A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations.

Background: Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation. Methods: We conducted this study at a New York City urban level-2 trauma center. The team was composed of members from the ED and pediatric departments. Electronic medical records of children aged 2 to 18 years presenting with AAE were evaluated. Monthly data on CXR utilization encompassing instances where the ordered CXR did not adhere to guidelines was collected before and after implementing interventions. The interventions included provider education, visual reminders, printed cards, grand-round presentations, and electronic medical records modifications. Results: The study encompassed 887 eligible patients with isolated AAE. Baseline data revealed a mean preintervention CXR noncompliance rate of 37.5% among children presenting to the ED with AAE. The interventions resulted in a notable decrease in unnecessary CXR utilization, reaching 16.7%, a reduction sustained throughout subsequent months. Conclusions: This QI project successfully reduced unnecessary CXR utilization in pediatric AAE. A multi-faceted approach involving education, visual aids, and electronic reminders aligned clinical practice with evidence-based guidelines. This QI initiative is a potential template for other healthcare institutions seeking to curtail unnecessary CXR usage in pediatric AAE.

Understanding curriculum as geo/biospheric text.

The world is experiencing crises related to the cascading effects of anthropization. These crises result from imperialist and capitalist practices that categorize and exploit the other (e.g., the land, the water, and their resources and beings) for maximizing profit. Such malpractices have led to climate crises of drought, famine, and extinctions. In the present, things are categorized through detachment, whereby the self-absorbed hyperbolic sees greatness in being and acting in meager ways, in nationalism and populism. In the midst of experiencing such a world of isms, this article suggests an important change for education-a curricular adjustment that not only allows for addressing subject matter (i.e., health and economics) and the subjects of such matters (i.e., the students and the teachers in the classrooms) but also acknowledges the importance of the other (i.e., the non-human world), which has been at the mercy of a singular reliance on the "incomplete" human consciousness. An inclusive curriculum underscores the different forms of concrete conscious beings and is mindful of a togetherness that ensures the continuation of life. "Event-ually", through highlighting each individual with the natural environment, the latent bonds each individual has with the other and another, and with the world itself, will expose themselves in new ways.

Entering the era of highly effective modulator therapies.

Since the discovery of the gene responsible for cystic fibrosis (CF) in 1989, hopes have been pinned on a future with novel therapies tackling the basis of the disease rather than its symptoms. These have become a reality over the last decade with the development through to the clinic of CF transmembrane conductance regulator (CFTR) modulators. These are oral drugs which improve CFTR protein function through either increasing the time the channel pore is open (potentiators) or facilitating its trafficking through the cell to its location on the cell membrane (correctors). The first potentiator, ivacaftor, is now licensed and available clinically in many parts of the world. It is highly effective with impressive clinical impact in the lungs and gastrointestinal tract; longer-term data from patient registries show fewer exacerbations, a slower rate of lung function loss and reduced need for transplantation in patients receiving ivacaftor. However, as a single drug, it is suitable for only a small minority of patients. The commonest CFTR mutation, F508del, requires both correction and potentiation for clinical efficacy. Two dual-agent drugs (lumacaftor/ivacaftor and tezacaftor/ivacaftor) have progressed through to licensing, although their short term impact is more modest than that of ivacaftor; this is likely due to only partial correction of protein misfolding and trafficking. Most recently, triple compounds have been developed: two different corrector molecules (elexacaftor and tezacaftor) which, by addressing different regions in the misfolded F508del protein, more effectively improve trafficking. In addition to large improvements in clinical outcomes in people with two copies of F508del, the combination is sufficiently effective that it works in patients with only one copy of F508del and a second, nonmodulator responsive mutation. For the first time, we thus have a drug suitable for around 85% of people with CF. Even more gains are likely to be possible when these drugs can be used in younger children, although more sensitive outcome measures are needed for this age group. Special consideration is needed for people with very rare mutations; those with nonmodulatable mutation combinations will likely require gene or messenger RNA-based therapeutic approaches, many of which are being explored. Although this progress is hugely to be celebrated, we still have more work to do. The international collaboration between trials networks, pharma, patient organizations, registries, and people with CF is something we are all rightly proud of, but innovative trial design and implementation will be needed if we are to continue to build on this progress and further develop drugs for people with CF.

