The Effect of a Simulation-based Intervention on Emergency Medicine Resident Management of Early Pregnancy Loss.

Background: The evaluation of patients with first-trimester vaginal bleeding and concern for early pregnancy loss (EPL) frequently occurs in the emergency department (ED), accounting for approximately 1.6% of all ED visits.1 Unfortunately, these patients consistently report negative experiences with ED care.2-8 In addition to environmental concerns, such as long wait times, patients often describe negative interactions with staff, including a perceived lack of empathy, the use of insensitive language, and inadequate counseling.2,3 These patients and their partners often view EPL as a traumatic loss of life and commonly experience prolonged grief reactions, including anxiety and depression.9-11 Poor satisfaction with care has been associated with worse mental health outcomes.12 These complaints represent an important opportunity for improvement in emergency medicine (EM) training.13 While no published literature to date describes the performance of EM residents in managing patients presenting with EPL, studies suggest that even obstetrics and gynecology (OB/GYN) residents find these interactions challenging.14,15 Simulation- and didactic-based training has been shown to be beneficial in improving OB/GYN resident EPL counseling and has been associated with improved patient outcomes.16 To our knowledge, this has yet to be replicated in EM residency training. Objectives: We aimed to develop and evaluate a simulation-based educational intervention to improve EM resident management of patients presenting with EPL.

Effect of Intranasal Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Treatment for epistaxis includes application of intranasal vasoconstrictors. These medications have a precaution against use in patients with hypertension. Given that many patients who present with epistaxis are hypertensive, these warnings are commonly overridden by clinical necessity. OBJECTIVE: Our aim was to determine the effects of intranasal vasoconstrictors on blood pressure. METHODS: We conducted a single-center, randomized, double-blind, placebo-controlled trial from November 2014 through July 2016. Adult patients being discharged from the emergency department (ED) at Mayo Clinic (Rochester, Minnesota) were recruited. Patients were ineligible if they had a contraindication to study medications, had a history of hypertension, were currently taking antihypertensive or antidysrhythmic medications, or had nasal abnormalities, such as epistaxis. Subjects were randomized to one of four study arms (phenylephrine 0.25%; oxymetazoline 0.05%; lidocaine 1% with epinephrine 1:100,000; or bacteriostatic 0.9% sodium chloride [saline]). Blood pressure and heart rate were measured every 5 min for 30 min. RESULTS: Sixty-eight patients were enrolled in the study; of these, 63 patients completed the study (oxymetazoline, n = 15; phenylephrine, n = 20; lidocaine with epinephrine, n = 11; saline, n = 17). We did not observe any significant differences in mean arterial pressure over time between phenylephrine and saline, oxymetazoline and saline, or lidocaine with epinephrine and saline. The mean greatest increases from baseline in mean arterial pressure, systolic and diastolic blood pressure, and heart rate for each treatment group were also not significantly different from the saline group. CONCLUSIONS: Intranasal vasoconstrictors did not significantly increase blood pressure in patients without a history of hypertension. Our findings reinforce the practice of administering these medications to patients who present to the ED with epistaxis, regardless of high blood pressure.

Implementation of an Opioid Detoxification Management Pathway Reduces Emergency Department Length of Stay.

OBJECTIVES: With the rise of opioid use in the United States, the increasing demand for treatment for opioid use disorders presents both a challenge and an opportunity to develop new care pathways for emergency department (ED) patients seeking opioid detoxification. We set out to improve the care of patients presenting to our ED seeking opioid detoxification by implementing a standardized management pathway and to measure the effects of this intervention. METHODS: We conducted a before-after study of the effects of an opioid detoxification management pathway on ED length of stay (EDLOS), use of resources (social worker consultation, laboratory tests obtained), and return visits to the same ED within 30 days of discharge. All data were collected retrospectively by review of the electronic health record. RESULTS: Ultimately, 107 patients presented to the ED that met criteria, 52 in the intervention period and 55 in the preintervention period. Median EDLOS in the intervention period was 152 (interquartile range [IQR] = 93-237) minutes compared to 312 (IQR = 187-468) minutes in the preintervention period (p < 0.001). Patients in the intervention period less frequently had a social work consultation (32.7% vs. 83.6%, p < 0.001) or had laboratory tests obtained (32.7% vs 74.5%, p < 0.001) and more frequently were prescribed a medication for withdrawal symptoms (57.7% vs. 29.1%, p = 0.003). CONCLUSIONS: Implementation of an opioid detoxification management pathway reduced EDLOS, reduced utilization of resources, and increased the proportion of patients prescribed medications for symptom relief.

Access to primary care and computed tomography use in the emergency department.

