Obstruction from endometriosis causing hydronephrosis and complex renal pelvis rupture: A case report.

Endometriosis presents a diagnostic conundrum due to its diverse clinical manifestations, ranging from asymptomatic to acute obstructive uropathy. This is a case of a 30-year-old woman with a history of endometriosis and rapidly progressing left flank pain culminating in rupture of the renal pelvis in her left kidney. Initial investigations revealed left-sided hydronephrosis without evidence of nephrolithiasis. Subsequent imaging showed active extravasation indicative of urinary obstruction attributable to endometriosis. Placement of a left nephrostomy tube alleviated her symptoms, and follow-up imaging revealed a distal ureteral stricture. A stent was subsequently placed, which resolved the obstruction and obviated the need for extensive surgical intervention. In this case, the patient's history of endometriosis prompted consideration of its role in urinary obstruction, despite the absence of typical symptoms, and underscores the importance of considering endometriosis as a potential cause of acute urinary obstruction, particularly in patients with a history of the disease. Physicians in the emergency department should maintain a high index of suspicion for endometriosis-related complications to facilitate timely intervention and prevent adverse outcomes. Awareness of the variable presentations of endometriosis is paramount for ensuring comprehensive patient care and optimal outcomes.

Imaging in a Pandemic: How Lack of Intravenous Contrast for Computed Tomography Affects Emergency Department Throughput.

Introduction: During the coronavirus 2019 pandemic, hospitals in the United States experienced a shortage of contrast agent, much of which is manufactured in China. As a result, there was a significantly decreased amount of intravenous (IV) contrast available. We sought to determine the effect of restricting the use of IV contrast on emergency department (ED) length of stay (LOS). Methods: We conducted a single-institution, retrospective cohort study on adult patients presenting with abdominal pain to the ED from March 7-July 5, 2022. Of 26,122 patient encounters reviewed, 3,028 (11.6%) included abdominopelvic CT with a complaint including "abdominal pain." We excluded patients with outside imaging and non-ED scans. Routine IV contrast agent was administered to approximately 74.6% of patients between March 7-May 6, 2022, when we altered usage guidelines due to a nationwide shortage. Between May 6-July 5, 2022, 32.8% of patients received IV contrast after institutional recommendations were made to limit contrast use. We compared patient demographics and clinical characteristics between groups with chi-square test for frequency data. We analyzed ED LOS with nonparametric Wilcoxon rank-sum test for continuous measures with focus before and after new ED protocols. We also used statistical process control charts and plotted the 1, 2 and 3 sigma control limits to visualize the variation in ED LOS over time. The charts include the average (mean) of the data and upper and lower control limits, corresponding to the number of standard deviations away from the mean. Results: After use of routine IV contrast was discontinued, ED LOS (229.0 vs 212.5 minutes, P = <0.001) declined by 16.5 minutes (95% confidence interval -10, -22). Conclusion: Intravenous contrast adds significantly to ED LOS. Decreased use of routine IV contrast in the ED accelerates time to CT completion. A policy change to limit IV contrast during a national shortage significantly decreased ED LOS.

Adult Congenital Heart Disease in the Emergency Department.

While congenital heart disease historically was a pathology primarily restricted to specialized pediatric centers, advances in technology have dramatically increased the number of people living into adulthood, the number of complications faced by these patients, and the number of patients visiting non-specialized emergency departments for these concerns. Clinicians need to be aware of the issues specific to patients' individual congenital defects but also have an understanding of how typical cardiac pathology may manifest in this special group of patients. This manuscript attempts to provide an overview of this diverse but increasingly common group of adult patients with congenital heart diseases, including a review of their anatomical variants, the complications they face at the highest rates, and ways that emergency physicians may need to manage these patients differently to avoid causing harm.

Evaluating urgent care center referrals to the emergency department.

