Measuring Emergency Department Staff Perceptions of Causes and Management of Violence.

BACKGROUND: Half of all reported violent incidents in health care settings occur in the emergency department (ED) placing all staff members at risk. However, research typically does not include all ED work groups or validated measures beyond nurses and physicians. OBJECTIVE: The aims of this study were to (a) validate an established instrument measuring perceptions of causes of violence and attitudes toward managing violence within an inclusive workforce sample; and (b) explore variation in perceptions, attitudes, and incidence of violence and safety to inform a violence prevention program. METHODS: This is an investigator-initiated single-site cross-sectional survey design assessing the psychometric properties of the Management of Aggression and Violence Attitude Scale (MAVAS) within a convenience sample (n = 134). Construct validity was assessed using exploratory factor analysis and reliability was evaluated by the Cronbach's α estimation. Descriptive, correlational, and inferential estimates explored differences in perceptions, attitudes, and incidence of violence and safety. RESULTS: Exploratory factor analysis indicated validity of the MAVAS with a seven-factor model. Its internal consistency was satisfactory overall (Cronbach's α= 0.87) and across all subscales (Cronbach's α values = 0.52-0.80). Significant variation in incidence of physical assault, perceptions of safety, and causes of violence was found between work groups. CONCLUSIONS: The MAVAS is a valid and reliable tool to measure ED staff members' perceptions of causes of violence and attitudes toward managing violence. In addition, it can inform training according to differences in work group learner needs.

Peer recovery coaches and emergency department utilization in patients with substance use disorders.

BACKGROUND: Although Emergency Departments (ED) frequently provide care for patients with substance use disorders (SUD), there are many barriers to connecting them with appropriate long-term treatment. One approach to subside risk in this population is the Peer Recovery Coach (PRC). PRCs are individuals with a lived experience of the rehabilitation process and are a powerful resource to bridge this gap in care by engaging patients and their families and providing system navigation, self-empowerment for behavior change, and harm reduction strategies. The purpose of this project is to describe an ED-based PRC program, evaluating its feasibility and efficacy. METHODS: This was a retrospective quality improvement project conducted at 3 suburban hospitals. All patients arriving to the ED were screened with a brief questionnaire in triage and patients identified as a high-risk had referral placed to a PRC if the patient consented. The PRC met with the patient at the ED bedside if possible. The PRC program members collected prospective data on patient engagement with the PRC at 30, 60, and 90 days post ED encounter. Using the EMR we identified the number of subsequent ED visits at 30, 60, and 90 days (for both medical and substance use disorder-related visits) from the index PRC visit. RESULTS: There were 448 individuals identified and included in this analysis between January 1, 2019 and June 30, 2020, of which 292 (66%) were male and the mean age was 44 (range 18-80). Most patients identified alcohol as the primary substance they used (289, 65%), followed by heroin/opiates (20%). At 30, 60, and 90 days, there were 110 (25%), 79 (18%), and 71 (16%) patients who were still actively engaged in the program, respectively. Among all patients in the cohort, there was essentially no decrease in mean visits before versus after the PRC engagement visit. However, among patients who had at least one prior ED visit, there were significant differences in mean visits across all visit-types: for patients with 1 prior ED visit, 90 day mean decrease in visits = 1.0 visits (95% CI 0.7-1.2), for patients with 5+ prior ED visits, 90 day mean decrease in visits = 3.6 visits (95% CI 2.4-4.8). CONCLUSION: We describe the implementation of an ED-based PRC program for patients with substance use disorders. While we demonstrated that it is feasible for the PRC to engage the patient while in the ED, there was poor follow-up with the program outpatient. For patients with at least one previous SUD visit to the ED, there was a statistically significant reduction in ED utilization after engaging with a PRC while in the ED, suggesting this may be a population that could be targeted to link patients to long term care and decrease repeated ED utilization.

Credentialing Pediatric Emergency Medicine Faculty in Point-of-Care Ultrasound: Expert Guidelines.