BACKGROUND: The decision to obtain a computed tomography CT scan in the emergency department (ED) is complex, including a consideration of the risk posed by the test itself weighed against the importance of obtaining the result. In patients with limited access to primary care follow up the consequences of not making a diagnosis may be greater than for patients with ready access to primary care, impacting diagnostic reasoning. We set out to determine if there is an association between CT utilization in the ED and patient access to primary care. METHODS: We performed a cross-sectional study of all ED visits in which a CT scan was obtained between 2003 and 2012 at an academic, tertiary-care center. Data were abstracted from the electronic medical record and administrative databases and included type of CT obtained, demographics, comorbidities, and access to a local primary care provider (PCP). CT utilization rates were determined per 1000 patients. RESULTS: A total of 595,895 ED visits, including 98,001 visits in which a CT was obtained (16.4%) were included. Patients with an assigned PCP accounted for 55% of all visits. Overall, CT use per 1000 ED visits increased from 142.0 in 2003 to 169.2 in 2012 (p < 0.001), while the number of annual ED visits remained stable. CT use per 1000 ED visits increased from 169.4 to 205.8 over the 10-year period for patients without a PCP and from 118.9 to 142.0 for patients with a PCP. Patients without a PCP were more likely to have a CT performed compared to those with a PCP (OR 1.57, 95%CI 1.54 to 1.58; p < 0.001). After adjusting for age, gender, year of visit and number of comorbidities, patients without a PCP were more likely to have a CT performed (OR 1.20, 95% CI 1.18 to 1.21, p < 0.001). CONCLUSIONS: The overall rate of CT utilization in the ED increased over the past 10 years. CT utilization was significantly higher among patients without a PCP. Increased availability of primary care, particularly for follow-up from the ED, could reduce CT utilization and therefore decrease costs, ED lengths of stay, and radiation exposure.

Point-of-Care Ultrasound Diagnosis of Traumatic Abdominal Wall Hernia.

Traumatic abdominal wall hernias due to blunt abdominal trauma in pediatric patients can pose a diagnostic challenge because of spontaneous hernia reduction. Ultrasonography may be superior to computed tomography for this indication in some cases because of the ability to dynamically and repeatedly assess the area of injury. Herniation can be induced or exaggerated via Valsalva maneuvers, which can facilitate its detection during dynamic assessment. We present the case of a 3-year-old boy who sustained blunt abdominal trauma, with a resultant abdominal wall hernia that was diagnosed using point-of-care ultrasound imaging. This hernia was not visualized with computed tomography, and point-of-care ultrasonography expedited admission for operative repair.

Predicting Early Rapid Response Team Activation in Patients Admitted From the Emergency Department: The PeRRT Score.

OBJECTIVES: Rapid response teams (RRTs) respond to signs of deterioration to avoid morbidity and mortality. Early RRT activation (eRRT) in patients admitted from the emergency department (ED) is associated with significantly increased mortality. Predicting these events may represent an opportunity to identify patients who would benefit from further resuscitation, aid disposition decision-making, or improve communication between ED and inpatient providers. We aimed to create a clinical prediction instrument to quantify the risk of eRRT. METHODS: We performed an observational cohort study of patients admitted to a non-intensive care unit (ICU) setting who triggered eRRT from January 2009 to December of 2012 compared to those who did not trigger eRRT. Age, sex, ED vital sign measurements, and final ED diagnosis by ICD-9 code were evaluated in a multivariable logistic regression model. The performance of prediction models was assessed using discrimination summarized by area under a receiver operating curve (AUC) and calibration with the Hosmer and Lemeshow goodness-of-fit test. The final model was used to create a simplified scoring system. RESULTS: The eRRT group consisted of 474 patients who were compared to 2,575 patients in the reference group. Age and sex did not add significant discrimination to the model and were eliminated from the simplified, final model. This model, which included vital signs and diagnosis category, was found to have an AUC of 0.754 (95% confidence interval [CI] = 0.730 to 0.778) and was used to create a simplified scoring system. The odds ratio for the association of a 1-unit increase in risk score with eRRT was 1.37 (95% CI = 1.32 to 1.41; p < 0.001). When internally validated, the score was found to have an AUC of 0.759 (95% CI = 0.735 to 0.753). Calculated scores ranged from -3 to 18, which corresponded to predicted probabilities of eRRT ranging from 5.1% to 72.2%. CONCLUSIONS: In summary, the PeRRT score is a simple tool that can be referenced by emergency providers at the bedside to quantify the risk of early RRT activation and potential deterioration, helping to answer the question, "How likely is my patient to trigger an RRT activation in the next twelve hours?" Given that patients who trigger eRRT have an elevated risk of morbidity and mortality, higher scores should result in resuscitative intervention, further observation in the ED, consideration of ICU admission, or direct enhanced communication between ED and inpatient providers. A prospective multicenter study is required to further validate this instrument.

