Peer recovery coaches and emergency department utilization in patients with substance use disorders.

BACKGROUND: Although Emergency Departments (ED) frequently provide care for patients with substance use disorders (SUD), there are many barriers to connecting them with appropriate long-term treatment. One approach to subside risk in this population is the Peer Recovery Coach (PRC). PRCs are individuals with a lived experience of the rehabilitation process and are a powerful resource to bridge this gap in care by engaging patients and their families and providing system navigation, self-empowerment for behavior change, and harm reduction strategies. The purpose of this project is to describe an ED-based PRC program, evaluating its feasibility and efficacy. METHODS: This was a retrospective quality improvement project conducted at 3 suburban hospitals. All patients arriving to the ED were screened with a brief questionnaire in triage and patients identified as a high-risk had referral placed to a PRC if the patient consented. The PRC met with the patient at the ED bedside if possible. The PRC program members collected prospective data on patient engagement with the PRC at 30, 60, and 90 days post ED encounter. Using the EMR we identified the number of subsequent ED visits at 30, 60, and 90 days (for both medical and substance use disorder-related visits) from the index PRC visit. RESULTS: There were 448 individuals identified and included in this analysis between January 1, 2019 and June 30, 2020, of which 292 (66%) were male and the mean age was 44 (range 18-80). Most patients identified alcohol as the primary substance they used (289, 65%), followed by heroin/opiates (20%). At 30, 60, and 90 days, there were 110 (25%), 79 (18%), and 71 (16%) patients who were still actively engaged in the program, respectively. Among all patients in the cohort, there was essentially no decrease in mean visits before versus after the PRC engagement visit. However, among patients who had at least one prior ED visit, there were significant differences in mean visits across all visit-types: for patients with 1 prior ED visit, 90 day mean decrease in visits = 1.0 visits (95% CI 0.7-1.2), for patients with 5+ prior ED visits, 90 day mean decrease in visits = 3.6 visits (95% CI 2.4-4.8). CONCLUSION: We describe the implementation of an ED-based PRC program for patients with substance use disorders. While we demonstrated that it is feasible for the PRC to engage the patient while in the ED, there was poor follow-up with the program outpatient. For patients with at least one previous SUD visit to the ED, there was a statistically significant reduction in ED utilization after engaging with a PRC while in the ED, suggesting this may be a population that could be targeted to link patients to long term care and decrease repeated ED utilization.

Emergency department sepsis huddles: Achieving excellence for sepsis benchmarks in New York State.

The sepsis order set at our institution was created with the intent to facilitate the prompt initiation of appropriate sepsis care. Once clinical features meeting criteria for systemic inflammatory response syndrome (SIRS) are identified and an infectious source is considered, a "sepsis huddle" is concomitantly initiated. The sepsis huddle was implemented in March of 2016 in order to increase compliance with the sepsis bundles. The sepsis huddle is called via overhead paging system in the emergency department (ED) to notify all staff that there is a patient present who meets SIRS criteria with concern for sepsis requiring immediate attention. The sepsis order set is utilized for these patients and includes laboratory testing, treatment, and monitoring items to meet sepsis "bundle" compliance. In addition, it suggests antibiotic options to be administered based on the presumed source of infection. Each team member responding to a sepsis huddle has a pre-established role outlined to facilitate timely treatment. The Centers for Medicare & Medicaid Services, (CMS), is part of the Department of Health and Human Services (HHS). CMS sepsis guidelines call for periodic patient reassessment, including repeat vital signs, pertinent physical examination findings, and timed lactic acid measurement to determine a patient's response to resuscitation efforts. Our established order set has automated some of these reassessment features to facilitate compliance. Sepsis huddle initiation also triggers a department staff member to track the timing and completion of serial blood draws. Utilizing and adhering to the guidelines of this methodology in the management of these patients has enabled our hospital to improve benchmarking compliance from previously underperforming at the 31st and 49th percentiles in 2015, prior to initiation of the huddle, to a peak compliance at the 81st and 91st percentiles in 2016 and 65th and 83rd percentiles in 2017 for the 3-hour and 6-hour bundles respectively.

Incidence of Clostridium difficile Infection After Sepsis Protocol Antibiotics.

