Developing a Medical Scribe Program at an Academic Hospital: The Hennepin County Medical Center Experience.

BACKGROUND: Medical scribes are frequently incorporated into the patient care model to improve provider efficiency and enable providers to refocus their attention to the patient rather than the electronic health record (EHR). The medical scribe program was based on four pillars (objectives): (1) provider satisfaction, (2) standardized documentation, (3) documentation components for risk adjustment, and (4) revenue enhancement. METHODS: The medical scribe program was deployed in nine non-resident-supported clinics (internal medicine, ophthalmology, orthopedics, hematology/oncology, urology), with the medical scribes (who have no clinical duties) supporting both physicians and advanced practice providers (nurse practitioners and physician assistants). This paper describes a prospective quasi-experimental study conducted at an academic, inner-city, hospital-based clinic system, RESULTS: A pre-post analysis showed positive results; of the 51 providers, 44 responded to the survey pre and 41 responded post. Respondents in the post-scribe group felt that a scribe was valuable (90.2%), that documentation time at the office improved (75.0% poor or marginal pre-scribe, vs. 24% post; p <0.0001), and that time spent on the EHR at home declined (63.6% with excessive or moderately high home EHR time pre vs. 31.7% post; p = 0.003). More providers felt satisfied with their role in clinic with the use of scribes, and more providers felt that with scribes they could listen sufficiently to patients (p <0.05). CONCLUSION: Scribe support was well received across the institution in multiple clinical settings. Benefits for providers were seen in documentation time and ability to listen to patients. Scribes appear to be an effective intervention for improving clinician work life.

Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure.

BACKGROUND: The King LT airway (King Systems, Noblesville, IN) is a popular extraglottic device that is widely used in the prehospital setting. We report a case of tracheal malplacement of the King airway with a severe kink in the distal tube. CASE REPORT: A 51-year-old unhelmeted motorcyclist collided with a freeway median and was obtunded when paramedics arrived. After bag mask ventilation, a King airway was placed uneventfully and the patient was transported to the emergency department. Because of the concern for an unstable cervical spine injury, a lateral cervical spine radiograph was obtained on arrival. No cervical injury was seen, but the King airway was noted to be malplaced; the King airway passed through the laryngeal inlet and became lodged on the anterior trachea, creating an acute kink between the two balloons. After reviewing the radiograph, ventilations were reassessed and remained adequate. Both balloons were deflated, and the King airway was removed; the patient was orotracheally intubated without complication. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The King airway is a valuable prehospital airway that can be placed quickly and blindly with high success rates by inexperienced providers; the King airway, however, is not without complication. Ventilation was not impaired in this patient, but tracheal malplacement may be an important cause of prehospital device failure. If a first placement attempt of a King airway device fails, it is reasonable to reattempt King airway placement with a new, unkinked device before abandoning King airway placement.

Tetrodotoxin poisoning outbreak from imported dried puffer fish--Minneapolis, Minnesota, 2014.

On June 13, 2014, two patients went to the Hennepin County Medical Center Emergency Department in Minneapolis, Minnesota, with symptoms suggestive of tetrodotoxin poisoning (i.e., oral paresthesias, weakness, and dyspnea) after consuming dried puffer fish (also known as globefish) purchased during a recent visit to New York City. The patients said two friends who consumed the same fish had similar, although less pronounced, symptoms and had not sought care. The Minnesota Department of Health conducted an investigation to determine the source of the product and samples were sent to the Food and Drug Administration (FDA) Center for Food Safety and Applied Nutrition for chemical and genetic analysis. Genetic analysis identified the product as puffer fish (Lagocephalus lunaris) and chemical analysis determined it was contaminated with high levels of tetrodotoxin. A traceback investigation was unable to determine the original source of the product. Tetrodotoxin is a deadly, potent poison; the minimum lethal dose in an adult human is estimated to be 2-3 mg. Tetrodotoxin is a heat-stable and acid-stable, nonprotein, alkaloid toxin found in many species of the fish family Tetraodontidae (puffer fish) as well as in certain gobies, amphibians, invertebrates, and the blue-ringed octopus. Tetrodotoxin exerts its effects by blocking voltage-activated sodium channels, terminating nerve conduction and muscle action potentials, leading to progressive paralysis and, in extreme cases, to death from respiratory failure. Because these fish were reportedly purchased in the United States, they pose a substantial U.S. public health hazard given the potency of the toxin and the high levels of toxin found in the fish.

