Managing Diabetes Mellitus in the Emergency Department.

Diabetes mellitus (DM) is a chronic medical condition that continues to increase in prevalence. Complications of DM, including diabetic ketoacidosis and hyperglycemic hyperosmolar state, often present in the emergency department requiring emergent management. Prompt assessment, diagnosis, evaluation of laboratory values, treatment, monitoring, and strict follow-up education are essential to the successful management of this complex disease. Common medications and management strategies are key elements to control DM. This article presents an overview of DM, including its prevalence, pathophysiology, presentations, and management.

Is Ketamine an Effective Treatment of Acute Agitation in the Emergency Department? Implications for APRN Practice.

This article reviews the results of a randomized controlled trial, "Rapid Agitation Control with Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial" by D. Barbic et al. (2021), comparing time to sedation, level of sedation, and adverse outcomes between intramuscular ketamine versus intramuscular midazolam and haloperidol among acutely agitated patients presenting to the emergency department (ED). The findings are discussed in the context of practice change for patient stabilization within the ED. Emergency department nurse practitioners must employ continuing education and remain current with clinical practices and treatment options to ensure that patients receive optimal safe care. Although the use of midazolam and haloperidol has historically been the first-line treatment for the acutely agitated patient, use of ketamine shows promise in providing a safe alternative for expedited patient stabilization for acutely agitated patients presenting to the ED.

Ophthalmologic Emergencies: Assessment and Management.

There are an estimated 2-3 million emergency department (ED) visits in the United States for eye complaints. Although most patients who present to the ED have nontraumatic eye complaints, many seek treatment for eye trauma, which is a leading cause of unilateral blindness and vison impairment. Given the prevalence of eye-related emergencies, it is imperative that emergency care providers understand how to recognize and treat eye complaints to prevent permanent vision loss and disability. This article covers basic eye anatomy and physiology, discusses a systematic approach to the eye examination, and presents the evidence-based treatment of selected, common nonemergent and emergent eye complaints. For each complaint, essential history questions, examination techniques, differentials, and emergency management have been presented.

Catamenial Pneumothorax: An Unusual Cause of Abdominal Pain.

A catamenial pneumothorax is a very rare condition resulting in spontaneous and recurrent pneumothoraces that occur in relationship with menses (T. Marjanski et al., 2016). Although rare, emergency providers should consider this condition when female patients present to the emergency department with chest discomfort and dyspnea during menstruation. This case describes a patient who presented to the emergency department with abdominal pain who was incidentally found to have a catamenial pneumothorax on diagnostic imaging for her complaint of acute abdominal pain.

Spontaneous Pneumothorax: Controversies in Treatment.

The Research to Practice column critiques a current research article and translates the findings, in the context of a case, to a practice change within emergency settings. This article reviews the findings of a randomized controlled trial conducted by A. Theille et al. (2017) comparing the use of needle decompression versus chest tube insertion for management of spontaneous pneumothorax. The study found that use of needle aspiration was safe and effective and was associated with fewer procedure-related complications and significantly shorter hospital stays. The investigators concluded that needle aspiration be used as a first-line, definitive treatment in management of a spontaneous pneumothorax. As emergency providers examine improved and equally effective approaches to care that are associated with less costs and potential complications, needle aspiration offers a beneficial approach and should be shared with patients when discussing treatment options to ensure shared decision making.

The Use of Activated Charcoal in Toxicology and Implications for APRN Practice.

This Research to Practice article is designed to help aid advanced practice registered nurses (APRNs) with up-to-date research guidelines in order to establish evidence-based changes in clinical practice within emergency medical care. The article, "Activated Charcoal and Poisoning: Is It Really Effective?" by Aksay et al. (2022), examines whether the usage of activated charcoal (AC) in current treatment protocols for ingested poisonings adds benefits, given recent controversies in its use. Study variables included clinical findings in relation to the drug being ingested, the frequency and usage of an antidote, the rate of being intubated, and the duration of being hospitalized comparing poisoned patients who received AC with those who did not. APRNs need to be aware of the current guidelines to help establish the appropriateness of use when administering AC and be able to evaluate patients during and after the administering of AC. Improved awareness and education regarding the different treatment modalities for toxicology patients such as AC can help with certain kinds of poisonings in the emergency department.

Strategies to Integrate the Practice of Social Emergency Medicine Into Routine Patient Care.

The Research to Practice column focuses on improving the research critique skills of advanced practice providers and to assist with the translation of research into practice. In this issue, we discuss the findings of a 2-phase, mixed-methods feasibility investigation conducted by A. S. Wallace et al. (2020) that developed and evaluated a screening process to identify social needs/risks for emergency department (ED) patients and connect them to community-based resources upon discharge. The results revealed that patients with identified social needs and referred to community resources tended to utilize the ED more than those without needs. This suggests the need for EDs to implement a standardized screening tool for social determinants of health (SDOH) on all ED patients for improved patient outcomes. Findings also highlighted a need for EDs to provide staff training and competence in the areas of patient communication and SDOH.

