Use of Naloxone in Angiotensin-Converting Enzyme Inhibitor Overdose: A Case Report.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitor overdose is an uncommonly presenting toxicologic emergency. Management is primarily supportive care, but a small body of evidence exists to support naloxone for management of hypotension. CASE REPORT: We present a case of accidental ACE inhibitor overdose. The patient took approximately 300 mg lisinopril over 48 h and presented for evaluation of syncope. He was hypotensive and unresponsive to fluids. We administered naloxone with immediate and sustained resolution in hypotension. The mechanism of action is briefly discussed. WHY SHOULD AN EMERGENCY MEDICINE PHYSICIAN BE AWARE OF THIS?: Naloxone is a rapid, low-risk, low-cost, and effective intervention for hypotension due to ACE inhibitor toxicity. It is supported by basic science research and clinical experience.

Effect on efficiency and cost-effectiveness when an observation unit is managed as a closed unit vs an open unit.

OBJECTIVE: To compare efficiency and cost-effectiveness of an observation unit (OU) when managed as a closed unit vs an open unit. METHODS: This observational, retrospective study of a 30-bed OU compared three time periods: Nov 2007 to Aug 2008 (period 1), Nov 2008 to Aug 2009 (period 2) and Nov 2010 to Aug 2011 (period 3). The OU was managed and staffed by non-emergency department physicians as an open unit during period 1, and a closed unit by emergency department physicians during periods 2 and 3. RESULTS: OU volume was greatest in period 3 (1 vs 3, 95% CI -235.8 to -127.9; 2 vs 3, 95% CI -191.9 to -84.095%). Periods 2 and 3 had shorter lengths of stay for discharged (1 vs 2, 95% CI -6.6 to 1.7; 1 vs 3, 95% CI -8.1 to -3.1) and admitted (1 vs 2, 95% CI -11.4 to -8.6; 1 vs 3, 95% CI -11.8 to -9.0) patients, less admission rates (P < .001), and less 30-day all cause admission rates after discharge (P < .0001). Cost was less during periods 2 and 3 for direct (1 vs 2, 95% CI -392.5 to -305.9; 1 vs 3, 95% CI -471.4 to -388.4), indirect (1 vs 2, 95% CI -249.5 to - 199.8; 1 vs 3, 95% CI -187 to-139.4) and total cost (1 vs 2, 95% CI -640.7 to -507; 1 vs 3, 95% CI -657.2 to -529). CONCLUSION: The same OU was more efficient and cost-effective when managed as a closed unit vs an open unit.

The effect of resident peer-to-peer education on compliance with urinary catheter placement indications in the emergency department.

OBJECTIVE This study aims to evaluate the effect of resident peer-to-peer education on knowledge of appropriate urinary catheter (UC) placement in the emergency department (ED) and to determine if this translates into further reduction in UC utilisation. Background Instituting guidelines for appropriate UC placement reduces UC utilisation in the ED. No study has explored if resident education in a teaching hospital would further reduce UC utilisation. METHODS An educational intervention implemented in February 2009 consisted of a lecture, distribution of pocket cards and a peer-administered weekly review of institutional UC guidelines. A 12-question multiple-choice test was given to residents prelecture and postlecture, and the 12-question test was repeated 3 months later. Retrospective chart review was performed to evaluate UC utilisation before, immediately after and 3 months after the educational intervention. RESULTS 30 residents completed all three tests. Significant differences were found between the mean test score pre-education and the mean test score immediately after education (9.43±1.17 vs 10.87±1.46, p<0.001) and between the mean test score pre-education and the mean test score 3 months posteducation (9.43±1.17 vs 10.43±1.28, p<0.001). There was no significant difference in UC utilisation or in the proportion of indicated UCs placed by residents within the three study periods. CONCLUSIONS Resident peer-to-peer education was associated with improvement of knowledge but did not result in decreased UC utilisation. A more active approach must be taken and other factors need to be further explored to reduce unnecessary placement of UC by residents in the ED.

The Case for Observation Medicine Education and Training in Emergency Medicine.

