Fewer emergency department alarms is associated with reduced use of medications for acute agitation.

BACKGROUND AND OBJECTIVES: Patient monitoring systems provide critical information but often produce loud, frequent alarms that worsen patient agitation and stress. This may increase the use of physical and chemical restraints with implications for patient morbidity and autonomy. This study analyzes how augmenting alarm thresholds affects the proportion of alarm-free time and the frequency of medications administered to treat acute agitation. METHODS: Our emergency department's patient monitoring system was modified on June 28, 2022 to increase the tachycardia alarm threshold from 130 to 150 and to remove alarm sounds for several arrhythmias, including bigeminy and premature ventricular beats. A pre-post study was performed lasting 55 days before and 55 days after this intervention. The primary outcome was change in number of daily patient alarms. The secondary outcomes were alarm-free time per day and median number of antipsychotic and benzodiazepine medications administered per day. The safety outcome was the median number of patients transferred daily to the resuscitation area. We used quantile regression to compare outcomes between the pre- and post-intervention period and linear regression to correlate alarm-free time with the number of sedating medications administered. RESULTS: Between the pre- and post-intervention period, the median number of alarms per day decreased from 1332 to 845 (-37%). This was primarily driven by reduced low-priority arrhythmia alarms from 262 to 21 (-92%), while the median daily census was unchanged (33 vs 32). Median hours per day free from alarms increased from 1.0 to 2.4 (difference 1.4, 95% CI 0.8-2.1). The median number of sedating medications administered per day decreased from 14 to 10 (difference - 4, 95% CI -1 to -7) while the number of escalations in level of care to our resuscitation care area did not change significantly. Multivariable linear regression showed a 60-min increase of alarm-free time per day was associated with 0.8 (95% CI 0.1-1.4) fewer administrations of sedating medication while an additional patient on the behavioral health census was associated with 0.5 (95% CI 0.0-1.1) more administrations of sedating medication. CONCLUSION: A reasonable change in alarm parameter settings may increase the time patients and healthcare workers spend in the emergency department without alarm noise, which in this study was associated with fewer doses of sedating medications administered.

CT utilization in evaluation of skin and soft tissue extremity infections in the ED: Retrospective cohort study.

OBJECTIVE: Skin and soft tissue infections (SSTI) are commonly diagnosed in the emergency department (ED). While most SSTI are diagnosed with patient history and physical exam alone, ED clinicians may order CT imaging when they suspect more serious or complicated infections. Patients who inject drugs are thought to be at higher risk for complications from SSTI and may undergo CT imaging more frequently. The objective of this study is to characterize CT utilization when evaluating for SSTI in ED patients particularly in patients with intravenous drug use (IVDU), the frequency of significant and actionable findings from CT imaging, and its impact on subsequent management and ED operations. METHODS: We performed a retrospective analysis of encounters involving a diagnosis of SSTI in seven EDs across an integrated health system between October 2019 and October 2021. Descriptive statistics were used to assess overall trends, compare CT utilization frequencies, actionable imaging findings, and surgical intervention between patients who inject drugs and those who do not. Multivariable logistic regression was used to analyze patient factors associated with higher likelihood of CT imaging. RESULTS: There were 4833 ED encounters with an ICD-10 diagnosis of SSTI during the study period, of which 6% involved a documented history of IVDU and 30% resulted in admission. 7% (315/4833) of patients received CT imaging, and 22% (70/315) of CTs demonstrated evidence of possible deep space or necrotizing infections. Patients with history of IVDU were more likely than patients without IVDU to receive a CT scan (18% vs 6%), have a CT scan with findings suspicious for deep-space or necrotizing infection (4% vs 1%), and undergo surgical drainage in the operating room within 48 h of arrival (5% vs 2%). Male sex, abnormal vital signs, and history of IVDU were each associated with higher likelihood of CT utilization. Encounters involving CT scans had longer median times to ED disposition than those without CT scans, regardless of whether these encounters resulted in admission (9.0 vs 5.5 h), ED observation (5.5 vs 4.1 h), or discharge (6.8 vs 2.9 h). DISCUSSION: ED clinicians ordered CT scans in 7% of encounters when evaluating for SSTI, most frequently in patients with abnormal vital signs or a history of IV drug use. Patients with a history of IVDU had higher rates of CT findings suspicious for deep space infections or necrotizing infections and higher rates of incision and drainage procedures in the OR. While CT scans significantly extended time spent in the ED for patients, this appeared justified by the high rate of actionable findings found on imaging, particularly for patients with a history of IVDU.