Emergency Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial).

OBJECTIVES: Desaturation leading to hypoxemia may occur during rapid sequence intubation (RSI). Apneic oxygenation (AO) was developed to prevent the occurrence of oxygen desaturation during the apnea period. The purpose of this study was to determine if the application of AO increases the average lowest oxygen saturation during RSI when compared to usual care (UC) in the emergency setting. METHODS: A randomized controlled trial was conducted at an academic, urban, Level I trauma center. All patients requiring intubation were included. Exclusion criteria were patients in cardiac or traumatic arrest or if preoxygenation was not performed. An observer, blinded to study outcomes and who was not involved in the procedure, recorded all times, while all saturations were recorded in real time by monitors on a secured server. Two-hundred patients were allocated to receive AO (n = 100) or UC (n = 100) by predetermined randomization in a 1:1 ratio. RESULTS: A total of 206 patients were enrolled. There was no difference in lowest mean oxygen saturation between the two groups (92, 95% confidence interval [CI] = 91 to 93 in AO vs. 93, 95% CI = 92 to 94 in UC; p = 0.11). CONCLUSION: There was no difference in lowest mean oxygen saturation between the two groups. The application of AO during RSI did not prevent desaturation of patients in this study population.

Plastic surgery telehealth consultation expedites Emergency Department treatment.

Plastic surgery is a field that is particularly amenable to a telehealth milieu, as visual exam and radiographs guide proper diagnosis and management. The goals of this study were to evaluate telehealth feedback executed through an iPad app for plastic surgery-related consultations. A Quality Assurance/Quality Improvement (QA/QI) study was conducted over a 1-month period during which patients with hand injuries, facial injuries, or acute wounds presenting to the Emergency Department (ED) of a level-one trauma centre and university hospital were monitored. The study utilized a commercial iPad application through which up to four images and a brief history could be sent to a remote Plastic Surgery Educator (PSE) for evaluation. The PSE would respond with best practice information, references and videos to assist ED point-of-care providers. During the 1-month period of this study, there were 42 ED consultations for plastic surgical conditions. There was a highly significant difference in overall mean response time between consultants and PSEs (48.3 minutes vs. 8.9 minutes respectively, p < 0.001). The agreement between PSEs and consultants regarding patient assessment and care was 85.7% for in-person consultations and 100% for phone consultations. In four cases of telephone consultations, the ED providers placed splints incorrectly on hand-injured patients. Our results show that telehealth consultations to a remote plastic surgeon based on digital images and a brief history were able to produce timely and accurate responses in an emergency care facility. This design may have significant impact in rural areas, underserved populations, or regions abroad.

Structured communication: teaching delivery of difficult news with simulated resuscitations in an emergency medicine clerkship.

