Implementation and evaluation of a store-and-forward teledermatology workflow in a United States safety-net hospital urgent care emergency center: A retrospective cohort study.

Background: Teledermatology (TD) is an important method for increasing access to care in outpatient settings. However, less is known regarding its use in emergency/urgent care centers. Objective: To evaluate the effect of TD on urgent care emergency center (UCEC) dwell time and postencounter utilization. Study type and methods: This retrospective cohort study evaluated patients in a safety-net hospital (Parkland Health, Dallas, Texas, USA) UCEC, who (1) received a TD consult in 2018, (2) were referred to dermatology clinic in 2017, or (3) were referred to dermatology clinic in 2018 without a TD consult. Results: We evaluated 2024 patients from 2017 to 2018. Of the 973 referred to dermatology clinic in 2018, 332 (34%) received TD consultations. Mean dwell time for patients receiving TD was longer versus the 2017 cohort (303 vs 204 minutes, respectively). Patients receiving TD consultation with inflammatory skin conditions had lower odds of dermatology clinic visits compared with those that did not (odds ratio, 0.5; 95% CI, 0.3-0.8). Teledermatology was not associated with differences in repeat UCEC utilization. Limitations: Single institution study and inability to account for differences in patient complexity. Conclusion: TD increases dwell time in a safety-net hospital's UCEC but can reduce dermatology clinic utilization for patients with inflammatory skin conditions.

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation).

Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.

Association of a Novel Protocol for Rapid Exclusion of Myocardial Infarction With Resource Use in a US Safety Net Hospital.

Importance: High-sensitivity cardiac troponin T (hs-cTnT) protocols for the evaluation of chest pain in the emergency department (ED) may reduce unnecessary resource use and overcrowding. Objective: To determine whether the implementation of a novel hs-cTnT protocol, which incorporated troponin values drawn at 0, 1, and 3 hours after ED presentation and the modified HEART score (history, electrocardiogram, age, risk factors), was associated with improvements in resource use while maintaining safety. Design, Setting, and Participants: This retrospective cohort study from Parkland Health and Hospital System, a large safety net hospital in Dallas, Texas, included data on 31 543 unique ED encounters in which patients underwent electrocardiographic and troponin testing from January 1, 2017, to October 16, 2018. The hs-cTnT protocol was implemented in December 2017. Main Outcomes and Measures: Resource use outcomes included trends in ED dwell time, troponin to disposition decision time (the difference between the first troponin draw time and the time an order was placed for inpatient admission, admission to observation, or discharge), and final patient disposition. Safety outcomes included readmission for myocardial infarction and death. Results: In 31 543 encounters, mean (SD) patient age was 54 (14.4) years and 14 675 patients (48%) were female. Department dwell time decreased by a mean of -1.09 (95% CI, -2.81 to 0.64) minutes per month in the preintervention period. The decline was steeper after the intervention (-4.69 [95% CI, -9.05 to -0.33] minutes per month) (P for interaction = .007). The troponin to disposition time was increasing in the preintervention period by 1.72 (95% CI, 1.08 to 2.36) minutes per month; postintervention, the mean difference increased more slowly (0.37 [95% CI, -1.25 to 1.99 minutes per month; P value for interaction = .007]). The proportion of patients discharged from the ED increased after the intervention (48% vs 54%, P < .001). Thirty-day major adverse cardiac event rates were low and did not differ before and after the intervention. Conclusions and Relevance: Implementation of a novel protocol incorporating serial hs-cTnT measurements over 3 hours with the Modified HEART Score was associated with reduction in ED dwell times and attenuation of temporal increases in time from troponin measurement to disposition. This or similar protocols to rule out myocardial infarction have the potential to reduce ED overcrowding and improve health care quality while maintaining safety.

Breast ultrasound utilization in a safety net emergency department.

