Improving CT scanner efficiency for trauma team activations in the emergency department.

BACKGROUND AND OBJECTIVES: A Trauma Team Activation (TTA) is initiated when a patient has sustained a life or limb-threatening injury thereby necessitating resources of a large care team. Previously, a CT scanner was cleared at the time of the prehospital TTA call. Wide variability in the time it took to stabilize patients often led to extended CT scanner idle time. A new policy was developed whereby the team leader would prompt the ED clerk to provide a '5-min heads-up' (5-min HU) notification to the CT scanner personnel as a patient was stabilized. At this point, the CT scanner was cleared. The purpose of this quality improvement project is to evaluate if the new policy saves CT scanner idle time. METHODS: Research interns prospectively followed incoming TTAs in the ED of a large, urban, Level I Trauma Center in November 2022. The interns collected the following time points: TTA notification page, 5-min HU notification, and arrival to CT. Data was analyzed using a non-parametric comparison test (Mann-Whitney U). RESULTS: A convenience sample of 46 TTAs was included. Trauma was blunt (85%; n = 39)) and penetrating (15%; n = 7). The median initial TTA announcement to CT arrival time was 24.0 min (IQR: 9.0 min). Previously, the scanner would have been held for this entire period. The median time from 5-min HU notification to CT arrival was 5.0 min (IQR: 4.0 min). The new policy saved a median of 19 min of CT scanner idle time per patient compared to the old policy (p < 0.0001). The total CT scanner time saved was 818 min (13.6 h). CONCLUSION: These data support the implementation of a 5-min HU policy in the ED for patients arriving as TTAs. This maximizes the availability of CT scanners for other patients in the ED while TTA patients are being stabilized.

Use of Needle Guide for Dynamic Real-Time Ultrasound-Directed Aspiration of Peritonsillar Abscess in the Emergency Department: A Case Series.

BACKGROUND: Needle aspiration is a common treatment of peritonsillar abscess (PTA). Point-of-care ultrasound (POCUS) can be used to guide this procedure. We describe our experience using a commercially available needle guide attached to an endocavitary ultrasound probe for dynamic real-time POCUS-guided PTA needle aspiration. DISCUSSION: A convenience sample of patients were treated using the needle guide. The primary author (Peter Kumasaka) performed or supervised emergency medicine residents and physician assistants (PAs) for each case in which the needle guide was used. The electronic medical records were abstracted for procedure success, various length of stay (LOS) data, and to determine use of computed tomography imaging and otorhinolaryngologist (ENT) consultation. Dynamic POCUS-guided needle aspiration using the needle guide (DNG) was performed on 8 patients. There were no unexpected return visits to the emergency department (ED) or to the ENT clinic for any of the patients. The median time to perform DNG was 9 min (range 8-17 min). Median LOS was 182 min (range 78-287 min). Median time from POCUS order to patient discharge was 82.5 min (range 66-237 min). Median time from starting procedure to discharge was 43 min (range 18-148 min). CONCLUSIONS: The needle guide is a useful adjunct to assist in PTA drainage. It provided rapid, safe, and efficient care. Additional research is needed to see how this technique compares with more traditional methods of PTA drainage.

A new technique for reduction of a posteriorly dislocated hip joint.

Posterior hip dislocation is commonly seen in the emergency department and requires urgent reduction to help avoid complications. Many techniques have been described to perform the reduction, all aimed at helping the physician gain a mechanical advantage to overcome the bony anatomy and large muscles groups involved. We describe a new technique that utilizes a hydraulic patient lift to help provide the traction force necessary to reduce posterior hip dislocations. The patient is secured to the bed with a strap or sheet tied over their pelvis and then a loop is secured under their popliteal region and secured to the hydraulic lift. The lift is engaged to create the desired traction, allowing the provider to manipulate the hip with adduction/abduction and/or internal/external rotation to achieve reduction. In addition, our method may also allow the provider to task switch more easily between other requirements, such as procedural sedation and attention to the patient's airway, especially in the single coverage emergency department.

Severity of diagnosis among patients with chest pain presenting to the emergency department after calling a nurse line.