INTRODUCTION: The objective is to describe the implementation and outcomes of a structured communication module used to supplement case-based simulated resuscitation training in an emergency medicine (EM) clerkship. METHODS: We supplemented two case-based simulated resuscitation scenarios (cardiac arrest and blunt trauma) with role-play in order to teach medical students how to deliver news of death and poor prognosis to family of the critically ill or injured simulated patient. Quantitative outcomes were assessed with pre and post-clerkship surveys. Secondarily, students completed a written self-reflection (things that went well and why; things that did not go well and why) to further explore learner experiences with communication around resuscitation. Qualitative analysis identified themes from written self-reflections. RESULTS: A total of 120 medical students completed the pre and post-clerkship surveys. Majority of respondents reported that they had witnessed or role-played the delivery of difficult news, but only few had real-life experience of delivering news of death (20/120, 17%) and poor prognosis (34/120, 29%). This communication module led to statistically significant increased scores for comfort, confidence, and knowledge with communicating difficult news of death and poor prognosis. Pre-post scores increased for those agreeing with statements (somewhat/very much) for delivery of news of poor prognosis: comfort 69% to 81%, confidence 66% to 81% and knowledge 76% to 90% as well as for statements regarding delivery of news of death: comfort 52% to 68%, confidence 57% to 76% and knowledge 76% to 90%. Respondents report that patient resuscitations (simulated and/or real) generated a variety of strong emotional responses such as anxiety, stress, grief and feelings of loss and failure. CONCLUSION: A structured communication module supplements simulated resuscitation training in an EM clerkship and leads to a self-reported increase in knowledge, comfort, and competence in communicating difficult news of death and poor prognosis to family. Educators may need to seek ways to address the strong emotions generated in learners with real and simulated patient resuscitations.

Impact of an emergency medicine clerkship on students' perceptions of emergency medicine.

PURPOSE: To determine the impact of an emergency medicine (EM) clerkship on senior (4th year) medical students' perceptions of the EM specialty. SUBJECTS AND METHODS: This was a pre/posttest observational study in a mandatory 4-week EM clerkship. Students were anonymously surveyed pre- and postclerkship regarding perceptions of EM. The survey used 24 statements grouped across four domains: 1) student EM clerkship expectations/experiences, 2) perceptions regarding EM physicians, 3) perceptions regarding patients in the emergency department (ED), and 4) EM as a desirable career. Data were analyzed using paired-sample t-tests, and comparisons made using McNemar's χ (2) test. RESULTS: A total of 385 of 407 students (94.6%) completed the pre- and postclerkship survey. There was no significant difference between mean ratings before and after related to perceptions regarding EM physicians (3.71 versus 3.71), ED patients (3.80 versus 3.76), or EM as a desirable career (3.88 versus 3.84). However, ratings regarding clerkship expectations/experiences decreased (3.88 versus 3.56, P=0.001). Of the 292 students that ranked their top three specialties in both pre- and postclerkship surveys, 46 (16%) included EM as a top choice preclerkship, with 31 of these maintaining this interest postclerkship. Conversely, 12 students (5%) became interested in EM postclerkship. Some survey-statement ratings were influenced and varied by urban versus community clerkship-rotation site. CONCLUSION: A mandatory senior EM clerkship did not significantly change overall students' perceptions regarding EM. Students with an interest in EM rated domains higher than those not interested, though there may have been an overall decline in perceptions related to clerkship expectations and experiences. Larger, multisite studies may help identify aspects of the field or EM clerkship that influence a student's ultimate career choice.

Terror medicine as part of the medical school curriculum.

Terror medicine, a field related to emergency and disaster medicine, focuses on medical issues ranging from preparedness to psychological manifestations specifically associated with terrorist attacks. Calls to teach aspects of the subject in American medical schools surged after the 2001 jetliner and anthrax attacks. Although the threat of terrorism persists, terror medicine is still addressed erratically if at all in most medical schools. This paper suggests a template for incorporating the subject throughout a 4-year medical curriculum. The instructional framework culminates in a short course for fourth year students, such as one recently introduced at Rutgers New Jersey Medical School, Newark, NJ, USA. The proposed 4-year Rutgers curriculum serves as a model that could assist other medical schools contemplating the inclusion of terror medicine in pre-clerkship and clerkship training.

Preparedness in America's prime danger zone and at the Boston Marathon bombing site.

