Integrating Pre-test Probability and Point-of-Care Ultrasound (POCUS) in the Emergency Department (ED) Diagnosis of Small Bowel Obstruction (SBO).

Introduction A computed tomography (CT) scan and point-of-care ultrasound (POCUS) are commonly employed for diagnosing small bowel obstructions (SBOs). Prior studies demonstrated that POCUS has 90-95% sensitivity and specificity compared with CT scanning, which is the gold standard. Unlike other imaging modalities (in which the ordering and performing clinician are not the same), POCUS-performing/interpreting sonologists must recognize the risk of confirmation bias in the POCUS application. Per Bayesian analysis, the likelihood of a diagnosis being true following a diagnostic test is based on the ordering clinician's pre-test probability and the test characteristics (sensitivity and specificity, from which positive and negative likelihood ratios can be calculated). Consequently, establishing pre-test probability is important in informing downstream diagnostic or therapeutic interventions, as pre-test probability influences post-test odds. Little research has been done on the role of POCUS sonologist's pre-test probability and actual POCUS results regarding SBO. This study assessed the role of POCUS, integrating pre-test probability and POCUS results to determine post-test odds. Methods One hundred six patients were recruited on a convenience basis and underwent POCUS and CT between April 2017 and December 2022. All sonographers were credentialed in POCUS. POCUS sonologists' pre-test probabilities and POCUS and CT results were captured, which were compared. Sensitivity, specificity, LR+, and LR- were calculated, and correlations were made between pre-test probability and POCUS and CT results.  Results POCUS exhibited a sensitivity of 92% and specificity of 90%, with a corresponding positive likelihood ratio (LR+) of 9.3 and a negative likelihood ratio (LR-) of 0.09 for diagnosing SBO. Among patients with a high pre-test probability of SBO, a negative ultrasound yielded post-test odds of 0.4%, whereas a positive POCUS yielded post-test odds of 39.6%. Among patients with a low pre-test probability, a negative POCUS resulted in post-test odds of 0%, while a positive POCUS led to post-test odds of 2.1%, yielding a number needed to scan (NNS) of ~50 to identify a patient with an SBO on CT. Conclusion This study confirmed POCUS's sensitivity and specificity of ~90-95% and a corresponding LR+ of 9.2 and LR- of 0.9. Pre-test probability substantially affected post-test odds. Patients with a high pre-test probability and a positive POCUS had post-test odds of 39.6 and should have a confirmatory CT, while those with a negative POCUS have very low post-test odds and very likely will not benefit from CT. Patients with low pre-test probability and a positive POCUS have post-test odds of 2.1%, similar to the Wells Score and HEART score; such patients may not benefit from a CT, though clinicians should use their judgment/discretion. Patients with a low pre-test probability and a negative POCUS have post-test odds of 0% and should not have a CT. Among low pre-test probability patients, the NNS was ~50 to identify patients with an SBO on CT.

Meaningless Use: Assessing Compliance With a Clinically Meaningless Emergency Department Documentation Requirement.