Evaluation of a COVID-19 emergency department observation protocol.

OBJECTIVES: Caring for patients with COVID-19 has resulted in a considerable strain on hospital capacity. One strategy to mitigate crowding is the use of ED-based observation units to care for patients who may have otherwise required hospitalization. We sought to create a COVID-19 Observation Protocol for our ED Observation Unit (EDOU) for patients with mild to moderate COVID-19 to allow emergency physicians (EP) to gather more data for or against admission and intervene in a timely manner to prevent clinical deterioration. METHODS: This was a retrospective cohort study which included all patients who were positive for SARS-CoV-2 at the time of EDOU placement for the primary purpose of monitoring COVID-19 disease. Our institution updated the ED Observation protocol partway into the study period. Descriptive statistics were used to characterize demographics. We assessed for differences in demographics, clinical characteristics, and outcomes between admitted and discharged patients. Multivariate logistic regression models were used to assess whether meeting criteria for the ED observation protocols predicted disposition. RESULTS: During the time period studied, 120 patients positive for SARS-CoV-2 were placed in the EDOU for the primary purpose of monitoring COVID-19 disease. The admission rate for patients in the EDOU during the study period was 35%. When limited to patients who met criteria for version 1 or version 2 of the protocol, this dropped to 21% and 25% respectively. Adherence to the observation protocol was 62% and 60% during the time of version 1 and version 2 implementation, respectively. Using a multivariate logistic regression, meeting criteria for either version 1 (OR = 3.17, 95% CI 1.34-7.53, p < 0.01) or version 2 (OR = 3.18, 95% CI 1.39-7.30, p < 0.01) of the protocol resulted in a higher likelihood of discharge. There was no difference in EDOU LOS between admitted and discharged patients. CONCLUSION: An ED observation protocol can be successfully created and implemented for COVID-19 which allows the EP to determine which patients warrant hospitalization. Meeting protocol criteria results in an acceptable admission rate.

Level-loading a health system by transferring emergency department patients to a community hospital: Prospective cohort study.

BACKGROUND: Emergency department boarding and crowding lead to worse patient outcomes and patient satisfaction. OBJECTIVE: We describe the implementation of a program to transfer patients requiring medical admission from an academic emergency department to a community hospital's medical floor and analyze its effects on patient outcomes. METHODS: A prospective cohort study was performed. Data was collected on patient flow through the transfer program. Patient characteristics, boarding time in the emergency department, and hospital-based outcome measures were compared between patients in the transfer program who were successfully transferred to the community hospital and patients who were admitted to the academic medical center. RESULTS: 79 patients were successfully transferred to the community hospital between November 23, 2020 and August 5, 2021, resulting in 279 bed days in the community hospital. Successfully transferred patients experienced a statistically shorter ED boarding time (5.7 vs. 10.9 h, p < 0.0001), ED length of stay (10.5 vs 16.1 h, p < 0.0001), and hospital length of stay (3.5 vs 5.7 days, p < 0.0001) compared to patients initially referred to the transfer program who were admitted to the academic medical center. There were no reported adverse events during transfer, upgrades to the ICU within 24 h of admission, or inpatient deaths for patients who were transferred. CONCLUSION: We implemented an academic emergency department to partner community hospital transfer program that safely level-loads medical patients in a healthcare system.