BACKGROUND AND OBJECTIVES: A Nurse Line (NL) is a resource that is commonly used by patients and hospitals to assist in the triage of patient medical complaints. We sought to determine whether patients with chief complaint of chest pain who presented to the ED after calling a NL were different from patients who presented directly to the ED. The primary aim was to test for differences in the severity of the causes of chest pain between the two groups. METHODS: This was a retrospective case-control chart review study. Data collected included demographic data, comorbidities, ED orders, ED interventions, patient primary diagnosis and disposition. RESULTS: 350 patients were included in the analysis: 175 patients called the NL and 175 age/sex matched patients did not call the NL. The mean age was 58.3 (SD 16.4; range 19.1-93.3) and 53.7% of patients were female. Race was similar between the groups. Patients were more likely to go directly to the ED without calling a NL if they had comorbidities. Among the total cohort, 36 patients were deemed to have a serious diagnosis related to the pain; this did not differ between groups (16 NL, 20 non-NL; OR = 1.11 95%CI 0.55-2.23). There were no differences of ED work-up or hospital admission (50 NL, 67 non-NL; OR = 0.85 95%CI 0.51-1.42) between the groups. CONCLUSION: NL call was not associated with differences in severity of diagnosis, work-up, hospital admission or patient demographics. Patients who presented to the ED with chest pain without calling a NL had more comorbidities.

Pneumothorax Complications During Placement of Peripheral Internal Jugular Intravenous Catheters.

BACKGROUND: A "peripheral IJ" is a 2.5-in angiocatheter placed in the internal jugular vein with ultrasound guidance but typically no barrier precautions. Previously published literature has shown safety with none to minimal complications. CASE REPORT: This report describes 2 cases of iatrogenic pneumothorax that occurred during this procedure. One was caused by an emergency medicine intern, the other by an experienced faculty member. Both occurred in petite women with low body mass indices. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important to remember that there are risks inherent with using the internal jugular vein for intravenous access. Particular vigilance should be used with patients who are thin.

Provider-in-triage prediction of hospital admission after brief patient interaction.

BACKGROUND AND OBJECTIVES: We sought to determine if emergency physician providers working in the triage area (PIT) of the ED could accurately predict the likelihood of admission for patients at the time of triage. Such predictions, if accurate, could decrease the time spent in the ED for patients who are admitted to the hospital by hastening downstream workflow. METHODS: This is a prospective cohort study of PIT providers at a large urban hospital. Physicians were asked to predict the likelihood of admission and confidence of prediction for patients after evaluating them in triage. Measures of predictive accuracy were calculated, including sensitivity, specificity, and area under the receiver operator characteristic (AUROC). RESULTS: 36 physicians (20 attendings, 16 residents) evaluated 340 patients and made predictions. The average patient age was 48 (range 18-94) and 52% were female. Seventy-three patients (21%) were admitted (5% observation, 85% general care/telemetry, 7% progressive care, 3% ICU). The sensitivity of determining admission for the entire cohort was 74%, the specificity was 84%, and the AUROC was 0.81. When physicians were at least 80% confident in their predictions, the predictions improved to sensitivity of 93%, specificity of 96%, and AUROC 0.95 (Graph 1). CONCLUSION: The accuracy of physician providers-in-triage of predicting hospital admission was very good when those predictions were made with higher degrees of confidence. These results indicate that while general predictions of admission are likely inadequate to guide downstream workflow, predictions in which the physician is confident could provide utility.

An Analysis of Changes in Emergency Department Visits After a State Declaration During the Time of COVID-19.

