Theodore I. Benzer

Implementation of a point-of-care satellite laboratory in the emergency department of an academic medical center. Impact on test turnaround time and patient emergency department length of stay.

CONTEXT Emergency department (ED) overcrowding has reached crisis proportions in the United States. Many hospitals are seeking to identify process reengineering efforts to reduce crowding and ED patient length of stay (LOS). OBJECTIVES To investigate the impact of a point-of-care testing (POCT) satellite laboratory in the ED of a large academic medical center. SETTING The ED of the Massachusetts General Hospital, Boston, Mass. DESIGN AND OUTCOME MEASURES Evaluation of physician satisfaction, turnaround time (TAT), and ED LOS before and after implementation of a POCT laboratory. ED LOS was measured by patient chart audits. TAT was assessed by manual and computer audits. Clinician satisfaction surveys measured satisfaction with test TAT and test accuracy. RESULTS Blood glucose, urine human chorionic gonadotropin, urine dipstick, creatine kinase-MB, and troponin tests were performed in the ED POCT laboratory. Test TAT declined an average of 87% after the institution of POCT. The ED LOS decreased for patients who received pregnancy testing, urine dipstick, and cardiac markers. Although these differences were not significant for individual tests, when the tests were combined, the decreased LOS was, on average, 41.3 minutes (P =.006). Clinician satisfaction surveys documented equivalent satisfaction with test accuracy between the central laboratory and the POCT laboratory. These surveys also documented dissatisfaction with central laboratory TAT and increased satisfaction with TAT of the POCT program (P <.001). CONCLUSIONS The POCT satellite laboratory decreased test TAT and decreased ED LOS. There was excellent satisfaction with test accuracy and TAT.

Solubilization and partial characterization of the tetrodotoxin binding component from nerve axons

Abstract The tetrodotoxin binding component from garfish olfactory nerve membranes has been solubilized using the nonionic detergent Triton X-100. Tetrodotoxin binds to the solubilized component with a dissociation constant KD = 2.5 × 10−9 M and under saturating conditions 1.95 × 10−12 moles of tetrodotoxin are bound per milligram of solubilized protein. Upon solubilization the toxin binding component becomes much less stable towards heat, chemical modification and enzymatic degradation. Sucrose gradient velocity sedimentation yields an S value of 9.2 for the extracted binding component and from gel filtration data the binding component appears to be slightly larger than β-D-galactosidase.

Change in physician knowledge and attitudes after implementation of a pneumonia practice guideline.

OBJECTIVE: To assess physicians’ response to implementation of an emergency department (ED) pneumonia practice guideline and determine if the guideline changed physicians’ knowledge and attitudes about pneumonia care.DESIGN: Prospective intervention study with cross-sectional and longitudinal physician surveys.SETTING: An urban, university teaching hospital ED.PARTICIPANTS: One hundred forty physicians who were responsible for the triage of at least one of 166 patients presenting to the ED with community-acquired pneumonia.MEASUREMENTS: Physician characteristics, attitudes about pneumonia care and guidelines, and ratings of guideline helpfulness and effects on patient care were obtained by self administered questionnaire before, during, and after a yearlong intervention.MAIN RESULTS: More than 73% of the physicians reported the guideline as helpful and more than 94% wanted it to be continued in the future. Most reported that the guideline would decrease costs and improve quality without any increase in adverse outcomes. Two thirds said they were more likely to treat patients with pneumonia as outpatients in the future because of the guideline. Among the 58 physicians with matching preintervention and postintervention survey data, the guideline decreased the beliefs that “all patients >65 years old with pneumonia should be admitted,” from 52% to 14% (p<.001), and that “patients with pneumonia have a >15% mortality rate,” from 11% to 5% (p<.007). The intervention did not significantly change general attitudes about practice guidelines. House officers rated the guideline as more helpful than attending physicians (p<.02).CONCLUSIONS: This locally developed, actively implemented guideline was well regarded by physicians. Guidelines can change practice and also alter underlying knowledge and attitudes about disease management. They may be most useful to those with less experience.

Implementation of point-of-care rapid urine testing for drugs of abuse in the emergency department of an academic medical center: impact on test utilization and ED length of stay.

We evaluated the impact of implementing a point-of-care (POC) rapid urine test panel for drugs of abuse on turnaround time (TAT), emergency department length of stay (LOS), and laboratory test utilization patterns. The mean TAT from sample collection to results reporting decreased by 69.4%, from 108 to 33 minutes, the mean LOS from 11.1 to 8.1 hours (27% P < .0001), and the median LOS from 8.0 to 7.0 hours (13% P = .0017). A method crossover between the POC and central laboratory methods revealed differences in sensitivity and specificity. Overall, there was no clear preference for either method. Differences in performance for individual drug classes were reconciled by providing interpretive comments with POC results. Following implementation, use of urine testing for drugs of abuse increased by 30%, which was offset by fewer requests for extended toxicology testing in the central laboratory and more selective ordering of toxicology tests not on the POC panel (alcohols and analgesics). The implementation of a POC urine test panel for drugs of abuse decreased LOS and TAT and essentially replaced central laboratory testing for drugs of abuse. Differences in sensitivity and specificity between POC and central laboratory results require provision of interpretive comments with results.

