Posts (142)

Thu, Oct 12 1:31pm · Social Media Scholarship as a Criterion for Academic Promotion

This is crosspost from the Mayo Clinic Social Media network. Below a video with our webinar on Social Media and Academic Promotion.

Thu, Oct 5 5:27am · Mayo Clinic EM in ACEP 2017

 

Sunday, October 29

3-3:50 p.m.

133 (Infomatics)

Measuring Radio-Frequency Identification Sensitivity and Precision in the Emergency Department: A Method for Clinically Relevant Assessment of Real-Time Location Services

Karalius VP, Nestler DM, Koenig KR, Hawthorne HJ, Hellmich TR, Pasupathy KS, Heaton HA

 

134 (Infomatics)

Characterization of Emergency Department Abandonment Using Real-Time Location System

Pasupathy K, Heaton H, Nestler D, Lovik K, Sadosty A, Finley J, Thompson K, Hellmich T, Sir M, Huschka T, Marisamy G

 

4-4:50 p.m.

137 (Administration/Practice Management)

Optimal Scheduling: Using Technology to Drive a Workload-Based Scheduling Model for Emergency Department Pharmacists

Rudis MI, Wutthisirisart P, Heaton HA, Pasupathy KS, Sir MY, Hellmich TR

 

141 (Administration/Practice Management)

Frequency and Effect of Interruptions on Resident Workload in the Emergency Department

Jones DD, Forsyth KL, Hawthorne HJ, El-Sherif N, Varghese RS, Runkle T, Sunga K,

Hellmich TR, Blocker RC

 

 

Monday, October 30

11-11:50 a.m.

234 (Pain Management)

Safety and Efficacy of Intravenous Lidocaine for Pain Management in the Emergency Department: A Systematic Review and Meta-Analysis

e Silva LOJ, Scherber K, Cabrera D, Motov S, West CP, Murad MH, Bellolio MF

 

12 noon-1 p.m.

EMF 2 (EMF Showcase Luncheon)

The Acute Otitis Media Decision Aid: Pathway to Shared Decisionmaking

Anderson JL, Hess EP, Brito Campana JP, Hargraves IG

 

Tuesday, October 31

10-10:50 a.m.

365 (Ultrasound)

Detecting Pericardial Effusions: Is One View Enough?

Corcoran J, Kane G, Muruganandan M, Liebmann O, Leo M, Nichols M, Kummer T

 

389 (Quality and Patient Safety)

My Visit Board: Improving Patient Understanding of Emergency Department Care

Funk E, Kummer T, Friedrich C, Lohse C, Heaton H

Tue, Sep 26 12:00am · The ED does not hand out opioids like candy

Author: Molly M. Jeffery, PhD @mollyjeffery


Everyone “knows” they hand out opioids like candy in the ED.  Or if they don’t now, they certainly used to.

 

That idea didn’t square with the clinical experience of any of the ED doctors I’ve talked to. We wanted to know what the clinical reality is across the country, so we used the OptumLabs Data Warehouse to look at opioid prescribing for acute pain in the ED and other settings. OLDW has a huge dataset of insurance claims covering millions of people over 20+ years. We looked at data from 2009-2015, focusing on people who were opioid naïve (no opioid fills in the past 6 months) and who did not have cancer and were not in hospice.  We converted all the prescriptions into mg of morphine equivalents (MME) to have a common unit of measure across drugs.

 

We compared the ED to other settings on how often prescriptions aligned with best practices for acute opioid prescribing on days supplied, daily dose, and opioid formulation (long-acting vs. immediate release). Then we followed people to find out whether they continued to use opioids after that initial prescription. (We used the CONSORT definition of chronic opioid use: an episode lasting 90+ calendar days and including either 10 fills or 120+ days supply.)

