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Open Access Publications from the University of California

Scholarly Works (33 results)

  • Article
  • Peer Reviewed
UC San Diego Previously Published Works (2015)

Background

Increased scrutiny is occurring from regulatory agencies about the use of nonsterile enema preparations in the emergency department (ED) for constipation. This includes the "off-label" use of milk and molasses (M&M) enemas, as there are no reported data in the medical literature to determine safety and efficacy.

Objectives

To evaluate the success and complication rates of administering M&M enemas in the ED.

Methods

This was a structured retrospective study at two EDs over 8 years. Primary success was defined as the patient having a bowel movement. Secondary measures of success included improved pain score by 2 or more points or lowering of a heart rate initially over 100 beats/min by 20 or more beats/min. Complications included: hemodynamic compromise, increased pain, electrolyte disturbances, bacteremia, bowel perforation, rectal pain or bleeding, cardiac dysrhythmias, anaphylaxis, electrolyte disturbances, dizziness or syncope, or hospital admission for issues surrounding enema.

Results

There were 2013 enemas given, of which 261 were M&M enemas; 214 were given alone. Success rates defined only as bowel evacuation for M&M enemas alone were 87.9% (188/214) and, when used after other treatment failures, were 82.4% (28/34) successful. Five additional patients improved with the secondary measures (90.2% success). There were 8/261 complications (3.1%), of which four had an increased heart rate, two had decreased blood pressure, one had an increased pain score, and one subsequently developed a fever.

Conclusion

M&M enemas have a low complication rate when used in the ED.
    Cover page: Safety and Efficacy of Milk and Molasses Enemas in the Emergency Department
    • Article
    • Peer Reviewed
    UC San Diego Previously Published Works (2020)
      Cover page: Preliminary Results of Initial Testing for Coronavirus (COVID-19) in the Emergency Department
      • Article
      • Peer Reviewed
      UC San Diego Previously Published Works (2020)

      Introduction

      On March 10, 2020, the World Health Organization declared a global pandemic due to widespread infection of the novel coronavirus 2019 (COVID-19). We report the preliminary results of a targeted program of COVID-19 infection testing in the ED in the first 10 days of its initiation at our institution.

      Methods

      We conducted a review of prospectively collected data on all ED patients who had targeted testing for acute COVID-19 infection at two EDs during the initial 10 days of testing (March 10-19, 2020). During this initial period with limited resources, testing was targeted toward high-risk patients per Centers for Disease Control and Prevention guidelines. Data collected from patients who were tested included demographics, clinical characteristics, and test qualifying criteria. We present the data overall and by test results with descriptive statistics.

      Results

      During the 10-day study period, the combined census of the study EDs was 2157 patient encounters. A total of 283 tests were ordered in the ED. The majority of patients were 18-64 years of age, male, non-Hispanic white, had an Emergency Severity Index score of three, did not have a fever, and were discharged from the ED. A total of 29 (10.2%) tested positive. Symptoms-based criteria most associated with COVID-19 were the most common criteria identified for testing (90.6%). All other criteria were reported in 5.51-43.0% of persons being tested. Having contact with a person under investigation was significantly more common in those who tested positive compared to those who tested negative (63% vs 24.5%, respectively). The majority of patients in both results groups had at least two qualifying criteria for testing (75.2%).

      Conclusion

      In this review of prospectively collected data on all ED patients who had targeted testing for acute COVID-19 infection at two EDs in the first 10 days of testing, we found that 10.2% of those tested were identified as positive. The continued monitoring of testing and results will help providers understand how COVID-19 is progressing in the community.
        Cover page: Preliminary Results of Initial Testing for Coronavirus (COVID-19) in the Emergency Department.
        • Article
        • Peer Reviewed
        Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 21, Issue 3 (2020)

        Introduction: On March 10, 2020, the World Health Organization declared a global pandemic due to widespread infection of the novel coronavirus 2019 (COVID-19). We report the preliminary results of a targeted program of COVID-19 infection testing in the ED in the first 10 days of its initiation at our institution.

        Methods: We conducted a review of prospectively collected data on all ED patients who had targeted testing for acute COVID-19 infection at two EDs during the initial 10 days of testing (March 10-19, 2020). During this initial period with limited resources, testing was targeted toward high-risk patients per Centers for Disease Control and Prevention guidelines. Data collected from patients who were tested included demographics, clinical characteristics, and test qualifying criteria. We present the data overall and by test results with descriptive statistics.

        Results: During the 10-day study period, the combined census of the study EDs was 2157 patient encounters. A total of 283 tests were ordered in the ED. The majority of patients were 18-64 years of age, male, non-Hispanic white, had an Emergency Severity Index score of three, did not have a fever, and were discharged from the ED. A total of 29 (10.2%) tested positive. Symptoms-based criteria most associated with COVID-19 were the most common criteria identified for testing (90.6%). All other criteria were reported in 5.51–43.0% of persons being tested. Having contact with a person under investigation was significantly more common in those who tested positive compared to those who tested negative (63% vs 24.5%, respectively). The majority of patients in both results groups had at least two qualifying criteria for testing (75.2%).