INTRODUCTION: The area between Newark and Elizabeth, NJ, contains major transportation hubs, chemical plants, and a dense population. This makes it "the most dangerous two miles in America," according to counterterrorism officials at the Federal Bureau of Investigation. This study compares medical response capabilities for terror and disaster in Newark, New Jersey's largest city, with those in Boston in view of that city's favorable response to the Marathon bombings in April 2013. Boston's numerous world-class medical facilities offer advantages unavailable in Newark and most other metropolitan locations. Thus, preparedness in Newark, despite its prime-danger designation, can also be instructive for many communities with similar medical resources. METHODS: Three categories of response capabilities are assessed: hospital resources, relevant personnel, and symposia/exercises. Data were derived from hospital Web sites, the New Jersey and Massachusetts Hospital Asso-ciations, communications with emergency response personnel, and interviews with spokespersons for hospitals. RESULTS: Boston's population (618,000) is more than twice Newark's (278,000), and the number of hospitals and hospital beds in each city reflects that proportion. However, Boston's seven general adult hospitals include five level 1 trauma centers (which can provide comprehensive trauma care), whereas Newark's four hospitals include only one such center.Beds per 1,000 people are similarly disparate in those trauma centers: five in Boston, 1.5 in Newark. Emergency Medical Services (EMS) personnel based in Boston and Newark are comparable in numbers, though full-time hospital physicians/dentists and nurses are not. The number of doctors at Boston's five level 1 centers is more than triple that at all four of Newark's hospitals (5,284 vs 1,494). The disparity between nurses at the two sites is even greater (6,784 vs 1,566).There is greater equivalency between the two cities both in content and frequency of symposia/exercises. Hospitals in each city have conducted numerous tabletop and action exercises including on communications efficiency, power outages, and dealing with a bombing or active shooter. Hospitals in each city also have participated in citywide drills with EMS, police, fire, and other responders. CONCLUSION: Commonalities in Newark and Boston's exercise approaches suggest that Boston's successful response at the Marathon might be replicated at least in part if the Newark area were similarly challenged. Whether Newark and similarly enabled communities would respond with comparable efficiency remains conjectural. Still, maintaining rigorous preparedness efforts seems a self-evident imperative, especially in an area deemed among the country's most inviting terrorist targets.

Digital store and forward imaging as a quality assessment tool for emergency plastic surgery consultations.

INTRODUCTION: Plastic surgery is a frequently consulted service in most emergency departments (EDs). The inclusion of a digital image with a plastic surgery consultation would allow the consultant to immediately assess the severity of the condition and either provide instruction to ED staff if minor or mobilize resources to facilitate operative management if more severe. METHODS: During a 4-month period, all plastic surgery consultations that were seen in person by one of 4 senior plastic surgery residents were included. In addition, an examination of all consultations seen during that time period at the plastic surgery clinic was undertaken to determine the quality of preclinic management. RESULTS: During the study period, 78 ED consultations were performed by the plastic surgery residents and included in the study. During the collection period, 374 patients were seen in the plastic surgery clinic. Of these, 154 patients were ED referrals. Evaluation by the senior author revealed that all consultations seen in the ED were appropriate and needed specialist management. Of the ED referrals sent to clinic, but not seen by a plastic surgery consultant in the ED several errors in patient management were noticed. CONCLUSIONS: The study demonstrated that ED consultations were appropriate for specialty evaluation in all cases, and that insufficient consultations were placed to provide optimal medical care. The role of telemedicine in creating more efficient and effective consultation processes is promising, but numerous legal barriers must be overcome before these modalities can be widely deployed.

Utility of initial prehospital end-tidal carbon dioxide measurements to predict poor outcomes in adult asthmatic patients.