Background and objectives: Urgent care centers (UCCs) are increasingly popular with an estimated number of 9600 stand-alone centers in the United States compared to emergency departments (EDs). These facilities offer a potentially more convenient and affordable option for patients seeking care for a variety of low-acuity conditions. Because of the limitations of UCCs, patients occasionally are referred to EDs for further care. Prior studies have attempted to evaluate the appropriateness of these UCC referrals. Our study is the first to consider if these referrals require ED-specific care and the diagnostic concordance of these referrals. Methods: We performed a retrospective chart review to identify patients who were referred from UCCs to our ED between October 2020 and June 2021. We used a Boolean search strategy to screen charts for the terms urgent care, emergency department, referral, or transfer. Cases were manually screened until 300 met the inclusion criteria. Cases had to feature the patient being seen by a UCC provider and directly referred to the ED on the same day. Patients who presented to the ED of their own volition were excluded. Three independent abstractors reviewed the charts. All abstractors and a senior investigator piloted the use of a data collection sheet and discussed the management of any ambiguous data. A senior physician reviewed all discrepancies among abstractors. Data collected included ED final diagnosis and whether the final diagnosis was similar to the UCC diagnosis. A referral was deemed to require ED-specific care and resources if (1) the patient was admitted, (2) imaging (other than an x-ray) was performed, (3) specialist consultation was required, or (4) care was provided in the ED that is not conventionally available at UCCs. Results: From the 300 patient charts, 55% of patients referred from UCCs to the ED did not require ED-specific care or resources and 64% had discordant diagnoses between UCC diagnosis and ED diagnosis. A total of 41% of patients underwent advanced imaging studies, 26% received specialty consultations, and 15% were admitted. Subgroup analysis for lacerations, extremity/fracture care, and abnormal electrocardiograms (ECGs) showed disproportionally high levels of discordant diagnoses and referrals that did not require ED-specific care or resources. Conclusion: Our data found that 55% of patients referred to EDs from UCCs did not require ED-specific care or resources and 64% carried a discordant diagnosis between UC and ED diagnosis. We suggest quality remedies, such as educational sessions and engagement with telemedicine sub-specialists as well as a coordinated formalized system for UCC to ED referrals.

The Case of the Red Extremities.

CASE PRESENTATION: A 37-year-old man with severe obstructive sleep apnea presented to the emergency department with burning pain, redness and swelling in his hands and feet, worsening for several weeks. Pertinent laboratory studies revealed polycythemia. DISCUSSION: Erythromelalgia is a clinical diagnosis characterized by painful burning, erythema, warmth, and edema usually involving the distal extremities. Therapeutic goals are focused on symptom reduction, while also managing the underlying condition in cases of secondary erythromelalgia. Pharmacological and non-pharmacological therapies have proven to be of limited success.

Measuring the opportunity loss of time spent boarding admitted patients in the emergency department: a multihospital analysis.

Emergency department (ED) crowding is an international crisis affecting the timeliness and quality of patient care. Boarding of admitted patients in the ED is recognized as a major contributor to ED crowding. The opportunity loss of this time is the benefit or value it could produce if it were used for something else. In crowded EDs, the typical alternative use of this time is to treat patients waiting to be seen. Various ED performance benchmarks related to inpatient boarding have been proposed, but they are not commonly reported and have yet to be evaluated to determine whether they correlate with the opportunity loss of time used for boarding. This study quantified several measures of ED boarding in a variety of hospital settings and looked for correlations between them and the opportunity loss of the time spent on boarding. In particular, average boarding time per admission was found to be easy to measure. Results revealed that it had a near-perfect linear correlation with opportunity loss. The opportunity loss of every 30 minutes of average boarding time equaled the time required to see 3.5 percent of the ED's daily census. For busy hospitals, the opportunity loss allowed sufficient time for staff to be able to see up to 36 additional patients per day. This correlation suggests that average boarding time per admission may be useful in evaluating efforts to reduce ED crowding and improve patient care.

Emergency department patient flow: the influence of hospital census variables on emergency department length of stay.

OBJECTIVES: The objective was to evaluate the association between hospital census variables and emergency department (ED) length of stay (LOS). This may give insights into future strategies to relieve ED crowding. METHODS: This multicenter cohort study captured ED LOS and disposition for all ED patients in five hospitals during five 1-week study periods. A stepwise multiple regression analysis was used to examine associations between ED LOS and various hospital census parameters. RESULTS: Data were analyzed on 27,325 patients on 161 study days. A significant positive relationship was demonstrated between median ED LOS and intensive care unit (ICU) census, cardiac telemetry census, and the percentage of ED patients admitted each day. There was no relationship in this cohort between ED LOS and ED volume, total hospital occupancy rate, or the number of scheduled cardiac or surgical procedures. CONCLUSIONS: In multiple hospital settings, ED LOS is correlated with the number of admissions and census of the higher acuity nursing units, more so than the number of ED patients each day, particularly in larger hospitals with busier EDs. Streamlining ED admissions and improving availability of inpatient critical care beds may reduce ED LOS.