Tiffany Murano

Early identification of dying trajectories in emergency department patients: potential impact on hospital care.

Emergency departments (EDs) provide care for many patients with an advanced, life-limiting illness. The ED clinical focus is on resuscitation and stabilization and suits the needs of the acutely ill and injured. However, this approach may not be concordant to patient goals-of-care in the seriously ill with chronic, severe end-stage, life-limiting disease. Initial ED management sets the trajectory for inpatient disposition/care, prompting palliative care (PC) leaders to recommend early patient-centered ED goal setting. Challenges include a lack of buy-in from ED clinicians and a hectic ED environment with competing demands. However, a onesize-fits-all approach to ED care is not optimal in the terminally ill. A simple approach to prognostication may serve as a trigger for goals-of-care considerations (or palliative team consults). To our knowledge, no study addresses early ED prognostication and impact on subsequent care provision and palliative outcomes. Lunney and colleagues define functional trajectories based on disease diagnosis/ progression/functional decline to serve as a prognostic guideline so patients/clinician can prepare for subsequent care and death. In this study we retrospectively classify patients that presented to the ED and subsequently died following hospital admission into such dying trajectories. The purpose was to compare subsequent inpatient care provision and related outcomes between those trajectory groups.

What Does Remediation and Probation Status Mean? A Survey of Emergency Medicine Residency Program Directors

OBJECTIVES Emergency medicine (EM) residency program directors (PDs) nationwide place residents on remediation and probation. However, the Accreditation Council for Graduate Medical Education and the EM PDs have not defined these terms, and individual institutions must set guidelines defining a change in resident status from good standing to remediation or probation. The primary objective of this study was to determine if EM PDs follow a common process to guide actions when residents are placed on remediation and probation. METHODS An anonymous electronic survey was distributed to EM PDs via e-mail using SurveyMonkey to determine the current practice followed after residents are placed on remediation or probation. The survey queried four designations: informal remediation, formal remediation, informal probation, and formal probation. These designations were compared for deficits in the domains of medical knowledge (MK) and non-MK remediation. The survey asked what process for designation exists and what actions are triggered, specifically if documentation is placed in a residents file, if the graduate medical education (GME) office is notified, if faculty are informed, or if resident privileges are limited. Descriptive data are reported. RESULTS Eighty-one of 160 PDs responded. An official policy on remediation and/or probation was reported by 41 (50.6%) programs. The status of informal remediation is used by 73 (90.1%), 80 (98.8%) have formal remediation, 40 (49.4%) have informal probation, and 79 (97.5%) have formal probation. There was great variation among PDs in the management and definition of remediation and probation. Between 81 and 86% of programs place an official letter into the residents file regarding formal remediation and probation. However, only about 50% notify the GME office when a resident is placed on formal remediation. There were no statistical differences between MK and non-MK remediation practices. CONCLUSIONS There is significant variation among EM programs regarding the process of remediation and probation. The definition of these terms and the actions triggered are variable across programs. Based on these findings, suggestions toward a standardized approach for remediation and probation in GME programs are provided.

Development and use of mobile containment units for the evaluation and treatment of potential Ebola virus disease patients in a United States hospital.

Ebola virus disease (EVD) has been the subject of recent attention due to the current outbreak in West Africa, as well as the appearance of a number of cases within the United States. The presence of EVD patients in the United States required health care systems to prepare for the identification and management of both patients under investigation and patients with confirmed EVD infection. This article discusses the development and use of a mobile containment unit in an extended treatment area as a novel approach to isolation and screening of potential EVD patients.

LIDOCAINE-INDUCED CARDIAC ARREST IN THE EMERGENCY DEPARTMENT: EFFECTIVENESS OF LIPID THERAPY

BACKGROUND Local anesthetics are commonly used in the emergency department (ED). Overdoses can lead to disastrous complications including cardiac toxicity and arrest. Recognition of local anesthetic systemic toxicity (LAST) is important; however, prevention is even more critical. Knowledge of proper lidocaine dosage can prevent LAST. LAST may be effectively treated with lipid emulsion therapy. Although the mechanism is not well understood, its use may have a profound impact on morbidity and mortality. CASE REPORT Fifty milliliters of 2% lidocaine was infiltrated for local anesthesia in a 35-year-old woman during the incision and drainage of a labial abscess. Following the procedure, the patient complained of vomiting, with rapid progression to an altered mental state and seizure requiring endotracheal intubation for airway protection. Suspecting lidocaine toxicity, intralipids were ordered. While waiting for the intralipids, the patient decompensated and suffered pulseless electrical activity (PEA) cardiac arrest. A 100-mL bolus of 20% intralipids was administered 3 minutes into the resuscitation, after which return of spontaneous circulation occurred. The intralipid bolus was then followed by a continuous infusion of 0.25 mL/kg/minute, for an infusion dose of 930 mL. Despite a complicated hospital course, the patient was discharged home neurologically intact. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We believe this patients cardiovascular collapse was secondary to an iatrogenic overdose of lidocaine. This is one of the first cases to support the efficacy of intravenous lipids in the treatment of LAST in humans in the ED.