STUDY OBJECTIVE: To determine if an initial (before treatment) prehospital end-tidal carbon dioxide (EtCO2) measurement in adult, non-chronic obstructive pulmonary disease (COPD), asthmatic patients predicts patient outcomes. METHODS: This is a retrospective chart review of EtCO2 assessment data in a convenience sample of adult, asthmatic patients transported via advanced life support (ALS) units to a large, urban, academic hospital. Initial EtCO2 measurements were obtained routinely on all respiratory distress patients in the field, and emergency department physicians were unaware of the results. Data were analyzed using descriptive statistics, including percentages, means, and 95% confidence intervals (CI). RESULTS: We reviewed data for prehospital initial EtCO2 measurements on 299 unique asthma patients (repeat visits by same patient were not included). Mean (SD) age was 43.1 years (12.5) and 142 (47.5%) were male. The mean EtCO2 measurement was 38.8 mmHg (SD ± 9.5; CI: 37.7-39.9; range: 14-82). Examination of initial EtCO2 measurements by deciles revealed that extreme values, in the lowest (14-28 mmHg) and highest (50-82 mmHg) deciles, experienced more markers of poor outcome than less extreme measurements. Patients were thus dichotomized by extreme (n = 59) or nonextreme (n = 240) EtCO2 measurements. More extreme patients were ultimately intubated (30.5 vs. 5.8%; p < 0.001; positive predictive value (ppv) = 30.5% ), and/or admitted to the intensive care unit (ICU) (28.8 vs. 6.7%; p <0.001; ppv = 28.8%), and/or died (5.1 vs. 0%; p = 0.007 [Fisher's exact test]; ppv = 5.1%), than nonextreme patients, respectively. CONCLUSION: Extreme (both low and high) prehospital initial EtCO2 measurements may be associated with markers of poor patient outcomes. Future work will prospectively determine whether the addition of this information improves early recognition of severe asthma episodes beyond clinical assessment.

Evaluation of a novel method of teaching endobronchial ultrasound: physician- versus respiratory therapist-proctored simulation training.

BACKGROUND: Computer endobronchial ultrasound (EBUS) simulators have been demonstrated to improve trainee procedural skills before attempting to perform EBUS procedures on patients. OBJECTIVE: To compare EBUS performance following training with computer simulation proctored by EBUS-trained respiratory therapists versus the same simulation training proctored by an interventional respirologist. METHODS: The present analysis was a prospective study of respiratory medicine trainees learning EBUS. Two cohorts of trainees were evaluated using a previously validated method using simulated cases with performance metrics measured by the simulator. Group 1 underwent EBUS training by performing 15 procedures on an EBUS simulator (n=4) proctored by an interventional respirologist. Group 2 received identical training proctored by a respiratory therapist with special training in EBUS (n=10). RESULTS: No significant differences between group 1 and group 2 were apparent for the primary outcome measures of total procedure time (15.15±1.34 min versus 14.78±2.88 min; P=0.816), the percentage of lymph nodes successfully identified (88.8±5.4 versus 80.91±8.9; P=0.092) or the percentage of successful biopsies (100.0±0.0 versus 98.75±3.95; P=0.549). The learning curves were similar between groups, and did not show an obvious plateau after 19 simulated procedures in either group. DISCUSSION: Acquisition of basic EBUS technical skills can be achieved using computer EBUS simulation proctored by specially trained respiratory therapists or by an interventional respirologist. There appeared to be no significant advantage to having an interventional respirologist proctor the computer EBUS simulation.

Palliative care provision in the emergency department: barriers reported by emergency physicians.

BACKGROUND: There is increasing interest in moving palliative care (PC) upstream to the emergency department (ED). However, barriers to PC provision in ED exist and are not yet clearly delineated. OBJECTIVE: To elicit the ED physicians' perceived barriers to provision of PC in the ED. METHODS: ED physicians at an urban, level-1 trauma center completed an anonymous survey. Participants ranked 23 statements on a five-point Likert-like scale (1=strongly disagree to 5=strongly agree). Statements covered four main domains of PC barriers: (1) education and training, (2) communication, (3) ED environment, and (4) personal beliefs. Respondents were also asked if they would initiate a PC consultation for ED-specific clinical scenarios (based on established triggers). RESULTS: Sixty-seven percent (30/45) of eligible participants completed the survey, average age 31 years. Respondents listed two major barriers to ED PC provision: lack of 24 hour availability of PC team (mean 4.4) and lack of access to complete medical records (mean 4.2). Almost all respondents agreed they would initiate a PC consultation for a hospice patient in respiratory distress, and the majority would consult for massive intracranial hemorrhage, traumatic arrest, or metastatic cancer. However inpatient triggers like frequent readmits for organ failure issues, e.g., dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), were rarely chosen for an ED PC consultation. CONCLUSION: We identify two main ED physician-perceived barriers to PC provision: lack of access to medical records and lack of 24/7 availability of PC team. ED physicians may not use the same criteria to initiate PC consultation as used in traditional inpatient PC trigger models. Outlining ED-specific triggers may help streamline the palliative consultation process.

