Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis.

INTRODUCTION: Emergency department (ED) overcrowding is linked to poor outcome and decreases patient satisfaction. Strategies to control Emergency department (ED) overcrowding has been subject of research. STUDY OBJECTIVES: The objective of this systematic review and meta-analysis was to investigate the impact of triage liaison providers (TLPs) on the ED throughput. METHODS: We searched PubMed, EMBASE, and Web of Science up to April 2019 for studies done in the United States. Primary outcomes were number of patients left without being seen (LWBS) and patients' emergency department length of stay (ED-LOS). ED-LOS data was pooled using mean difference with random effect model. Risk Ratio (RRs) for LWBS was calculated with random effect model with 95% confidence interval (95% CI). RESULTS: Twelve studies encompassing 329,340patients were included in the meta-analysis. Implementation of the TLP system using attending physicians was associated with a decrease in risk of LWBS 0.62 (95% CI 0.54, 0.71), The change in ED-LOS after implementation of TLP was too heterogeneous to pool the data with the mean ΔED-LOS ranging from -82 to +20 min. Stratification of studies by disposition, admitted versus discharged, did not decrease the heterogeneity. CONCLUSION: Implementation of TLP can decrease the rate of LWBS however this review is inconclusive about the effect of TLP on ED-LOS due to the high heterogeneity observed in the literature.

The Effect of Pay-for-Performance Compensation Model Implementation on Vaccination Rate: A Systematic Review.

BACKGROUND AND OBJECTIVES: Pay-for-performance (P4P) is broadly defined as financial incentives to providers for attaining prespecified quality outcomes. Providers, payers, and public officials have worked over the years to develop innovative solutions to rapidly and consistently bring new diagnostic tests and therapies to our patients. P4P has been instituted in various forms over the last 30 years. Vaccines are one of society's greatest public health innovations and vaccination programs provide a unique opportunity for P4P programs. We attempted to investigate the effect of P4P compensation model implementation on the vaccination rate. METHODS: Utilizing a systematic review and meta-analysis approach, we searched PubMed, Embase, Scopus, and Web of Science from inception to December 2018. RESULTS: Nine articles were included with poor to moderate quality. Improvements in vaccination rates after implementation of P4P were statistically significant in 8 of 9 of studies. However, due to the heterogeneity of the methods used, we could not pool the data. CONCLUSION: The results of this systematic review indicate that the implementation of P4P programs can increase the vaccination rate. In recent times when it has become increasingly more popular not to vaccinate, implementing P4P becomes even more important if it is shown to be an effective tool in increasing vaccination rates.

Serial Sonographic Assessment of Pulmonary Edema in Patients With Hypertensive Acute Heart Failure.

OBJECTIVES: Objective measures of clinical improvement in patients with acute heart failure (AHF) are lacking. The aim of this study was to determine whether repeated lung sonography could semiquantitatively capture changes in pulmonary edema (B-lines) in patients with hypertensive AHF early in the course of treatment. METHODS: We conducted a feasibility study in a cohort of adults with acute onset of dyspnea, severe hypertension in the field or at triage (systolic blood pressure ≥ 180 mm Hg), and a presumptive diagnosis of AHF. Patients underwent repeated dyspnea and lung sonographic assessments using a 10-cm visual analog scale (VAS) and an 8-zone scanning protocol. Lung sonographic assessments were performed at the time of triage, initial VAS improvement, and disposition from the emergency department. Sonographic pulmonary edema was independently scored offline in a randomized and blinded fashion by using a scoring method that accounted for both the sum of discrete B-lines and degree of B-line fusion. RESULTS: Sonographic pulmonary edema scores decreased significantly from initial to final sonographic assessments (P < .001). The median percentage decrease among the 20 included patient encounters was 81% (interquartile range, 55%-91%). Although sonographic pulmonary edema scores correlated with VAS scores (ρ = 0.64; P < .001), the magnitude of the change in these scores did not correlate with each other (ρ = -0.04; P = .89). CONCLUSIONS: Changes in sonographic pulmonary edema can be semiquantitatively measured by serial 8-zone lung sonography using a scoring method that accounts for B-line fusion. Sonographic pulmonary edema improves in patients with hypertensive AHF during the initial hours of treatment.

