Association of Educational Intervention With Knowledge of Airway Injury After Endotracheal Intubation and Tube Size Selection.

In this nonrandomized controlled trial, an educational intervention for emergency medicine residents was developed to increase knowledge of airway injury following prolonged intubation and reduce the proportion of large-for-height endotracheal tubes placed in the emergency department.

Assessment of safety and effectiveness of non-neurosurgical management for minimal traumatic brain injury (TBI).

BACKGROUND: Patients with mild traumatic brain injury (TBI) and intracranial hemorrhage often receive neurosurgical consultation. However, only a small proportion of patients require intervention. Our hypothesis is that low-risk minimal TBI patients managed without immediate neurosurgical consultation will have a reasonable safety and effectiveness outcome profile. METHODS: A non-neurosurgical management protocol for adult minimal TBI was implemented at a level I trauma center as an interdisciplinary quality-improvement initiative in November 2018. Minimal TBI was defined as Glasgow Coma Scale (GCS) of 15 secondary to blunt mechanism, without anticoagulant or antiplatelet therapy, and isolated pneumocephalus and/or traumatic subarachnoid hemorrhage on head CT imaging. Safety was assessed by in-hospital mortality, neurosurgical interventions, and ED revisits within two weeks of discharge. Effectiveness was assessed by neurosurgical consult rate and length of stay. Outcomes were compared 8-months pre- and post-protocol implementation. RESULTS: A total of 97 patients were included, of which 49 were pre-protocol and 48 were post-protocol There was no difference in rates of in-hospital mortality [0 (0%) vs 0 (0%)], neurosurgical procedure [1 (2.1%) vs 0 (0%)], operations [0 (0%) vs 0 (0%)], and ED revisits [1 (2.0%) vs 2 (4.2%), p = 0.985] between the periods. There was a significant reduction in neurosurgical consults post-protocol implementation (92% vs 29%, p<0.001). CONCLUSION: A protocol for minimal TBI patients effectively reduced neurosurgical consultation without changes in safety profile. Such an interdisciplinary management protocol for low-risk neurotrauma can effectively utilize the neurosurgery consult services by stratifying neurologically stable TBI patient.

Decision Support to Improve Critical Care Services Documentation in an Academic Emergency Department.

OBJECTIVES: Critical care services (CCS) documentation affects billing, operations, and research. No studies exist on documentation decision support (DDS) for CCS in the emergency department (ED). We describe the design, implementation, and evaluation of a DDS tool built to improve CCS documentation at an academic ED. METHODS: This quality improvement study reports the prospective design, implementation, and evaluation of a novel DDS tool for CCS documentation at an academic ED. CCS-associated ED diagnoses triggered a message to appear within the physician note attestation workflow for any patient seen in the adult ED. The alert raised awareness of CCS-associated diagnoses without recommending specific documentation practices. The message disappeared from the note automatically once signed. We measured current procedural terminology (CPT) codes 99291 or 99292 (representing CCS rendered) for 8 months before and after deployment to identify CCS documentation rates. We performed state-space Bayesian time-series analysis to evaluate the causal effect of our intervention on CCS documentation capture. We used monthly ED volume and monthly admission rates as covariate time-series for model generation. RESULTS: The study included 92,350 ED patients with an observed mean proportion CCS of 3.9% before the intervention and 5.8% afterward. The counterfactual model predicted an average response of 3.9% [95% CI 3.5-4.3%]. The estimated absolute causal effect of the intervention was 2.0% [95% CI 1.5-2.4%] (p = 0.001). CONCLUSION: A DDS tool measurably increased ED CCS documentation. Attention to user workflows and collaboration with compliance and billing teams avoided alert fatigue and ensures compliance.

Effect of Smartphone App-Based Education on Clinician Prescribing Habits in a Learning Health Care System: A Randomized Cluster Crossover Trial.

