Scott E. Rudkin

Improving Service Quality by Understanding Emergency Department Flow: A White Paper and Position Statement Prepared For the American Academy of Emergency Medicine

Emergency Department (ED) crowding is a common problem in the United States and around the world. Process reengineering methods can be used to understand factors that contribute to crowding and provide tools to help alleviate crowding by improving service quality and patient flow. In this article, we describe the ED as a service business and then discuss specific methods to improve the ED quality and flow. Methods discussed include demand management, critical pathways, process-mapping, Emergency Severity Index triage, bedside registration, Lean and Six Sigma management methods, statistical forecasting, queuing systems, discrete event simulation modeling and balanced scorecards. The purpose of this review is to serve as a background for emergency physicians and managers interested in applying process reengineering methods to improving ED flow, reducing waiting times, and maximizing patient satisfaction. Finally, we present a position statement on behalf of the American Academy of Emergency Medicine addressing these issues.

Antiemetic Use in Pediatric Gastroenteritis: A National Survey of Emergency Physicians, Pediatricians, and Pediatric Emergency Physicians

The objective of this study was to review the use of antiemetics for pediatric gastroenteritis and to determine prescribing patterns of physicians. A mailed cross-sectional survey instrument was sent to randomly selected board-certified emergency medicine, pediatric, and pediatric emergency medicine specialists. A total of 1665 surveys were mailed, with 593 completed surveys returned (35.6% response rate). A majority of responders (60.9%) reported using antiemetics for pediatric gastroenteritis at least once in the past year, with a greater than 50% usage for all three specialty groups. Promethazine was the most commonly used antiemetic in all specialties, and per rectum the most common route of administration. Adverse reactions following a single dose of antiemetic were most frequently reported with prochlorperazine. The most common reason for antiemetic use was to prevent further dehydration. The most common concern regarding antiemetic use was potential for side effects. Occasional antiemetic use appears to be a common practice in treating pediatric gastroenteritis, regardless of specialty. Given the absence of literature on efficacy or safety, these drugs should be used only with careful consideration to potential side effects.

Technological and Organizational Adaptation of EMR Implementation in an Emergency Department

Implementation of large Health Information Technology (HIT) systems is critical to healthcare organizations and has seen heavy investment. However, research has not fully explored the adaptation of HIT systems, particularly the tensions between individual flexibility and organizational needs in the adaptation process. This study analyzes how Emergency Department (ED) clinicians adapted to a new hospital-wide Electronic Medical Records (EMR) system. We present four adaptation cases revealing two interrelated types of adaptations—technical and organizational—as responses to the new system in use. First, individual clinicians respond to the immediate alteration in workflows caused by the EMR, while the organizational adaptations later mitigate the changes in healthcare quality control resulting from the clinicians’ initial adaptation. Our analysis reflects the critical nature and value of both adaptation types, with an emphasis on the triggers and process of organizational adaptation, for the successful implementation of a socio-technical-political system in a healthcare organization.

The worsening of ED on-call coverage in California: 6-year trend

To reassess problems with on-call physician coverage in California, we repeated our anonymous 2000 survey of the California chapter of the American College of Emergency Physicians. Physicians responded from 77.4% of California emergency departments (EDs), 51.0% of ED directors, and 34% of those surveyed. Of 21 specialties, on-call availability worsened since 2000 for 9, was unchanged for 11, and improved for 1. Of ED directors, 54% report medical staff rules require on-call duty, down from 72% in 2000. Hospitals have increased specialist on-call payments (from 21% to 35%, with 75% paying at least one specialty). Most emergency physicians (80.3%) report insurance status negatively affects on-call physician responsiveness, up from 42% in 2000. Emergency departments with predominantely minority or uninsured patients had fewer specialists and more trouble accessing them. Insurance status has a major negative effect on ED consultation and follow-up care. The on-call situation in California has worsened substantially in 6 years.

Prospective correlation of arterial vs venous blood gas measurements in trauma patients.