History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis.

BACKGROUND: Acute cholecystitis (AC) is a common differential for patients presenting to the emergency department (ED) with abdominal pain. The diagnostic accuracy of history, physical examination, and bedside laboratory tests for AC have not been quantitatively described. OBJECTIVES: We performed a systematic review to determine the utility of history and physical examination (H&P), laboratory studies, and ultrasonography (US) in diagnosing AC in the ED. METHODS: We searched medical literature from January 1965 to March 2016 in PubMed, Embase, and SCOPUS using a strategy derived from the following formulation of our clinical question: patients-ED patients suspected of AC; interventions-H&P, laboratory studies, and US findings commonly used to diagnose AC; comparator-surgical pathology or definitive diagnostic radiologic study confirming AC; and outcome-the operating characteristics of the investigations in diagnosing AC were calculated. Sensitivity, specificity, and likelihood ratios (LRs) were calculated using Meta-DiSc with a random-effects model (95% CI). Study quality and risks for bias were assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. RESULTS: Separate PubMed, Embase, and SCOPUS searches retrieved studies for H&P (n = 734), laboratory findings (n = 74), and US (n = 492). Three H&P studies met inclusion/exclusion criteria with AC prevalence of 7%-64%. Fever had sensitivity ranging from 31% to 62% and specificity from 37% to 74%; positive LR [LR+] was 0.71-1.24, and negative LR [LR-] was 0.76-1.49. Jaundice sensitivity ranged from 11% to 14%, and specificity from 86% to 99%; LR+ was 0.80-13.81, and LR- was 0.87-1.03. Murphy's sign sensitivity was 62% (range = 53%-71%), and specificity was 96% (range = 95%-97%); LR+ was 15.64 (range = 11.48-21.31), and LR- was 0.40 (range = 0.32-0.50). Right upper quadrant pain had sensitivity ranging from 56% to 93% and specificity of 0% to 96%; LR+ ranged from 0.92 to 14.02, and LR- from 0.46 to 7.86. One laboratory study met criteria with a 26% prevalence of AC. Elevated bilirubin had a sensitivity of 40% (range = 12%-74%) and specificity of 93% (range = 77%-99%); LR+ was 5.80 (range = 1.25-26.99), and LR- was 0.64 (range = 0.39-1.08). Five US studies with a prevalence of AC of between 10% and 46%. US sensitivity was 86% (range = 78%-94%) and specificity was 71% (range = 66%-76%); LR+ was 3.23 (range = 1.74-6.00), and LR- was 0.18 (range = 0.10-0.33). CONCLUSION: Variable disease prevalence, coupled with limited sample sizes, increases the risk of selection bias. Individually, none of these investigations reliably rule out AC. Development of a clinical decision rule to include evaluation of H&P, laboratory data, and US are more likely to achieve a correct diagnosis of AC.

Identification of a pediatric intra-abdominal cystic lymphangioma using point-of-care ultrasonography.

Intra-abdominal cystic lymphangiomas are rare, benign congenital tumors that often present with vague symptoms, making diagnosis difficult. We report a case of a 4-year-old patient who presented to the emergency department with nonspecific abdominal pain. Her diagnosis of intra-abdominal cystic lymphangioma was facilitated by point-of-care ultrasonography.

Is there a correlation of sonographic measurements of true vocal cords with gender or body mass indices in normal healthy volunteers?

