Improving management of hyponatraemia by increasing urine testing in the emergency department.

Hyponatraemia on hospital admission is associated with increased length of stay, healthcare expenditures and mortality. Urine studies collected before fluid or diuretic administration are essential to diagnose the underlying cause of hyponatraemia, thereby empowering admitting teams to employ the appropriate treatment. A multidisciplinary quality improvement (QI) team led by internal medicine residents performed a QI project from July 2020 through June 2021 to increase the rate of urine studies collected before fluid or diuretic administration in the emergency department (ED) in patients admitted with moderate to severe hyponatraemia. We implemented two plan-do-study-act (PDSA) cycles to address this goal. In PDSA Cycle #1, we displayed an educational poster in employee areas of the ED and met with nursing staff at their monthly meetings to communicate the project and answer questions. We also obtained agreement from ED attending physicians and nursing leaders to support the project. In PDSA Cycle #2, we implemented a structural change in the nursing triage process to issue every patient who qualified for bloodwork with a urine specimen container labelled with a medical record number on registration so that the patient could provide a sample at any point, including while in the waiting area. After PDSA Cycle #1, urine specimen collection increased from 34.5% to 57.5%. After PDSA Cycle #2, this increased further to 59%. We conclude that a combination of educational and structural changes led to a significant increase in urine specimen collection before fluid or diuretic administration among patients presenting with moderate-to-severe hyponatraemia in the ED.

Association of Early Serum Phosphate Levels and Mortality in Patients with Sepsis.

BACKGROUND: Metabolic derangements in sepsis influence phosphate levels, which may predict mortality outcomes. We investigated the association between initial phosphate levels and 28-day mortality in patients with sepsis. METHODS: We conducted a retrospective analysis of patients with sepsis. Initial (first 24 hours) phosphate levels were divided into phosphate quartile groups for comparisons. We used repeated-measures mixed-models to assess differences in 28-day mortality across the phosphate groups, adjusting for other predictors identified by the Least Absolute Shrinkage and Selection Operator variable selection technique. RESULTS: A total of 1,855 patients were included with 13% overall 28-day mortality (n=237). The highest phosphate quartile (>4.0 milligrams per deciliter [mg/dL]) had a higher mortality rate (28%) than the three lower quartiles (P<0.001). After adjustment (age, organ failure, vasopressor administration, liver disease), the highest initial phosphate was associated with increased odds of 28-day mortality. Patients in the highest phosphate quartile had 2.4 times higher odds of death than the lowest (≤2.6 mg/dL) quartile (P<0.01), 2.6 times higher than the second (2.6-3.2 mg/dL) quartile (P<0.01), and 2.0 times higher than the third (3.2-4.0 mg/dL) quartile (P=0.04). CONCLUSION: Septic patients with the highest phosphate levels had increased odds of mortality. Hyperphosphatemia may be an early indicator of disease severity and risk of adverse outcomes from sepsis.

Acute Herpes Zoster Radiculopathy of the Lower Extremity With Dermatomal Rash and Lumbar Nerve Enhancement on MRI.

Herpes zoster is a frequent cause of neuralgia and dermatomal vesicular rash secondary to reactivation of latent varicella zoster virus. However, it rarely presents with acute lumbar radiculopathy and the diagnosis can be quite challenging in such cases. Nerve signal abnormalities on magnetic resonance imaging are well recognized in herpes zoster neuropathy or plexopathy affecting the extremities, although gadolinium enhancement is characteristically absent. In this article, we describe a case of acute herpes zoster lumbosacral radiculopathy with characteristic vesicular dermatomal rash and second ever reported finding of gadolinium enhancement of the lumbar nerve on magnetic resonance imaging.

Sepsis and Shock Response Team: Impact of a Multidisciplinary Approach to Implementing Surviving Sepsis Campaign Guidelines and Surviving the Process.

The Surviving Sepsis Campaign guidelines are designed to decrease mortality through consistent application of a 7-element bundle. This study evaluated the impact of improvement in bundle adherence using a time-series analysis of compliance with the bundle elements before and after interventions intended to improve the process, while also looking at hospital mortality. This article describes interventions used to improve bundle compliance and hospital mortality in patients admitted through the emergency department with sepsis, severe sepsis, or septic shock. Quality improvement methodology was used to develop high-impact interventions that led to dramatically improved adherence to the Surviving Sepsis Campaign guidelines bundle. Improved performance was associated with a significant decrease in the in-hospital mortality of severe sepsis patients presenting to the emergency department.

Cocaine use in elder patients presenting to an inner-city emergency department.

OBJECTIVES: To determine the prevalence of cocaine use in a population of elder patients presenting to an inner-city academic emergency department (ED). METHODS: This was a prospective, blinded observational study of patients aged 60 years or older who presented to a large urban ED over a six-month period. A urine drug screen was performed on patients who had a sample obtained during treatment for routine analysis. Patients' demographic data were collected and compared. RESULTS: A total of 5,677 visits met the inclusion criteria. Urine samples were obtained in 911 (16%) of these visits with 852 unique individuals. There were 18 cocaine-positive results among the 911 visits, for a rate of 2.0%. The rate of positive subjects was also 2.0% (17/852). The cocaine users were younger (66.4 +/- 7.2 vs. 76.0 +/- 8.7 years), predominantly male (88.9% vs. 46.6%), and more likely to be diagnosed with drug or alcohol abuse as compared with the cocaine-negative patients. However, there were no significant differences in disposition between the cocaine-positive and cocaine-negative groups. CONCLUSIONS: Elder patients may have a higher prevalence of cocaine use than previously estimated by national registries.