Impact of emergency department-based intensive care unit on outcomes of decompensating boarding emergency department patients.

Objectives: Emergency department (ED) boarding, or remaining in the ED after admission before transfer to an inpatient bed, is prevalent. Boarding patients may decompensate before inpatient transfer, necessitating escalation to the intensive care unit (ICU). We evaluated the impact of an ED-ICU on decompensating boarding ED patients. Methods: This is a retrospective single-center observational study. We identified decompensated boarding ED patients necessitating critical care before departure from the ED from October 2012 to December 2021. An automated query and manual chart review extracted data. Three cohorts were defined: pre-ED-ICU implementation (Group 1), post-ED-ICU implementation with ED-ICU care (Group 2), and post-ED-ICU implementation with inpatient ICU admission without ED-ICU care (Group 3). Primary outcome was ICU length of stay (LOS). Secondary outcomes included hospital LOS, in-hospital mortality, and ICU admissions with ICU LOS <24 hours. Between-groups comparisons used multiple regression analysis for continuous variables, χ2 tests and multivariable logistic regression analysis for binary variables, and follow-up contrasts for statistically significant omnibus tests. Results: A total of 1123 visits met inclusion criteria: 225 in Group 1, 780 in Group 2, and 118 in Group 3. Mean ICU LOS was shorter for Group 2 than Group 1 or 3 (47.4 vs 92.3 vs 103.9 hours, P < 0.001). Mean hospital LOS was shorter for Group 2 than Group 1 or 3 (185.1 vs 246.8 vs 257.3 hours, P < 0.01). In-hospital mortality was similar between groups. The proportion of ICU LOS <24 hours was lower for Group 2 than Group 1 or 3 (16.5 vs 27.1 vs 32.2%, P < 0.01). Conclusion: For decompensating boarding ED patients, ED-ICU care was associated with decreased ICU and hospital LOS, similar mortality, and fewer short-stay ICU admissions, suggesting ED-ICU care is associated with downstream resource preservation.

The Two-Bag Method for Management of Adult Diabetic Ketoacidosis-Experience With 634 Patients.

PURPOSE: To compare key resource utilization and safety outcomes of adult emergency department (ED) patients in diabetic ketoacidosis (DKA) managed via the Two-Bag or traditional One-Bag method. MATERIALS AND METHODS: This is a retrospective review at an academic medical center ED. Patients were included if >18 years, met diagnostic criteria for DKA (pH ≤ 7.30, bicarbonate ≤ 18 mmol/L, anion gap ≥ 10), and were managed via a standardized order set (either Two-Bag or One-Bag Method). Comparisons used independent-groups t-tests for continuous variables and χ2 tests for binary variables. RESULTS: We identified 634 patients with DKA managed via the Two-Bag method, and 107 managed via the One-Bag method. Cohorts were similar in demographics and presenting laboratories. The Two-Bag Method was associated with 8.1 h shorter to first bicarbonate >18 mmol/L (11.9 vs 20.0, P < .001), and 24 fewer IV fluid bags (5.3 vs 29.7, P < .001). Incidence of hypokalemia (potassium <3.0 mmol/L) was 53% lower in the Two-Bag cohort (6.6 vs 14.0%, P = .03); incidence of hypoglycemia (glucose <70 mg/dL) was 5.8 versus 10.3%, P = .16. CONCLUSIONS: For adult ED patients in DKA, the Two-Bag Method was associated with faster resolution of acidosis, fewer IV fluid bags charged, lower incidence of hypokalemia, and trend toward lower incidence of hypoglycemia compared to the One-Bag Method.

Euglycemic Diabetic Ketoacidosis: Experience with 44 Patients and Comparison to Hyperglycemic Diabetic Ketoacidosis.