Management of Priapism in the Emergency Department.

Patients presenting to the emergency department with priapism require immediate evaluation and treatment. Priapism is a urological emergency that carries the risk of erectile dysfunction if not managed in a timely manner. Therefore, it is important for providers to be able to identify and manage these patients emergently. Priapism has various causes, and knowing the difference between high-flow and low-flow priapism will help determine the appropriate patient management. Although the prevalence of priapism is thought to be low, there have been increasing reports over the years linked to new drugs used for the treatment of erectile dysfunction (Roghmann et al., 2013). For this reason, it is imperative that providers understand the etiology behind the different causes of priapism. Using a case of drug-induced priapism as an exemplar, this article discusses the epidemiology, etiology, and management of priapism conditions.

The Emergency Medicine Physician Workforce: Projections for 2030.

STUDY OBJECTIVE: The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians. METHODS: To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios. RESULTS: The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030. CONCLUSION: The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

The Undertriage of Older Adults in the Emergency Department: A Review of Interventions.

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse and the emergency nurse and to assist with the translation of research into practice. A topic and a research study are selected for each column. A patient scenario is presented as a vehicle, in which to review and critique, the findings of the selected research study. In this column, we review the conclusions of A. Malinovska, L. Pitasch, N. Geigy, C. H. Nickel, and R. Bingisser (2019) from their article, titled "Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients."

Addressing Fall Risk From the Emergency Department: What Are We Missing?

The Research to Practice column focuses on improving the research critique skills of emergency nurses and advanced practice providers to assist with the translation of research into practice. In this issue, we discuss the findings of a secondary data analysis conducted by K. Davenport, M. Alazemi, J. Sri-On, and S. Liu (2020) that examined emergency department provider identification of modifiable risk factors when assessing older adults who present after a fall. The results found that providers frequently miss identifying and intervening in modifiable risk factors that contribute to adverse outcomes and readmissions following discharge. The results suggest future research needs and have implications for emergency nurse practitioner educational preparation.

Racial Bias Among Emergency Providers: Strategies to Mitigate Its Adverse Effects.

The Research to Practice column presents an analysis of current and controversial research findings with implications for practice change relevant to emergency care settings. This review critiques Johnson et al.'s (2016) investigation, titled "The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias," that examined emergency department characteristics and stressors and their effects on physician racial bias and decision making. Their findings suggest that unconscious biases can affect clinical decisions when providers experience increased cognitive stress. The implications are significant for emergency providers as resources are especially strained during the COVID-19 pandemic and as the adverse effects of unconscious bias on health disparities and patient outcomes have become clearly apparent. Implicit bias training (IBT) is recommended for emergency providers and has significant implications for medical and nurse educators in executing and evaluating IBT outcomes.

Are Antibiotics Useful in Acute Chronic Obstructive Pulmonary Disease Exacerbations? Implications for APRN Practice.

The Research to Practice column aims to provide advanced practice registered nurses (APRNs) with an analysis of current research topics with implications for practice change within emergency care settings. The article, "Antibiotics for Exacerbations of Acute Chronic Obstructive Pulmonary Disease?" conducted by D. Vollenweider, A. Frei, C. Streurer-Stey, J. Garcia-Aymerich, and M.A. Puhan (2018), examines a Cochrane systematic review and meta-analysis of randomized controlled trials. The investigators evaluate the findings that compare clinical outcomes including adverse events, re-exacerbation, treatment failure, and mortality among intensive care unit patients, inpatient, and outpatient populations treated with antibiotics or placebo medications for acute chronic obstructive pulmonary disease (COPD) exacerbations. The findings are discussed in the context of narrowing the evidence gap to improve clinical recommendations. Their findings have implications for APRN practice, including the signs and symptoms associated with an underlying bacterial triggered COPD exacerbation and the patient populations most likely to benefit from antibiotic therapy.

Death and Dying in the Emergency Department.

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and to assist with the translation of research into practice. For each column, a topic and a particular research study are selected. The stage is set with a case presentation. The research article is then reviewed and critiqued, and the findings are discussed in relation to the case presented. Our current column discusses factors associated with the quality of the death and dying experience in the emergency department (ED) from the perspective of health care providers with implications for APRN practice and strategies using the following study: . "Exploring the quality of the dying and death experience in the emergency department: An integrative literature review," International Journal of Nursing Studies, 85, 106-117. Our case involves a man with metastatic colon cancer where his oncology nurse practitioner recommends no further treatment and tells him he has approximately 6 months to live.