Blood culture algorithm implementation in emergency department patients as a diagnostic stewardship intervention.

OBJECTIVE: Blood cultures (BCx) are important for selecting appropriate antibiotic treatment. Ordering BCx for conditions with a low probability of bacteremia has limited utility, thus improved guidance for ordering BCx is needed. Inpatient studies have implemented BCx algorithms, but no studies examine the intervention in an Emergency Department (ED) setting. METHODS: We performed a quasi-experimental pre and postintervention study from January 12, 2020, to October 31, 2023, at a single academic adult ED and implemented a BCx algorithm. The primary outcome was the blood culture event rates (BCE per 100 ED admissions) pre and postintervention. Secondary outcomes included adverse event rates (30-day ED and hospital readmission and antibiotic days of therapy). Seven ED physicians and APP reviewed BCx for appropriateness, with monthly feedback provided to ED leadership and physicians. RESULTS: After the BCx algorithm implementation, the BCE rate decreased from 12.17 BCE/100 ED admissions to 10.50 BCE/100 ED admissions. Of the 3,478 reviewed BCE, we adjudicated 2,153 BCE (62%) as appropriate, 653 (19%) as inappropriate, and 672 (19%) as uncertain. Adverse safety events were not statistically different pre and postintervention. CONCLUSIONS: Implementation of an ED BCx algorithm demonstrated a reduction in BCE, without increased adverse safety events. Future studies should compare outcomes of BCx algorithm implementation in a community hospital ED without intensive chart review.

Accuracy and Feasibility of Three-Dimensional Ultrasound Testing in Eye Clinic and Emergency Department Patients with Vision Complaints.

BACKGROUND: Ocular emergencies comprise 2-3% of emergency department (ED) visits, with retinal detachment requiring emergency surgery. Two-dimensional ultrasound is a rapid bedside tool but is highly operator dependent. OBJECTIVE: We determined three-dimensional ultrasound (3DUS) feasibility, acceptability, and usability in eye pathology detection using the ophthalmologist examination as reference standard. METHODS: We performed a prospective, blinded cohort study of a 3DUS-enabling device in 30 eye clinic and ED patients with visual symptoms and calculated 3DUS performance characteristics. Two expert readers interpreted the 3DUS images for pathology. All participants completed surveys. RESULTS: 3DUS sensitivity was 0.81, specificity 0.73, positive predictive value 0.54, negative predictive value 0.91, and likelihood ratio (LR)+/LR- 3.03 and 0.26, respectively. Novice and expert sonographers had "substantial" agreement in correct diagnosis of abnormal vs. normal (κ = 0.68, 95% confidence interval 0.48-0.88). Most patients indicated that 3DUS is fast, comfortable, helps them understand their problem, and improves provider interaction/care, and all sonographers agreed; 4/5 sonographers felt confident performing ultrasound. Expert readers correctly identified an abnormal eye in 83/120 scans (76%) and correct diagnosis in 72/120 scans (65%), with no statistical difference between novice (79%; 69%) and expert (72%; 61%) sonographers (p = 0.39, p = 0.55), suggesting reduced operator dependence. Reader diagnosis confidence and image quality varied widely. Image acquisition times were fast for novice (mean 225 ± 83 s) and expert (201 ± 51) sonographers, with fast expert reader interpretation times (225 ± 136). CONCLUSIONS: A 3DUS-enabling device demonstrates a sensitivity of 0.81 and specificity of 0.73 for disease detection, fast image acquisition, and may reduce operator dependence for detecting emergent retinal pathologies. Further technological development is needed to improve diagnostic accuracy in identifying and characterizing retinal pathology.

Current Use, Training, and Barriers of Point-of-Care Ultrasound in Anesthesiology: A National Survey of Veterans Affairs Hospitals.

