Improving Emergency Department Care for Aging Missourians: Guidelines, Accreditation, and Collaboration.

Aging baby-boomers present significant challenges to accessible, affordable emergency care in America for patients of all ages. St. Louis physicians served as early innovators in the field of geriatric emergency medicine. This manuscript summarizes a multi-institutional November 2016 symposium reviewing the Missouri history of geriatric emergency care. In addition, this manuscript describes multispecialty organizations' guidelines, healthcare outcomes research, contemporary medical education paradigms, and evolving efforts to disseminate guideline-based geriatric emergency care using a "Boot Camp" approach and implementation science. This manuscript also reviews local adaptations to emergency medical services and palliative care, as well as the perspectives of emergency department leaders exploring the balance between infrastructure and personnel required to promote guideline-based geriatric emergency care with the anticipated benefits. This discussion is framed within the context of the American College of Emergency Physician's planned geriatric emergency department accreditation process scheduled to begin in 2018.

Emergency medicine and palliative care.

The emergency department cares for seriously ill patients across the trajectory of illness from diagnosis to death or cure. Emergency departments participate in critical illness trajectories that include initiation of life-sustaining therapies as well as caring for patients and families in their final moments of life. Emergency clinicians are uniquely poised to identify critical palliative care interventions to be used when patients and families are most in need with respect to symptom management, decisions regarding intervention and procedures to sustain life and participate in critically important decisions regarding withdrawing and withholding nonbeneficial life-sustaining therapies.

Propofol for deep procedural sedation in the ED.

UNLABELLED: We sought to evaluate the use of propofol (2,6-diisopropylphenol) for ED procedural sedation, particularly when administered in a routine fashion for a variety of indications. METHODS: This was a prospective observational study conducted in an urban teaching ED. Propofol was administered by handheld syringe and combined with fentanyl. Measurements included propofol and fentanyl dose, serial vital signs, pulse oximetry, adverse events, and patient and physician satisfaction. RESULTS: One hundred thirty-six subjects (18 to 69 years) were enrolled. Procedures included 82 (60.3%) abscess incision and drainages and 47 (34.6%) orthopedic reductions. Adverse events occurred in 14 cases (10.3%; 95% confidence interval 5.2% to 15.4%), including hypotension in 5, hypoxemia in 7, and apnea in 5. One patient required intubation. Both patient and physician satisfaction were excellent. CONCLUSIONS: ED procedural sedation with propofol was effective and well accepted by patients and physicians. However, it produced a significant incidence of hypotension, hypoxemia, and apnea.

High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections.

STUDY OBJECTIVE: We sought to determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) among emergency department (ED) patients with skin and soft tissue infections, identify demographic and clinical variables associated with MRSA, and characterize MRSA by antimicrobial susceptibility and genotype. METHODS: This was a prospective observational study involving a convenience sample of patients who presented with skin and soft tissue infections to a single urban public hospital ED in California. Nares and infection site cultures were obtained. A health and lifestyle questionnaire was administered, and predictor variables independently associated with MRSA were determined by multivariate logistic regression. All S aureus isolates underwent antibiotic susceptibility testing. Eighty-five MRSA isolates underwent genotyping by pulsed field gel electrophoresis, staphylococcal chromosomal cassette mec (SCC mec ) typing, and testing for Panton-Valentine leukocidin genes. RESULTS: Of 137 subjects, 18% were homeless, 28% injected illicit drugs, 63% presented with a deep or superficial abscess, and 26% required admission for the infection. MRSA was present in 51% of infection site cultures. Of 119 S aureus isolates (from infection site and nares), 89 (75%) were MRSA. Antimicrobial susceptibility among MRSA isolates was trimethoprim/sulfamethoxazole 100%, clindamycin 94%, tetracycline 86%, and levofloxacin 57%. Among predictor variables independently associated with MRSA infection, the strongest was infection type being furuncle (odds ratio 28.6). Seventy-six percent of MRSA cases fit the clinical definition of community associated. Ninety-nine percent of MRSA isolates possessed the SCC mec IV allele (typical of community-associated MRSA), 94.1% possessed Panton-Valentine leukocidin genes, and 87.1% belonged to a single clonal group (ST8:S). CONCLUSION: In this urban ED population, MRSA is a major pathogen in skin and soft tissue infections. Although studies from other practice settings are needed, MRSA should be considered when empiric antibiotic therapy is selected for such infections.