Snakebite! Crotalinae Envenomation of a Man in Rhode Island.

The incidence of poisonous snakebites has regional variance. Health care providers' knowledge and comfort in treating these envenomated patients depends on the density of poisonous snakes in their environment, with practitioners in the southern U.S. typically treating more exposed patients than those in colder regions in the North. We present a rare case of a confirmed copperhead snakebite that occurred in Rhode Island. We will review Copperhead bites, clinical management and treatment options.

Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias.

BACKGROUND AND OBJECTIVES: Medical simulation and human factors engineering (HFE) may help investigate and improve clinical telemetry systems. Investigators sought to (1) determine the baseline performance characteristics of an Emergency Department (ED) telemetry system implementation at detecting simulated arrhythmias and (2) improve system performance through HFE-based intervention. METHODS: The prospective study was conducted in a regional referral ED over three 2-week periods from 2010 to 2012. Subjects were clinical providers working at the time of unannounced simulation sessions. Three-minute episodes of sinus bradycardia (SB) and of ventricular tachycardia (VT) were simulated. An experimental HFE-based multi-element intervention was developed to (1) improve system accessibility, (2) increase system relevance and utility for ED clinical practice and (3) establish organisational processes for system maintenance and user base cultivation. The primary outcome variable was overall simulated arrhythmia detection. Pre-intervention system characterisation, post-intervention end-user feedback and real-world correlates of system performance were secondary outcome measures. RESULTS: Baseline HFE assessment revealed limited accessibility, suboptimal usability, poor utility and general neglect of the telemetry system; one simulated VT episode (5%) was detected during 20 pre-intervention sessions. Systems testing during intervention implementation recorded detection of 4 out of 10 arrhythmia simulations (p=0.03). Twenty post-intervention sessions revealed more VT detections (8 of 10) than SB detections (3 of 10) for a 55% overall simulated arrhythmia detection rate (p=0.001). CONCLUSIONS: Experimental investigations helped reveal and mitigate weaknesses in an ED clinical telemetry system implementation. In situ simulation and HFE methodologies can facilitate the assessment and abatement of patient safety hazards in healthcare environments.

Physician discretion is safe and may lower stress test utilization in emergency department chest pain unit patients.

INTRODUCTION: Chest pain unit (CPU) observation with defined stress utilization protocols is a common management option for low-risk emergency department patients. We sought to evaluate the safety of a joint emergency medicine and cardiology staffed CPU. METHODS: Prospective observational trial of consecutive patients admitted to an emergency department CPU was conducted. A standard 6-hour observation protocol was followed by cardiology consultation and stress utilization largely at their discretion. Included patients were at low/intermediate risk by the American Heart Association, had nondiagnostic electrocardiograms, and a normal initial troponin. Excluded patients were those with an acute comorbidity, age >75, and a history of coronary artery disease, or had a coexistent problem restricting 24-hour observation. Primary outcome was 30-day major adverse cardiovascular events-defined as death, nonfatal acute myocardial infarction, revascularization, or out-of-hospital cardiac arrest. RESULTS: A total of 1063 patients were enrolled over 8 months. The mean age of the patients was 52.8 ± 11.8 years, and 51% (95% confidence interval [CI], 48-54) were female. The mean thrombolysis in myocardial infarction and Diamond & Forrester scores were 0.6% (95% CI, 0.51-0.62) and 33% (95% CI, 31-35), respectively. In all, 51% (95% CI, 48-54) received stress testing (52% nuclear stress, 39% stress echocardiogram, 5% exercise, 4% other). In all, 0.9% patients (n = 10, 95% CI, 0.4-1.5) were diagnosed with a non-ST elevation myocardial infarction and 2.2% (n = 23, 95% CI, 1.3-3) with acute coronary syndrome. There was 1 (95% CI, 0%-0.3%) case of a 30-day major adverse cardiovascular events. The 51% stress test utilization rate was less than the range reported in previous CPU studies (P < 0.05). CONCLUSIONS: Joint emergency medicine and cardiology management of patients within a CPU protocol is safe, efficacious, and may safely reduce stress testing rates.

Web survey and embedded intervention on emergency department personnel perceptions of role in patient experience.

Investigators examined emergency department (ED) personnel's perceived job responsibilities and insights into determinants of patient experience. Surveys queried subjects on their perceptions of select clinical care-related actions (CCAs) to assess discipline-specific and service-specific CCA ownership and valuation. Investigators surveyed 153 of 634 ED personnel. A total of 3047 responses to 3802 queries indicated that a specified CCA was 'always' (58.2%) or 'sometimes' (21.9%) the subject's responsibility. A total of 3645 of 3797 responses indicated the CCA specified was 'always' (84.2%) or 'sometimes' (11.8%) important to the patient experience. Twelve percent of subjects reported not being responsible for monitoring or correcting medical errors. After exposure to survey queries, subjects indicated changing or re-considering how they communicate with patients (28.1%), deliver clinical care (20.2%), and arrange disposition/follow-up (20.3%). ED personnel's perceptions of CCA ownership and importance to patient experience were assessed. Subjects reported detectable levels of anticipated job-related behavioral changes traceable to survey-embedded intervention.

Color-coding and human factors engineering to improve patient safety characteristics of paper-based emergency department clinical documentation.

OBJECTIVE: Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented. BACKGROUND: Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments. METHODS: During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0-23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues. RESULTS: Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40). CONCLUSIONS: Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.