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Open Access Publications from the University of California

Scholarly Works (5 results)

  • Article
Independent Study Projects (2019)
Past studies suggest that patients who leave without being seen by a physician (LWBS) from a hospital’s emergency department (ED) represent a quality and safety concern, and thus LWBS rates have often been used as an ED performance metric. There are few recent studies, however, that have examined the characteristics of the LWBS population at hospitals in the United States.
    Cover page: Patients who leave the emergency department without being seen and their follow-up behavior: a retrospective descriptive analysis
    • Article
    • Peer Reviewed
    Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 24, Issue 3 (2023)

    Introduction: The coronavirus 2019 (COVID-19) pandemic has presented various unprecedented challenges to healthcare systems globally, prompting society to adopt new preventative strategies to curb spread of the disease. Those experiencing homelessness have been particularly impacted because of barriers to practicing social distancing, inability to isolate, and poor access to care. Project Roomkey was established in California as a statewide measure to provide non-congregate shelter options for individuals experiencing homelessness to properly quarantine. On goal in this study was to analyze the effectiveness of hotel rooms as a safe disposition alternative to hospital admission for patients experiencing homelessness and who were also positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

    Methods: This was a retrospective, observational study that included chart review of patients who were discharged to the hotel from March 2020–December 2021. We recorded demographic information, index visit details, number of emergency department (ED) visits both a month prior to and following the index visit, admission rates, and number of deaths.

    Results: During this 21-month study period, a total of 2,015 patients who identified as undomiciled were tested for SARS-COV-2 in the ED for various reasons. Of those patients, 83 were discharged from the ED to the hotel. Of the 83 patients, 40 (48.2%) ultimately tested positive for SARS-CoV-2 during their index visit. Two patients returned to the ED within seven days with COVID-19-related symptoms, and 10 patients within 30 days. Two patients required subsequent admission with COVID-19 pneumonia. No deaths were recorded within the 30-day follow-up period.

    Conclusion: The availability of a hotel served as a safe alternative to hospital admission for patients experiencing homelessness and who were either suspected or confirmed to have COVID-19. It is reasonable to consider similar measures in the management of other transmissible diseases for patients experiencing homelessness who require isolation.

      Cover page: Use of Hotels as a Disposition Alternative to Hospital Admission for Undomiciled Patients Undergoing SARS-CoV-2 TestingCreative Commons 'BY' version 4.0 license
      • Multimedia
      Symposium 2025 (2025)

      Objectives: Emergency Department (ED) boarding of admitted patients is associated with worsened patient outcomes, delays in medical care, increased ED crowding and reduced patient satisfaction.  Utilization of alternatives to hospital admission such as ED observation, hospital at home/home health and the Medicare Skilled Nursing Facility 3-day waiver program, which are all value-based care programs, can help alleviate ED boarding.  Identifying details associated with short-stay admissions (those in which patients are discharged within 24 hours of admission) may help optimize use of these alternatives to hospital admission.  At our health system, we have a large managed care population for which these value-based initiatives are fundamental to cost-effective care.  This study aimed to identify and characterize short stay admissions from the ED among managed care patients with the larger, long-term goal of optimizing ED dispositions and utilization of alternatives to admissions.   

       

      Methods: This retrospective, observational descriptive cohort study was conducted at an academic health system’s two EDs over 12 months.  Included were managed care commercial and Medicare patients attributed to our health system who had an ED visit that resulted in an inpatient or observation admission lasting

       

      Results/Findings: Over the study time period, 198 managed care patients with short-stay admissions were identified.  71.2% (n= 141) of the patients were >/= 65 years.  The average LACE+ score was 64 with a median of 68.  91 patients (46%) were admitted to a Medicine service.  107 patients (54%) were admitted to a Specialty Service.  The most frequent diagnoses among the Medicine admission cohort were those disease conditions or symptoms relating to infection (n=13 or 6.6%), pulmonary (n=7 or 3.5%) and gastroenterology (n=7 or 3.5%%) and among the Specialty Service admission cohort were those disease conditions or symptoms relating to cardiology (n=29 or 14.7%), neurology (n=15 or 7.6%), gynecology (n=5 or 2.5%), and Urology (n=6, 3%).  The remaining admissions among both cohorts involved varied disease conditions or symptoms (n=116 , 58.6%).  The majority of patients (n= 167 or 84.3%) were discharged home, 19 patients (9.6%) were discharged to a SNF, rehab facility or transferred to another hospital.  12 patients (6.1%) left Against Medical Advice.    