Introduction A New York State initiative requests that Emergency Department (ED) providers document in the electronic health record (EHR) each admitted patient's employment status and, if applicable, their mode of commute. This initiative diverts them from their primary duties and increases the likelihood they will either disregard the request or input incorrect information to complete the data fields as fast as possible. This study intends to understand how well providers adhere to this regulation, which, while important for society as a whole, has little clinical relevance, especially in the ED, where the focus is to identify and treat emergent conditions. We hypothesized that clinician-collected employment data would contain many more "N/A" responses than registration-collected employment data (the "gold standard").  Methods We took a randomly selected convenience sample of 100 patients admitted from the ED and compared each patient's provider-entered response to the employment data field to the registration-recorded response. The EHR operates such that the "Employment" field must be completed in order to complete the admission electronically. Data fields collected were: last name, first name, date of birth, medical record number, date and time of arrival, date and time of admission, attending physician, resident physician (if there was one), mid-level provider (if there was one), provider-entered employment status, registration-entered employment status, admitting service (eg, Medicine, Surgery, OB/Gyn), and disposition level (eg, ICU). We assessed the percent of employment data that was concordant between the provider's entry and the registration clerk's entry. We also assessed for the potential confounding variable of how busy the ED was at time of admission, as providers may not take ask about employment or enter such data during particularly busy times. Finally, we interviewed providers to elicit reasons they did not enter accurate data. Statistical significance was set a priori at p <0.05. Results One hundred six patients were screened; six were excluded because one of the authors (MR) was their attending physician. For 92 of the remaining 100 patients, providers recorded employment as "N/A," and for eight patients they recorded "retired." For seven of these eight patients, provider entry matched registration entry (87.5% concordance). To adjust for whether how busy the ED was may have impacted the accuracy of data entry, admissions were categorized according to what time of day the patient was admitted. There was no statistically significant correlation between how busy the ED was and accuracy of data entry. The majority of providers stated they responded "NA" because the employment information was unrelated to the ED visit.  Conclusion In New York, for each patient admitted from the ED, the ED provider is requested to enter the patient's job information and, if they commute to work, the method they use. However, this takes providers' attention away from what they should be doing most: diagnosing and treating patients. This study highlights the unintended consequence of requesting data fields that are not clinically relevant and, from the patient and provider perspective, are not good investments of time and energy and distract from the clinical visit. Persons interpreting such clinically irrelevant data should do so with caution, as the results are unlikely to reflect the truth of what the questions intend to determine.

Novel Discharge Center for Transition of Care in Vulnerable Emergency Department Treat and Release Patients.

Introduction The majority of emergency department (ED) patients are discharged following evaluation and treatment. Most patients are recommended to follow up with a primary care provider (PCP) or specialist. However, there is considerable variation between providers and EDs in discharge process practices that might facilitate such follow-up (e.g., simply discharging patients with follow-up physician names/contact information vs. making appointments for patients). Patients who do not follow up with their PCPs or specialists are more likely to be readmitted within 30 days than those who do. Furthermore, vulnerable patients have difficulty arranging transitional care appointments due to poor health literacy, inadequate insurance, appointment availability, and self-efficacy. Our innovative ED discharge process utilizes an Emergency Department Discharge Center (EDDC) staffed by ED Care Coordinators and assists patients with scheduling post-discharge appointments to improve rates of follow-up with outpatient providers. This study describes the structure and activities of the EDDC, characterizes the EDDC patient population, and demonstrates the volume and specialties of appointments scheduled by EDDC Care Coordinators. The impact of the EDDC on operational metrics (72-hour returns, 30-day admissions, and length-of-stay [LOS]) and the impact of the EDDC on patient satisfaction are evaluated. Methods The Long Island Jewish Medical Center (LIJMC) EDDC is an intervention developed in July 2020 within a 583-bed urban hospital serving a racially, ethnically, and socio-economically diverse population, with many patients having limited access to healthcare. Data from the Emergency Medicine Service Line (EMSL), an ED Care Coordinator database, and manual chart review were collected from July 2020 to July 2021 to examine the impact of the EDDC on 72-hour returns, 30-day admissions, and Press Ganey's® "likelihood to recommend ED" score (a widely used patient satisfaction survey question). The EDDC pilot cohort was compared to non-EDDC discharged patients during the same period. Results In unadjusted analysis, EDDC patients were moderately less likely to return to the ED within 72 hours (5.3% vs. 6.5%; p = 0.0044) or be admitted within 30 days (3.4% vs. 4.2%). The program was particularly beneficial for uninsured and elderly patients. For both EDDC and non-EDDC patients, most revisits and 30-day admissions were for the same chief complaint as the index visit. The length-of-stay increased by ~10 minutes with no impact on satisfaction with ED visits. Musculoskeletal conditions (~20%) and specialties (~15%) were the most commonly represented. Approximately 10% of referrals were to obtain a PCP. Nearly 90% were to new providers or specialties. Most scheduled appointments occurred within a week.  Conclusion This novel EDDC program, developed to facilitate outpatient follow-up for discharged ED patients, produced a modest but statistically significant difference in 72-hour returns and 30-day admissions for patients with EDDC-scheduled appointments vs. those referred to outpatient providers using the standard discharge process. ED LOS increased by ~10 minutes for EDDC vs. non-EDDC patients, with no difference in satisfaction. Future analyses will investigate impacts on 72-hour returns, 30-day admissions, LOS, and satisfaction after adjusting for characteristics such as age, insurance, having a PCP, and whether the scheduled appointment was attended.

