Relation Between Pediatric Emergency Department Activity and Patient Complexity.

OBJECTIVES: Potentially projecting pediatric emergency department (ED) volume trends is a matter that has been researched extensively. It is vital to understand the relation between patient complexity and department volumes to properly staff and allocate resources within the ED. Multiple studies have analyzed ED volumes based on disease severity; however, the degree of illness was determined by triage classification. This study proposed a novel method of evaluating the relation between pediatric ED patient complexity, centered on Current Procedural Terminology (CPT) code, and day of the week. METHODS: This was a retrospective study of pediatric patients presenting to the ED between January 1, 2010 and December 31, 2015. This study looked at the relation between individuals with CPT codes who were evaluated in the pediatric ED on a particular day of the week and evaluated in the pediatric ED either the day before, the day of, and the day after a legal holiday. RESULTS: A total of 81,698 (54%) male and 70,002 (46%) female patients were analyzed. No relation was noted between ED patient complexity, based on their CPT code, and the day of the week (P = 0.41). Individual, nonstatistically significant differences between the day of the week and pediatric ED volumes were identified, however. CONCLUSIONS: We identified no relation between pediatric ED patient complexity, assessed by CPT code, and the day of the week. Furthermore, a more multifactorial and granular analysis may be necessary to model resource constraints by type and time of day to more effectively manage ED resources. CPT-based modeling may benefit superimposed financial analyses of demand-capacity management.

Assessment of Written Feedback for Emergency Medicine Residents.

OBJECTIVES: An essential component of resident growth is a learning environment with high-quality feedback. Criteria have been developed for characterizing and assessing written feedback quality in internal medicine residents by Jackson et al. Our primary goal was to describe feedback characteristics and assess the quality of written feedback for emergency medicine (EM) residents. Our secondary goals were to evaluate the relation between feedback quality and objective outcome measures. METHODS: This retrospective study was conducted between July 1, 2016 and July 1, 2018. EM residents with an Accreditation Council for Graduate Medical Education composite score (ACS), an in-service score, and written evaluations completed by an attending physician or EM resident in each of the 2 years of the study period were included. RESULTS: Overall, most of the evaluations contained 1 (21%), 2 (23%), or 3 (17%) feedback items. Feedback tended to be positive (82%) and the feedback quality of the evaluations was more likely to be high (44%). There was an association between feedback quality and ACS change (P < 0.0001), but not in-service score change (P = 0.63). Resident evaluations were more likely than attending evaluations to correlate with ACS change (P < 0.00001). CONCLUSIONS: The written evaluations contained few individual feedback items. Evaluations generally focused on the feedback characteristics of professionalism and interpersonal communication. The general feedback quality of evaluations tended to be high and correlated with an increase in ACSs.

The effect of practice settings on individual Doctor Press Ganey scores: A retrospective cohort review.

OBJECTIVE: The Press Ganey (PG) survey is a patient experience survey mailed to patients upon discharge from the emergency department (ED). It is a nationally recognized survey that is commonly used to measure patient's perception of the healthcare delivered. Emergency medicine physicians at Staten Island University Hospital staff two distinct sites: a tertiary-care setting (SIUH-N) and a community setting (SIUH-S). The goal of our study was to compare the effect of different ED practice settings, within the same hospital and healthcare system, on individual attending physician PG scores. METHODS: This was a retrospective, observational study of EM physicians, conducted at Staten Island University Hospital between January 1, 2015 and December 31, 2016. Physicians with PG survey responses from both sites were included. The number of responses and mean scores for the four doctor specific survey questions and the doctor overall score were extracted from PG surveys. RESULTS: Mean PG scores at SIUH-N were significantly lower than the mean scores at SIUH-S in each of the four doctor-specific questions, as well as the doctor overall score (p < 0.05). 16 out of 18 doctors demonstrated higher doctor overall scores at SIUH-S. CONCLUSION: Variables other than the individual doctor may be influencing the PG survey responses and perceptions of care. The PG survey may underestimate the impact of different practice settings on individual doctor PG scores.

