Overcoming stagnant flow: A scoping review of vertical movement in the emergency department.

OBJECTIVES: Improving emergency department (ED) patient flow has plagued many hospitals worldwide. "Vertical" flow improves throughput by maximizing use of chairs and waiting areas instead of beds. This process, however, is inconsistently described in the literature. The objective of this study was to collate existing evidence of successful vertical care programs. METHOD: A scoping review was conducted within several databases utilizing key search terms to capture relevant traditional and gray literature. All articles were uploaded into Covidence (n = 1000). After duplicates were removed, remaining abstracts were initially screened by two reviewers (n = 731). Records identified by at least one reviewer subsequently underwent a two-reviewer full-text screening for inclusion (n = 46). This process yielded 36 articles. Finally, each record underwent data extraction by two independent study members and any inconsistencies were resolved by a third study member. Extracted data included 21 predetermined variables. Descriptive statistics were used to summarize results. RESULTS: Of the 36 included articles, most were published from the United States (91.7%), after 2014 (55.6%), and as a peer-reviewed article or abstract/conference proceeding (86.1%). While every article discussed some aspect of vertical flow, most (77.8%) were observational studies. Only half of the studies reported details of staffing and/or physical resources. A variety of challenges and success strategies were described, with several themes identified. Positive outcomes were reported by most articles (86%), although measurement of outcomes varied with the two most common being length of stay (69.4%) and arrival-to-provider time (55.6%). CONCLUSIONS: The findings of this scoping review provide the first summative report of existing literature on vertical flow processes within the ED setting. Despite different measurable outcomes and varied processes, most articles support the use of vertical flow to improve throughput.

Diabetic Ketoacidosis.

This article reviews the most current literature on diabetic ketoacidosis, including how to make the diagnosis and management. It discusses euglycemic diabetic ketoacidosis and the risk factors for this rare but dangerous disease process. Pertinent pearls and pitfalls encountered by the emergency physician when managing these patients are included. Because these patients often stay in the emergency department for prolonged periods, recommendations on transitioning to subcutaneous insulin are included, along with dosing recommendations. Finally, the article reviews how to disposition patients with diabetic ketoacidosis and examines important factors that lead to a successful discharge home.

A Comparison between Conventional and Extracorporeal Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

There is limited evidence comparing the use of extracorporeal cardiopulmonary resuscitation (ECPR) to CPR in the management of refractory out-of-hospital cardiac arrest (OHCA). We conducted a systematic review and meta-analysis to compare survival and neurologic outcomes associated with ECPR versus CPR in the management of OHCA. We searched PubMed, EMBASE, and Scopus to identify observational studies and randomized controlled trials comparing ECPR and CPR. We used the Newcastle−Ottawa Scale and Cochrane's risk-of-bias tool to assess studies' quality. We used random-effects models to compare outcomes between the pooled populations and moderator analysis to identify sources of heterogeneity and perform subgroup analysis. We identified 2088 articles and included 13, with 18,620 patients with OHCA. A total of 16,701 received CPR and 1919 received ECPR. Compared with CPR, ECPR was associated with higher odds of achieving favorable neurologic outcomes at 3 (OR 5, 95% CI 1.90−13.1, p < 0.01) and 6 months (OR 4.44, 95% CI 2.3−8.5, p < 0.01). We did not find a significant survival benefit or impact on neurologic outcomes at hospital discharge or 1 month following arrest. ECPR is a promising but resource-intensive intervention with the potential to improve long-term outcomes among patients with OHCA.

How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA. METHODS: We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity. RESULTS: We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies. CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.

Manual Palpation vs. Femoral Arterial Doppler Ultrasound for Comparison of Pulse Check Time During Cardiopulmonary Resuscitation in the Emergency Department: A Pilot Study.

BACKGROUND: Manual palpation (MP) is frequently employed for pulse checks, but studies have shown that trained medical personnel have difficulty accurately identifying pulselessness or return of spontaneous circulation (ROSC) using MP. Any delays in identifying pulselessness can lead to significant delays in starting or resuming high-quality chest compressions. OBJECTIVES: This study explored whether femoral arterial Doppler ultrasound (FADU) decreases pulse check duration during cardiopulmonary resuscitation (CPR) compared with MP among patients in the emergency department (ED) receiving CPR directed by emergency medicine physicians who had received minimal additional didactic ultrasound training. METHODS: We performed a prospective observational cohort study from October 2018 to May 2019 at an urban community ED. Using convenience sampling, we enrolled patients arriving at our ED or who decompensated during their ED stay and received CPR. For continuous data, median (interquartile range [IQR]) were calculated, and medians were compared using Kruskal-Wallis test. RESULTS: Fifty-two eligible patients were enrolled and 135 pulse checks via MP and 35 via FADU were recorded. MP observations had a median (IQR) of 11.00 (7.36-15.48) s, whereas FADU had a median (IQR) of 8.98 (5.45-13.85) s. There was a difference between the two medians of 2.02 s (p = 0.05). CONCLUSIONS: In this study, the use of FADU was superior to MP in achieving shorter pulse check times. Further research is needed to confirm the accuracy of FADU for identifying ROSC as well as to determine whether FADU can improve clinical outcomes.