Reducing Unnecessary 'Admission' Chest X-rays: An Initiative to Minimize Low-Value Care.

Introduction Internal medicine admission services often request a baseline admission chest X-ray (CXR) for patients already admitted to the emergency department (ED) and who are waiting for inpatient beds, despite rarely providing clinical value. Adverse consequences of such CXRs include unnecessary radiation exposure, cost, time, and false positives, which can trigger a diagnostic cascade. Extraneous CXRs performed on already-admitted ED patients can delay inpatient transfer, thereby increasing boarding and crowding, which in turn may affect mortality and satisfaction. In 2016, our ED and internal medicine hospitalist services implemented guidelines (reflecting those of the American College of Radiology) to reduce unnecessary admission CXRs. All relevant providers were educated on the guideline. The primary aim of this study was to determine if there were changes in the percentage of patients with pre-admission and admission CXRs following guideline implementation. Our secondary aim was to determine which patient characteristics predict getting a CXR. Methods All ED and internal medicine hospitalist providers were educated once about the guideline. We performed a retrospective analysis of pre- vs. post-guideline data. Patients were included if admitted to the internal medicine service during those timeframes with an admission diagnosis unrelated to the cardiac or pulmonary systems. A CXR performed during ED evaluation prior to the admission disposition time was recorded as "pre-admission," and if performed after disposition time it was recorded as "admission." A CXR was "unwarranted" if the admission diagnosis did not suggest a CXR was necessary. The numerator was the number of unnecessary admission CXRs ordered on patients with diagnoses unrelated to the cardiac or pulmonary systems (minus those with a pre-admission CXR); the denominator was the number of such admissions (minus those with a pre-admission CXR). Variables of interest that might influence whether a CXR was ordered were age, gender, respiratory rate ≥20, cardiac- or pulmonary-related chief complaint, ED diagnosis category, or past medical history.  Results Among admitted patients with diagnoses that did not suggest a CXR was warranted, there was no change in the percentage of admission CXRs (21.7% to 25.6%, p = 0.2678), whereas the percentage with pre-admission CXRs decreased (66.6% to 60.7%, p = 0.0152). This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated (p = .0121). In multivariate analysis, risk factors for an unwarranted CXR were age >40 (risk ratio (RR) = 2.9) and past medical history of cardiovascular disease (e.g., myocardial infarction, atrial fibrillation), renal disease, or hyperkalemia.  Conclusion This educational initiative was not associated with the intended decrease in ordering unwarranted admission CXRs among ED boarding patients, though there was an unanticipated decrease in pre-admission CXRs. This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated. Organizations interested in reducing processes with little clinical value might adopt a similar program while emphasizing the lack of benefit to admitted patients through iterative educational programs on hospital admitting services.

Globe Rupture - A Case Report and Review of Emergency Department Diagnosis and Management.

Globe ruptures, while uncommon, must be promptly recognized to optimize the possibility of preserving vision. Differentiating open globe injuries from corneal abrasions, hyphema, and other ocular injuries is critical. When a globe rupture is identified, prompt ophthalmology consultation, placement of a rigid eye shield, administration of prophylactic systemic antibiotics (and antifungals with an appropriate history), and a tetanus vaccine update (if needed) are key to a successful outcome, so long as the visual prognosis is not dismal. We describe a case of ocular trauma presenting as a blood blister adherent to the cornea, which was initially assessed (by the triage nurse) to be a blood clot but later identified as a globe rupture. We include a discussion of globe rupture recognition and its management by the emergency department.

Patella Fracture Identified Using Point-of-care Ultrasound.