OBJECTIVES: The purpose of this study was to determine current use, training needs, and barriers to point-of-care ultrasound (POCUS) use among anesthesiologists in practice. DESIGN: Multicenter, prospective, observational study. SETTING: Anesthesiology departments in the Veterans Affairs Healthcare System in the United States. PARTICIPANTS: Chiefs of staff and chiefs of anesthesiology departments. INTERVENTIONS: A web-based survey was conducted between June 2019 and March 2020. Chiefs of staff answered questions about facility-level POCUS use, training, competency, and policies. Anesthesiology chiefs responded to a follow-up survey with specialty-specific POCUS questions. The results of the 2020 survey were compared with a similar survey conducted by the authors' group in 2015. MEASUREMENTS AND MAIN RESULTS: All chiefs of staff (n = 130) and 77% of anesthesiology chiefs (n = 96) completed the survey. The most common POCUS applications used were central and peripheral vascular access (69%-72%), peripheral nerve blocks (66%), and evaluation of cardiac function (29%-31%). Compared with 2015, there was a statistically significant increase in desire for training (p = 0.00015), but no significant change in POCUS use (p = 0.31). Training was most desired for volume-status assessment (52%), left ventricular function (47%), pneumothorax (47%), central line placement (40%), peripheral nerve blocks (40%), and pleural effusion (40%). The most common barriers to POCUS use were lack of funding for training (35%), trained providers (33%), and training opportunities (28%). CONCLUSIONS: A significant increase in desire for POCUS training was seen among anesthesiologists practicing in the Veterans Affairs healthcare system since 2015, and lack of training continues to be a top barrier for POCUS use among anesthesiologists.

Point-Of-Care Ultrasound Screening for Proximal Lower Extremity Deep Venous Thrombosis.

Acute lower extremity deep venous thrombosis (DVT) is a serious vascular disorder that requires accurate and early diagnosis to prevent life-threatening sequelae. While whole leg compression ultrasound with color and spectral Doppler is commonly performed in radiology and vascular labs, point-of-care ultrasound (POCUS) is becoming more common in the acute care setting. Providers appropriately trained in focused POCUS can perform a rapid bedside examination with high sensitivity and specificity in critically ill patients. This paper describes a simplified yet validated approach to POCUS by describing a three-zone protocol for lower extremity DVT POCUS image acquisition. The protocol explains the steps in obtaining vascular images at six compression points in the lower extremity. Beginning at the level of the proximal thigh and moving distally to the popliteal space, the protocol guides the user through each of the compression points in a stepwise manner: from the common femoral vein to the femoral and deep femoral vein bifurcation, and, finally, to the popliteal vein. Further, a visual aid is provided that may assist providers during real-time image acquisition. The goal in presenting this protocol is to help make proximal lower extremity DVT exams more accessible and efficient for POCUS users at the patient's bedside.

Robotic Optical Coherence Tomography Retinal Imaging for Emergency Department Patients: A Pilot Study for Emergency Physicians' Diagnostic Performance.

STUDY OBJECTIVE: To evaluate the diagnostic performance of emergency physicians' interpretation of robotically acquired retinal optical coherence tomography images for detecting posterior eye abnormalities in patients seen in the emergency department (ED). METHODS: Adult patients presenting to Duke University Hospital emergency department from November 2020 through October 2021 with acute visual changes, headache, or focal neurologic deficit(s) who received an ophthalmology consultation were enrolled in this pilot study. Emergency physicians provided standard clinical care, including direct ophthalmoscopy, at their discretion. Retinal optical coherence tomography images of these patients were obtained with a robotic, semi-autonomous optical coherence tomography system. We compared the detection of abnormalities in optical coherence tomography images by emergency physicians with a reference standard, a combination of ophthalmology consultation diagnosis and retina specialist optical coherence tomography review. RESULTS: Nine emergency physicians reviewed the optical coherence tomography images of 72 eyes from 38 patients. Based on the reference standard, 33 (46%) eyes were normal, 16 (22%) had at least 1 urgent/emergency abnormality, and the remaining 23 (32%) had at least 1 nonurgent abnormality. Emergency physicians' optical coherence tomography interpretation had 69% (95% confidence interval [CI], 49% to 89%) sensitivity for any abnormality, 100% (95% CI, 79% to 100%) sensitivity for urgent/emergency abnormalities, 48% (95% CI, 28% to 68%) sensitivity for nonurgent abnormalities, and 64% (95% CI, 44% to 84%) overall specificity. In contrast, emergency physicians providing standard clinical care did not detect any abnormality with direct ophthalmoscopy. CONCLUSION: Robotic, semi-autonomous optical coherence tomography enabled ocular imaging of emergency department patients with a broad range of posterior eye abnormalities. In addition, emergency provider optical coherence tomography interpretation was more sensitive than direct ophthalmoscopy for any abnormalities, urgent/emergency abnormalities, and nonurgent abnormalities in this pilot study with a small sample of patients and emergency physicians.