Introduction: Euglycemic diabetic ketoacidosis (DKA) (glucose <250 milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period. Methods: This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18 years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18 millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250 milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250 mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t-tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05. Results: We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P < 0.05) and lower initial glucose (195 vs 561 mg/dL, P < 0.001) and potassium (4.3 vs 5.3 mmol/L, P < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P = 0.003. Mean times to first bicarbonate >18 mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70 mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P = 0.02); incidence of hypokalemia (<3.3 mmol/L) was 27.3 vs 19.1% (P = 0.23). Conclusion: Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia.

Cost-effectiveness of an Emergency Department-Based Intensive Care Unit.

Importance: Value in health care is quality per unit cost (V = Q/C), and an emergency department-based intensive care unit (ED-ICU) model has been associated with improved quality. To assess the value of this care delivery model, it is essential to determine the incremental direct cost of care. Objective: To determine the association of an ED-ICU with inflation-adjusted change in mean direct cost of care, net revenue, and direct margin per ED patient encounter. Design, Setting, and Participants: This retrospective economic analysis evaluated the cost of care delivery to patients in the ED before and after deployment of the Joyce and Don Massey Family Foundation Emergency Critical Care Center, an ED-ICU, on February 16, 2015, at a large academic medical center in the US with approximately 75 000 adult ED visits per year. The pre-ED-ICU cohort was defined as all documented ED visits by patients 18 years or older with a complete financial record from September 8, 2012, through June 30, 2014 (660 days); the post-ED-ICU cohort, all visits from July 1, 2015, through April 21, 2017 (660 days). Fiscal year 2015 was excluded from analysis to phase in the new care model. Statistical analysis was performed March 1 through December 30, 2021. Exposures: Implementation of an ED-ICU. Main Outcomes and Measures: Inflation-adjusted direct cost of care, net revenue, and direct margin per patient encounter in the ED. Results: A total of 234 884 ED visits during the study period were analyzed, with 115 052 patients (54.7% women) in the pre-ED-ICU cohort and 119 832 patients (54.5% women) in the post-ED-ICU cohort. The post-ED-ICU cohort was older (mean [SD] age, 49.1 [19.9] vs 47.8 [19.6] years; P < .001), required more intensive respiratory support (2.2% vs 1.1%; P < .001) and more vasopressor use (0.5% vs 0.2%; P < .001), and had a higher overall case mix index (mean [SD], 1.7 [2.0] vs 1.5 [1.7]; P < .001). Implementation of the ED-ICU was associated with similar inflation-adjusted total direct cost per ED encounter (pre-ED-ICU, mean [SD], $4875 [$15 175]; post-ED-ICU, $4877 [$17 400]; P = .98). Inflation-adjusted net revenue per encounter increased by 7.0% (95% CI, 3.4%-10.6%; P < .001), and inflation-adjusted direct margin per encounter increased by 46.6% (95% CI, 32.1%-61.2%; P < .001). Conclusions and Relevance: Implementation of an ED-ICU was associated with no significant change in inflation-adjusted total direct cost per ED encounter. Holding delivery costs constant while improving quality demonstrates improved value via the ED-ICU model of care.

Association of intentional cooling, achieved temperature and hypothermia duration with in-hospital mortality in patients treated with extracorporeal cardiopulmonary resuscitation: An analysis of the ELSO registry.

