Mark A. Merlin

Impact of Scribes on Performance Indicators in the Emergency Department

OBJECTIVES The objective was to quantify the effect of scribes on three measures of emergency physician (EP) productivity in an adult emergency department (ED). METHODS For this retrospective study, 243 clinical shifts (of either 10 or 12 hours) worked by 13 EPs during an 18-month period were selected for evaluation. Payroll data sheets were examined to determine whether these shifts were covered, uncovered, or partially covered (for less than 4 hours) by a scribe; partially covered shifts were grouped with uncovered shifts for analysis. Covered shifts were compared to uncovered shifts in a clustered design, by physician. Hierarchical linear models were used to study the association between percentage of patients with which a scribe was used during a shift and EP productivity as measured by patients per hour, relative value units (RVUs) per hour, and turnaround time (TAT) to discharge. RESULTS RVUs per hour increased by 0.24 units (95% confidence interval [CI] = 0.10 to 0.38, p = 0.0011) for every 10% increment in scribe usage during a shift. The number of patients per hour increased by 0.08 (95% CI = 0.04 to 0.12, p = 0.0024) for every 10% increment of scribe usage during a shift. TAT was not significantly associated with scribe use. These associations did not lose significance after accounting for physician assistant (PA) use. CONCLUSIONS In this retrospective study, EP use of a scribe was associated with improved overall productivity as measured by patients treated per hour (Pt/hr) and RVU generated per hour by EPs, but not as measured by TAT to discharge.

Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses.

INTRODUCTION This study proposes that intranasal (IN) naloxone administration is preferable to intravenous (IV) naloxone by emergency medical services for opioid overdoses. Our study attempts to establish that IN naloxone is as effective as IV naloxone but without the risk of needle exposure. We also attempt to validate the use of the Glasgow Coma Scale (GCS) in opioid intoxication. METHODS A retrospective chart review of prehospital advanced life support patients was performed on confirmed opioid overdose patients. Initial and final unassisted respiratory rates (RR) and GCS, recorded by paramedics, were used as indicators of naloxone effectiveness. The median changes in RR and GCS were determined. RESULTS Three hundred forty-four patients who received naloxone by paramedics from January 1, 2005, until December 31, 2007, were evaluated. Of confirmed opioid overdoses, change in RR was 6 for the IV group and 4 for the IN group (P = .08). Change in GCS was 4 for the IV group and 3 for the IN group (P = .19). Correlations between RR and GCS for initial, final, and change were significant at the 0.01 level (rho = 0.577, 0.462, 0.568, respectively). CONCLUSION Intranasal naloxone is statistically as effective as IV naloxone at reversing the effects of opioid overdose. The IV and IN groups had similar average increases in RR and GCS. Based on our results, IN naloxone is a viable alternative to IV naloxone while posing less risk of needle stick injury. Additionally, we demonstrated that GCS is correlated with RR in opioid intoxication.

Prevalence of Methicillin-Resistant Staphylococcus aureus on the Stethoscopes of Emergency Medical Services Providers

Objective. The investigation seeks to determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) on the stethoscopes of emergency medical services (EMS) providers. While stethoscopes are known fomites for MRSA, the prevalence of MRSA in the prehospital setting is not well documented in the literature. Methods. This was a prospective, observational cohort study of 50 stethoscopes provided by consecutive, consenting EMS providers at our academic emergency department (ED). Stethoscopes were swabbed with saline culture applicators and samples were cultured on a commercial MRSA test kit containing mannitol salt agar with oxacillin. After 72 hours of incubation at 37°C, two emergency physicians and one microbiologist analyzed the plates independently. MRSA colonization was recorded as positive if all three reviewers agreed that colonization had occurred. Results. Of 50 stethoscopes, 16 had MRSA colonization, and 16 (32%) EMS professionals had no recollection of when their stethoscopes had been cleaned last. Reported length of time since last cleaning was grouped into six categories: one to seven days, eight to 14 days, 15 to 30 days, 31 to 180 days, 181 days to 365 days, and unknown. The median time frame reported since the last cleaning was one to seven days. In the model, an increase from one time category to the next increased the odds of MRSA colonization by 1.86 (odds ratio = 1.86, p = 0.038). Conclusions. In this ED setting, MRSA was found on approximately one in three stethoscopes of EMS professionals. A longer length of time since the last stethoscope cleaning increased the odds of MRSA colonization.