Impact of iodinated contrast allergies on emergency department operations.

OBJECTIVES: Adverse reactions to intravenous (IV) iodinated contrast media are classified by the American College of Radiology (ACR) Manual on Contrast Media as either allergic-like (ALR) or physiologic (PR). Premedication may be beneficial for patients who have prior documented mild or moderate ALR. We sought to perform a retrospective analysis of patients who received computed tomography (CT) imaging in our emergency department (ED) to establish whether listing of an iodinated contrast media allergy results in a delay in care, increases the use of non-contrast studies, and to quantify the incidence of listing iodinated contrast allergies which do not necessitate premedication. METHODS: We performed a retrospective analysis of CT scans performed in our academic medical center ED during a 6-month period. There were 12,737 unique patients of whom 454 patients had a listed iodinated contrast allergy. Of these, 106 received IV contrast and were categorized as to whether premedication was necessary. Descriptive statistics were used to evaluate patient demographics, clinical characteristics, and operational outcomes. A multivariate linear regression model was used to predict time from order to start (OTS time) of CT imaging while controlling for co-variates. RESULTS: Non-allergic patients underwent contrast-enhanced CT imaging at a significantly higher rate than allergic patients (45.9% vs. 23.3%, p < 0.01). The OTS time for allergic patients who underwent contrast-enhanced CT imaging was 360 min and significantly longer than the OTS time for non-allergic patients who underwent contrast-enhanced CT imaging (118 min, p < 0.001). Of the 106 allergic patients who underwent contrast-enhanced CT imaging, 27 (25.5%) did not meet ACR criteria for necessitating premedication. The average OTS time for these 27 patients was 296 min, significantly longer than the OTS for non-allergic patients (118 min, p < 0.01) and did not differ from the OTS time for the 79 patients who did meet premedication criteria (382 min, p = 0.23). A multivariate linear regression showed that OTS time was significantly longer if a contrast allergy was present (p < 0.001). CONCLUSION: A chart-documented iodinated contrast allergy resulted in a significant increase in time to obtain a contrast-enhanced CT study. This delay persisted among patients who did not meet ACR criteria for premedication. Appropriately deferring premedication could potentially reduce the ED length-of-stay by over 4 h for these patients.

COVID-19 Seroprevalence in ED Health Care Professionals Study: A Cross-Sectional Study.

INTRODUCTION: ED health care professionals are at the frontline of evaluation and management of patients with acute, and often undifferentiated, illness. During the initial phase of the SARS-CoV-2 outbreak, there were concerns that ED health care professionals may have been at increased risk of exposure to SARS-CoV-2 due to difficulty in early identification of patients. This study assessed the seroprevalence of SARS-CoV-2 antibodies among ED health care professionals without confirmed history of COVID-19 infection at a quaternary academic medical center. METHODS: This study used a cross-sectional design. An ED health care professional was deemed eligible if they had worked at least 4 shifts in the adult emergency department from April 1, 2020, through May 31, 2020, were asymptomatic on the day of blood draw, and were not known to have had prior documented COVID-19 infection. The study period was December 17, 2020, to January 27, 2021. Eligible participants completed a questionnaire and had a blood sample drawn. Samples were run on the Roche Cobas Elecsys Anti-SARS-CoV-2 antibody assay. RESULTS: Of 103 health care professionals (16 attending physicians, 4 emergency residents, 16 advanced practice professionals, and 67 full-time emergency nurses), only 3 (2.9%; exact 95% CI, 0.6%-8.3%) were seropositive for SARS-CoV-2 antibodies. DISCUSSION: At this quaternary academic medical center, among those who volunteered to take an antibody test, there was a low seroprevalence of SARS-CoV-2 antibodies among ED clinicians who were asymptomatic at the time of blood draw and not known to have had prior COVID-19 infection.