       

       

      Conclusion: In this population of managed care, short-stay admission patients with a medium to high risk of readmission based on LACE+ score, approximately half the patients were admitted to a Medicine service with the most frequent admitting diagnoses related to infection.  Among the patients admitted to a Specialty Service, the most frequent admitting diagnosis or symptoms related to a cardiac condition.  The majority of patients were discharged to home.  Understanding this population may help to focus opportunities in which alternatives to admission may be leveraged, when appropriate.  

      • 1 supplemental PDF
      • Article
      • Peer Reviewed
      UC San Diego Previously Published Works (2022)

      Introduction

      Though acetaminophen overdoses are common, acetaminophen induced methemoglobinemia is rare and it is thought to be due to oxidative stress from reactive metabolites. However, few prior cases of sulfhemoglobinemia in the setting of acetaminophen overdose have been reported. We report a case of mixed methemoglobinemia and sulfhemoglobinemia in the setting of a large, isolated acetaminophen ingestion.

      Case report

      A 30-year-old African American male presented after intentionally ingesting 50 tablets of 500 mg acetaminophen two days prior. He was cyanotic and tachypneic. Peripheral oxygen saturation was 78 % on room air and minimally improved with high-flow oxygen. He was noted to have leukocytosis, thrombocytopenia, anion gap metabolic acidosis with lactic acidemia, acute kidney injury, transaminitis, hyperbilirubinemia, and coagulopathy. Arterial partial pressure of oxygen was normal. Methemoglobin and sulfhemoglobin concentrations were 8.5 % and 5.2 %, respectively. Along with intravenous N-acetylcysteine, methylene blue was administered without clinical improvement. Hemolytic anemia was subsequently noted. Glucose-6- phosphate dehydrogenase (G6PD) deficiency was then confirmed with a quantitative assay and genetic testing. He also received one dose of intravenous metoclopramide. The patient ultimately required eight units of packed red blood cells and several weeks of hemodialysis before discharge on hospital day 43.

      Discussion

      Acetaminophen is structurally related to compounds known to cause methemoglobinemia and sulfhemoglobinemia. We hypothesize that these dyshemoglobinemias were triggered by acetaminophen-induced oxidative stress. The role of G6PD deficiency in the formation of sulfhemoglobinemia is unclear. Acetaminophen overdoses presenting with methemoglobinemia should prompt concern for underlying G6PD deficiency. Coincidental sulfhemoglobinemia should be considered if the clinical presentation is more severe than the methemoglobin concentration alone would suggest. Use of methylene blue in this case, despite the low measured methemoglobin percentage, which likely triggered hemolytic anemia; methylene blue use in a similar circumstance should be weighed carefully against the risk of harm.
        Cover page: Sulfhemoglobinemia and methemoglobinemia following acetaminophen overdoseCreative Commons 'BY-NC-ND' version 4.0 license
        • Article
        • Peer Reviewed
        UC San Diego Previously Published Works (2022)

        Introduction

        Pediatric organophosphate insecticide poisonings are rare in the United States, and life-threatening toxicity is rarely seen. We report 2 accidental ingestions of the organophosphate insecticide coumaphos that resulted in life-threatening symptoms.

        Case reports

        A 7-year-old boy and 10-year-old girl both presented from home after accidental ingestion of 1 "spoonful" of coumaphos 20% liquid (Asuntol; Bayer de Mexico, S.A. de C.V., Mexico D.F., Mexico). There were no other known ingestions. Both became rapidly symptomatic, with the boy developing dyspnea, vomiting, and depressed mental status and the girl developing headache and nausea. Soon afterward, the boy had witnessed cardiopulmonary arrest and the girl developed altered mental status and flaccid paralysis. Both were treated initially with atropine, but required no additional doses. On arrival to the pediatric intensive care unit (ICU), both patients received pralidoxime with subsequent plasma exchange and continuous venovenous hemodiafiltration (CVVHDF). Transient anemia, coagulopathy, transaminitis, and hyperglycemia developed in both patients. The girl was extubated on hospital day 6 and the boy on hospital day 11. The girl's course was complicated by aspiration pneumonia and an isolated seizure. The boy's course was complicated mainly by anoxic brain injury, associated seizures, neuroagitation, spasticity, and autonomic instability. The girl was discharged on hospital day 16 and remains asymptomatic 32 days after ingestion. As of 90 days after ingestion, the boy remains admitted to inpatient rehabilitation.

        Discussion

        The clinical benefit of pralidoxime, plasma exchange, and CVVHDF is uncertain in these cases. The optimal treatment regimen for organophosphate insecticide toxicity remains poorly defined.
          Cover page: Accidental organophosphate poisoning: A case series of 2 pediatric coumaphos exposuresCreative Commons 'BY-NC-ND' version 4.0 license
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