Utilization of Warning Lights and Siren Based on Hospital Time-Critical Interventions

OBJECTIVE The objective of this study was to evaluate the time saved by usage of lights and siren (L&S) during emergency medical transport and measure the total number of time-critical hospital interventions gained by this time difference. METHODS A retrospective study was performed of all advanced life support (ALS) transports using lights and siren to this university emergency department during a three-week period. Consecutive times were measured for 112 transports and compared with measured transport times for a personal vehicle traveling the same day of the week and time of day without lights and siren. The time-critical hospital interventions are defined as procedures or treatments that could not be performed in the prehospital setting requiring a physician. The project assessed whether the patients received the hospital interventions within the average time saved using lights and siren transport. RESULTS The average difference in time with versus without L&S was -2.62 minutes (95% CI: -2.60- -2.63, paired t-test p<0.0001). The average transport time with L&S was 14.5±7.9 minutes (min) (1 standard deviation/minute (min), range=1-36 min.). The average transport time without L&S was 17.1±8.3 min (range=1-40 min). Of the 112 charts evaluated, five patients (4.5%) received time-critical hospital interventions. No patients received time-critical interventions within the time saved by utilizing lights and siren. Longer distances did not result in time saved with lights and siren. CONCLUSIONS Limiting lights and siren use to the patients requiring hospital interventions will decrease the risks of injury and death, while adding the benefit of time saved in these critical patients.

OxyContin® Abuse and Overdose

Abstract Background: OxyContin® (controlled-release oxycodone hydrochloride) (Purdue Pharma, Stamford, CT) was approved in 1995 by the US Food and Drug Administration (FDA) for moderate-to-severe chronic pain. Crushing and snorting the delayed-release tablets results in a rapid release of the drug, increased absorption, and high peak serum concentrations. The propensity for addiction to OxyContin® and the trend of increased prescription drug abuse have made it imperative for physicians and health care providers to recognize the clinical presentation of overdose and know how to manage associated complications. Objectives: In this review of OxyContin®, we discuss current trends in its abuse and the clinical presentation of overdose. We review the specific effects of the drug on body systems and the recognition of symptomatology, differential diagnosis, and management. Discussion: Many of the clinical findings in acute opioid overdoses are nonspecific, making diagnosis difficult. OxyContin® overdose presents with a typical opiate toxidrome, including decreased respirations, miosis, hypothermia, bradycardia, hypotension, and altered mental status. The presence of coingestants can cloud the clinical picture. If OxyContin® overdose is suspected, early ventilation and oxygenation should be administered, which is generally sufficient to prevent death. Even in the absence of a confirmation, cautious administration of naloxone–the opiate receptor antagonist and antidote for opioid overdoses–may have both diagnostic and therapeutic effects. Summary: With increasing rates of prescription drug abuse, OxyContin® will continue to present challenges to physicians and health care providers. Physicians should be aware of potential patients who are seeking OxyContin® for recreational use.

Naloxone in cardiac arrest with suspected opioid overdoses

INTRODUCTION Naloxones use in cardiac arrest has been of recent interest, stimulated by conflicting results in both human case reports and animal studies demonstrating antiarrhythmic and positive ionotropic effects. We hypothesized that naloxone administration during cardiac arrest, in suspected opioid overdosed patients, is associated with a change in cardiac rhythm. METHODS From a database of 32,544 advanced life support (ALS) emergency medical dispatches between January 2003 and December 2007, a retrospective chart review was completed of patients receiving naloxone in cardiac arrest. Forty-two patients in non-traumatic cardiac arrest were identified. Each patient received naloxone because of suspicion by a paramedic of acute opioid use. RESULTS Fifteen of the 36 (42%) (95% confidence interval [CI]: 26-58) patients in cardiac arrest who received naloxone in the pre-hospital setting had an improvement in electrocardiogram (EKG) rhythm. Of the participants who responded to naloxone, 47% (95% CI: 21-72) (19% [95% CI: 7-32] of all study subjects) demonstrated EKG rhythm changes immediately following the administration of naloxone. DISCUSSION Although we cannot support the routine use of naloxone during cardiac arrest, we recommend its administration with any suspicion of opioid use. Due to low rates of return of spontaneous circulation and survival during cardiac arrest, any potential intervention leading to rhythm improvement is a reasonable treatment modality.