BACKGROUND: Many hospitals have or will be opening an observation unit (OU), the majority managed by the emergency department (ED). Graduating emergency medicine (EM) residents will be expected to have the knowledge and skills necessary to appropriately identify and manage patients in this setting. Our objective is to examine the current state of observation medicine (OM) education and prevalence in EM training. METHODS: In a follow-up to the 2019 Society for Academic Emergency Medicine (SAEM) OM Interest Group meeting, we convened an expert panel of OM physicians who are members of both the SAEM OM Interest Group and the American College of Emergency Physicians Section of OM. The panel of six emergency physicians representing geographic diversity was formed. A structured literature review was performed yielding 16 educational publications and sources pertaining to OM education and training across all specialties. REPORT ON THE EXISTING LITERATURE: Only a small number of EM residencies have a required or elective OM rotation in an OU. An OM rotation in a protocol-driven ED OU gives residents experience managing patients in this setting and improves skills integral to EM and part of the EM milestones and Accreditation Council for Graduate Medical Education (ACGME) core competencies: reassessment, disposition decision making, risk stratification, team management, and practicing cost-appropriate care. Even without a formal rotation, multiple OM educational resources can be incorporated into EM resident education and didactics. Education research opportunity exists. CONCLUSIONS: This panel believes that OM is an important component of EM that should be incorporated into EM residency as the knowledge and skills learned such as risk stratification, disposition decision making, and team management augment those needed for the practice of EM. There is a distinct opportunity for EM educators to better equip their trainees for a career in EM by including OM education and experience in EM residency training.

A 90-second magnetocardiogram using a novel analysis system to assess for coronary artery stenosis in Emergency department observation unit chest pain patients.

BACKGROUND: Magnetocardiography (MCG) has been shown to non-invasively detect coronary artery stenosis (CAS). Emergency department (ED) patients with possible acute coronary syndrome (ACS) are commonly placed in an observation unit (OU) for further evaluation. Our objective was to compare a novel MCG analysis system with stress testing (ST) and/or coronary angiography (CA) in non-high risk EDOU chest pain patients. METHODS: This is a prospective pilot study of non-high risk EDOU chest pain patients evaluated with ST and/or CA that underwent a resting 90-second MCG scan between August 2017 and February 2018. A positive MCG scan was defined as having current dipole deviations with dispersion or splitting during the repolarization phase. ST, CA and major adverse cardiac events (MACE) 30 days and 6 months post-discharge assessed. RESULTS: Of 101 study patients, mean age was 56 years and 53.6% were male. MCG scan sensitivity with 95% CI was 27.3% [7.3%, 60.7%], specificity 77.8% [67.5%, 85.6%], PPV 13.0% [3.4%, 34.7%] and NPV 89.7% [80.3%, 95.2%] compared to ST, and 33.3% [7.5%, 70.7%], 78.3% [68.4%, 86.2%], 13% [5.2%, 29.0%] and 92.3% [88.2%, 95.1%] respectively compared to ST and CA. No patients had positive ST, CA or MACE 30 days and 6 months post-discharge. CONCLUSION: This pilot study suggests a resting 90-second MCG scan shows promise in evaluating EDOU chest pain patients for CAS and warrants further study as an alternative testing modality to identify patients safe for discharge. Larger studies are needed to assess accuracy of MCG using this novel analysis system.

Ethical considerations for emergency care providers during pandemic influenza--ready or not...

When an infectious pandemic occurs in the United States, emergency care providers (ECPs) will be on the frontlines caring for infected, potentially infected, and non-infected patients. Logistically, the current emergency care system is not ready for a pandemic, but are the providers ethically ready? Some of the most difficult and challenging issues that will be raised during a pandemic will be ethical in nature. An ECP likely will be confronted with ethical values and value conflicts underlying restriction of liberty, duty to care, and resource allocation. This report summarizes the ethical concerns and challenges that ECPs face during an infectious pandemic, and raises ethical questions that may arise related to the role of an ECP as a healthcare provider and stakeholder.

Care of Respiratory Conditions in an Observation Unit.

In adults, respiratory disorders are the second most frequent diagnoses treated in emergency department observation units (EDOUs) and account for the most frequent indication for placement of pediatric patients into an EDOU. With appropriate patient selection, chronic obstructive pulmonary disease exacerbations, and community-acquired pneumonia can be managed in the EDOU. EDOU management results in equivalent or better outcomes than inpatient care with decreased length of stay, increased patient satisfaction, lower cost and in some studies decreased mortality. Evidence-based protocols are important to ensure appropriate patients are placed in the EDOU, standardize best practice interventions, and guide disposition decisions.

Reduction in Radiation Exposure through a Stress Test Algorithm in an Emergency Department Observation Unit.

