Pragmatic Randomized Controlled Pilot Trial on Trigger Point Injections With 1% Lidocaine Versus Conventional Approaches for Myofascial Pain in the Emergency Department.

BACKGROUND: Myofascial neck and back pain is an increasingly common chief symptom in the emergency department. Currently, there are no widely accepted conventional therapies, and there is little evidence on the efficacy of interventions such as trigger point injections (TPIs). OBJECTIVE: This study evaluates whether TPIs with 1% lidocaine can improve myofascial back and neck pain compared with conventional therapies. Secondary outcomes include changes in length of stay and number of opioid prescriptions on discharge. METHODS: This single-center, prospective, randomized, pragmatic trial was carried out in patients clinically determined to have myofascial back or neck pain. Patients were randomized into the experimental arm (TPI with 1% lidocaine) or the control arm (standard conventional approach). Numeric Rating Scores (NRS) for pain and additional surveys were obtained prior to and 20 min after the intervention. RESULTS: The NRS for pain was lower in the TPI group compared with the control group after adjustment for initial pain (median difference -3.01; 95% confidence interval -4.20 to -1.83; p < 0.001). Median length of stay was 2.61 h for the TPI group and 4.63 h for the control group (p < 0.001). More patients in the control group (47.4%) were discharged home with an opioid compared with the TPI group (2.9%) (p < 0.001). CONCLUSIONS: TPI is an effective method for managing myofascial pain in the emergency department. This study indicates it may improve pain compared with conventional methods, reduce length of stay in the emergency department, and reduce opioid prescriptions on discharge.

Use of occipital nerve block in emergency department treatment of status migrainosus.

Migraine headaches make up a significant proportion of emergency department visits. There are multiple pharmacologic treatment modalities for migraine abortive therapy; however, these treatments are rarely targeted to the precise area of pain and thus elicit multiple systemic effects. It has been well established in the anesthesia pain literature that occipital nerve blocks can provide not only immediate pain relief from occipital migraines, but can also result in a long-term resolution of occipital migraines. In this case report, we present how an occipital nerve block in the emergency department resulted in immediate and long-lasting resolution of a patient's occipital migraine.

Triage physicians in an academic emergency department: Impact on resident education.

BACKGROUND: Overcrowding in emergency departments (EDs) in the United States has been linked to worse patient outcomes. Implementation of countermeasures such as a physician-in-triage (PIT) system have improved patient care and decreased wait times. The purpose of this study was to evaluate how a PIT system affects medical resident education in an academic ED. METHODS: This was a retrospective observational comparison of resident metrics at a single-site, urban, academic ED before and after implementing a PIT system. Resident metrics of average emergency severity index (ESI), patients-per-hour, and in-training-examination scores were measured before and six months after the implementation of the PIT system. RESULTS: In total, 18,231 patients were evaluated by all residents in the study period before PIT implementation compared to 17,008 in the study period following PIT implementation. The average ESI among patients evaluated by residents decreased from 3.00 to 2.68 (p < 0.01, 95% confidence interval [CI] = 0.31 to 0.33), while average resident patient-per-hour rate decreased from 1.41 to 1.32 (p < 0.01, 95% CI = 0.05 to 0.13] and ITE scores saw no statistically significant change of 76.11 to 78.26 (p = 0.26, 95% CI = -5.75 to 1.45). While these differences are statistically significant, they are likely not clinically significant. CONCLUSIONS: Our implementation of PIT system at one academic medical center minimally increased the acuity and minimally decreased the number of patients that residents see. This suggested that in our center, a PIT program did not detract from ED resident clinical education. However, further research with alternative markers in multiple centers is needed.

The Effects of Implementing a "Waterfall" Emergency Physician Attending Schedule.

INTRODUCTION: Increases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput. To compensate, ED administrators often look to modifying staffing models to improve efficiencies. METHODS: This study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs. We examined 9,082 pre-intervention ED visits and 8,983 post-intervention ED visits. RESULTS: The change in DDOC, LWBS rate, and elopement rate demonstrated statistically significant improvement from a mean of 65.1 to 35 minutes (P <0.001), 1.12% to 0.92% (P = 0.004), and 3.96% to 1.95% (P <0.001), respectively. The change in DDIS from 312 to 324.7 minutes was not statistically significant (P = 0.310). The number of patient sign-outs increased after the implementation of a waterfall schedule (P <0.001). CONCLUSION: Implementing a waterfall schedule improved DDOC time while decreasing the percentage of patients who LWBS and eloped. The DDIS and number of patient sign-outs appears to have increased post implementation, although this may have been confounded by the increase in patient volumes and ED boarding from the pre- to post-intervention period.

Public Performance Metrics: Driving Physician Motivation and Performance.

