Amyloid-related imaging abnormalities (ARIA): diagnosis, management, and care in the setting of amyloid-modifying therapy.

Amyloid-related imaging abnormalities, were originally described by dementia care experts. The wider use of aducanumab and now lecanemab warrant broader understanding by the health care provider continuum. The optimal care approach for patients with Alzheimer's dementia, treated with amyloid-targeted therapy, includes proper clinical diagnosis, complication surveillance, specific imaging protocols, expert specialty consultation, integrated treatment strategies, and proper facility system planning. Improved awareness and understanding of amyloid-modifying therapy, both benefits and potential complications, among the health care provider continuum is paramount to the success of complex care programs. Specifically, recognition of treatment high risk, high benefit groups, and the interface of concurrent antiplatelet and anticoagulation. This integrated acute, specialty, and primary care approach should improve patient care quality and outcome.

Medicolegal aspects of documentation and the electronic health record / Aspectos medicolegales de la documentación y la historia clínica electrónica

Introduction: The busiest times in the hospital are often met by the greatest challenges in complete and comprehensive documentation of the patient care event. The near complete transition to the Electronic Health Record (EHR) was to be the solution to a host of provider documentation concerns. It is clear the EHR provides reliability, reproducibility, integration, evidence based decision-making, multidisciplinary contribution across the entire healthcare spectrum.Methods: The use of a consensus of expert opinion supplemented by focused literature review allows a balanced evidence based presentation of data. Results: Documentation is not a perfect tool however, as issues with efficiency, reliability, use of shortcut maneuvers and potential for increased medico-legal risk have been raised. The solution is attention to documentation detail, and creation of systems that facilitate excellence. The focus on electronic documentation systems should include continual evaluation, ongoing improvement, involvement of a multidisciplinary patient care team and vendor receptiveness to in EHR development and operations. Conclusion: The most effective use of the EHR as a risk management tool requires documentation knowledge, targeted analysis, product improvement and co-development of clinical-commercial resource.(AU)

Introducción: Los momentos de mayor actividad en el hospital a menudo se enfrentan con los mayores desafíos en cuanto a la documentación completa y exhaustiva del evento de atención al paciente. La transición casi completa a la historia clínica electrónica (HCE) iba a ser la solución a una serie de preocupaciones sobre la documentación de los proveedores. Está claro que la HCE proporciona confiabilidad, reproducibilidad, integración, toma de decisiones basada en la evidencia y contribución multidisciplinaria en todo el espectro de la atención médica.Métodos: El uso de un consenso de opinión de expertos complementado con una revisión de la literatura enfocada permite una presentación equilibrada de los datos basada en la evidencia.Resultados: La documentación no es una herramienta perfecta, ya que se han planteado problemas de eficiencia, confiabilidad, uso de maniobras abreviadas y la posibilidad de un mayor riesgo medicolegal. La solución es la atención al detalle de la documentación y la creación de sistemas que faciliten la excelencia. El enfoque en los sistemas de documentación electrónica debe incluir evaluación continua, mejora continua, participación de un equipo multidisciplinario de atención al paciente y receptividad de los proveedores en el desarrollo y las operaciones de la HCE. Conclusión: El uso más eficaz de la HCE como herramienta de gestión de riesgos requiere conocimiento de la documentación, análisis específicos, mejora del producto y desarrollo conjunto de recursos clínico-comerciales.(AU)

Medicolegal aspects of documentation and the electronic health record.

