe rate of VL use and study positivity before and after implementation of the decision-making tool were examined in addition to measures of ED throughput, rate of concomitant pulmonary embolism, disposition of examined patients from the ED, observed thrombus distribution in duplex ultrasound studies positive for DVT, and calculated personnel costs of after-hours VL use. ResultsA total of 391 after-hours, ED-initiated venous duplex ultrasound studies were obtained during the 4-year study period (n = 213 before intervention, n = 178 after intervention; P = .12). Whereas the period immediately after the start of the intervention saw a decrease in VL use, this was not sustained. Studies performed after the intervention were not more likely to be positive for acute DVT (12.2% vs 18%; P = .1179). The average Wells score was 2.8 (range, 0-6). VL personnel were called in 347 times during the 4-year period, with a total cost of $14,643.40. Nurse-ordered studies were significantly more likely to be positive, with 22% revealing acute DVT compared with 12% for physician-ordered studies (P = .042). The intervention resulted in significant improvements in ED throughput, with time between triage and study request falling from 226 minutes to 165 minutes (P < .001). Observed thrombus distribution revealed involvement of the most proximal external iliac system in a minority of cases (11%), whereas most thrombi (89%) were limited to the femoropopliteal, calf, and superficial venous systems. ConclusionsA requirement for ED providers to document a Wells score before obtaining an after-hours venous duplex ultrasound study resulted in only a transient decrease in VL use but improved ED throughput. Studies ordered by nurses were significantly more likely to be positive, possibly as a result of consistent protocol adherence compared with the physicians. Future studies may warrant investigation into this provider variance.

The Video-Consulting Emergency protocol: a proposition from the World Society of Emergency Surgery members for the initial management of non-traumatic acute abdomen.

Our aim is to propose the Video-Consulting Emergency (VCE) protocol as a tool to improve the decision-making process between an on-site emergency physician and a remote acute care surgeon using a smartphone, the FaceTime application, and the Acute Abdominal Decision Making (AADM®) model proposed by World Society of Emergency Surgeons members. The VCE protocol involves the emergency physician and the on-call emergency surgeon. Both must be provided with a smartphone for 24-hour VC with FaceTime application. The AADM® model is a simple, systematic, diagnostic methodology developed by WSES to guide and support physicians throughout the management of acute abdominal pain in the emergency department (ED). FaceTime videoconsulting and the AADM® model con simply systematize the clinical reasoning of the emergency physician when evaluating acute non-traumatic abdomen. The VCE protocol in ED could be fundamental for an effective first surgical screening and it is an interesting clinical tool with the potential to improve clinical evaluation of patients admitted for acute abdomen. The videoconsulting application could decrease healthcare costs related to unnecessary exams, admissions, surgeries or transfers.

Implementation of an Antibiotic Therapy Protocol for Open Fractures in the Emergency Department

CONTEXTWell established in the Emergency Department (ED) literature is that the most important factor in decreasing subsequent infection rate in open fractures is the time to first administration of antibiotics. As such, the authors developed a new ED open fracture antibiotic protocol to facilitate more expeditious antibiotic administration and appropriate choice of antibiotics.METHODSDuring Phase 1 of this project, the authors identified the 2012 - 2016 historical length of time from presentation of an open fracture to the possible initiation of antibiotic therapy at their institution. Results demonstrated critical areas for improvement in both timing and types of antibiotics administered. Phase 2 of the study evaluated the effect of the new open fracture antibiotic protocol. Sample cases from both phases were then further identified based on type of open fracture, time to initiation of antibiotics from ED presentation, type of antibiotics, and time to definitive treatment. Analyses were performed using GraphPad proprietary software.RESULTSA random sample of 110 patients were included from Phase 1 and 27 patients from Phase 2. A total of 43 Phase 1 patients were administered cefazolin (Kefzol, Ancef); the remainder of the patients received a number of different antibiotics. During Phase 2, all 27 patients received cefazolin and Gentamycin if necessary per the new protocol. The average time to initiation of antibiotics was 0.907 hours during Phase 1 compared to 0.568 hours in Phase 2. The new protocol also significantly decreased the average time to antibiotics in ED from 2.17 hours to 1.82 hours when including EMS transfer time. Average time to definitive treatment in the operating room was 6.63 hours during Phase 1 and was significantly lowered to 3.97 hours during Phase 2.CONCLUSIONSTiming to initiation of antibiotics after open fractures is the most important aspect to decrease infection rates. In order to decrease these times, the authors implemented a new ED protocol that specifically stated the type of antibiotic to be given based on the open fracture without orthopedics needing to be notified before administration. Ideally, the use of such protocols in ED settings will serve to greatly decrease infection risks after open fracture.