Impact of Education and Data Feedback on Antibiotic Prescribing for Urinary Tract Infections in the Emergency Department: An Interrupted Time-Series Analysis.

BACKGROUND: Urinary tract infections (UTIs) are often misdiagnosed or treated with exceedingly broad-spectrum antibiotics, leading to negative downstream effects. We aimed to implement antimicrobial stewardship (AS) strategies targeting UTI prescribing in the emergency department (ED). METHODS: We conducted a quasi-experimental prospective AS intervention outlining appropriate UTI diagnosis and management across 3 EDs, within an academic and 2 community hospitals, in North Carolina, United States. The study was divided into 3 phases: a baseline period and 2 intervention phases. Phase 1 included introduction of an ED-specific urine antibiogram and UTI guideline, education, and department-specific feedback on UTI diagnosis and antibiotic prescribing. Phase 2 included re-education and provider-specific feedback. Eligible patients included adults with an antibiotic prescription for UTI diagnosed in the ED from 13 November 2018 to 1 March 2021. Admitted patients were excluded. The primary outcome was guideline-concordant antibiotic use, assessed using an interrupted time-series regression analysis with 2-week intervals. RESULTS: Overall, 8742 distinct patients with 10 426 patient encounters were included. Ninety-two percent of all encounters (n = 9583) were diagnosed with cystitis and 8.1% with pyelonephritis (n = 843). There was an initial 15% increase in guideline-concordant antibiotic prescribing in phase 1 compared with the preintervention period (incidence rate ratio [IRR], 1.15; 95% confidence interval [CI], 1.03-1.29). A significant increase in guideline-concordant prescriptions was seen with every 2-week interval during phase 2 (IRR, 1.03; 95% CI, 1.01-1.04). CONCLUSIONS: This multifaceted AS intervention involving a guideline, education, and provider-specific feedback increased guideline-concordant antibiotic choices for treat-and-release patients in the ED.

Cardiopulmonary Emergencies in Older Adults.

Older adults are susceptible to serious illnesses, including atrial fibrillation, congestive heart failure, pneumonia, and pulmonary embolism. Atrial fibrillation is the most common arrhythmia in this age group and can cause complications such as thromboembolic events and stroke. Congestive heart failure is the most common cause of hospital admission and readmission in the older adult population. Older adults are at higher risk for pulmonary embolism because of age-related changes and comorbidities. Pneumonia is also prevalent and is one of the leading causes of death.

A Case Report of a Migrated Pelvic Coil Causing Pulmonary Infarct in an Adult Female.

INTRODUCTION: It is possible but rare for a pelvic coil to migrate to the pulmonary vasculature, which can cause cardiac damage, arrhythmias, pulmonary infarct, and thrombophlebitis. The few cases reported typically do not describe removal of the coils, as patients were asymptomatic. CASE REPORT: A 39-year-old female with recent coil embolization of her left internal iliac and ovarian veins for pelvic congestion syndrome presented with one month of right-sided chest pain and dyspnea. Imaging revealed a migrated pelvic coil in the patient's right main pulmonary artery with pulmonary infarcts and a pleural effusion. CONCLUSION: Interventional radiology successfully removed the coil endovascularly, with significant symptom improvement. This prevented a more-invasive open surgical procedure and resolved symptoms without requiring long-term anticoagulation or monitoring.