Vital Signs Predict Rapid-Response Team Activation Within Twelve Hours of Emergency Department Admission.

INTRODUCTION: Rapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration marked by decline in vital signs. Traditionally emergency department (ED) disposition is partially based on the patients' vital signs (VS) at the time of hospital admission. We aimed to identify which patients will have RRT activation within 12 hours of admission based on their ED VS, and if their outcomes differed. METHODS: We conducted a case-control study of patients presenting from January 2009 to December 2012 to a tertiary ED who subsequently had RRT activations within 12 hours of admission (early RRT activations). The medical records of patients 18 years and older admitted to a non-intensive care unit (ICU) setting were reviewed to obtain VS at the time of ED arrival and departure, age, gender and diagnoses. Controls were matched 1:1 on age, gender, and diagnosis. We evaluated VS using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all patients. Our study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational studies. RESULTS: A total of 948 patients were included (474 cases and 474 controls). Patients who had RRT activations were more likely to be tachycardic (odds ratio [OR] 2.02, 95% CI [1.25-3.27]), tachypneic (OR 2.92, 95% CI [1.73-4.92]), and had lower oxygen saturations (OR 2.25, 95% CI [1.42-3.56]) upon arrival to the ED. Patients who had RRT activations were more likely to be tachycardic at the time of disposition from the ED (OR 2.76, 95% CI [1.65-4.60]), more likely to have extremes of systolic blood pressure (BP) (OR 1.72, 95% CI [1.08-2.72] for low BP and OR 1.82, 95% CI [1.19-2.80] for high BP), higher respiratory rate (OR 4.15, 95% CI [2.44-7.07]) and lower oxygen saturation (OR 2.29, 95% CI [1.43-3.67]). Early RRT activation was associated with increased healthcare utilization and worse outcomes including increased rates of ICU admission within 72 hours (OR 38.49, 95%CI [19.03-77.87]), invasive interventions (OR 5.49, 95%CI [3.82-7.89]), mortality at 72 hours (OR 4.24, 95%CI [1.60-11.24]), and mortality at one month (OR 4.02, 95%CI [2.44-6.62]). CONCLUSION: After matching for age, gender and ED diagnosis, we found that patients with an abnormal heart rate, respiratory rate or oxygen saturation at the time of ED arrival or departure are more likely to trigger RRT activation within 12 hours of admission. Early RRT activation was associated with higher mortality at 72 hours and one month, increased rates of invasive intervention and ICU admission. Determining risk factors of early RRT activation is of clinical, operational, and financial importance, as improved medical decision-making regarding disposition would maximize allocation of resources while potentially limiting morbidity and mortality.

Impact of an Emergency Department Observation Unit Management Algorithm for Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes. METHODS AND RESULTS: This retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 day's duration. CONCLUSIONS: Implementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.

Validation of a decision rule for selective TSH screening in atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is the most common cardiac dysrhythmia. Current guidelines recommend obtaining thyroid-stimulating hormone (TSH) levels in all patients presenting with AF. Our aim was to investigate the utility of TSH levels for emergency department (ED) patients with a final diagnosis of AF while externally validating and potentially refining a clinical decision rule that recommends obtaining TSH levels only in patients with previous stroke, hypertension, or thyroid disease. METHODS: We conducted a retrospective, cross-sectional study of consecutive patients who presented to an ED from January 2011 to March 2014 with a final ED diagnosis of AF. Charts were reviewed for historical features and TSH level. We assessed the sensitivity and specificity of the previously derived clinical decision rule. RESULTS: Of the 1,964 patients who were eligible, 1,458 (74%) had a TSH level available for analysis. The overall prevalence of a low TSH (<0.3µIU/mL) was 2% (n=36). Elevated TSH levels (>5µIU/mL) were identified in 11% (n=159). The clinical decision rule had a sensitivity of 88.9% (95% CI [73.0-96.4]) and a specificity of 27.5% (95% CI [25.2-29.9]) for identifying a low TSH. When analyzed for its ability to identify any abnormal TSH values (high or low TSH), the sensitivity and specificity were 74.4% (95% CI [67.5-80.2]) and 27.3% (95% CI [24.9-29.9]), respectively. CONCLUSION: Low TSH in patients presenting to the ED with a final diagnosis of AF is rare (2%). The sensitivity of a clinical decision rule including a history of thyroid disease, hypertension, or stroke for identifying low TSH levels in patients presenting to the ED with a final diagnosis of atrial fibrillation was lower than originally reported (88.9% vs. 93%). When elevated TSH levels were included as an outcome, the sensitivity was reduced to 74.4%. We recommend that emergency medicine providers not routinely order TSH levels for all patients with a primary diagnosis of AF. Instead, these investigations can be limited to patients with new onset AF or those with a history of thyroid disease with no known TSH level within three months.