What is the prevalence and success of remediation of emergency medicine residents

Introduction The primary objective of this study was to determine the prevalence of remediation, competency domains for remediation, the length, and success rates of remediation in emergency medicine (EM). Methods We developed the survey in Surveymonkey™ with attention to content and response process validity. EM program directors responded how many residents had been placed on remediation in the last three years. Details regarding the remediation were collected including indication, length and success. We reported descriptive data and estimated a multinomial logistic regression model. Results We obtained 126/158 responses (79.7%). Ninety percent of programs had at least one resident on remediation in the last three years. The prevalence of remediation was 4.4%. Indications for remediation ranged from difficulties with one core competency to all six competencies (mean 1.9). The most common were medical knowledge (MK) (63.1% of residents), patient care (46.6%) and professionalism (31.5%). Mean length of remediation was eight months (range 1–36 months). Successful remediation was 59.9% of remediated residents; 31.3% reported ongoing remediation. In 8.7%, remediation was deemed “unsuccessful.” Training year at time of identification for remediation (post-graduate year [PGY] 1), longer time spent in remediation, and concerns with practice-based learning (PBLI) and professionalism were found to have statistically significant association with unsuccessful remediation. Conclusion Remediation in EM residencies is common, with the most common areas being MK and patient care. The majority of residents are successfully remediated. PGY level, length of time spent in remediation, and the remediation of the competencies of PBLI and professionalism were associated with unsuccessful remediation.

Usefulness of the Mortality in Severe Sepsis in the Emergency Department score in an urban tertiary care hospital

BACKGROUND The Mortality in Severe Sepsis in the Emergency Department (MISSED) score is a newly proposed scoring system. The goal of this study is to determine if the MISSED score is generalizable to an urban tertiary care hospital. METHODS This is a retrospective chart review conducted from July 2012 to June 2014. Inclusion criteria consisted of adult emergency department (ED) patients with severe sepsis, defined as lactate level 4mmol/L or greater. Demographics, lactate, international normalized ratio (INR), albumin, intensive care unit admission, and ED intubation were analyzed using χ(2) test, t test, and logistic regression. The MISSED score was calculated using the variables albumin 27g/L or less, INR 1.3 or greater, and age 65years or older and analyzed using the area under the curve. The primary outcome was inhospital mortality. RESULTS A total of 182 patients met inclusion criteria, and mortality was 32%. Patients in the mortality group had older age (58.1±17.2 vs 62.7±14.7; P=.07), higher lactate (5.9±2.7 vs 7.3±3.1; P<.01), lower albumin (34.3±8.3 vs 25.6±7.1; P<.0001), higher INR (1.4±0.6 vs 2.4±1.9; P<.0001), ED intubation (21% vs 56%; P<.0001), and intensive care unit admission (41% vs 78%; P<.0001). The regression model found that albumin of 27g/L or less (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.05-3.36), INR 1.3 or greater (OR, 8.3; 95% CI, 3.35-20.51), and ED intubation (OR, 5.6; 95% CI, 2.56-12.35) predicted mortality. The area under the curve for the MISSED score was 0.78 (95% CI, 0.73-0.85). CONCLUSION The MISSED score is useful for predicting mortality in ED patients with severe sepsis.

