Sukhjit S. Takhar

Diagnosis and Management of Urinary Tract Infection and Pyelonephritis

Urinary tract infections (UTIs) are the most common bacterial infections treated in the outpatient setting and range in severity from minimally symptomatic cystitis to severe septic shock in a wide array of patients. Diagnosis of uncomplicated cystitis can be inferred from history and physical, and confirmed by urinalysis. Appropriate antimicrobial therapy should rapidly improve symptoms in all UTIs. Treatment can be further tailored according to severity of illness, analysis of individualized risk factors, and antimicrobial resistance patterns. This article discusses treatment options in light of bacterial resistance in the twenty-first century.

Fluoroquinolone-Resistant and Extended-Spectrum beta-Lactamase Producing Escherichia coli Infections in Patients with Pyelonephritis, United States

Prevalence of fluoroquinolone resistance now exceeds treatment guideline thresholds for alternative antimicrobial drug strategies.

Inability of Polymerase Chain Reaction, Pyrosequencing, and Culture of Infected and Uninfected Site Skin Biopsy Specimens to Identify the Cause of Cellulitis

BACKGROUND The cause of cellulitis is unclear. Streptococcus pyogenes, and to a lesser extent, Staphylococcus aureus, are presumed pathogens. METHODS We conducted a study of adults with acute cellulitis without drainage presenting to a US emergency department research network. Skin biopsy specimens were taken from the infected site and a comparable uninfected site on the opposite side of the body. Microbiology was evaluated using quantitative polymerase chain reaction (PCR), pyrosequencing, and standard culture techniques. To determine the cause, the prevalence and quantity of bacterial species at the infected and uninfected sites were compared. RESULTS Among 50 subjects with biopsy specimens from infected and uninfected sites, culture rarely identified a bacterium. Among 49 subjects with paired specimens from infected and uninfected sites tested with PCR, methicillin-susceptible S. aureus was identified in 20 (41%) and 17 (34%), respectively. Pyrosequencing identified abundant atypical bacteria in addition to streptococci and staphylococci. Among 49 subjects with paired specimens tested by pyrosequencing, S. aureus was identified from 11 (22%) and 15 (31%) and streptococci from 15 (31%) and 20 (41%) of the specimens, respectively. Methicillin-resistant S. aureus was not found by culture or PCR, and S. pyogenes was not identified by any technique. CONCLUSIONS The bacterial cause of cellulitis cannot be determined by comparing the prevalence and quantity of pathogens from infected and uninfected skin biopsy specimens using current molecular techniques. Methicillin-susceptible S. aureus was detected but not methicillin-resistant S. aureus or S. pyogenes from cellulitis tissue specimens. For now, optimal treatment will need to be guided by clinical trials. Noninfectious causes should also be explored.

Usability of the Massachusetts Prescription Drug Monitoring Program in the Emergency Department: A Mixed-methods Study.

OBJECTIVES Prescription drug monitoring programs (PDMPs) are underutilized, despite evidence showing that they may reduce the epidemic of opioid-related addiction, diversion, and overdose. We evaluated the usability of the Massachusetts (MA) PDMP by emergency medicine providers (EPs), as a systems usability may affect how often it is used. METHODS This was a mixed-methods study of 17 EPs. We compared the time and number of clicks required to review one patients record in the PDMP to three other commonly performed computer-based tasks in the emergency department (ED: ordering a computed tomography [CT] scan, writing a prescription, and searching a medication history service integrated within the electronic medical record [EMR]). We performed semistructured interviews and analyzed participant comments and responses regarding their experience using the MA PDMP. RESULTS The PDMP task took a longer time to complete (mean = 4.22 minutes) and greater number of mouse clicks to complete (mean = 50.3 clicks) than the three other tasks (CT-pulmonary embolism = 1.42 minutes, 24.8 clicks; prescription = 1.30 minutes, 19.5 clicks; SureScripts = 1.45 minutes, 9.5 clicks). Qualitative analysis yielded four main themes about PDMP usability, three negative and one positive: 1) difficulty accessing the PDMP, 2) cumbersome acquiring patient medication history information within the PDMP, 3) nonintuitive display of patient medication history information within the PDMP, and 4) overall perceived value of the PDMP despite an inefficient interface. CONCLUSIONS The complicated processes of gaining access to, logging in, and using the MA PDMP are barriers to preventing its more frequent use. All states should evaluate the PDMP usability in multiple practice settings including the ED and work to improve provider enrollment, login procedures, patient information input, prescription data display, and ultimately, PDMP data integration into EMRs.