A 49-year-old female fell from standing. Her right knee extended into the air. She had acute right knee pain preventing weight-bearing. Her knee was most comfortable fully-extended. She could not flex it due to pain, nor extend it against resistance. Tenderness and a horizontal defect were noted over the anterior knee. Bedside ultrasound demonstrated a horizontally-fractured patella (confirmed on X-ray) with intact femoral and patellar tendons. She was put in a knee immobilizer and underwent surgery, with return to full function and activities. Ultrasound can identify patella fractures and help with early evaluation, management, and specialty referral, as well as ordering more-focused imaging. In one study, POCUS (point-of-care ultrasound) for patella fracture had 95% sensitivity, 63% specificity, 86% positive predictive value, and 83% negative predictive value. The dynamic nature of ultrasound allows a ruptured patella (87% sensitivity) or quadriceps tendon (100% sensitivity) to be excluded with high certainty.

Reining in Unnecessary Admission EKGs: A Successful Interdepartmental High-Value Care Initiative.

Introduction Unnecessary "admission electrocardiograms (EKGs)" on admitted patients waiting ("boarding") in the emergency department (ED) are often ordered. We introduced evidence-based EKG ordering guidelines and determined changes in the percent of patients with "preadmission" and "admission" EKGs ordered before vs. after guideline introduction and which patient characteristics predicted EKG ordering. Methods In 2016, our ED, cardiology, and hospitalist services implemented EKG ordering guidelines to reduce unnecessary ED EKGs ordered after disposition. We compared pre- vs. post-guideline EKG ordering to determine whether guidelines were associated with changes in "preadmission" or "admission EKG" ordering. Patients with an admission diagnosis unrelated to cardiac or pulmonary systems were included. An EKG was "admission" if the order time was after disposition time. The numerator was the number of "admission EKGs" ordered; the denominator was the total number of such admissions; those with "preadmission EKGs" were excluded from this analysis. Variables that might influence EKG ordering were explored. The chi-square test with Bonferroni adjustment was used to compare 2015 vs. 2016 percentages of patients with an "admission EKG." Results There was a decrease in unwarranted "admission EKGs" among ED boarding patients (44.1% pre-implementation to 27.5% by two years post-implementation) and an increase in unwarranted "preadmission EKGs" (66.1% pre-implementation to 72.8% post-implementation). Age ≥40 and past medical history independently predicted EKG ordering. Discussion The decrease in the ordering of "admission EKGs" but "preadmission EKGs" suggests the decline reflects a true change in ordering and not a general environmental/ecologic decline in ordering. This highlights the importance of careful guideline development and implementation.

The Best of Both Worlds: Eliminating Creatine Kinase-Muscle/Brain (CK-MB) Testing in the Emergency Department Leads to Lower Costs Without Missed Clinical Diagnoses.

The 2014 American Heart Association/American College of Cardiology (AHA/ACC) clinical guidelines recommend cardiac troponin as a superior biomarker to creatine kinase (CK) and creatine kinase-muscle/brain (CK-MB) for the detection of acute coronary syndrome (ACS), namely myocardial infarction and unstable angina. In April 2018, our Emergency Department (ED) transitioned from using standard troponin to using high-sensitivity troponin T, and adopted a clinical guideline consistent with the AHA/ACC. The guideline recommended high-sensitivity troponin T without CK/CK-MB testing in the majority of clinical situations, limiting CK/CK-MB testing to two specific clinical cases: 1) estimated glomerular filtration rate (eGFR) value <15 mL/min, or 2) recent acute coronary syndrome (ACS) event. Per our ED's policy, a "negative" troponin T was defined as being below the limit of detection (LOD) (i.e., <6 ng/L); such a value obtained at least 3 hours after symptom onset "ruled out" an ACS event and did not require a repeat troponin. The goal of this retrospective study was to determine whether the guideline limiting CK-MB testing missed clinically-significant cardiac outcomes (ACS or new diagnosis of coronary artery disease [CAD]) or was associated with mortality. Pre-implementation data (July 1, 2017 - December 31, 2017) was compared with post-implementation data (July 1, 2018 - December 31, 2018). After guideline introduction, CK/CK-MB ordering decreased by nearly 90%, while troponin ordering increased by nearly 20%, likely due to the introduction in June 2018 of high-sensitivity troponin T, which yielded numerous intermediate/indeterminate-range results that prompted repeat testing. Fewer than 1.5% of patients with a "negative" troponin (below the LOD) and a "positive" CK-MB (above the upper limit of normal [ULN]) had ACS or new-diagnosis CAD; patients with either diagnosis did not expire during their hospital stay or within 30 days of their index visit. CK-MB Index, which has a higher specificity than CK, only found ACS or new CAD among 0.8% of positive results. Considering both decreased CK/CK-MB and increased troponin ordering, the net annual direct cost savings in cardiac biomarker testing was extrapolated to $12,700. Had our institution not transitioned to higher cost high-sensitivity troponin ($2.054/unit) from standard troponin ($1.65/unit), and had the rate of troponin ordering increased solely proportionate to the rate of ED visit increase (2% year-over-year) rather than increase nearly 20% (likely due to the transition to high-sensitivity troponin), then the total six-month direct costs on troponin testing would have been $14,632 instead of $21,267.12, and annual direct cost savings would have been $18,945.80 instead of $12,700. The new ED clinical guideline did not result in a significant number of missed ACS or new-diagnosis CAD, and was associated with direct cost savings. These savings probably underestimate total savings, as the reduced number of "false-positive" CK-MB results likely prevented additional costs, such as hospitalization, specialty consultation, coronary calcium CT, echocardiogram, cardiac stress test, and coronary artery catheterization.

