J. Rosario

Movement Disorder Emergencies

A 35-year-old female patient was brought into the emergency department by EMS one weekend morning after being found down by her parents, with a chief complaint of altered mental status, confusion, and somnolence. Upon arrival the patient was drowsy but arousable and able to converse. She admitted to taking a handful of her muscle relaxant medicine (cyclobenzaprine) with some alcohol that prior evening when she had an argument with her boyfriend. Her past medical history included depression, for which she took escitalopram 10 mg daily. The muscle relaxant was given to her recently for an acute muscle spasm of her lower back. She denied any other drugs or medications.

Non-traumatic Retinal Detachment Diagnosed via Bedside Ultrasonography

The authors report a case of an elderly patient with left eye retinal detachment who presented to the emergency department (ED). Bedside ultrasonography of the retina revealed a hyperechoic, smooth, folded membrane within the vitreous, consistent with a diagnosis of retinal detachment. Ophthalmological consultation was obtained, and the patient healed well after surgical repair.

Sepsis Cards and Facts: A Simple Way to Increase Sepsis Bundle Compliance

Objective The objective of this study was to improve sepsis bundle compliance via an educational intervention in our emergency department (ED). Methods This was a before and after study. Historical data on sepsis bundle compliance was obtained from our quality officer. Data were collected for 30 consecutive days to compare sepsis bundle compliance rates before and after the intervention. Descriptive statistics were compiled, and the z-test for proportions was used to calculate statistical significance. The intervention was two-fold: 1) a bright yellow card with sepsis criteria listed was posted on all ED workstation computers and 2) there was a daily email blast for one month with “sepsis facts.” These email blasts were short pearls that highlighted the importance of recognizing and treating sepsis. Results The sepsis bundle compliance rates in the month prior to the intervention was 38%. In the month during the targeted intervention, the compliance rate increased to 56%. There was a statistically significant increase in bundle compliance rates during the intervention (p=0.0399). We also administered a survey to the ED attendings and residents following the completion of the study to assess whether they perceived that our intervention was helping them increase compliance with ordering the sepsis bundle. The response rate was 94%. To the question “Did you feel the sepsis cards placed on the workstations make you more likely to consider sepsis earlier in patients under your care in the emergency department?” 70% answered agree or strongly agree. To the question “Were you more likely to order the sepsis bundle after receiving the daily Sepsis Facts?” 29% were neutral while 59% answered agree or strongly agree. Finally, to the question “Did you feel the sepsis cards and sepsis facts help you improve the care of Septic patients in the emergency department?” 76% answered agree or strongly agree. Conclusion Sepsis criteria reminders and email blasts highlighting the importance of treating and recognizing sepsis can improve compliance with sepsis bundle ordering within the emergency department.

198 Adherence to Standardized Sepsis Order Set Associated With Lower 30-Day Hospital Re-Admission Rate

presence of infection. Subsequently, 3 “Surviving SepsisCampaigns” (SSC) have occurred. Each advocated updated, research-based approaches for “best practices” for the septic patient admitted to a hospital, such as prompt administration of appropriate antibiotics and crystalloids. However, no prior publications exist regarding septic patients who are treated and released from an emergency department (ED). The short-term mortality of patients who are septic, yet deliberately treated and released from an ED, is currently unknown. We focused upon this population because at this time, a prudent emergency physician, who deliberately institutes an outpatient treatment plan for a septic patient who does not appear to require hospital admission, could cite no peer-reviewed literature to support this common practice. Thus, in the rare event that such a patient unexpectedly deteriorated after treatment and release from an ED, and the quality of that medical care were called into question, the emergency physician could not cite peer-reviewed literature to support their decision.We seek to remediate this deficiency, hypothesizing that patient deaths within 7 days are vanishingly rare to absent among this cohort. Methods: We investigated the 7-day mortality of septic patients seen at 1 academic emergency department in 2015, who were deliberately treated as outpatients, and who manifest SIRS criteria in the ED and then were released from the ED with a diagnosis of selected infectious complaints (IC). IC included community-acquired pneumonia, cellulitis (with or without abscess), pyelonephritis, pelvic inflammatory disease, influenza, and viral syndrome. Patient charts were located retrospectively via a large local electronic database. We investigated vital signs at arrival and before discharge, whether and how much IV fluid was administered, among other variables. Screening of charts for patients with an IC diagnosis was followed by hand-searching of charts for evidence of SIRS criteria. SIRS criteria are not highly specific. However, we utilized SIRS, not qSOFA, for the diagnosis of sepsis, because the 2016 “Sepsis-3” update derived and validated the use of the quick Sequential Organ Failure Assessment (qSOFA) score as a prognostic instrument, to adjudicate risk for mortality. Despite this, qSOFA has not been validated as a diagnostic instrument for sepsis. SIRS criteria are highly sensitive but are not highly specific, but no better diagnostic criteria have been validated. Further, evidence-based medicine (EBM) criteria teach that all patients in a study about prognosis must be correctly diagnosed at the inception of the cohort. Thus, it is circular reasoning, and therefore impermissible, to use qSOFA for diagnosis of sepsis. Results: Of the 6245 charts screened, 164 were SIRS positive. None of this cohort suffered 7-day mortality. The 95% confidence interval (CI) of a proportion is approximately 3/n; thus, the 95% confidence interval is 0 to 2 deaths. This CI will further narrow as we enter more patients, if none died within 7 days. Conclusions: When emergency physicians use their clinical judgement to treat and release septic patients from the ED, the risk of short-term mortality is low. It is safe and reasonable to treat and release a select subset of septic patients from an ED.