PURPOSE: The purpose of this study is to (1) assess the diagnostic yield of ultrasounds performed in the emergency department for suspected breast abscess and determine the rates of reimaging, discordance, and emergent intervention in a large, busy safety net hospital and (2) determine clinical factors significantly associated with abscess as a way to improve patient selection for emergent breast ultrasounds. METHODS: A total of 581 consecutive breast ultrasounds performed in the emergency department for suspected abscess over 15 months were retrospectively reviewed for imaging, demographics, laboratory data, and physical exam findings. Breast abscess was confirmed by combining imaging, clinical, and laboratory data. Linear logistic regression analysis estimated the likelihood of abscess, and the cross-validated area under the receiver operating characteristic curve (AUC) evaluated diagnostic performance. RESULTS: Final diagnoses included abscess (153/581, 26%), cancer (29/581, 5%), granulomatous mastitis (41/581, 7%), normal (120/581, 21%), and other/indeterminate (238/581, 41%). Factors associated with abscess included induration, fluctuance, erythema, drainage, smoking, diabetes, and Black race. Based on these factors, the AUC of the characteristics predictive of abscess was 0.77 (CI, 0.72-0.81). Six breast cancers were not diagnosed on ultrasound. 40% of ultrasounds (231/581) were considered incomplete/inadequate. CONCLUSION: 74% (428/581) of emergent breast ultrasounds in our population were negative for abscess, while 21% (6/29) of cancers were not diagnosed, and 40% (231/581) of exams were incomplete/inadequate. Patient selection for emergent ultrasounds can be improved, allowing patients with a low likelihood of abscess to be imaged in a more optimal setting.

Year in review 2011: Critical Care--Out-of-hospital cardiac arrest and trauma.

In 2011, numerous studies were published in Critical Care focusing on out-of-hospital cardiac arrest, cardiopulmonary resuscitation, trauma, and some related airway, respiratory, and response time factors. In this review, we summarize several of these studies, including those that brought forth advances in therapies for the post-resuscitative period. These advances involved hypothesis-generating concepts in therapeutic hypothermia as well as the impact of early percutaneous coronary artery interventions and the potential utility of extracorporeal life support after cardiac arrest. There were also articles pertaining to the importance of timing in prehospital airway management, the outcome impact of hyperoxia, and the timing of end-tidal carbon dioxide measurements to predict futility in cardiac arrest resuscitation. In other articles, additional perspectives were provided on the classic correlations between emergency medical service response intervals and outcomes.

Excited Delirium Syndrome (ExDS): defining based on a review of the literature.

BACKGROUND: Patients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include hyperthermia, "superhuman" strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as "Excited Delirium" deaths. OBJECTIVES: This article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations. DISCUSSION: Excited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both. CONCLUSIONS: Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.

Year in review 2010: Critical Care--Cardiac arrest and cardiopulmonary resuscitation.

This review will summarize some of the data published in 2010 and focus on papers published in Critical Care in regard to cardiac arrest and cardiopulmonary resuscitation. In particular, we discuss the latest research in therapeutic hypothermia after cardiac arrest, including methods of inducing hypothermia, potential protective mechanisms, spontaneous hypothermia versus therapeutic hypothermia, and several predictors of outcome. Furthermore, we will discuss the effects of bystander-initiated cardiopulmonary resuscitation (CPR) in patients with physician-assisted advanced cardiac life support, the role of hypercapnea in near-death experiences during cardiac arrest, markers of endothelial injury and endothelial repair after CPR, and the prognostic value of cell-free plasma DNA as a marker of poor outcome after cardiac arrest.

Year in review 2009: Critical Care--cardiac arrest, trauma and disasters.

During 2009, Critical Care published nine papers on various aspects of resuscitation, prehospital medicine, trauma care and disaster response. One article demonstrated that children as young as 9 years of age can learn cardiopulmonary resuscitation (CPR) effectively, although, depending on their size, some may have difficulty performing it. Another paper showed that while there was a trend toward mild therapeutic hypothermia reducing S-100 levels, there was no statistically significant change. Another predictor study also showed a strong link between acute kidney injury and neurologic outcome while another article described a program in which kidneys were harvested from cardiac arrest patients and showed an 89% graft survival rate. One experimental investigation indicated that when a pump-less interventional lung assist device is present, leaving the device open (unclamped) while performing CPR has no harmful effects on mean arterial pressures and it may have positive effects on blood oxygenation and CO2 clearance. One other study, conducted in the prehospital environment, found that end-tidal CO2 could be useful in diagnosing pulmonary embolism. Three articles addressed disaster medicine, the first of which described a triage system for use during pandemic influenza that demonstrated high reliability in delineating patients with a good chance of survival from those likely to die. The other two studies, both drawn from the 2008 Sichuan earthquake experience, showed success in treating crush injured patients in an on-site tent ICU and, in the second case, how the epidemiology of earthquake injuries and related factors predicted mortality.

Year in review 2008: Critical Care--trauma.

