Spontaneous Expulsive Suprachoroidal Hemorrhage.

BACKGROUND: Spontaneous Expulsive Suprachoroidal Hemorrhage (SESCH) is an extremely rare phenomenon that leads to atraumatic spontaneous globe rupture. Only a handful of SESCH cases have been reported worldwide, primarily in developing countries. Risk factors associated with SESCH include uncontrolled hypertension, previous eye surgery, glaucoma, atherosclerosis, advanced age, and corneal damage. CASE REPORT: We report a case of expulsive suprachoroidal hemorrhage in a ninety-seven-year-old female. The patient presented to the emergency department with painful bleeding from her right eye. She denied any trauma or injury to the eye. She denied any use of anticoagulation. Physical examination showed a right ocular hematoma with mild active bleeding. She had exophthalmos and proptosis with extrusion of the ocular structures. A computed tomography scan of the orbits demonstrated right globe rupture with diffuse hemorrhage. Ophthalmology was consulted, and the patient subsequently had an evisceration of her right eye. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous expulsive choroidal hemorrhage is exceedingly rare. SESCH predominantly affects diseased eyes in the elderly. Early recognition of impending globe rupture in patients who present with suprachoroidal hemorrhage is necessary and requires prompt ophthalmology consultation. Emergency physicians must be aware that an atraumatic open globe can occur and requires immediate evaluation by an ophthalmologist and emergent repair in the operating suite.

Improving Discharge Outcomes by Using a Standardized Risk Assessment and Intervention Tool Facilitated by Advanced Pediatric Providers.

OBJECTIVES: Pediatric discharge from the inpatient setting is a complex, error-prone process. In this study, we evaluated the outcomes of using a standardized process for hospital discharge of pediatric patients. METHODS: A 1-year pre- and postintervention pilot study was designed to improve discharge transition of care. The bundle intervention, facilitated by advanced practice providers, included risk identification and intervention. Process and outcome metrics included patient satisfaction measures on the discharge domain (overall discharge, speed of discharge process, whether they felt ready for discharge), use of handouts, scheduling of follow-up appointments, and postdischarge phone call. RESULTS: Significant improvements were found in all aspects of patient satisfaction, including speed of the discharge process and instructions for discharge, discharge readiness, and the overall discharge process. Length of stay decreased significantly after intervention. The checklist identified ∼4% of discharges without a correct primary care physician. Significant differences were found for scheduled primary care appointment before discharge and patients receiving handouts. The bundle identified risks that may complicate transition of care in approximately half of the patients. Phone communication occurred with almost half of the patients after discharge. CONCLUSIONS: Integration of an evidence-based discharge checklist can improve processes, increase delivery of patient education, and improve patient and family perceptions of the discharge process. Involvement of key stakeholders, use of evidence-based interventions with local adaptation, and use of a consistent provider responsible for implementation can improve transitions of care.