Diagnosis and management of urinary tract infection in the emergency department and outpatient settings.

Emergency physicians encounter urinary tract infections (UTIs) in a wide spectrum of disease severity and patient populations. The challenges of managing UTIs in an emergency department include limited history, lack of follow-up, and lack of culture and susceptibility results. Most patients do not require an extensive diagnostic evaluation and can be safely managed as outpatients with oral antibiotics. The diagnostic approach to and treatment of adults presenting to emergency departments with UTIs are reviewed.

U.S. Emergency Department Visits for Meningitis, 1993–2008

OBJECTIVES Large-scale epidemiologic studies of meningitis in the emergency department (ED) setting are lacking. Using a nationwide sample, the authors determined the frequency of meningitis visits and characterize management. METHODS Using National Hospital Ambulatory Medical Care Survey (NHAMCS) data, 1993 through 2008, meningitis diagnoses were studied and national rates were estimated via standard weighting procedures. RESULTS Meningitis was diagnosed at 1,048,000 visits (95% confidence interval [CI] = 893,000 to 1,203,000) during 1993 through 2008. This is 66,000 cases annually, or 62 per 100,000 visits, with no change over time (p = 0.20). ED diagnoses were unspecified (60%), viral (31%), bacterial (8%), and fungal (1%) meningitis. Median age was 24 years (interquartile range = 9 to 40 years). While 1.97 times as many adults were diagnosed with meningitis (95% CI = 1.83 to 2.13), meningitis accounted for a similar proportion of visits among children and adults (ratio = 1.33, 95% CI = 0.58 to 2.63). Per population, children were more likely to have a meningitis visit (31 vs. 21 per 100,000; ratio = 1.48, 95% CI =1.003 to 2.10); children aged younger than 3 years had the highest rate (98 per 100,000, 95% CI =63 to 133). Spring and summer visits were 1.25 times as numerous as fall a nd winter (95% CI= 1.15 to 1.36). Third-generation cephalosporins were administered in 42%, analgesics in 19%, and antiemetics in 15% of cases, and 66% were admitted to the hospital (95% CI= 58% to 73%). CONCLUSIONS Meningitis is rare, diagnosed at 62 per 100,000 ED visits. Rates have been stable over time. Children are 1.48 times more likely to have a visit for meningitis, although adults make twice as many visits. Absence of consensus guidelines for patients suspected of having viral meningitis but being tested for bacterial meningitis may lead to variability in admission and prescribing decisions.

The hazard of software updates to clinical workstations: a natural experiment

Emergency department (ED) electronic tracking boards provide a snapshot view of patient status and a quick link to other clinical applications, such as a web-based image viewer client to view current and previous radiology images from the picture archiving and communication systems (PACS). We describe a case where an update to Microsoft Internet Explorer severed the link between the ED tracking board and web-based image viewer. The loss of this link resulted in decreased web-based image viewer access rates for ED patients during the 10 days of the incident (2.8 views/study) compared with image review rates for a similar 10-day period preceding this event (3.8 views/study, p<0.001). Single-click user interfaces that transfer user and patient contexts are efficient mechanisms to link disparate clinical systems. Maintaining hazard analyses and rigorously testing all software updates to clinical workstations, including seemingly minor web-browser updates, are important to minimize the risk of unintended consequences.