Influence of Framing: Recruitment to a Diabetes Disease Management Program From an Emergency Department Improves Enrollment and Outcomes.

Introduction Disease management programs (DMPs) provide education, self-management skills, care coordination, and frequent clinical assessment and medication adjustment. Our health system's diabetes mellitus (DM) DMP recruited patients from an emergency department (ED) and outpatient settings (primary care physicians' [PCP] and endocrinologists' offices; cold calling patients with poorly-controlled diabetes). We investigated whether recruitment to a DMP from an ED is feasible and effective, hypothesizing such patients would have better enrollment rates, future A1c control, and ED utilization because their receptiveness to change was "framed" by their ED visit. "Framing" is the notion that the same problem presented using a different context impacts response to the information. Being told in an acute-care ED setting one has newly-diagnosed or poorly-controlled DM, or DM-related complications may influence desire/commitment to enroll in the DMP and make lifestyle/medication changes. That is, acute illness or acute setting may influence/"frame" willingness to enroll and improve glycemic control.  Methods We captured all DMP recruitees' demographic, medical, insurance, A1c, and recruitment venue characteristics and evaluated future enrollment rates, A1c, and ED utilization from any ED in our health system. We analyzed pre- vs. post-recruitment changes in A1c and ED visit rates, comparing patients recruited from the ED who enrolled, patients recruited from the ED who did not enroll, patients recruited from outpatient settings who enrolled, and patients recruited from outpatient settings who did not enroll. Continuous enrollment predictor and outcome variables were compared using the Mann-Whitney test; categorical outcome variables were compared using Fisher's exact test. Results There were no statistically significant differences in characteristics (including mean baseline A1c [~11.4%]) among patients recruited from the ED, clinics, or cold calling. Twenty-five percent of all ED-recruited patients enrolled vs. 35% from outpatient settings. When a recruiter familiar with the DMP was in the ED, 41% of ED patients enrolled vs. 12% at other times (p=0.0001). Nearly 84% of ED visits were for direct DM-related causes (eg, diabetic ketoacidosis, hyperosmolar hyperglycemic state) or complications with a well-established link to diabetes (eg, acute coronary syndrome, stroke, wound infection); there was no statistically-significant difference in enrollment rates between patients whose ED visit was vs. was not for a DM-related complaint (53.8% vs. 60.0%, p=0.8018). No other variables, including whether the patient had newly diagnosed DM, were associated with enrollment. Enrollees with worse baseline glycemic control (A1c ≥11%) had a greater median A1c decrease (3.5% vs. 1.9%) vs. those with less-poor baseline glycemic control (A1c <11%) or those declining the program (p=0.05). Post-recruitment ED visits-per-patient-per-month decreased among patients recruited from the ED (-0.08), but not among those recruited from outpatient settings. (+0.08), p<0.0001). Conclusion ED recruitment to a diabetes DMP is feasible and effective. An ED-based diabetes DMP recruiter had enrollment rates substantially greater than a cold-calling DMP recruiter, comparable to enrollment rates from PCPs and endocrinologists, suggesting the importance of the recruitment framing/context. ED-recruited patients achieved substantial improvements in A1c and future ED visit rates.