BACKGROUND: Ultrasound is a readily available, non-invasive technique to visualize airway dimensions at the patient's bedside and possibly predict difficult airways before invasively looking; however, it has rarely been used for emergency investigation of the larynx. There is limited literature on the sonographic measurements of true vocal cords in adults and normal parameters must be established before abnormal parameters can be accurately identified. OBJECTIVES: The primary objective of the following study is to identify the normal sonographic values of human true vocal cords in an adult population. A secondary objective is to determine if there is a difference in true vocal cord measurements in people with different body mass indices (BMIs). The third objective was to determine if there was a statistical difference in the measurements for both genders. MATERIALS AND METHODS: True vocal cord measurements were obtained in healthy volunteers by ultrasound fellowship trained emergency medicine physicians using a high frequency linear transducer orientated transversely across the anterior surface of the neck at the level of the thyroid cartilage. The width of the true vocal cord was measured perpendicularly to the length of the cord at its mid-portion. This method was duplicated from a previous study to create a standard of measurement acquisition. RESULTS: A total of 38 subjects were enrolled. The study demonstrated no correlation between vocal cord measurements and patient's characteristics of height, weight, or BMI's. When accounting for vocal cord measurements by gender, males had larger BMI's and larger vocal cord measurements compared with females subjects with a statistically significant different in right vocal cord measurements for females compared with male subjects. CONCLUSION: No correlation was seen between vocal cord measurements and person's BMIs. In the study group of normal volunteers, there was a difference in size between the male and female vocal cord size.

Sonographic diagnosis of bilateral pneumothorax following an acupuncture session.

We present the case of a 57-year-old woman who presented with the acute onset of chest pain and dyspnea, which started while undergoing acupuncture for neck pain. A bedside ultrasound revealed bilateral pneumothoraces, which were confirmed radiographically. We discuss the details of the case, the sonographic features of pneumothorax, and the role of bedside ultrasonography in the assessment of an acutely dyspneic patient.

Diagnostic accuracy of history, physical examination, and bedside ultrasound for diagnosis of extremity fractures in the emergency department: a systematic review.

OBJECTIVES: Understanding history, physical examination, and ultrasonography (US) to diagnose extremity fractures compared with radiography has potential benefits of decreasing radiation exposure, costs, and pain and improving emergency department (ED) resource management and triage time. METHODS: The authors performed two electronic searches using PubMed and EMBASE databases for studies published between 1965 to 2012 using a strategy based on the inclusion of any patient presenting with extremity injuries suspicious for fracture who had history and physical examination and a separate search for US performed by an emergency physician (EP) with subsequent radiography. The primary outcome was operating characteristics of ED history, physical examination, and US in diagnosing radiologically proven extremity fractures. The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). RESULTS: Nine studies met the inclusion criteria for history and physical examination, while eight studies met the inclusion criteria for US. There was significant heterogeneity in the studies that prevented data pooling. Data were organized into subgroups based on anatomic fracture locations, but heterogeneity within the subgroups also prevented data pooling. The prevalence of fracture varied among the studies from 22% to 70%. Upper extremity physical examination tests have positive likelihood ratios (LRs) ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US sensitivities varied between 85% and 100%, specificities varied between 73% and 100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between 0 and 0.2. CONCLUSIONS: Compared with radiography, EP US is an accurate diagnostic test to rule in or rule out extremity fractures. The diagnostic accuracy for history and physical examination are inconclusive. Future research is needed to understand the accuracy of ED US when combined with history and physical examination for upper and lower extremity fractures.

Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm.