 

The CDC recommends [https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf]  acute prescriptions should be for less than 7 days supply, but less than 3 days is better.  There is little guidance on the best starting dose, but the CDC recommends that chronic opioid users (who have built up some tolerance) remain below 90 MME, but below 50 MME is safer. Finally, the CDC says opioid treatment should start with immediate release opioids; extended release/long-acting formulations are generally dangerous for opioid naïve people.

 

In brief, the results of our study was that prescriptions written in the ED were more likely to meet each of the measures of safe prescribing than prescriptions written in other settings: they were shorter and for lower doses, and they were more likely to be immediate-release. And patients receiving their prescription in the ED were less likely to continue to use opioids.

 

These weren’t small differences. You can check out the paper for full results, but as an example, among the commercially insured, 3.1% of prescriptions written in the ED exceeded 7 days vs. 19.1% written in non-ED settings; 14.3% of prescriptions written in the ED exceeded 50 MME per day vs. 22.8% of prescriptions written in non-ED settings. (With a sample size of >5.2 million prescriptions, all of these differences are statistically significant at any conventional level.)

 

And patients receiving prescriptions written in the ED were 46% to 58% less likely to continue using opioids chronically than those seen in non-ED settings.

 

ED physicians will probably not be surprised by our findings, but they may be surprising to other physicians and policymakers. We checked whether this pattern has changed over time. It hasn’t; the ED was better than non-ED settings across the whole study period.

 

I would guess that some non-ED physicians will argue that the patients seen in the ED are so different that this isn’t a fair comparison. It’s true that patients don’t randomly decide whether to show up at the ED or another setting (like primary care or surgeons office) for treatment of their pain. We address some of this difference by limiting our population to people who are not currently taking prescription opioids and excluded cancer and hospice patients—in nearly all these cases, the recommended opioid treatment regimen is the same: a short course of opioids at a low dose.

 

Furthermore, we found that in all treatment settings, patients receiving prescriptions that met all our measures were less likely to continue to use opioids. The differences were huge in the non-ED setting: the risk of continued use was about 4 times higher with prescriptions that didn’t meet the measures vs. those written in the same setting that did meet the measures.

 

We hope that this research will be helpful to physicians and patients deciding how to treat acute pain. The characteristics of your first opioid prescription are strongly associated with your risk of continuing to use opioids long term. Given the suffering caused by opioid misuse and addiction, I think many people may be willing to try non-opioid treatments for their pain to reduce their risk of long term opioid use. Although a small number of people may eventually need opioids, avoiding opioids as a first line of treatment for acute pain makes a lot of sense.

 

Reference

Wed, Jul 19 1:55pm · How to best identify patients that have a high likelihood of dying in one year?

Author: Caitlin Loprinzi-Brauer, MD @cloprinzi

To determine who should have goals of care discussions, encourage advanced care planning and consider palliative medicine consultation

 

Cardiopulmonary resuscitation (CPR) is the only medical intervention that does not need consent to be preformed. In medicine all patients are assumed to be a full code and undergo CPR and most times intubation (insertion of a breathing tube), unless otherwise documented. For many having all interventions preformed in attempt to save their life is what they want and what would be recommended by most medical professionals. As patients age or have a decline in their health secondary to medical comorbidities, many patients do not want aggressive heroic measures taken, particularly in times of critical illness. Also, as people age and medial comorbidities increase, the likelihood of survival following cardiac arrest decreases.

Value-based decision-making is about eliciting a patient’s values and goals in order to guide treatment; however, patients are not always empowered or able to communicate their wishes. Advance healthcare directives (AHD) can help patients communicate their wishes regarding their care and can guide conversations with surrogate decision-makers when the patient lacks capacity for such discussions. Understanding patients’ goals and values is especially important in the case of critically ill patients presenting to the emergency department (ED) who would receive life-sustaining treatments unless this is not what the patient wants.

 

We externally validated and derived a clinical prediction tool previously created by an ED group in Australia (Richardson P et al. https://www.ncbi.nlm.nih.gov/pubmed/25062815). We identified patients likely to die within one-year;, as these patients ideally should have advanced care planning (i.e. completed an advanced directive or similar document) including their code status documented (ie, Do not resuscitate or Do not intubate).