Importance: Effective methods for engaging clinicians in continuing education for learning-based practice improvement remain unknown. Objective: To determine whether a smartphone-based app using spaced education with retrieval practice is an effective method to increase evidence-based practice. Design, Setting, and Participants: A prospective, unblinded, single-center, crossover randomized clinical trial was conducted at a single academic medical center from January 6 to April 24, 2020. Vanderbilt University Medical Center clinicians prescribing intravenous fluids were invited to participate in this study. Interventions: All clinicians received two 4-week education modules: 1 on prescribing intravenous fluids and 1 on prescribing opioid and nonopioid medications (counterbalancing measure), over a 12-week period. The order of delivery was randomized 1:1 such that 1 group received the fluid management module first, followed by the pain management module after a 4-week break, and the other group received the pain management module first, followed by the fluid management module after a 4-week break. Main Outcomes and Measures: The primary outcome was evidence-based clinician prescribing behavior concerning intravenous fluids in the inpatient setting and pain medication prescribing on discharge from the hospital. Results: A total of 354 participants were enrolled and randomized, with 177 in group 1 (fluid then pain management education) and 177 in group 2 (pain management then fluid education). During the overall study period, 16 868 questions were sent to 349 learners, with 11 783 (70.0%) being opened: 10 885 (92.4%) of those opened were answered and 7175 (65.9%) of those answered were answered correctly. The differences between groups changed significantly over time, indicated by the significant interaction between educational intervention and time (P = .002). Briefly, at baseline evidence-concordant IV fluid ordered 7.2% less frequently in group 1 than group 2 (95% CI, -19.2% to 4.9%). This was reversed after training at 4% higher (95% CI, -8.2% to 16.0%) in group 1 than group 2, a more than doubling in the odds of evidence-concordant ordering (OR, 2.56, 95% CI, 0.80-8.21). Postintervention, all gains had been reversed with less frequent ordering in group 1 than group 2 (-9.5%, 95% CI, -21.6% to 2.7%). There was no measurable change in opioid prescribing behaviors at any time point. Conclusions and Relevance: In this randomized clinical trial, use of smartphone app learning modules resulted in statistically significant short-term improvement in some prescribing behaviors. However, this effect was not sustained over the long-term. Additional research is needed to understand how to sustain improvements in care delivery as a result of continuous professional development at the institutional level. Trial Registration: ClinicalTrials.gov Identifier: NCT03771482.

Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings.

STUDY OBJECTIVE: Abnormal findings unrelated to the indication for testing are identified on emergency department (ED) imaging studies. We report the design and implementation of an electronic health record-based interdisciplinary referral system and our experience from the first 13 months of ensuring that patients with incidental radiology findings were connected with the appropriate outpatient surveillance. METHODS: Our informatics team standardized the contemporaneous reporting of critical radiology alerts using our ED trackboard and created a companion follow-up request form for the treating ED clinicians to complete. The forms were routed to nurse case managers, who arranged follow-ups based on the findings and clinical significance. The primary outcome was the proportion of ED patient visits with identified incidental findings that had documented communication of the incidental findings and surveillance plans. RESULTS: Over the first 13 months after implementation, 932 ED patient visits had critical radiology alert referrals, for a total of 982 incidental findings. The primary outcome (confirmed post-ED communication and documented follow-up plan) was attained in 888 (95.3%, 95% confidence interval [CI] 93.9% to 96.6%) ED patient visits with confirmed post-ED communication and documented follow-up plans. The team was unable to contact or confirm follow-up with 44 (4.7%, 95% CI 3.4 to 6.1) patients by telephone or through the health care system's electronic communication tools. CONCLUSION: We report the implementation of a standardized notification and referral system for ED patients with incidental radiology findings. The development of a reliable notification and follow-up system is an important patient safety intervention given the opportunity to potentially identify undiagnosed malignancies.

Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project.

BACKGROUND: Patients taking high doses of opioids, or taking opioids in combination with other central nervous system depressants, are at increased risk of opioid overdose. Coprescribing the opioid-reversal agent naloxone is an essential safety measure, recommended by the surgeon general, but the rate of naloxone coprescribing is low. Therefore, we set out to determine whether a targeted clinical decision support alert could increase the rate of naloxone coprescribing. METHODS: We conducted a before-after study from January 2019 to April 2021 at a large academic health system in the Southeast. We developed a targeted point of care decision support notification in the electronic health record to suggest ordering naloxone for patients who have a high risk of opioid overdose based on a high morphine equivalent daily dose (MEDD) ≥90 mg, concomitant benzodiazepine prescription, or a history of opioid use disorder or opioid overdose. We measured the rate of outpatient naloxone prescribing as our primary measure. A multivariable logistic regression model with robust variance to adjust for prescriptions within the same prescriber was implemented to estimate the association between alerts and naloxone coprescribing. RESULTS: The baseline naloxone coprescribing rate in 2019 was 0.28 (95% confidence interval [CI], 0.24-0.31) naloxone prescriptions per 100 opioid prescriptions. After alert implementation, the naloxone coprescribing rate increased to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions (P < .001). The adjusted odds of naloxone coprescribing after alert implementation were approximately 28 times those during the baseline period (95% CI, 15-52). CONCLUSIONS: A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build.

