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Open Access Publications from the University of California

Volume 17, Issue 4, 2016

Volume 17 Issue 4

Treatment Protocol Assessment

Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm

Introduction: Unilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a common emergency department (ED) presentation. Proximal DVT (thrombus in the popliteal or femoral veins) can usually be diagnosed and treated at the initial ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep venous thrombosis (IC-DVT) often remains a consideration. The current standard for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography (WLUS), a test that is unavailable in many hospitals outside normal business hours. When WLUS is not available from the ED, recommendations for managing suspected IC-DVT vary. The objective is to use current evidence and recommendations to (1) propose a diagnostic algorithm for ICDVTwhen definitive testing (WLUS) is unavailable; and (2) summarize the controversy surrounding IC-DVTtreatment.

Discussion: The Figure combines D-dimer testing with serial CUS or a single deferred FLUS for the diagnosis of IC-DVT. Such an algorithm has the potential to safely direct the management of suspected IC-DVT when definitive testing is unavailable. Whether or not to treat diagnosed IC-DVT remains widely debated and awaiting further evidence.

Conclusion: When IC-DVT is not ruled out in the ED, the suggested algorithm, although not prospectively validated by a controlled study, offers an approach to diagnosis that is consistent with current data and recommendations. When IC-DVT is diagnosed, current references suggest that a decision betwee nanticoagulation and continued follow-up outpatient testing can be based on shared decision-making. The risks of proximal progression and life-threatening embolization should be balanced against the generally more benign natural history of such thrombi, and an individual patient’s risk factors for both thrombus propagation and complications of anticoagulation.

Endemic Infections

Perception of the risks of Ebola, Enterovirus-E68 and Influenza Among Emergency Department Patients

Introduction: Emerging infectious diseases often create concern and fear among the public. Ebola Virus Disease (EVD) and Enterovirus (EV-68) are uncommon viral illnesses compared to influenza. The objective of this study is to determine risk for these viral diseases and then determine how public perception of influenza severity and risk of infection relate to more publicized but less common emerging infectious diseases such as EVD and EV-68 among a sample of adults seeking care an American emergency department.

Methods: Included were consenting adults who sought care in two different urban emergency departments in Seattle, WA in November, 2014. Excluded were those who were not fluent in English, in police custody, had decreased level of consciousness, a psychiatric emergency, or required active resuscitation. Patients were approached to participate in an anonymous survey performed on a tablet computer. Information sought included demographics, medical comorbidities, risk factors for EVD and EV-68, and perceptions of disease likelihood, severity and worry for developing EVD, EV-68 or influenza along with subjective estimates of the number of people who have died of each virus over the year in the US.

Results: A total of 262 (88.5% participation rate) patients participated in the survey. Overall, participants identified that they were more likely to get influenza compared to EVD (p<0.001) or EV-68 (p<0.001), but endorsed worry and concern about getting both EVD and EV-68 despite having little or no risk for these viral diseases. Nearly two-thirds (64%) of participants had at-least one risk factor for an influenza-related complication. Most participants (64%) believed they could get influenza in the next 12 months. Only 52% had received a seasonal influenza vaccine.

Conclusions: Perception of risk for EVD, EV-68 and influenza is discordant with actual risk as well as self-reported use of preventive care. Influenza is a serious public health problem and the emergency department is an important health care location to educate patients.

Patient Safety

The Decline in Hydrocodone/Acetaminophen Prescriptions in Emergency Departments in the Veterans Health Administration Between 2009 to 2015

Introduction: The purpose of the study was to measure national prescribing patterns for hydrocodone/acetaminophen among veterans seeking emergency medical care, and to see if patterns have changed since this medication became a Schedule II controlled substance.

Methods: We conducted a retrospective cohort study of emergency department (ED) visits within the Veterans Health Administration (VA) between January 2009 and June 2015. We looked at demographics, comorbidities, utilization measures, diagnoses, and prescriptions.

Results: During the study period, 1,709,545 individuals participated in 6,270,742 ED visits and received 471,221 prescriptions for hydrocodone/acetaminophen (7.5% of all visits). The most common diagnosis associated with a prescription was back pain. Prescriptions peaked at 80,776 in 2011 (8.7% of visits), and declined to 35,031 (5.6%) during the first half of 2015 (r=‒0.99, p<0.001). The percentage of hydrocodone/acetaminophen prescriptions limited to 12 pills increased from 22% (13,949) in 2009 to 31% (11,026) in the first half of 2015. A prescription was more likely written for patients with a painscore≥7 (OR 3.199, CI [3.192‒3.205]), a musculoskeletal (OR 1.622, CI [1.615‒1.630]) or soft tissue(OR 1.656, CI [1.649‒1.664]) diagnosis, and those below the first quartile for total ED visits (OR 1.282, CI [1.271‒1.293]) and total outpatient ICD 9 codes (OR 1.843, CI [1.833‒1.853]).