222 Delta Lactate (3-Hour Lactate Minus Initial Lactate) Predicts In-Hospital Death in Sepsis Patients

Study Objectives: Opt-out, non-targeted screening has been recommended by the Centers for Disease Control and the US Preventive Services Task Force, yet these recommendations are not widely implemented. In 2017, our emergency department (ED) initiated opt-out, non-targeted HIV and HCV screening. This study will evaluate the effectiveness of this process to detect new HIV diagnoses by comparing the number of rapid HIV tests, reflexed confirmatory tests, and new HIV positive diagnoses between the traditional targeted, opt-in process and the recommended opt-out, nontargeted HIV screening approach. Methods: A retrospective analysis compared the first 12 months of opt-out, nontargeted HIV and HCV screening and 12 months of opt-in, targeted HIV testing results in an urban emergency department. Opt-out, non-targeted HIV testing included all patients age 13 or older and HCV screening included all patients age 18 or older, presenting to the ED who required serum labs as part of their standard medical evaluation in the ED. The electronic medical record was utilized to create an integrated screening process, provide rapid confirmation testing, and provider notification for positive HIV and HCV results. Per California state law, patients were notified of testing and given a chance to opt-out, but were not explicitly consented. Rapid HIV screening was done via 4th generation Antigen Antibody tests which were auto-reflexed for in house confirmatory testing via the Genius analyzer. HCV screening was done via the Architect analyzer and auto-reflexed for RNA and PCR confirmatory testing. An additional tube was collected along with ordered serum labs and later used for confirmatory testing without the need to re-stick the patient. Additionally, confirmatory testing for HIV was done onsite, enabling same-day results and patient notification HIV status. In an effort to not increase turnaround time to discharge (TATd) any results acquired after patient discharge or elopement were added to an electronic worklist that was reviewed the following day to notify the patient and link them to follow-up care. Results: The previous 12-month period utilizing opt-in, targeted testing yielded 2,273 initial HIV tests, 72 confirmatory tests, and 21 new HIV diagnoses (positive rate 1⁄4 0.9%). Opt-out, non-targeted HIV testing over a 12-month period yielded 11,794 rapid HIV tests, 121 reflexed confirmatory tests, and 38 new HIV diagnoses (positive rate 1⁄4 0.3%). Opt-out, non-targeted HCV testing yielded 12,304 initial HCV tests, 1,053 positive antibody results, 469 positive RNA results (positive rate 1⁄4 3.8%). Conclusions: This new testing algorithm produced a 6-fold increase in the number of HIV tests and, more importantly, doubled the number of new HIV diagnoses. Despite the reduction in positive rate from 0.9% in targeted testing to 0.3% in nontargeted testing, opt-out, non-targeted testing is effective in identifying more new diagnoses that otherwise would have gone undetected. Same-day results in the ED provided an opportunity to engage the patient in a dialog about HIV, explain the disease, treatment options, and other expectations. Additionally, prompt diagnosis coupled with dedicated work of an HIV-specific care coordinator the new diagnoses as well as many known positives are now connected to proper care and anti-retro viral therapy.

Communicating Value in Simulation: Cost-Benefit Analysis and Return on Investment

Value-based health care requires a balancing of medical outcomes with economic value. Administrators need to understand both the clinical and the economic effects of potentially expensive simulation programs to rationalize the costs. Given the often-disparate priorities of clinical educators relative to health care administrators, justifying the value of simulation requires the use of economic analyses few physicians have been trained to conduct. Clinical educators need to be able to present thorough economic analyses demonstrating returns on investment and cost-effectiveness to effectively communicate with administrators. At the 2017 Academic Emergency Medicine Consensus Conference Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes, our breakout session critically evaluated the cost-benefit and return on investment of simulation. In this paper we provide an overview of some of the economic tools that a clinician may use to present the value of simulation training to financial officers and other administrators in the economic terms they understand. We also define three themes as a call to action for research related to cost-benefit analysis in simulation as well as four specific research questions that will help guide educators and hospital leadership to make decisions on the value of simulation for their system or program.