The PREDICT screening tool is composed by six variables that are easy to collect within a clinical ED visit and is easy to utilize in the fast-paced environment of the ED. Each criterion is assigned different points as seen in the table below:

PREDICT criteria and score

Feature Points
Referral to palliative care team for a non-cancer diagnosis 12
Current residence in nursing home 3
Department of intensive care unit (ICU) admission with multi-organ failure 10
Current diagnosis of cancer 10
2 medical admissions in the past year 3
Age at ED visit in years
   55-65 1
   66-75 2
   76 3

 

In our study, we applied the PREDICT tool to 927 patients older than 55 years of age presenting to the ED. A fourth of them (26%) were deceased at one year. Patients from the deceased group were older, had a higher PREDICT score, had an increased number of comorbidities, were more likely to live in a nursing home, and were more likely to have an AHD on file. Of the 147 patients with PREDICT scores ≥13, 55% were deceased at one year. The AUC of the PREDICT score was 0.717, sensitivity 33% and specificity was 90% to predict 1-year mortality. High specificity is preferred in this scenario, however a table with different sensitivity and specificity and ROC curves depending on the PREDICT score cutoff used are presented in the full article.

 

We further refined the clinical prediction tool to improve the original PREDICT criteria, and the PREDICT minus ICU admission with multiorgan failure (modified PREDICT) appeared to have a diagnostic test accuracy performance similar to the original PREDICT score. We selected this as the preferred model, as the variable of ICU admission with multiorgan failure is not always available at the time of assessment in the ED, was the hardest one to extract from the records, and will make the model easier to apply earlier in the course of an ED visit. By removing the ICU admission variable, this clinical tool, could result in earlier calculation of the PREDICT score during an ED visit. This time could be used for initiating conversations regarding AHD and, if appropriate, allow placement of palliative care consultation before inpatient admission.

 

PREDICT and modified PREDICT have advantages over other prognostic indices. Other indices require a patient be assessed for factors not regularly gathered in the context of a brief clinical encounter in the ED setting, require the use of the complex non-cancer hospice guidelines that may not be familiar to those who work outside of hospice and palliative medicine, incorporate laboratory values that may not be available or up-to-date, cannot be applied until the patient has final disposition from the ED, or cannot be applied to patients until they are dismissed from the hospital. PREDICT and modified PREDICT use data commonly available in the medical record or that are clinically relevant to an ED physician and are generally collected within the confines of a clinical encounter in the ED. Further, either PREDICT score could be discussed directly with the patient and their caregivers while they are in the ED and, thus, AHD, goals-of-care discussions and, when applicable, the need for palliative care consultation can be identified earlier and, possibly, initiated before the patient is admitted to the hospital.

Link to the paper

 

Reference

  • Moman RN, Loprinzi Brauer CE, Kelsey KM, Havyer RD, Lohse CM, Bellolio MF. PREDICTing Mortality in the Emergency Department: External Validation and Derivation of a Clinical Prediction Tool. Acad Emerg Med. 2017 Jul;24(7):822-831. doi: 10.1111/acem.13197. Epub 2017 May 29. PubMed PMID: 2840162

Sat, Jul 15 7:39am · Apneic Oxygenation actually works (for some things)

 

Author: Lucas Silva (@lucasojesilva12)

 

In the last few years, the use of apneic oxygenation has been recommended by experts for management of high-risk airway situations, including emergency intubations in the ED (1), and for patients at risk for difficult laryngoscopy and intubation in the operating room (2).

The relative simplicity and safety of this intervention and the potential to turn intubation in a safer procedure, with higher success rates and fewer complications, led to a rapid and widespread use of the concept and to its even being considered by some as standard of care despite relatively scarce evidence to support its use (1). Recently, ICU-based studies have shown conflicting results on the effectiveness of apneic oxygenation using different approaches (3-8).

