Amber Lin

Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study

Study objective: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high‐performing, low‐performing, and high‐performance improving hospitals to reduce ED crowding. Methods: In this mixed‐methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case‐mix‐adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). Results: We engaged 4 high‐performing, 4 low‐performing, and 4 high‐performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length‐of‐stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data‐driven management, and performance accountability. Conclusion: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.

ECG Predictors of Cardiac Arrhythmias in Older Adults With Syncope

Study objective: Cardiac arrhythmia is a life‐threatening condition in older adults who present to the emergency department (ED) with syncope. Previous work suggests the initial ED ECG can predict arrhythmia risk; however, specific ECG predictors have been variably specified. Our objective is to identify specific ECG abnormalities predictive of 30‐day serious cardiac arrhythmias in older adults presenting to the ED with syncope. Methods: We conducted a prospective, observational study at 11 EDs in adults aged 60 years or older who presented with syncope or near syncope. We excluded patients with a serious cardiac arrhythmia diagnosed during the ED evaluation from the primary analysis. The outcome was occurrence of 30‐day serous cardiac arrhythmia. The exposure variables were predefined ECG abnormalities. Independent predictors were identified through multivariate logistic regression. The sensitivities and specificities of any predefined ECG abnormality and any ECG abnormality identified on adjusted analysis to predict 30‐day serious cardiac arrhythmia were also calculated. Results: After exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%) with serious cardiac arrhythmias in the ED, the study cohort included 3,416 patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious cardiac arrhythmia within 30 days from the index ED visit (median time to diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus rhythm, multiple premature ventricular conductions, short PR interval, first‐degree atrioventricular block, complete left bundle branch block, and Q wave/T wave/ST‐segment abnormalities consistent with acute or chronic ischemia on the initial ED ECG increased the risk for a 30‐day serious cardiac arrhythmia. This combination of ECG abnormalities had a similar sensitivity in predicting 30‐day serious cardiac arrhythmia compared with any ECG abnormality (76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to 48.3%]). Conclusion: In older ED adults with syncope, approximately 3% receive a diagnosis of a serious cardiac arrhythmia not recognized on initial ED evaluation. The presence of specific abnormalities on the initial ED ECG increased the risk for 30‐day serious cardiac arrhythmias.

Decreasing Time to Pain Relief for Emergency Department Patients with Extremity Fractures

Significant delays occur in providing adequate pain relief for patients who present to the emergency department (ED) with extremity fractures. The median time to pain medication administration for patients presenting to our ED with extremity fractures was 72.5 minutes. We used a multidisciplinary approach to implement three improvement cycles with the goal of reducing the median time to pain medication by 15% over an eight month time period. First, we redesigned nursing triage and treatment processes. Second, we improved nursing documentation standardization to ensure accurate tracking of patients who declined pain medication. Third, through consensus building within our physician group, we implemented a department-wide standard of care to provide early pain relief for extremity fractures. Median time to pain medication for patients with an extremity fracture reduced significantly between the pre-and post-intervention periods (p=0.009). The average monthly median time to medication was 72.5 minutes (95% CI: 57.1 to 88.0) before the intervention (Jan 2013-Oct 2014) and 49.8 minutes (95% CI: 42.7 to 56.9) after the intervention (November 2014 to June 2016). In other words, monthly median time was 31% faster (22.7 minute difference) in the post intervention period. Implementing three key interventions reduced the time to pain medication for patients with extremity injuries. Since June 2016 the reductions in median time to medication have continued to improve.

Stroke Prophylaxis After a New Emergency Department Diagnosis of Atrial Fibrillation

Up to 25% of all new atrial fibrillation (AF) diagnoses are made in the emergency department (ED); however, this patient population is often understudied and overlooked. Prior efforts to characterize oral anticoagulation (OAC) prescribing patterns after an ED visit for incident AF is scant, although

Early Fever after Trauma: Does it Matter?