Impact of an Asynchronous Spaced Education Learning Intervention on Emergency Medicine Clinician Opioid Prescribing.

Introduction Opioid prescribing has contributed to the opioid crisis and education has focused on improved opioid stewardship. We aimed to evaluate the impact of an asynchronous high-quality education to change emergency medicine (EM) clinician opioid prescribing. Methods We conducted a retrospective cohort study of a spaced-education intervention in EM clinicians who work at an urban, university-affiliated academic medical center emergency department. We developed opioid prescribing educational content and investigated whether prescriber participation in a novel asynchronous educational program, QuizTime, was associated with a change in EM clinician opioid prescribing practices and whether those prescribing practice changes would be maintained. The primary outcome was the frequency of opioid prescriptions by attributable emergency department discharges. We compared the frequency during the post-intervention period, 24 months following QuizTime education (July 2018 - June 2020) to the baseline period (November 2016 - March 2018). The secondary outcomes were total morphine milligram equivalent (MME) and the number of tablets dispensed per prescription. We analyzed the outcomes by EM clinicians' level of participation in QuizTime education. Results During the study period, there was an overall reduction in opioid prescribing per attributable emergency department discharge (p < 0.001). Among the 45 prescribers who enrolled in QuizTime, there was a significant reduction of 4.3 (95% CI: 3.9, 4.6, p < 0.001) opioid prescriptions per 100 ED discharges in the post-intervention period compared to baseline. Among the 11 non-enrollees, there was a significant reduction of 2.4 (95% CI: 1.7, 3.1, p < 0.001) opioid prescriptions per 100 emergency department discharges in the post-intervention period compared to baseline. The prescribers enrolled in QuizTime had a significantly larger reduction in prescriptions compared to those who did not enroll (p < 0.001). A decreasing trend of total MME and the number of tablets dispensed was observed (p < 0.001). However, there was insufficient evidence to show a reduction in the number of tablets dispensed or MME per day. Conclusion EM clinician participation in the QuizTime Pain Management educational program was associated with a nearly two-fold decrease in opioid prescriptions per emergency department discharge compared to peers who chose not to enroll.

LVS-HARMED Risk Score for Incident Heart Failure in Patients With Atrial Fibrillation Who Present to the Emergency Department: Data from a World-Wide Registry.

Background Heart failure (HF) is a common complication to atrial fibrillation (AF), leading to rehospitalization and death. Early identification of patients with AF at risk for HF might improve outcomes. We aimed to derive a score to predict 1-year risk of new-onset HF after an emergency department (ED) visit with AF. Methods and Results The RE-LY AF (Randomized Evaluation of Long-Term Anticoagulant Therapy) registry enrolled patients with AF presenting to an ED in 47 countries, and followed them for a year. The end point was HF hospitalization and/or HF death. Among 15 400 ED patients, 9765 had no prior HF (mean age, 64.9±14.9 years). Within 1 year, new-onset HF developed in 6.8% of patients, of whom 21% died of HF. Independent predictors of HF included left ventricular hypertrophy (odds ratio [OR], 1.47; 95% CI, 1.19-1.82), valvular heart disease (OR, 1.55; 95% CI, 1.18-2.04), smoking (OR, 1.42; 95% CI, 1.12-1.78), height (OR, 0.93; 95% CI, 0.90-0.95 per 3 cm), age (OR, 1.11; 95% CI, 1.07-1.15 per 5 years), rheumatic heart disease (OR, 1.77, 95% CI, 1.24-2.51), prior myocardial infarction (OR, 1.85; 95% CI, 1.45-2.36), remaining in AF at ED discharge (OR, 1.86; 95% CI, 1.46-2.36), and diabetes (OR, 1.33; 95% CI, 1.09-1.64). A continuous risk prediction score (LVS-HARMED [left ventricular, valvular heart disease, smoking or other tobacco use, height, age, rheumatic heart disease, myocardial infarction, emergency department discharge rhythm, and diabetes]) had good discrimination (C statistic, 0.735; 95% CI, 0.716-0.755). Validation was conducted internally using bootstrapping (optimism-corrected C statistic, 0.705) and externally (C statistic, 0.699). The 1-year incidence of HF hospitalization and/or HF death across quartile groups of the score was 1.1%, 4.5%, 6.9%, and 14.4%, respectively. LVS-HARMED also predicted incident stroke (C statistic, 0.753; 95% CI, 0.728-0.778). Conclusions The LVS-HARMED score predicts new-onset HF after an ED visit for AF. Preventative strategies should be considered in patients with high LVS-HARMED HF risk.

