Impact of a Standardized Patient Hand-off Tool on Communication between Emergency Medical Services Personnel and Emergency Department Staff.

INTRODUCTION: Handoff communication between Emergency Medical Services (EMS) and Emergency Department (ED) staff is critical to ensure quality patient care. In January 2016, the Southwest Texas Regional Advisory Council (STRAC) implemented MIST (Mechanism, Injuries, vital Signs, Treatments), a standardized EMS to ED handoff tool. The En route Care Research Center conducted a Pre-MIST implementation survey of ED staff in December 2015 and a Post-MIST follow-up survey in July 2017 to determine the impact of the MIST handoff tool on the perceived quality of transmission of pertinent patient information and in the overall handoff experience. METHODS: We administered a nine-item Likert scale questionnaire to Brooke Army Military Medical Center (BAMC) ED providers and nurses before and after implementation of MIST. The questionnaire captured perceived competence and satisfaction with handoff communication (Cronbach's alpha 0.73). We analyzed responses for the total sample and by occupation (providers and nurses), and we calculated odds ratios to determine items that may be most predictive of a positive handoff experience from the perspective of the ED staff. We performed chi-square tests and reported data as percentages. RESULTS: Total respondents Pre- and Post-MIST were 128 (62%) nurses and 80 (38%) providers (MDs, DOs, and PAs). Following the implementation of MIST, more respondents reported that they were "informed of prehospital treatments" (p < 0.001), that "Red/Blue Trauma Alert Criteria were conveyed" (p < 0.001), and that the "time to give the report was sufficient to convey pertinent information" (p < 0.001). Nurses more frequently reported that "Red/Blue Trauma Alert Criteria were conveyed" post-MIST (p < 0.01). Providers more frequently reported that "Assessment findings were conveyed" (p < 0.05), that they 'interrupted the report for clarification" (p < 0.04), that "time to give the report was sufficient to convey pertinent information" (p < 0.001) and that they "felt positive about the overall handoff experience" (p < 0.03) Post-MIST. Overall satisfaction with the handoff was associated with frequently being informed of prehospital treatments (OR 5.5; 2.1-14.4) and frequently receiving a copy of the prehospital record (OR 2.9; 1.1-7.2). CONCLUSIONS: These data demonstrate that providers and nurses reported an improvement in the handoff experience Post-MIST. This study supports the use of a standardized handoff tool at this critical step in patient care.

Evaluation and management of pulmonary hypertension in the emergency department setting.

BACKGROUND: Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance and pulmonary arterial pressure and is associated with significant morbidity and mortality. OBJECTIVE: This narrative review evaluates PH, outlines the complex pathophysiologic derangements, and addresses the emergency department (ED) management of this patient population. DISCUSSION: Approximately 10-20% of individuals in the United States suffer from PH. Each year nearly 12,000 PH patients seek care in the ED for a variety of symptoms which may or may not be related to PH. There are 5 classes of PH, some of which respond to particular therapies outlined in this review. As presenting complaints are frequently vague and non-specific, emergency physicians must recognize manifestations of PH and complications related to PH to deliver appropriate care. Early imaging with chest radiograph, bedside echocardiogram, and computed tomography can assist in determining the underlying etiology of PH exacerbation. Restarting oral or intravenous PH medications that may have been discontinued is crucial in initial management. Immense care should be taken to avoid hypoxia and hypercarbia as well as maintaining right ventricular preload support. In addition to correction of underlying precipitants, judicious vasopressor and inotrope use can help to correct pathophysiology and avoid further airway intervention. CONCLUSIONS: An understanding of the pathophysiology of PH and available emergency treatments can assist emergency clinicians in reducing the immediate morbidity and mortality associated with this disease. Restarting maintenance PH medications and proper selection of vasopressors and inotropes will benefit decompensating patients with PH.

Randomized Controlled Trial of a Web-Based Intervention to Disseminate Clinical Practice Guidelines for Posttraumatic Stress Disorder: The PTSD Clinicians Exchange.