Case Report: Emergency Department Diagnosis of Melorheostosis in the Upper Extremity: A Rare Disease with an Unusual Presentation

BACKGROUND Melorheostosis is a rare disease that affects fewer than 1:1,000,000 persons worldwide and most typically affects the lower extremities. It is a non-hereditary disease that may be debilitating due to chronic pain, contractures of the soft tissue, and even shortening of the affected limbs. Although it most commonly occurs in the lower extremities, melorheostosis has been reported in various locations throughout the body. OBJECTIVE This case report describes a patient who presented to the Emergency Department (ED) with this rare disease in an uncommonly affected bone. CASE REPORT The patient was a 21-year-old man who presented to the ED with pain in his left upper extremity that he attributed to playing sports 3 days before presentation. Plain films revealed periosteal hyperostosis typical of melorheostosis in several of his carpals, metacarpals, and phalanges, as well as the humerus and ulna. The patient was discharged with orthopedic follow-up and pain medication. CONCLUSION Melorheostosis is a rare disease that has characteristic radiographic findings likened to the appearance of melting wax flowing down the side of a candle. In certain cases, the disease can be debilitating and may require chronic pain management and even operative intervention. If this diagnosis is made in the ED, the emergency physician should provide adequate pain management and refer the patient to an orthopedic specialist for a work-up to rule out other sclerosing bone dysplasias.

Defining uniform processes for remediation, probation, and termination in residency training

It is important that residency programs identify trainees who progress appropriately, as well as identify residents who fail to achieve educational milestones as expected so they may be remediated. The process of remediation varies greatly across training programs, due in part to the lack of standardized definitions for good standing, remediation, probation, and termination. The purpose of this educational advancement is to propose a clear remediation framework including definitions, management processes, documentation expectations and appropriate notifications. Informal remediation is initiated when a resident’s performance is deficient in one or more of the outcomes-based milestones established by the Accreditation Council for Graduate Medical Education, but not significant enough to trigger formal remediation. Formal remediation occurs when deficiencies are significant enough to warrant formal documentation because informal remediation failed or because issues are substantial. The process includes documentation in the resident’s file and notification of the graduate medical education office; however, the documentation is not disclosed if the resident successfully remediates. Probation is initiated when a resident is unsuccessful in meeting the terms of formal remediation or if initial problems are significant enough to warrant immediate probation. The process is similar to formal remediation but also includes documentation extending to the final verification of training and employment letters. Termination involves other stakeholders and occurs when a resident is unsuccessful in meeting the terms of probation or if initial problems are significant enough to warrant immediate termination.

PATTERN OF EMS CALLS FOR ASSAULTS IN AN URBAN ENVIRONMENT

Objective: To prospectively validate the ability of EMS dispatch codes to identify patients with low-acuity illnesses, using patient need for only basic life support (BLS) care as a proxy for low illness acuity. Methods: This prospective cohort study was conducted in an urban city with a single advanced life support (ALS) level EMS provider. The 911 center was certified in using EMS dispatch protocols from Priority Medical Dispatch. Patients were included if they requested emergency assistance between July 2002 and June 2003 and they were assigned one of 28 previously derived low acuity EMS dispatch codes. Dispatch data, level of care actually provided, and disposition were obtained for each patient. For each low-acuity dispatch code, we used descriptive statistics to calculate the fraction of patients who received only BLS level care and the 95% confidence interval. We prospectively defined a low-acuity patient as an individual who received only BLS level care. Results: EMS cared for 30,806 patients during the study period. 11,334 (36.5%) met inclusion criteria and 10,782 (95.1%) received BLS care. 22 of the 28 codes resulted in low-acuity care at least 90% of the time. The performance of selected low-acuity diagnoses include: abdominal pain (EMS dispatch code: 1A) 97.5% BLS, 95% CI: 96.3%–98.4%; assault (4A) 98.4% BLS, 95% CI: 95.5%– 99.7%; back pain (5A) 97.6% BLS, 95% CI: 95.7%–98.8%, falls (17A) 92.6% BLS, 95% CI: 90.6%–94.4%, eye problems (16A) 100% BLS, 95% CI: 97.6%–100%; headache (18A) 95% BLS, 95% CI: 90%–98%; traumatic injuries (21A, 30A, 30B1) 95.7% BLS, 95% CI: 94.3%–96.8%, abnormal behavior/suicide attempt (25A, 25B) 97.7% BLS, 95% CI: 97.1%–98.2%, pregnancy/miscarriage (24A, B, D) 92.7% BLS, 95% CI: 90.8%–92.3%; and general illness (26A) 94.4% BLS, 95% CI: 93.4%–95.3%. Conclusions: This validation study confirms that most of the previously derived EMS dispatch codes do accurately identify patients who primarily require BLS level prehospital care, a proxy for low-acuity patients. These lowacuity codes can be used to triage EMS responses and EMS patients based upon dispatch information when using the Priority Medical Dispatch protocols and a certified 911 call center.