STUDY OBJECTIVE: In the initial period of the coronavirus disease 2019 (COVID-19) pandemic, there has been a substantial decrease in the number of patients seeking care in the emergency department. A first step in estimating the impact of these changes is to characterize the patients, visits, and diagnoses for whom care is being delayed or deferred. METHODS: We conducted an observational study, examining demographics, visit characteristics, and diagnoses for all ED patient visits to an urban level 1 trauma center before and after a state emergency declaration and comparing them with a similar period in 2019. We estimated percent change on the basis of the ratios of before and after periods with respect to 2019 and the decline per week using Poisson regression. Finally, we evaluated whether each factor modified the change in overall ED visits. RESULTS: After the state declaration, there was a 49.3% decline in ED visits overall, 35.2% (95% confidence interval -38.4 to -31.9) as compared with 2019. Disproportionate declines were seen in visits by pediatric and older patients, women, and Medicare recipients, as well as for presentations of syncope, cerebrovascular accidents, urolithiasis, and abdominal and back pain. Significant proportional increases were seen in ED visits for upper respiratory infections, shortness of breath, and chest pain. CONCLUSION: There have been significant changes in patterns of care seeking during the COVID-19 pandemic. Declines in ED visits, especially for certain demographic groups and disease processes, should prompt efforts to understand these phenomena, encourage appropriate care seeking, and monitor for the morbidity and mortality that may result from delayed or deferred care.

Elimination of Routine Screening Laboratory Tests for Psychiatric Admission: A Quality Improvement Initiative.

OBJECTIVE: Research has shown that routine screening laboratory tests for patients with mental health symptoms admitted to psychiatry units find little unexpected clinical abnormalities. This study examined the effects on cost of care and patient safety measures of a hospital change in policy in which such routine tests were no longer required. METHODS: This retrospective cohort study analyzed data from all patients admitted from the emergency department (ED) to inpatient psychiatry at a tertiary care hospital 4 months before and 4 months after the policy change. Primary outcome measures were number and costs of laboratory tests ordered in the ED and during the inpatient stay. Secondary measures included length of stay (LOS) and number of hospital consultations during admission, patient transfers to nonpsychiatry services, and inpatient deaths. Chi-square tests and Wilcoxon rank sum tests were used to examine group differences. RESULTS: In total, data from 1,910 patients were included (886 preimplementation and 1,024 postimplementation). The median number of lab tests ordered during the hospital stay decreased from three (interquartile range [IQR]=3) to two (IQR=3). The median total lab charges decreased from $445 (IQR=$291) to $312 (IQR=$497). Mean ED LOS decreased by 5.5 hours, and the proportion of patients with no blood lab orders increased from 22% to 40%. No increases in consultations or transfers were noted. No patients died at any point. CONCLUSIONS: A policy that avoids routine laboratory screening tests for patients admitted to inpatient psychiatry can save money, improve patient care, and decrease LOS, without increasing adverse outcomes.

Serum SNTF, a Surrogate Marker of Axonal Injury, Is Prognostic for Lasting Brain Dysfunction in Mild TBI Treated in the Emergency Department.

Mild traumatic brain injury (mTBI) causes persisting post-concussion syndrome for many patients without abnormalities on conventional neuroimaging. Currently, there is no method for identifying at-risk cases at an early stage for directing concussion management and treatment. SNTF is a calpain-derived N-terminal proteolytic fragment of spectrin (αII-spectrin1-1176) generated in damaged axons following mTBI. Preliminary human studies suggest that elevated blood SNTF on the day of mTBI correlates with white matter disruption and lasting brain dysfunction. Here, we further evaluated serum SNTF as a prognostic marker for persistent brain dysfunction in uncomplicated mTBI patients treated in a Level I trauma center emergency department. Compared with healthy controls (n = 40), serum SNTF increased by 92% within 24 h of mTBI (n = 95; p < 0.0001), and as a diagnostic marker exhibited 100% specificity and 37% sensitivity (AUC = 0.87). To determine whether the subset of mTBI cases positive for SNTF preferentially developed lasting brain dysfunction, serum levels on the day of mTBI were compared with multiple measures of brain performance at 90 days post-injury. Elevated serum SNTF correlated significantly with persistent impairments in cognition and sensory-motor integration, and predicted worse performance in each test on a case by case basis (AUC = 0.68 and 0.76, respectively). SNTF also predicted poorer recovery of cognitive stress function from 30 to 90 days (AUC = 0.79-0.90). These results suggest that serum SNTF, a surrogate marker for axonal injury after mTBI, may have potential for the rapid prognosis of lasting post-concussion syndrome and impaired functional recovery following CT-negative mTBI. They provide further evidence linking axonal injury to persisting brain dysfunction after uncomplicated mTBI. A SNTF blood test, either alone or combined with other markers of axonal injury, may have important utilities for research, prognosis, management and treatment of concussion.