INTRODUCTION: The management of sepsis includes the prompt administration of intravenous antibiotics. There is concern that sepsis treatment protocols may be inaccurate in identifying true sepsis and exposing patients to potentially harmful antibiotics, sometimes unnecessarily. This study was designed to investigate those concerns by focusing on in-hospital Clostridium difficile infection (CDI), which is a known complication of exposure to antibiotics. METHODS: Our emergency department (ED) recently implemented a protocol to help combat sepsis and increase compliance with the 2017 Sepsis CMS Core Measures (SEP-1) guidelines. In this single-center, retrospective cohort analysis we queried the electronic health record to gather data on nosocomial CDI and antibiotics prescribed over a five-year period to analyze the effect of the introduction of a sepsis protocol order set. The primary goal of this study was to measure the hospital-wide CDI rate for three years prior to implementation of the sepsis bundle, and then compare this to the hospital-wide CDI rate two years post-implementation. As a secondary outcome, we compared the number of antibiotics prescribed in the ED 12 months prior to administration of the sepsis protocol vs 12 months post-initiation. RESULTS: Over the course of five years, the hospital averaged 9.4 nosocomial CDIs per 10,000 patient hours. Prior to implementation of the sepsis bundle, the average CDI rate was 11.6 (±1.11, 95%) and after implementation the average rate dropped to 6.2 (±1.27, 95%, p<0.01). The mean number of antibiotics ordered per patient visit was 0.33 (±0.015, 95%) prior to bundle activation, and, following sepsis bundle activation, the rate was 0.38 (±0.019, 95%, p<0.01). This accounted for 38% of all ED patient visits receiving antibiotics, a 5% increase after the sepsis bundle was introduced. CONCLUSION: In this study, we found that CDI infections declined after implementation of a sepsis bundle. There was, however an increase in the number of patients being exposed to antibiotics after this hospital policy change. There are more risks than just CDI with antibiotic exposure, and these were not measured in this study. Subsequent studies should focus on the ongoing effects of timed, protocolized care and the associated risks.

Upper Cervical Epidural Abscess Resulting in Respiratory Compromise After Lumbar Steroid Injection.

BACKGROUND: Spinal epidural abscesses have a prevalence of 3 out of every 10,000 admissions. Abscesses above the level of C2, defined as upper cervical epidural abscesses, are even rarer still. CASE REPORT: We discuss a case in which a 45-year-old male patient developed an upper cervical epidural abscess 48 h after receiving a lumbar steroid injection. The patient presented with diminished strength in all four extremities and respiratory distress secondary to the space-occupying lesion near his spinal cord. His hospital course included surgical decompression and antibiotics. He was eventually discharged to rehabilitation, but never regained full strength in his arms or legs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients who present with back or neck pain, fever, and neurologic deficits may have epidural abscess. In some patients, neurologic deficits may include respiratory distress if the upper cervical region is involved, and these patients have the possibility of airway decompensation. The diagnostic imaging modality of choice in patients with epidural abscess is MRI with gadolinium. Management involves supportive care, broad-spectrum antibiotics, which include coverage for methicillin-resistant Staphylococcus aureus, and early neurosurgical consultation.

Goal-directed Focused Ultrasound Milestones Revised: A Multiorganizational Consensus.

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

Prevalence of the "double-line" sign when performing focused assessment with sonography in trauma (FAST) examinations.

The double-line sign (DLS) is a wedge-shaped hypoechoic area in Morison's pouch bounded on both sides by echogenic lines. It represents a false-positive finding for free intraperitoneal fluid when performing focused assessment with sonography in trauma examinations. The purpose of this study was to determine the prevalence of DLS. Secondarily, the study will further investigate the relationship between the presence of a DLS and body mass index (BMI). This was a prospective study that enrolled patients over a 7-month period. Inclusion criteria were patients ≥ 18 years of age presenting to the Emergency Department (ED) requiring a FAST examination as part of the patient's standard medical care. Each examination was performed by one of six experienced ultrasonographers. Presence or absence of the DLS was established in real time and gender, height, weight, and BMI were recorded for each patient. The overall prevalence rate of DLS and the corresponding 95 % confidence interval were calculated, as well as the prevalence rates broken down by BMI characterized as underweight, normal weight, overweight, and obese; and age category (18-29, 30-64, and 65+). The Chi-square test and a Fisher's exact test for BMI category were used to compare the prevalence rates of positive DLS among the different demographic groups. 100 patients were enrolled in the study; the overall prevalence was 27 %. There was no statistical significance among the different demographic groups or BMI. The DLS is a prevalent finding. We believe this sign has become more apparent due to improved imaging technology and resolution.

Saline Flush Test: Can Bedside Sonography Replace Conventional Radiography for Confirmation of Above-the-Diaphragm Central Venous Catheter Placement?