Successful management of excited delirium syndrome with prehospital ketamine: two case examples.

Excited delirium syndrome (ExDS) is a medical emergency usually presenting first in the prehospital environment. Untreated ExDS is associated with a high mortality rate and is gaining recognition within organized medicine as an emerging public safety problem. It is highly associated with male gender, middle age, chronic illicit stimulant abuse, and mental illness. Management of ExDS often begins in the field when first responders, law enforcement personnel, and emergency medical services (EMS) personnel respond to requests from witnesses who observe subjects exhibiting bizarre, agitated behavior. Although appropriate prehospital management of subjects with ExDS is still under study, there is increasing awareness of the danger of untreated ExDS, and the danger associated with the need for subject restraint, whether physical or chemical. We describe two ExDS patients who were successfully chemically restrained with ketamine in the prehospital environment, and who had good outcomes without complication. These are among the first case reports in the literature of ExDS survival without complication using this novel prehospital sedation management protocol. This strategy bears further study and surveillance by the prehospital care community for evaluation of side effects and unintended complications.

Feasibility of bedside thoracic ultrasound in the helicopter emergency medical services setting.

INTRODUCTION: Bedside thoracic ultrasound has been shown to be a valuable diagnostic tool in the emergency department. The purpose of this study was to evaluate the feasibility of bedside thoracic ultrasound in the prehospital HEMS setting. SETTING: Air ambulance helicopters during patient transportation. METHODS: This was a prospective pilot study. 71 consecutive, nonpregnant patients over 18 years old were enrolled. While in flight, providers completed limited bedside thoracic ultrasounds with the patient supine and recorded their interpretation of the presence or absence of the ultrasonographic sliding lung sign on a closed data-set instrument. RESULTS: 41 (58%) of the eligible patients had a recorded thoracic ultrasound acquired in flight. The level of agreement in image interpretation between the flight crew and expert reviewer was substantial (Kappa 0.67, CI 0.44-0.90). The reviewer rated 54% of all images as "good" in quality. The most common reason cited for not completing the ultrasound was lack of enough provider time or space limitations within the aircraft cabin. CONCLUSION: The results of this study suggest that, with limited training, bedside thoracic ultrasound image acquisition and interpretation for the sliding lung sign in the HEMS setting is feasible.

Absence of electrocardiographic change after prolonged application of a conducted electrical weapon in physically exhausted adults.

BACKGROUND: Conducted electrical weapons (CEWs) are used by law enforcement for control of subjects by causing neuromuscular incapacitation. There has been scrutiny of CEWs and their potential role in the occasional sudden death of subjects in custody. There is a hypothesized causal relationship due to induced cardiac dysrhythmia. Previous work has not shown dysrhythmia induction in resting humans. However, these devices are not often used on resting individuals in the field. OBJECTIVE: We sought to determine if exposure to a CEW in a physically exhausted human sample population caused detectable change in the 12-lead electrocardiogram (ECG). METHODS: Human volunteers were enrolled. All subjects had a baseline ECG obtained and then underwent an exercise regimen until exhaustion. The volunteers then received a continuous 15-s application from a TASER® X26 CEW (TASER International, Scottsdale, AZ). CEW electrodes were placed on random positions of their anterior thoraces. Electrode positions involved at least a 12-inch spread and always encompassed the normal anatomic position of the heart. An ECG was obtained immediately after CEW exposure. ECGs were interpreted by a blinded cardiologist. RESULTS: At baseline, 24/25 ECGs were normal. One baseline ECG was abnormal due to several monomorphic premature ventricular complexes. After CEW exposure, all 25 ECGs were interpreted as normal. CONCLUSIONS: Prolonged CEW application in an exhausted human sample did not cause a detectable change in their 12-lead ECGs. Theories of CEW-induced dysrhythmia in non-rested humans are not supported by our findings.

Introduction of the conducted electrical weapon into a hospital setting.

