The Impact of Community Health Information Exchange Usage on Time to Reutilization of Hospital Services.

PURPOSE: Few studies have determined whether clinician usage of a community health information exchange (HIE) directly improves patient care transitions. We hypothesized that lookup in the HIE by primary care physicians of patients recently released from the hospital would increase the time until hospital reuse. METHODS: We identified a retrospective cohort of 8,216 hospital inpatients aged over 18 years that were discharged from January 1, 2021 through November 30, 2021 using the Paso del Norte Health Information Exchange, in El Paso County, Texas. All patients had a primary care physician visit within 30 days after hospital discharge, and we identified patients that were looked up in the HIE close to that visit. Of the cohort, 2,627 were rehospitalized and 3,809 visited an emergency department (ED) during the follow-up window. The remaining 1,780 patients were controls. We conducted survival analysis, censoring at the second ED or inpatient visit or end of the study window (January 31, 2022). The model was adjusted by ethnicity, gender, insurance, and age. RESULTS: Lookup in the HIE was significantly associated with reducing the likelihood of visiting the ED by 53% and being rehospitalized by 61%. Lookup in the HIE was associated with an increased median time to use of the ED after inpatient discharge from 99 to 238 patient days. Ethnicity, insurance, gender, and age were also significant predictors of hospital reuse. CONCLUSIONS: Increased utilization of community HIEs by primary care physicians on behalf of their recently discharged patients may dramatically increase the time until inpatient or ED reuse.

Assessment of nationally recommended antibiotics for treatment of UTI in U.S.-Mexico border emergency departments.

BACKGROUND: Urinary tract infections (UTIs) seen in the emergency department are commonly treated as an outpatient with oral antibiotics. Given that antibiotics are available for over-the-counter purchase in Mexico, there is speculation that potential misuse and overuse of antibiotics in United States-Mexico border areas could lead to antibiotic resistance patterns that would render some empiric treatments for UTIs less effective. The purpose of this study was to examine the effectiveness of Infectious Disease Society of America (IDSA) guideline-recommended antibiotics for treatment of outpatient UTI diagnosed in the emergency department. Data were collected from a county hospital on the U.S.-Mexico border with a metropolitan area of over 2 million people. Secondary analysis included frequency of urine culture isolated, resistance rates of urine pathogens, and prescriber habits. METHODS: This study was a retrospective chart review of adult patients diagnosed and treated for UTI from August 1, 2019, to February 29, 2020. Culture results of included patients were analyzed against in vitro-tested antibiotics. Bacterial isolate frequency, resistance rates, and prescribing habits were collected. RESULTS: A total of 985 patient charts were reviewed, of which 520 patients met inclusion criteria for analysis of prescribing habits. Of these, 329 positive bacterial culture growths were included in the analysis of antibiotic resistance rates. Oral antibiotics with comparatively lower resistance rates were amoxicillin/clavulanate, cefdinir, cefuroxime, and nitrofurantoin. Oral antibiotics with notably high resistance rates included trimethoprim-sulfamethoxazole (TMP-SMX), tetracycline, ciprofloxacin, levofloxacin, and cephalexin. Nitrofurantoin was prescribed most frequently for outpatient treatment of UTI/cystitis (41.6%) while cephalexin was the most commonly prescribed antibiotic for outpatient treatment of pyelonephritis (50%). CONCLUSION: Our findings suggest that, while part of standard IDSA guidelines, fluoroquinolones and TMP-SMX are not ideal empiric antibiotics for treatment of outpatient UTI in the U.S.-Mexico border region studied due to high resistance rates. Although not listed as first line agents per current IDSA recommendations, 2nd and 3rd generation cephalosporins, and amoxicillin/clavulanate would be acceptable options given resistance patterns demonstrated in accordance with IDSA allowance for tailoring selection to local resistance. Nitrofurantoin appears to be consistent with recommendations and demonstrates a favorable resistance profile for treatment of outpatient UTI within this region.

Development and Evaluation of an Automated Manual Resuscitator-Based Emergency Ventilator-Alternative.