A Case Series of Double Sequence Defibrillation

Abstract Introduction: Double Sequence Defibrillation or Double Simultaneous Defibrillation (DSD) is the use of two defibrillators almost simultaneously at their highest allowed energy setting to treat refractory ventricular fibrillation (RVF). One set of pads is placed in the Anterior-Posterior position and the other set of pads is placed in the Anterior-Lateral Position. Both defibrillation buttons are pressed simultaneously. We sought to determine ROSC and survival rates in a large EMS system when DSD is routinely utilized for RVF. Method: A retrospective case series was performed of all patients who received DSD from January 1, 2015 to April 30, 2015. During the four month period, we requested physicians to instruct paramedics to use DSD on patients after three refractory episodes of VF. All Advanced Cardiac Life Support (ALS) patients treated by paramedics are discussed via telephone communication with a physician in the system of 100 ALS treated patients per day. Results: From January 1, 2015 to April 1, 2015, a total of 7 patients were treated with DSD. The mean age was 62 (Range: 45–78), with mean resuscitation time of 34.3 minutes before first DSD (Range: 23–48). The mean number of single shocks was 5.4 prior to DSD (Range: 3–9), with a mean of 2 DSD shocks delivered. VF converted after DSD in 5 cases (57.1%). Four patients survived to admission (43%). Three patients survived to discharge with no or minimal neurologic disability (28.6%). The mean Cerebral Performance Category Scale was 3.4 with 1 indicating good cerebral performance and 5 indicating Brain Death. Discussion: The correct amount of energy in joules for VF remains unknown. In this case series, significant patients converted out of VF. The reason for improved VF conversion may be several factors including additional defibrillation vectors, increased energy, more energy across myocardium, and unknown variables. Additional research is underway to determine if routine DSD will result in improved survival compared to standard defibrillation techniques.

Hyponatremia: evaluation and management.

Abstract Background: Hyponatremia is one of the most common electrolyte disorders encountered in clinical practice. The pathophysiology is complex, but its understanding is vital to the disorders evaluation and treatment. The clinical manifestations of hyponatremia include headache, dizziness, nausea/vomiting, seizures, obtundation, and death. Undercorrection must be avoided, but overly aggressive treatment can also be detrimental. Objectives: We review normal water physiology, including central osmosensory mechanisms, that are now becoming better understood. We will then review the classification and causes of hyponatremia and the clinical evaluation and workup of the disorder. Treatment options will be briefly reviewed. Discussion: Evaluation of hyponatremia begins with a detailed history and physical examination. Appropriate urine and serum studies can contribute to the evaluation and classification of the disorder. Treatment decisions are based on the underlying cause and severity of symptoms. Conclusion: We present an extensive review of the physiology, pathophysiology, clinical evaluation, and management of hyponatremia.

Use of a limited lights and siren protocol in the prehospital setting vs standard usage

OBJECTIVE Our objective was to determine if implementing a standard lights and sirens (L&S) protocol would reduce their use and if this had any effect on patient disposition. METHODS In a prospective cohort study, we trained emergency medical services (EMS) personnel from 4 towns in an L&S protocol and enrolled control personnel from 4 addition towns that were not using the protocol. We compare the use of L&S between them over a 6-month period. Our protocol restricted the usage of L&S to patients who had maladies requiring expedited transport. Emergency medical services personnel from the control towns had no such restrictions and were not aware that we were tracking their usage of L&S. We also considered if patient disposition was affected by the judicious usage of L&S. RESULTS Prehospital EMS personnel who were trained in an L&S protocol were 5.6 times less likely to use L&S when compared with those not trained. Of the 808 patients transported by both types of workers, no difference in patient disposition was observed. CONCLUSIONS Our protocol significantly reduced the use of L&S. Judicious use of L&S has significant implications for transport safety. By allowing for selective transport with L&S usage, we observed no impact in patient disposition.

Causes of Sudden Cardiac Arrest in Young Athletes

Abstract Knowledge of sudden cardiac death in young athletes is imperative for all physicians and allied health professionals. The complete differential diagnosis of a young patient with sudden cardiac arrest will result in proper work-up and treatment. In this article, we review several etiologies of sudden cardiac death, including hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, Wolff-Parkinson-White syndrome, long QT syndrome, Brugada syndrome, and commotio cordis. Clinical findings, work-up, treatment, long-term management, and athlete preparticipation screening guidelines are discussed.