Daniel J. Egan

Vascular Abdominal Emergencies

Patients with nonspecific abdominal pain can have any one of many disease processes. The physical examination may not reveal clear abnormalities, making the diagnosis more difficult. Vascular abdominal emergencies are not common but, when present, may be catastrophic, with significant morbidity and, frequently, mortality. Most of the conditions are time sensitive, leaving the integrity of organ blood flow at risk. Thromboembolic disease leads to ischemia and eventual infarction of the intra-abdominal organs. Aneurismal dilation of the aorta with rupture leads to rapid hypovolemic shock and death if not diagnosed. A high index of suspicion is critical to the successful diagnosis.

Falling through the cracks? Missed opportunities for earlier HIV diagnosis in a New York City Hospital

Summary Newly diagnosed HIV-positive patients have frequent health care encounters prior to diagnosis representing missed opportunities for diagnosis. This study determines the proportion of patients with new HIV diagnoses with encounters in the 3 years prior to diagnosis. We describe the characteristics of newly diagnosed patients and of “late testers” (CD4 <200 cells/mm3 at the time of diagnosis). We identified all newly diagnosed with HIV in emergency department, inpatient, and outpatient settings between May 1, 2006, and December 31, 2009. Data abstractors searched hospital records to identify all emergency department, inpatient, and outpatient visits for the 3 years prior to diagnosis. In all, 23,271 HIV tests were performed and 253 persons were newly diagnosed (1.1%); 152 new positives (60.1%) made at least one prior visit. Of patients with CD4 counts available, 104/175 (59.4%) had CD4 <200 cells/mm3. Patients with at least one prior visit had a median of three. There was no difference in numbers of visits between late testers and non-late testers, although late testers were more likely to have ED visits. Most newly diagnosed HIV-positive patients had multiple encounters prior to diagnosis. Many of these patients presented with CD4 counts below 200 cells/mm3, indicating true missed opportunities for earlier diagnosis.

Interstitial ectopic pregnancy presenting after failed termination of pregnancy

Pregnant women frequently present to the ED for complaints related to the first trimester of pregnancy. The emergency physician must confirm the presence of an intrauterine pregnancy for many such complaints. Bedside ultrasound with well‐delineated criteria has become standard practice for many emergency physicians for this purpose. In the following case report, an interstitial pregnancy was identified by the emergency physician using bedside sonography in a 29‐year‐old woman presenting 2 weeks after dilation and aspiration for termination of pregnancy. The ED physician identified an inappropriately thin endomyometrial mantle raising suspicion for the diagnosis of an interstitial pregnancy. The case illustrates the importance of this uterine wall measurement given the otherwise normal appearance of a pregnancy within the uterus.

Goal-directed Focused Ultrasound Milestones Revised: A Multiorganizational Consensus

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

Nonoccupational Post-Exposure Prophylaxis for HIV in New York State Emergency Departments:

New York State (NYS) established guidelines for nonoccupational post-exposure prophylaxis (nPEP) to HIV in 1997. To assess current nPEP practices in NYS Emergency Departments (EDs), we electronically surveyed all ED directors in NYS, excluding Veterans’ Affairs hospitals, about nPEP and linkage-to-care protocols in the EDs. Basic descriptive statistics were used for analysis. The response rate was 96% (184/191). Of respondents, 88% reported evaluating any patient with a possible nonoccupational exposure to HIV, in accordance with NYS guidelines. Of these, 83% provided the patient with a starter pack of medications, while 4% neither supplied nor prescribed antiretroviral drugs in the ED. Sexually transmitted infection screening, risk reduction counseling, and education about symptoms of acute HIV seroconversion were performed inconsistently, despite NYS guidelines recommendations. Only 22% of EDs confirmed whether linkage to follow-up care was successful. Most NYS EDs prescribe nPEP to appropriate patients but full implementation of guidelines remains incomplete.