BACKGROUND: The TASER(®) X26 Conducted Electrical Weapon (CEW) provides painful stimuli and neuromuscular incapacitation to potentially violent persons. Use by law enforcement in society is common. Presenting a CEW is known to de-escalate some situations. Health care personnel sometimes encounter violent persons within the confines of the hospital. CEW use by health care security personnel has not been described. OBJECTIVE: The objective is to describe results from the introduction of the CEW into a hospital environment. METHODS: Upon introducing the CEW into an urban hospital campus, standardized reports were made describing all CEW use by hospital security. Reports were retrospectively reviewed for the first 12 months of CEW use. Collected data included force options used, potential injuries avoided, witness comments, outcomes, and whether the CEW required full activation or if inactive presentation was sufficient to control the situation. Rates of security personnel injuries were also gathered. Descriptive analysis was applied. RESULTS: Twenty-seven CEW deployments occurred: four were inactive presentation, 20 were presentation with LASER sight activation, and three were probe deployments with a 5-s delivery of electrical current. Two persons required evaluation for minor injuries not related to CEW use. Witnesses reported that in all incidents, injuries were likely avoided due to CEW presentation or use. CEW use aborted one suicide attempt. Personnel injury rates decreased during the study period. CONCLUSION: CEW introduction into a health care setting demonstrated the ability to avert and control situations that could result in further injury to subjects, patients, and personnel. This correlates with a decrease in injury for hospital personnel. Further study is recommended for validation.

Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly.

BACKGROUND: Blunt head trauma patients who have been alert but are deteriorating (talk and deteriorate [T&D]) due to a rapidly expanding epidural hematoma (EDH) usually have poor outcome if they must wait for hospital transfer for evacuation. We therefore have continued to teach skull trephination to emergency physicians (EPs). We are unaware of any literature on EP trephination for EDH in the age of computed tomography (CT) scanning. METHODS: Patients with EDH from blunt trauma, either in our institution or known to our graduate network, who were T&D with anisocoria despite intubation plus medical therapy, and who had pre-transfer EP trephination, were compared to those who were transferred without trephination. RESULTS: There were 5 patients with blunt trauma and CT-proven EDH who were T&D with anisocoria who underwent Emergency Department (ED) trephination at outlying hospitals before transfer. All 5 had improvement in condition and good outcomes. Three had complete recovery without disability and 2 others had mild disability with good cognitive function. None had complications. Two patients with T&D and anisocoria were transferred without trephination. Both had good neurologic outcomes. The mean time to pressure relief in the trephination group vs. transfer group was 55 vs. 207 min, respectively. CONCLUSION: In T&D patients with CT-proven EDH and anisocoria, ED skull trephination before transfer resulted in uniformly good outcomes without complications. Time to relief of intracranial pressure was significantly shorter with trephination. Neurologic outcomes were not different.

Development and Implementation of an Interdisciplinary Intensive Primary Care Clinic for High-Need High-Cost Patients in a Safety Net Hospital.

In 2010, payment for some of Hennepin County Medical Center's highest need patients changed from fee for service to a per capita formula. This financial stress led the institution to employ a population health lens that revealed a significant concentration of spending on a small segment of the population. Finding high rates of potentially avoidable inpatient and emergency care, an organizational effort was initiated to attempt to manage this high-need, high-cost population more effectively. A freestanding interdisciplinary intensive primary care clinic was developed. Nurses led a risk stratification process to identify eligible patients for co-located medical, care coordination, and social services from multidisciplinary care teams. Workflows to engage the population were designed to reduce readmissions and inappropriate use of emergency services. Soon after opening, the clinic added mental health and substance use professionals. For people entering the clinic between January 2010 and July 2017, utilization and financial data were collected for the year before (pre) and after (post) enrollment (n = 487). Bivariate statistics and outlier analyses facilitated comparisons between pre/post enrollment. Patients visited the new clinic twice per month on average and outpatient costs almost doubled. Overall costs were 16% lower, with the largest decrease seen in inpatient costs. This experience has led to ongoing investment, replication, and expansion of the model. An interdisciplinary intensive primary care clinic for high-utilizing, underserved patients is a promising intervention. Multidisciplinary teams and ongoing institutional support are critical to program success. Payment reform is essential to the development of such programs.

Bispectral index monitoring in helicopter emergency medical services patients.

Background. Many critically ill patients are given sedatives and paralytics to facilitate aeromedical transport. Bispectral index (BIS) monitoring is a computer-derived electroencephalography (EEG) analog currently used to monitor the level of awareness of sedated patients. It gives a score of 1-100, with 1 representing no brain function and 100 representing a completely alert patient. Objective. To evaluate whether critically ill patients are adequately sedated during aeromedical transport. Methods. This was a prospective, observational study of a convenience sample of critically ill patients transported by helicopter. All intubated patients who received sedatives and/or paralytics to facilitate transport were eligible for enrollment by the attending clinician. Prior to liftoff, a BIS sensor was applied to the patient's forehead. Minimum, maximum, and mean BIS index scores were recorded every minute during transport. Results. Forty-seven patients (57% male) were enrolled, with a median age of 60 years (interquartile range [IQR] 18-81, range 14 to 86 years). The median duration of monitoring was 15.0- minutes (IQR 6.0-26.0, range 2 to 33). The median BIS score was 54.6 (IQR 38.6-67.3, range 28 to 89.5). Only two patients (4.3%, 95% confidence interval [CI] 0.5% to 14.8%) had at least one BIS score greater than 85, the accepted threshold for recall. Conclusion. These results suggest that patients are adequately sedated during air medical transport.