BACKGROUND: The use of ultrasound (US) to diagnose an abdominal aortic aneurysm (AAA) has been well studied in the radiology literature, but has yet to be rigorously reviewed in the emergency medicine arena. OBJECTIVES: This was a systematic review of the literature for the operating characteristics of emergency department (ED) ultrasonography for AAA. METHODS: The authors searched PubMed and EMBASE databases for trials from 1965 through November 2011 using a search strategy derived from the following PICO formulation: Patients-patients (18+ years) suspected of AAA. Intervention-bedside ED US to detect AAA. Comparator-reference standard for diagnosing an AAA was a computed tomography (CT), magnetic resonance imaging (MRI), aortography, official US performed by radiology, ED US reviewed by radiology, exploratory laparotomy, or autopsy results. AAA was defined as ≥ 3 cm dilation of the aorta. Outcome-operating characteristics (sensitivity, specificity, and likelihood ratios [LR]) of ED abdominal US. The papers were analyzed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) guidelines. RESULTS: The initial search strategy identified 1,238 articles; application of inclusion/exclusion criteria resulted in seven studies with 655 patients. The weighted average prevalence of AAA in symptomatic patients over the age of 50 years is 23%. On history, 50% of AAA patients will lack the classic triad of hypotension, back pain, and pulsatile abdominal mass. The sensitivity of abdominal palpation for AAA increases as the diameter of the AAA increases. The pooled operating characteristics of ED US for the detection of AAA were sensitivity 99% (95% confidence interval [CI] = 96% to 100%) and specificity 98% (95% CI = 97% to 99%). CONCLUSIONS: Seven high-quality studies of the operating characteristics of ED bedside US in diagnosing AAA were identified. All showed excellent diagnostic performance for emergency bedside US to detect the presence of AAA in symptomatic patients.

Systematic review: is real-time ultrasonic-guided central line placement by ED physicians more successful than the traditional landmark approach?

INTRODUCTION: The superiority of ultrasonic-guided compared with landmark-guided central venous catheter (CVC) placement is not well documented in the Emergency Department. OBJECTIVE: To systematically review the literature comparing success rates between ultrasonic- and landmark-guided CVC placement by ED physicians. METHODS: PubMed and EMBASE databases were searched for randomised controlled trials from 1965 to 2010 using a search strategy derived from the following PICO formulation: PATIENTS: Adults requiring emergent CVC placement except during cardiopulmonary resuscitation. INTERVENTION: CVC placement using real-time ultrasonic guidance. Comparator: CVC placement using anatomical landmarks. OUTCOME: Comparison of success rates of CVC placement between ultrasonic- versus landmark-guided techniques. ANALYSIS: Success rates between CVC placement methods using a Forest Plot (95% CI) calculated by Review Manager Version 5.0. RESULTS: Search identified 944 articles of which 938 were excluded by title/abstract relevance, two not randomised, one cardiac arrest, one no landmark control, one success rate not calculated. A single study of 130 patients (65 ultrasonic- vs 65 landmark-guided) selected for internal jugular vein placement remained. Successful internal jugular CVC was significantly (p=0.02) more likely in the ultrasound-guided (93.9%) compared with landmark-guided (78.5%) techniques with an OR of 1.2 (95% CI 1.0 to 1.4). Complications rates were significantly (p=0.04) lower in ultrasonic (4.6%) versus landmark (16.9%) technique, OR=3.7 (95% CI 1.1 to 12.5). CONCLUSION: Only one single high quality study illustrating that ED ultrasound- versus landmark-guided internal jugular catheter placement had higher success rates with lower complication rates.

Identification of intraluminal thrombus by ultrasonography in emergency department patients with acute deep venous thrombosis.

BACKGROUND: Traditionally, the diagnosis of deep venous thrombosis (DVT) using duplex ultrasonography (DU) has relied on the absence of venous compressibility. Visualization of an intraluminal thrombus is considered an uncommon finding. OBJECTIVES: The purpose of this study is to determine the frequency of intraluminal thrombus in emergency department (ED) patients diagnosed with acute DVT. METHODS: Retrospective chart review of adult ED patients with DU examinations demonstrating acute DVT. Patients with chronic DVT or patients in whom DU did not demonstrate DVT were excluded from data analysis. Study reports and ultrasound images were reviewed and analyzed for the presence of intraluminal thrombus. RESULTS: There were 189 patients who met inclusion criteria, of which 160 (85%) were found to have intraluminal thrombus. CONCLUSION: Intraluminal thrombi are present in the majority of patients in our ED in whom acute DVT is identified by DU.