The cases not seen: Patterns of emergency department visits and procedures in the era of COVID-19.

OBJECTIVE: Prior data suggest Emergency Department (ED) visits for many emergency conditions decreased during the initial COVID-19 surge. However, the pandemic's impact on the wide range of conditions seen in EDs, and the resources required for treating them, has been less studied. We sought to provide a comprehensive analysis of ED visits and associated resource utilization during the initial COVID-19 surge. METHODS: We performed a retrospective analysis from 5 hospitals in a large health system in Massachusetts, comparing ED encounters from 3/1/2020-4/30/2020 to identical weeks from the prior year. Data collected included demographics, ESI, diagnosis, consultations ordered, bedside procedures, and inpatient procedures within 48 h. We compared raw frequencies between time periods and calculated incidence rate ratios. RESULTS: ED volumes decreased by 30.9% in 2020 compared to 2019. Average acuity of ED presentations increased, while most non-COVID-19 diagnoses decreased. The number and incidence rate of all non-critical care ED procedures decreased, while the occurrence of intubations and central lines increased. Most subspecialty consultations decreased, including to psychiatry, trauma surgery, and cardiology. Most non-elective procedures related to ED encounters also decreased, including craniotomies and appendectomies. CONCLUSION: Our health system experienced decreases in nearly all non-COVID-19 conditions presenting to EDs during the initial phase of the pandemic, including those requiring specialty consultation and urgent inpatient procedures. Findings have implications for both public health and health system planning.

World Health Organization Surgical Safety Checklist Modification: Do Changes Emphasize Communication and Teamwork?

BACKGROUND: The World Health Organization's (WHO) surgical safety checklist is meant to be customized to facilitate local implementation, encourage full-team participation, and promote a culture of safety. Although it has been globally adopted, little is known about the extent of checklist modification and the type of changes made. METHODS: Nonsubspecialty surgical checklists were obtained through online search and targeted hospital requests. A detailed coding scheme was created to capture modifications to checklist content and formatting. Descriptive statistics were performed. RESULTS: Of 155 checklists analyzed, all were modified. Compared with the WHO checklist, those in our sample contained more lines of text (median: 63 [interquartile range: 50-73] versus 56) and items (36 [interquartile range: 30-43] versus 28). A median of 13 new items were added. Items most frequently added included implants/special equipment (added by 84%), deep vein thrombosis prophylaxis/anticoagulation (added by 75%), and positioning (added by 63%). Checklists removed a median of 5 WHO items. The most frequently removed item was the pulse oximeter check (removed in 75%), followed by 4 items (each removed in 39%-48%) that comprise part of the WHO Checklist's "Anticipated Critical Events" section, which is intended for exchanging critical information. The surgeon was not explicitly mentioned in the checklist in 12%; the anesthesiologist/certified registered nurse anesthetist in 14%, the circulator in 10%, and the surgical tech/scrub in 79%. CONCLUSIONS: Checklists are highly modified but often enlarged with items that may not prompt discussion or teamwork. Of concern is the frequent removal of items from the WHO's "Anticipated Critical Events" section.

External validation of the diffuse intrinsic pontine glioma survival prediction model: a collaborative report from the International DIPG Registry and the SIOPE DIPG Registry.

