Code Help: Can This Unique State Regulatory Intervention Improve Emergency Department Crowding?

INTRODUCTION: Emergency department (ED) crowding adversely affects multiple facets of high-quality care. The Commonwealth of Massachusetts mandates specific, hospital action plans to reduce ED boarding via a mechanism termed "Code Help." Because implementation appears inconsistent even when hospital conditions should have triggered its activation, we hypothesized that compliance with the Code Help policy would be associated with reduction in ED boarding time and total ED length of stay (LOS) for admitted patients, compared to patients seen when the Code Help policy was not followed. METHODS: This was a retrospective analysis of data collected from electronic, patient-care, timestamp events and from a prospective Code Help registry for consecutive adult patients admitted from the ED at a single academic center during a 15-month period. For each patient, we determined whether the concurrent hospital status complied with the Code Help policy or violated it at the time of admission decision. We then compared ED boarding time and overall ED LOS for patients cared for during periods of Code Help policy compliance and during periods of Code Help policy violation, both with reference to patients cared for during normal operations. RESULTS: Of 89,587 adult patients who presented to the ED during the study period, 24,017 (26.8%) were admitted to an acute care or critical care bed. Boarding time ranged from zero to 67 hours 30 minutes (median 4 hours 31 minutes). Total ED LOS for admitted patients ranged from 11 minutes to 85 hours 25 minutes (median nine hours). Patients admitted during periods of Code Help policy violation experienced significantly longer boarding times (median 20 minutes longer) and total ED LOS (median 46 minutes longer), compared to patients admitted under normal operations. However, patients admitted during Code Help policy compliance did not experience a significant increase in either metric, compared to normal operations. CONCLUSION: In this single-center experience, implementation of the Massachusetts Code Help regulation was associated with reduced ED boarding time and ED LOS when the policy was consistently followed, but there were adverse effects on both metrics during violations of the policy.

System-Level Process Change Improves Communication and Follow-Up for Emergency Department Patients With Incidental Radiology Findings.

The appropriate communication and management of incidental findings on emergency department (ED) radiology studies is an important component of patient safety. Guidelines have been issued by the ACR and other medical associations that best define incidental findings across various modalities and imaging studies. However, there are few examples of health care facilities designing ways to manage incidental findings. Our institution aimed to improve communication and follow-up of incidental radiology findings in ED patients through the collaborative development and implementation of system-level process changes including a standardized loop-closure method. We assembled a multidisciplinary team to address the nature of these incidental findings and designed new workflows and operational pathways for both radiology and ED staff to properly communicate incidental findings. Our results are based on all incidental findings received and acknowledged between November 1, 2016, and May 30, 2017. The total number of incidental findings discovered was 1,409. Our systematic compliance fluctuated between 45% and 95% initially after implementation. However, after overcoming various challenges through optimization, our system reached a compliance rate of 93% to 95%. Through the implementation of our new, standardized communication system, a high degree of compliance with loop closure for ED incidental radiology findings was achieved at our institution.

Replacement variant histone genes contain intervening sequences.

The nucleotide sequences of two chicken histone genes encoding replacement variant H3.3 polypeptides are described. Unlike the replication variant genes of chickens (and almost all other organisms), these genes contain intervening sequences; introns are present in both genes in the 5' noncoding and coding sequences. Furthermore, the replacement variant histone mRNAs are post-transcriptionally polyadenylated. The locations, but not the sizes, of the two introns within the coding segments of the two genes have been exactly conserved, whereas the intron positions in their respective 5' flanking regions differ. Although both H3.3 genes predict the identical histone polypeptide sequence, they are as different from one another as each of them is from a more common replication variant H3.2 gene in silent base substitutions within the coding sequences. Thus, the H3.3 polypeptide sequence has been precisely maintained over a great evolutionary period, suggesting that this class of histones performs a strongly selected biological function. Although replacement variant histones can account for more than 50% of the total H3 protein in the nuclei of specific chicken tissues, the steady-state level of H3.3 mRNA is nearly the same (and is quite low) in all tissues and ages of animals examined. These properties suggest novel mechanisms for the control of the basal histone biosynthesis which takes place outside of the S phase of the cell cycle.