Eleven papers on trauma published in Critical Care during 2008 addressed traumatic brain injury (TBI), burns, diagnostic concerns and immunosuppression. In regard to TBI, preliminary results indicate the utility of either magnetic resonance imaging (MRI) or ultrasound in measuring optic nerve sheath diameter to identify elevated intracranial pressure (ICP) as well as the potential benefit of thiopental for refractory ICP. Another investigation demonstrated that early extubation of TBI patients whose Glasgow Coma Scale score was 8 or less did not result in additional incidence of nosocomial pneumonia. Another study indicated that strict glucose control resulted in worse outcomes during the first week after TBI, but improved outcomes after the second week. Another paper showed the prolonged neuroprotective advantages of progesterone administration in TBI patients. There was also guidance on improved classifications of renal complications in burn patients. Another study found that patients with inhalation injuries and increased interleukin-6 (IL-6) and IL-10 and decreased IL-7 had increased mortality rates. One literature review described the disadvantages of prolonged immobilization or additional use of MRI for ruling out cervical spine injuries in obtunded TBI patients already cleared by computerized tomography scans. Other investigators found that higher N-terminal pro B-type natriuretic peptide (NT-proBNP) levels may be useful markers for post-traumatic cardiac impairment. Finally, an experimental model showed that both splenic apoptosis and lymphocytopenia may occur shortly after severe hemorrhage, thus increasing the threat of immunosuppression in those with severe blood loss.

The lifesaving potential of specialized on-scene medical support for urban tactical operations.

Since the 1980s, the specialized field of tactical medicine has evolved with growing support from numerous law-enforcement and medical organizations. On-scene backup from tactical emergency medical support (TEMS) providers has not only permitted more immediate advanced medical aid to injured officers, victims, bystanders, and suspects, but also allows for rapid after-incident medical screening or minor treatments that can obviate an unnecessary transport to an emergency department. The purpose of this report is to document one very explicit benefit of TEMS deployment, namely, a situation in which a police officer's life was saved by the routine on-scene presence of specialized TEMS physicians. In this specific case, a police officer was shot in the anterior neck during a law-enforcement operation and became moribund with massive hemorrhage and compromised airway. Two TEMS physicians, who had been integrated into the tactical law-enforcement team, were on scene, controlled the hemorrhage, and provided a surgical airway. By the time of arrival at the hospital, the patient had begun purposeful movements and, within 12 hours, was alert and oriented. Considering the rapid decline in the patient's condition, it was later deemed by quality assurance reviewers that the on-scene presence of these TEMS providers was lifesaving.

Conductive electrical devices: a prospective, population-based study of the medical safety of law enforcement use.

BACKGROUND: To examine police compliance with policies for the proper use of conductive electrical devices (CEDs) and, in turn, track any associated medical events following CED application. METHODS: Prospective, population-based, 15-month study of police activations of CEDs after their introduction into the police force of a large U.S. city (residential population, 1.25 million). Local policy for use was consistent with the recommendations of International Association of Chiefs of Police. Data collected included age, sex, predefined rationale for use, target distance, activation duration, total energy delivered, policy compliance, and medical findings or events within the first 12 hours. RESULTS: Among 426 consecutive CED activations (November 1, 2004 through January 31, 2006), the suspects' mean age (years +/- standard deviation) was 30 +/- 10 (range, 13-72) years and 90.4% were male. Suspects' mean distance from the officer was 5.0 +/- 4.5 feet (range, 0-21). Reasons for use included: evading or resisting arrest (33.3%, n = 142), public intoxication or disorderly conduct (15.8%, n = 76), interrupting a felony in progress (9.3%, n = 45), and interrupting an assault on an officer or public servant (6.0%, n = 29). Mean total duration of exposures was 8.6 +/- 5.9 seconds, and total energy delivered per suspect was 227 +/- 156 joules. Officers followed policy in all cases and, accordingly, all suspects rapidly received medical evaluation or simple first aid. No suspect required further treatment except one who was later found to have severe toxic hyperthermia and who died within 2 hours of activation despite rapid on-scene intervention. In 5.4% of deployments (n = 23), CED use was deemed to have clearly prevented the use of lethal force by police. CONCLUSION: Police were compliant with policy in all cases, and, in addition to avoiding the use of lethal force in a significant number of circumstances, the safety of CED use was demonstrated despite one death subsequently attributed to lethal toxic hyperthermia. Collaborative nationwide research using similar registries is strongly recommended to document compliance and ensure ongoing safety monitoring.