Bedside Ultrasound Diagnosis of an Aortocaval Fistula in the Emergency Department

*Department of Emergency Medicine, NYU School of Medicine, New York, New York, †Department of Emergency Medicine, Mount Sinai St. Luke’s Roosevelt Hospital Center, New York, New York, and ‡Department of Emergency Medicine, Lutheran Hospital, Brooklyn, New York Reprint Address: Daniel J. Egan, MD, Department of Emergency Medicine, NYU School of Medicine, 462 First Avenue, Suite A345, New York, NY 10016

Increased rates of rapid point-of-care HIV testing using patient care technicians to perform tests in the ED

BACKGROUND Various emergency department (ED) HIV testing models are reported in the literature but may not all be sustainable. We sought to determine whether changing an ED rapid HIV testing program from counselor-based to ED technician-based resulted in more testing. METHODS We evaluated data from an ED rapid HIV testing program. Triage nurses offered testing to patients. In 2009, counselors performed rapid testing weekdays from 10:00 am to 6:00 pm. In 2010, ED technicians were trained to perform the test and replaced counselors. We compared the numbers of tests performed during the same 6-month periods in 2009 and 2010. Study personnel abstracted results through medical record review. RESULTS A total of 241 oral tests were performed in 2009 compared with 1483 in 2010, representing slightly more than a 6-fold increase. In 2010, there was a steady increase in testing month by month. Incorporating patient volume, testing rates increased from 1.3% to 8.1%. Oral testing yielded no positive test results in 2009, but 7 individuals (0.47%) tested newly positive during the testing period of 2010. Of those with a documented CD4 count within 100 days of the positive result, 4 of 5 had CD4 counts less than 200. CONCLUSIONS We present a novel approach to HIV testing using existing staff within the ED. This new ED technician-based model led to large increases in rates of testing.

A quality framework to improve routine rapid HIV screening, diagnosis, and linkage to care at a high-volume, urban emergency department in New York City

Abstract Background Early identification and treatment of HIV infection reduces morbidity and mortality and the likelihood of transmission to others. In 2010, the Spencer Cox Center for Health at St Lukes and Roosevelt Hospitals partnered with the emergency department to move from a counsellor-based to an integrated model of oral rapid HIV antibody (RHIV) testing in the hospitals two emergency rooms in New York City. For this descriptive study, we collected data for patients seen in the emergency department, and new HIV-positive patients linked to care between 2011 and 2012, to understand barriers to programme implementation and improve quality of routine rapid HIV testing services. Methods Over 24 months between Jan 1, 2011, and Dec 31, 2012, we implemented the integrated HIV testing model and conducted several monitoring and quality improvement projects. Every month, we measured the number of patients eligible, triaged, offered, accepted, and completed the RHIV test, and the number who tested positive and were linked to care. Data were collected from emergency department, outpatient, and inpatient electronic health records, and were compiled as a necessary part of quality management and the provision of linkage to care. Additional analyses included acceptance rate by site and by triage nurse. Nurses with fewer than 20 triage visits were excluded. Acceptance rate data were extracted from the emergency department electronic health record in aggregate form on a monthly basis, and entered into SPSS for statistical analysis. Findings Model change resulted in a six-fold increase in testing within 6 months. Of the 339 449 triaged visits, patients from 323 575 (95·3%) visits were eligible for screening (>13 years, triage acuity level III or higher), 305 791 (90·1%) patients were offered the RHIV test, and 34 598 (11·3%) eligible people accepted HIV testing. Among these, 25 690 (74·3%) tests were completed. 81 (0·32%) new HIV cases were identified, of which 61 (75·3%) had an HIV primary care visit within 90 days of preliminary test. In subanalyses, we identified significant differences in individual and site performance for test acceptance and test completion. Among the 105 nurses included in the analysis, acceptance rates ranged from 0·4% to 30·8% (mean 10·8%). Nurses at one emergency room had a significantly higher mean acceptance rate (0·13, SD 0·06) than did nurses at the other (0·08, SD 0·07; p Interpretation Integrating routine, near-universal screening into a high-volume emergency department is feasible. From these results, five quality gaps were identified for targeted intervention: eligibility, test offer, acceptance rate, test completion, and linkage to care. These gaps are likely to exist in other routine screening programmes, and each can be targeted with additional measurement and quality interventions. Interventions that we have evaluated include changes in the emergency medical room, dissemination of individual performance reports, and collaboration with the local health department to reach patients lost to follow-up. Funding The St Lukes and Roosevelt Hospitals routine RHIV testing programme receives grant funding from the New York City Department of Health and Mental Hygiene for costs associated with RHIV testing of uninsured patients.

