Evaluation of a Novel Handoff Communication Strategy for Patients Admitted from the Emergency Department.

INTRODUCTION: Miscommunication during inter-unit handoffs between emergency and internal medicine physicians may jeopardize patient safety. Our goal was to evaluate the impact of a structured communication strategy on the quality of admission handoffs. METHODS: We conducted a mixed-methods, pre-test/post-test study at a 560-bed academic health center with 60,000 emergency department (ED) patient visits per year. Admission-handoff best practices were integrated into a modified SBAR format, resulting in the Situation, Background, Assessment, Responsibilities & Risk, Discussion & Disposition, Read-back & Record (SBAR-DR) model. Physician handoff conversations were recorded and transcribed for the 60 days before (n=110) and 60 days after (n=110) introduction of the SBAR-DR strategy. Transcriptions were scored by two blinded physicians using a 16-item scoring instrument. The primary outcome was the composite handoff quality score. We assessed physician perceptions via a post-intervention survey. RESULTS: The composite quality score improved in the post-intervention phase (7.57 + 2.42 vs. 8.45 + 2.51, p=.0085). Three of the 16 individual scoring elements also improved, including time for questions (70.6% vs. 82.7%, p=.0344) and confirmation of disposition plan (41.8% vs. 62.7%, p=.0019). The majority of emergency and internal medicine physicians felt that the SBAR-DR model had a positive impact on patient safety and handoff efficiency. CONCLUSION: Implementation of the SBAR-DR strategy resulted in improved verbal handoff quality. Agreement upon a clear disposition plan was the most improved element, which is of great importance in delineating responsibility of care and streamlining ED throughput. Future efforts should focus on nurturing broader physician buy-in to facilitate institution-wide implementation.

Recognizing and managing adrenal disorders in the emergency department [digest].

Primary and secondary adrenal insufficiency are underrecognized conditions among emergency department patients, affecting an estimated 10% to 20% of critically ill patients. The signs and symptoms of cortisol deficit can be nonspecific and wide-ranging, and identification and swift treatment with stress-dosing of hydrocortisone is vital to avoid life-threatening adrenal crisis. Laboratory evaluation focuses on identification of electrolyte abnormalities typical of adrenal insufficiency, and while additional testing may depend on the type and severity of symptoms, it should not delay corticosteroid replacement. This issue provides recommendations on effective management of patients presenting with adrenal insufficiency, with particular attention to the management of critically ill and septic patients, pregnant patients, and children. [Points & Pearls is a digest of Emergency Medicine Practice.].

Recognizing and managing adrenal disorders in the emergency department

Primary and secondary adrenal insufficiency are underrecognized conditions among emergency department patients, affecting an estimated 10% to 20% of critically ill patients. The signs and symptoms of cortisol deficit can be nonspecific and wide-ranging, and identification and swift treatment with stress-dosing of hydrocortisone is vital to avoid life-threatening adrenal crisis. Laboratory evaluation focuses on identification of electrolyte abnormalities typical of adrenal insufficiency, and while additional testing may depend on the type and severity of symptoms, it should not delay corticosteroid replacement. This issue provides recommendations on effective management of patients presenting with adrenal insufficiency, with particular attention to the management of critically ill and septic patients, pregnant patients, and children.

Bitten by a Dragon.

Komodo dragons (Varanus komodoensis) are large lizards known to take down prey even larger than themselves. They rarely attack humans. A 38-year-old woman was bitten by a Komodo dragon on her hand while cleaning its enclosure. She was transiently hypotensive. The wounds were extensively cleaned, and she was started on prophylactic antibiotics. Her wounds healed without any infectious sequelae. Komodo dragon bites are historically thought to be highly infectious and venomous. Based on a literature review, neither of these are likely true. As in any bite, initial stabilization followed by wound management are the main components to therapy.

Hypovolemia Resulting in Platypnea-Orthodeoxia Syndrome.

BACKGROUND: Platypnea-orthodeoxia syndrome is a rare disease entity that is characterized by dyspnea and desaturation in the upright position that resolves when the patient is in the supine position. CASE REPORT: An 80-year-old man presented with epistaxis but was noted to be hypoxic and was unresponsive to supplemental oxygenation. His oxygen saturation improved with supine positioning, however, which is consistent with platypnea-orthodeoxia syndrome. This improved with overnight intravenous hydration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients with hypoxia and paradoxical improvement in oxygen saturation with supine positioning, consider platypnea-orthodeoxia as a potential cause.