Bradley D. Shy

A conceptual framework for improved analyses of 72-hour return cases

For more than 25 years, emergency medicine researchers have examined 72-hour return visits as a marker for high-risk patient visits and as a surrogate measure for quality of care. Individual emergency departments frequently use 72-hour returns as a screening tool to identify deficits in care, although comprehensive departmental reviews of this nature may consume considerable resources. We discuss the lack of published data supporting the use of 72-hour return frequency as an overall performance measure and examine why this is not a valid use, describe a conceptual framework for reviewing 72-hour return cases as a screening tool, and call for future studies to test various models for conducting such quality assurance reviews of patients who return to the emergency department within 72 hours.

Emergency medicine residents' use of psychostimulants and sedatives to aid in shift work

OBJECTIVES We evaluated the frequency that emergency medicine house staff report use of stimulants and sedatives to aid in shift work and circadian transitions. METHODS We surveyed residents from 12 regional emergency medicine programs inviting them to complete a voluntary, anonymous electronic questionnaire regarding their use of stimulants and sedatives. RESULTS Out of 485 eligible residents invited to participate in the survey, 226 responded (47% response frequency). The reported use of prescription stimulants for shift work is uncommon (3.1% of respondents.) In contrast, 201 residents (89%) report use of caffeine during night shifts, including 118 residents (52%) who use this substance every night shift. Eighty-six residents (38%) reported using sedative agents to sleep following shift work with the most common agents being anti-histamines (31%), nonbenzodiazepine hypnotics such as zolpidem (14%), melatonin (10%), and benzodiazepines (9%). CONCLUSION Emergency medicine residents report substantial use of several classes of hypnotics to aid in shift work. Despite anecdotal reports, use of prescription stimulants appears rare, and is notably less common than use of sedatives and non-prescription stimulants.

Implications of ECASS III error on emergency department treatment of ischemic stroke.

In the recent article, “Metformin Overdose with a Resultant Serum pH of 6.59: Survival without Sequalae,” the authors reported successful treatment of a patient with extreme lactic acidosis (1). On page e79, they summarized “Although the exact mechanisms of both metformin-associated metabolic acidosis and its treatment remain unclear, aggressive supportive therapy, particularly the rapid correction of severe metabolic acidosis with sodium bicarbonate or renal replacement therapy . can salvage metformin overdose patients with even the most profound . derangements.” Despite this positive summary, the authors write earlier on the same page, “Correction of acidosis with sodium bicarbonate remains controversial.” For the readers of The Journal of EmergencyMedicine, it would perhaps be interesting and also useful to know that available data in the literature have given a rational explanation of the positive effects of correction of the very low blood pH inmetabolic acidosis, and thus, correction of acidosis will probably not be controversial. The glycolytic enzyme phosphofructokinase is pH dependent, as its activity decreases with decreasing pH, and thus, glucose utilization in brain cells will be impaired (2,3). Therefore, the clinical consequences of decreasing blood pH are drowsiness, stupor, coma, and death in coma; and a prerequisite for recovery from coma in such patients is increase and normalization of the very low blood pH (4). The reported patient “arrived awake and verbal, but rapidly became obtunded”; on hospital day 2, the blood pH was 7.36 and on hospital day 10 “she was transferred to an inpatient psychiatric facility without any apparent permanent deficits . ” Similar successful treatment is reported also in reference 6 of the original paper (1).

Hepatic Artery Pseudoaneurysm Rupture: A Case Report and Review of the Literature

BACKGROUND Ruptured hepatic artery pseudoaneurysm, a type of visceral artery aneurysm, is a rare condition that is life threatening if not diagnosed and treated rapidly in the emergency department (ED). Patients presenting with this condition require aggressive resuscitation. Endovascular embolization is the first-line treatment option. OBJECTIVES We present a case of spontaneously ruptured hepatic artery pseudoaneurysm and provide a review of the current literature on this topic, focusing on appropriate ED management. CASE REPORT A 41-year-old woman with a history of systemic lupus erythematosus and multiple hepatic bilomas presented to the ED in critical condition with sudden onset of severe abdominal pain and hemodynamic instability. She was found to have a ruptured hepatic artery pseudoaneurysm with marked hemoperitoneum on computed tomography angiography. She was aggressively resuscitated and successfully managed via endovascular embolization. CONCLUSION Ruptured hepatic artery pseudoaneurysm is a life-threatening condition that must be rapidly diagnosed and managed in the ED. Visceral artery aneurysm rupture is a diagnosis that should be considered in any patient presenting to the ED with hemodynamic instability and abdominal pain. Definitive management is with endovascular embolization.

