Cheryl Courage

Evaluation of screening criteria for palliative care consultation in the MICU: A multihospital analysis

Background There are currently no comprehensive studies in critical care settings that have set out to examine the association of palliative care screening criteria with multiple, adverse patient outcomes. Methods A 7-item palliative care screen was developed from consensus reports. Medical intensive care unit (MICU) nurses at four hospitals screened patients upon admission during a 16-week period. Outcomes included percentage of patients screened and their percentage with consultations ordered. Patient screen scores were compared with mortality, hospice discharge and length of stay (LOS). Results During the period, 1071 patients were admitted to MICUs, of which, 59.3% were screened; 35.3% of patients screened positive. Patients with positive screens (n=225) were more likely to have a consult ordered (33.6% vs 3.4%; p<0.001), and likelihood of consult increased with higher screen scores. Patients with positive screens had significantly longer hospital and MICU LOS (p<0.001), and had increased risk of inpatient mortality (p<0.001) and hospice discharge (p<0.001). Criteria of ‘admission from a skilled nursing facility’ and ‘readmission to the ICU’ were significant predictors of LOS; ‘cancer,’ ‘post cardiac arrest,’ and ‘team perceived need’ were predictors of the composite variable of mortality/hospice discharge. ‘End-stage dementia’ and ‘intracranial bleed’ were not predictive of adverse outcomes. Conclusions Decisions on the appropriateness for palliative care consultation in the MICU can be aided using a trigger screen. We recommend the use of this screen be considered in the MICU with the suggested revisions. Additional studies are needed to determine if the use of the trigger screen is associated with improved clinical outcomes.

Strain Echocardiography in Acute Cardiovascular Diseases.

Echocardiography has become a critical tool in the evaluation of patients presenting to the emergency department (ED) with acute cardiovascular diseases and undifferentiated cardiopulmonary symptoms. New technological advances allow clinicians to accurately measure left ventricular (LV) strain, a superior marker of LV systolic function compared to traditional measures such as ejection fraction, but most emergency physicians (EPs) are unfamiliar with this method of echocardiographic assessment. This article discusses the application of LV longitudinal strain in the ED and reviews how it has been used in various disease states including acute heart failure, acute coronary syndromes (ACS) and pulmonary embolism. It is important for EPs to understand the utility of technological and software advances in ultrasound and how new methods can build on traditional two-dimensional and Doppler techniques of standard echocardiography. The next step in competency development for EP-performed focused echocardiography is to adopt novel approaches such as strain using speckle-tracking software in the management of patients with acute cardiovascular disease. With the advent of speckle tracking, strain image acquisition and interpretation has become semi-automated making it something that could be routinely added to the sonographic evaluation of patients presenting to the ED with cardiovascular disease. Once strain imaging is adopted by skilled EPs, focused echocardiography can be expanded and more direct, phenotype-driven care may be achievable for ED patients with a variety of conditions including heart failure, ACS and shock.

Hyperbaric oxygen therapy for systemic gas embolism after hydrogen peroxide ingestion.

BACKGROUND Hydrogen peroxide is a commonly available product and its ingestion has been demonstrated to produce in vivo gas bubbles, which can embolize to devastating effect. OBJECTIVE We report two cases of hydrogen peroxide ingestion with resultant gas embolization, one to the portal system and one cerebral embolus, which were successfully treated with hyperbaric oxygen therapy (HBO), and review the literature. CASE REPORT Two individuals presented to our center after unintentional ingestion of concentrated hydrogen peroxide solutions. Symptoms were consistent with portal gas emboli (Patient A) and cerebral gas emboli (Patient B), which were demonstrated on imaging. They were successfully treated with HBO and recovered without event. CONCLUSIONS As demonstrated by both our experience as well as the current literature, HBO has been used to successfully treat gas emboli associated with hydrogen peroxide ingestion. We recommend consideration of HBO in any cases of significant hydrogen peroxide ingestion with a clinical picture compatible with gas emboli.

Ultrasound Training in the Emergency Medicine Clerkship.