Clinical Pathologic Conference: A 65-year-old Male With Left-Sided Chest Pain. A Case of an Unexpected Occupational Hazard

The authors present a case of a 65-year-old male who presented four times to the emergency department (ED) with left-sided chest pain. On the first three visits, the patient was admitted with a different diagnosis related to his chest pain. On the final visit, an abnormality on an imaging study performed in the ED led to the ultimate diagnostic test revealing the cause of the patients symptoms. The patients clinical presentation and ultimate clinical course are summarized, and a discussion of the differential diagnoses of his condition is presented.

A demographic study of patients presenting for HIV non-occupational postexposure prophylaxis and those newly diagnosed with HIV at a large urban hospital

Abstract Background The Spencer Cox Center for Health operates non-occupational postexposure prophylaxis (nPEP) and rapid HIV screening programmes at St Lukes and Roosevelt Hospitals in New York City, USA, funded in part by the New York City Department of Health and Mental Hygiene. The aim of this study was to explore the possibility of disparities in nPEP awareness and/or accessibility by comparing the demographics of individuals presenting for nPEP and those newly diagnosed HIV-positive individuals within the same large urban hospital centre. Both programmes are collaborative efforts between the hospitals HIV centre (Spencer Cox Center for Health) and the emergency department, with patients identified primarily in the emergency department and linked to care at the HIV centre. Methods Demographic data were extracted from electronic medical records of patients who underwent HIV rapid antibody testing and had newly diagnosed HIV infections, and of patients who received nPEP, between January, 2011, and June, 2013. All data were entered into an SPSS database for descriptive analysis. Characteristics of patients who received nPEP and those who were newly HIV diagnosed were compared with the χ 2 test and Wilcoxon test. Findings The study population comprised 929 participants, 769 from the nPEP programme and 160 newly diagnosed through the rapid HIV screening programme. Most participants were men (774 [83%]), white (323 [35%]), and reported as a risk factor that they were men who had sex with men (540 [58%]). Mean age was 32 years (range 14–74). For those newly diagnosed with HIV with a documented CD4 cell count, 52 (42%) patients had a CD4 count of fewer than 200 cells per μL, 24 (19%) patients had CD4 count in the range 200–349 cells per μL, and 49 (39%) patients had a CD4 count of more than 350 cells per μL. Most participants resided in boroughs in New York City (799 [86%]), with 519 (56%) from Manhattan. Univariate analysis showed that nPEP patients differed significantly from those newly diagnosed with HIV by race (p vs 29 [20%] of 144), commercially insured (392 [51%] of 769 vs 39 [24%] of 160), and young (mean age 32 years vs 37 years, t 927 =−6·4; p vs 119 [18%] of 652), publicly insured (53 [33%] of 160 vs 82 [11%] of 769), and reside in the Bronx (18 [11%] of 159 vs 51 [7%] of 766). Interpretation Differences in race, insurance status, age, and geographical area of residence suggest disparities in nPEP awareness and/or accessibility, and demonstrate a need for public health efforts to educate people about and facilitate access to nPEP in communities at high risk of HIV infection. Possible limitations of this study include varied stage of disease progression among the newly diagnosed sample, the limited number of sites providing nPEP relative to those providing HIV screening, and a lack of ability to survey the newly diagnosed population as to their awareness of nPEP. We aim to do further analysis with zip code geomapping to refine our understanding of differences in geographical distribution of patients accessing nPEP and those accessing HIV testing services. Funding These programmes are supported in part by the New York City Department of Health and Mental Hygiene.