Duplicated or Ectopic Renal Collecting System in Two Adult Emergency Department Patients.

BACKGROUND: Duplicated renal collecting system is a urological anomaly often found in pediatric patients. It is less commonly diagnosed in adulthood, particularly in a pregnant patient. Many point-of-care ultrasonography users may not be aware of this diagnosis, particularly in patients in the emergency department. It is important to recognize the duplicated system because in general, patients will often have hydronephrosis in only one renal pole rather than the entire kidney, which corresponds to an unequal renal function as documented on renal nuclear medicine functional scans. As a consequence, if the sonographer only identifies one ureter and incompletely visualizes the kidney, obstruction of one of the duplicated structures may be missed. CASE REPORT: We report 2 cases of duplicated ureter in patients in the emergency department who present with flank pain and urinary symptoms. Both patients were adult females, one pregnant, with duplicated ureter and severe right upper pole hydroureteronephrosis. The first patient was admitted for intravenous antibiotic therapy for pyelonephritis in pregnancy. The second was discharged with oral antibiotics and urgent urologic follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Duplicated ureter should be considered in patients with recurrent urinary tract infections or enuresis. Point-of-care ultrasonography users should note the differential hydronephrosis between upper and lower renal poles and may visualize duplicate or ectopic ureteronephrosis or ureterocele. Patients should be prescribed prophylactic antibiotics and have urgent urologic follow-up because the untreated condition can lead to irreversible renal damage.

Validity and reliability of telephone administration of the patient-specific functional scale for the assessment of recovery from snakebite envenomation.

OBJECTIVES: Although more than 1.8 million people survive snakebite envenomation each year, their recovery is understudied. Obtaining long-term follow-up is challenging in both high- and low-resource settings. The Patient-Specific Functional Scale (PSFS) is an easily administered, well-accepted patient-reported outcome that is validated for assessing limb recovery from snakebite envenomation. We studied whether the PSFS is valid and reliable when administered by telephone. METHODS: This is a secondary analysis of data from a randomized clinical trial. We analyzed the results of PSFS collected in-person on days 3, 7, 14, 21, and 28 and by telephone on days 10, 17, and 24. We assessed the following scale psychometric properties: (a) content validity (ceiling and floor effects), (b) internal structure and consistency (Cronbach's alpha), and (c) temporal and external validity using Intraclass Correlation Coefficient (ICC). Temporal stability was assessed using Spearman's correlation coefficient and agreement between adjacent in-person and telephonic assessments with Cohen's kappa. Bland Altman analysis was used to assess differential bias in low and high score results. RESULTS: Data from 74 patients were available for analysis. Floor effects were seen in the early post-injury time points (median: 3 (IQR: 0, 5) at 3 days post-enrollment) and ceiling effects in the late time points (median: 9 (IQR: 8, 10). Internal consistency was good to excellent with both in-person (Cronbach α: 0.91 (95%CI 0.88, 0.95)) and telephone administration (0.81 (0.73, 0.89). Temporal stability was also good (ICC: 0.83 (0.72, 0.89) in-person, 0.80 (0.68, 0.88) telephone). A strong linear correlation was found between in-person and telephone administration (Spearman's ρ: 0.83 (CI: 0.78, 0.84), consistency was assessed as excellent (Cohen's κ 0.81 (CI: 0.78, 0.84), and Bland Altman analysis showed no systematic bias. CONCLUSIONS: Telephone administration of the PSFS provides valid, reliable, and consistent data for the assessment of recovery from snakebite envenomation.