AIM: To investigate whether intentional cooling, achieved temperature and hypothermia duration were associated with in-hospital death in patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. METHODS: This is a retrospective analysis of the Extracorporeal Life Support Organization Registry. Patients 18-79 years of age who received ECPR between 2010 and 2019 were included. We compared outcomes for intentional cooling versus no intentional cooling. Then, among those who completed intentional cooling, we compared the outcomes between i) achieved temperature ≤ 34 °C, 34-36 °C, and > 36 °C, and ii) duration ≤ 36 °C for < 12 h, 12-48 h, and ≥ 48 h. The primary outcome was in-hospital mortality within 90 days. Cox proportional hazard models were generated with adjustment for covariates. RESULTS: Among 4,214 ECPR patients, 1,511 patients were included in the final analysis. After multivariable adjustment, there was no significant difference in in-hospital mortality between patients with intentional cooling and no intentional cooling (hazard ratio [HR], 1.06 [95% CI 0.93-1.21]; p = 0.394). In the 609 patients who completed intentional cooling, temperature at 34-36 °C had a significantly lower adjusted HR for in-hospital mortality compared with > 36 °C (HR, 0.73 [0.55-0.96]; p = 0.025). Moreover, temperature ≤ 36 °C for 12-48 h had a significantly lower adjusted HR for in-hospital mortality compared with ≤ 36 °C for < 12 h (HR, 0.69 [0.53-0.90]; p = 0.005). CONCLUSION: Intentional cooling was not associated with lower in-hospital mortality in ECPR patients. However, among patients with intentional cooling, achieving temperature of 34-36 °C for 12-48 h was associated with lower in-hospital mortality.

ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation.

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA. METHODS: We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale. RESULTS: Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26). CONCLUSION: We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.

Novel Negative Pressure Procedural Tent Reduces Aerosolized Particles in a Simulated Prehospital Setting.

BACKGROUND/OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of Emergency Medical Services (EMS) providers to maintain personal safety during the treatment and transport of patients potentially infected. Increased rates of COVID-19 infection in EMS providers after patient care exposure, and notably after performing aerosol-generating procedures (AGPs), have been reported. With an already strained workforce seeing rising call volumes and increased risk for AGP-requiring patient presentations, development of novel devices for the protection of EMS providers is of great importance.Based on the concept of a negative pressure room, the AerosolVE BioDome is designed to encapsulate the patient and contain aerosolized infectious particles produced during AGPs, making the cabin of an EMS vehicle safer for providers. The objective of this study was to determine the efficacy and safety of the tent in mitigating simulated infectious particle spread in varied EMS transport platforms during AGP utilization. METHODS: Fifteen healthy volunteers were enrolled and distributed amongst three EMS vehicles: a ground ambulance, an aeromedical-configured helicopter, and an aeromedical-configured jet. Sodium chloride particles were used to simulate infectious particles and particle counts were obtained in numerous locations close to the tent and around the patient compartment. Counts near the tent were compared to ambient air with and without use of AGPs (non-rebreather mask, continuous positive airway pressure [CPAP] mask, and high-flow nasal cannula [HFNC]). RESULTS: For all transport platforms, with the tent fan off, the particle generator alone, and with all AGPs produced particle counts inside the tent significantly higher than ambient particle counts (P <.0001). With the tent fan powered on, particle counts near the tent, where EMS providers are expected to be located, showed no significant elevation compared to baseline ambient particle counts during the use of the particle generator alone or with use of any of the AGPs across all transport platforms. CONCLUSION: Development of devices to improve safety for EMS providers to allow for use of all available therapies to treat patients while reducing risk of communicable respiratory disease transmission is of paramount importance. The AerosolVE BioDome demonstrated efficacy in creating a negative pressure environment and workspace around the patient and provided significant filtration of simulated respiratory droplets, thus making the confined space of transport vehicles potentially safer for EMS personnel.

Emergency department length of stay and outcomes of emergency department-based intensive care unit patients.

OBJECTIVE: Emergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED-based intensive care units (ED-ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED-ICU on patient outcomes. METHODS: We retrospectively analyzed adult ED patients managed in the ED-ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48-hour mortality, and hospital mortality. Multivariable analyses' covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3). RESULTS: We included 5859 ED visits with subsequent care in the ED-ICU. Median age, CCI, eSAPS3, ED LOS, and ED-ICU LOS were 62 years (interquartile range [IQR], 48-73 years), 5 (IQR, 2-8), 46 (IQR, 36-56), 3.6 hours (IQR, 2.5-5.3 hours), and 8.5 hours (IQR, 5.3-13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (ß = -3.4; 95% confidence interval [CI], -5.9 to -1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84-0.88), 48-hour mortality (OR, 0.89; 95% CI, 0.82-0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85-0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88-0.93), but no associations with other outcomes. CONCLUSIONS: We observed no significant associations between ED LOS before ED-ICU transfer and worsened outcomes, suggesting an ED-ICU may mitigate the risks of ED boarding of patients who are critically ill.