Efficiency and Usability of a Near Field Communication-Enabled Tablet for Medication Administration

Background Barcode-based technology coupled with the electronic medication administration record (e-MAR) reduces medication errors and potential adverse drug events (ADEs). However, many current barcode-enabled medication administration (BCMA) systems are difficult to maneuver and often require multiple barcode scans. We developed a prototype, next generation near field communication-enabled medication administration (NFCMA) system using a tablet. Objective We compared the efficiency and usability of the prototype NFCMA system with the traditional BCMA system. Methods We used a mixed-methods design using a randomized observational cross-over study, a survey, and one-on-one interviews to compare the prototype NFCMA system with a traditional BCMA system. The study took place at an academic medical simulation center. Twenty nurses with BCMA experience participated in two simulated patient medication administration scenarios: one using the BCMA system, and the other using the prototype NFCMA system. We collected overall scenario completion time and number of medication scanning attempts per scenario, and compared those using paired t tests. We also collected participant feedback on the prototype NFCMA system using the modified International Business Machines (IBM) Post-Study System Usability Questionnaire (PSSUQ) and a semistructured interview. We performed descriptive statistics on participant characteristics and responses to the IBM PSSUQ. Interview data was analyzed using content analysis with a qualitative description approach to review and categorize feedback from participants. Results Mean total time to complete the scenarios using the NFCMA and the BCMA systems was 202 seconds and 182 seconds, respectively (P=.09). Mean scan attempts with the NFCMA was 7.6 attempts compared with 6.5 attempts with the BCMA system (P=.12). In the usability survey, 95% (19/20) of participants agreed that the prototype NFCMA system was easy to use and easy to learn, with a pleasant interface. Participants expressed interest in using the NFCMA tablet in the hospital; suggestions focused on implementation issues, such as storage of the mobile devices and infection control methods. Conclusions The NFCMA system had similar efficiency to the BCMA system in a simulated scenario. The prototype NFCMA system was well received by nurses and offers promise to improve nurse medication administration efficiency.

Forearm ultrasound-guided nerve blocks vs landmark-based wrist blocks for hand anesthesia in healthy volunteers.

OBJECTIVE Although ultrasound-guided regional nerve blocks have become more commonplace in the emergency department, there is no evidence to suggest that they are more effective than traditional landmark-based wrist blocks for hand anesthesia. We hypothesized that ultrasound-guided forearm nerve blocks would provide superior analgesia as compared with conventional landmark-based wrist blocks. METHODS Eighteen paired nerve injections were performed by an experienced operator on 12 healthy volunteers. Each subjects right arm was assigned to receive either an ultrasound-guided forearm block with a saline placebo wrist block or a traditional landmark-based wrist block with a saline placebo ultrasound-guided forearm block. The subjects left arm then received the alternate approach. All blocks were performed with 3 mL of 1% lidocaine. We evaluated sensory block to pinprick. Secondary outcome variables included pain associated with injection, participants subjective assessment of block effectiveness, and presence of any complications. RESULTS At 15 minutes postinjection, 14 of 18 (78%; 95% confidence interval [CI], 59%-97%) ultrasound-guided forearm blocks were successful, as opposed to 10 of 18 (56%; 95% CI, 33%-79%) anatomic wrist blocks. The ultrasound-guided forearm blocks had a 22% (95% CI, 2%-42%; P=.032) higher rate of success than the wrist blocks. The ultrasound-guided forearm block was subjectively felt to be denser by 12 of 18 (67%) subjects (P=.0034)). CONCLUSIONS Ultrasound-guided forearm nerve blocks performed by an experienced operator result in more effective hand anesthesia than traditional anatomic landmark-based wrist blocks.

Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure: A Quasi-Experimental Study

OBJECTIVE To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19). METHODS We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated. RESULTS The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 - 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% - 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% - 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats. CONCLUSION With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure.