Characterization of Emergency Department Quality Assurance Cases Seen Within a Midwestern United States Health System.

BACKGROUND: Hospital quality-assurance (QA) processes, including peer-review committees, seek to identify high-risk areas. PURPOSE: To characterize emergency department (ED) cases sent for QA review. METHODS: A retrospective observational study was conducted of ED cases sent to a QA committee from November 2018 through July 2022 at three midwestern US hospitals. The QA records analyzed for these cases included the original incident report, case summary, and the committee determinations. RESULTS: One hundred and forty-seven cases were reviewed by the ED QA Committee. The most frequent referrals came from physicians. Common diagnostic categories included infectious (21%), cardiac (16%), gastrointestinal (11%), and neurologic (10%) concerns. Of the cases, 51% were considered nonpreventable, 33% were potentially preventable, and 9% were preventable. Inpatient boarding in the ED was explicitly implicated as a contributing factor in 6% of case reports. CONCLUSIONS: Peer physician reporting represent the largest referral source sent for review with the most frequent diagnostic categories, including infectious, cardiac, gastrointestinal, and neurological conditions. Preventable concerns were rare. IMPLICATIONS: This study provides a better understanding of the referral sources, diagnostic categories, and committee determinations in ED quality concerns. These results can target future investigations into case reporting and patient safety.

Evaluation of computed tomography perfusion and angiogram use in stroke evaluation for thrombectomy at a community emergency department setting.

PURPOSE: Evaluate concordance of provider practices with clinical guidelines for thrombectomy screening in an emergency department (ED) via computed tomography perfusion and angiogram (CT-P/A). METHODS: A retrospective observational study was conducted for patients 18 years or older who received a CT-P/A of the head and neck in a US Midwestern ED between September 2019 through June 2021. Healthcare system records reviewed for patient information, CT-P/A findings, and treatment decisions. RESULTS: During study period, 68,403 patients presented to the ED with 718 (1.1%) receiving a CT-P/A. Of these patients, 105 (14.6%) were transferred to a regional facility for potential thrombectomy, with 74 (70.5%) receiving procedure, 28 (26.7%) not receiving procedure, and 3 (2.9%) with insufficient follow-up information. Of patients receiving CT-P/A, 23 met DAWN criteria for thrombectomy, with 21 (91.3%) transferred for potential thrombectomy and 20 (95.2%) receiving the procedure; in comparison, 81 patients (11.7%) did not meet all DAWN criteria and were transferred for potential thrombectomy, with 52 (64.2%) receiving procedure. Lastly, 55 patients met DEFUSE-3 criteria for thrombectomy with 49 (89.1%) being transferred for potential thrombectomy and 45 (91.8%) receiving procedure. In comparison, 53 patients who did not meet all DEFUSE-3 criteria were transferred for potential thrombectomy, with 27 (50.9%) receiving procedure. CONCLUSIONS: This study helps to understand CT-P/A usage, especially in patients that fall outside of treatment criteria in the current thrombectomy literature. Results may have value to institutions interested in using CT-P/A as a diagnostic tool as well as institutions already incorporating it in stroke assessments.

Characteristics and retention of emergency department patients who left without being seen (LWBS).

A retrospective observational study was conducted for patients 18 years or older presenting to a Midwestern emergency department (ED) in the United States during February 2019-January 2020 to characterize associated subsequent care utilization in patients who left the ED without being seen. Patients were classified as left without being seen (LWBS) based on documented ED disposition. The healthcare system's records were reviewed for any associated utilizations within 3 weeks following the initial ED encounter. During the study period, 45,456 patients presented to the ED, with 2269 (5.0%) classified as LWBS. The median documented time until patients left the ED was 112 min. Of these patients, 1257 (55.4%) had a subsequent encounter within the health system within 3 weeks and 920 (73.2%) of these visits were determined to be related to the LWBS chief complaint. These visits included 67.5% of patients returning to ED or hospital, 27.5% to primary care or an urgent care clinic, and 5.0% to a specialty or other provider appointment. Of patients returning to ED, 78.1% did so within 72 h. Patients without a subsequent health system associated encounter tended to be younger, female, non-White, and present with possible lower-acuity chief complaints. At least one-half of LWBS patients sought care related to the concerns by a health system provider within 3 weeks of the initial encounter within the same system. The high prevalence of ED returns within a narrow turnaround window highlights a missed opportunity to provide services to these patients during their initial encounter.