        Conclusion: In this review of prospectively collected data on all ED patients who had targeted testing for acute COVID-19 infection at two EDs in the first 10 days of testing, we found that 10.2% of those tested were identified as positive. The continued monitoring of testing and results will help providers understand how COVID-19 is progressing in the community.

          Cover page: Preliminary Results of Initial Testing for Coronavirus (COVID-19) in the Emergency DepartmentCreative Commons 'BY' version 4.0 license
          • Article
          Independent Study Projects (2019)
          With a rapidly growing older adult population in the United States, the importance of age-appropriate care in the emergency department (ED) is becoming increasingly recognized. The University of California, San Diego (UCSD) La Jolla ED has adopted the use of a specialized health and welfare screening and referral system in its Senior Emergency Care Unit (SECU) to address the unique needs of older adult patients. Trained geriatric nurses screen patients and positive screens generate automatic referrals. Between December 1, 2016 and October 31, 2018 a total of 974 eligible patients were screened. Of these, 354 patients had one or more positive screens and received referrals. A retrospective chart review was used to examine clinical and demographic characteristics of patients to evaluate outcomes of the screening and referral system. Statistical analysis include: two sample t-tests to compare average age between groups; chi-square and likelihood ratio tests to compare demographic characteristics in patients who did and did not receive a referral, follow through with referrals, and return to the ED within 30-days; and logistic regression to asses if referral generation or follow-up predicted 30-day return to the ED. Patients receiving one or more referrals were older (M = 80, SD = 9.2) than those who did not receive any referrals [(M = 77, SD = 8.3), t(674) = 5.07, p<0.01] and patients who followed through with referrals were older (M = 81, SD = 9.2) than those who did not attend any referral follow-up [(M = 78, SD = 9.0), t(151) = 2.67, p<0.05]. Patients who were discharged received referrals at higher rates than expected compared to those who were admitted (χ2 LR (13) 27.096, p=0.012) and patients reporting Black or African American race attended follow-up at lower than expected rates compared to patients reporting other races (χ2 LR (6) =13.575, p= 0.035). Across all referrals, follow-up was less than 50% suggesting a need for quality improvement in the system.
            Cover page: Characteristics and outcomes of geriatric patients who were screened through the Geriatric Emergency Nurse Initiative Expert (GENIE) risk screening and referral system
            • Article
            • Peer Reviewed
            UC San Diego Previously Published Works (2018)

            Study objective

            To evaluate whether the availability of Electronic Health Records (EHRs) reduces throughput time and utilization of advanced imaging for patients in an academic ED.

            Data sources

            All patients arriving at an academic Emergency Department (ED) via ambulance between June 1, 2011, and June 4, 2012, were included in the study. This accounted for 9,970 unique ambulance patient visits.

            Study design

            Retrospective noninterventional analysis of patients in an academic ED. The primary independent variable was whether the patient had a prior EHR at the study hospital. Main outcomes were throughput time, number of advanced diagnostic imaging studies (CT, MRI, ultrasound), and the associated cost of these imaging studies. A set of controls, including age, gender, ICD9 codes, acuity measures, and NYU ED algorithm case severity classifications, was used in an ordinary least-squares (OLS) regression framework to estimate the association between EHR availability and the outcome measures.

            Principal findings

            A patient with a prior EHR experienced a mean reduction in CT scans of 13.9 percent ([4.9, 23.0]). There was no material change in throughput time for patients with a prior EHR and no difference in utilization of other imaging studies across patients with a prior EHR and those without. Cost savings associated with prior EHRs are $22.52 per patient visit.

            Conclusion

            EHR availability for ED patients is associated with a reduction in CT scans and cost savings but had no impact on throughput time or order frequency of other imaging studies.
              Cover page: The Effect of Access to Electronic Health Records on Throughput Efficiency and Imaging Utilization in the Emergency Department
              • Article
              • Peer Reviewed
              UC San Diego Previously Published Works (2016)

              Background

              The Centers of Disease Control and Prevention have declared prescription drug abuse an epidemic in the United States. However, demographic data correlating prescription-related deaths with actual prescriptions written is not well described. The purpose of this study is to compare toxicology reports on autopsy for prescription-related deaths with Prescription Drug Monitor Program (PDMP) data.

              Methods

              This is a retrospective analysis comparing 2013 San Diego Medical Examiner data on 254 unintentional prescription-related deaths obtained for 12 months before death with data from the California PDMP. Data were analyzed on age, sex, whether there was information on the PDMP, types and quantities of prescribed medications, number of pharmacies and providers involved, and whether there was a match between the Medical Examiner toxicology report and data from the PDMP.

              Results

              In 2013, there were 254 unintentional prescription-related deaths; 186 patients (73%) had PDMP data 12 months before death. Ingesting prescription medications with illicit drugs, alcohol, and/or over-the-counter medications accounted for 40% of the unintentional deaths. Opioids were responsible for the majority of single medication deaths (36; 70.6%). The average number of prescriptions was 23.5 per patient, and the average patient used 3 pharmacies and had 4.5 providers. Chronic prescription use was found in 68.8% of patients with PDMP data.