Mass casualty incidents such as those that are being experienced during the novel coronavirus disease (COVID-19) pandemic can overwhelm local healthcare systems, where the number of casualties exceeds local resources and capabilities in a short period of time. The influx of patients with lung function deterioration as a result of COVID-19 has strained traditional ventilator supplies. To bridge the gap during ventilator shortages and to help clinicians triage patients, manual resuscitator devices can be used to deliver respirations to a patient requiring breathing support. Bag-valve mask (BVM) devices are ubiquitous in ambulances and healthcare environments, however require a medical professional to be present and constantly applying compression to provide the patient with respirations. We developed an automated manual resuscitator-based emergency ventilator-alternative (AMREV) that provides automated compressions of a BVM in a repetitive manner and is broadly compatible with commercially-available BVM devices approximately 5 inches (128 mm) in diameter. The AMREV device relieves the medical professional from providing manual breathing support and allows for hands-free operation of the BVM. The AMREV supports the following treatment parameters: 1) adjustable tidal volume (V T ), 2) positive end-expiratory pressure (PEEP) (intrinsic and/or external), 3) 1:1 inspiratory: expiratory ratio, and 4) a controllable respiratory rate between 10-30 breaths per minute. The relationship between the inherent resistance and compliance of the lung and the delivered breaths was assessed for the AMREV device. Adjustable V T of 110-700 ml was achieved within the range of simulated lung states. A linear increase in mean airway pressure (P aw ), from 10-40 cmH2O was observed, as the resistance and compliance on the lung model moved from normal to severe simulated disease states. The AMREV functioned continuously for seven days with less than 3.2% variation in delivered V T and P aw . Additionally, the AMREV device was compatible with seven commercially-available BVM setups and delivered consistent V T and P aw within 10% between models. This automated BVM-based emergency-use resuscitator can provide consistent positive pressure, volume-controlled ventilation over an extended duration when a traditional ventilator is not available. True ventilator shortages may lead to manual resuscitators devices such as the AMREV being the only option for some healthcare systems during the COVID-19 pandemic.

Evaluation and management of urethral foreign bodies and description of a novel ultrasound-guided catheter-based extraction technique.

There are numerous reports in the medical literature documenting urethral foreign bodies with nearly all cases found in men and often associated with underlying psychiatric disorders, autoerotic stimulation, and/or intoxication. Patients most commonly presented with localized penile pain, hematuria, dysuria, and occasionally obstruction. Although endoscopic removal by a urologist is often the first-line treatment, this report describes evaluation and management considerations and presents a novel extraction technique that may allow emergency physicians in consultation with urology to perform removal of some unusual urethral foreign bodies in the emergency department. We report a novel extraction technique using a pediatric foley catheter under ultrasound guidance that has been applied during multiple encounters with 2 individuals who have each presented multiple times at a single emergency department (ED) for evaluation because of urethral foreign body insertion. The foreign body materials have ranged from small pieces of rubber to cellophane to styrofoam and most commonly plastic utensils. Urologic extraction may be required in some cases, but ED removal can be considered. A final discussion of the creation of a multidisciplinary care plan to address resource use concerns also is described.

Complications of subcutaneous penile modifications: a discussion of emergency department presentations and management.

BACKGROUND: Subcutaneous penile modifications (SPMs) are more prevalent in Southeast Asian culture and have been growing in popularity in Western culture. SPMs are often made of domino tiles, or other available pieces of plastic, shaved into a desired shape and placed in unsterile conditions. Previous literature indicates a high risk of infection and the need for surgical removal. CASE PRESENTATIONS: Seven patients presented to the emergency department in the Southwest border region with complications from SPMs. All the patients complained of pain, four presented with signs of infection, and four SPMs required removal in the emergency department. Removal consisted of a dorsal penile nerve block and making an incision over the SPM to remove the foreign body. Three of the patients had their SPMs done during a previous incarceration under unsterile conditions. CONCLUSIONS: SPMs appear to be growing in popularity among Western culture, and emergency department health care providers should be aware of trends in body modifications as well as potential complications. The conditions in which SPMs are often placed pose a high risk for infection. In some cases, placement and/or removal of SPMs pose a risk of damage to the corpora, arteries, and nerves of the penis. In the absence of overt bleeding, or suggestion of neurologic injury, dorsally placed superficial foreign bodies of the penis may be amenable to emergency department removal.

Development and Review of the Chest Tube High-Feedback Educational Simulation Trainer (CHEST).

INTRODUCTION: Emergency medicine physicians must receive training in chest tube placement. This life-saving skill must be completed quickly and competently to prevent morbidity and mortality. Training on live patients is no longer an appropriate or acceptable practice. Current training devices have been noted to be costly, may be difficult to store, or may require time-consuming cleanup or setup. METHODS: Fifteen Chest tube High-feedback Educational Simulation Trainers were created. Frames were made from wood and PVC, and soft tissue layers were designed using silicone and polyurethane foam. Nine training sites volunteered to test the model and provided feedback on the acceptability of the task trainer for skill training. RESULTS: Survey findings demonstrated that the model was realistic for teaching, portable, and was easy to use and maintain. In our model, the outer skin was noted to tear easily, thus limiting its use for suture training. Overall programs reported that they would use this model if it was available for the same or lower cost than current models. CONCLUSIONS: An inexpensive task trainer was created that was easy to store, quick to set up, durable, easy to clean, and rated as effective at training the skill of chest tube insertion.

A Simulation-Based Workshop to Improve Residents' Collaborative Clinical Practice.