INTRODUCTION: The busiest times in the hospital are often met by the greatest challenges in complete and comprehensive documentation of the patient care event. The near complete transition to the Electronic Health Record (EHR) was to be the solution to a host of provider documentation concerns. It is clear the EHR provides reliability, reproducibility, integration, evidence based decision-making, multidisciplinary contribution across the entire healthcare spectrum. METHODS: The use of a consensus of expert opinion supplemented by focused literature review allows a balanced evidence based presentation of data. RESULTS: Documentation is not a perfect tool however, as issues with efficiency, reliability, use of shortcut maneuvers and potential for increased medico-legal risk have been raised. The solution is attention to documentation detail, and creation of systems that facilitate excellence. The focus on electronic documentation systems should include continual evaluation, ongoing improvement, involvement of a multidisciplinary patient care team and vendor receptiveness to in EHR development and operations. CONCLUSION: The most effective use of the EHR as a risk management tool requires documentation knowledge, targeted analysis, product improvement and co-development of clinical-commercial resource.

Emergency medicine provider efficiency: the learning curve, equilibration and point of diminishing returns.

OBJECTIVE: This study described the spectrum of emergency department (ED) physician performance correlating annual workload, experience and facility issues. METHODS: Retrospective review reported physician hours worked comparing productivity measures--patients per hour (PPH) or relative value unit (RVU) per hour, as 'best fit' trend line and facility volume subgroups by analysis of variance. RESULTS: 912 physicians evaluated 2,407,833 patients in 61 ED. Staff productivity was 1.72±0.44 PPH (1.2±0.30-2.1±0.32 PPH) and 4.43±1.21 RVU/h (2.9±0.80-5.4±0.82 RVU/h). There was less variation with facility size 2.58±0.36 (2.41±0.22-2.72±0.37 RVU/visit) from smaller to larger (p<0.001). Maximal efficiency occurs at 5.0 RVU/h generated at 1550 annual hours (130 monthly) compared with 1800 h full-time equivalent (FTE) physicians (R(2)=0.084). Productivity begins at 4.0 RVU/h for casual (<250 h/year), 4.4 RVU/h for part time (<500 h), achieving equilibrium (5.0 RVU/h) for three-quarters to full time (1250-1800 h) with a decline in full-time providers (2000-2500 h/year). Efficiency was less in smaller ED less than 15,000 (1.22±0.30 PPH, 2.95±0.80 RVU/h) compared with larger greater than 45,000 (2.07±0.32 PPH, 5.43±0.82 RVU/h; p<0.001). The RVU/visit generated were less varied (2.41±0.22) in smaller versus (2.64±0.38) larger facilities with a 2.8 RVU/h equilibration point (p<0.001). CONCLUSION: Maximal productivity is reached at 86% (1550 h) annual workload and efficiency declines at conventional FTE (≈ 1800 h). A distinct 'learning curve' was found in newer, casual providers and smaller facilities.

Initial cardiac rhythm correlated to emergency department survival.

BACKGROUND: This study attempted to correlate the initial cardiac rhythm and survival from prehospital cardiac arrest, as a secondary end-point. METHODS: Prospective, randomized, double-blinded clinical intervention trial where bicarbonate was administered to 874 prehospital cardiopulmonary arrest patients in prehospital urban, suburban, and rural emergency medical service environments. RESULTS: This group's manifested an overall survival rate of 13.9% (110 of 793) of prehospital cardiac arrest patients. The most common presenting arrhythmia was ventricular fibrillation (VF) (45.0%), asystole (ASY) (34.4%), and pulseless electrical activity (PEA) (15.7%). Less commonly found were normal sinus rhythm (NSR) (1.8%), other (1.8%), ventricular tachycardia (VT) (0.6%), and atrioventricular block (AVB) (0.5%) as prearrest rhythms. The best survival was noted in those with a presenting rhythm of AVB (57.1%), VT (33.3%), VF (15.7%), NSR (14.3%), PEA (11.2%), and ASY (11.1%) (p = 0.02). However, there was no correlation between the final cardiac rhythm and outcome, other than an obvious end-of-life rhythm. CONCLUSION: The most common presenting arrhythmia was VF (45%), while survival is greatest in those presenting with AVB (57.1%).

The Outcome of Cardiac Dysfunction in Critically Ill Trauma Patients: Myocardial Contusion Complicated by Refractory Hypotension.