Emergency department discharge following successful radiologic reduction of ileocolic intussusception in children: A protocol based prospective observational study

PurposePediatric intussusception's first line treatment consists of fluoroscopic guided air enema reduction. Postprocedure, these patients are usually admitted overnight for observation. The purpose of our study was to document the results of emergency department (ED) observation and discharge protocol after successful reduction of ileocolic intussusception. MethodsA prospective observational study was conducted after implementation of an ED protocol for ileocolic intussusception from 10/2014 to 7/2017 and compared these patients to a historical cohort immediately prior to protocol initiation (10/2011–9/2014). Data collected included demographics, total time in the ED and hospital, enema reduction, recurrence, and requirement for operative intervention. Results reported as means with standard deviation and medians reported with interquartile ranges (IQR). Results115 patients were treated with the prospective protocol and were compared to a 90 patient historical cohort. Reduction was successful in 84%–89% of cases. Median hospital time after enema was shorter in the protocol group [4.8 h (4.25, 14.97) versus 19.7 h (13.9, 33.45), p < 0.01]. Only 33% of patients were admitted following the protocol; the most common admission reason was persistent abdominal discomfort. ConclusionED observation and discharge after successful air enema reduction in children with ileocolic intussusception are safe, facilitate early discharge, and reduce hospital resource utilization. Level of evidenceIII.

Evaluation of a Focused Cardiac Ultrasound Protocol in a Pediatric Emergency Department.

The objective of this study was to evaluate the implementation of a focused cardiac ultrasound (FoCUS) protocol in a pediatric emergency department (PED). We conducted a cross-sectional, observational, quality improvement project in a PED of an urban tertiary care children's hospital. A FoCUS protocol was collaboratively developed by pediatric cardiology and pediatric emergency medicine. This included a reference document with definitions, indications, image acquisition guidelines, and interpretation expectations. We measured physician-sonographer performance against pediatric cardiologist interpretation of stored cine clips as our reference standard. Focused cardiac ultrasound interpretation was dichotomized for the presence or absence of pericardial effusion, depressed left ventricular function, and chamber size abnormalities. Run charts were used to compare the number FoCUS performed each month and the quality of captured cine clips with those from the previous year. Ninety-two FoCUSs were performed by 34 different physician-sonographers from January to December 2016. The prevalence of FoCUS abnormalities was 18.5%. For pericardial effusion, sensitivity was 100% (95% confidence interval [CI], 48%-100%) and specificity was 99% (95% CI, 94%-100%). For depressed function, sensitivity was 100% (95% CI, 54%-100%) and specificity was 99% (95% CI, 94%-100%). For chamber size abnormalities, sensitivity was 100% (95% CI, 54%-100%) and specificity was 95% (95% CI, 89%-99%). The median number of monthly FoCUS increased from 1 (preprotocol) to 5 (postprotocol), and the median rate of adequate studies increased from 0% to 55%. We report the collaborative development and successful implementation of a PED FoCUS protocol. Physician-sonographer interpretation of FoCUS yielded acceptable results. Improvements in FoCUS utilization and cine clip adequacy were observed.

Implementing a STEMI system of care in urban Bangalore: Rationale and Study Design for heart rescue India.