BACKGROUND: The Accreditation Council for Graduate Medical Education expects residents to attain competency in systems-based practice by advocating for quality patient care, working in interprofessional teams, and implementing system solutions to prevent errors. Diabetes in pregnancy was identified as an area for improvement through comprehensive interdisciplinary and interprofessional care. OBJECTIVE: An interdisciplinary and interprofessional workshop was created by 3 regional academic institutions to improve collaborative practice, clinical knowledge, and clinical judgment of residents. METHODS: A workshop consisting of 4 clinical simulation stations for ultrasound assessment, glycemic control, hyperglycemic emergencies, and macrosomia complications was designed to address gaps in quality of care. Workshop participants were residents from 6 programs and students in nursing, pharmacy, and sonography. Attitude and clinical knowledge were measured preworkshop and postworkshop, and at 3-month and 6- to 7-month follow-up. RESULTS: There were increases in average clinical knowledge scores across time points from residents: 56.4% preworkshop, 64.8% postworkshop, 66.0% at 3-month follow-up, and 68.1% at 6- to 7-month follow-up. Additionally, participants reported positive attitudes toward interprofessional education and indicated high overall satisfaction. CONCLUSIONS: Residents demonstrated improved knowledge and attitudes toward interprofessional training after participating in a large-scale simulation workshop focused on the care of patients with diabetes in pregnancy.

Virtual Reality as an Interview Technique in Evaluation of Emergency Medicine Applicants.

NEED FOR INNOVATION: Current interviewing strategies and the standardized letter of evaluation may not provide enough insight into preferred resident characteristics. Emergency medicine (EM) residency programs are challenged with identifying trainees who can problem solve, communicate, and work well with fellow health professionals. BACKGROUND: Structured interviews have previously been used and can help predict success but candidates have reported a negative impression with their use. OBJECTIVE OF INNOVATION: This structured virtual reality (VR) interviewing method was designed so that interviewers can observe the communication abilities, subtle personality traits, and teamwork skills of applicants interviewed at an EM residency program. DEVELOPMENT PROCESS: A consumer VR headset became available and in combination with an interactive team game was incorporated into a standardized team-based interview session. This session was designed to allow observation of candidates' communication, problem solving, and teamwork skills. IMPLEMENTATION PHASE: Surveys were collected to examine the satisfaction of EM residency applicants who participated in this novel standardized interviewing method using a VR headset. After the submission of rank lists, but prior to Match Day, those who interviewed were e-mailed a voluntary, anonymous, and confidential survey asking about their interview experience, specifically about the VR portion. The survey was sent to 102 applicants with 63 responses for a 62% response rate at the completion of the 2015 to 2016 interview season. OUTCOMES: Overall study findings suggested that participants had a highly favorable impression of the VR portion of the interview. Specifically, participants reported that this interview technique was appropriate and worthwhile. Additionally, participants attested that the Oculus portion of the interview gave insight to their work ethic, personality, and communication skills and how they work with others. REFLECTIVE DISCUSSION: The novel interviewing method used in this study allowed interviewers to gain insight beyond that of the paperwork and brief face-to-face interaction. Study findings suggest that interviewees accepted the use of this novel interview method. It has been incorporated into our interview process for three consecutive years.

Intraosseous Vascular Access Device as a Transarticular K-wire Alternative in Mallet Finger Laceration.

Mallet finger is a common injury often treated without operative intervention. When there is concern for skin integrity or a large articular component is involved, simple operative repair may be needed. This has been performed with transarticular Kirschner wire (K-wire) placement. This case discusses the novel use of an intraosseous vascular access device (IOVAD) as a potential adjunct to stabilization and alternative to treatment with operative K-wire fixation. A 53-year-old man was successfully treated using the inner trocar of the EZ-IO® system for a mallet finger injury with laceration, shown in comparison with another standard manual pinning approach using an 18-gauge needle. An IOVAD can be used successfully as an alternative to K-wire placement in patients with mallet finger injuries.

Mass casualty incidents and B-Con training.

OBJECTIVE: The purpose of this study was to determine if providing mass casualty training, utilizing the Bleeding Control for the Injured (B-Con) course would allow participants to feel more confident to provide bystander aid to wounded victims in a mass casualty incident (MCI). DESIGN: Quasi-experimental pre-post intervention study. SETTING: Participants were healthcare providers attending a trauma research conference hosted by a medical university. INTERVENTIONS: Participants were given a group lecture in each of the three B-Con skill areas. These include: bleeding control with a tourniquet, bleeding control with gauze, and airway control with a jaw thrust. Participants were then divided into three groups and practiced each skill with instruction from B-Con certified trainers. MAIN OUTCOMES MEASURES: The primary outcome was scores from pre- to post-intervention in the categories of self-efficacy, perceived benefit, perceived susceptibility, perceived barriers, and perceived severity related to involvement in an MCI. RESULTS: The study included 67 participants, all identifying as medical providers. Means in the categories of self-efficacy, perceived benefit, perceived susceptibility, perceived barriers, and perceived severity significantly increased from pre-intervention to post-intervention among the paired variables. CONCLUSIONS: This study demonstrates the effectiveness of B-Con training in improving the confidence of participants. By increasing the number of persons who are trained for an MCI, there will be an increased probability that triage and immediate care will be rendered when needed. Future research needs to be completed evaluating the effect of training on a layperson study sample.