BACKGROUND: This work attempted to define the care and course of those most severely affected patients in the setting of blunt chest trauma, who had hypotension refractory to routine fluid resuscitation. METHODS: Twenty-three critically ill blunt trauma ICU patients were resuscitated and enrolled with ongoing hypotension required placement of a pulmonary artery catheter. The REF(®)Explorer (Baxter, Edwards, Anaheim, CA) catheter was placed in the right heart measuring pressure, volume and oxygen utilization information, as well as recording Injury Severity Score, EKG, CXR, CPK/MB and echocardiography over the initial 72-h time period. RESULTS: There were an approximately 2,300 Level I trauma patients admitted annually over a 4-year period with an overall mortality rate of 4.3% (100) patients with 3.4% (79) patients "ruling in" with elevated cardiac enzymes, associated with an increased mortality rate of 6.7% (p < 0.05). The 23 patients were male (17, 74%), mean age 41.2 years, with no past medical history (19, 83%), in a motor vehicle accident (21, 91%), with pulmonary injury (9, 39%), undergoing celiotomy in (10, 44%). They presented with moderate to severe trauma acuity defined as mean GCS of 8.6, TS of 11.3, and ISS of 34 with an increased mean hospital stay of 15 days versus 6 days in the ICU; and a 26 days versus 10 days overall stay for those with myocardial contusion (p < 0.05). Analysis of diagnostic variables found an abnormal EKG in (21, 91%), CXR in (20, 87%) and echocardiogram in (8, 37%). The total CPK was found to be elevated, mean 2,219 (204-8,278 U/l), while the MB fraction was normal 2.3 ± 1.3%. Invasive cardiac monitoring found an increase in CO of 1.6 l/min from 5.9 to 7.8 l/min during the first 24 h of recovery. Survival was worsened with increased ISS (29 vs. 43) p < 0.02, but improved with longer ICU (17 vs. 8) p < 0.03 and hospital (39 vs. 7) p < 0.05 stay in days. The analysis of commonly used diagnostic modalities - EKG, CXR, ECHO, or CO, did not correlate with survival, but the total CPK was increased in survivors (2,715 vs. 1,432 U/l) p < 0.009. CONCLUSION: There is worsened morbidity with a 2-fold increase in ICU LOS and hospital stay, and a 1.5-fold increase in mortality in the severe myocardial contusion group. The diagnostic dilemma posed by lack of definitive testing continues unresolved after analysis of routinemodalities - EKG, CXR, ECHO, CPK or CO - failing to yield a "best test".

Customer satisfaction with patient care: "Where's the Beef?".

STUDY OBJECTIVE: This was an attempt to present an analysis of the literature examining objective information concerning the subject of customer service, as it applies to the current medical practice. Hopefully this information will be synthesized to generate a cogent approach to correlate customer service with quality. METHODS: Articles were obtained by an English language search of MEDLINE from January 1976 to July 2005. This computerized search was supplemented with literature from the author's personal collection of peer reviewed articles on customer service in a medical setting. This information was presented in a qualitative fashion. RESULTS: There is a significant lack of objective data correlating customer service objectives, patient satisfaction, and quality of care. Patients present predominantly for the convenience of emergency department care. Specifics of satisfaction are directed to the timing, and amount of "caring." Demographic correlates including symptom presentation, practice style, location, and physician issues directly impact on satisfaction. It is most helpful to develop a productive plan for the "difficult patient" emphasizing communication and empathy. CONCLUSION: The current emergency medicine customer service dilemmas are a complex interaction of both patient and physician factors specifically targeting both efficiency and patient satisfaction. Awareness of these issues can help to maximize efficiency, minimize subsequent medicolegal risk and improve patient care.

Customer satisfaction.