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.

Novel Negative Pressure Helmet Reduces Aerosolized Particles in a Simulated Prehospital Setting.

BACKGROUND/OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has created challenges in maintaining the safety of prehospital providers caring for patients. Reports have shown increased rates of Emergency Medical Services (EMS) provider infection with COVID-19 after patient care exposure, especially while utilizing aerosol-generating procedures (AGPs). Given the increased risk and rising call volumes for AGP-necessitating complaints, development of novel devices for the protection of EMS clinicians is of great importance.Drawn from the concept of the powered air purifying respirator (PAPR), the AerosolVE helmet creates a personal negative pressure space to contain aerosolized infectious particles produced by patients, making the cabin of an EMS vehicle safer for providers. The helmet was developed initially for use in hospitals and could be of significant use in the prehospital setting. The objective of this study was to determine the efficacy and safety of the helmet in mitigating simulated infectious particle spread in varied EMS transport platforms during AGP utilization. METHODS: Fifteen healthy volunteers were enrolled and distributed amongst three EMS vehicles: a ground ambulance, a medical helicopter, and a medical jet. Sodium chloride particles were used to simulate infectious particles, and particle counts were obtained in numerous locations close to the helmet and around the patient compartment. Counts near the helmet were compared to ambient air with and without use of AGPs (non-rebreather mask [NRB], continuous positive airway pressure mask [CPAP], and high-flow nasal cannula [HFNC]). RESULTS: Without the helmet fan on, the particle generator alone and with all AGPs produced particle counts inside the helmet significantly higher than ambient particle counts. With the fan on, there was no significant difference in particle counts around the helmet compared to baseline ambient particle counts. Particle counts at the filter exit averaged less than one despite markedly higher particle counts inside the helmet. CONCLUSION: Given the risk to EMS providers by communicable respiratory diseases, development of devices to improve safety while still enabling use of respiratory therapies is of paramount importance. The AerosolVE helmet demonstrated efficacy in creating a negative pressure environment and provided significant filtration of simulated respiratory droplets, thus making the confined space of transport vehicles potentially safer for EMS personnel.

Early Convalescent Plasma for High-Risk Outpatients with Covid-19.

BACKGROUND: Early administration of convalescent plasma obtained from blood donors who have recovered from coronavirus disease 2019 (Covid-19) may prevent disease progression in acutely ill, high-risk patients with Covid-19. METHODS: In this randomized, multicenter, single-blind trial, we assigned patients who were being treated in an emergency department for Covid-19 symptoms to receive either one unit of convalescent plasma with a high titer of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or placebo. All the patients were either 50 years of age or older or had one or more risk factors for disease progression. In addition, all the patients presented to the emergency department within 7 days after symptom onset and were in stable condition for outpatient management. The primary outcome was disease progression within 15 days after randomization, which was a composite of hospital admission for any reason, seeking emergency or urgent care, or death without hospitalization. Secondary outcomes included the worst severity of illness on an 8-category ordinal scale, hospital-free days within 30 days after randomization, and death from any cause. RESULTS: A total of 511 patients were enrolled in the trial (257 in the convalescent-plasma group and 254 in the placebo group). The median age of the patients was 54 years; the median symptom duration was 4 days. In the donor plasma samples, the median titer of SARS-CoV-2 neutralizing antibodies was 1:641. Disease progression occurred in 77 patients (30.0%) in the convalescent-plasma group and in 81 patients (31.9%) in the placebo group (risk difference, 1.9 percentage points; 95% credible interval, -6.0 to 9.8; posterior probability of superiority of convalescent plasma, 0.68). Five patients in the plasma group and 1 patient in the placebo group died. Outcomes regarding worst illness severity and hospital-free days were similar in the two groups. CONCLUSIONS: The administration of Covid-19 convalescent plasma to high-risk outpatients within 1 week after the onset of symptoms of Covid-19 did not prevent disease progression. (SIREN-C3PO ClinicalTrials.gov number, NCT04355767.).