Barriers to the Right to Health Among Patients of a Public Emergency Department After Implementation of the Affordable Care Act.

Purpose: Emergency physicians are witnesses to the impact of socioeconomic determinants of health on physical and psychiatric illness. Understanding structural barriers to the right to health (RTH) serves as a foundation for interventions to promote health equity. This study was performed to determine self-described barriers to fulfillment of the RTH among a public emergency department (ED) patient population. Methods: A convenience sample survey between June and August 2014 of 200 patients in public ED assessing demographic characteristics and desired assistance with 36 barriers to fulfillment of the RTH. Results: There was a high demand for specialty care (91%, 182/200), access to primary care (87.5%, 175/200), and access to health insurance (86%, 172/200). Undocumented residents were significantly more likely to cite health insurance as the most important area for assistance (p=0.04). Conclusion: Despite implementation of Affordable Care Act, access to health care and insurance were still perceived as the most important barriers among underserved patient populations, particularly undocumented groups.

Human-Centered Design of a Low Molecular Weight Heparin Order Set to Reduce Medication Errors.

Inpatient anticoagulation medication errors for venous thromboembolism (VTE) therapy are common. Our VTE Team identified frequent dosing and duplicate order errors for therapeutic-dose low molecular weight heparin, which (lacking computerized physician order entry) was ordered using blank forms. To decrease such errors, a nonmandatory order form with weight-based dosing and prechecked orders discontinuing existing injectable anticoagulation was developed using human-centered design innovation principles/processes emphasizing end-user engagement in all phases: observation, exploring solutions, and rapid prototyping/feedback. Three physicians independently reviewed ordering errors the year before versus after implementation. Before implementation, 11% of orders contained any error versus 10.5% after implementation (p = .82); 6.2% had a dosing or duplicate therapy error versus 4.2% after implementation (all made when the form was not used; p = .19). No dosing or duplicate therapy errors were made when the form was used. Were the form mandatory, all such ordering errors would likely have been eliminated, leaving 11% before versus 6.3% after implementation orders with any error (p = .015), and 6.2% before versus 0% after implementation orders with duplicate or dosing therapy errors (p < .001). Human-centered design of an anticoagulation order form can reduce anticoagulation order errors; such principles can be applied to other health care innovations, including electronic order sets.

Transitioning to E-Prescribing: Preformatted Prescription Forms Improve Safety, Formulary Compliance, Prescribing Satisfaction, and Perceived Efficiency.

OBJECTIVES: Compared with blank prescriptions, electronic prescribing (e-prescribing) is safer and more formulary-compliant, satisfying, and efficient. Owing to cost, fewer publicly funded organizations use e-prescribing but may afford preformatted prescription forms. We investigated whether preformatted prescription forms confer similar benefits as e-prescribing. METHODS: Two preformatted prescription forms containing medications' name, strength, dose, route, frequency, number of refills, and restrictions were released in an adult medicine clinic, which previously used blank forms. Pharmacy data were evaluated for changes in prescribing safety and formulary compliance. Surveys assessed changes in prescribing satisfaction and perceived efficiency. RESULTS: Preformatted prescription forms yielded safer, more formulary-compliant prescribing than blank forms. Among medications preformatted on forms, a smaller percentage of pharmacy interventions were for prescribing errors compared with the same medications prescribed previously using blank forms (54% vs. 31%, P = 0.014). Among medications preformatted on forms, a smaller percentage of pharmacy interventions were for formulary noncompliance compared with the same medications prescribed previously using blank forms (21% vs. 4%, P = 0.002).Nearly all respondents felt preformatted forms helped with legibility and choosing the correct dose and proper strength. Fifty percent of respondents indicated the forms improved medication selection.Preformatted forms were perceived as more satisfying and efficient. Ninety-three percent of respondents stated they would use the forms on their next patient. CONCLUSIONS: Preformatted prescription forms achieved the major objectives of e-prescribing: safer, more formulary-compliant, satisfying, and efficient prescribing. They can serve as a transitional phase to e-prescribing for resource-constrained organizations such as publicly funded clinics.

Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound.

BACKGROUND: Gonorrhea is the second most common sexually transmitted infection. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Diagnosis in the emergency department (ED) must be suspected clinically, as confirmatory tests are often not available. Point-of-care ultrasound (POCUS) can aid in diagnosis and appropriate management by identifying tenosynovitis and excluding arthritis. CASE REPORT: A 26-year-old man with multiple recent sex partners presented to the ED with slowly progressing right wrist pain and swelling over 5 days. His dorsal right wrist was swollen, with slightly decreased range of motion owing to mild pain, and no warmth, tenderness, erythema, or drainage. Multiple hemorrhagic, gray-purple blisters were noted over both hands. Serum white blood cell count was 12 × 103/µL; C-reactive protein was 30.3 mg/L. POCUS of the dorsal right wrist found no joint effusion; the extensor tendon sheath contained a large anechoic space with clear separation of the extensor tendons, suggesting a tendon sheath effusion/tenosynovitis. DGI was suspected, without septic arthritis. The patient was admitted and treated with ceftriaxone and azithromycin. Gonococcus grew from blood cultures and pharyngeal swabs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DGI must be suspected clinically, as confirmatory tests are often not available in the ED. Not all patients present with arthritis, tenosynovitis, and dermatitis. It is often difficult to differentiate tenosynovitis from arthritis. POCUS can aid in diagnosis by identifying tenosynovitis (vs. arthritis or simple soft-tissue swelling), allowing timely appropriate DGI diagnosis and management, and, importantly, averting unnecessary arthrocentesis.

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial.

BACKGROUND: Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. OBJECTIVE: The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. METHODS: DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. RESULTS: DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). CONCLUSIONS: Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality.

Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality.

INTRODUCTION: Attending physician judgment is the traditional standard of care for emergency department (ED) admission decisions. The extent to which variability in admission decisions affect cost and quality is not well understood. We sought to determine the impact of variability in admission decisions on cost and quality. METHODS: We performed a retrospective observational study of patients presenting to a university-affiliated, urban ED from October 1, 2007, through September 30, 2008. The main outcome measures were admission rate, fiscal indicators (Medicaid-denied payment days), and quality indicators (15- and 30-day ED returns; delayed hospital admissions). We asked each Attending to estimate their inpatient admission rate and correlated their personal assessment with actual admission rates. RESULTS: Admission rates, even after adjusting for known confounders, were highly variable (15.2%-32.0%) and correlated with Medicaid denied-payment day rates (p=0.038). There was no correlation with quality outcome measures (30-day ED return or delayed hospital admission). There was no significant correlation between actual and self-described admission rate; the range of mis-estimation was 0% to 117%. CONCLUSION: Emergency medicine attending admission rates at this institution are highly variable, unexplained by known confounding variables, and unrelated to quality of care, as measured by 30-day ED return or delayed hospital admission. Admission optimization represents an important untapped potential for cost reduction through avoidable hospitalizations, with no apparent adverse effects on quality.

Prescription for antidepressant in reducing future alcohol-related readmission in patients suffering from depression and alcohol use disorder: a retrospective medical record review.

