Leon D. Sanchez

Opioid Prescribing in a Cross Section of US Emergency Departments

STUDY OBJECTIVE Opioid pain reliever prescribing at emergency department (ED) discharge has increased in the past decade but specific prescription details are lacking. Previous ED opioid pain reliever prescribing estimates relied on national survey extrapolation or prescription databases. The main goal of this study is to use a research consortium to analyze the characteristics of patients and opioid prescriptions, using a national sample of ED patients. We also aim to examine the indications for opioid pain reliever prescribing, characteristics of opioids prescribed both in the ED and at discharge, and characteristics of patients who received opioid pain relievers compared with those who did not. METHODS This observational, multicenter, retrospective, cohort study assessed opioid pain reliever prescribing to consecutive patients presenting to the consortium EDs during 1 week in October 2012. The consortium study sites consisted of 19 EDs representing 1.4 million annual visits, varied geographically, and were predominantly academic centers. Medical records of all patients aged 18 to 90 years and discharged with an opioid pain reliever (excluding tramadol) were individually abstracted by standardized chart review by investigators for detailed analysis. Descriptive statistics were generated. RESULTS During the study week, 27,516 patient visits were evaluated in the consortium EDs; 19,321 patients (70.2%) were discharged and 3,284 (11.9% of all patients and 17.0% of discharged patients) received an opioid pain reliever prescription. For patients prescribed an opioid pain reliever, mean age was 41 years (SD 14 years) and 1,694 (51.6%) were women. Mean initial pain score was 7.7 (SD 2.4). The most common diagnoses associated with opioid pain reliever prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity fracture (7.1%) or sprain (6.5%). The most common opioid pain relievers prescribed were oxycodone (52.3%), hydrocodone (40.9%), and codeine (4.8%). Greater than 99% of pain relievers were immediate release and 90.0% were combination preparations, and the mean and median number of pills was 16.6 (SD 7.6) and 15 (interquartile range 12 to 20), respectively. CONCLUSION In a study of ED patients treated during a single week across the country, 17% of discharged patients were prescribed opioid pain relievers. The majority of the prescriptions had small pill counts and almost exclusively immediate-release formulations.

Prevalence of Bicycle Helmet Use by Users of Public Bikeshare Programs

STUDY OBJECTIVE Public bikeshare programs are becoming increasingly common in the United States and around the world. These programs make bicycles accessible for hourly rental to the general public. We seek to describe the prevalence of helmet use among adult users of bikeshare programs and users of personal bicycles in 2 cities with recently introduced bikeshare programs (Boston, MA, and Washington, DC). METHODS We performed a prospective observational study of adult bicyclists in Boston, MA, and Washington, DC. Trained observers collected data during various times of the day and days of the week. Observers recorded the sex of the bicycle operator, type of bicycle, and helmet use. All bicycles that passed a single stationary location in any direction for a period of between 30 and 90 minutes were recorded. RESULTS There were 43 observation periods in 2 cities at 36 locations; 3,073 bicyclists were observed. There were 562 (18.3%; 95% confidence interval [CI] 16.4% to 20.3%) bicyclists riding shared bicycles. Overall, 54.5% of riders were unhelmeted (95% CI 52.7% to 56.3%), although helmet use varied significantly with sex, day of use, and type of bicycle. Bikeshare users were unhelmeted at a higher rate compared with users of personal bicycles (80.8% versus 48.6%; 95% CI 77.3% to 83.8% versus 46.7% to 50.6%). Logistic regression, controlling for type of bicycle, sex, day of week, and city, demonstrated that bikeshare users had higher odds of riding unhelmeted (odds ratio [OR] 4.4; 95% CI 3.5 to 5.5). Men had higher odds of riding unhelmeted (OR 1.6; 95% CI 1.4 to 1.9), as did weekend riders (OR 1.3; 95% CI 1.1 to 1.6). CONCLUSION Use of bicycle helmets by users of public bikeshare programs is low. As these programs become more popular and prevalent, efforts to increase helmet use among users should increase.

Heart rate variability in elite American track-and-field athletes.