Enteric sensory neurons communicate with interstitial cells of Cajal to affect pacemaker activity in the small intestine.

Enteric sensory neurons (the AH neurons) play a role in control of gastrointestinal motor activity; AH neuron activation has been proposed to change propulsion into segmentation. We sought to find a mechanism underlying this phenomenon. We formulated the hypothesis that AH neurons increase local ICC-MP (interstitial cells of Cajal associated with the myenteric plexus) pacemaker frequency to disrupt peristalsis and promote absorption. To that end, we sought structural and physiological evidence for communication between ICC-MP and AH neurons. We designed experiments that allowed us to simultaneously activate AH neurons and observe changes in ICC calcium transients that underlie its pacemaker activity. Neurobiotin injection in AH neurons together with ICC immunohistochemistry proved the presence of multiple contacts between AH neuron varicosities and the cell bodies and processes of ICC-MP. Generating action potential activity in AH neurons led to increase in the frequency and amplitude of calcium transients underlying pacemaker activity in ICC. When no rhythmicity was seen, rhythmic calcium transients were evoked in ICC. As a control, we stimulated nitrergic S neurons, which led to reduction in ICC calcium transients. Hence, we report here the first demonstration of communication between AH neurons and ICC. The following hypothesis can now be formulated: AH neuron activation can disrupt peristalsis directed by ICC-MP slow wave activity, through initiation of a local pacemaker by increasing ICC pacemaker frequency through increasing the frequency of ICC calcium transients. Evoking new pacemakers distal to the proximal lead pacemaker will initiate both retrograde and antegrade propulsion causing back and forth movements that may disrupt peristalsis.

On the origin of rhythmic calcium transients in the ICC-MP of the mouse small intestine.

Interstitial cells of Cajal associated with the myenteric plexus (ICC-MP) are pacemaker cells of the small intestine, producing the characteristic omnipresent electrical slow waves, which orchestrate peristaltic motor activity and are associated with rhythmic intracellular calcium oscillations. Our objective was to elucidate the origins of the calcium transients. We hypothesized that calcium oscillations in the ICC-MP are primarily regulated by the sarcoplasmic reticulum (SR) calcium release system. With the use of calcium imaging, study of the effect of T-type calcium channel blocker mibefradil revealed that T-type channels did not play a major role in generating the calcium transients. 2-Aminoethoxydiphenyl borate, an inositol 1,4,5 trisphosphate receptor (IP(3)R) inhibitor, and U73122, a phospholipase C inhibitor, both drastically decreased the frequency of calcium oscillations, suggesting a major role of IP(3) and IP(3)-induced calcium release from the SR. Immunohistochemistry proved the expression of IP(3)R type I (IP(3)R-I), but not type II (IP(3)R-II) and type III (IP(3)R-III) in ICC-MP, indicating the involvement of the IP(3)R-I subtype in calcium release from the SR. Cyclopiazonic acid, a SR/endoplasmic reticulum calcium ATPase pump inhibitor, strongly reduced or abolished calcium oscillations. The Na-Ca exchanger (NCX) in reverse mode is likely involved in refilling the SR because the NCX inhibitor KB-R7943 markedly reduced the frequency of calcium oscillations. Immunohistochemistry revealed 100% colocalization of NCX and c-Kit in ICC-MP. Testing a mitochondrial NCX inhibitor, we were unable to show an essential role for mitochondria in regulating calcium oscillations in the ICC-MP. In summary, ongoing IP(3) synthesis and IP(3)-induced calcium release from the SR, via the IP(3)R-I, are the major drivers of the calcium transients associated with ICC pacemaker activity. This suggests that a biochemical clock intrinsic to ICC determines the pacemaker frequency, which is likely directly linked to kinetics of the IP(3)-activated SR calcium channel and IP(3) metabolism.

Hippocampal cell proliferation and spatial memory performance after social instability stress in adolescence in female rats.

We investigated the immediate and lasting effect of social instability stress in adolescence [SS: daily 1h isolation and change of cage partner postnatal days (P) 30-45] on cell proliferation in the hippocampus and on spatial memory using an object spatial location (SL) test. Female rats were treated with bromodeoxyuridine (BrdU) P43-45, and on P49, SS had reduced cell hippocampal cell proliferation/survival compared to controls as indicated by BrdU immunoreactive cell counts (p=0.009), and did not differ in Ki67 immunoreactive cell counts (p=0.15) from CTL. A separate group of SS and CTL rats were tested at P47 and P48, and again at P72 and P73 on the SL test using 1 and 8h retention intervals. SS and CTL females did not differ in adolescence, but CTL had better memory than SS as adults (p=0.03). The better memory performance of CTL rats is not due to differential investigation of objects during the familiarization pre-tests or by differential locomotor activity. The lasting memory reduction and reduced cell proliferation/survival in SS rats is consistent with the hypothesis that ongoing development of the hippocampus renders the adolescent particularly vulnerable to chronic social stress.