PURPOSE: This paper seeks to present an analysis of the literature examining objective information concerning the subject of customer service, as it applies to the current medical practice. Hopefully, this information will be synthesized to generate a cogent approach to correlate customer service with quality. DESIGN/METHODOLOGY/APPROACH: Articles were obtained by an English language search of MEDLINE from January 1976 to July 2005. This computerized search was supplemented with literature from the author's personal collection of peer-reviewed articles on customer service in a medical setting. This information was presented in a qualitative fashion. FINDINGS: There is a significant lack of objective data correlating customer service objectives, patient satisfaction and quality of care. Patients present predominantly for the convenience of emergency department care. Specifics of satisfaction are directed to the timing, and amount of "caring". Demographic correlates including symptom presentation, practice style, location and physician issues directly impact on satisfaction. It is most helpful to develop a productive plan for the "difficult patient", emphasizing communication and empathy. Profiling of the customer satisfaction experience is best accomplished by examining the specifics of satisfaction, nature of the ED patient, demographic profile, symptom presentation and physician interventions emphasizing communication--especially with the difficult patient. ORIGINALITY/VALUE: The current emergency medicine customer service dilemmas are a complex interaction of both patient and physician factors specifically targeting both efficiency and patient satisfaction. Awareness of these issues particular to the emergency patient can help to maximize efficiency, minimize subsequent medicolegal risk and improve patient care if a tailored management plan is formulated.

Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest.

OBJECTIVE: This study evaluates the effect of early administration of an empirical (1 mEq/kg) sodium bicarbonate dose on survival from prehospital cardiac arrest within brief (<5 minutes), moderate (5-15 minutes), and prolonged (>15 minutes) down time. METHODS: Prospective randomized, double-blinded clinical intervention trial that enrolled 874 prehospital cardiopulmonary arrest patients managed by prehospital, suburban, and rural regional emergency medical services. Over a 4-year period, the randomized experimental group received an empirical dose of bicarbonate (1 mEq/kg) after standard advanced cardiac life support interventions. Outcome was measured as survival to emergency department, as this was a prehospital study. RESULTS: The overall survival rate was 13.9% (110/792) for prehospital arrest patients. There was no difference in the amount of sodium bicarbonate administered to nonsurvivors (0.859 +/- 0.284 mEq/kg) and survivors (0.8683 +/- 0.284 mEq/kg) (P = .199). Overall, there was no difference in survival in those who received bicarbonate (7.4% [58/420]), compared with those who received placebo (6.7% [52/372]) (P = .88; risk ratio, 1.0236; 0.142-0.1387). There was, however, a trend toward improved outcome with bicarbonate in prolonged (>15 minute) arrest with a 2-fold increase in survival (32.8% vs 15.4%; P = .007). CONCLUSION: The empirical early administration of sodium bicarbonate (1 mEq/kg) has no effect on the overall outcome in prehospital cardiac arrest. However, a trend toward improvement in prolonged (>15 minutes) arrest outcome was noted.

Survival from prehospital cardiac arrest is critically dependent upon response time.

STUDY OBJECTIVE: This study correlated the delay in initiation of bystander cardiopulmonary resuscitation (ByCPR), basic (BLS) or advanced cardiac (ACLS) life support, and transport time (TT) to survival from prehospital cardiac arrest. This was a secondary endpoint in a study primarily evaluating the effect of bicarbonate on survival. DESIGN: Prospective multicenter trial. SETTING: Patients treated by urban, suburban, and rural emergency medical services (EMS) services. PATIENTS: Eight hundred and seventy-four prehospital cardiac arrest patients. INTERVENTIONS: This group underwent conventional ACLS intervention followed by empiric early administration of sodium bicarbonate noting resuscitation times. Survival was measured as the presence of vital signs on emergency department (ED) arrival. Data analysis utilized Student's t-test and logistic regression (p<0.05). RESULTS: Survival was improved with decreased time to BLS (5.52 min versus 6.81 min, p=0.047) and ACLS (7.29 min versus 9.49 min, p=0.002) intervention, as well as difference in time to return of spontaneous circulation (ROSC). The upper limit time interval after which no patient survived was 30 min for ACLS time, and 90 min for transport time. There was no overall difference in survival except at longer arrest times when considering the primary study intervention bicarbonate administration. CONCLUSION: Delay to the initiation of BLS and ACLS intervention influenced outcome from prehospital cardiac arrest negatively. There were no survivors after prolonged delay in initiation of ACLS of 30 min or greater or total resuscitation and transport time of 90 min. This result was not influenced by giving bicarbonate, the primary study intervention, except at longer arrest times.