Myonecrosis: A Rare Complication of Cryoneurolysis.

BACKGROUND: Considered a safe and effective procedure, cryoneurolysis has been used to provide pain relief for chronic joint pain for decades. The procedure is similar to common ultrasound-guided percutaneous procedures. Although the literature is limited on the efficacy and safety of cryoneurolysis, there is a consensus that the use of cryoneurolysis is effective, with a risk profile similar to that of other percutaneous procedures. CASE REPORT: We are reporting the case of a 74-year-old male who underwent cryoneurolysis for chronic right knee pain. Initially, the patient had complete symptomatic improvement, but subsequently developed rigors and right knee swelling, prompting him to seek emergency medical care. Computed tomography angiography was significant for myonecrosis and phlegmon with early abscess formation. The patient continued to improve symptomatically with i.v. antibiotics. He was discharged home on hospital day 8 with a peripherally inserted central catheter. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cryoneurolysis will likely continue to gain popularity as an option for pain management in osteoarthritis and other degenerative joint diseases. It is essential for physicians to be alert to the possibility of severe, albeit rare, complications of a seemingly safe procedure, given the potential to impact a patient's morbidity and quality of life drastically.

Effect of New York State Electronic Prescribing Mandate on Opioid Prescribing Patterns.

BACKGROUND: Drug overdose was the leading cause of injury and death in 2013, with drug misuse and abuse causing approximately 2.5 million emergency department (ED) visits in 2011. The Electronic Prescriptions for Controlled Substances (EPCS) program was created with the goal of decreasing rates of prescription opioid addiction, abuse, diversion, and death by making it more difficult to "doctor-shop" and alter prescriptions. OBJECTIVE: In this study, we describe the opioid-prescribing patterns of emergency physicians after the introduction of the New York State EPCS mandate. METHODS: We conducted a retrospective, single-center, descriptive study with a pre-/post-test design. The pre-implementation period used for comparison was April 1-July 31, 2015 and the post-implementation period was April 1-July 31, 2016. All ED discharge prescriptions for opioid medications prior to and after the initiation of New York State EPCS were identified. RESULTS: During the pre-implementation study period, 22,221 patient visits were identified with 1366 patients receiving an opioid prescription. During the post-implementation study period, 22,405 patient visits were identified with 642 patients receiving an opioid prescription. This represented an absolute decrease of 724 (53%) opioid prescriptions (p < 0.0001), which is an absolute difference of 2.3% (95% confidence interval 2.0-2.6%). CONCLUSIONS: There was a significant decline in the overall number of opioid prescriptions after implementation of the New York EPCS mandate.

Pneumocephalus after Epidural Injection.

BACKGROUND: Pneumocephalus, or air in the intracranial space, is most commonly encountered after trauma or surgery. Epidural injections are commonly performed in obstetrics and pain management. Complications are uncommon and include hemorrhage, cerebrospinal fluid leak, and infection. A rare complication is pneumocephalus, described in only a few case reports of epidural anesthesia. CASE REPORT: We describe a 34-year-old woman complaining of a generalized headache 6 days after an unremarkable vaginal delivery that was assisted by an epidural injection. A noncontrast computed tomography scan of the head revealed pneumocephalus secondary to epidural injection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pneumocephalus is an uncommon but serious complication of an epidural procedure. Emergency physicians must be aware of this complication entity and maintain this entity in their differential diagnosis given the potential for significant morbidity.

Effect of an emergency department opioid prescription policy on prescribing patterns.