Prolonged training leads to changes in autonomic cardiac balance. This sympathetic and parasympathetic balance can now be studied using heart rate variability (HRV). Studies have shown that endurance athletes have an elevated level of parasympathetic tone in comparison to sedentary people. The effect of resistance training on autonomic tone is less clear. We hypothesized a significant difference in HRV indices in endurance-trained vs. power-trained track-and-field athletes. One hundred forty-five athletes (58 women) were tested prior to the 2004 U.S.A. Olympic Trials. Heart rate variability data were collected using the Omegawave Sport Technology System. Subjects were grouped according to training emphasis and gender. The mean age of the athletes was 24.8 years in each group. There were significant (p ≤ 0.01) differences by sex in selected frequency domain variables (HFnu, LFnu, LH, LHnu) and for PNN50 (p ≤ 0.04) for the time domain variables. Two-factor analyses of variance showed differences for only the main effect of sex and not for any other grouping method or interaction. Elite athletes have been shown to have higher parasympathetic tone than recreational athletes and nonathletes. Our data show differences by sex, but not between aerobically and power-based athletes. Whether this is due to an aerobic component of resistance training, an overall prolonged training effect, or some genetic difference remains unclear. Further study is needed to assess the impact of resistance training programs on autonomic tone and cardiovascular fitness. This information will be valuable for the practitioner to use in assessing an athletes response to a prescribed training regimen.

Procedure lab used to improve confidence in the performance of rarely performed procedures.

Objectives The objective of this study is to assess the efficacy of an animal procedure lab in improving the level of comfort in performing important emergency medicine procedures. The procedures included central venous line, chest tube, cricothyrotomy, pericardiocentesis, venous cutdown, and thoracotomy. Methods The students were physicians participating in the Tuscan Emergency Medicine Initiative as part of a certificate program in emergency medicine. They attended a 1-h lecture discussing the procedures to be performed. Participants filled out a questionnaire before and after the lab, which asked how many times they had performed each procedure, how comfortable they felt, on a five-point scale, performing each procedure, and whether they felt comfortable performing it by themselves, with assistance or whether they would not feel comfortable performing the procedure. Differences in rated numerical values for each procedure before and after the lab were analyzed using a two-tailed t-test. Alpha was set at 0.95. Results In all, there were 20 participants with a wide range of experience. A statistical improvement was observed in comfort level and willingness to perform the procedures independently (P<0.01). The only non-significant change was in willingness to perform central lines. Conclusions The use of an animal lab improves the comfort level of practitioners in performing procedures. Although procedures are best learned on patients with supervision, this is not always feasible. This lab is a useful adjunct to teaching in emergency medicine and allows participants exposure to critical procedures.

Patient care transitions from the emergency department to the medicine ward: evaluation of a standardized electronic signout tool

OBJECTIVE To evaluate the impact of a new electronic handoff tool for emergency department to medicine ward patient transfers over a 1-year period. DESIGN Prospective mixed-methods analysis of data submitted by medicine residents following admitting shifts before and after eSignout implementation. SETTING University-based, tertiary-care hospital. PARTICIPANTS Internal medicine resident physicians admitting patients from the emergency department. INTERVENTION An electronic handoff tool (eSignout) utilizing automated paging communication and responsibility acceptance without mandatory verbal communication between emergency department and medicine ward providers. MAIN OUTCOME MEASURES (i) Incidence of reported near misses/adverse events, (ii) communication of key clinical information and quality of verbal communication and (iii) characterization of near misses/adverse events. RESULTS Seventy-eight of 80 surveys (98%) and 1058 of 1388 surveys (76%) were completed before and after eSignout implementation. Compared with pre-intervention, residents in the post-intervention period reported similar number of shifts with a near miss/adverse event (10.3 vs. 7.8%; P = 0.27), similar communication of key clinical information, and improved verbal signout quality, when it occurred. Compared with the former process requiring mandatory verbal communication, 93% believed the eSignout was more efficient and 61% preferred the eSignout. Patient safety issues related to perceived sufficiency/accuracy of diagnosis, treatment or disposition, and information quality. CONCLUSIONS The eSignout was perceived as more efficient and preferred over the mandatory verbal signout process. Rates of reported adverse events were similar before and after the intervention. Our experience suggests electronic platforms with optional verbal communication can be used to standardize and improve the perceived efficiency of patient handoffs.

Anterior Versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by Computed Tomography Chest Wall Measurement

OBJECTIVES Recent research describes failed needle decompression in the anterior position. It has been hypothesized that a lateral approach may be more successful. The aim of this study was to identify the optimal site for needle decompression. METHODS A retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides. RESULTS The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces (p < 0.01). CONCLUSIONS With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.