Introduction The curriculum in most emergency medicine (EM) clerkships includes very little formalized training in point-of-care ultrasound. Medical schools have begun to implement ultrasound training in the pre-clinical curriculum, and the EM clerkship is an appropriate place to build upon this training. The objectives are (1) to evaluate the effectiveness of implementing a focused ultrasound curriculum within an established EM clerkship and (2) to obtain feedback from medical students regarding the program. Methods We conducted a prospective cohort study of medical students during an EM clerkship year from July 1, 2011, to June 30, 2012. Participants included fourth-year medical students (n=45) enrolled in the EM clerkship at our institution. The students underwent a structured program focused on the focused assessment with sonography for trauma exam and ultrasound-guided vascular access. At the conclusion of the rotation, they took a 10-item multiple choice test assessing knowledge and image interpretation skills. A cohort of EM residents (n=20) also took the multiple choice test but did not participate in the training with the students. We used an independent samples t-test to examine differences in test scores between the groups. Results The medical students in the ultrasound training program scored significantly higher on the multiple-choice test than the EM residents, t(63)=2.3, p<0.05. The feedback from the students indicated that 82.8% were using ultrasound on their current rotations and the majority (55.2%) felt that the one-on-one scanning shift was the most valuable aspect of the curriculum. Discussion Our study demonstrates support for an ultrasound training program for medical students in the EM clerkship. After completing the training, students were able to perform similarly to EM residents on a knowledge-based exam.

When a Patient Declines Curative Care: Management of a Ruptured Aortic Aneurysm

The management of major vascular emergencies in the emergency department (ED) involves rapid, aggressive resuscitation followed by emergent definitive surgery. However, for some patients this traditional approach may not be consistent with their goals and values. We explore the appropriate way to determine best treatment practices when patients elect to forego curative care in the ED, while reviewing such a case. We present the case of a 72-year-old patient who presented to the ED with a ruptured abdominal aortic aneurysm, but refused surgery. We discuss the transition of the patient from a curative to a comfort care approach with appropriate direct referral to hospice from the ED. Using principles of autonomy, decision-making capacity, informed consent, prognostication, and goals-of-care, ED clinicians are best able to align their approach with patients’ goals and values.

Effectiveness of an urban emergency department call-back system in the successful linkage to treatment of sexually transmitted infections.

Objectives There is a high incidence of asymptomatic sexually transmitted infections (STIs) in emergency department (ED) patients. There is no historical indication, physical examination finding, or rapidly available laboratory testing specific for detecting STIs in women. This study was conducted to describe the performance of an ED call-back system for STI screening and linkage to care for treatment. Success was defined as the ability to contact STI-positive women who were undertreated and confirm their return for definitive treatment. Methods This retrospective, observational study of women 16 years and older evaluated those undertreated for STIs in the ED during the 13-month study period. A structured chart review was performed to determine the proportion of patients returning to an affiliated hospital ED or clinic for treatment after contact by telephone or letter. Results Of 361 patients identified as undertreated, 29.4% (95% confidence interval [CI] 24.7–34.1) did not return for definitive treatment. The method of contact was associated with patient return for treatment. Of the 276 patients contacted by telephone, 19.6% did not return for treatment (95% CI 14.9–24.3); of the 83 patients contacted by letter, 60.2% did not return for treatment (95% CI 49.7–70.8; P < 0.0001). Conclusions A large proportion of patients undertreated for an STI did not return despite a notification of need for further treatment. This study had a high rate of successful telephone contact (76.5%), but contact did not substantially increase the overall proportion of patients who were linked to care and returned to the ED for treatment.

989: A COMPUTER-BASED DECISION SUPPORT TOOL ACCURATELY IDENTIFIES SEVERE SEPSIS IN ED PATIENTS.

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) of three agents on the inflammatory cytokine TNF-α were monitored at different time intervals following LPS injection in mice that were respectively treated with atropine, pirenzepine, AF-dx116, and normal saline. Results: Both atropine and pirenzepine pretreatment improved the rate of survival and prolonged the survival time. On the contrary, AF-dx116 accelerated the death. Atropine and pirenzepine administration prior to LPS induction of the inflammatory response resulted in reduced TNF-α level, while AF-dx116 administration elevated TNFα level. Conclusions: The administration of atropine or pirenzepine may have a beneficial clinical effect on septic mices.