Emergency medicine physicians' ability to predict hospital admission at the time of triage.

BACKGROUND: We seek to determine if experienced emergency medicine physicians can accurately predict the likelihood of admission for patients at the time of triage. Such predictions, if proven to be accurate, could decrease the time spent in the ED for patients who will ultimately be admitted by hastening downstream workflow. METHODS: This is a prospective cohort study of experienced physicians at a large urban hospital. Physicians were asked to predict the likelihood of admission for patients based only on information available in the EMR at the time of triage. Physicians also predicted the service to which the patients would be admitted. Physicians provided a confidence level of their prediction. Measures of predictive accuracy were calculated, including sensitivity, specificity, and area under the receiver operating characteristic curve. RESULTS: 35 physicians evaluated 398 patient charts and made predictions. Sensitivity of determining admission for the entire cohort was 51.8%. The specificity was 89.1%. For those predictions made with a confidence level of >90%, sensitivity was 61.5% and specificity was 95.7%. Among physicians correctly predicting admission, the admitting service was predicted accurately 88.6% of the time. CONCLUSION: Physicians performed poorly at predicting which patients would be admitted at the time of triage, even when they were confident in their predictions. Conversely, physicians accurately predicted who would be discharged. Physicians predicted with reasonable accuracy the service to which patients were ultimately admitted. More research and operational assessment needs to be performed to determine if these predictions can help improve ED efficiency.

Placement of a cervical collar increases the optic nerve sheath diameter in healthy adults.

INTRODUCTION: Blunt head trauma is a common cause of increased intracranial pressure (ICP). Ultrasound measurement of the optic nerve sheath diameter (OSND) is an accurate and non-invasive way to detect increased ICP. Blunt trauma patients are often immobilized in a rigid cervical spine collar. Our objective was to describe the changes in ONSD following the placement of a c-collar and determine if any changes were time-dependent. METHODS: We performed a prospective cohort study measuring the ONSD of healthy volunteers before and after placement of a c-collar. Two physicians obtained the measurements. Each eye was scanned twice using a standardized technique. This was done before c-collar placement, 5min after placement and 20min after placement. A mean of both eyes was calculated and analyzed using descriptive statistics. An intraclass correlation coefficient (ICC) was used to assess inter-rater reliability. RESULTS: Twenty study participants with a mean age of 37.1years old were enrolled. The mean baseline ONSD was 3.77mm (95% CI 3.48-4.07). The mean ONSD 5 min after the c-collar was placed was 4.47 (95% CI 4.17-4.78). The mean ONSD at 20min after c-collar placement was 4.53 (95% CI 4.13-4.92). These changes were statistically significant (p=0.003 and <0.001). Reliability was relatively strong overall (ICC=0.74; 95% CI: 0.65, 0.81). CONCLUSION: The placement of a cervical collar increased the ONSD at 5min and this change remained increased at 20min. Future study should assess whether similar results are found in patients with blunt head trauma.

Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary.

BACKGROUND: Acute nondisplaced fractures (NDFs) are common in the emergency department (ED), and providers often obtain postsplinting x-rays to identify displacement that potentially occurs during the splinting process. Our objectives are to (1) determine how often x-rays are obtained after splinting of NDFs, (2) identify if postsplinting x-rays change treatment management in the ED, and (3) identify if there are medical complications at follow-up. METHODS: A retrospective chart review of ED patients who were discharged with hand, wrist, ankle, or foot fractures was conducted to determine patients with definite NDFs that were verified by a radiologist, underwent splinting, and either had postsplint x-rays or not. Bone displacement during the splinting procedure was determined by the postsplint x-rays in the ED. Internal movement of bones or management change was also determined for patients who did not undergo postsplint x-rays in the ED but had obtained an x-ray at their follow-up visit (in-network providers only). RESULTS: Our results demonstrate that no patients required further manipulation or operative management due to the splinting that occurred in the ED. These results take into account both patients who had postsplint x-rays conducted in the ED (27 patients) and those who received x-rays in follow-up consults (179 patients). There was minimal incidence of interval movement in the latter group (14 patients), none of which resulted in management change. CONCLUSION: These data conclude that postsplinting x-rays of NDFs are unnecessary. Removal of this procedure from routine practice will help decrease patient and hospital cost, time, and radiation exposure.