ABSTRACT: As point-of-care ultrasound (POCUS) becomes standard practice in pediatric emergency medicine (PEM), it is important to have benchmarks in place for credentialing PEM faculty in POCUS. Faculty must be systematically trained and assessed for competency in order to be credentialed in POCUS and granted privileges by an individual institution. Recommendations on credentialing PEM faculty are needed to ensure appropriate, consistent, and responsible use of this diagnostic and procedural tool. It is our intention that these guidelines will serve as a framework for credentialing faculty in PEM POCUS.

Use of Point-of-Care Ultrasound in the Emergency Department: Insights From the 2012 Medicare National Payment Data Set.

OBJECTIVES: Point-of-care ultrasound is a valuable tool with potential to expedite diagnoses and improve patient outcomes in the emergency department. However, little is known about national patterns of adoption. This study examined nationwide point-of-care ultrasound reimbursement among emergency medicine (EM) practitioners and examined regional and practitioner level variations. METHODS: Data from the 2012 Center for Medicare and Medicaid Services Fee-for-Service Provider Utilization and Payment Data include all practitioners who received more than 10 Medicare Part B fee-for-service reimbursements for any Healthcare Common Procedure Coding System code in 2012. Odds ratios (ORs) and descriptive statistics were calculated to assess relationships between ultrasound reimbursement and practice location, nearby presence of an EM residency, and time elapsed since practitioner graduation. RESULTS: Of 52,928 unique EM practitioners, 391 (0.7%) received limited ultrasound reimbursements for a total of 16,389 scans in 2012. Urban counties had an OR of 5.4 (95% confidence interval, 3.8-7.8) for receiving point-of-care ultrasound reimbursements compared to rural counties. Counties with an EM residency had an OR of 84.7 (95% confidence interval, 42.6-178.8) for reimbursement compared to counties without. The OR for receiving reimbursement was independent of medical school graduation year (P = .83); however, recent graduates performed more scans (P = .02). CONCLUSIONS: A small minority of EM practitioners received reimbursements for point-of-care ultrasound from Medicare beneficiaries. These practitioners were more likely to reside in urban and academic settings. Future efforts should assess the degree to which our findings reflect either low point-of-care ultrasound use or low rates of billing for ultrasound examinations that are performed.

Goal-directed Focused Ultrasound Milestones Revised: A Multiorganizational Consensus.

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

Near-miss in focused lower-extremity ultrasound for deep venous thrombosis.

BACKGROUND: Focused, proximal compression ultrasound (FPCUS) is a commonly used point-of-care study in the Emergency Department (ED). Pelvic vein deep venous thrombosis (DVT) is a rare presentation, and Emergency Physicians need to be aware of the limitations and pitfalls of FPCUS. OBJECTIVE: A case of external iliac vein DVT diagnosed in the ED is presented, with a focus on subtle signs seen during FPCUS that led to the diagnosis and additional ultrasound techniques to aid in appropriate point-of-care diagnosis. CASE REPORT: We describe a patient who presented with lower-extremity pain and was subsequently diagnosed with external iliac DVT. A FPCUS study by Emergency Physicians was performed and demonstrated subtle findings that led to further investigation and appropriate diagnosis. CONCLUSION: Emergency physicians using FPCUS in the evaluation of lower-extremity pain or swelling need to be aware of the pitfalls, limitations, and advanced techniques to avoid misdiagnosis while evaluating for DVT.

Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED.

OBJECTIVE: The diagnosis of cholecystitis or biliary tract disease in children and adolescents is an uncommon occurrence in the emergency department and other acute care settings. Misdiagnosis and delays in diagnosing children with cholecystitis or biliary tract disease of up to months and years have been reported in the literature. We discuss the technique and potential utility of point-of-care ultrasound evaluation in a series of pediatric patients with suspected cholecystitis or biliary tract disease. METHODS: We present a nonconsecutive case series of pediatric and adolescent patients with abdominal pain diagnosed with cholecystitis or biliary tract disease using point-of-care ultrasound. The published sonographic criteria is 3 mm or less for the upper limits of normal gallbladder wall thickness and is 3 mm or less for normal common bile duct diameter (measured from inner wall to inner wall) in children. Measurements above these limits were considered abnormal, in addition to the sonographic presence of gallstones, pericholecystic fluid, and a sonographic Murphy's sign. RESULTS: Point-of care ultrasound screening detected 13 female pediatric patients with cholecystitis or biliary tract disease when the authors were on duty over a 5-year period. Diagnoses were confirmed by radiology imaging or at surgery and surgical pathology. CONCLUSIONS: Point-of-care ultrasound to detect pediatric cholecystitis or biliary tract disease may help avoid misdiagnosis or delays in diagnosis in children with abdominal pain.