              Conclusions

              The PDMP data highlight important patterns that can provide valuable insight to clinicians making decisions regarding types and amounts of medications they prescribe. Although there is no guaranteed solution to prevent prescription-related deaths, PDMP data can be useful to prevent coprescribing and medication interaction and by following best clinical practices.
                Cover page: A description of Medical Examiner prescription-related deaths and prescription drug monitoring program data
                • Article
                • Peer Reviewed
                UC San Diego Previously Published Works (2022)
                Background and Objectives: Risk stratification tools for febrile neutropenia exist but are infrequently utilized by emergency physicians. Procalcitonin may provide emergency physicians with a more objective tool to identify patients at risk of decompensation. Materials and Methods: We conducted a retrospective cohort study evaluating the use of procalcitonin in cases of febrile neutropenia among adult patients presenting to the Emergency Department compared to a non-neutropenic, febrile control group. Our primary outcome measure was in-hospital mortality with a secondary outcome of ICU admission. Results: Among febrile neutropenic patients, a positive initial procalcitonin value was associated with significantly increased odds of inpatient mortality after adjusting for age, sex, race, and ethnicity (AOR 9.912, p < 0.001), which was similar, though greater than, our non-neutropenic cohort (AOR 2.18, p < 0.001). All febrile neutropenic patients with a positive procalcitonin were admitted to the ICU. Procalcitonin had a higher sensitivity and negative predictive value (NPV) in regard to mortality and ICU admission for our neutropenic group versus our non-neutropenic control. Conclusions: Procalcitonin appears to be a valuable tool when attempting to risk stratify patients with febrile neutropenia presenting to the emergency department. Procalcitonin performed better in the prediction of death and ICU admission among patients with febrile neutropenia than a similar febrile, non-neutropenic control group.
                  Cover page: Procalcitonin as a Predictive Tool for Death and ICU Admission among Febrile Neutropenic Patients Visiting the Emergency Department
                  • Article
                  • Peer Reviewed
                  UC San Diego Previously Published Works (2015)

                  Background

                  Emergency physicians regularly encounter agitated patients. In extremely agitated and violent patients, the onset of many traditional medications is relatively slow and often requires additional medication. Ketamine is frequently used in emergency departments (EDs) for procedural sedation and intubation, but has recently been suggested as a treatment for acute agitation.

                  Objectives

                  We sought to examine the use of ketamine in the treatment of acute agitation in an ED setting, including vital sign changes as a result of this medication.

                  Methods

                  This is a structured review of an historical cohort of patients over 7 years at two university EDs. Patients were included if they received ketamine as treatment for acute agitation. Abstracted data included age, vital signs including hypoxia, any additional medications for agitation, and alcohol/drug intoxication.

                  Results

                  Ketamine was administered for agitation on 32 visits involving 27 patients. Preadministration systolic blood pressure was 131 ± 20 mm Hg, with an average postadministration increase of 17 ± 25 mm Hg. The average baseline heart rate was 98 ± 23 beats/min, with an average increase of 8 ± 17 beats/min. No patients became hypoxic; 62.5% of patients required additional calming medication. Alcohol or drug intoxication was present in 40.6% of patients.

                  Conclusions

                  We found ketamine was used rarely, but had few major adverse effects on vital signs even in a population with 21.9% alcohol intoxication. However, a high proportion (62.5%) of patients required additional pharmacologic treatment for agitation, implying that administering ketamine is useful only for initial control of severe agitation.
                    Cover page: Ketamine Use for Acute Agitation in the Emergency Department
                    • Article
                    • Peer Reviewed
                    UC San Diego Previously Published Works (2015)

                    Background

                    Although an elevated white blood cell count is a widely utilized measure for evidence of infection and an important criterion for evaluation of systemic inflammatory response syndrome, its component band count occupies a more contested position within clinical emergency medicine. Recent studies indicate that bandemia is highly predictive of a serious infection, suggesting that clinicians who do not appreciate the value of band counts may delay diagnosis or overlook severe infections.

                    Objectives

                    Whereas previous studies focused on determining the quantitative value of the band count (ie, determining sensitivity, threshold for bandemia, etc.), this study directs attention to patient-centered outcomes, hypothesizing that the degree of bandemia predisposes patients to subsequent negative clinical outcomes associated with underappreciated severe infections.

                    Methods

                    This retrospective study of electronic medical records includes patients who initially presented to the emergency department (ED) with bandemia and were subsequently discharged from the ED. These patients were screened for repeat ED visits within 7 days and death within 30 days.

                    Results

                    In patients with severe bandemia who were discharged from the ED, there was a 20.9% revisit rate at 7 days and a 4.9% mortality rate at 30 days, placing severely bandemic patients at 5 times significantly greater mortality compared to nonbandemic patients (P = .032).

                    Conclusion

                    Our review of patient outcomes suggests that the degree of bandemia, especially in the setting of concurrent tachycardia or fever, is associated with greater likelihood of negative clinical outcomes.
                      Cover page: Clinical outcomes of ED patients with bandemia
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