BackgroundA system of care designed to measure and improve process measures such as symptom recognition, emergency response, and hospital care has the potential to reduce mortality and improve quality of life for patients with ST-elevation myocardial infarction (STEMI).ObjectiveTo document the methodology and rationale for the implementation and impact measurement of the Heart Rescue India project on STEMI morbidity and mortality in Bangalore, India.Study DesignA hub and spoke STEMI system of care comprised of two interventional, hub hospitals and five spoke hospitals will build and deploy a dedicated emergency response and transport system covering a 10 Km. radius area of Bangalore, India. High risk patients will receive a dedicated emergency response number to call for symptoms of heart attack. A dedicated operations center will use geo-tracking strategies to optimize response times including first responder motor scooter transport, equipped with ECG machines to transmit ECG's for immediate interpretation and optimal triage. At the same time, a dedicated ambulance will be deployed for transport of appropriate STEMI patients to a hub hospital while non-STEMI patients will be transported to spoke hospitals. To enhance patient recognition and initiation of therapy, school children will be trained in basic CPR and signs and symptom of chest pain. Hub hospitals will refine their emergency department and cardiac catheterization laboratory protocols using continuous quality improvement techniques to minimize treatment delays. Prior to hospital discharge, secondary prevention measures will be initiated to enhance long-term patient outcomes.

Safety of a Brief Emergency Department Observation Protocol for Patients With Presumed Fentanyl Overdose

Fentanyl overdoses are increasing and few data guide emergency department (ED) management. We evaluate the safety of an ED protocol for patients with presumed fentanyl overdose. At an urban ED, we used administrative data and explicit chart review to identify and describe consecutive patients with uncomplicated presumed fentanyl overdose (no concurrent acute medical issues) from September to December 2016. We linked regional ED and provincial vital statistics databases to ascertain admissions, revisits, and mortality. Primary outcome was a composite of admission and death within 24 hours. Other outcomes included treatment with additional ED naloxone, development of a new medical issue while in the ED, and length of stay. A prespecified subgroup analysis assessed low-risk patients with normal triage vital signs. There were 1,009 uncomplicated presumed fentanyl overdose, mainly by injection. Median age was 34 years, 85%were men, and 82% received out-of-hospital naloxone. One patient was hospitalized and one discharged patient diedwithin 24 hours (combined outcome 0.2%; 95% confidence interval [CI] 0.04% to 0.8%). Sixteen patients received additional ED naloxone (1.6%; 95% CI 1.0% to 2.6%), none developed a new medical issue (0%; 95% CI 0% to 0.5%), and median length of stay was 173 minutes (interquartile range 101 to 267). For 752 low-risk patients, no patients were admitted or developed a new issue, and one died postdischarge; 3 (0.4%; 95% CI 0.01% to 1.3%) received ED naloxone. In our cohort of ED patients with uncomplicated presumed fentanyl overdose-typically after injection-deterioration, admission, mortality, and postdischarge complications appear low; the majority can be discharged afterbrief observation. Patients with normal triage vital signs are unlikely to require ED naloxone.

Regional "Call 911" Emergency Department Protocol to Reduce Interfacility Transfer Delay for Patients With ST-Segment-Elevation Myocardial Infarction.

BackgroundWe evaluated the first‐medical‐contact‐to‐balloon (FMC2B) time after implementation of a “Call 911” protocol for ST‐segment–elevation myocardial infarction (STEMI) interfacility transfers in a regional system.Methods and ResultsThis is a retrospective cohort study of consecutive patients with STEMI requiring interfacility transfer from a STEMI referring hospital, to one of 35 percutaneous coronary intervention‐capable STEMI receiving centers (SRCs). The Call 911 protocol allows the referring physician to activate 911 to transport a patient with STEMI to the nearest SRC for primary percutaneous coronary intervention. Patients with interfacility transfers were identified over a 4‐year period (2011–2014) from a registry to which SRCs report treatment and outcomes for all patients with STEMI transported via 911. The primary outcomes were median FMC2B time and the proportion of patients achieving the 120‐minute goal. FMC2B for primary 911 transports were calculated to serve as a system reference. There were 2471 patients with STEMI transferred to SRCs by 911 transport during the study period, of whom 1942 (79%) had emergent coronary angiography and 1410 (73%) received percutaneous coronary intervention. The median age was 61 years (interquartile range [IQR] 52–71) and 73% were men. The median FMC2B time was 111 minutes (IQR 88–153) with 56% of patients meeting the 120‐minute goal. The median STEMI referring hospital door‐in‐door‐out time was 53 minutes (IQR 37–89), emergency medical services transport time was 9 minutes (IQR 7–12), and SRC door‐to‐balloon time was 44 minutes (IQR 32–60). For primary 911 patients (N=4827), the median FMC2B time was 81 minutes (IQR 67–97).ConclusionsUsing a Call 911 protocol in this regional cardiac care system, patients with STEMI requiring interfacility transfers had a median FMC2B time of 111 minutes, with 56% meeting the 120‐minute goal.