Acute myocardial infarction with left bundle-branch block: disproportional anterior ST elevation due to right ventricular myocardial infarction in the presence of left bundle-branch block.

A case of inferior and right ventricular acute myocardial infarction in the presence of left bundle-branch block is presented. The electrocardiogram manifests disproportional, discordant ST elevation in leads II, III, and aVF and in leads V(1) through V(4).

Successful transcutaneous pacing in 2 severely hypothermic patients.

The clinical condition of profound hypothermia is well described in the medical literature. There have been many case reports and studies describing successful aspects of caring for this problem. Significant bradycardia is a known pathophysiologic consequence of profound hypothermia. Transcutaneous pacing for this condition is not a routine or recommended practice in the literature. This case report details 2 patients with profound hypothermia and resultant bradycardia with hypotension. In both cases, transcutaneous pacing was successfully applied and used as part of the resuscitation. In both cases, transcutaneous pacing was required to maintain an adequate blood pressure so that continuous arteriovenous rewarming could be used during the resuscitation. Both cases had successful outcomes, and the rewarming process was greatly assisted by the pacing procedure.

Traumatic brain injury.

Traumatic brain injury (TBI) is a significant source of morbidity and mortality throughout the world. This article discusses the epidemiology, pathophysiology, and clinical presentations of minor, moderate, and severe TBI. Controversial topics, such as hypertonic saline for increased intracranial pressure, prehospital intubation of patients who have experienced TBI, and the use of recombinant factor VIIa, are addressed.

End-tidal carbon dioxide monitoring during procedural sedation.

OBJECTIVE: To prospectively determine whether end-tidal carbon dioxide (ETCO2) monitors can detect respiratory depression (RD) and the level of sedation in emergency department (ED) patients undergoing procedural sedation (PS). METHODS: This was a prospective observational study conducted in an urban county hospital of adult patients undergoing PS. Patients were monitored for vital signs, depth of sedation per the physician by the Observer's Assessment of Alertness/Sedation scale (OAA/S), pulse oximetry, and nasal-sample ETCO2 during PS. Respiratory depression was defined as an oxygen saturation <90%, an ETCO2 >50 mm Hg, or an absent ETCO2 waveform at any time during the procedure. The physician also determined whether protective airway reflexes were lost during the procedure and assisted ventilation was required, or whether there were any other complications. Rates of RD were compared with the physician assessment of airway loss and between agents using chi-square statistics. Spearman's rho analysis was used to determine whether there was a correlation between ETCO2 and the OAA/S score. RESULTS: Seventy-four patients were enrolled in the study. Forty (54.1%) received methohexital, 21 (28.4%) received propofol, ten (13.5%) received fentanyl and midazolam, and three (4.1%) received etomidate. Respiratory depression was seen in 33 (44.6%) patients, including 47.5% of patients receiving methohexital, 19% receiving propofol (p = 0.008), 80% receiving fentanyl and midazolam, and 66.6% receiving etomidate. No correlation between OAA/S and ETCO2 was detected. Eleven (14.9%) patients required assisted ventilation at some point during the procedure, all of whom met the criteria for RD. Pulse oximetry detected 11 of the 33 patients with RD. Post-hoc analysis revealed that all patients with RD had an ETCO2 >50 mm Hg, an absent waveform, or an absolute change from baseline in ETCO2 >10 mm Hg. CONCLUSIONS: There was no correlation between ETCO2 and the OAA/S score. Using the criteria of an ETCO2 >50 mm Hg, an absolute change >10 mm Hg, or an absent waveform may detect subclinical RD not detected by pulse oximetry alone. The ETCO2 may add to the safety of PS by quickly detecting hypoventilation during PS in the ED.

Bispectral electroencephalographic analysis of patients undergoing procedural sedation in the emergency department.