We aimed to perform external validation of the recently developed survival prediction model for diffuse intrinsic pontine glioma (DIPG), and discuss its utility. The DIPG survival prediction model was developed in a cohort of patients from the Netherlands, United Kingdom and Germany, registered in the SIOPE DIPG Registry, and includes age <3 years, longer symptom duration and receipt of chemotherapy as favorable predictors, and presence of ring-enhancement on MRI as unfavorable predictor. Model performance was evaluated by analyzing the discrimination and calibration abilities. External validation was performed using an unselected cohort from the International DIPG Registry, including patients from United States, Canada, Australia and New Zealand. Basic comparison with the results of the original study was performed using descriptive statistics, and univariate- and multivariable regression analyses in the validation cohort. External validation was assessed following a variety of analyses described previously. Baseline patient characteristics and results from the regression analyses were largely comparable. Kaplan-Meier curves of the validation cohort reproduced separated groups of standard (n = 39), intermediate (n = 125), and high-risk (n = 78) patients. This discriminative ability was confirmed by similar values for the hazard ratios across these risk groups. The calibration curve in the validation cohort showed a symmetric underestimation of the predicted survival probabilities. In this external validation study, we demonstrate that the DIPG survival prediction model has acceptable cross-cohort calibration and is able to discriminate patients with short, average, and increased survival. We discuss how this clinico-radiological model may serve a useful role in current clinical practice.

The international diffuse intrinsic pontine glioma registry: an infrastructure to accelerate collaborative research for an orphan disease.

Diffuse intrinsic pontine glioma (DIPG), a rare, often fatal childhood brain tumor, remains a major therapeutic challenge. In 2012, investigators, funded by the DIPG Collaborative (a philanthropic partnership among 29 private foundations), launched the International DIPG Registry (IDIPGR) to advance understanding of DIPG. Comprised of comprehensive deidentified but linked clinical, imaging, histopathological, and genomic repositories, the IDIPGR uses standardized case report forms for uniform data collection; serial imaging and histopathology are centrally reviewed by IDIPGR neuro-radiologists and neuro-pathologists, respectively. Tissue and genomic data, and cell cultures derived from autopsies coordinated by the IDIPGR are available to investigators for studies approved by the Scientific Advisory Committee. From April 2012 to December 2016, 670 patients diagnosed with DIPG have been enrolled from 55 participating institutions in the US, Canada, Australia and New Zealand. The radiology repository contains 3558 studies from 448 patients. The pathology repository contains tissue on 81 patients with another 98 samples available for submission. Fresh DIPG tissue from seven autopsies has been sent to investigators to develop primary cell cultures. The bioinformatics repository contains next-generation sequencing data on 66 tumors. Nine projects using data/tissue from the IDIPGR by 13 principle investigators from around the world are now underway. The IDIPGR, a successful alliance among philanthropic agencies and investigators, has developed and maintained a highly collaborative, hypothesis-driven research infrastructure for interdisciplinary and translational projects in DIPG to improve diagnosis, response assessment, treatment and outcome for patients.

Development of the SIOPE DIPG network, registry and imaging repository: a collaborative effort to optimize research into a rare and lethal disease.

Diffuse intrinsic pontine glioma (DIPG) is a rare and deadly childhood malignancy. After 40 years of mostly single-center, often non-randomized trials with variable patient inclusions, there has been no improvement in survival. It is therefore time for international collaboration in DIPG research, to provide new hope for children, parents and medical professionals fighting DIPG. In a first step towards collaboration, in 2011, a network of biologists and clinicians working in the field of DIPG was established within the European Society for Paediatric Oncology (SIOPE) Brain Tumour Group: the SIOPE DIPG Network. By bringing together biomedical professionals and parents as patient representatives, several collaborative DIPG-related projects have been realized. With help from experts in the fields of information technology, and legal advisors, an international, web-based comprehensive database was developed, The SIOPE DIPG Registry and Imaging Repository, to centrally collect data of DIPG patients. As for April 2016, clinical data as well as MR-scans of 694 patients have been entered into the SIOPE DIPG Registry/Imaging Repository. The median progression free survival is 6.0 months (95% Confidence Interval (CI) 5.6-6.4 months) and the median overall survival is 11.0 months (95% CI 10.5-11.5 months). At two and five years post-diagnosis, 10 and 2% of patients are alive, respectively. The establishment of the SIOPE DIPG Network and SIOPE DIPG Registry means a paradigm shift towards collaborative research into DIPG. This is seen as an essential first step towards understanding the disease, improving care and (ultimately) cure for children with DIPG.