Adult Chest Pain in the Pediatric Emergency Department: Treatment and Timeliness From Door In To Door Out.

The American College of Cardiology Foundation/American Heart Association guidelines for acute coronary syndrome (ACS) recommend immediate aspirin (ASA) administration, an electrocardiogram (ECG) in less than 10 minutes, and a door-in to door-out (DIDO) time less than 30 minutes for interfacility transfer. We sought to determine if compliance is hindered when adults with suspected ACS present to pediatric facilities. Visits to the 2 tertiary care emergency departments of a pediatric healthcare system using an adult chest pain protocol were examined from October 2006 to September 2012. Patients older than 18 years with a diagnosis suggestive of ACS and an initial ECG interpretation were identified. Proportions of patients receiving ASA were calculated as well as median times to ECG and DIDO. Bivariate analysis of ECG and DIDO time and the proportion of the patients receiving ASA was conducted for ECG findings positive and negative for ACS. One hundred thirteen patients were identified. Aspirin was administered in 69% of eligible cases. Electrocardiogram and DIDO times met recommended intervals in 42% (median, 12 minutes) and 5% (median, 59 minutes) of the patients, respectively. No significant differences between positive (22% of total) and negative (78% of total) ECG findings groups were detected in median DIDO time (57 vs 59 minutes, P = 0.99), time to ECG (14 vs 12 minutes, P = 0.45), or the proportion receiving ASA (84% vs 64%, P = 0.08). Despite the use of an emergency department protocol, compliance with the American College of Cardiology Foundation/American Heart Association guidelines for adults with suspected ACS remained challenging at this pediatric center. The ECG findings did not seem to impact ASA administration, ECG time, or DIDO time.

Analysis of serum lactate level in septic shock at Emergency Department of Patan Hospital, Nepal

Background: Sepsis is a leading cause of death in emergency department. Serum lactate level assessment can play an important role for risk assessment and prognostication in critically ill septic patient.Objective: The objective of this study is to determine the relevance of initial serum lactate measurement after the implementation of sepsis protocol in emergency department, based on guidelines of Surviving Sepsis Campaign.Methods: This was a cross sectional descriptive study conducted at Patan Hospital from January 2014 to January 2015 among 94 sample of serum lactate who had clinical suspicion of sepsis as per established sepsis emergency department protocol. Data of serum lactate sent from emergency department was noted from the registry book of department of biochemistry, Patan Academy of Health Sciences. Based on clinical practice the obtained lactate results were stratified intothreerisk groups: high (&gt; 4 mmol/L), intermediate (2.5 to 3.99 mmol/L) and low (&lt; 2.5 mmol/L).Result: Out of the total 94 samples, 56 (59.6%) were male and 38 (40.4%) were female. Mean lactate level in males was 5.73 mmol/L and that in females was 5.47 mmol/L. Abnormal lactate level was predominantly high 85 (80%) out of which 31 (29%) had intermediate whereas more than half 54 (50.76%) had high lactate level.Conclusion: This study tells that clinically diagnosed sepsis do have higher serum lactate level. So, in our context, this needs to be explored to be used for early diagnosis of sepsis.Journal of Kathmandu Medical CollegeVol. 5, No. 2, Issue 16, Apr.-Jun., 2016, page: 49-51