An emergency department-based intensive care unit is associated with decreased hospital length of stay for upper gastrointestinal bleeding.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is associated with substantial morbidity, mortality, and intensive care unit (ICU) utilization. Initial risk stratification and disposition from the Emergency Department (ED) can prove challenging due to limited data points during a short period of observation. An ED-based ICU (ED-ICU) may allow more rapid delivery of ICU-level care, though its impact on patients with UGIB is unknown. METHODS: A retrospective observational study was conducted at a tertiary U.S. academic medical center. An ED-ICU (the Emergency Critical Care Center [EC3]) opened in February 2015. Patients presenting to the ED with UGIB undergoing esophagogastroduodenoscopy within 72 h were identified and analyzed. The Pre- and Post-EC3 cohorts included patients from 9/2/2012-2/15/2015 and 2/16/2015-6/30/2019. RESULTS: We identified 3788 ED visits; 1033 Pre-EC3 and 2755 Post-EC3. Of Pre-EC3 visits, 200 were critically ill and admitted to ICU [Cohort A]. Of Post-EC3 visits, 682 were critically ill and managed in EC3 [Cohort B], whereas 61 were critically ill and admitted directly to ICU without care in EC3 [Cohort C]. The mean interval from ED presentation to ICU level care was shorter in Cohort B than A or C (3.8 vs 6.3 vs 7.7 h, p < 0.05). More patients in Cohort B received ICU level care within six hours of ED arrival (85.3 vs 52.0 vs 57.4%, p < 0.05). Mean hospital length of stay (LOS) was shorter in Cohort B than A or C (6.2 vs 7.3 vs 10.0 days, p < 0.05). In the Post-EC3 cohort, fewer patients were admitted to an ICU (9.3 vs 19.4%, p < 0.001). The rate of floor admission with transfer to ICU within 24 h was similar. No differences in absolute or risk-adjusted mortality were observed. CONCLUSION: For critically ill ED patients with UGIB, implementation of an ED-ICU was associated with reductions in rate of ICU admission and hospital LOS, with no differences in safety outcomes.

Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact.

Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub-optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs-which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage-are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer-reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work-ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors-including the co-existence of other front-end interventions and delays in ED throughput not addressed by PIT-we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site-specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision-makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.

Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation.

INTRODUCTION: Emergency department (ED) patients are frequently ventilated with excessively large tidal volumes for predicted body weight based on height, which has been linked to poorer patient outcomes. We hypothesized that supplying tape measures to respiratory therapists (RT) would improve measurement of actual patient height and adherence to a lung-protective ventilation strategy in an ED-intensive care unit (ICU) environment. METHODS: On January 14, 2019, as part of a ventilator-associated pneumonia prevention bundle in our ED-based ICU, we began providing RTs with tape measures and created a best practice advisory reminding them to record patient height. We then retrospectively collected data on patient height and tidal volumes before and after the intervention. RESULTS: We evaluated 51,404 tidal volume measurements in 1,826 patients over the 4 year study period; of these patients, 1,579 (86.5%) were pre-intervention and 247 (13.5%) were post-intervention. The intervention was associated with a odds of the patient's height being measured were 10 times higher post-intervention (25.1% vs 3.2%, P <0.05). After the bundle was initiated, we observed a significantly higher percentage of patients ventilated with mean tidal volumes less than 8 cubic centimeters per kilogram (93.9% vs 84.5% P < 0.05). CONCLUSION: Patients in an ED-ICU environment were ventilated with a lung-protective strategy more frequently after an intervention reminding RTs to measure actual patient height and providing a tape measure to do so. A significantly higher percentage of patients had height measured rather than estimated after the intervention, allowing for more accurate determination of ideal body weight and calculation of lung-protective ventilation volumes. Measuring all mechanically ventilated patients' height with a tape measure is an example of a simple, low-cost, scalable intervention in line with guidelines developed to improve the quality of care delivered to critically ill ED patients.