Validity and reliability of telephone administration of the patient-specific functional scale for the assessment of recovery from snakebite envenomation

Objectives Although more than 1.8 million people survive snakebite envenomation each year, their recovery is understudied. Obtaining long-term follow-up is challenging in both high- and low-resource settings. The Patient-Specific Functional Scale (PSFS) is an easily administered, well-accepted patient-reported outcome that is validated for assessing limb recovery from snakebite envenomation. We studied whether the PSFS is valid and reliable when administered by telephone. Methods This is a secondary analysis of data from a randomized clinical trial. We analyzed the results of PSFS collected in-person on days 3, 7, 14, 21, and 28 and by telephone on days 10, 17, and 24. We assessed the following scale psychometric properties: (a) content validity (ceiling and floor effects), (b) internal structure and consistency (Cronbach’s alpha), and (c) temporal and external validity using Intraclass Correlation Coefficient (ICC). Temporal stability was assessed using Spearman’s correlation coefficient and agreement between adjacent in-person and telephonic assessments with Cohen’s kappa. Bland Altman analysis was used to assess differential bias in low and high score results. Results Data from 74 patients were available for analysis. Floor effects were seen in the early post-injury time points (median: 3 (IQR: 0, 5) at 3 days post-enrollment) and ceiling effects in the late time points (median: 9 (IQR: 8, 10). Internal consistency was good to excellent with both in-person (Cronbach a: 0.91 (95%CI 0.88, 0.95)) and telephone administration (0.81 (0.73, 0.89). Temporal stability was also good (ICC: 0.83 (0.72, 0.89) in-person, 0.80 (0.68, 0.88) telephone). A strong linear correlation was found between in-person and telephone administration (Spearman’s Ró: 0.83 (CI: 0.78, 0.84), consistency was assessed as excellent (Cohen’s capa 0.81 (CI: 0.78, 0.84), and Bland Altman analysis showed no systematic bias. Conclusions Telephone administration of the PSFS provides valid, reliable, and consistent data for the assessment of recovery from snakebite envenomation.

Validity and reliability of telephone administration of the patient-specific functional scale for the assessment of recovery from snakebite envenomation

Objectives Although more than 1.8 million people survive snakebite envenomation each year, their recovery is understudied. Obtaining long-term follow-up is challenging in both high- and low-resource settings. The Patient-Specific Functional Scale (PSFS) is an easily administered, well-accepted patient-reported outcome that is validated for assessing limb recovery from snakebite envenomation. We studied whether the PSFS is valid and reliable when administered by telephone. Methods This is a secondary analysis of data from a randomized clinical trial. We analyzed the results of PSFS collected in-person on days 3, 7, 14, 21, and 28 and by telephone on days 10, 17, and 24. We assessed the following scale psychometric properties: (a) content validity (ceiling and floor effects), (b) internal structure and consistency (Cronbach’s alpha), and (c) temporal and external validity using Intraclass Correlation Coefficient (ICC). Temporal stability was assessed using Spearman’s correlation coefficient and agreement between adjacent in-person and telephonic assessments with Cohen’s kappa. Bland Altman analysis was used to assess differential bias in low and high score results. Results Data from 74 patients were available for analysis. Floor effects were seen in the early post-injury time points (median: 3 (IQR: 0, 5) at 3 days post-enrollment) and ceiling effects in the late time points (median: 9 (IQR: 8, 10). Internal consistency was good to excellent with both in-person (Cronbach a: 0.91 (95%CI 0.88, 0.95)) and telephone administration (0.81 (0.73, 0.89). Temporal stability was also good (ICC: 0.83 (0.72, 0.89) in-person, 0.80 (0.68, 0.88) telephone). A strong linear correlation was found between in-person and telephone administration (Spearman’s Ró: 0.83 (CI: 0.78, 0.84), consistency was assessed as excellent (Cohen’s capa 0.81 (CI: 0.78, 0.84), and Bland Altman analysis showed no systematic bias. Conclusions Telephone administration of the PSFS provides valid, reliable, and consistent data for the assessment of recovery from snakebite envenomation.