Implementing an Inpatient Protocol: Improving Time to Treatment for STEMIs

SESSION TITLE: Cardiovascular 2 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Recent studies suggest a higher mortality for inpatient STEMIs compared to STEMI patients who arrive in the emergency department (ED) or are transferred from an outside facility. The question of how to improve outcomes and definition of optimum treatment in hospitalized patients experiencing a STEMI merits greater concern and attention across the nation. Part of the increased mortality can be due to less timely reperfusion as a result of unfamiliar personnel on non-cardiac floors. St Luke's Hospital, a community hospital in suburban Missouri, recently instituted a protocol for inpatient STEMIs in order to decrease time to reperfusion. The focus was to give non-cardiology personnel the appropriate guidance to facilitate reperfusion similar to the ED protocol. This analysis of recent inpatient STEMIs was done to identify gaps and barriers to prompt treatment; including difficulty in identifying symptoms, interpreting ECGs, as well as long delays in decision making. METHODS: For the last ten years there has been a protocol in place at our hospital for STEMI patients that come through the ED in association with national door-to-balloon time (D2B) initiatives. The goal is to apply a similar protocol to inpatients already in the hospital. We instituted a protocol for treatment of inpatients STEMIs according to the current standards of care established by the American College of Cardiology. This protocol includes four steps that need to be followed to implement timely treatment: 1) identify a STEMI on an ECG, 2) have the ECG over-read by a qualified physician, 3) activate the STEMI team, and 4) have the care handed off to the STEMI team of cardiac catheterization laboratory nurses and the interventional cardiologist on call. We defined the initial time as the time that the ECG was performed; a “door” time was deemed inappropriate and any other measure was too ambiguous. RESULTS: Prior to initiating the protocol, there were 8 inpatient STEMI patients; and 7 inpatient STEMI patients after the protocol implementation. The average time to reperfusion for patients prior to the change was 406 minutes. The average time to reperfusion for patients after the protocol rollout was 68 minutes. A significant improvement was achieved with time to reperfusion defined as time of the initial ECG to balloon or device intervention after implementation of the inpatient STEMI protocol (p<0.05). CONCLUSIONS: In a community hospital, it is feasible and necessary to implement a protocol for inpatient STEMI management which will greatly improve the time to appropriate treatment. Some areas identified for improvement include false activations, following a protocol on non-cardiac floors, and stricter definition of time-to-treatment, as this was difficult to determine since the patient did not have “door” time but rather, a symptom that prompted an ECG. CLINICAL IMPLICATIONS: It is possible and necessary to implement a protocol for inpatient STEMI management to improve time to appropriate treatment in a community hospital; however there are still areas identified for further research. DISCLOSURE: The following authors have nothing to disclose: Erika Leung, Ryan Medas, Mary Randazzo, Tinashe Maduke, Onyema Nnanna, Morton Rinder No Product/Research Disclosure Information

A comprehensive regional clinical and educational ECPR protocol decreases time to ECMO in patients with refractory out-of-hospital cardiac arrest.

Extracorporeal membrane oxygenation within CPR (ECPR) may improve survival for refractory out-of-hospital cardiac arrest (OHCA). We developed a prehospital, emergency department (ED), and hospital-based clinical and educational protocol to improve the key variable of time-to-ECPR (TTE). In a single urban health region we involved key prehospital, clinical, and administrative stakeholders over a 2-year period, to develop a regional ECPR program with destination to a single urban tertiary care hospital. We developed clear and reproducible inclusion criteria and processes, including measures of program efficiency. We conducted seminars and teaching modules to paramedics and hospital-based clinicians including monthly simulator sessions, and performed detailed reviews of each treated case in the form of report cards. In this before-and-after study we compared patients with ECPR attempted prior to, and after, protocol implementation. The primary outcome was TTE, defined as the time of initial professional CPR to establishment of extracorporeal circulation. We compared the median TTE for patients in the two groups using the Wilcoxon signed rank test. Four patients were identified prior to the protocol and managed in an ad hoc basis; for nine patients the protocol was utilized. Overall favourable neurological outcomes among ECPR-treated patients were 27%. The median TTE was 136 minutes (IQR 98 - 196) in the pre-protocol group, and 60 minutes (IQR 49 - 81) minutes in the protocol group (p=0.0165). An organized clinical and educational protocol to initiate ECPR for patients with OHCA is feasible and significantly reduces the key benchmark of time-to-ECPR flows.