BACKGROUND: Staten Island University Hospital is located in NYC, where the opioid epidemic has resulted in significant mortalities from unintentional overdoses. In 2013 as a response to the rising threat to our community, our Emergency Department (ED) administration adopted a clinical practice policy focused on decreasing the prescription of controlled substances. The effects of this policy on our provider prescription patterns are presented here. METHODS: A retrospective chart review of patients prescribed opioids from the ED before and after policy implementation was performed. Dates chosen for analysis was November 1, 2012 through January 31, 2013 and November 1, 2013 through January 31, 2014; these time periods were used to serve as a seasonally comparative group pre and post clinical practice policy implementation. Opioids written for the treatment of cough, and for children under eighteen were excluded from analysis. Patient age, sex, diagnoses, and prescription formulation, strength, and pill number was recorded for each patient receiving an opioid prescription. RESULTS: There was a drop in the total prescriptions from 1756 to 1128 without a change in the average number of pills (12.78 vs 12.44) or average total dose prescribed (69.39 vs 68.98) mg of morphine equivalent per prescription. Additionally, there were sizable reductions in opioid prescriptions written for arthralgias/myalgias, dental pain, soft tissue injuries, and headaches. CONCLUSION: The opioid clinical policy had a clear effect in decreasing the number of patients prescribed opioids. Such policies may be the key to reducing the epidemic and saving lives from unintentional opioid overdoses.

Characteristics of Patients Who Return to the Emergency Department After an Observation Unit Assessment.

Introduction: Emergency Department observation units (EDOU) transition patients from the emergency department (ED) to dedicated areas where they can receive continuous monitoring. Understanding patient return visits after EDOU discharge is important for optimizing healthcare. The objective of this study was to investigate the correlation between demographic and clinical features and the likelihood of returning to the ED within 30 days following their initial assessment in the EDOU. Methods: This retrospective, observational cohort study of adult EDOU subjects was conducted between February 1, 2018 - January 31, 2023. Adult patients evaluated in the EDOU and returned to the ED within 30 days were identified. Subjects were compared to those assessed in the EDOU but did not return to the ED within 30 days. The analysis took into account multiple visits by the same subject and made adjustments for variables including gender, ethnicity, insurance status, primary diagnosis, and disposition, using a generalized linear mixed model. Results: A total of 14,910 EDOU encounters were analyzed and 2,252 (15%) patients returned to the ED within 30 days. The analysis took into account several variables demonstrated a significant association with the likelihood of returning to the ED within 30 days. These included gender (p=0.0002), ethnicity (p=0.005), race (p=0.0004), insurance status (p<0.0001), primary diagnosis (p<0.0001), and disposition (p<0.001). Emergency severity index and length of stay were not associated with returning. Conclusions: Understanding these factors may guide interventions, enhance EDOU care, and reduce resource strain. Further research should explore these associations and long-term intervention impacts for improved outcomes.

Femoral nerve blocks versus standard pain control for hip fractures: a retrospective comparative analysis.

OBJECTIVE: Pain control for hip fractures is often achieved via intravenous opioids. However, opioids can have dangerous adverse effects, including respiratory depression and delirium. Peripheral nerve blockade is an alternative option for pain control that reduces the need for opioid analgesia. The purpose of this study was to compare the use of femoral nerve blocks versus standard pain control for patients with hip fractures. METHODS: This retrospective study included adult patients presenting to the emergency department with isolated hip fractures between April 2021 and September 2022. The intervention group included all patients who received a femoral nerve block during this time. An equivalent number of patients who received standard pain control during that period was randomly selected to represent the control group. The primary outcome was preoperative opioid requirement, assessed by morphine milligram equivalents (MMEs). RESULTS: During the study period, 90 patients were included in each group. Mean preoperative MME was 10.3 (95% confidence interval [CI], 7.4-13.2 MME) for the intervention group and 14.0 (95% CI, 10.2-17.8 MME) for the control group (P=0.13). Patients who received a femoral nerve block also had shorter time from emergency department triage to hospital discharge (7.2 days; 95% CI, 6.2-8.0 days) than patients who received standard care (8.6 days; 95% CI, 7.210.0 days). However, this difference was not statistically significant (P=0.09). CONCLUSION: Femoral nerve blockade is a safe and effective alternative to opioids for pain control in patients with hip fractures.

