Trends in the Evaluation and Management of Back Pain in Emergency Departments, United States, 2007-2016.

OBJECTIVE: Back pain is one of the most common pain syndromes in the United States, but there has been limited recent description of the role of emergency departments (EDs) in caring for patients with back pain. We investigated trends in the evaluation and management of back pain in U.S. EDs from 2007 to 2016. METHODS: We performed a retrospective analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative annual survey of ED visits, which includes data on patient-, hospital-, and visit-level characteristics. We evaluated trends among adult ED visits for back pain, including demographics, resource utilization, and disposition. Trends were assessed through the use of survey-weighted analyses. RESULTS: Visit rates as a proportion of overall ED visits were stable from 2007 to 2016 (9.1% [95% confidence interval (CI): 8.5-9.6] vs. 9.3% [95% CI: 8.6-10.0]; P = 0.44). Admission rates declined from 6.4% (95% CI: 5.1-8.0) to 5.0% (95% CI: 3.5-6.9; P < 0.001). Imaging utilization increased from 51.7% (95% CI: 49.3-54.1) to 57.6% (95% CI: 53.3-61.7; P = 0.023), with an increase of 58.3% in computed tomography. Overall opioid utilization declined from 53.5% (95% CI: 49.4-57.5) to 46.5% (95% CI: 43.2-49.8; P < 0.001). Tramadol use increased over the study period (4.1% [95% CI: 3.0-5.8] vs. 8.4% [95% CI: 6.6-10.7]; P < 0.001). CONCLUSIONS: Opioid utilization during ED visits for back pain decreased from 2007 to 2016, whereas tramadol use more than doubled. Care intensity increased significantly despite declining admission rates. Further research into optimal strategies for back pain management in the ED is needed.

One-way-street revisited: Streamlined admission of critically-ill trauma patients.

INTRODUCTION: Emergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding. MATERIALS & METHODS: This was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing. RESULTS: A total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p < 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p < 0.01). The reduction in ED LOS was sustained when comparing initial results (2013-2014) to recent data (2015-2018). CONCLUSION: This study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.

A Novel Application of Ultrasound-Guided Interscalene Anesthesia for Proximal Humeral Fractures.

BACKGROUND: Proximal humeral fractures are commonly encountered in the emergency department (ED). These injuries are often associated with significant pain, with patients often receiving multiple doses of opiate medications while awaiting definitive management. The interscalene nerve block has been efficacious as perioperative analgesia for patients undergoing operative shoulder repair. The utilization of the interscalene nerve block in the ED for proximal humeral fractures is largely unexplored. DISCUSSION: We report the use of an ultrasound-guided interscalene nerve block in the ED for a patient presenting with significant pain from a proximal humerus fracture. The procedure provided excellent regional anesthesia with no additional need for intravenous or oral opiates during the rest of her ED course. With the significant risks associated with pain medication, particularly opiates, regional anesthesia may be an excellent option for the appropriate patient in the ED. CONCLUSIONS: As documented in this report, the ultrasound-guided interscalene block, in particular, may be utilized as a means to provide adequate pain control for patients with proximal humerus fractures in the ED.

Optimizing Value of Colon Surgery in Michigan.

OBJECTIVE: To assess the value of bundling perioperative care measures in colon surgery. BACKGROUND: Surgical site infections (SSI) in colectomy are associated with increased morbidity and cost. Perioperative care bundling has been designed to improve processes of care surrounding colectomy operations. METHODS: Retrospective cohort study performed by the Michigan Surgical Quality Collaborative (MSQC) of patients who underwent elective colon surgery from 2012 to 2015. We identified 3,387 patients in the MSQC database who underwent colon surgery. Of these cases, 332 had associated episodic cost data. RESULTS: High compliance (3-6 bundle elements) and low compliance (0-2 bundle elements) had a risk-adjusted SSI rate of 8.2% (95% confidence interval, CI, 7.2-9.2%) and 16.0% (95% CI, 12.9-19.1%), respectively (P < 0.01). When compared with low compliance, the high compliance group had an absolute risk reduction of 3.6% (P < 0.01), 2.9% (P < 0.01) and 1.3% (P < 0.01) for SSI rates in superficial space, deep space, and organ space, respectively. Low compliance had an average episodic cost of $20,046 (95% CI, $17,281-$22,812) whereas high compliance had an episodic cost of $15,272 (95% CI, $14,354-$16,192). This showed a $4,774 (95% CI, $1,859-$7,688) and 23.8% cost reduction (P < 0.01). Facility base payments decreased 14.8% ($13,444; $11,458), professional payments decreased 43.9% ($5,180; $2,906), and other payments decreased 36.2% ($1,422; $908). CONCLUSIONS: A colectomy perioperative care bundle in Michigan is associated with improved value of surgical care. We will expand efforts to implement perioperative care bundles in Michigan to improve outcomes and reduce costs.