Resident Experience of Abuse and Harassment in Emergency Medicine: Ten Years Later

BACKGROUND In 1995, a Society for Academic Emergency Medicine in-service survey reported high rates of verbal and physical abuse experienced by Emergency Medicine (EM) residents. We sought to determine the prevalence of abuse and harassment 10 years later to bring attention to these issues and determine if there has been a change in the prevalence of abuse over this time period. OBJECTIVES To determine the prevalence of abuse and harassment in a sample of EM residencies. METHODS We conducted a cross-section survey of EM residents from 10 residencies. EM residents were asked about their experience with verbal abuse, verbal threats, physical threats, physical attacks, sexual harassment, and racial harassment; and by whom. The primary outcome of the study was the prevalence of abuse and harassment as reported by EM residents. RESULTS There were 196 of 380 residents (52%) who completed the survey. The prevalence of any type of abuse experienced was 91%; 86% of residents experienced verbal abuse, 65% verbal threats, 50% physical threats, 26% physical attacks, 23% sexual harassment, and 26% racial harassment. Women were more likely than men to encounter sexual harassment (37% [38/102] vs. 8% [7/92]; p < 0.001). Racial harassment was not limited to minorities (23% [16/60] for Caucasians vs. 26% [29/126] for non-Caucasians; p = 0.59). Senior residents were more likely to have encountered verbal and physical abuse. Only 12% of residents formally reported the abuse they experienced. CONCLUSION Abuse and harassment during EM residency continues to be commonplace and is underreported.

Creatine kinase-MB does not add additional benefit to a negative troponin in the evaluation of chest pain☆

OBJECTIVE The aim of this study was to determine whether current troponin assay alone can be used for initial screening for acute myocardial infarction (AMI) and whether creatine kinase-MB (CK-MB) can safely be eliminated from this evaluation in the emergency department (ED). METHODS A retrospective cohort study of patients who had cardiac troponin T (Roche, Basel, Switzerland) and CK-MB ordered at an urban academic level 1 trauma center with more than 55,000 annual visits. Patients with troponin testing in the ED were identified over a period of 12 months, and corresponding CK-MB indexes were examined identifying patients with negative troponins (<0.01) and positive CK-MB indexes (>6.0). In these patients, further cardiac markers, hospital course, and 30-day mortality were then evaluated. A 99% confidence interval around point estimate was used in data analysis. RESULTS During the study period, there were 11,092 separate ED patient encounters where a patient had at least one troponin resulted. Most (97.9%) of the samples had an associated CK-MB ordered. There were 7545 initial negative troponins representing 68% of all initial samples. Seven of these had an associated positive MB index. When subsequent troponins were evaluated, an additional 4910 negative troponins were identified, with 4 patients having a positive MB. None of these 11 patients were judged to have ruled in for AMI by the treating physicians. The rate of true-positive CK-MB index with negative troponin was 0% (99% confidence interval, 0-0.04%). CONCLUSION Our results suggest that CK-MB is not necessary in the initial screening for AMI and may safely be omitted in patients with negative troponins.

Ophthalmologic Procedures in the Emergency Department

Ophthalmologic emergencies account for up to 3% of visits to emergency departments in the United States. Although isolated ocular complaints are rarely life-threatening, they can lead to significant short- and long-term morbidity, including permanent visual loss. The role of the emergency physician in management of ocular emergencies is similar to that for other chief complaints: to recognize and diagnose emergency conditions, to provide appropriate initial therapy, and to ensure correct disposition. This article reviews several of the essential ophthalmologic procedures that are within the scope of emergency medical practice. Slit lamp examination, foreign body removal, use of ultrasound, tonometry, and other emergency ophthalmologic procedures are discussed.

Modeling Hourly Resident Productivity in the Emergency Department

Study objective Resident productivity, defined as new patients per hour, carries important implications for emergency department operations. In high‐volume academic centers, essential staffing decisions can be made on the assumption that residents see patients at a static rate. However, it is unclear whether this model mirrors reality; previous studies have not rigorously examined whether productivity changes over time. We examine residents’ productivity across shifts to determine whether it remained consistent. Methods This was a retrospective cohort study conducted in an urban academic hospital with a 3‐year emergency medicine training program in which residents acquire patients ad libitum throughout their shift. Time stamps of all patient encounters were automatically logged. A linear mixed model was constructed to predict productivity per shift hour. Results A total of 14,364 8‐ and 9‐hour shifts were worked by 75 residents between July 1, 2010, and June 20, 2015. This comprised 6,127 (42.7%) postgraduate year (PGY) 1 shifts, 7,236 (50.4%) PGY‐2 shifts, and 998 (6.9%) PGY‐3 nonsupervisory shifts (Table 1). Overall, residents treated a mean of 10.1 patients per shift (SD 3.2), with most patients at Emergency Severity Index level 3 or more acute (93.8%). In the initial hour, residents treated a mean of 2.14 patients (SD 1.2), and every subsequent hour was associated with a significant decrease, with the largest in the second, third, and final hours. Table 1 Characteristics of the study participants and shifts evaluated. Conclusion Emergency medicine resident productivity during a single shift follows a reliable pattern that decreases significantly hourly, a pattern preserved across PGY years and types of shifts. This suggests that resident productivity is a dynamic process, which should be considered in staffing decisions and studied further.