Comparison of conventional guaiac to four immunochemical methods for fecal occult blood testing: Implications for clinical practice in hospital and outpatient settings

BACKGROUND Fecal occult blood testing (FOBT) is one method to screen for colorectal cancer and to assess for gastrointestinal bleeding in hospitalized patients. Differences in the analytical sensitivity among various methods may have significant clinical repercussions. METHODS We evaluated the analytical performance of 5 different FOBT methods (standard guaiac-based method and four immunochemical methods) using patient samples and spiked stool specimens. RESULTS The analytical sensitivity measured using spiked stool samples varied from <8 to 1500 ug hemoglobin/gram of stool. In some cases the results differed significantly from the manufacturers reported analytical sensitivity. Analysis of 71 stool samples measured by all 5 methods showed a discrepant result in 31 cases (43.7%). The rate of positive samples varied by method from 8.5% to 42.2%. CONCLUSIONS These results demonstrate significant differences in the analytical performance among FOBT methods. Careful method validation and selection of a method with appropriate sensitivity is essential when choosing an FOBT method for colorectal cancer screening or for the assessment of gastrointestinal bleeding in the emergency department and hospital inpatients.

Use of Imaging in the Emergency Department: Physicians Have Limited Effect on Variation

PURPOSE To quantify interphysician variation in imaging use during emergency department (ED) visits and examine the contribution of factors to this variation at the patient, visit, and physician level. MATERIALS AND METHODS This study was HIPAA compliant and approved by the institutional review board of Partners Healthcare System (Boston, Mass), with waiver of informed consent. In this retrospective study of 88 851 consecutive ED visits during 2011 at a large urban teaching hospital, a hierarchical logistic regression model was used to identify multiple predictors for the probability that low- or high-cost imaging would be ordered during a given visit. Physician-specific random effects were estimated to articulate (by odds ratio) and quantify (by intraclass correlation coefficient [ICC]) interphysician variation. RESULTS Patient- and visit-level factors found to be statistically significant predictors of imaging use included measures of ED busyness, prior ED visit, referral source to the ED, and ED arrival mode. Physician-level factors (eg, sex, years since graduation, annual workload, and residency training) did not correlate with imaging use. The remaining amount of interphysician variation was very low (ICC, 0.97% for low-cost imaging; ICC, 1.07% for high-cost imaging). These physician-specific odds ratios of imaging estimates were moderately reliable at 0.78 (95% confidence interval [CI]: 0.77, 0.79) for low-cost imaging and 0.76 (95% CI: 0.74, 0.78) for high-cost imaging. CONCLUSION After careful and comprehensive case-mix adjustment by using hierarchical logistic regression, only about 1% of the variability in ED imaging utilization was attributable to physicians.

Case records of the Massachusetts General Hospital. Case 40-2013. A 36-year-old man with agitation and paranoia.

Dr. David P. Curley (Emergency Medicine): A 36-year-old man with a history of alcohol and substance abuse was admitted to this hospital because of severe agitation and paranoia. The patient’s girlfriend reported that the patient had been sober for approximately 20 months, until he lost his job. Three days before admission, he began drinking alcohol and taking “bath salts” (psychoactive drugs) intranasally after having had no sleep and minimal oral intake. The night before admission, increasing agitation developed and was associated with apparent auditory and visual hallucinations that people were trying to harm him. On the morning of admission, shortly after snorting more bath salts, he ran outside unclothed, shouting that someone was trying to strangle him. His girlfriend called the police, who found him running naked in the street. When emergency medical services personnel arrived, they found him restrained by police officers, combative, and confused, with nonsensical, paranoid, and rambling speech. The pulse was 157 beats per minute, with bounding radial pulses, and the respiratory rate was 24 breaths per minute. The pupils were 5 mm in diameter. The skin was flushed, warm, and diaphoretic. A capillary glucose level was 268 mg per deciliter (14.9 mmol per liter). Soft restraints were applied, and oxygen was administered through a nonrebreather face mask. The patient was transported to the emergency department at this hospital. En route, he suddenly became quiet, and a seizure was suspected. The administration of midazolam was attempted, but the patient pulled out the intravenous catheter. On arrival, the patient was unable to communicate. His history was obtained from his girlfriend. He had a history of depression, alcohol abuse, and drug abuse (including heroin, cocaine, and prescription opiates). His only medication was fluox etine, which he reportedly had not taken for 2 weeks. He was allergic to shellfish and had no known allergies to medications. He smoked cigarettes. He lived with his girlfriend and had recently lost his job at a service station. He had a family history of hypertension, coronary artery disease, and diabetes mellitus. On examination, the patient was agitated, f lailing his arms and legs, jerking his head, and making loud incomprehensible sounds. He was unable to cooperate during the examination and required restraining by several security officers. Case 40-2013: A 36-Year-Old Man with Agitation and Paranoia