BACKGROUND Fever is strongly associated with poor outcome after traumatic brain injury (TBI). We hypothesized that early fever is a direct result of brain injury and thus would be more common in TBI than in patients without brain injury and associated with inflammation. METHODS We prospectively enrolled patients with major trauma with and without TBI from a busy Level I trauma center intensive care unit (ICU). Patients were assigned to one of four groups based on their presenting Head Abbreviated Injury Severity Scale scores: multiple injuries: head Abbreviated Injury Scale (AIS) score greater than 2, one other region greater than 2; isolated head: head AIS score greater than 2, all other regions less than 3; isolated body: one region greater than 2, excluding head/face; minor injury: no region with AIS greater than 2. Early fever was defined as at least one recorded temperature greater than 38.3°C in the first 48 hours after admission. Outcome measures included neurologic deterioration, length of stay in the ICU, hospital mortality, discharge Glasgow Outcome Scale-Extended, and plasma levels of seven key cytokines at admission and 24 hours (exploratory). RESULTS Two hundred sixty-eight patients were enrolled, including subjects with multiple injuries (n = 59), isolated head (n = 97), isolated body (n = 100), and minor trauma (n = 12). The incidence of fever was similar in all groups irrespective of injury (11–24%). In all groups, there was a significant association between the presence of early fever and death in the hospital (6–18% vs. 0–3%), as well as longer median ICU stays (3–7 days vs. 2–3 days). Fever was significantly associated with elevated IL-6 at admission (50.7 pg/dL vs. 16.9 pg/dL, p = 0.0067) and at 24 hours (83.1 pg/dL vs. 17.1 pg/dL, p = 0.0025) in the isolated head injury group. CONCLUSION Contrary to our hypothesis, early fever was not more common in patients with brain injury, though fever was associated with longer ICU stays and death in all groups. Additionally, fever was associated with elevated IL-6 levels in isolated head injury. LEVEL OF EVIDENCE Prognostic and Epidemiological study, level III.

Suicidal bupropion ingestions in adolescents: increased morbidity compared with other antidepressants

Abstract Objective: Bupropion is often categorized as a newer generation antidepressant and assessed with serotonin reuptake inhibitors as a lower risk than older tricyclic antidepressants (TCAs). The objective of this study was to compare outcomes in adolescent suicide from ingestions between bupropion and TCA medications. Study design: An analysis of the National Poison Data System for exposures coded “suspected suicide” in adolescents (age: 13–19) was undertaken for the years 2013–2016 and included TCAs or bupropion. We compared clinical effects, therapies and medical outcomes. Results: Over the four-year period there were 2253 bupropion and 1496 TCA adolescent suspected suicide calls. There was a significant linear increase in bupropion ingestions over the four years. Across all years, there were on average 189.2 (95% CI: 58.1–320.4; p = .01) more ingestions of bupropion than TCA. When comparing bupropion to a TCA, ingestions of bupropion were significantly more likely to be accompanied by seizure (30.7% vs 3.9%; p < .01), to be admitted (74.8% vs 61.6%; p < .01) and medical outcomes to be coded as a major outcome (19.3% vs 10.0%; p < .01). The number of cases with death or major clinical outcome for both increased over the four-year period. Ingestions of bupropion were less likely to have hypotension (2.7% vs 8.0%; p < .01) and less likely to be intubated (5.6% vs 16.4%; p < .01) as compared to ingestions of TCA. Conclusions: Adolescents who overdose on a single medication in a suicide attempt with bupropion have a statistically significant higher incidence of major outcomes and seizures. The risks of bupropion as a potential means of suicidal gesture by overdose must be considered, and weighed against its benefits and side effect profile when choosing an appropriate agent for the treatment of depression in adolescents.

A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database

OBJECTIVE To compare odds of survival to hospital discharge among pediatric out-of-hospital cardiac arrest (OHCA) patients receiving either bag-valve-mask ventilation (BVM), supraglottic airway (SGA) or endotracheal intubation (ETI), after adjusting for the propensity to receive a given airway intervention. METHODS Retrospective cohort study using the Cardiac Arrest Registry to Enhance Survival (CARES) database from January 1 201-December 31, 2015. The CARES registry includes data on cardiac arrests from 17 statewide registries and approximately 55 additional US cities. We included patients less than18 years of age who suffered a non-traumatic OHCA and received a resuscitation attempt by Emergency Medical Services (EMS). The key exposure was the airway management strategy (BVM, ETI, or SGA). The primary outcome was survival to hospital discharge. RESULTS Of the 3793 OHCA cases included from 405 EMS agencies, 1724 cases were analyzed after limiting the analysis to EMS agencies that used all 3 devices. Of the 1724, 781 (45.3%) were treated with BVM only, 727 (42.2%) ETI, and 215 (12.5%) SGA. Overall, 20.7% had ROSC and 10.9% survived to hospital discharge. After using a propensity score analysis, the odds ratio for survival to hospital discharge for ETI compared to BVM was 0.39 (95%CI 0.26-0.59) and for SGA compared to BVM was 0.32 (95% CI 0.12-0.84). These relationships were robust to the sensitivity analyses including complete case, EMS-agency matched, and age-stratified. CONCLUSIONS BVM was associated with higher survival to hospital discharge compared to ETI and SGA. A large randomized clinical trial is needed to confirm these findings.