Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED.

BACKGROUND: Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes. OBJECTIVES: We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets. METHODS: We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates. RESULTS: There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates. CONCLUSIONS: An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock.

Clinical effectiveness of bougienage for esophageal coins in a pediatric ED.

OBJECTIVE: To describe a tertiary care pediatric emergency department (PED) experience with bougienage for esophageal coins. METHODS: This was a large retrospective case series of children with esophageal coins presenting to a tertiary PED from January 2004 to October 2012. Bougienage eligibility criteria were medically stable, no prior gastro-esophageal surgery or disease, single coin, and witnessed ingestion within 24 hours. Abstracted data were age, signs and symptoms, coin type, management, efficacy, complications, returns, length of stay (LOS), and hospital charges. Main outcomes included procedural success and complications. Secondary outcomes included LOS and hospital charges. RESULTS: There were 245 patients with esophageal coins with 136/145 (94%) successful bougienage procedures and 109/109 (100%) successful surgical retrievals. There were 18 minor complications and 5 return visits for patients with bougienage. There were 10 minor and 2 major complications with surgical retrieval. Patients undergoing bougienage were 4 years (SD 2) vs 3 years (SD 3) for surgical retrieval (P < 0.001). Mean LOS for successful bougienage was 137 minutes (SD 54) vs 769 (SD 535) for surgical retrieval. The difference in the means was 632, 95% CI for the difference in means of -723 to -541 (P < .001). Mean charges for successful bougienage were $984 (SD $576) vs. $7022 (SD $3132) for surgical retrieval. The difference in means was $6038, 95% CI -$6,580 to -$5,496 (P < .001). CONCLUSIONS: Esophageal bougienage is safe and highly effective. It is also more time and cost efficient than other treatment options.

The Cost and Burden of the Residency Match in Emergency Medicine.

INTRODUCTION: To obtain a residency match, medical students entering emergency medicine (EM) must complete away rotations, submit a number of lengthy applications, and travel to multiple programs to interview. The expenses incurred acquiring this residency position are burdensome, but there is little specialty-specific data estimating it. We sought to quantify the actual cost spent by medical students applying to EM residency programs by surveying students as they attended a residency interview. METHODS: Researchers created a 16-item survey, which asked about the time and monetary costs associated with the entire EM residency application process. Applicants chosen to interview for an EM residency position at our institution were invited to complete the survey during their interview day. RESULTS: In total, 66 out of a possible 81 residency applicants (an 81% response rate) completed our survey. The "average applicant" who interviewed at our residency program for the 2015-16 cycle completed 1.6 away, or "audition," rotations, each costing an average of $1,065 to complete. This "average applicant" applied to 42.8 programs, and then attended 13.7 interviews. The cost of interviewing at our program averaged $342 and in total, an average of $8,312 would be spent in the pursuit of an EM residency. CONCLUSION: Due to multiple factors, the costs of securing an EM residency spot can be expensive. By understanding the components that are driving this trend, we hope that the academic EM community can explore avenues to help curtail these costs.