INTRODUCTION: Clinicians are urged to decrease radiation exposure from unnecessary medical procedures. Many emergency department (ED) patients placed in an observation unit (EDOU) do not require chest pain evaluation with a nuclear stress test (NucST). We sought to implement a simple ST algorithm that favors non-nuclear stress test (Non-NucST) options to evaluate the effect of the algorithm on the proportion of patients exposed to radiation by comparing use of NucST versus Non-NucST pre- and post-algorithm. METHODS: An ST algorithm was introduced favoring Non-NucST and limiting NucST to a subset of EDOU patients in October 2008. We analyzed aggregate data before (Jan-Sept 2008, period 1) and after (Jan-Sept 2009 and Jan-Sept 2010, periods 2 and 3 respectively) algorithm introduction. A random sample of 240 EDOU patients from each period was used to compare 30-day major adverse cardiac events (MACE). We calculated confidence intervals for proportions or the difference between two proportions. RESULTS: A total of 5,047 STs were performed from Jan-Sept 2008-2010. NucST in the EDOU decreased after algorithm introduction from period 1 to 2 (40.7%, 95% CI [38.3-43.1] vs. 22.1%, 95% CI [20.1-24.1]), and remained at 22.1%, 95% CI [20.3-24.0] in period 3. There was no difference in 30-day MACE rates before and after algorithm use (0.1% for period 1 and 3, 0% for period 2). CONCLUSION: Use of a simple ST algorithm that favors non-NucST options decreases the proportion of EDOU chest pain patients exposed to radiation exposure from ST almost 50% by limiting NucST to a subset of patients, without a change in 30-day MACE.

Cost-effectiveness of noninvasive ventilation for chronic obstructive pulmonary disease-related respiratory failure in Indian hospitals without ICU facilities.

INTRODUCTION: The majority of Indian hospitals do not provide intensive care unit (ICU) care or ward-based noninvasive positive pressure ventilation (NIV). Because no mechanical ventilation or NIV is available in these hospitals, the majority of patients suffering from respiratory failure die. OBJECTIVE: To perform a cost-effective analysis of two strategies (ward-based NIV with concurrent standard treatment vs standard treatment alone) in chronic obstructive pulmonary disease (COPD) respiratory failure patients treated in Indian hospitals without ICU care. MATERIALS AND METHODS: A decision-analytical model was created to compare the cost-effectiveness for the two strategies. Estimates from the literature were used for parameters in the model. Future costs were discounted at 3%. All costs were reported in USD (2012). One-way, two-way, and probabilistic sensitivity analysis were performed. The time horizon was lifetime and perspective was societal. RESULTS: The NIV strategy resulted in 17.7% more survival and was slightly more costly (increased cost of $101 (USD 2012) but resulted in increased quality-adjusted life-years (QALYs) (1.67 QALY). The cost-effectiveness (2012 USD)/QALY in the standard and NIV groups was $78/QALY ($535.02/6.82) and $75/QALY ($636.33/8.49), respectively. Incremental cost-effectiveness ratio (ICER) was only $61 USD/QALY. This was substantially lower than the gross domestic product (GDP) per capita for India (1489 USD), suggesting the NIV strategy was very cost effective. Using a 5% discount rate resulted in only minimally different results. Probabilistic analysis suggests that NIV strategy was preferred 100% of the time when willingness to pay was >$250 2012 USD. CONCLUSION: Ward-based NIV treatment is cost-effective in India, and may increase survival of patients with COPD respiratory failure when ICU is not available.

Decreasing troponin turnaround time in the emergency department using the central laboratory: A process improvement study.

OBJECTIVES: To implement collaborative process improvement measures to reduce emergency department (ED) troponin turnaround time (TAT) to less than 60min using central laboratory. DESIGN AND METHODS: This was an observational, retrospective data study. A multidisciplinary team from the ED and laboratory identified opportunities and developed a new workflow model. Process changes were implemented in ED patient triage, staffing, lab collection and processing. Data collected included TAT of door-to-order, order-to-collect, collect-to-received, received-to-result, door-to-result, ED length of stay, and hemolysis rate before (January-August, 2011) and after (September 2011-June 2013) process improvement. RESULTS: After process improvement and implementation of the new workflow model, decreased median TAT (in min) was seen in door-to-order (54 [IQR43] vs. 11 [IQR20]), order-to-collect (15 [IQR 23] vs. 10 [IQR12]), collect-to-received (6 [IQR8] vs. 5 [IQR5]), received-to-result (30 [IQR12] vs. 24 [IQR11]), and overall door-to-result (117 [IQR60] vs. 60 [IQR40]). A troponin TAT of <60min was realized beginning in May 2012 (59 [IQR39]). Hemolysis rates decreased (14.63±0.74 vs. 3.36±1.99, p<0.0001), as did ED length of stay (5.87±2.73h vs. 5.15±2.34h, p<0.0001). Conclusion Troponin TAT of <60min using a central laboratory was achieved with collaboration between the ED and the laboratory; additional findings include a decreased ED length of stay.