Delivery of best-practice care for posttraumatic stress disorder (PTSD) is a priority for clinicians working with active duty military personnel and veterans. The PTSD Clinicians Exchange, an Internet-based intervention, was designed to assist in disseminating clinically relevant information and resources that support delivery of key practices endorsed in the Veterans Administration (VA)-Department of Defense (DoD) Clinical Practice Guidelines (CPG) for the Management of Posttraumatic Stress. We conducted a randomized controlled trial to examine the effectiveness of the Clinicians Exchange intervention in increasing familiarity and perceived benefits of 26 CPG-related and emerging practices. The intervention consisted of ongoing access to an Internet resource featuring best-in-class resources for practices, self-management of burnout, and biweekly e-mail reminders highlighting selected practices. Mental health clinicians (N = 605) were recruited from three service sectors (VA, DoD, community); 32.7% of participants assigned to the Internet intervention accessed the site to view resources. Individuals who were offered the intervention increased their practice familiarity ratings significantly more than those assigned to a newsletter-only control condition, d = 0.27, p = .005. From baseline to 12-months, mean familiarity ratings of clinicians in the intervention group increased from 3.0 to 3.4 on scale of 1 (not at all) to 5 (extremely); mean ratings for the control group were 3.2 at both assessments. Clinicians generally viewed the CPG practices favorably, rating them as likely to benefit their clients. The results suggest that Internet-based resources may aid more comprehensive efforts to disseminate CPGs, but increasing clinician engagement will be important.

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.

STUDY OBJECTIVE: We compare aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access. METHODS: In a randomized, blinded, placebo-controlled trial, we enrolled a convenience sample of adults presenting to an urban tertiary care ED with chief complaints including nausea or vomiting. We randomized subjects to 1 of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale from enrollment to 30 minutes postintervention. Secondary outcomes included receipt of rescue antiemetic medications and adverse events. RESULTS: We enrolled 122 subjects, of whom 120 (98.3%) completed the study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41 received inhaled saline solution placebo and oral ondansetron. The mean decrease in nausea visual analog scale score in each arm was 30 mm (95% confidence interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. The proportions of subjects who received rescue antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95% CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were no adverse events. CONCLUSION: Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone.

Ultra-brief behavioral skills trainings for blood injection injury phobia.

BACKGROUND: Blood injection injury (BII) phobia is common, with debilitating consequences to the health and well being of many of its sufferers. BII phobia presents with a unique fear response that can involve drops in blood pressure and ultimately fainting. The aim of this study was to provide proof of concept for a line of brief, easy to implement, video-based interventions for reducing phobic avoidance and fears in BII sufferers. One of the interventions was a novel Hypoventilation Respiratory Training (HRT) aimed at reducing the exaggerated ventilation response (hyperventilation) seen in BII phobia. The response has been linked to cerebral vasoconstriction and fainting symptoms. METHOD: Sixty BII patients were randomly assigned to one of three 12-min video-guided trainings: Symptom-Associated Tension (SAT) training, Relaxation Skills Training (RST), or HRT. Experiential and cardiorespiratory activity to phobic stimuli was assessed before and after training. RESULTS: Both SAT and HRT resulted in overall greater reductions of phobic fears and symptoms than RST. SAT significantly increased heart rate during exposure, and HRT led to significantly reduced ventilation, increases in PCO2 , and elevated blood pressure throughout exposure and recovery. Treatment expectancy was rated equally high across conditions, whereas credibility ratings were highest for HRT. CONCLUSIONS: Brief, video-based instructions in muscle tension and normocapnic breathing are effective in reducing BII symptom severity and require minimal time and expertise. HRT may be particularly helpful in reducing fainting caused by cerebral vasoconstriction.

Clinical Mimics: An Emergency Medicine-Focused Review of Influenza Mimics.