Euglycemic diabetic ketoacidosis associated with SGLT2i use: Case series.

INTRODUCTION: Euglycemic diabetic ketoacidosis (EuDKA) associated with Sodium-Glucose Cotransporter-2 inhibitor (SGLT2i) use has been described but remains poorly understood. Data on Emergency Department (ED) presentation, resource utilization, and safety outcomes for these patients are lacking. We report a case series of patients diagnosed with EuDKA in the ED. METHODS: An electronic medical record search identified adult patients presenting to a large tertiary ED with EuDKA. They were screened for concurrent use of SGLT2i. Clinical presentation, resource utilization, safety, and disposition data were collected and described. RESULTS: Five patients were included for analysis. Median age [range] was 57 [43-73] years. Presenting symptoms included nausea, vomiting, fatigue, and altered mental status. Initial results included: serum glucose 191 mg/dL [176-215], venous pH 7.01 [6.95-7.30], serum HCO3 8 mEq/L [6-13], anion gap 27 [26-31], serum beta-hydroxybutyrate 9.9 mmol/L [9.2-12.3], and urine ketones 150 [150-150]. Patients remained on an insulin infusion for 18.77 h [11.25-56.48]. There were zero episodes of hypoglycemia and one episode of hypokalemia while on insulin infusion. Time to resolution of metabolic acidosis was 23.82 h [15.45-24.77]. DISCUSSION: We report a case series of ED patients with EuDKA associated with SGLT2i use, and describe presentation characteristics, resource utilization, and safety outcomes. Emergency physicians should be aware of the association between SGLT2i use and EuDKA. An appropriate work-up should be pursued for patients taking an SGLT2i who present with symptoms suggestive of DKA, including nausea, vomiting, malaise, and altered mental status, or are noted to have an unexplained elevated anion gap metabolic acidosis.

Splenic volvulus of a wandering spleen.

BACKGROUND: Wandering spleen is a rare condition in which the spleen is not anchored properly, due to congenital or acquired weakness of the splenic ligaments. This allows the spleen to migrate to any portion of the abdomen or pelvis, and can cause complications, including a splenic volvulus. The presentation of splenic volvulus of a wandering spleen ranges from mild pain to a surgical emergency. Splenic volvulus of a wandering spleen can cause significant morbidity and mortality, and often warrants surgical intervention. Cases of splenic volvulus of a wandering spleen have been reported in radiology and surgery literature, however there are no reports in emergency medicine literature in North America. CASE REPORT: A 37-year-old female presented to the ED with seven days of mild left upper quadrant abdominal pain that acutely worsened. She underwent laboratory studies which were near her baseline values. A CT abdomen pelvis demonstrated findings consistent with splenic volvulus of a wandering spleen. She was taken emergently to the operating room for exploratory laparotomy, detorsion of spleen, and splenectomy. Her postoperative course was uneventful and she was discharged on hospital day six. Splenic volvulus of a wandering spleen is rare, though carries significant morbidity and mortality, especially if unrecognized. The presentation of splenic volvulus is variable, ranging from minor symptoms to an acute abdomen. Early diagnosis can prevent downstream complications, including development of vascular congestion, ischemia or infarcted intra-abdominal organs. Emergency Physicians should consider splenic volvulus in the differential diagnosis as an etiology of left-sided abdominal pain.

Emergency Department-based Intensive Care Unit Use Peaks Near Emergency Department Shift Turnover.