OBJECTIVE: To determine whether there is a correlation between the level of sedation achieved during procedural sedation (PS) in the emergency department as determined by bispectral electroencephalographic (EEG) analysis (BIS) and the rate of respiratory depression (RD), the patient's perception of pain, recall of the procedure, and satisfaction. METHODS: This was a prospective observational study conducted in an urban county hospital of adult patients undergoing PS using propofol, methohexital, etomidate, and the combination of fentanyl and midazolam. Consenting patients were monitored by vital signs, pulse oximetry, nasal-sample end-tidal carbon dioxide (ETCO(2)), and BIS monitors during PS. Respiratory depression (RD) was defined as an oxygen saturation <90%, a change from baseline ETCO(2) of >10 mm Hg, or an absent ETCO(2) waveform at any time during the procedure. After the procedure, patients were asked to complete three 100-mm visual analog scales (VASs) concerning their perception of pain, recall of the procedure, and satisfaction with the procedure. Patients were divided into four groups based on the lowest BIS score recorded during the procedure, group 1, >85; group 2, 70-85; group 3, 60-69; group 4, <60. Rates of RD and VAS outcomes were compared between groups using chi-square statistics. RESULTS: One hundred eight patients were enrolled in the study. No serious adverse events were noted. RD was seen in three of 14 (21.4%) of the patients in group 1, seven of 34 (20.6%) in group 2, 16 of 26 (61.5%) in group 3, and 18 of 34 (52.9%) in group 4. The rate of RD in patients in group 2 was not significantly different from that in group 1 (p = 0.46). The rate of RD in group 2 was significantly lower than that in groups 3 (p = 0.0003) and 4 (p = 0.006). For the VAS data, when group 1 was compared with the combined groups 2, 3, and 4, it had significantly higher rates of pain (p = 0.003) and recall (p = 0.001), and a dissatisfaction rate (p = 0.085) that approached significance. When groups 2, 3, and 4 were compared with chi-square test, there was not a significant difference in pain (p = 0.151), recall (p = 0.27), or satisfaction (p = 0.25). CONCLUSIONS: Patients with a lowest recorded BIS score between 70 and 85 had the same VAS outcomes as more deeply sedated patients and the same rate of RD as less deeply sedated patients. This range of scores represented the optimally sedated patients in this study.

Randomized clinical trial of propofol versus methohexital for procedural sedation during fracture and dislocation reduction in the emergency department.

UNLABELLED: Although methohexital has been well studied for use in emergency department (ED) procedural sedation (PS), propofol has been evaluated less extensively for ED use. OBJECTIVE: The authors hypothesized that there is no difference in the depth of sedation and the rate of respiratory depression (RD) between propofol and methohexital in PS during the reduction of fractures and dislocations in the ED. METHODS: This was a randomized prospective study of nonintoxicated adult patients undergoing PS for fracture or dislocation reduction in the ED between July 2001 and March 2002. Patients were randomized to receive either propofol or methohexital, 1 mg/kg intravenously, followed by repeat boluses of 0.5 mg/kg every 2 minutes until adequate sedation was achieved. Doses, vital signs, end-tidal CO(2) (ETCO(2)) by nasal cannulae, pulse oximetry, and bispectral electroencephalogram analysis (BIS) scores were recorded. RD was defined as an ETCO(2) greater than 50 torr, an oxygen saturation less than 90% at any time, or an absent ETCO(2) waveform. After returning to baseline mental status, patients completed three 100-mm visual analog scales (VASs) regarding pain associated with the procedure, recall of the procedure, and satisfaction. RD rates and VAS outcomes were compared with chi-square tests. RESULTS: There were 109 patients enrolled; six were excluded for study protocol violations. Of the remaining 103 patients, 52 received methohexital (reduction successful in 94%) and 51 received propofol (98% successful). No cardiac rhythm abnormalities or significant decline in systolic blood pressure (>20%) was detected. Six patients required bag-valve-mask-assisted ventilations during the procedure, all for less than 1 minute; four of these patients received methohexital, and two received propofol. By the authors' definition, RD was seen in 25 of 52 (48%) patients receiving methohexital and 25 of 51 (49%) patients receiving propofol (p = 0.88). The mean minimum recorded BIS score was 66.2 (95% confidence interval [CI] = 62 to 70) for methohexital and 66 (95% CI = 60 to 71) for propofol. VAS results showed similar rates of reported pain, recall, and satisfaction for the two agents. CONCLUSIONS: The authors were unable to detect a significant difference in the level of subclinical RD or the level of sedation by BIS between the two agents. The use of either agent seems to be safe in the ED.