OBJECTIVE The objective of this study is to assess if venous blood gas (VBG) results (pH and base excess [BE]) are numerically similar to arterial blood gas (ABG) in acutely ill trauma patients. METHODS We prospectively correlated paired ABG and VBG results (pH and BE) in adult trauma patients when ABG was clinically indicated. A priori consensus threshold of clinical equivalence was set at ± less than 0.05 pH units and ± less than 2 BE units. We hypothesized that ABG results could be predicted by VBG results using a regression equation, derived from 173 patients, and validated on 173 separate patients. RESULTS We analyzed 346 patients and found mean arterial pH of 7.39 and mean venous pH of 7.35 in the derivation set. Seventy-two percent of the paired sample pH values fell within the predefined consensus equivalence threshold of ± less than 0.05 pH units, whereas the 95% limits of agreement (LOAs) were twice as wide, at -0.10 to 0.11 pH units. Mean arterial BE was -2.2 and venous BE was -1.9. Eighty percent of the paired BE values fell within the predefined ± less than 2 BE units, whereas the 95% LOA were again more than twice as wide, at -4.4 to 3.9 BE units. Correlations between ABG and VBG were strong, at r(2) = 0.70 for pH and 0.75 for BE. CONCLUSION Although VBG results do correlate well with ABG results, only 72% to 80% of paired samples are clinically equivalent, and the 95% LOAs are unacceptably wide. Therefore, ABG samples should be obtained in acutely ill trauma patients if accurate acid-base status is required.

Electronic health record solutions to reduce central line-associated bloodstream infections by enhancing documentation of central line insertion practices, line days, and daily line necessity

BACKGROUND Central line-associated bloodstream infections (CLABSIs) continue to cause preventable morbidity and mortality, but methods for tracking and ensuring consistency of CLABSI-prevention activities remain underdeveloped. METHODS We created an integrated electronic health record solution to prompt sterile central venous catheter (CVC) insertion, CVC tracking, and timely line removal. The system embedded central line insertion practices (CLIP) elements in inserter procedure notes, captured line days and new lines, matching each with its CLIP form and feeding back compliance, and enforced daily documentation of line necessity in physician progress notes. We examined changes in CLIP compliance and form submission, number of new line insertions captured, and necessary documentation. RESULTS Standard reporting of CLIP compliance, which measures compliance per CLIP form received, artificially inflated CLIP compliance relative to compliance measured using CVC placements as the denominator; for example, 99% per CLIP form versus 55% per CVC placement. This system established a higher threshold for CLIP compliance using this denominator. Identification of CVCs increased 35%, resulting in a decrease in CLABSI rates. The system also facilitated full compliance with daily documentation of line necessity. CONCLUSIONS Integrated electronic health records systems can help realize the full benefit of CLABSI prevention strategies by promoting, tracking, and raising the standard for best practices behavior.

Positive Cerebrospinal Fluid Cultures After Normal Cell Counts Are Contaminants

Previous literature on meningitis reports that cerebrospinal fluid (CSF) culture contaminants are threefold more common than true pathogens. Clinical follow-up of patients with CSF contaminants is costly, time-consuming, and potentially unnecessary. In this study, we hypothesized that, in immunocompetent Emergency Department (ED) patients with normal CSF cell counts and negative Gram stains, all positive bacterial cultures are contaminants and patient follow-up is unnecessary. We retrospectively reviewed 191 ED charts of patients with positive CSF cultures over 5 years. We abstracted lumbar puncture results, disposition, and follow-up activities, and determined monetary charges. There were 137 patients (72%) who met inclusion criteria with CSF white blood cells < or = 7 microL, negative Gram stain, and immunocompetence. Ninety-eight were discharged from the ED and 39 were admitted to the hospital for reasons other than meningitis. All 137 positive cultures were found to be contaminants, with coagulase-negative staphylococci found most commonly. Follow-up activities included telephone calls (49%), repeat ED visits (13%), repeat lumbar punctures (9%), unnecessary antibiotic treatment (6%), and hospitalizations (6%), generating

An unusual presentation of subfrontal meningioma: A case report and literature review for Foster Kennedy syndrome

55,000 in charges. Follow-up may be unnecessary in ED patients with positive bacterial CSF cultures who were discharged from the ED, if their initial lumbar punctures were normal.