Penile incarceration secondary to an S-shaped lead pipe: removal with Dremel Moto-Tool.

BACKGROUND: Penile incarceration or strangulation is a urologic emergency. OBJECTIVES: Several techniques to remove metallic objects strangulating the penis are described in the literature. The method utilized depends on the severity of the incarceration and the tools that are readily accessible. Prompt action and resourcefulness, with expeditious removal, prevents organ ischemia and vascular or mechanical sequelae. CASE REPORT: We describe a case in which a Dremel Moto-Tool was used to remove a lead pipe strangulating a penile shaft, after failure of the string technique. CONCLUSION: A hospital-based Emergency Medical Services and Rescue program is a valuable resource to provide the tools needed for management of penile strangulation. Features of safe removal, including protecting the tissues from heat damage and mechanical injury from the cutting blade, are described.

Rectal motion in patients receiving preoperative radiotherapy for carcinoma of the rectum.

PURPOSE: To assess the movement of rectum, mesorectum, and rectal primary during a course of preoperative chemoradiotherapy. METHODS AND MATERIALS: Seventeen patients with Stage II or III rectal cancer had a planning CT scan with rectal contrast before commencement of preoperative chemoradiation. The scan was repeated during Weeks 1, 3, and 5 of chemoradiation. The rectal primary (gross tumor volume), rectum, mesorectum, and bladder were contoured on all four scans. An in-house biomechanical model-based deformable image registration technique, Morfeus, was used to measure the three-dimensional spatial change in these structures after bony alignment. The required planning target volume margin for this spatial change, after bone alignment, was also calculated. RESULTS: Rectal contrast was found to introduce a systematic error in the position of all organs compared with the noncontrast state. The largest change in structures during radiotherapy was in the anterior and posterior directions for the mesorectum and rectum and in the superior and inferior directions for the gross tumor volume. The planning target volume margins required for internal movement for the mesorectum based on the three scans acquired during treatment are 4 mm right, 5 mm left, 7 mm anterior, and 6 mm posterior. For the rectum, values were 8 mm right, 8 mm left, 8 mm anterior, and 9 mm posterior. The greatest movement of the rectum occurred in the upper third. CONCLUSIONS: Contrast is no longer used in CT simulation. Assuming bony alignment, a nonuniform margin of 8 mm anteriorly, 9 mm posteriorly, and 8 mm left and right is recommended.

Exploring ethics in practice: creating moral community in healthcare one place at a time.

Examining everyday ethical situations in clinical practice is a vital but often overlooked activity for nursing leaders and practitioners, as well as most other healthcare professionals. In this paper, we share how a series of practitioner-led Ethics in Practice sessions (EIPs), which originated within a busy urban teaching hospital, were adapted and translated, first into home care and more recently, into an EIP session for public health nurses. The success of EIP sessions rests with their focus on issues that are selected by practitioners. The aims of EIPs are to foster ethical leadership within communities of practice, create safe places to share concerns, use relevant research evidence and other literature to support informed discussion, and generate stories that deepen our understanding of the ethical situations we encounter in our work. We hope our experience inspires nursing leaders, nursing colleagues and fellow healthcare professionals to consider using the EIP approach to build moral community and the idea of moral imagination with their clinical colleagues, one place at a time.