INTRODUCTION: As providers transition from "fee-for-service" to "pay-for-performance" models, focus has shifted to improving performance. This trend extends to the emergency department (ED) where visits continue to increase across the United States. Our objective was to determine whether displaying public performance metrics of physician triage data could drive intangible motivators and improve triage performance in the ED. METHODS: This is a single institution, time-series performance study on a physician-in-triage system. Individual physician baseline metrics-number of patients triaged and dispositioned per shift-were obtained and prominently displayed with identifiable labels during each quarterly physician group meeting. Physicians were informed that metrics would be collected and displayed quarterly and that there would be no bonuses, punishments, or required training; physicians were essentially free to do as they wished. It was made explicit that the goal was to increase the number triaged, and while the number dispositioned would also be displayed, it would not be a focus, thereby acting as this study's control. At the end of one year, we analyzed metrics. RESULTS: The group's average number of patients triaged per shift were as follows: Q1-29.2; Q2-31.9; Q3-34.4; Q4-36.5 (Q1 vs Q4, p < 0.00001). The average numbers of patients dispositioned per shift were Q1-16.4; Q2-17.8; Q3-16.9; Q4-15.3 (Q1 vs Q4, p = 0.14). The top 25% of Q1 performers increased their average numbers triaged from Q1-36.5 to Q4-40.3 (ie, a statistically insignificant increase of 3.8 patients per shift [p = 0.07]). The bottom 25% of Q1 performers, on the other hand, increased their averages from Q1-22.4 to Q4-34.5 (ie, a statistically significant increase of 12.2 patients per shift [p = 0.0013]). CONCLUSION: Public performance metrics can drive intangible motivators (eg, purpose, mastery, and peer pressure), which can be an effective, low-cost strategy to improve individual performance, achieve institutional goals, and thrive in the pay-for-performance era.

Occipital Nerve Blocks in the Emergency Department for Initial Medication-Refractory Acute Occipital Migraines.

Migraines are consistently among the top 20 primary coded diagnoses in emergency departments, constituting 4.5% of all chief complaints. In a significant subset of these, pain arises from the occipital region innervated by the greater (GON) and lesser occipital nerve. In this case series, we present three patients with occipital migraines who received GON blockade with 1% lidocaine. The blockade was performed only after first-line treatment with metoclopramide and possibly additional medications as ordered by triage physician, failed to adequately alleviate pain by 40 minutes after medication administration. Patients were contacted a minimum of seven days following treatment. All three patients experienced significant analgesia and relief of symptoms within 15 minutes of blockade and sustained relief through a seven-day follow-up period.

Characterizing Frequent Flyers of an Emergency Department Using Cluster Analysis.

Emergency department (ED) overcrowding has been a pain point in hospitals across the globe. "Frequent flyers," who visited the ED at a much higher rate than average, account for almost one third of ED visits even though they represent only a small proportion of all ED patients. In this study, we used data-mining methods to cluster ED frequent flyers at a large academic medical center in the US. The objective was to identify distinct types of frequent flyers, and the common characteristics associated with each type. The results show that the frequent flyers at the ED have three subgroups each exhibiting distinct characteristics: (1) the elderly with chronic health conditions, (2) middle-aged males with unhealthy behavior, and (3) adult females who are generally healthy. These findings may inform targeted interventional strategies for patients of each subgroup, who likely have distinct reasons for visiting the ED frequently, to reduce ED overcrowding.

Emergency department patient experience: Same location, same provider, different scores by different survey methods.

BACKGROUND: Recent findings on emergency department (ED) patient experience surveys and concerns for the low response rates challenge the quality and reliability of the survey reports. We assessed the consistency of an ED patient experience survey report and identified the effects of patient demographics on ED patient experiences. METHODS: We conducted a prospective, cross-sectional study at a university-based ED from July to December 2017. We obtained ED patient experience scores from an institutional version (IS) survey and the Press Ganey Associates-distributed survey (PGA). We compared top box scores from the two reports using frequency analysis and performed multivariable logistic regressions to identify associations between IS patient demographics and scores. RESULTS: We obtained 289 PGA and 234 IS responses. The IS reported significant, higher top box scores in doctor-specific patient questions compared to PGA (all four P-values < 0.01). Female, Christian and White patients were more likely to give top box scores (OR 3.07, OR 2.22 and OR 2.41, P-value < 0.05, respectively). CONCLUSION: We found significant differences in ED patient experience scores between the IS and PGA surveys. We recommend that healthcare providers consider patient demographic variables when interpreting ED experience score reports. Multiple survey techniques and distribution methods may be adopted to best capture ED patient experiences.

Deep arteriovenous malformations in the basal ganglia, thalamus, and insula: multimodality management, patient selection, and results.

OBJECTIVE: This study sought to describe a single institution's experience treating arteriovenous malformations (AVMs) of the basal ganglia, thalamus, and insula in a multimodal fashion. METHODS: We conducted a retrospective review of all deep AVMs treated at our institution between 1997 and 2011 with attention to patient selection, treatment strategies, and radiographic and functional outcomes. RESULTS: A total of 97 patients underwent initial treatment at our institution. 64% presented with hemorrhage with 29% located in the basal ganglia, 41% in the thalamus, and 30% in the insula. 80% were Spetzler-Martin grade III-IV. Initial treatment was microsurgical resection in 42%, stereotactic radiosurgery (SRS) in 45%, and observation in 12%. Radiographic cure was achieved in 54% after initial surgical or SRS treatment (71% and 23%, respectively) and in 63% after subsequent treatments, with good functional outcomes in 78% (median follow-up 2.2 years). Multivariate logistic regression analysis revealed treatment group and age as factors associated with radiographic cure, whereas Spetzler-Martin score and time to follow-up were significantly associated with improved/unchanged functional status at time of last follow-up. Posttreatment hemorrhage occurred in 11% (7% of surgical and 18% of SRS patients). CONCLUSIONS: Modern treatment of deep AVMs includes a multidisciplinary approach utilizing microsurgery, SRS, embolization, and observation. Supplementary grading adds meaningfully to traditional Spetzler-Martin grading to guide patient selection. Surgical resection is more likely to result in obliteration compared with SRS, and is associated with satisfactory results in carefully selected patients.