Case 40-2013

Dr. David P. Curley (Emergency Medicine): A 36-year-old man with a history of alcohol and substance abuse was admitted to this hospital because of severe agitation and paranoia. The patient’s girlfriend reported that the patient had been sober for approximately 20 months, until he lost his job. Three days before admission, he began drinking alcohol and taking “bath salts” (psychoactive drugs) intranasally after having had no sleep and minimal oral intake. The night before admission, increasing agitation developed and was associated with apparent auditory and visual hallucinations that people were trying to harm him. On the morning of admission, shortly after snorting more bath salts, he ran outside unclothed, shouting that someone was trying to strangle him. His girlfriend called the police, who found him running naked in the street. When emergency medical services personnel arrived, they found him restrained by police officers, combative, and confused, with nonsensical, paranoid, and rambling speech. The pulse was 157 beats per minute, with bounding radial pulses, and the respiratory rate was 24 breaths per minute. The pupils were 5 mm in diameter. The skin was flushed, warm, and diaphoretic. A capillary glucose level was 268 mg per deciliter (14.9 mmol per liter). Soft restraints were applied, and oxygen was administered through a nonrebreather face mask. The patient was transported to the emergency department at this hospital. En route, he suddenly became quiet, and a seizure was suspected. The administration of midazolam was attempted, but the patient pulled out the intravenous catheter. On arrival, the patient was unable to communicate. His history was obtained from his girlfriend. He had a history of depression, alcohol abuse, and drug abuse (including heroin, cocaine, and prescription opiates). His only medication was fluox etine, which he reportedly had not taken for 2 weeks. He was allergic to shellfish and had no known allergies to medications. He smoked cigarettes. He lived with his girlfriend and had recently lost his job at a service station. He had a family history of hypertension, coronary artery disease, and diabetes mellitus. On examination, the patient was agitated, f lailing his arms and legs, jerking his head, and making loud incomprehensible sounds. He was unable to cooperate during the examination and required restraining by several security officers. Case 40-2013: A 36-Year-Old Man with Agitation and Paranoia

Appropriateness of Extremity Magnetic Resonance Imaging Examinations in an Academic Emergency Department Observation Unit

Introduction Emergency departments (ED) and hospitals face increasing challenges related to capacity, throughput, and stewardship of limited resources while maintaining high quality. Appropriate utilization of extremity magnetic resonance imaging (MRI) examinations within the emergency setting is not well known. Therefore, this study aimed to determine indications for and appropriateness of MRI of the extremities for musculoskeletal conditions in the ED observation unit (EDOU). Methods We conducted this institutional review board-approved, retrospective study in a large, quaternary care academic center and Level I trauma center. An institutional database was queried retrospectively to identify all adult patients undergoing an extremity MRI while in the EDOU during the two-year study period from October 2013 through September 2015. We compared clinical history with the American College of Radiology (ACR) Appropriateness Criteria® for musculoskeletal indications. The primary outcome was appropriateness of musculoskeletal MRI exams of the extremities; examinations with an ACR Criteria score of seven or higher were deemed appropriate. Secondary measures included MRI utilization and imaging findings. Results During the study period, 22,713 patients were evaluated in the EDOU. Of those patients, 4,409 had at least one MRI performed, and 88 MRIs met inclusion criteria as musculoskeletal extremity examinations (2% of all patients undergoing an MRI exam in the EDOU during the study period). The most common exams were foot (27, 31%); knee (26, 30%); leg/femur (10, 11%); and shoulder (10, 11%). The most common indications were suspected infection (42, 48%) and acute trauma (23, 26%). Fifty-six percent of exams were performed with intravenous contrast; and 83% (73) of all MRIs were deemed appropriate based on ACR Criteria. The most common reason for inappropriate imaging was lack of performance of radiographs prior to MRI. Conclusion The majority of musculoskeletal extremity MRI examinations performed in the EDOU were appropriate based on ACR Appropriateness Criteria. However, the optimal timing and most-appropriate site for performance of many clinically appropriate musculoskeletal extremity MRIs performed in the EDOU remains unclear. Potential deferral to the outpatient setting may be a preferred population health management strategy.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population

OBJECTIVE This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. METHODS Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. RESULTS After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. CONCLUSIONS Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.