Point-of-care ultrasound thoracic "Quick Look" identifies potentially dangerous chest tube insertion sites.

PURPOSE: Emergency and trauma physicians typically rely on anatomic landmarks to determine the proper intercostal space for emergent tube thoracostomy. However, physicians using this technique select a potentially dangerous insertion site too inferior in nearly one-third of cases, which have the potential to result in subdiaphragmatic puncture. We investigated a point-of-care ultrasound (POCUS) thoracic "Quick Look" procedure as a technique to allow visualization of underlying structures to avoid tube misplacement. METHODS: We performed an observational study of adult emergency department patients and their treating physicians. The patient's emergency physician was asked to rapidly identify and mark a hypothetical tube thoracostomy insertion site on the patient's chest wall. An ultrasound fellow then performed a POCUS thoracic "Quick Look" exam with a phased-array probe placed directly over the marked site. Over one regular respiratory cycle, the identification of standard lung pattern was considered a negative scan whereas visualization of the diaphragm with underlying liver or spleen was considered a positive scan. Time for completion of the "Quick Look" scan was measured and inter-rater reliability was determined through image review by a single, blinded ultrasound director. RESULTS: Seventy-six thoracic "Quick Look" scans were performed on patient subjects, of which 17% (13/76, 95%CI 8-26%) were positive. The average time for performing the "Quick Look" exam was 43 s (95%CI 30-57). Inter-rater reliability of the thoracic "Quick Look" was excellent (κ = 0.95). CONCLUSION: Thoracic "Quick Look" exams performed at mock chest tube insertion sites demonstrated potentially dangerous insertions in 17% of the cases. POCUS thoracic "Quick Look" may be a rapid and reliable technique that improves safety when placing an emergent chest tube.

Screening, Brief Intervention, and Referral to Treatment in the Emergency Department: An Examination of Health Care Utilization and Costs.

BACKGROUND: There is increasing interest in deploying screening, brief intervention, and referral to treatment (SBIRT) practices in emergency departments (ED) to intervene with patients at risk for substance use disorders. However, the current literature is inconclusive on whether SBIRT practices are effective in reducing costs and utilization. OBJECTIVE: This study sought to evaluate the health care costs and health care utilization associated with SBIRT services in the ED. RESEARCH DESIGN: This study analyzed downstream health care utilization and costs for patients who were exposed to SBIRT services within an Allegheny County, Pennsylvania, ED through a program titled Safe Landing compared with 3 control groups of ED patients (intervention hospital preintervention, and preintervention and postintervention time period at a comparable, nonintervention hospital). SUBJECTS: The subjects were patients who received ED SBIRT services from January 1 to December 31 in 2012 as part of the Safe Landing program. One control group received ED services at the same hospital during a previous year. Two other control groups were patients who received ED services at another comparable hospital. MEASURES: Measures include total health care costs, 30-day ED visits, 1-year ED visits, inpatient claims, and behavioral health claims. RESULTS: Results found that patients who received SBIRT services experienced a 21% reduction in health care costs and a significant reduction in 1-year ED visits (decrease of 3.3 percentage points). CONCLUSIONS: This study provides further support that SBIRT programs are cost-effective and cost-beneficial approaches to substance use disorders management, important factors as policy advocates continue to disseminate SBIRT practices throughout the health care system.

Incorporating screening, brief intervention, and referral to treatment into emergency nursing workflow using an existing computerized physician order entry/clinical decision support system.

INTRODUCTION: The objective of this study was to evaluate whether screening, brief intervention, and referral to treatment (SBIRT) could be incorporated into the emergency nursing workflow using a computerized physician order entry/clinical decision support system. We report demographic and operational factors associated with failure to initiate the protocol and revenue collection from SBIRT. METHODS: We conducted a retrospective, observational cohort analysis of a protocol adding SBIRT to the emergency nursing workflow of a single, tertiary care urban emergency department for all adult patient visits in 2012. Emergency nurses prescreened for unhealthy alcohol or drug use during triage assessment and, when positive, administered SBIRT during treatment area care, all documented in the computerized physician order entry/clinical decision support system. Using multivariable logistic regression, we report demographic and operational factors associated with failure to initiate the protocol. From October 2012, we submitted charges for brief interventions and analyzed collection results. RESULTS: The inclusion criteria were met for 47,693 visits. Of these, 39,758 (83.4%) received triage protocol initiation. Variables associated with decreased odds of protocol initiation were younger age (odds ratio [OR] for rising age, 1.044; 95% confidence interval [CI], 1.042-1.045), arrival by ambulance (OR, 0.37; 95% CI, 0.35-0.40), and higher triage acuity (OR, 0.08; 95% CI, 0.07-0.09). Of visits with protocol initiation, 21.4% were documented as positive for at-risk alcohol and/or drug use. However, brief interventions were only administered during 971 visits. During the billing period, $3617.53 was collected on charges of $10,829.15 for 262 completed brief interventions. DISCUSSION: In this study electronic documentation of adults with at-risk alcohol and/or drug use was feasible by emergency nurses, but SBIRT execution and subsequent revenue collection were challenging.

Pennsylvania SBIRT Medical and Residency Training: developing, implementing, and evaluating an evidenced-based program.

Medical residents do not receive adequate training in screening, brief intervention, and referral to treatment (SBIRT) for alcohol and other drug use disorders. The federally funded Pennsylvania SBIRT Medical and Residency Training program (SMaRT) is an evidence-based curriculum with goals of training residents in SBIRT knowledge and skills and disseminating the curriculum throughout the medical residency programs. The SMaRT program collaborates with 4 hospital systems and 7 residency sites, with a target of 1147 residents to be trained. This brief report describes the design of the SMaRT program curriculum, implementation across settings and programs, and its evaluation methods.

Introduction to biofilms in family medicine.

The management of common infections in family medicine can be complicated by poor treatment response or infection recurrence. Bacteria can grow as free-floating, planktonic bacteria or complex communities called biofilms. Biofilms promote bacterial growth and diversity and offer unique environments, including both aerobic and anaerobic layers, to bacteria. Although most treatments are tested against planktonic bacteria grown in the laboratory, infections in patients usually are the more complex and difficult to treat biofilms. Biofilms offer bacteria enhanced resistance to antimicrobial therapies that may otherwise be effective against planktonic bacteria. In many cases, difficulty treating recurring and recalcitrant infections can be explained by the important role of biofilms.

Clinical application of treating biofilms-associated infections in family medicine.

The management of common infections in family medicine may be complicated by poor treatment response or infection recurrence. In many cases, difficulty in treating these infections can be explained by the important role of biofilms, complex microbial communities with unique survival properties that promote infection resistance, recurrence, and persistence. Biofilms have been demonstrated to play important roles in infections involving the sinuses, ears, and ischemic wounds. Biofilms also commonly grow on medical devices, such as indwelling catheters, where they serve as an important nidus of persistent infection. Understanding the role of biofilms in medical infections suggests preventive and treatment strategies that will directly target the important resistive mechanisms of biofilms.