Euglycemic diabetic ketoacidosis associated with SGLT2i use: Case series.

INTRODUCTION: Euglycemic diabetic ketoacidosis (EuDKA) associated with Sodium-Glucose Cotransporter-2 inhibitor (SGLT2i) use has been described but remains poorly understood. Data on Emergency Department (ED) presentation, resource utilization, and safety outcomes for these patients are lacking. We report a case series of patients diagnosed with EuDKA in the ED. METHODS: An electronic medical record search identified adult patients presenting to a large tertiary ED with EuDKA. They were screened for concurrent use of SGLT2i. Clinical presentation, resource utilization, safety, and disposition data were collected and described. RESULTS: Five patients were included for analysis. Median age [range] was 57 [43-73] years. Presenting symptoms included nausea, vomiting, fatigue, and altered mental status. Initial results included: serum glucose 191 mg/dL [176-215], venous pH 7.01 [6.95-7.30], serum HCO3 8 mEq/L [6-13], anion gap 27 [26-31], serum beta-hydroxybutyrate 9.9 mmol/L [9.2-12.3], and urine ketones 150 [150-150]. Patients remained on an insulin infusion for 18.77 h [11.25-56.48]. There were zero episodes of hypoglycemia and one episode of hypokalemia while on insulin infusion. Time to resolution of metabolic acidosis was 23.82 h [15.45-24.77]. DISCUSSION: We report a case series of ED patients with EuDKA associated with SGLT2i use, and describe presentation characteristics, resource utilization, and safety outcomes. Emergency physicians should be aware of the association between SGLT2i use and EuDKA. An appropriate work-up should be pursued for patients taking an SGLT2i who present with symptoms suggestive of DKA, including nausea, vomiting, malaise, and altered mental status, or are noted to have an unexplained elevated anion gap metabolic acidosis.

The Inpatient Discharge Lounge as a Potential Mechanism to Mitigate Emergency Department Boarding and Crowding.

Delayed access to inpatient beds for admitted patients contributes significantly to emergency department (ED) boarding and crowding, which have been associated with deleterious patient safety effects. To expedite inpatient bed availability, some hospitals have implemented discharge lounges, allowing discharged patients to depart their inpatient rooms while awaiting completion of the discharge process or transportation. This conceptual article synthesizes the evidence related to discharge lounge implementation practices and outcomes. Using a conceptual synthesis approach, we reviewed the medical and gray literature related to discharge lounges by querying PubMed, Google Scholar, and Google and undertaking backward reference searching. We screened for articles either providing detailed accounts of discharge lounge implementations or offering conceptual analysis on the subject. Most of the evidence we identified was in the gray literature, with only 3 peer-reviewed articles focusing on discharge lounge implementations. Articles generally encompassed single-site descriptive case studies or expert opinions. Significant heterogeneity exists in discharge lounge objectives, features, and apparent influence on patient flow. Although common barriers to discharge lounge performance have been documented, including underuse and care team objections, limited generalizable solutions are offered. Overall, discharge lounges are widely endorsed as a mechanism to accelerate access to inpatient beds, yet the limited available evidence indicates wide variation in design and performance. Further rigorous investigation is required to identify the circumstances under which discharge lounges should be deployed, and how discharge lounges should be designed to maximize their effect on hospitalwide patient flow, ED boarding and crowding, and other targeted outcomes.

Hospital Capacity Command Centers: A Benchmarking Survey on an Emerging Mechanism to Manage Patient Flow.