OBJECTIVES: Resuscitation often requires rapid vascular access via central venous catheters. Chest radiography is the reference standard to confirm central venous catheter placement and exclude complications. However, radiographs are often untimely. The purpose of this study was to determine whether dynamic sonographic visualization of a saline flush in the right side of the heart after central venous catheter placement could serve as a more rapid confirmatory study for above-the-diaphragm catheter placement. METHODS: A consecutive prospective enrollment study was conducted in the emergency departments of 2 major tertiary care centers. Adult patients of the study investigators who required an above-the-diaphragm central venous catheter were enrolled during the study period. Patients had a catheter placed with sonographic guidance. After placement of the catheter, thoracic sonography was performed. The times for visualization of the saline flush in the right ventricle and sonographic exclusion of ipsilateral pneumothorax were recorded. Chest radiography was performed per standard practice. RESULTS: Eighty-one patients were enrolled; 13 were excluded. The mean catheter confirmation time by sonography was 8.80 minutes (95% confidence interval, 7.46-10.14 minutes). The mean catheter confirmation time by chest radiograph availability for viewing was 45.78 minutes (95% confidence interval, 37.03-54.54 minutes). Mean sonographic confirmation occurred 36.98 minutes sooner than radiography (P< .001). No discrepancy existed between sonographic and radiographic confirmation. CONCLUSIONS: Confirmation of central venous catheter placement by dynamic sonographic visualization of a saline flush with exclusion of pneumothorax is an accurate, safe, and more efficient method than confirmation by chest radiography. It allows the central line to be used immediately, expediting patient care.

Mirror image artifact mimicking heterotopic pregnancy on transvaginal ultrasound: case series.

Vaginal bleeding in early pregnancy is a common emergency department complaint. Point-of-care ultrasound is a useful tool to evaluate for intrauterine ectopic pregnancy. Emergency physicians performing these studies need to be cognizant of artifacts produced by ultrasound technology, as they can lead to misdiagnosis. We present two cases where mirror-image artifacts initially led to a concern for heterotopic pregnancies but were excluded on further imaging.

Bilateral hydronephrosis and cystitis resulting from chronic ketamine abuse.

Ketamine associated urinary dysfunction has become increasingly more common worldwide. Point-of-care ultrasound (POCUS) is an established modality for diagnosing hydronephrosis in the emergency department. We describe a case of a young male ketamine abuser with severe urinary urgency and frequency in which POCUS performed by the emergency physician demonstrated bilateral hydronephrosis and a focally thickened irregular shaped bladder. Emergency physicians should consider using POCUS evaluate for hydronephrosis and bladder changes in ketamine abusers with lower urinary tract symptoms. The mainstay of treatment is discontinuing ketamine abuse.

Appendicitis Diagnosed by Emergency Physician Performed Point-of-Care Transvaginal Ultrasound: Case Series.

Lower abdominal pain in females of reproductive age continues to be a diagnostic dilemma for the emergency physician (EP). Point-of-care ultrasound (US) allows for rapid, accurate, and safe evaluation of abdominal and pelvic pain in both the pregnant and non-pregnant patient. We present 3 cases of females presenting with right lower quadrant and adnexal tenderness where transvaginal ultrasonography revealed acute appendicitis. The discussion focuses on the use of EP- performed transvaginal US in gynecologic and intra-abdominal pathology and discusses the use of a staged approach to evaluation using US and computed tomography, as indicated.

Near-miss in focused lower-extremity ultrasound for deep venous thrombosis.

BACKGROUND: Focused, proximal compression ultrasound (FPCUS) is a commonly used point-of-care study in the Emergency Department (ED). Pelvic vein deep venous thrombosis (DVT) is a rare presentation, and Emergency Physicians need to be aware of the limitations and pitfalls of FPCUS. OBJECTIVE: A case of external iliac vein DVT diagnosed in the ED is presented, with a focus on subtle signs seen during FPCUS that led to the diagnosis and additional ultrasound techniques to aid in appropriate point-of-care diagnosis. CASE REPORT: We describe a patient who presented with lower-extremity pain and was subsequently diagnosed with external iliac DVT. A FPCUS study by Emergency Physicians was performed and demonstrated subtle findings that led to further investigation and appropriate diagnosis. CONCLUSION: Emergency physicians using FPCUS in the evaluation of lower-extremity pain or swelling need to be aware of the pitfalls, limitations, and advanced techniques to avoid misdiagnosis while evaluating for DVT.