Utility of dual read in the setting of prostate MRI interpretation.

PURPOSE: The purpose of this study is to assess the utility of dual reader interpretation of prostate MRI in the evaluation/detection of prostate cancer, using the PI-RADS v2.1 scoring system. METHODS: We performed a retrospective study to assess the utility of dual reader interpretation for prostate MRI. All MRI cases compiled for analysis were accompanied with prostate biopsy pathology reports that included Gleason scores to correlate to the MRI PI-RADS v2.1 score, tissue findings and location of pathology within the prostate gland. To assess for dual reader utility, two fellowship trained abdominal imagers (each with > 5 years of experience) provided independent and concurrent PI-RADS v2.1 scores on all included MRI examinations, which were then compared to the biopsy proven Gleason scores. RESULTS: After application of inclusion criteria, 131 cases were used for analysis. The mean age of the cohort was 63.6 years. Sensitivity, specificity and positive/negative predictive values were calculated for each reader and concurrent scores. Reader 1 demonstrated 71.43% sensitivity, 85.39% specificity, 69.77% PPV and 86.36% NPV. Reader 2 demonstrated 83.33% sensitivity, 78.65% specificity, 64.81% PPV and 90.91% NPV. Concurrent reads demonstrated 78.57% sensitivity, 80.9% specificity, 66% PPV and 88.89% NPV. There was no statistically significant difference between the individual readers or concurrent reads (p = 0.79). CONCLUSION: Our results highlight that dual reader interpretation in prostate MRI is not needed to detect clinically relevant tumor and that radiologists with experience and training in prostate MRI interpretation establish acceptable sensitivity and specificity marks on PI-RADS v2.1 assessment.

The Effect of an Iodinated Contrast Material Shortage on Ordering Patterns in the Emergency Department.

Introduction Iodinated contrast media (ICM) is essential to emergency department care in differentiating and delineating life-threatening pathologies. In May 2022, due to the COVID-19 outbreak, there was an unprecedented disruption in the manufacturing of iodinated contrast. The primary goal of this study was to describe the effects of an ICM shortage on the ordering patterns of emergency medicine physicians. Methods This was a retrospective, observational study with a pre-/post-test design. The study included two 28-day periods. All subjects who underwent a CT were included in the study. The subgroup of patients who underwent a repeat CT with ICM contrast within 1-24 hours was identified. Results During the pre- and post-implementation study periods, 4,574 and 3,973 CT studies were performed. The median length of stay (p=0.013) and time to first CT (p<0.001) both decreased during the post-implementation period. During the post-implementation period, more non-contrast CTs were ordered (p<0.001). During the post-implementation period, there was an increase in non-contrast studies followed by a repeat study with contrast (p=0.003). Conclusions A global ICM shortage resulted in a shift in the ordering patterns of Emergency Medicine (EM) physicians. More non-contrast CT scans were ordered. However, there was also an increase in repeat imaging with ICM material.

MD and DO: Differing Medical Degrees and the Associated Perceptions.

PURPOSE: To highlight perspectives about differing medical degrees and graduate medical education amongst current allopathic (MD) and osteopathic (DO) radiology residents. MATERIALS AND METHOD: Two hundred sixty-eight radiology residents were interviewed using an approved Association of Program Coordinators in Radiology (APCR) survey designed to evaluate perceptions of allopathic and osteopathic radiology residents regarding type of medical degree and their career development. The surveys were kept anonymous with no identifiable information. Residents in their first through fourth years of training replied with an approximate equal distribution amongst the different years. RESULTS: Based on the 268 respondents, DOs' more so than MDs', reported that their degree type altered their medical careers (P < 0.0001) and that they were advised to not pursue a radiology residency based on degree type (P< 0.0001). In addition, a large majority of both DOs' and MDs' felt that residency selection is favored towards the allopathic degree (P= 0.0451). CONCLUSION: This survey-based study does reveal perceived differences in the residency recruitment process based on degree type. Future discussions to bridge this perceived gap will be important, especially in light of the recent ACGME merger between the 2 educational pathways.