To evaluate the current evidence, we performed a systematic review and meta-analysis on the use of apneic oxygenation during emergency intubation (ED or ICU intubations), looking at outcomes as hypoxemia, first-pass success, and lowest oxygen saturation.  

Here the link to the paper (open access!):

http://www.annemergmed.com/article/S0196-0644(17)30582-6/fulltext

 

After a comprehensive literature search, including 4 large databases, we found 1,386 studies for review. After screening the titles and abstracts and removing duplicates, we identified 77 potentially relevant studies. After full-text review, a total of 14 studies met the inclusion criteria: 6 ICU studies, 6 ED studies, and 2 mixed ED and ICU studies. The included studies involved 2,023 participants, with 1,168 patients receiving apneic oxygenation during intubation and 855 not receiving it. Eight studies including 982 patients receiving apneic oxygenation and 855 not receiving it, underwent meta-analysis.

In this study, we found that the use of apneic oxygenation during emergency intubation appears to be associated with increased peri-intubation oxygen saturation and first-pass success rates, as well as decreased incidence of hypoxemia in patients intubated in the ED or ICU. The use of apneic oxygenation was associated with a decrease in ICU length of stay, but there was no difference in duration of mechanical ventilation and ICU mortality. We found no reports of adverse events related to the use of apneic oxygenation, despite different approaches and settings.

 

Main findings:

  • Hypoxemia (SpO2 < 93%)
    • Meta-analysis of 8 studies, 1837 patients;
    • Odds ratio (OR) 0.66; 95% confidence interval (CI) 0.52 to 0.84.
  • First-Pass Success (success on the first attempt of laryngoscopy)
    • Meta-analysis of 6 studies, 1658 patients;
    • OR 1.59; 95% CI 1.04 to 2.44.
  • Lowest Oxygen Saturation Peri-Intubation
    • Meta-analysis of 6 studies, 1043 patients;
    • Weighted Mean Difference +2.2%; 95% CI 0.8% to 3.6%.

 

Limitations regarding our study, however, have to be acknowledged. The major limitation relates to the quality of included studies, which warrants a moderate to low level of certainty in the estimates. Another important limitation is the different approaches used to apneic oxygenation in terms of preoxygenation and other peri-intubation variables and co-interventions. The different methods of preoxygenation between groups could affect the likelihood of developing hypoxemia during the apneic period; therefore, the effect of apneic oxygenation was not isolated in some of the included studies. The maintenance of airway patency during apneic oxygenation was not described in most of the studies, and that might affect the quality of this intervention. The clinical heterogeneity of patients intubated in the ED and ICU in regard to their cardiorespiratory baseline status is also an important factor to be considered, and which approach is better among the spectrum of sickness in patients requiring emergency intubation still has to be evaluated by future studies.

In summary, in our meta-analysis apneic oxygenation was associated with increased peri-intubation SpO2, decreased hypoxemia, and increased first-pass intubation success.

 

Bottom-line: The current body of evidence supports the role of apneic oxygenation as an important adjunct for emergency airway management.

 

FULL-ARTICLE: (open access)

 

REFERENCES

  1. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59:165-175.e161.
  2. Berkow L, Hagberg CA, Crowley M. Airway management for induction of general anesthesia. In: Post TWU, Waltham MA, eds. UpToDate.
  3. Besnier E, Guernon K, Bubenheim M, et al. Pre-oxygenation with high-flow nasal cannula oxygen therapy and non-invasive ventilation for intubation in the intensive care unit. Intensive Care Med. 2016;42:1291-1292.
  4. Jaber S, Monnin M, Girard M, et al. Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in the intensive care unit: the single-centre, blinded, randomised controlled OPTINIV trial. Intensive Care Med. 2016;42:1877-1887.
  5. Miguel-Montanes R, Hajage D, Messika J, et al. Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Crit Care Med. 2015;43:574-583.
  6. Semler MW, Janz DR, Lentz RJ, et al. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. Am J Respir Crit Care Med. 2016;193:273-280.
  7. Simon M, Wachs C, Braune S, et al. High-flow nasal cannula versus bag-valve-mask for preoxygenation before intubation in subjects with hypoxemic respiratory failure. Respir Care. 2016;61:1160-1167.
  8. Vourc’h M, Asfar P, Volteau C, et al. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomized controlled clinical trial. Intensive Care Med. 2015;41:1538-1548.

