Brandon Allen

An Assessment of Emergency Department Throughput and Provider Satisfaction after the Implementation of a Scribe Program

Objectives. To assess the impact of a scribe program on an academic, tertiary care facility. Methods. A retrospective analysis of emergency department (ED) data, prior to and after scribe program implementation, was used to quantitatively assess the impact of the scribe program on measures of ED throughput. An electronic survey was distributed to all emergency medicine residents and advanced practice providers to qualitatively assess the impact of the scribe program on providers. Results. Several throughput time measures were significantly lower in the postscribe group, compared to prescribe implementation, including time to disposition. The left without being seen (LWBS) decrease was not statistically significant. A total of 30 providers responded to the survey. 100% of providers indicated scribes are a valuable addition to the department and they enjoy working with scribes. 90% of providers indicated scribes increase their workplace satisfaction and quality of life. Conclusions. Through evaluation of prescribe and postscribe implementation, the postscribe time period reflects many throughput improvements not present before scribes began. Scribe Program implementation led to improved ED throughput for discharged patients with further system-wide challenges needing to be addressed for admitted patients.

Vertebral Arteriovenous Fistula: An Unwelcome Thrill

Cervical vertebral AV fistulae are uncommon vascular lesions involving abnormal communication between the extradural vertebral artery and surrounding venous structures. We examine the case of a female evaluated in the emergency department with a vertebral AV fistula presenting classically as pulsatile tinnitus and later successfully treated with standard endovascular techniques. A discussion on the etiology, pathophysiology, and management of vertebral AV fistulae follows.

Amatoxin: A Review

This paper presents a comprehensive review of amatoxin poisoning. The paper discusses the biochemistry of amatoxin, as well as the clinical manifestations of amatoxin ingestion. In addition, the evaluation of the patient with amatoxin ingestion is discussed, along with the treatment—including newer therapy—and the ultimate prognosis of the syndrome.

Bilateral and Simultaneous Rupture of the Triceps Tendon in a Patient without Predisposing Factors

Tendon rupture is typically associated with predisposing features including renal failure, hyperparathyroidism, and connective tissue elastosis. We present a case in which none of these risk factors is present and in a completely healthy patient. To our knowledge, this has never been reported in the literature.

Endocarditis-Induced Mycotic Brain Aneurysm following Right MCA Stroke

The diagnosis of cerebrovascular accident is extremely common in emergency medicine; however, CVA resulting from hemorrhage following mycotic brain aneurysm following embolic stroke is extremely uncommon. This case reports such an event.

A case of dens fracture: a pictorial review and discussion.

Dens fractures are more common in the elderly and may present after minimal trauma and with minimal neck pain. The case reports a case of a significant fracture after minimal trauma, presenting with neurologic symptoms and minimal neck pain.

Comparison of 3 Symptom Classification Methods to Standardize the History Component of the HEART Score

Objectives: The History, Electrocardiography, Age, Risk factors, Troponin (HEART) score enables rapid risk stratification of emergency department patients presenting with chest pain. However, the subjectivity in scoring introduced by the history component has been criticized by some clinicians. We examined the association of 3 objective scoring models with the results of noninvasive cardiac testing. Methods: Medical records for all patients evaluated in the chest pain center of an academic medical center during a 1-year period were reviewed retrospectively. Each patient’s history component score was calculated using 3 models developed by the authors. Differences in the distribution of HEART scores for each model, as well as their degree of agreement with one another, as well as the results of cardiac testing were analyzed. Results: Seven hundred forty nine patients were studied, 58 of which had an abnormal stress test or computed tomography coronary angiography. The mean HEART scores for models 1, 2, and 3 were 2.97 (SD 1.17), 2.57 (SD 1.25), and 3.30 (SD 1.35), respectively, and were significantly different (P < 0.001). However, for each model, the likelihood of an abnormal cardiovascular test did not correlate with higher scores on the symptom component of the HEART score (P = 0.09, 0.41, and 0.86, respectively). Conclusions: While the objective scoring models produced different distributions of HEART scores, no model performed well with regards to identifying patients with abnormal advanced cardiac studies in this relatively low-risk cohort. Further studies in a broader cohort of patients, as well as comparison with the performance of subjective history scoring, is warranted before adoption of any of these objective models.