Sustained reductions in urinary catheter use over 5 years: bedside nurses view themselves responsible for evaluation of catheter necessity.

BACKGROUND: Multiple approaches are needed to improve urinary catheter use and sustain compliance with the appropriate indications for catheter use. METHODS: We evaluated the effect of 3 interventions over 5 years: a nurse-driven multidisciplinary effort for early urinary catheter removal, an intervention in an emergency department to promote appropriate placement, and twice-weekly assessment of urinary catheter prevalence with periodic feedback on performance for nonintensive care units. We also assessed the views of bedside nurses, case managers, and nurse managers with respect to appropriate catheter use, how often need is assessed, and who they consider responsible for the evaluation of urinary catheter need. RESULTS: There was a significant reduction in urinary catheter use from 17.3%-12.7% during the 5-year period (linear regression with time as independent variable, R(2), 0.61; P < .0001). Of bedside nurses responding to the questionnaire, 222 of 227 (97.8%) identified themselves as responsible or as sharing the responsibility for catheter necessity evaluation, 223 of 229 (97.4%) were confident in their knowledge, and 166 of 222 (74.8%) viewed physicians as receptive to their requests for catheter removal >70% of the time. CONCLUSIONS: A multifaceted approach to promote appropriate urinary catheter use is associated with sustained reductions in catheter use. Bedside nurses view themselves responsible for the evaluation of catheter presence and need.

Urinary catheters in the emergency department: very elderly women are at high risk for unnecessary utilization.

BACKGROUND: Many of the urinary catheters (UCs) placed in the emergency department (ED) might not be necessary. We evaluated compliance with our institutional UC utilization guidelines and assessed factors influencing utilization. METHODS: We conducted a 12-week retrospective observational study evaluating UC utilization in all admissions from the ED. Data included reason for placement, presence of a physician's order for placement, resident physician involvement, and patient age and sex. RESULTS: Out of 4521 patients evaluated, 532 (11.8%) had a UC placed. Of these UCs, 371 (69.7%) were indicated, and 312 (58.6%) had a physician's order documented. The mean age of the patients who had a UC placed without an indication was 71.3 ± 18.8 years, that of patients with an indication was 60.0 ± 22.4 years (P < .0001), and that of patients who did not have a UC placed was 56.2 ± 22.6 years (P < .0001). Half of the women aged ≥80 years who had a UC placed did not have an indication according to our institutional guidelines. Multivariate logistic regression showed that women were 1.9 times more likely than men, and those age ≥80 years were 2.9 times more likely than those age ≤50 years, to have a UC placed without an indication. CONCLUSION: Very elderly women are at high risk for inappropriate UC utilization in the ED. Interventions are needed to address this vulnerable population.

Effect of establishing guidelines on appropriate urinary catheter placement.

OBJECTIVES: Avoiding placement of unnecessary urinary catheters (UCs) in the emergency department (ED) affects UC utilization during hospitalization. The authors sought to evaluate the effect of establishing institutional guidelines for appropriate UC placement coupled with emergency physician (EP) education on UC utilization. METHODS: Urinary catheter utilization was measured before and after the establishment of guidelines and EP education. Data collected included the presence of a UC on ED arrival, placement of a UC in the ED, documentation of a physician order for UC placement, reasons for placement, and compliance with the guidelines. Chi-square analyses were used to study the association between pre- and postintervention time periods and catheter use. RESULTS: A total of 377 (15%) patients had UCs; only 151 (47%) UCs initially placed in the ED had a physician order documented. UC placement was appropriately indicated in 75.5% of patients with a documented physician order, but in only 52% of cases without a documented physician order (p<0.001). The physician intervention was associated with an overall reduction in UC utilization from 16.4% to 13% (p=0.018). Physicians ordered 40% fewer UCs postintervention compared to preintervention. Preintervention, a physician order for UC placement was found indicated in 72.6% patients, compared to 82.2% patients with UC placed postintervention (p=0.21). CONCLUSIONS: Establishing guidelines for UC placement and physician education in the ED were associated with a marked reduction in utilization. However, addressing appropriate UC utilization may require evaluating other factors such as nursing influence on utilization.