Resource utilization of adult patients referred to the emergency department from an urgent care center.

BACKGROUND: The rise of urgent care centers (UCC) continues to serve as an alternative to emergency departments (ED) for patients with a perceived lower acuity complaint. Patients that are deemed to be higher acuity are often evaluated at an UCC and then redirected to EDs. However, limited data exist on resource utilization by patients who are transferred from UCCs to EDs. The objective of this study was to compare resource utilization in the ED between patients who were transferred from UCCs and those who were initially evaluated in the ED. METHODS: This was a retrospective study of adult patients transferred from UCCs in Staten Island, NY to Staten Island University Hospital, between 1 March 2018 and 31 December 2018.  The first group (UCC Group) included those initially evaluated at an UCC and then referred to the ED. The second group (ED Group) included those who had their initial evaluation in the ED. RESULTS: 572 subjects were enrolled in the UCC Group, and 84,481 in the ED Group. The UCC Group was more likely to undergo laboratory tests, plain radiographs and computed tomography, electrocardiograms, intravenous fluids, and parenteral medications. Patients in the UCC group were also more likely to be admitted to an inpatient bed or placed into ED observation (p < 0.0001). Overall, ED length of stay was longer in the UCC Group (p < 0.001). CONCLUSIONS: Patients referred from an UCC required more ED resources and were more likely to be admitted to a hospital bed compared to those who initially self-referred to the ED.

Comparison of Hands-On Versus Online Learning in Teaching Ultrasound Skills for Achilles Tendon Rupture: A Pilot Study.

Introduction In the emergency department, the diagnosis of an Achilles tendon rupture (ATR) is reportedly missed in greater than 20% of cases. A limited number of studies evaluate the use of cadaver models as a potential ultrasound teaching and training modality. We hypothesize that emergency medicine residents can effectively utilize point-of-care ultrasound (POCUS) on cadaver models and a focused teaching intervention to assess their ability to detect ATRs. Methods A prospective study of 23 EM residents was performed. All participants in the study were divided into two learner groups: (a) independent and (b) hands-on. The independent learner group received a 30-minute online didactic lecture demonstrating how to diagnose ATRs. The hands-on learner group received direct instruction on cadaver lower leg models with a ruptured and normal Achilles tendon (AT). Both groups then participated in identifying either normal or ruptured ATs on six cadaver lower leg models. Results The sensitivity and specificity were 89% and 82% in the independent learner group 96% and 100% in the hands-on learner group, respectively. The overall sensitivity and specificity were 91% and 88%, respectively. There was a trend toward successful identification with increased years of residency training. Conclusions In this study, lower leg and ankle cadaver models were found to be as effective as an independent learner model for potential POCUS teaching and training modality in both novice and more advanced trainees.

Demographics and clinical patterns of burns requiring emergency hospitalization at a regional north-eastern us burn center.

BACKGROUND: There are known demographic and clinical patterns related to burn injuries and care associated with national and global geography. Still, limited data sources exist to facilitate the study of trends in the regionalization of burn care. OBJECTIVES: The current study aims to investigate the demographics and clinical characteristics of patients that presented to the Emergency Department (ED) and were subsequently admitted for treatment to the inpatient unit of a regional burn center. METHODS: This retrospective, single-center study was conducted between 1 February 2018 and 31 July 2019, of ED patients who presented with a burn injury and were subsequently admitted to the hospital. RESULTS: We identified 329 patients with burn injuries requiring hospitalization. The median age was 22 years [IQR 2-53], and 195 (59%) subjects were males. Monthly and seasonal variations in admissions were identified. The majority of burns occurred at home (84%) and secondary to a scalding injury (59%). The lower extremity was the most common site of injury (29%). Most subjects received antibiotics (59%) and narcotic analgesia (56%) in the ED. The median hospital length of stay was four days [IQR 2-11]. Many subjects did not require surgical intervention (64%) and did not experience complications (79%). CONCLUSIONS: In this study, we describe the demographics and clinical characteristics of patients that presented to the ED and were subsequently admitted to a regional burn center. Analyzing the epidemiological information and clinical management of burns may better prepare healthcare providers to offer care to patients with burn injuries.