INTRODUCTION: The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians. The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied. We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED. We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times. METHODS: An electronic health record search identified all patients managed in the ED and ED-ICU in 2016 and 2017. We analyzed the number of ED arrivals per hour, the number of ED-ICU consults per hour, the time interval from ED arrival to ED-ICU consult, the distribution throughout the day, and the relationship with shift turnover times in the main ED. RESULTS: A total of 160,198 ED visits were queried, of which 5308 (3.3%) were managed in the ED-ICU. ED shift turnover times were 7 am, 3 pm, and 11 pm. The mean number of ED-ICU consults placed per hour was 221 (85 standard deviation), with relative maximums occurring near ED turnover times: 10:31 pm-11:30 pm (372) and 2:31 pm-3:30 pm (365). The minimum was placed between 7:31 am - 8:30 am (88), shortly after the morning ED turnover time. The median interval from ED arrival time to ED-ICU consult order was 161 minutes (range 6-1,434; interquartile range 144-174). Relative minimums were observed for patients arriving shortly prior to ED turnover times: 4:31 am - 5:30 am (120 minutes [min]), 12:31 pm - 1:30 pm (145 min), and 9:31 pm - 10:30 pm (135 min). Relative maximums were observed for patients arriving shortly after ED turnover times: 7:31 am - 8:30 am (177 min), 4:31 pm - 5:30 pm (218 min), and 11:31 pm - 12:30 am (179 min). CONCLUSION: ED-ICU utilization was highest near ED shift turnover times, and utilization was dissimilar to overall ED arrival patterns. Patients arriving immediately prior to ED shift turnover received earlier consults to the ED-ICU, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of emergency clinicians. These findings may guide operational planning, staffing models, and timing of shift turnover for other institutions implementing ED-ICUs. Future studies could investigate whether an ED-ICU model improves critically ill patients' outcomes by minimizing ED provider handoffs.

Utilization of a Resuscitative Care Unit for Initial Triage, Management, and Disposition of Minor Intracranial Hemorrhage.

Management of minor intracranial hemorrhage typically involves ICU admission. ICU capacity is increasingly strained, resulting in increased emergency department boarding of critically ill patients. Our objectives were to implement a novel protocol using our emergency department-based resuscitative care unit for management of management of minor intracranial hemorrhage patients in the emergency department setting, to provide timely and appropriate critical care, and to decrease inpatient ICU utilization. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Single large academic medical center in the United States. PATIENTS: Adult patients presenting to the emergency department with management of minor intracranial hemorrhage managed via our resuscitative care unit-management of minor intracranial hemorrhage protocol from September 2017 to April 2019. INTERVENTION: Implementation of a resuscitative care unit-management of minor intracranial hemorrhage protocol. MEASUREMENTS AND MAIN RESULTS: Demographic data, need for vasoactive infusions in the emergency department, emergency department and hospital length of stay, emergency department disposition, and 30-day outcomes (readmission, mortality, need for neurosurgical procedure) were collected. Fifty-five patients were identified, with mean age 67.1 ± 20.0 years. Mean Glasgow Coma Scale on presentation was 14.8 ± 0.5, and 66% had a history of trauma. Locations of hemorrhage were subdural (42%), intraparenchymal (35%), subarachnoid (15%), intratumoral (7%), and intraventricular (2%). Nineteen patients (35%) were discharged from the emergency department, 22 (40%) were admitted to general care, and 14 (26%) were admitted to intensive care. In discharged patients, there was no mortality or neurosurgical interventions at 30 days. In a subgroup analysis of 36 patients with a traumatic mechanism, 18 (50%) were able to be discharged from the emergency department after management in the resuscitative care unit. CONCLUSIONS: Initial management of emergency department patients with minor intracranial hemorrhage in a resuscitative care unit appears safe and feasible and was associated with a substantial rate of discharge from the emergency department (35%) and a low rate of admission to an inpatient ICU (26%). Use of this strategy was associated with rapid initiation of ICU-level care, which may help alleviate the challenge of increasing emergency department boarding time of critically ill patients facing many institutions.