A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers

Introduction A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit. To address the healthcare needs of this vulnerable patient population, we piloted a multidisciplinary intervention seeking to create and use individualized patient care plans that alter utilization through coordinated care. Our goals were to assess feasibility primarily, and to assess resource use secondarily. Methods We evaluated the effects of a single-site interventional study targeted at a population of adult sickle-cell disease super-utilizers using a pre- and post-implementation design. The pre-intervention period was 06/01/13 to 12/31/13 (seven months) and the post-intervention period was 01/01/14 to 02/28/15 (14 months). Our approach included patient-specific best practice advisories (BPA); an ED management protocol; and formation of a “medical home” for these patients. Results For 10 subjects targeted initially we developed and implemented coordinated care plans; after deployment, we observed a tendency toward reduction in ED and inpatient utilization across all measured indices. Between the annualized pre- and post-implementation periods we found the following: ED visits decreased by 16.5 visits/pt-yr (95% confidence interval [CI] [−1.32–34.2]); ED length of state (LOS) decreased by 115.3 hours/pt-yr (95% CI [−82.9–313.5]); in-patient admissions decreased by 4.20 admissions/pt-yr (95% CI [−1.73–10.1]); in-patient LOS decreased by 35.8 hours/pt-yr (95% CI [−74.9–146.7]); and visits where the patient left before treatment were reduced by an annualized total of 13.7 visits. We observed no patient mortality in our 10 subjects, and no patient required admission to the intensive care unit 72 hours following discharge. Conclusion This effort suggests that a targeted approach is both feasible and potentially effective, laying a foundation for broader study.

Anti-MuSK-Positive Myasthenic Crisis in a 7-Year-Old Female

A seven-year-old African American female with anti-MuSK-positive Juvenile Myasthenia Gravis collapsed while at school from progressively worsening weakness and dyspnea. On initial emergency department presentation, she required 15 liters per minute of supplemental oxygen to maintain oxygen saturation above 92%. Initial pulmonary function tests and venous blood gas led to the decision to place her on noninvasive positive pressure ventilation (NPPV) with BiPAP in the emergency department. Due to worsening hypercarbia, she later required mechanical intubation in the PICU and underwent IVIG therapy followed by plasmapheresis in order to achieve a stable discharge from the hospital. A respiratory virus panel PCR was positive for influenza A, influenza B, and rhinovirus, likely precipitating the respiratory failure and myasthenic crisis in this seven-year-old patient. Given the rarity of this condition, this case report is to provide further education to the clinician managing severe, prepubertal Juvenile Myasthenia Gravis and myasthenic crisis.

Implementation of an evidence- based algorithm reduces blood culture overuse in an adult emergency department

Bloodstream infections, or bacteremia, continue to be a leading cause of morbidity and mortality in hospitalized patients, particularly in the elderly and in those admitted to the Intensive Care Unit (ICU) [1-4]. Up to 35% of total mortality in ICUs has been attributed to bloodstream infections [1], and the mortality associated with a diagnosis of bacteremia consistently exceeds 20% in the general hospitalized patient population [2,3,5,6]. Moreover, the presence of bacteremia has been shown to affect patients’ longterm outcome and recovery, even after the initial infection has been treated [5-7]. Thus, the timely and accurate diagnosis of bacteremia is essential. Blood cultures are a critical tool in the diagnosis and treatment of bacteremia, showing not only the presence of bacteria in the bloodstream but also identifying the causative pathogen and providing antibiotic sensitivity data that enables providers to optimize antimicrobial therapy to each individual patient. Sets of two to three 20-ml blood cultures have been shown to yield sensitivities of 90% and 98%, respectively, for identifying the causative pathogen in bloodstream infections [8].