Safety considerations in learning new procedures: a survey of surgeons.

BACKGROUND: There exists a tension between surgical innovation and safety. The learning curve associated with the introduction of new procedures/technologies has been associated with preventable patient harm. Surgeon's perceptions regarding the safety of methods for learning new procedures/technologies are largely uncharacterized. MATERIALS AND METHODS: A survey was designed to evaluate surgeons' perceptions related to learning new procedures/technologies. This included clinical vignettes across two domains: (1) experience with an operation (e.g., colectomy) and (2) experience with a technology (e.g., laparoscopy). This study also focuses on a surgeon's perceptions of existing credentialing/privileging requirements. Participants were faculty surgeons (n = 150) at two large Midwestern academic health centers. RESULTS: Survey response rate was 77% (116/150). 69% of respondents believed the processes of credentialing/privileging is "far too relaxed" or "too relaxed" for ensuring patient safety. Surgeons most commonly indicated a mini-fellowship is required to learn a new laparoscopic procedure. However, that requirement differed based on a surgeon's prior experience with laparoscopy. For example, to learn laparoscopic colectomy, 35% of respondents felt a surgeon with limited laparoscopic experience should complete a mini-fellowship, whereas 3% felt this was necessary if the surgeon had extensive laparoscopic experience. In the latter scenario, most respondents felt a surgeon should scrub in cases performed by an expert (38%) or perform cases under a proctor's supervision (33%) when learning laparoscopic colectomy. CONCLUSIONS: Many surgeons believe existing hospital credentialing/privileging practices may be too relaxed. Moreover, surgeons believe the "one-size-fits-all" approach for training practicing surgeons may not protect patients from unsafe introduction of new procedures/technologies.

A Scoping Review of Emergency Department Discharge Risk Stratification.

INTRODUCTION: Although emergency department (ED) discharge presents patient-safety challenges and opportunities, the ways in which EDs address discharge risk in the general ED population remains disparate and largely uncharacterized. In this study our goal was to conduct a review of how EDs identify and target patients at increased risk at time of discharge. METHODS: We conducted a literature search to explore how EDs assess patient risk upon discharge, including a review of PubMed and gray literature. After independently screening articles for inclusion, we recorded study characteristics including outcome measures, patient risk factors, and tool descriptions. Based on this review and discussion among collaborators, major themes were identified. RESULTS: PubMed search yielded 384 potentially eligible articles. After title and abstract review, we screened 235 for potential inclusion. After full text and reference review, supplemented by Google Scholar and gray literature reviews, we included 30 articles for full review. Three major themes were elucidated: 1) Multiple studies include retrospective risk assessment, whereas the use of point-of-care risk assessment tools appears limited; 2) of the point-of-care tools that exist, inputs and outcome measures varied, and few were applicable to the general ED population; and 3) while many studies describe initiatives to improve the discharge process, few describe assessment of post-discharge resource needs. CONCLUSION: Numerous studies describe factors associated with an increased risk of readmission and adverse events after ED discharge, but few describe point-of-care tools used by physicians for the general ED population. Future work is needed to investigate standardized tools that assess ED discharge risk and patients' needs upon ED discharge.

Telehealth use in emergency care during coronavirus disease 2019: a systematic review.

OBJECTIVE: The coronavirus disease 2019 pandemic has presented emergency departments (EDs) with many challenges to address the acute care needs of patients. Many EDs have leveraged telehealth to innovatively respond to these challenges. This review describes the landscape of telehealth initiatives in emergency care that have been described during the coronavirus disease 2019 pandemic. METHODS: We conducted a comprehensive, systematic review of the literature using PubMed, supplemented by a review of the gray literature (ie, non-peer reviewed), with input from subject matter experts to identify telehealth initiatives in emergency care during coronavirus disease 2019. We categorized types of telehealth use based on purpose and user characteristics. RESULTS: We included 27 papers from our review of the medical literature and another 8 sources from gray literature review. The vast majority of studies (32/35) were descriptive in nature, with the additional inclusion of 2 cohort studies and one randomized clinical trial. There were 5 categories of ED telehealth use during the pandemic: (1) pre-ED evaluation and screening, (2) within ED (including as a means of limiting staff and patient exposure and facilitating consultation with specialists), (3) post-ED discharge monitoring and treatment, (4) educating trainees and health care workers, and (5) coordinating resources and patient care. CONCLUSION: Telehealth has been used in a variety of manners during the coronavirus disease 2019 pandemic, enabling innovation in emergency care delivery. The findings from this study can be used by institutions to consider how telehealth may address challenges in emergency care during the coronavirus disease 2019 pandemic and beyond. Because few studies included cost data and given the variability in institutional resources, how organizations implement telehealth programs will likely vary. Future work should further explore barriers and facilitators of innovation, and the impact on care delivery and patient outcomes.