 

Sat, May 20 7:35pm · Really, how dangerous can it be? Motocross injuries in the emergency department

Author: Lucas Silva (@lucasojesilva12)

Rider in photo: Elisa M. Smith, MD (EM Resident at Mayo Clinic, Rochester, MN)

 

An 18 year-old freshman of the University of Minnesota went back to Wabasha, his hometown, to ride motocross with his high-school friends over the weekend. He was jumping over an obstacle when he suddenly lost control in mid-air and was ejected from his bike, hitting his head and losing his consciousness for 30 seconds. EMS transported him to the emergency department (ED) for evaluation.

In the ED, he reported headache, nausea, and back pain. His GCS was 15 and he had no neurologic deficits on exam.  The emergency providers ordered CTs of the head, neck, chest, abdomen/pelvis with spine reconstructions which revealed a stable lumbar spine fracture. The patient was discharged from the hospital one day later with concussion instructions and outpatient follow-up with the Spine Clinic.

Motocross is a popular that has seen an increasing number of injuries related to the rising on participation (1, 2). Its burden on ED visits, however, has not been well described for adult patients. Motocross has one of the highest incidence rates of injuries compared with other high-impact sports (3) and emergency providers should be aware of the risks associated with this activity, in order to facilitate early recognition and management of injuries in these patients.

In a study of consecutive adult patients presenting to our academic ED with motocross-related injuries over a 6-year period we aimed to describe the rates of head and spine injuries.

We found that adult patients evaluated in the ED after motocross trauma had high rates of head and spine injuries and marked levels of morbidity and mortality (Table 1). Among 145 ED visits, 95% of the patients were male and the median age was 25 years.  Almost half of the patients had head and/or spine injuries (67/145, 46.2%).  Almost 93% of patients with head or spine injuries were wearing a helmet at the time of injury.  Among the 43 patients with head injuries, almost 85% were concussions (and over 75% of these were associated with loss of consciousness), 7 were associated with at least 1 head CT abnormality, including skull fracture (n = 2), subdural hematoma (n = 1), subarachnoid hemorrhage (n = 4), intraparenchymal hemorrhage (n = 3), and diffuse axonal injury (n = 3). Approximately 70% of the 46 spinal injuries were acute fractures.  Six patients (4%) had significant persistent neurologic injuries, including:  3 patients with severe TBIs (including 2 with persistent cognitive impairment and 1 in a persistent vegetative state); 2 patients with paraplegia; 1 patient with right upper extremity weakness.  One patient had a minor sensory deficit.  One patient died.

Our findings demonstrate that almost one half of adult ED patients evaluated following motocross accidents had head and/or spine injuries with 4% resulting in significant impairment, and 0.7% died. The long-term functional and economic burden caused by these injuries in these young patients is unknown. Emergency providers and motocross participants should be aware of the high rates of head and spine injuries associated with this sport.  The development of improved safety procedures or equipment may help to mitigate these injuries.