Economic impact of additional radiographic studies after registered diagnostic medical sonographer (RDMS)-certified emergency physician-performed identification of cholecystitis by ultrasound.

BACKGROUND: The standard evaluation of patients with right upper quadrant (RUQ) abdominal pain consists of a history and physical examination, laboratory analysis, and radiological investigation. Given the increasing availability of bedside ultrasound in the Emergency Department (ED), a growing proportion of Emergency Physicians are now performing their own ultrasound examinations in patients with RUQ abdominal pain to circumvent diagnostic delays and improve patient care. OBJECTIVE: To determine the economic "opportunity" costs of additional radiographic testing after identification of acute cholecystitis by focused ED ultrasound performed by registered diagnostic medical sonographer (RDMS)-certified personnel. METHODS: A retrospective analysis of a consecutive sample of patients with "positive" focused ED ultrasounds of the RUQ that were significant for cholecystitis, who presented from June 1, 2005 through February 30, 2006. Cost analysis was performed using standard Medicare compensation indices for radiological examinations of the abdomen/hepatobiliary system. RESULTS: There were 37 patients enrolled; 32 patients exhibited RUQ pain with a focused ED ultrasound significant for cholecystitis. Eight (25%) patients received no further radiographic tests and exhibited positive pathology. Twenty-four (75%) patients had additional diagnostic examinations; 22 (92%) showed positive pathology. Based upon Medicare compensation indices, an opportunity cost of $6885.34 was incurred at our institution over 9 months due to additional examinations. Using nationally comparable indices, this was extrapolated to an opportunity cost of $63 million (95% confidence interval $48.3-$78.9 million) per year across the nation, assuming that 50% of patients with cholecystitis present to the ED and receive an ultrasound examination by an RDMS-certified Emergency Physician. CONCLUSIONS: In this small sample, additional radiological testing after ED ultrasounds significant for acute cholecystitis led to sizable economic costs on a local and national level. Formal cost-benefit analyses are needed to evaluate the full economic and patient care implications of ED ultrasound use in this setting.

Feasibility of emergency physician diagnosis of hypertrophic pyloric stenosis using point-of-care ultrasound: a multi-center case series.

Hypertrophic pyloric stenosis (HPS) is an acute abdominal emergency in infants that often presents to Emergency Departments. The clinical diagnosis of HPS relies on palpation of an olive-sized mass in the right upper quadrant of an infant with a history of projectile vomiting. However, studies have shown that clinicians cannot detect the olive in 11% to 51% of cases. Ultrasonography is the imaging modality of choice to diagnose HPS. HPS has a highly characteristic sonographic appearance that makes it readily identifiable on ultrasound. To our knowledge, there have been no reports documenting the ability of Emergency Physicians to diagnose HPS using point-of-care ultrasound. We present a multi-center case series (n = 8) of HPS diagnosed by Emergency Physician-performed ultrasound. We review the technique of incorporating point-of-care ultrasound into the physical examination of infants with suspected HPS and discuss the possible role of point-of-care ultrasound in the management of these patients.

Difficult central line placement due to variant internal jugular vein anatomy.

The internal jugular vein (IJV) is an optimal location for obtaining central venous access due to its superficial location. However, there are many potential pitfalls of using the landmark technique, including aberrant anatomy of the IJV, proximity to the carotid artery and cupola of the lung, body habitus, and prior neck surgery. Our case study demonstrates how the use of ultrasound greatly simplified cannulation of an aberrant IJV in a dialysis patient.