Remote patient monitoring for ED discharges in the COVID-19 pandemic.

COVID-19 has had a significant effect on healthcare resources worldwide, with our knowledge of the natural progression of the disease evolving for the individual patient. To allow for early detection of worsening clinical status, protect hospital capacity and provide extended access for vulnerable patients, our emergency department developed a remote patient monitoring programme for discharged patients with COVID-19. The programme uses a daily emailed secure link to a survey in which patients submit biometric and symptoms data for monitoring. Patients' meeting criteria are escalated to a physician for a phone or video visit. Here, we describe the development, implementation and preliminary analysis of utilisation of the programme.

Communicating value to patients-a high-value care communication skills curriculum.

INTRODUCTION: With rising health care costs in the United States, trainees will be increasingly challenged in discussing testing stewardship with patients. OBJECTIVE: We piloted a high-value care (HVC) communication skills curriculum utilizing the Four Habits Model for communication. We hoped residents would 1) learn to apply the Four Habits communication model to HVC discussions with standardized patients (SP) and 2) improve value-based communication skills through training in a high-intensity curriculum with feedback from trained faculty facilitators and peers. METHODS: Thirty interns at the University of Minnesota were randomized to a standard HVC communication SP encounter (n = 15) or a high-intensity HVC communication skills curriculum (n = 15). The high-intensity curriculum included video and audio-recorded SP encounters followed by facilitated small group discussions/feedback. Experiences were reported in a post-intervention survey; communication skills were assessed with the CARE empathy scale. RESULTS: 70% (21/30) of interns (57% high intensity, 43% standard) responded to the survey. In total, 88% of high intensity v. 44% of standard interns agreed/strongly agreed that the curriculum was valuable for their communication skills. High-intensity interns were more likely to report that feedback was valuable with subsequent incorporation of feedback into future patient encounters. High-intensity participants also reported higher levels of interest in future HVC curricula (55% vs 22%). CONCLUSION: There was no difference in overall performance on the CARE empathy scale. Our HVC high-intensity skills curriculum was well received by interns and provided opportunities to practice structured conversations and debrief around testing stewardship.

Emergency department approach to gastric tube complications and review of the literature.

Nasogastric and orogastric tubes (NGT/OGT) are commonly used in emergency and critical care settings, with indications including medicinal administration, gastric decompression, and enteral feeding. Previous studies have highlighted a variety of complications associated with tube placement. These range from minor occurrences such as nose bleeds and sinusitis, to more severe cases highlighting tracheobronchial perforation, tube knotting, asphyxia, pulmonary aspiration, pneumothorax, and even intracranial insertion. Patients who suffer from these complications face additional obstacles including increased time spent in intensive care settings, healthcare associated costs, and nosocomial infections. Various bedside tests have been developed to reduce the risk of these complications, and current clinical protocol has characterized radiographic imaging as the gold standard. However, air insufflation, CO2 detection (capnography), aspirate pH testing, and point of care ultrasound (POCUS) have all been implemented with varying degrees of utility. Here we present a case involving a 60-year-old male who was brought to the ED and suffered a right sided pneumothorax (PTX) following improper OGT placement. In this case, air insufflation was utilized, but was ineffective in detecting the properly placed tube; leakage of an endotracheal tube cuff served as a lead for misplacement while imaging was conducted. The purpose of this study is not only to highlight the numerous complications that are possible with NGT and OGT placement, but also to propose the use of multiple bedside tests (pH testing, CO2 detection, POCUS) as an alternative to radiographic imaging to increase sensitivity and specificity for detection of improperly placed tubes.

Adoption of low tidal volume ventilation in the emergency department: A quality improvement intervention.

BACKGROUND: Ventilator tidal volumes of >8 mL/kg of predicted body weight (PBW) may increase the risk of lung injury. We sought to evaluate the impact of a quality improvement intervention among intubated Emergency Department (ED) patients to protocolize the prescription of low tidal volume ventilation. METHODS: In this before-and-after study, the average tidal volume delivered to ED patients receiving volume assist-control ventilation was compared before (2007-2014) and after (2015-2016) implementation of a ventilator initiation protocol (the quality improvement intervention). The intervention emphasized 1) measurement of the patient's height to calculate PBW and therefore tailor the tidal volume to estimated lung size (<8 mL/kg PBW), and 2) focused education and reference materials for ED physicians and respiratory therapists. RESULTS: Among ventilated ED patients meeting inclusion criteria in the before (N = 2185) and after (N = 774) cohorts, the mean (±SD) tidal volume decreased from 9.0 ±â€¯1.4 mL/kg to 7.2 ±â€¯0.9 mL/kg PBW following the intervention (absolute difference 1.8 mL/kg, 95% confidence interval 1.7 to 1.9 mL/kg, p < 0.001). The proportion of patients receiving low tidal volume ventilation increased after the intervention (72%), as compared to before (23%). Low tidal volume ventilation continued to be utilized at 24 h after ICU admission in patients who remained intubated in the cohort following the intervention (mean tidal volume 7.3 mL/kg PBW). CONCLUSIONS: Pairing a ventilator initiation protocol with focused education and resources for emergency physicians and respiratory therapists was associated with a significant reduction in tidal volume delivered to ED patients.