Altered mental status from olanzapine overdose treated with physostigmine.

BACKGROUND: Olanzapine is commonly prescribed to patients with schizophrenia. One retrospective study demonstrates the efficacy of physostigmine in reversing mental status changes induced by olanzapine. We report two patients with delirium due to confirmed olanzapine overdose treated with physostigmine. One patient's mental status transiently returned to normal. The other patient completely recovered. CASE 1: A 25-year-old man ingested 300 mg of olanzapine. On presentation, he was agitated, delirious, tachycardic, had dry skin and mucous membranes, and dilated pupils (6 mm) minimally reactive to light. Physostigmine, 0.5 mg, was given intravenously (IV) without effect. Additional physostigmine doses of 1.5 mg IV administered 5 minutes later and then 1 mg IV resulted in the patient having a clear sensorium and normal mentation. The patient's mental status continued to remain normal for the duration of his hospital stay. Olanzapine was identified in the urine by high performance liquid chromatography. CASE 2: A 20-year-old female ingested 600 mg of olanzapine. On presentation, she was tachycardic, obtunded, and minimally responsive to painful stimuli, with decreased bowel sounds, dry skin and dry mucous membranes. Physostigmine, 2 mg, was given IV. Shortly thereafter she regained full consciousness and began speaking coherently. She remained in this condition for approximately 30 minutes, and then became obtunded. Her serum olanzapine concentration was 1230 ng/mL. No further doses of physostigmine were administered. On day 3 of admission her mental status returned to normal. CONCLUSION: We report two cases of olanzapine-induced mental status changes treated with physostigmine. The utility of physostigmine as a safe or necessary antidote in the setting of olanzapine overdose remains to be determined.

Thiamine and Alzheimer's disease. A pilot study.

As a test of the significance of previously described biochemical abnormalities in thiamine-dependent enzymes in brains and other tissues in patients with Alzheimer's disease, a double-blind, placebo-controlled, crossover, outpatient pilot study compared the effects of 3 g/d of oral thiamine hydrochloride for three months with those of a niacinamide placebo. Eleven moderately impaired patients with "probable Alzheimer's disease" by the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria completed the study. All patients were well nourished and had no stigmata of dietary thiamine deficiency. Their initial mean +/- SEM Mini-Mental State Examination score was 14.2 +/- 1.4, and the mean age was 72 years. Global cognitive rating by the Mini-Mental State Examination was higher during three months with 3 g/d of oral thiamine hydrochloride than with niacinamide placebo. Behavioral ratings, however, did not differ significantly, nor did clinical state when it was judged subjectively.

Day care for dementia patients: an analysis of a four-year program.

A day care program for patients with dementia was developed by the Burke Rehabilitation Center in 1979. Sixty-nine patients have taken part in the program, some for as long as three years. The majority of patients stay in the program for one to two years. This pilot program was designed to provide a structured series of daily activities for the patient with dementia and to give those responsible for their care at home a period of freedom each week from the responsibilities of care. The program has been well received by the patients and appreciated by their families. It has not altered the steady progression of intellectual decline. It has made it possible for families to continue to keep patients at home and delay nursing placement or the hiring of additional help at home. It is cost effective when compared with the general alternative of nursing home placement. Similar programs could be conducted outside health care facilities at lower cost to patients and their families. Family support group discussions have eased the burden for the caregiver and have been useful in discovering new ideas for better patient management.

Computerized data base for evaluation and follow-up of demented outpatients.

In the course of evaluating and following more than 600 geriatric outpatients referred to a subspecialty clinic because of cognitive impairment, standardized computer-compatible evaluation and follow-up forms were developed, as well as a computerized data base. The forms cover medical, neurologic, psychiatric, psychometric, and clinical laboratory examinations; they help health professionals to perform thorough, standardized, and efficient examinations focused on those characteristics relevant to dementias. The computerized data base facilitates follow-up and other clinical studies. This article presents both the forms and their translation into query-language terminology.