Independent Dosing of Propofol and Ketamine May Improve Procedural Sedation Compared With the Combination “Ketofol”

To the Editor: In their recent article on ketofol, Andolfatto et al demonstrate that this combination medication appears no safer than propofol alone. However, more consideration is merited for the strategy of using propofol and ketamine together for the initial sedation administration, followed by propofol monotherapy for subsequent boluses. The pharmacodynamics of ketamine requires 30 to 120 minutes of monitoring after administration compared with a maximum of 10 to 15 minutes for propofol. Because of this substantially longer duration of effect, it is illogical to redose the ketamine component of ketofol near the end of a lengthy procedure when propofol alone would suffice. Furthermore, ketamine appears to dissociate patients in a dichotomous manner, meaning that providing small additional boluses of the drug to already dissociated patients may provide zero clinical benefit. These concerns about the coadministration of the 2 agents have been suggested before, yet most emergency medicine investigations of ketofol nevertheless have studied the combined formulation. We believe that independent dosing of the 2 drugs is superior to the combined dosing, but it may also be superior to propofol alone. As the data suggest from this most recent article by Andolfatto et al, ketamine may provide patients with an increased sedation consistency versus providers’ having to rely solely on intermittent doses of propofol. We hope that further studies may demonstrate that separating the administration of these 2 agents can provide the sedation consistency of ketamine with the rapid recovery time inherent with propofol boluses.

A novel program to improve patient safety by integrating peer review into the emergency medicine residency curriculum.

BACKGROUND Evaluating the quality of care as part of a quality improvement process is required in many clinical environments by accrediting bodies. It produces metrics used to evaluate department and individual provider performance, provides outcomes-based feedback to clinicians, and identifies ways to reduce error. DISCUSSION To improve patient safety and train our residents to perform peer review, we expanded our quality assurance program from a narrow, administrative process carried out by a small number of attendings to an educationally focused activity of much greater scope incorporating all residents on a monthly basis. We developed an explicit system by which residents analyze sets of high-risk cases and record their impressions onto structured databases, which are reviewed by faculty. At monthly meetings, results from the months case reviews are presented, learning points discussed, and corrective actions are proposed. CONCLUSION By integrating Clinical Quality Review (CQR) as a core, continuous component of the residency curriculum, we increased the number of cases reviewed more than 10-fold and implemented a variety of clinical process improvements. An anonymous survey conducted after 2 years of resident-led CQR indicated that residents value their exposure to the peer review process and feel it benefits them as clinicians, but also that the program requires a significant investment of time that can be burdensome.

Bedside Ultrasound to Evaluate Pulmonary Embolism Masquerading as ST Elevation Myocardial Infarction (STEMI).

We present a case highlighting the use of bedside ultrasound to aid in the diagnosis of pulmonary embolism (PE). This patient had chest pain and electrocardiogram (ECG) findings that seemed otherwise consistent with ST elevation myocardial infarction (STEMI); ultrasound was instrumental in his diagnosis and subsequent treatment. The frequent similarities in presentation of these two diseases are well described. Several relevant studies have shown how bedside ultrasound can evaluate undifferentiated shock and suggest PE in cases such as this.

Bouncing Back Elsewhere: Multilevel Analysis of Return Visits to the Same or a Different Hospital After Initial Emergency Department Presentation

Study objective Analyses of 72‐hour emergency department (ED) return visits are frequently used for quality assurance purposes and have been proposed as a means of measuring provider performance. These analyses have traditionally examined only patients returning to the same hospital as the initial visit. We use a health information exchange network to describe differences between ED visits resulting in 72‐hour revisits to the same hospital and those resulting in revisits to a different site. Methods We examined data from a 31‐hospital health information exchange of all ED visits during a 5‐year period to identify 72‐hour return visits and collected available encounter, patient, and hospital variables. Next, we used multilevel analysis of encounter‐level, patient‐level, and hospital‐level data to describe differences between initial ED visits resulting in different‐site and same‐site return visits. Results We identified 12,621,159 patient visits to the 31 study EDs, including 841,259 same‐site and 107,713 different‐site return visits within 72 hours of initial ED presentation. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the initial‐visit characteristics’ predictive relationship that any return visit would be at a different site: daytime visit (OR 1.10; 95% CI 1.07 to 1.12), patient‐hospital county concordance (OR 1.40; 95% CI 1.36 to 1.44), male sex (OR 1.27; 95% CI 1.24 to 1.30), aged 65 years or older (OR 0.55; 95% CI 0.53 to 0.57), sites with an ED residency (OR 0.41; 95% CI 0.40 to 0.43), sites at an academic hospital (OR 1.12; 95% CI 1.08 to 1.15), sites with high density of surrounding EDs (OR 1.73; 95% CI 1.68 to 1.77), and sites with a high frequency of same‐site return visits (OR 0.10; 95% CI 0.10 to 0.11). Conclusion This analysis describes how ED encounters with early revisits to the same hospital differ from those with revisits to a second hospital. These findings challenge the use of single‐site return‐visit frequency as a quality measure, and, more constructively, describe how hospitals can use health information exchange to more accurately identify early ED return visits and to support programs related to these revisits.

Correction: Correction to ‘Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning’ [Annals of Emergency Medicine 69 (2017) 98-107.e6]

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

The Complexities of Studying Computerized Physician Order Entry: Implications for the Perceived Effectiveness of Stroke Order Sets

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