Impact of Emergency Department Crowding on Delays in Acute Stroke Care.

INTRODUCTION: Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care. METHODS: We used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our urban academic ED from July 2016-August 2018. We used capacity logs to determine the degree of ED crowding at the time of patients' presentation and classified them as ordinal variables (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT) among patients potentially eligible for alteplase or endovascular therapy on presentation, door-to-needle time (DTN) for alteplase delivery, and door-to-groin puncture (DTP) times for endovascular therapy. Bivariate comparisons were made using t-tests, chi-square, and Wilcoxon rank-sum tests as appropriate. We used regression models to examine the relationship after accounting for patient demographics, transfer status, arrival mode, and initial stroke severity by the National Institutes of Health Stroke Scale. RESULTS: Of the 1379 patients with ischemic stroke presenting during the study period, 1081 (78%) presented at times of normal capacity, 203 (15%) during high ED crowding, and 94 (7%) during severe crowding. Median DIT was 26 minutes (interquartile range [IQR] 17-52); DTN time was 43 minutes (IQR 31-59); and median DTP was 58.5 minutes (IQR 56.5-100). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing. CONCLUSION: In our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.

Acute and delayed toxicity from co-ingestion of methylene chloride and methanol.

Methylene chloride is a volatile, chlorinated hydrocarbon and colorless solvent found in multiple industrial products including paint strippers, metal cleaners, automotive products, pesticides and aerosol containers. Occupational exposure to methylene chloride is reported in automotive technicians, painters, and other industrial workers with adverse health effects including gastrointestinal, neurological, as well as hepato-renal injuries. International Agency for Research on Cancer (IARC) classifies methylene chloride as a 2 A carcinogen. Through a series of reactions catalyzed by cytochrome P450 2E1 (CYP2E1), metabolism of methylene chloride leads to the formation of formyl chloride, and ultimately carbon monoxide (CO). Most reports of methylene chloride toxicity are due to dermal and inhalational exposure in occupational settings. Ingestion of methylene chloride is uncommon, yet can lead to significant toxicity and prolonged CO toxicity. Methylene chloride is frequently formulated with methanol; individuals who intentionally ingest methylene chloride can experience concomitant methanol toxicity. We present a case of acute ingestion of paint stripper containing methanol and methylene chloride. We discuss the clinical presentation, key management decisions, relevant pathophysiology and biochemistry, as well as the clinical course and management.

Strategies for New Skill Acquisition by Practicing Surgeons.

OBJECTIVE: To understand how practicing surgeons utilize available training methods, which methods are perceived as effective, and important barriers to using more effective methods. DESIGN: Online survey designed to characterize surgeon utilization and perception of available training methods. SETTING: Two large Midwestern academic health centers. PARTICIPANTS: 150 faculty surgeons. METHODS: Nominal values were compared using a McNemar's Test and Likert-like values were compared using a paired t-test (IBM SPSS Statistics v. 21.0; New York, NY). RESULTS: Survey response rate was 81% (122/150). 98% of surgeons reported learning a new procedure or technology after formal training. Many surgeons reported scrubbing in expert cases (78%) and self-directed study (66%), while few surgeons (6%) completed a mini-fellowship. The modalities used most commonly were scrubbing in expert cases (34%) and self-directed study (27%). Few surgeons (7%) believed self-directed study would be most effective, whereas 31% and 16% believed operating under supervision and mini-fellowships would be most effective, respectively. Surgeons believed more effective methods "would require too much time" or they had "confidence in their ability to implement safely." CONCLUSIONS: Practicing surgeons use a variety of training methods when learning new procedures and technologies, and there is disconnect between commonly used training methods and those deemed most effective. Confidence in surgeon's ability was cited as a reason for this discrepancy; and surgeons found time associated with more effective methods to be prohibitive.