Elizabeth M. Schoenfeld

Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients.

STUDY OBJECTIVE We examine the central venous catheter placement rate during the implementation of an ultrasound-guided peripheral intravenous access program. METHODS We conducted a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. RESULTS During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. CONCLUSION The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.

ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access☆☆☆

OBJECTIVE The objective of the study was to assess the success rate of emergency department (ED) technicians in placing ultrasound (US)-guided peripheral intravenous (i.v.) catheters. METHODS In this prospective, observational trial, 19 ED technicians were taught to use US guidance to obtain i.v. access. Training sessions consisted of didactic instruction and hands-on practice. The ED technicians were then prospectively followed. The US guidance for i.v. access was limited to patients with difficult access. The primary outcome was successful peripheral i.v. placement. RESULTS A total of 219 attempts were recorded, with a success rate of 78.5% (172/219). There was a significant correlation between operator experience and success rate. Complications were reported in 4.1% of patients and included 5 arterial punctures and 1 case of a transient paresthesia. CONCLUSIONS Emergency department technicians can be taught to successfully place US-guided IVs in patients with difficult venous access. Teaching this skill to ED technicians increases the pool of providers available in the ED to obtain access in this patient population.

Clinical decision rules for diagnostic imaging in the emergency department: A research agenda

BACKGROUND Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging. OBJECTIVES The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED). METHODS The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference. RESULTS A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED? CONCLUSIONS The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.

Mastitis and Methicillin-Resistant Staphylococcus Aureus (MRSA): The Calm Before the Storm?

BACKGROUND Post-partum mastitis is a common infection in breastfeeding women, with an incidence of 9.5-16% in recent literature. Over the past decade, community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a significant pathogen in soft-tissue infections presenting to the emergency department. The incidence of mastitis caused by MRSA is unknown at this time, but likely increasing. OBJECTIVES We review the data on prevention and treatment of mastitis and address recent literature demonstrating increases in MRSA infections in the post-partum population and how we should change our practices in light of this emerging pathogen. CASE REPORT We present a case of simple mastitis in a health care worker who failed to improve until treated with antibiotics appropriate for a MRSA infection. CONCLUSION Recent evidence suggests that just as MRSA has become the prominent pathogen in other soft-tissue infections, mastitis is now increasingly caused by this pathogen. Physicians caring for patients with mastitis need to be aware of this bacteriologic shift to treat appropriately.

Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians

&NA; Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient’s capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician‐directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high‐quality, patient‐centered emergency care.

Weekend Emergency Department Visits in Nebraska: Higher Utilization, Lower Acuity

BACKGROUND We know very little about differences in Emergency Department (ED) utilization and acuity on weekends compared with weekdays. Understanding such differences may help elucidate the role of the ED in the health care delivery system. STUDY OBJECTIVE To compare patterns of ED use on weekends with weekdays and analyze the differences between these two groups. METHODS The Health Care Utilization Project (HCUP) is a national state-by-state billing database from acute-care, non-federal hospitals. Data from Nebraska in 2004 was used to compare ED-only patient visits (patients discharged home or transferred to another health care facility) and ED-admitted visits (patients admitted to the same hospital after an ED visit) for weekend vs. weekday frequency, billed charges, sex, age, and primary payer. RESULTS Of all non-admitted patients who visited the ED, 34.5% came in on weekends. This yielded ED utilization rates of 25 visits/1,000 people on weekdays and 33 visits/1,000 people on weekends, an increase of 32% on weekends. Weekend-only ED patients of all ages and payer categories were charged lower hospital facility fees than weekday-only ED patients; USD 777 vs. USD 921, respectively (p < 0.001). Weekend ED patients were less likely to be admitted and less likely to die while in the ED (2 deaths/1000 ED visits for weekend-only patients vs. 3 deaths/1000 ED visits for weekday-only [p < 0.001]). CONCLUSIONS In Nebraska, EDs care for a greater number of low-acuity patients on weekends than on weekdays. This highlights the important role EDs play within the ambulatory care delivery system.

Young Patients with Suspected Uncomplicated Renal Colic are Unlikely to Have Dangerous Alternative Diagnoses or Need Emergent Intervention

Introduction In the United States there is debate regarding the appropriate first test for new-onset renal colic, with non-contrast helical computed tomography (CT) receiving the highest ratings from both Agency for Healthcare Research and Quality and the American Urological Association. This is based not only on its accuracy for the diagnosis of renal colic, but also its ability to diagnose other surgical emergencies, which have been thought to occur in 10–15% of patients with suspected renal colic, based on previous studies. In younger patients, it may be reasonable to attempt to avoid immediate CT if concern for dangerous alternative diagnosis is low, based on the risks of radiation from CTs, and particularly in light of evidence that patients with renal colic have a very high likelihood of having multiple CTs in their lifetimes. The objective is to determine the proportion of patients with a dangerous alternative diagnosis in adult patients age 50 and under presenting with uncomplicated (non-infected) suspected renal colic, and also to determine what proportion of these patients undergo emergent urologic intervention. Methods Retrospective chart review of 12 months of patients age 18–50 presenting with “flank pain,” excluding patients with end stage renal disease, urinary tract infection, pregnancy and trauma. Dangerous alternative diagnosis was determined by CT. Results Two hundred and ninety-one patients met inclusion criteria. One hundred and fifteen patients had renal protocol CTs, and zero alternative emergent or urgent diagnoses were identified (one-sided 95% CI [0–2.7%]). Of the 291 encounters, there were 7 urologic procedures performed upon first admission (2.4%, 95% CI [1.0–4.9%]). The prevalence of kidney stone by final diagnosis was 58.8%. Conclusion This small sample suggests that in younger patients with uncomplicated renal colic, the benefit of immediate CT for suspected renal colic should be questioned. Further studies are needed to determine which patients benefit from immediate CT for suspected renal colic, and which patients could undergo alternate imaging such as ultrasound.