Ethical issues in the access to emergency care for undocumented immigrants.

Patients who are undocumented immigrants (UIs) frequently present to emergency departments in the United States, especially in communities with large immigrant populations. Emergency physicians confront important ethical issues when providing care for these patients. This article examines those ethical issues and recommends best practices in emergency care for UIs. After a brief introduction and description of the UI population, the article proposes central principles of emergency medical ethics as a framework for emergency physician decisions and actions. It then considers the role of law and public policy in health care for UIs, including the Emergency Medical Treatment and Labor Act, the Patient Protection and Affordable Care Act, and current practices of the US Immigration and Customs Enforcement agency. The article concludes with discussion of the scope of emergency physician practice and with recommendations regarding best practices in ED care for UIs.

Ethical issues and obligations with undocumented immigrants relying on emergency departments for dialysis.

Undocumented immigrants with end-stage renal disease in the United States are uniquely disadvantaged in their ability to access dialysis. This article examines the unique circumstances of the medical condition and healthcare system, including the relevant legal and regulatory influences that largely relegate undocumented immigrants to relying on emergency-only dialysis through a hospital's Emergency Medical Treatment and Labor Act obligations. We explore the ethical implications of this current state, emphasizing the adverse effects on patients and staff alike. We also review necessary actions that range from the actions an individual emergency physician to changes needed in federal policy.

Assessing psychiatric safety in suicidal emergency department patients.

We provide a review of the assessment of suicidal emergency department patients and includes a legal and ethical perspective. Screening tools and psychiatric consultation are important adjuncts to the ED evaluation of potentially suicidal patients. Suicide risk should be assessed, and if positive, an appropriate and safe disposition should be arranged. The aim of this article is to review these assessment tools and consider ethical issues, such as patient autonomy, accountability of the emergency physician, and consultant to Emergency Medical Treatment and Labor Act (EMTALA) as well as confidentiality, privacy, and social issues.

Iejimalides A and B inhibit lysosomal vacuolar H+-ATPase (V-ATPase) activity and induce S-phase arrest and apoptosis in MCF-7 cells.

Iejimalides are novel macrolides that are cytostatic or cytotoxic against a wide range of cancer cells at low nanomolar concentrations. A recent study by our laboratory characterized the expression of genes and proteins that determine the downstream effects of iejimalide B. However, little is known about the cellular target(s) of iejimalide or downstream signaling that lead to cell-cycle arrest and/or apoptosis. Iejimalides have been shown to inhibit the activity of vacuolar H(+)-ATPase (V-ATPase) in osteoclasts, but how this inhibition may lead to cell-cycle arrest and/or apoptosis in epithelial cells is not known. In this study, MCF-7 breast cancer cells were treated with iejimalide A or B and analyzed for changes in cell-cycle dynamics, apoptosis, lysosomal pH, cytoplasmic pH, mitochondrial membrane potential, and generation of reactive oxygen species. Both iejimalides A and B sequentially neutralize the pH of lysosomes, induce S-phase cell-cycle arrest, and trigger apoptosis in MCF-7 cells. Apoptosis occurs through a mechanism that involves oxidative stress and mitochondrial depolarization but not cytoplasmic acidification. These data confirm that iejimalides inhibit V-ATPase activity in the context of epithelial tumor cells, and that this inhibition may lead to a lysosome-initiated cell death process.