The diagnosis of cardiac dysfunction in critically III trauma patients with blunt chest trauma and presumed myocardial contusion: the critical nature of end diastolic volume.

BACKGROUND: To evaluate prospectively the effectiveness of monitoring end-diastolic volume (EDV) vs pulmonary artery occlusion pressure (PAO) as an estimate of cardiac preload in hemodynamically unstable critically ill 23 myocardial contusion patients with blunt chest trauma admitted to a university trauma center.. METHODS: Patients were resuscitated (ATLS guidelines) with intubation and volume replacement for altered consciousness, hypoxemia or hemodynamic instability. Volume resuscitation and pulmonary artery catheterization were started to measure PAO, EDV, and oxygen utilization parameters. Myocardial performance was determined in both static (0., 24., 48., 72. hours) and dynamic condition after 500cc fluid bolus. RESULTS: A moderate injury severity (GCS 9, TS 11, ISS 34) with MVA mechanism (91%), an average ICU stay of 14 days and a 39% mortality were revealed. Correlation of PAO, EDV with CO, CI demonstrated that EDV is more reliable than PAO However, factoring heart rate into CO determination was more reliable than single preload estimates of EDV-PAO-HR, HR-EDV, and HR-PAO. EDV-PAO-HR were correlated more strongly with cardiac output from 24 to 96 hours. A higher AV02 decrease was associated with improved survival, and a nearly significant decrease in EDV. Dynamic comparison found no change in cardiac performance with a small volume challenge. CONCLUSION: Simultaneous consideration of PAO, EDV, HR allowed the most accurate determination of cardiac output.

Abdominal pain in a child associated with dental amalgam ingestion.

We present the case of a child with abdominal cramping found to have radiopaque matter in his gastrointestinal tract on plain radiography. The parents denied ingestion of a foreign substance but specific questioning revealed a visit for dental care the previous day. This may serve to illustrate the benefits of taking a careful goal-directed history as opposed to the often recommended open-ended approach.

Drug seeking behavior.

CONCEPT: Drug seeking behavior (DSB) is often mixed in illicit drug diversion confounding legitimate attempts to control acute and chronic pain. OBJECTIVE: To review the literature of acute and chronic pain control against the medical and legal context of DSB. DESIGN: Retrospective literature review from National Library of Medical Computerized Data Base 1990--2004. PATIENTS: Preference to human prospective on retrospective clinical trials. RESULTS: Drug use and abuse have significant adverse consequences. Pain control is desirable and necessary with chronic pain syndromes more prone to DSB. This behavior can be accurately profiled and information used to assist recovery. CONCLUSION: It is desirable to address DSB stressing acceptance and a multidisciplinary approach to recovery.

Does serum prolactin indicate the presence of seizure in the emergency department patient?

STUDY OBJECTIVE: We sought to evaluate whether there was a correlation between elevated serum prolactin in patients presenting with the question of seizure. METHODS: A Convenience sample of 200 consecutive patients were chosen who had a serum prolactin measurement in the setting of seizure activity. RESULTS: The prolactin level was within a range of 3.90-294.00 mg/dl with an upper limit of normal being 29.9 mg/dl. Patients were ultimately diagnosed with seizure in 54.5% (109 of 200) with an abnormal prolactine in 31.0% (62 of 200). The sensitivity of this serum prolactin was 42%, the specificity was 82%, positive predictive value (PPV) of 74%, and negative predictive value (NPV) of 54%. There was an overall accuracy of 60% in the diagnosis of seizure, with a likelihood ratio of 2.4 (95% Confidence Interval [CI], 1.5-3.9). CONCLUSION: The measurement of serum prolactin is helpful as a confirmatory test, but not as screening test in the emergency department setting.