Does computed tomographic scan affect diagnosis and management of patients with suspected renal colic?

BACKGROUND: Patients with renal colic commonly present to the emergency department (ED) and are usually treated with analgesics, antiemetics and hydration. Computed tomographic (CT) scan is commonly utilized in evaluating patients with suspected renal colic. OBJECTIVES: We compared diagnosis and treatment plans before and after CT in patients with suspected renal colic with the aim to evaluate how often changes in diagnosis, treatment and disposition are made. METHODS: In this prospective observational study, we enrolled a convenience sample of clinically Stable ED patients older than 17 with suspected renal colic for whom CT was planned. Exclusion criteria were: chronic kidney disease, urinary tract infection, recent CT and history of previous kidney stone. Pre-CT and Post-CT surveys were completed by the treating provider. RESULTS: The discharge diagnosis was renal colic in 62 of 93 enrolled patients (67%). Urinalysis showed blood in 52 of these patients (84%). CT confirmed obstructing kidney or bladder stone in 50 patients. There were five cases of alternative diagnoses noted on CT scan. After CT scan, 7 patients had changes in disposition. Sixteen providers felt that CT would not change management. In these cases, CT offered no alternative diagnosis and didn't change disposition. CONCLUSION: CT scan didn't change management when providers did not expect it would. This indicates that providers who are confident with the diagnosis of renal colic should consider forgoing a CT scan. CT scan did occasionally find important alternative diagnoses and should be utilized when providers are considering other concerning pathology.

Lacunar stroke in a teenager after minor head trauma: case report and literature review.

Ischemic strokes in children and young adults are fortunately rare. Contrasted with adult ischemic strokes, pediatric stroke etiologies vary greatly and are often unknown. Childhood lacunar strokes and trauma-induced strokes represent particularly uncommon subsets and have been reported infrequently in the literature. It is unique to find a combination of the 2-a lacunar stroke induced by trauma. Underreporting of these trauma-induced ischemic strokes could be responsible for perpetuating the lack of recognition. Here we present a lacunar stroke in a young woman associated with a water sport accident and explore relevant literature encircling deep brain ischemia coinciding with trauma.

Emergency department patient knowledge and physician communication regarding CT scans.

OBJECTIVES: This study evaluated several aspects of patients' and providers' knowledge and attitude regarding emergency CT scan use. Specifically, is patient awareness of radiation risks changing over time and do levels of education affect this knowledge? Meanwhile, do emergency medicine providers discuss risks with patients and do patients want to know about these risks? METHODS: We conducted a survey of clinically stable patients in the emergency department (ED) after undergoing a CT scan. RESULTS: 200 patients were surveyed. 82 (41%) were aware that CT scans are associated with radiation exposure. 50 (25%) patients were aware that radiation from CT can increase overall lifetime risk of cancer compared with only 2/76 (3%) conducted in 2002. 29 (14.5%) providers specifically discussed radiation risk with patients prior to the CT. There was a significant trend towards knowledge that CT uses x-rays among those with more education. However, there was no association between level of education and knowledge of cancer risk associated with radiation risk from CT. 82 (41%) would have liked more information regarding radiation risks from the provider. CONCLUSIONS: ED patient knowledge has increased significantly over the past 8 years. At the same time, there is a trend towards ED providers more commonly discussing these risks. Level of education is associated with knowledge that CT uses x-rays, but not with knowledge that this is associated with a greater risk of cancer. Patients often want to be informed of these risks.