 

Table 1. Emergency Department Visits—Baseline Characteristics and Outcomesa  (used with permission)

  ED Visits
 

Variable

All
(N=145)
Head Injuries (n=43) Spine Injuries (n=46)
Age, y 25 (21-38) 27 (21-40) 25.5 (21-38.5)
Male sex 138 (95.2) 41 (95.3) 43 (93.5)
ED Glasgow coma scaleb      
3 3 (2.1) 3 (7) 2 (4.35)
4-8 2 (1.4) 2 (4.7) 0 (0)
9-14 3 (2.1) 3 (7) 2 (4.35)
15 135 (94.4) 35 (81.3) 42 (91.3)
Head injury (n=43)      
Loss of consciousness 33 (76.8)
Concussion 36 (83.7)
Skull fracture 2 (4.7)
Epidural hematoma 0 (0)
Subdural hematoma 1 (2.3)
Subarachnoid hemorrhage 4 (9.3)
Intraparenchymal hemorrhage 3 (7)
Diffuse axonal injury 3 (7)
Spine injury (n=46)      
Acute spinal fracture 32 (69.6)
Epidural hematoma 4 (8.7)
Acute disc herniation 1 (2.2)
Ligamentous injury 5 (10.9)
Cervical strain 3 (6.5)
Thoracolumbar strain 10 (21.7)
CT imaging      
Head 83 (57.2) 41 (95.3) 36 (78.3)
Any spine 106 (73.1) 41 (95.3) 46 (100)
Cervical spine 105 (72.4) 40 (93) 46 (100)
Lumbar spine 85 (58.6) 33 (76.7) 41 (89.1)
Thoracic spine 61 (42.1) 32 (74.4) 42 (91.3)
ED disposition      
Home 40 (27.6) 7 (16.2) 4 (8.7)
General surgical floor 53 (36.5) 18 (41.9) 19 (41.3)
Intensive care unitc 21 (14.5) 12 (27.9) 12 (26)
Operating room 31 (21.4) 6 (14) 11 (24)
Head or spine intervention or surgery 10 (6.9) 5 (11.6) 8 (17.4)
Persistent neurologic deficit at hospital discharge 7 (4.8) 5 (11.6) 4 (8.7)
Hospital length of stay, d 2 (0-4) 2 (1-5) 3 (1-5)
In-hospital death 1 (0.7) 1 (2.3) 1 (2.2)

Abbreviations: CT, computed tomography; ED, emergency department.

a Data are summarized as number (%) or median (interquartile range).

b Data not available for 2 patients.

c Includes all types of intensive care units at our institution.

 

FULL-ARTICLE:

  • Silva LOJe, Fernanda Bellolio M, Smith EM, et al. Motocross-associated head and spine injuries in adult patients evaluated in an emergency department. The American Journal of Emergency Medicine doi: https://doi.org/10.1016/j.ajem.2017.04.058

 

REFERENCES

  1. Sharma VK, Rango J, Connaughton AJ, et al. The Current State of Head and Neck Injuries in Extreme Sports. Orthopaedic journal of sports medicine 2015;3(1):2325967114564358. doi: 10.1177/2325967114564358 [published Online First: 2015/11/05]
  2. Singh R, Theobald P, Hamad AK, et al. Motocross biking for competition and for recreation: a prospective analysis of 423 injured riders. BMJ Open Sport &amp;amp; Exercise Medicine 2015;1(1)
  3. Gobbi A, Tuy B, Panuncialman I. The incidence of motocross injuries: a 12-year investigation. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2004;12(6):574-80. doi: 10.1007/s00167-004-0510-z [published Online First: 2004/05/11]

 

 

Thu, May 4 9:55am · Anaphylaxis Management

This is a great resource

Wed, Apr 26 11:18am · The Future of Healthcare

This is a video recorded during Mayo Clinic Emergency Grand Rounds presented by Felix Ankel, MD (@felixankel) and Daniel Cabrera, MD (@CabreraERDR) on April 25th 2017.

Healthcare is changing rapidly and the tectonic changes in the way we learn, teach, practice and deliver healthcare are based on a different way to manage knowledge, the close collaboration with artificial intelligence, the ways we create networks and a paradigm change from restricted and episodic healthcare to a continuous unrestricted model.

“The real problem of humanity is the following: we have paleolithic emotions; medieval institutions; and god-like technology”

– E.O. Wilson

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