Reductions in Clostridium difficile Infection (CDI) Rates Using Real-Time Automated Clinical Criteria Verification to Enforce Appropriate Testing

Intern Emerg Med (2011) 6:267–269 DOI 10.1007/s11739-010-0437-y CE - MEDICAL ILLUSTRATION An unusual presentation of subfrontal meningioma: a case report and literature review for Foster Kennedy syndrome Shahram Lotfipour • Kris Chiles • J. Akiva Kahn Tareg Bey • Scott Rudkin Received: 17 December 2009 / Accepted: 13 July 2010 / Published online: 26 August 2010 O SIMI 2010 Introduction Foster Kennedy syndrome, named after neurologist Robert Foster Kennedy (1884–1952), describes unilateral ipsilat- eral optic atrophy and contralateral papilledema from an intracranial mass. This syndrome is unreliably associated with anosmia and ipsilateral proptosis [1]. It originates from variety of intracranial pathologies, but most often a subfrontal mass. We present a case of Foster Kennedy syndrome and review its etiology, pathology and incidence in intracranial tumors. Case report A 47-year-old woman was brought in by her family to the Emergency Department (ED) for psychiatric care. The patient had been homeless for 17 years prior to the visit, but had recently been taken in by her family, and brought in for evaluation of her personality changes. She denied any recent S. Lotfipour T. Bey S. Rudkin Irvine School of Medicine, University of California, Orange, USA K. Chiles Highland General Hospital, Oakland, USA J. A. Kahn Thomas Jefferson University, Philadelphia, USA S. Lotfipour (&) Department of Emergency Medicine and Public Health, Clinical Science Education, University of California, Irvine School of Medicine, 200 S. Manchester Avenue, Suite 710, Orange, CA 92868, USA e-mail: SHL@uci.edu head trauma. She admitted to abusing crack cocaine for 13 years with her last use 4 months ago. She denied any trouble with ambulation, dizziness, and changes in hearing or other alterations in sensation. She denied any suicidal or homicidal ideation. The patient denied any auditory halluci- nations, but did report that she had been experiencing visual hallucinations and visual disturbances for at least 6–8 months. She reported complete blindness in the left eye, and shadow perception in her right for an unknown length of time. Her past medical history was notable for major depression. The patient did not have a previous history of hallucinations or psychosis, and had never been hospitalized for psychiatric reasons. The patient was not on any medica- tions, and was allergic to penicillin and codeine. The gyne- cologic, surgical and family histories were noncontributory. Initial vital signs were: temperature 36.9°C, pulse 86 beats/min, blood pressure 95/63 mm/Hg, respiratory rate 16 breaths/min, and oxygen saturation 100% on room air. On physical examination, the patient was alert and oriented to person, place and time. Her left pupil was nonreactive to direct light with a normal consensual light response and inability to count fingers with either eye. Extraocular movements were intact and cranial nerves IV through XII were normal. Further evaluation revealed she had anosmia, left optic nerve atrophy and right papilledema. Laboratory studies were normal and urine toxicology was negative. Per hospital protocol initially a non-contrast computed tomography (CT) of the head revealed a large homogenous mass in the anterior cranial fossa (Fig. 1) measuring 8.0 9 6.1 cm. The mass had a calcified rim, and had eroded into the ethmoid sinus and bilateral orbits. A magnetic resonance imaging (MRI) confirmed the diagnosis of a subfrontal meningioma (Fig. 2). The patient was started on phenytoin for seizure pro- phylaxis and dexamethasone to reduce cerebral edema. She

A Comparison of Urolithiasis in the Presence and Absence of Microscopic Hematuria in the Emergency Department

C. difficile PCR testing identifies both colonized and infected patients, making it critical to only test patients that meet clinical criteria for C. difficile infection (CDI). We implemented an automated order-entry protocol that reduced inappropriate testing by 64% and hospital-onset (HO) CDI Standardized Infection Ratio (SIR) from 1.62 to 0.82.