Acute Kidney Injury After Computed Tomography: A Meta-analysis

Study objective Computed tomography (CT) is an important imaging modality used in the diagnosis of a variety of disorders. Imaging quality may be improved if intravenous contrast is added, but there is a concern for potential renal injury. Our goal is to perform a meta‐analysis to compare the risk of acute kidney injury, need for renal replacement, and total mortality after contrast‐enhanced CT versus noncontrast CT. Methods We searched MEDLINE (PubMed), the Cochrane Library, CINAHL, Web of Science, ProQuest, and Academic Search Premier for relevant articles. Included articles specifically compared rates of renal insufficiency, need for renal replacement therapy, or mortality in patients who received intravenous contrast versus those who received no contrast. Results The database search returned 14,691 articles, inclusive of duplicates. Twenty‐six unique articles met our inclusion criteria, with an additional 2 articles found through hand searching. In total, 28 studies involving 107,335 participants were included in the final analysis, all of which were observational. Meta‐analysis demonstrated that, compared with noncontrast CT, contrast‐enhanced CT was not significantly associated with either acute kidney injury (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.83 to 1.07), need for renal replacement therapy (OR 0.83; 95% CI 0.59 to 1.16), or all‐cause mortality (OR 1.0; 95% CI 0.73 to 1.36). Conclusion We found no significant differences in our principal study outcomes between patients receiving contrast‐enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient‐ and illness‐level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.

The Diagnosis and Management of Patients with Renal Colic across a Sample of US Hospitals: High CT Utilization Despite Low Rates of Admission and Inpatient Urologic Intervention

Objectives Symptomatic ureterolithiasis (renal colic) is a common Emergency Department (ED) complaint. Variation in practice surrounding the diagnosis and management of suspected renal colic could have substantial implications for both quality and cost of care as well as patient radiation burden. Previous literature has suggested that CT scanning has increased with no improvements in outcome, owing at least partially to the spontaneous passage of kidney stones in the majority of patients. Concerns about the rising medical radiation burden in the US necessitate scrutiny of current practices and viable alternatives. Our objective was to use data from a diverse sample of US EDs to examine rates of and variation in the use of CT scanning, admission, and inpatient procedures for patients with renal colic and analyze the influence of patient and hospital factors on the diagnostic testing and treatment patterns for patients with suspected renal colic. Methods We conducted a retrospective cohort study of adult patients who received a diagnosis of renal colic via a visit to an ED at 444 US hospitals participating in the Premier Healthcare Alliance database from 2009–2011. We modeled use of CT, admission, and inpatient urologic intervention as functions of both patient characteristics and hospital characteristics. Results Over the 2-year period, 307,612 patient visits met inclusion criteria. Among these patients, 254,211 (82.6%) had an abdominal CT scan, with 91.5% being non-contrast (“renal protocol”) CT scans. Nineteen percent of visits (58,266) resulted in admission or transfer, and 9.8% of visits (30,239) resulted in a urologic procedure as part of the index visit. On multivariable analysis male patients, Hispanic patients, uninsured patients, and privately insured patients were more likely to have a CT scan performed. Older patients and those covered by Medicare were more likely to be admitted, and once admitted, white patients and privately insured patients were more likely to have a urologic intervention. Only hospital region was associated with variation in CT rates, and this variation was minimal. Region and size of the hospital were associated with admission rates, and hospitals with more practicing urologists had higher intervention rates. Conclusions In this dataset, the majority of patients did not require admission or immediate intervention. Despite this, the large majority received CT scans, in a cohort representing 15–20% of all US ED visits. The CT rate was minimally variable at the hospital level, but the admission rates varied 2-fold, suggesting that hospital-level factors affect patient management. The high rate of CT usage coupled with the low rate of immediate intervention suggests that further research is warranted to identify patients who are at low risk for an immediate intervention, and could potentially be managed with ultrasound alone, expectant management, or delayed CT.

Validity of STONE scores in younger patients presenting with suspected uncomplicated renal colic.

OBJECTIVES Recent studies have cast doubt on the routine need for emergent computed tomographic (CT) scan in patients with suspected renal colic. A clinical prediction rule, the STONE score, was recently published with the goal of helping clinicians predict obstructive kidney stones in noninfected flank pain patients before CT scan. We sought to examine the validity of this score in younger, noninfected flank pain patients. METHODS A secondary analysis of a retrospective cohort study was performed to determine the validity of STONE scores for predicting the outcome of obstructive kidney stone in patients age 18 to 50 years presenting with flank pain suggestive of uncomplicated ureterolithiasis. Validity was measured by calculation of the area under the curve of the receiver operating characteristic curve. Sensitivity, specificity, negative predictive value, positive predictive value, and ±likelihood ratios were calculated for various cutoff values. RESULTS Of 134 patients who met inclusion criteria, 56.7% were female, average age was 37 years, and 52% had an obstructing kidney stone by CT scan. The receiver operating characteristic curve for the STONE score had an area under the curve of 0.87 (95% confidence interval, 0.80-0.93) and indicated that a cutoff of greater than or equal to 8 would have a sensitivity of 78.6%, specificity of 84.4%, negative predictive value of 78.3%, positive predictive value of 84.6%, and +likelihood ratio of 4.9. CONCLUSIONS This analysis suggests that the STONE score is valid in younger populations. It can aid in determining pretest probability and help inform conversations about the likelihood of the diagnosis of renal colic before imaging, which may be useful for decision making.