BACKGROUND: Influenza viruses are a significant cause of morbidity and mortality in the United States. Given the wide range of symptoms, emergency physicians must maintain a broad differential diagnosis in the evaluation and treatment of patients presenting with influenza-like illnesses. OBJECTIVE: This review addresses objective and subjective symptoms commonly associated with influenza and discusses important mimics of influenza viruses, while offering a practical approach to their clinical evaluation and treatment. DISCUSSION: Influenza-like symptoms are common in the emergency department (ED), and influenza accounts for > 200,000 hospitalizations annually. The three predominant types are A, B, and C, and these viruses are commonly transmitted through aerosolized viral particles with a wide range of symptoms. The most reliable means of identifying influenza in the ED is rapid antigen detection, although consideration of local prevalence is required. High-risk populations include children younger than 4 years, adults older than 50 years, adults with immunosuppression or chronic comorbidities, pregnancy, obesity, residents of long-term care facilities, and several others. The Centers for Disease Control and Prevention recommends treatment with neuraminidase inhibitors in these populations. However, up to 70% of patients with these symptoms may have a mimic. These mimics include infectious and noninfectious sources. The emergency physician must be aware of life-threatening mimics and assess for these conditions while beginning resuscitation and treatment. CONCLUSIONS: The wide range of symptoms associated with influenza overlap with several life-threatening conditions. Emergency physicians must be able to rapidly identify patients at risk for complications and those who require immediate resuscitation.

A Case of Brachiocephalic Fistula Steal and the Emergency Physician's Approach to Hemodialysis Arteriovenous Fistula Complications.

BACKGROUND: Chronic kidney disease is common in the United States, with many patients maintained on hemodialysis (HD). The process of HD requires vascular access through an arteriovenous (AV) fistula, AV graft, or central venous catheter. Today, as a result of the National Kidney Foundation's "Fistula First" initiative, nearly 55% of HD patients utilize an AV fistula. As there is significant morbidity and mortality associated with fistula placement and recurrent fistula cannulation, emergency physicians must be equipped to recognize and treat fistula complications. OBJECTIVE: To detail a case study of vascular insufficiency (vascular steal) presenting to an emergency department (ED) and provide an evidence-based approach to the emergency assessment and management of HD AV fistula complications. DISCUSSION: A 66-year-old man presented to the ED with left upper extremity pain, paresthesias, and loss of grip strength of 1-week duration 15 days after placement of left upper extremity brachiocephalic fistula. He was diagnosed with dialysis access-associated steal syndrome and taken to the operating room for revision. Patients with HD fistulas may experience several complications, including vascular insufficiency, hemorrhage, infection, stenosis, thrombosis, aneurysms, or pseudoaneurysms. Emergency physicians must be able to identify these complications and deliver timely treatment. CONCLUSIONS: A comprehensive understanding of the appropriate management of AV fistula complications is paramount for the emergency physician. Early recognition and treatment of vascular insufficiency resulting from fistula creation, fistula hemorrhage, fistula infection, stenosis, thrombosis, and aneurysms or pseudoaneurysms is vital to reducing the morbidity and mortality associated with HD.

Emergency Medicine Management of Sickle Cell Disease Complications: An Evidence-Based Update.

BACKGROUND: Sickle cell disease (SCD) affects approximately 100,000 individuals in the United States. Due to alterations in the structural conformation of hemoglobin molecules under deoxygenated conditions, patients with SCD are predisposed to numerous sequelae, many of which require acute intervention. OBJECTIVE: Our aim was to provide emergency physicians with an evidence-based update regarding the diagnosis and management of SCD complications. DISCUSSION: SCD patients experience significant morbidity and mortality secondary to cerebrovascular accident, acute chest syndrome, acute vaso-occlusive pain crises, SCD-related multi-organ failure, cholecystitis, acute intrahepatic cholestasis, acute sickle hepatic crisis, acute hepatic sequestration, priapism, and renal disease. Emergency physicians must recognize acute manifestations of SCD in order to deliver timely management and determine patient disposition. CONCLUSIONS: A comprehensive review of the emergency department management of acute SCD complications is provided. Comprehensive understanding of these aspects of SCD can assist physicians in expediting patient evaluation and treatment, thus decreasing the morbidity and mortality associated with this hemoglobinopathy.