BACKGROUND: Delayed hospital and emergency department (ED) patient throughput, which occurs when demand for inpatient care exceeds hospital capacity, is a critical threat to safety, quality, and hospital financial performance. In response, many hospitals are deploying capacity command centers (CCCs), which co-locate key work groups and aggregate real-time data to proactively manage patient flow. Only a narrow body of peer-reviewed articles have characterized CCCs to date. To equip health system leaders with initial insights into this emerging intervention, the authors sought to survey US health systems to benchmark CCC motivations, design, and key performance indicators. METHODS: An online survey on CCC design and performance was administered to members of a hospital capacity management consortium, which included a convenience sample of capacity leaders at US health systems (N = 38). Responses were solicited through a targeted e-mail campaign. Results were summarized using descriptive statistics. RESULTS: The response rate was 81.6% (31/38). Twenty-five respondents were operating CCCs, varying in scope (hospital, region of a health system, or entire health system) and number of beds managed. The most frequent motivation for CCC implementation was reducing ED boarding (n = 24). The most common functions embedded in CCCs were bed management (n = 25) and interhospital transfers (n = 25). Eighteen CCCs (72.0%) tracked financial return on investment (ROI); all reported positive ROI. CONCLUSION: This survey addresses a gap in the literature by providing initial aggregate data for health system leaders to consider, plan, and benchmark CCCs. The researchers identify motivations for, functions in, and key performance indicators used to assess CCCs. Future research priorities are also proposed.

Use of Hospital Capacity Command Centers to Improve Patient Flow and Safety: A Scoping Review.

OBJECTIVES: Delayed emergency department (ED) and hospital patient throughput is recognized as a critical threat to patient safety. Increasingly, hospitals are investing significantly in deploying command centers, long used in airlines and the military, to proactively manage hospital-wide patient flow. This scoping review characterizes the evidence related to hospital capacity command centers (CCCs) and synthesizes current data regarding their implementation. METHODS: As no consensus definition exists for CCCs, we characterized them as units (i) involving interdisciplinary, permanently colocated teams, (ii) using real-time data, and (iii) managing 2 or more patient flow functions (e.g., bed management, transfers, discharge planning, etc.), to distinguish CCCs from transfer centers. We undertook a scoping review of the medical and gray literature published through April 2019 related to CCCs meeting these criteria. RESULTS: We identified 8 eligible articles (including 4 peer-reviewed studies) describing 7 CCCs of varying designs. The most common CCC outcome measures related to transfer volume (n = 5) and ED boarding (n = 4). Several CCCs also monitored patient-level clinical parameters. Although all articles reported performance improvements, heterogeneity in CCC design and evidence quality currently restricts generalizability of findings. CONCLUSIONS: Numerous anecdotal accounts suggest that CCCs are being widely deployed in an effort to improve hospital patient flow and safety, yet peer-reviewed evidence regarding their design and effectiveness is in its earliest stages. The costs, objectives, and growing deployment of CCCs merit an investment in rigorous research to better measure their processes and outcomes. We propose a standard definition, conceptual framework, research priorities, and reporting standards to guide future investigation of CCCs.

Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact.

Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub-optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs-which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage-are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer-reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work-ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors-including the co-existence of other front-end interventions and delays in ED throughput not addressed by PIT-we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site-specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision-makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.

Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy.

BACKGROUND: Despite significant advances, patient safety remains a critical public health concern. Daily huddles-discussions to identify and respond to safety risks-have been credited with enhancing safety culture in operationally complex industries including aviation and nuclear power. More recently, huddles have been endorsed as a mechanism to improve patient safety in healthcare. This review synthesises the literature related to the impact of hospital-based safety huddles. METHODS: We conducted a systematic review of peer-reviewed literature related to scheduled, multidisciplinary, hospital-based safety huddles through December 2019. We screened for studies (1) in which huddles were the primary intervention being assessed and (2) that measured the huddle programme's apparent impact using at least one quantitative metric. RESULTS: We identified 1034 articles; 24 met our criteria for review, of which 19 reflected unit-based huddles and 5 reflected hospital-wide or multiunit huddles. Of the 24 included articles, uncontrolled pre-post comparison was the prevailing study design; we identified only two controlled studies. Among the 12 unit-based studies that provided complete measures of statistical significance for reported outcomes, 11 reported statistically significant improvement among some or all outcomes. The objectives of huddle programmes and the language used to describe them varied widely across the studies we reviewed. CONCLUSION: While anecdotal accounts of successful huddle programmes abound and the evidence we reviewed appears favourable overall, high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles, particularly at the hospital-wide level, is in its earliest stages. Additional rigorous research-especially focused on huddle programme design and implementation fidelity-would enhance the collective understanding of how huddles impact patient safety and other targeted outcomes. We propose a taxonomy and standardised reporting measures for future huddle-related studies to enhance comparability and evidence quality.