BACKGROUND: Patients suffering from major depressive disorder are more likely to suffer from alcohol use disorder. The data is inconclusive for the effectiveness of antidepressant treatment of patients suffering from both illnesses in regards to improving sobriety and reducing alcohol-related healthcare expenses such as hospitalizations. The objective of this study is to determine if a new prescription of an antidepressant upon inpatient discharge is associated with a reduction in the number of future acute alcohol-related hospital readmissions to the same institution in patients suffering from major depressive disorder and alcohol-use disorder. METHODS: A retrospective, medical record review study was conducted at a publicly-supported hospital in Sylmar, CA. A query was performed for adult patients admitted between 1/1/2005-12/31/2013 who had ICD-9 codes for both alcohol-use disorder and depression. Index admission was the first hospitalization in which the patient was currently consuming alcohol and had depression as identified by physician documentation as a problem. Acute alcohol-related admissions were those for alcohol intoxication or withdrawal (indicating current alcohol use). Patients were excluded if they were receiving an antidepressant on index admission, <18 years old, no patient data available, or not currently consuming alcohol; 139 patients met inclusion criteria. Multivariate logistical regression analysis was performed on the primary predictive variable of discharge prescription of an antidepressant along with other independent variables for alcohol readmissions: homelessness, family history of alcohol use disorder, and smoking. RESULTS: Discharging patients with a prescription of an antidepressant was not associated with a reduction in acute alcohol-related readmission. There was no difference in acute alcohol-related readmissions between patients discharged with (44.6 %) versus without (47.0 %) a prescription for an antidepressant (p = 0.863). The median number of days between index admission and first readmission for those discharged on an antidepressant was 141 days while those who were not was 112 days (p = 0.284). CONCLUSION: Discharging patients suffering from both alcohol-use disorder and major depressive disorder with a prescription for an antidepressant is not associated with a reduction in future readmissions, nor significantly increase the number of days to readmission. The study does not support the concept of antidepressants in reducing acute alcohol-related readmissions.

Dementia Care Management in an Underserved Community: The Comparative Effectiveness of Two Different Approaches.

OBJECTIVES: To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. METHODS: We randomized 151 patient-caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient-caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. RESULTS: Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. DISCUSSION: Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected.

Effect of adding piperacillin-tazobactam to automated dispensing cabinets on promptness of first-dose antibiotics in hospitalized patients.

PURPOSE: Significant improvements in order-to-administration times for critical first doses of i.v. antibiotic therapy through the use of automated dispensing cabinets (ADCs) are reported. METHODS: In a retrospective pre-post analysis conducted at a large academic medical center, pharmacy and medical records were reviewed to evaluate average times to administration of first doses of i.v. piperacillin-tazobactam therapy during designated periods before and after the addition of selected i.v. antibiotics to ADCs on patient care units. Inpatients who received a specified i.v. piperacillin-tazobactam formulation were included in the analysis. The primary endpoint was the total time from prescribing to administration; the impact of ADC use on other time intervals (e.g., from scanning of orders to administration, from pharmacist verification and release of orders to administration) was also evaluated. RESULTS: A total of 121 subjects were included in the preimplementation (n = 65) and postimplementation (n = 56) samples. There was a significant 1.7-hour reduction in the mean ± S.D. order-to-administration time (from 4.5 ± 4.1 to 2.9 ± 2.5 hours, p = 0.009) for piperacillin-tazobactam first doses with the use of ADCs. Subgroup analyses showed significant reductions in the mean ± S.D. scan-to-administration time (from 3.3 ± 3.4 to 1.7 ± 1.5 hours, p = 0.001) and release-to-administration time (from 2.4 ± 2.4 to 1.4 ± 1.5 hours, p = 0.034). CONCLUSION: The addition of a piperacillin-tazobactam product and other commonly used i.v. antibiotics to ADCs was associated with a significantly reduced order-to-administration time for piperacillin-tazobactam first doses. This change was accounted for by a significant reduction in the time between order entry and drug administration.

Innovative use of technologies and methods to redesign care: the problem of care transitions.

Organizations are redesigning models of care in today's rapidly changing health care environment. Using proven innovation techniques maximizes likelihood of effective change. Our safety-net hospital aims to reduce high emergency department visit, admission, and readmission rates, key components to health care cost control. Twenty-five clinical stakeholders participated in mixed-methods innovation exercises to understand stakeholders, frame problems, and explore solutions. We identified existing barriers and means to improve post-emergency department/post-inpatient discharge care coordination/communication among patient-centered medical home care team members, including patients. Physicians and staff preferred automated e-mail notifications, including patient identifiers, medical home/primary care provider information, and relevant clinical documentation, to improve communication efficiency/efficacy.