Increases in exhaled nitric oxide after acute stress: association with measures of negative affect and depressive mood.

BACKGROUND: Increases in fractional exhaled nitric oxide (FeNO) have been observed after acute laboratory stress, which could indicate a strengthening of immune defenses in acute stress because of the quick onset of the response and the role of nitric oxide in airway-protective functions. In addition, because sustained psychological distress and depression are known to deteriorate immune defenses systems, they may dampen the FeNO response to acute stress. METHODS: FeNO and negative affect were measured before and after a speech and mental arithmetic stressor. We examined the association of stress-induced FeNO changes with momentary negative affect and questionnaires of perceived stress, anxious mood, and depressive mood in 39 asthma patients and 41 healthy controls. RESULTS: FeNO increased from baseline to stress in participants with asthma (from 3.38 [0.102] to 3.46 [0.103] ln(ppb)) and controls (2.86 [0.098] to 2.92 [0.099]; F(4,141) = 3.26, p = .014), but the magnitude of the FeNO response did not differ between groups (F < 1). Only low levels of depressive mood were associated with FeNO increases after stress (most pronounced at 0 minute poststress; t(76) = 3.87, p < .001). In contrast, only higher perceived stress was associated with FeNO increases (most pronounced at 0 minute poststress; t(75) = 4.09, p < .001), and momentary negative affect was associated with higher FeNO throughout assessments (ß = 0.08, t(114) = 8.27, p = .005). Associations of FeNO with psychological variables were largely unrelated to asthma status and inhaled corticosteroid use. CONCLUSIONS: Depressive mood is associated with a reduced mobilization of airway nitric oxide in acute stress, whereas other indicators of negative affect are positively associated with overall FeNO levels and reactivity.

Hypoventilation training for asthma: a case illustration.

Hyperventilation-induced hypocapnia is common among asthma patients. This case study illustrates both methodology and results from a patient undergoing training in capnometry-assisted respiratory training (CART). CART is a 4-week training aimed at normalizing basal and acute levels of end-tidal carbon dioxide (PCO(2)) using a portable capnometer. In the presented case, basal levels of PCO(2) increased from hypocapnic to normocapnic range over the course of treatment. Improvements were accompanied by improvements in lung function and reductions in diurnal lung function variability. Improvements remained stable throughout follow-up.

Stress-induced respiratory pattern changes in asthma.

OBJECTIVES: To build upon prior research on stress-related breathing pattern changes in asthma. Previous research has considered a limited set of respiratory parameters and has remained equivocal. Emotions and stress are known to change the respiratory pattern. In asthma, certain breathing patterns have adverse effects on the airways and lead to symptom exacerbation. METHODS: We studied respiration during resting conditions and an acute psychosocial stressor (a free speech and mental arithmetic task) in participants with asthma (n = 20) and healthy controls (n = 19). The respiratory pattern was recorded with respiratory inductance plethysmography. Partial pressure of end-tidal carbon dioxide (PCO(2)) was measured with capnometry before and after stress. RESULTS: The overall minute ventilation was higher in asthma (mean [standard deviation] = 9.0 [4.0] L versus 6.8 [4.1] L, p < .05), but levels of the PCO(2) were comparable (34.6 [3.5] mm Hg versus 35.0 [3.7] mm Hg, p = .667) to healthy controls during prestress and poststress phases. Participants with asthma also showed a significant lengthening of inspiration, expiration, and the total respiratory cycle during stress compared with healthy controls (p < .05). During stress tasks, all participants showed marked increases in tidal volume, inspiratory flow, minute ventilation, tidal volume instability, ribcage contribution to tidal volume, and ribcage-abdominal asynchrony. A significant increase in tidal volume instability and a tendency toward lengthening of expiration and the total respiratory cycle were observed in quiet-sitting periods at prestress to poststress in asthma. CONCLUSIONS: Expiratory lengthening and variable tidal volumes are characteristic for individuals with asthma during psychosocial stress. The function and possible association of these changes with symptom exacerbations require further study.