Toxicological Screening of Drug Facilitated Crime among Travelers in Dhaka, Bangladesh

Introduction: Drug-facilitated robberies, primarily of public transport passengers, are a massively increasing public health emergency and law enforcement challenge in Dhaka, the capital city of Bangladesh. Methods:We conducted a prospective clinical and toxicological study of 38 patients with acute poisoning who had been admitted to Dhaka Medical College Hospital between October 2008 and December 2008 and suspected to be victims of drug-facilitated crimes. Blood samples were obtained on admission and one hour later to identify changing concentrations of the drugs used by the perpetrators. Toxicological screening was performed by LC-TOF/MS and LC-MS/MS analysis of the blood samples of 22 of these patients. Results:All of the patients in our series were male, 17-60 years of age, and none had any memory of the time between the ingestion of the drug and the onset of unconsciousness. All had lost the valuables they had been carrying at the time of the incident. On admission, 50 of the patients had a Glasgow Coma Score (GCS) of 5-10. Most of them were poisoned while travelling (79), most frequently by bus (70). They had been offered tea (21), other drinks (26), prickles (18), herbal medicines (10) or cigarettes (5) by the suspected perpetrators. Screening by LC-TOF/MS and LC-MS/MS revealed pharmacologically active concentrations of lorazepam in the blood samples of all 22 cases (191±138 µg/l, mean±SD); midazolam in 12 (149±99 µg/l); diazepam in 3 (217±144 µg/l) and nordiazepam in 6 cases (364±186 µg/l). In five cases the lorazepam concentration of the second blood sample was at least 15 higher than in the sample drawn on admission one hour earlier, indicating continuing absorption. This suggests that only these five patients had been admitted within the 1-2 hour long absorption phase. Almost all of the patients left the hospital unnoticed after clearing up, two likely prematurely within 12 hours of admission, and no mortality was observed. Conclusions:This study reveals flexibility of the criminals in Dhaka in using different mixtures of benzodiazepines to incapacitate and then rob their victims.The findings of our study have important implications for the clinical management of drug-facilitated crime victims. In particular, they highlight an urgent need to widely deploy rapid diagnostic and analytical forensic and clinical toxicology facilities in Bangladesh, introduce and implement modifications to emergency department protocols, and provide post-recovery psychological support for victims who often suffer existentially threatening economic losses in addition to the poisoning.

A review of urinary tract infection management for patients admitted to the emergency department: Assessment of adherence to guidelines and identification of hospitalization criteria

Background & objectives Community-acquired urinary tract infections (UTIs) are the second most common indication for antibiotic prescription in France. Previous studies on the adherence to guideline on antibiotic use reported a prevalence of inappropriate prescriptions varying from 20 to 50%, both in the community and hospital settings. The misuse of antibiotics not only have an important economic impact but can also lead to therapeutic impasses. This study aimed at establishing the current management of UTIs for patients admitted to the emergency department (ED) of our hospital. Methods This retrospective observational study was conducted in the European Hospital of Marseille January 2015 and May 2016. Consecutive patients admitted to the ED for a suspected UTI were included, including patients hospitalized ( n = 50) or discharged ( n = 50) after their ED admission. Assessment of adherence to guidelines for antibiotic prescription was conducted using the guidelines of the French-speaking society of infectious disease (SPILF). Results In the hospitalized group, 22 (44%) antibiotic prescriptions initiated at the ED did not comply with national guidelines. The two main causes for inappropriate prescriptions were the use of two antibiotics in patients with no severity criteria (15, 68%) and/or the use of a non-recommended drug (6, 27%). In this group, 17 (35%) antibiotic prescriptions ordered by the urologist on patients’ discharge did not comply with national guidelines. The two main causes of inappropriate prescriptions were the use of a non-recommended drug (9, 53%) and an inadequate duration of treatment (9, 53%). In the discharged group, 29 (60%) of the antibiotic prescriptions ordered at the ED did not comply with national guidelines. The two main causes of inappropriate prescriptions were an inadequate duration of treatment (23, 79%) and the use of a non-recommended drug (19, 66%). We could also identify discrepancies between reasons for hospitalization in our cohort compared to the criteria for hospitalization mentioned in the national guidelines. Discussion & conclusions This study has identified areas of improvement for the management of UTIs in our hospital. Our suggestions for optimization include educational materials and a decision tree displayed at the ED and specific therapeutic protocols in our computerized prescription system.