Process for Delivering Timely Antibiotics to Febrile Bone Marrow Transplant Patients in the Emergency Department.

PURPOSE: Patients with a history of a bone marrow transplant (BMT) have a higher risk of infectious complications because of an immunocompromised state. It has been shown that giving timely antibiotics in 1 hour or less from presentation to the emergency department (ED) decreases morbidity and mortality in this patient population. We hypothesize that a quality improvement (QI) process, termed BMT Fever, will improve timely administration of antibiotics for this population presenting to the ED. METHODS: This is a QI process designed to improve the administration of antibiotics to BMT patients with a subjective or objective fever presenting to the ED. The percent of patients receiving antibiotics within 1 hour or less was compared pre- and post-intervention. RESULTS: Upon implementation of the BMT Fever QI process, the percentage of patients with febrile BMT receiving antibiotics within 1 hour or less per fiscal quarter significantly improved from six out of 28 patients (21%) to 147 out of 173 patients (85%), P value < .05. CONCLUSION: By implementing a QI process that addresses five structural obstacles, we were able to improve our timely administration of antibiotics to patients with febrile BMT presenting to the ED.

Case Report: Disposition of Symptomatic Probable COVID-19.

INTRODUCTION: The novel coronavirus disease 2019 (COVID-19) presents a challenge for healthcare providers in terms of diagnosis, management, and triage of cases requiring admission. CASE REPORT: A 47-year-old male with symptoms suspicious for COVID-19, pulse oximetry of 93% on room air, and multifocal pneumonia was risk stratified and safely discharged from the emergency department (ED) despite having moderate risk of progression to acute respiratory distress syndrome. He had resolution of his symptoms verified by telephone follow-up. CONCLUSION: Various risk-stratifying tools and techniques can aid clinicians in identifying COVID-19 patients who can be safely discharged from the ED.

Bradycardia after Tube Thoracostomy for Spontaneous Pneumothorax.

We present the case of an elderly patient who became bradycardic after chest tube insertion for spontaneous pneumothorax. Arrhythmia is a rare complication of tube thoracostomy. Unlike other reported cases of chest tube induced arrhythmias, the bradycardia in our patient responded to resuscitative measures without removal or repositioning of the tube. Our patient, who had COPD, presented with shortness of breath due to spontaneous pneumothorax. Moments after tube insertion, patient developed severe bradycardia that responded to Atropine. In patients requiring chest tube insertion, it is important to be prepared to provide cardiopulmonary resuscitative therapy in case the patient develops a life-threatening arrhythmia.

The effect of a hybrid training program.

Improving nursing communication skills and HCAHPS scores.

Teaching the Emergency Department Patient Experience: Needs Assessment from the CORD-EM Task Force.

INTRODUCTION: Since the creation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction (PS) scores, patient experience (PE) has become a metric that can profoundly affect the fiscal balance of hospital systems, reputation of entire departments and welfare of individual physicians. While government and hospital mandates demonstrate the prominence of PE as a quality measure, no such mandate exists for its education. The objective of this study was to determine the education and evaluation landscape for PE in categorical emergency medicine (EM) residencies. METHODS: This was a prospective survey analysis of the Council of Emergency Medicine Residency Directors (CORD) membership. Program directors (PDs), assistant PDs and core faculty who are part of the CORD listserv were sent an email link to a brief, anonymous electronic survey. Respondents were asked their position in the residency, the name of their department, and questions regarding the presence and types of PS evaluative data and PE education they provide. RESULTS: We obtained 168 responses from 139 individual residencies, representing 72% of all categorical EM residencies. This survey found that only 27% of responding residencies provide PS data to their residents. Of those programs, 61% offer simulation scores, 39% provide third-party attending data on cases with resident participation, 37% provide third-party acquired data specifically about residents and 37% provide internally acquired quantitative data. Only 35% of residencies reported having any organized PE curricula. Of the programs that provide an organized PE curriculum, most offer multiple modalities; 96% provide didactic lectures, 49% small group sessions, 47% simulation sessions and 27% specifically use standardized patient encounters in their simulation sessions. CONCLUSION: The majority of categorical EM residencies do not provide either PS data or any organized PE curriculum. Those that do use a heterogeneous set of data collection modalities and educational techniques. American Osteopathic Association and Accreditation Council for Graduate Medical Education residencies show no significant differences in their resident PS data provision or formal curricula. Further work is needed to improve education given the high stakes of PS scores in the emergency physician's career.

Pharmacy collected medication histories in an observation unit.

BACKGROUND: Clear processes to facilitate medication reconciliation in a hospital setting are still undefined. The observation unit allows for a high patient turnover rate, where obtaining accurate medication histories is critical. OBJECTIVES: The objective of this study was to assess the ability of pharmacists and student pharmacists to identify discrepancies in medication histories obtained at triage in observation patients. METHODS: Pharmacists and student pharmacists obtained a medication history for each patient placed in observation status. Patients were excluded if they were unable to provide a medication history and family, caregiver, or community pharmacy was also unable to provide the history. A comparison was made between triage and pharmacy collected medication histories to identify discrepancies. RESULTS: A total of 501 medications histories were collected, accounting for 3213 medication records. There were 1176 (37%) matched medication records and 1467 discrepancies identified, including 808 (55%) omissions, 296 (20.2%) wrong frequency, 278 (19%) wrong dose, 51 (3.5%) discontinued, and 34 (2.3%) wrong medication. There was an average of 2.9 discrepancies per patient profile. In all, 76 (15%) of the profiles were matched. The median time to obtain a medication history was 4 min (range: 1-48 min). CONCLUSION: Pharmacy collected medication histories in an observation unit identify discrepancies that can be reconciled by the interdisciplinary team.

A Delphi Method Analysis to Create an Emergency Medicine Educational Patient Satisfaction Survey.

INTRODUCTION: Feedback on patient satisfaction (PS) as a means to monitor and improve performance in patient communication is lacking in residency training. A physician's promotion, compensation and job satisfaction may be impacted by his individual PS scores, once he is in practice. Many communication and satisfaction surveys exist but none focus on the emergency department setting for educational purposes. The goal of this project was to create an emergency medicine-based educational PS survey with strong evidence for content validity. METHODS: We used the Delphi Method (DM) to obtain expert opinion via an iterative process of surveying. Questions were mined from four PS surveys as well as from group suggestion. The DM analysis determined the structure, content and appropriate use of the tool. The group used four-point Likert-type scales and Lynn's criteria for content validity to determine relevant questions from the stated goals. RESULTS: Twelve recruited experts participated in a series of seven surveys to achieve consensus. A 10-question, single-page survey with an additional page of qualitative questions and demographic questions was selected. Thirty one questions were judged to be relevant from an original 48-question list. Of these, the final 10 questions were chosen. Response rates for individual survey items was 99.5%. CONCLUSION: The DM produced a consensus survey with content validity evidence. Future work will be needed to obtain evidence for response process, internal structure and construct validity.