Patient perspectives on emergency department initiation of medication for alcohol use disorder.

OBJECTIVE: Alcohol use disorder (AUD) is a leading cause of preventable death and is a frequent diagnosis in the emergency department (ED). Treatment in the ED, however, typically focuses on managing the sequelae of AUD, such as acute withdrawal, rather than addressing the underlying addiction. For many patients, these ED encounters are a missed opportunity to connect with medication for AUD. In 2020, our ED created a pathway to offer patients with AUD treatment with naltrexone (NTX) during their ED visit. The aim of this study was to identify what barriers and facilitators patients perceive to NTX initiation in the ED. METHODS: Adopting the theoretical framework of the behavior change wheel (BCW), we conducted qualitative interviews with patients to elicit their perspectives on ED initiation of NTX. Interviews were coded and analyzed using both inductive and deductive approaches. Themes were categorized according to patients' capabilities, opportunities, and motivations. Barriers were then mapped through the BCW to design interventions that will improve our treatment pathway. RESULTS: Twenty-eight patients with AUD were interviewed. Facilitators of accepting NTX included having recently experienced sequelae of AUD, rapid management of withdrawal symptoms by the ED provider, having a choice between intramuscular and oral formulations of the medication, and experiencing positive interactions in the ED that destigmatized the patient's AUD. Barriers to accepting treatment included lack of provider knowledge about NTX, dependence on alcohol as self-treatment for psychiatric trauma and physical pain, perceived discriminatory treatment and stigma about AUD, aversion to potential side effects, and lack of access to continued treatment. CONCLUSIONS: Initiation of treatment of AUD with NTX in the ED is acceptable to patients and can be facilitated by knowledgeable ED providers who create a destigmatizing environment, effectively manage withdrawal symptoms, and connect patients to providers who will continue treatment.

Assessment of an Opioid Stewardship Program on Perioperative Opioid Prescribing in a Safety-Net Health System.

This quality improvement study involves comparison of opioid prescription data before and after implementation of an opioid stewardship program in a safety-net medical system.

Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder.

BACKGROUND: Alcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aims of this study are to identify barriers and facilitators to the treatment of AUD in the ED, and to design interventions to address identified barriers. METHODS: Using an implementation science approach based on the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers' capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions. RESULTS: Facilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team. CONCLUSIONS: A large evidence-practice gap exists for the treatment of AUD with Naltrexone, and the ED visit is a missed opportunity for intervention. ED providers are optimistic about implementing AUD treatment in the ED but described many barriers, especially related to knowledge, clarification of roles, and stigma associated with AUD. Applying a formal implementation science approach guided by the Behavior Change Wheel allowed us to transform qualitative interview data into evidence-based interventions for the implementation of an ED-based program for the treatment of AUD.

Barriers to the Right to Health Among Patients of a Public Emergency Department After Implementation of the Affordable Care Act.

Purpose: Emergency physicians are witnesses to the impact of socioeconomic determinants of health on physical and psychiatric illness. Understanding structural barriers to the right to health (RTH) serves as a foundation for interventions to promote health equity. This study was performed to determine self-described barriers to fulfillment of the RTH among a public emergency department (ED) patient population. Methods: A convenience sample survey between June and August 2014 of 200 patients in public ED assessing demographic characteristics and desired assistance with 36 barriers to fulfillment of the RTH. Results: There was a high demand for specialty care (91%, 182/200), access to primary care (87.5%, 175/200), and access to health insurance (86%, 172/200). Undocumented residents were significantly more likely to cite health insurance as the most important area for assistance (p=0.04). Conclusion: Despite implementation of Affordable Care Act, access to health care and insurance were still perceived as the most important barriers among underserved patient populations, particularly undocumented groups.

Abdominal pain in children.

Abdominal pain and gastrointestinal symptoms such as vomiting or diarrhea are common chief complaints in young children who present in emergency departments. It is the emergency physician's role to differentiate between a self-limited process such as viral gastroenteritis or constipation and more life-threatening surgical emergencies. Considering the difficulties inherent in the pediatric examination, it is not surprising that appendicitis, intussusception, and malrotation with volvulus continue to be among the most elusive diagnoses. This article reviews both the self-limited and more life-threatening gastrointestinal conditions that may present in the emergency department.

Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation.

Succinylcholine is often used to facilitate neonatal and pediatric rapid sequence intubation in the emergency department, and most relevant literature recommends administering atropine prior to succinylcholine to reduce the risk of bradycardia. Given the potential complications associated with combining these medications, we searched the published literature for evidence supporting this practice. Most studies recommending atropine premedication were undertaken in the operating room setting and pertained to repeated succinylcholine dosing. Furthermore, there is little published evidence to indicate that succinylcholine-related bradycardia is a clinically important side effect. Several authors have called for the practice to cease, but, to date, these calls have gone unheeded. We found no evidence supporting atropine's use in pediatric patients prior to single-dose succinylcholine. Atropine premedication for emergency department rapid sequence intubation is unnecessary and should not be viewed as a "standard of care."

Apparent life-threatening events in infants: high risk in the out-of-hospital environment.

STUDY OBJECTIVE: The purpose of this study is to define the prevalence and significance of apparent life-threatening events among infants in the out-of-hospital setting. METHODS: This was a retrospective, cohort, outcome study of infants for whom a caregiver activated the emergency medical services (EMS) system. For purposes of the study, an apparent life-threatening event was defined as an episode of apnea, skin color change, or change in muscle tone. Study data characteristics included initial physical appearance, work of breathing, circulation skin signs, pulse rate, respiratory rate, and overall concern for the chief complaint as interpreted by EMS personnel. RESULTS: Sixty (7.5%) of 804 infants encountered by EMS during the study period met our criteria for apparent life-threatening event. Mean age was 3.1+/-3.3 months, and 55% were boys. Of the infants with apparent life-threatening event, 50 (83.3%) infants appeared to be in no distress, 8 (13.3%) infants were in mild distress, and 2 (3.3%) infants were in moderate distress. General physical appearance, work of breathing, circulatory signs, respiratory rate, and pulse rate were not clinically abnormal in the study group as a whole. Critical conditions associated with apparent life-threatening event included pneumonia or bronchiolitis (12%), seizure (8%), sepsis (7%), intracranial hemorrhage (3%), bacterial meningitis (2%), dehydration (2%), and severe anemia (2%). Limitations of the study included retrospective design and inability to follow up study patients beyond hospital discharge. CONCLUSION: An apparent life-threatening event in an infant can present without signs of acute illness and is commonly encountered in the EMS setting. It is often associated with significant medical conditions, and EMS personnel should be aware of the clinical importance of an apparent life-threatening event. Infants meeting criteria for an apparent life-threatening event should receive a timely and thorough medical evaluation.

Abdominal surgical emergencies in infants and young children.

Surgical emergencies can be missed easily in children, who are not always able to volunteer relevant information. Awareness of the entities discussed in this review might help the EP uncover subtle clues to early diagnoses that might not be initially apparent. Ill-appearing children who have abdominal pain and vomiting should be considered to have ischemic or necrotic bowel until proven otherwise. Possible diagnoses include volvulus, intussusception, and necrotizing enterocolitis. Bilious vomiting, especially in a young infant, should be considered to be an indication of a high bowel obstruction such as midgut volvulus, which warrants immediate surgical consultation. Significant rectal bleeding with abdominal pain can result from intussusception, volvulus, or an inflamed Meckel's diverticulum. Rectal bleeding with unstable vital signs can result from an upper GI bleed (eg, peptic ulcer disease). Painless rectal bleeding can result from a Meckel's diverticulum, polyps, arteriovenous malformation, or a tumor. Examination of the genitalia is imperative, especially in boys, to exclude the possibility of an incarcerated hernia or testicular torsion.

Common complaints in the first 30 days of life.

Visits to the emergency department (ED) by neonates and their parents can cause anxiety for parents and the ED staff. Many of the presenting complaints are unique to the neonatal population, and an understanding of both common problems and true medical emergencies is paramount. This article discusses the complaints the EDs have seen more frequently as a result of earlier newborn discharges from hospitals.