The influence of urban, suburban, or rural locale on survival from refractory prehospital cardiac arrest.

There are many variables that can have an effect on survival in cardiopulmonary arrest. This study examined the effect of urban, suburban, or rural location on the outcome of prehospital cardiac arrest as a secondary end point in a study evaluating the effect of bicarbonate on survival. The proportion of survivors within a type of EMS provider system as well as response times were compared. This prospective, randomized, double-blind clinical intervention trial enrolled 874 prehospital cardiopulmonary arrest patients encountered by prehospital urban, suburban, and rural regional EMS area. Population density (patients per square mile) calculation allowed classification into urban (>2000/mi2), suburban (>400/mi2), and rural (0-399/mi2) systems. This group underwent standard advanced cardiac life support (ACLS) intervention with or without early empiric administration of bicarbonate in a 1-mEq/kg dose. A group of demographic, diagnostic, and therapeutic variables were analyzed for their effect on survival. Times were measured from collapse until onset of medical intervention and survival measured as the presence of ED vital signs on arrival. Data analysis used chi-squared with Pearson correlation for survivorship and Student t test comparisons for response times. The overall survival rate was approximately 13.9% (110 of 793), ranging from 9% rural, 14% for suburban, and 23% for urban sites for 372 patients (P=.007). Survival differences were associated with classification of arrest locale in this sample-best for urban, suburban, followed by rural sites. There was no difference in time to bystander cardiopulmonary resuscitation, but medical response time (basic life support) was decreased for suburban or urban sites, and intervention (ACLS) and transport times were decreased for suburban sites alone. Although response times were differentiated by location, they were not necessarily predictive of survival. Factors other than response time such as patient population or resuscitation skill could influence survival from cardiac arrest occurring in diverse prehospital service areas.

Prehospital cardiac arrest and the adverse effect of male gender, but not age, on outcome.

OBJECTIVE: To analyze the incidence and outcome of prehospital cardiac arrest as it correlated to gender and age as a secondary end point in an interventional clinical trial. METHODS: This prospective, randomized, double-blinded clinical intervention trial enrolled 874 prehospital cardiopulmonary arrest patients encountered by prehospital urban, suburban, and rural regional emergency medical service (EMS) areas. This trial evaluated outcome and profiled demographic predictors of cardiac arrest patients refractory to defibrillation with intravenous access who underwent standard advanced cardiac life support (ACLS) intervention and empiric early administration of bicarbonate. Survival was measured to the emergency department (ED), and data analysis used chi-square with Pearson correlation. RESULTS: The overall survival rate was 14.2%. There was no age correlate to survival, with an average age of 67.4 for both groups. Male patients had a 2.4-fold increased incidence (70.7 vs. 29.3%, p = 0.001) of arrest, which was associated with a 60% increase in mortality (19.6% vs. 11.8, p = 0.004) compared with women. The risk of unfavorable outcome was increased for men (OR 1.826, 95% CI 1.182-2.821; RR 1.097, 95% CI 1.025-1.180) on univariate analysis. There appeared to be no intergroup differences found with other historical variables, such as the presence of myocardial infarction (MI), hypertension (HTN), diabetes mellitus (DM), congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), which were analyzed. However, HTN was found more commonly (2.2 times) in men (69.1 vs. 30.9%) than in women but did not correlate with survival. CONCLUSIONS: Male gender, but not age, is associated with both an increased incidence and a worsened outcome in prehospital cardiac arrest.