Description of the Use of Incentives and Penalties for Point-of-Care Ultrasound Documentation Compliance in an Academic Emergency Department.

Objectives Incomplete documentation and submission to the electronic health record of performed point-of-care ultrasound (POCUS) studies is problematic from a patient care, medicolegal, and billing standpoint. Positive and negative financial incentives may be used to motivate physicians to complete documentation workflow. The most efficacious route to improve POCUS workflow completion remains to be determined. Materials and methods A retrospective analysis of POCUS documentation in an academic emergency department during four distinct six-month blocks was performed. POCUS workflow completion was assessed without incentives (Baseline), with financial bonus (Incentive), interim period (Washout), and with a negative financial incentive (Penalty) to determine the effect of these incentives on workflow completion. Results There was an appreciable increase in the rate of POCUS studies documented between the "Baseline" (no incentive) and "Incentive" (small financial bonus) time periods. The improvement remained stable during the "Washout" (interim) period, and then increased further in the "Penalty" (negative financial incentive) period. This improvement was relatively diffuse among the providers studied. A similar pattern - improvements in the Incentive and Penalty periods with stability in the Washout - was also observed in the POCUS volume data (number of studies performed). Conclusions This study reveals a positive association between the implementation of both financial incentives and financial penalties, which increases in POCUS documentation among attending physicians at an academic emergency department.

A model for rapid emergency department expansion for the COVID-19 pandemic.

COVID-19 has caused global dramatic change in medical practices including the introduction of temporary screening and assessment areas outside the footprint of the main hospital structures. Following the initial surge of patients with novel coronavirus (2019-nCoV) in the United States, our medical center rapidly designed and constructed an alternative assessment and treatment site in a converted parking garage deck for emergency department patients with suspected or confirmed 2019-nCoV. During the first month after opening, 651 patients were treated in this alternative assessment area including 54 patients who tested positive for 2019-nCoV. This accounted for 55% of the 98 patients with confirmed novel coronavirus (2019-nCoV) who were treated in our ED. This report provides a blueprint for the necessary steps, materials, labor needs and barriers, both anticipated and unanticipated, to rapidly construct an alternative ED treatment site during a pandemic.

Managing sedation in the mechanically ventilated emergency department patient: a clinical review.

Managing sedation in the ventilated emergency department (ED) patient is increasingly important as critical care unit admissions from EDs increase and hospital crowding results in intubated patients boarding for longer periods. The objectives of this review are 3-fold; (1) describe the historical perspective of how sedation of the ventilated patient has changed, (2) summarize the most commonly used sedation and analgesic agents, and (3) provide a practical approach to sedation and analgesia in mechanically ventilated ED patients. We searched PubMed using keywords "emergency department post-intubation sedation," "emergency department critical care length of stay," and "sedation in mechanically ventilated patient." The search results were limited to English language and reviewed for relevance to the subject of interest. Our search resulted in 723 articles that met the criteria for managing sedation in the ventilated ED patient, of which 19 articles were selected and reviewed. Our review of the literature found that the level of sedation and practices of sedation and analgesia in the ED environment have downstream consequences on patient care including overall patient centered outcomes even after the patient has left the ED. It is reasonable to begin with analgesia in isolation, although sedating medications should be used when patients remain uncomfortable and agitated after initial interventions are performed.