Follow up of patients referred to a dementia service.

Eighty-five patients referred to a dementia clinic in a prosperous suburban setting were followed for as long as 48 months. Progressive dementia occurred in 55 of the 56 patients in whose cases it was predicted. Three-year mortality rates were 83 per cent for multi-infarct dementia, 57 per cent for mixed vascular plus Alzheimer dementia, and 37 per cent for Alzheimer disease. The differences in death rates among the different diagnostic groups support the validity of the clinical distinctions drawn. A subspecialty clinic can accurately identify progressive intellectual impairment in the elderly. The data suggest that patients who have depression complicating organic brain disease are at risk for progressive intellectual impairment, even if not demented when first seen. Intellectual deterioration appears to be a poor prognostic sign in older people.

Complications of long-term opioid therapy for management of chronic pain: the paradox of opioid-induced hyperalgesia.

While opioids remain a valid and effective analgesic strategy for patients suffering from a wide variety of painful conditions, they are not a panacea. Increasingly, physicians must balance patient expectations of adequate pain control with known limitations of opioid pharmaceuticals including adverse effects, tolerance, addiction, withdrawal, and drug diversion. Further complicating the issue over the last decade is a growing body of evidence suggesting chronic opioid use may unexpectedly worsen the perception of pain in some individuals. This syndrome, termed opioid-induced hyperalgesia (OIH), fundamentally changes our understanding of opioid pharmacodynamics and may influence our approach to management of chronic pain. This manuscript describes the concept OIH and provides an overview of basic science and clinical research to date attempting to characterize this syndrome, as well as ascertain its clinical relevance. The potential existence of OIH in humans is framed within the context of our current understanding of opioids and our prescribing patterns so that physicians may begin to incorporate these ideas into their philosophy of pain management as further information develops. Animal studies reliably validate OIH in controlled models. Rigorous research protocols in humans are lacking, and we cannot yet confidently conclude that OIH manifests in clinically significant ways. However, clinicians should consider the possibility of OIH when evaluating outcomes of patients on chronic opioid therapy.

Monoamine oxidase inhibitor poisoning resulting from Internet misinformation on illicit substances.

The Internet may represent a new mechanism by which adolescents initiate the use of illicit substances. The existence of multiple partisan websites providing misinformation regarding the safety of these substances may lead to an increase in unsafe behavior among this age group. Adverse outcomes related to Internet-based drug information are rarely identified. We report a case of an adolescent whose use of the Internet to obtain drug information led to severe poisoning from the combination of a monoamine oxidase inhibitor, harmaline, and a hallucinogenic tryptamine, 5-methoxydimethyltryptamine (5-MeO-DMT).

Lesions in the dentate hilum and CA2/CA3 regions of the rat hippocampus produce cognitive deficits that correlate with site-specific glial activation.

Thirty male rats pressed a lever three times (FR3) when a stimulus light (sD) was off to obtain sucrose pellets. They were then evenly divided into sham Controls versus groups lesioned bilaterally in the hippocampus by stercotaxic injection of ibotenic acid into the dentate hilum (HIL) or the CA2/CA3 region (CA2/3). On measures of recall of the FR3-sD task taken during the initial 30 min of a postlesion test session, the CA2/3 and especially the HIL groups showed significant (p < .05) impairments relative to the Controls. During an ensuing 30-min period, rats were reshaped to criterion, beginning at FR1, and no appreciable intergroup differences were noted on this schedule or at FR1-sD. At FR2-sD, the HIL but not the CA2/3 group showed some impairment relative to Controls. At FR3-sD, both the CA2/3 and HIL groups had impaired task performance. An immunocytochemical index of glial activation showed higher reactivity in CA2/3 or the dentate hilum among CA2/3 or HIL animals, respectively, that was associated with the degree to which they showed an FR3-sD performance deficit.