Estimates of Total Burned Surface Area by Emergency Department Clinicians and Burn Specialists.

Introduction Correctly assessing burn size is extremely important since it is directly associated with a patient's subsequent management. Further, an accurate assessment of the total body surface area (TBSA) involved is crucial to decide if specialty care in a burn unit is necessary, whereby overestimation has the potential to lead to unnecessary patient transfers and undesirable burdens on the healthcare system and inconvenience to patients. The goal of this study was to identify whether burn injury estimates of TBSA percentage correlate between emergency department (ED) clinician and burn specialists. Methods This was a retrospective study conducted between February 1, 2018 and July 31, 2019 of patients with a burn injury who were evaluated by both an ED clinician and a burn specialist during the same ED visit. Charts were reviewed to identify the documentation of TBSA by pre-hospital personnel, ED nursing staff, ED mid-level providers (MLP), ED attending physicians, burn consultant MLPs, and burn consultant attending physicians. Results During the study period, 189 subjects with both an ED and burn consultant. The median age was 11 years [interquartile range (IQR) 1-49], and 103 (54%) were males. More than half of the subjects (n=106, 56%) were under the age of 18. There was a statistically significant correlation between estimates of TBSA between ED and burn consultants overall (p<0.0001). Furthermore, there was a statistically significant correlation between ED and burn MLPs (p<0.0001) as well as ED and burn attending physicians (p<0.0001). When adjusted for MLP and attending sex, there was still a correlation among all groups (p<0.0001). Conclusions In this study, there was a statistically significant correlation between estimates of TBSA between ED and burn consultants.

Should Radiologists Comment on Incidental Findings of Vascular Calcifications Found on Abdominal/Pelvic CT in Patients Less Than 50 Years of Age?

RATIONALE AND OBJECTIVES: To evaluate if incidental abdominopelvic calcified atherosclerosis (ACA) in patients under 50 years of age correlates with cardiovascular disease (CVD) risk factors. Most studies evaluating calcific atherosclerosis and associated increased risk of CVD have concentrated on middle age and older populations. MATERIALS AND METHODS: A retrospective review of 519 emergency department patients, aged 25-50 years, receiving computed tomography (CT) was performed and ACA correlated with lipid panels obtained via chart review. Those with calcified atherosclerosis were subdivided by vessel location and calcification burden (mild, moderate, or severe). Patients were followed for six years. Normality, Wilcoxon-Mann-Whitney, Kruskal-Wallis, and chi-square tests were performed. RESULTS: Two hundred and sixty-nine patients with incidental ACA on CT and 250 without ACA were studied. Atherosclerotic calcifications had a statistically significant correlation with elevated triglyceride (128 mg/dL vs 105 mg/dL; p = 0.0003) and decreased high-density lipoprotein (38 mg/dL vs 41 mg/dL; p = 0.0032) as compared to the control. Patients with ACA were at higher risk of stroke, heart attack, and death (p < 0.0001) during a six-year follow-up period. CONCLUSION: Incidental atherosclerotic calcification on abdominopelvic CT in patients under 50 years of age correlated with elevated triglycerides and decreased high-density lipoprotein as well as higher risk of cardiovascular events. Since radiologists may be the first to identify this finding and CVD is the leading cause of US deaths, proper recognition and reporting of calcification is valuable.