Conclusion: Hydrocodone/acetaminophen is the most frequently prescribed ED medication in the VA. The rate of prescribing has decreased since 2011, with the rate of decline remaining unchanged after it was classified as a Schedule II controlled substance. The proportion of prescriptions falling within designated guidelines has increased but is not at goal.

Health Outcomes

Trends in Hospital Admission and Surgical Procedures following ED visits for Diverticulitis

Introduction: Diverticulitis is a common diagnosis in the emergency department (ED). Outpatient management of diverticulitis is safe in selected patients, yet the rates of admission and surgical procedures following ED visits for diverticulitis are unknown, as are the predictive patient characteristics. Our goal is to describe trends in admission and surgical procedures following ED visits for diverticulitis, and to determine which patient characteristics predict admission.

Methods: We performed a cross-sectional descriptive analysis using data on ED visits from 2006-2011 to determine change in admission and surgical patterns over time. The Nationwide Emergency DepartmentSample database, a nationally representative administrative claims dataset, was used to analyze ED visits for diverticulitis. We included patients with a principal diagnosis of diverticulitis (ICD-9 codes562.11, 562.13). We analyzed the rate of admission and surgery in all admitted patients and in low-risk patients, defined as age <50 with no comorbidities (Elixhauser). We used hierarchical multivariate logistic regression to identify patient characteristics associated with admission for diverticulitis.

Results: From 2006 to 2011 ED visits for diverticulitis increased by 21.3% from 238,248 to 302,612, while the admission rate decreased from 55.7% to 48.5% (-7.2%, 95% CI [–7.78 to -6.62]; p<0.001 for trend). The admission rate among low-risk patients decreased from 35.2% in 2006 to 26.8% in 2011 (-8.4%, 95% CI [–9.6 to –7.2]; p<0.001 for trend). Admission for diverticulitis was independently associated with male gender, comorbid illnesses, higher income and commercial health insurance.The surgical rate decreased from 6.5% in 2006 to 4.7% in 2011 (-1.8%, 95% CI [–2.1 to –1.5]; p<0.001 for trend), and among low-risk patients decreased from 4.0% to 2.2% (- 1.8%, 95% CI [–4.5 to –1.7]; p<0.001 for trend).

Conclusion: From 2006 to 2011 ED visits for diverticulitis increased, while ED admission rates andsurgical rates declined, with comorbidity, sociodemographic factors predicting hospitalization. Future work should focus on determining if these differences reflect increased disease prevalence, increased diagnosis, or changes in management.

  • 1 supplemental file

Prehospital Care

Accuracy of Perceived Estimated Travel Time by EMS to a Trauma Center in San Bernardino County, California

Introduction: Mobilization of trauma resources has the potential to cause ripple effects throughout hospital operations. One major factor affecting efficient utilization of trauma resources is a discrepancy between the prehospital estimated time of arrival (ETA) as communicated by emergency medical services (EMS) personnel and their actual time of arrival (TOA). The current study aimed to assess the accuracy of the perceived prehospital estimated arrival time by EMS personnel in comparison to their actual arrival time at a Level II trauma center in San Bernardino County, California.

Methods: This retrospective study included traumas classified as alerts or activations that were transported to Arrowhead Regional Medical Center in 2013. We obtained estimated arrival time and actual arrival time for each transport from the Surgery Department Trauma Registry. The difference between the median of ETA and actual TOA by EMS crews to the trauma center was calculated for these transports. Additional variables assessed included time of day and month during which the transport took place.

Results: A total of 2,454 patients classified as traumas were identified in the Surgery Department Trauma Registry. After exclusion of trauma consults, walk-ins, handoffs between agencies, downgraded traumas, traumas missing information, and traumas transported by agencies other than American Medical Response, Ontario Fire, Rialto Fire or San Bernardino County Fire, we included a final sample size of 555 alert and activation classified traumas in the final analysis. When combining all transports by the included EMS agencies, the median of the ETA was 10 minutes and the median of the actual TOA was 22 minutes (median of difference=9 minutes, p<0.0001). Furthermore, when comparing the difference between trauma alerts and activations, trauma activations demonstrated an equal or larger difference in the median of the estimated and actual time of arrival (p<0.0001). We also found month and time of day to be associated with variability in the difference between the median of the estimated andactual arrival time (p=0.0082 and p=0.0005 for month and time of the day, respectively).

Conclusion: EMS personnel underestimate their travel time by a median of nine minutes, which may cause the trauma team to abandon other important activities in order to respond to the emergency department prematurely. The discrepancy between ETA and TOA is unpredictable, varying by month and time of day. As such, a better method of estimating patient arrival time is needed.

Impact of Prehospital Care on Outcomes in Sepsis: A Systematic Review

Introduction: Sepsis is a common and potentially life-threatening response to an infection. International treatment guidelines for sepsis advocate that treatment be initiated at the earliest possible opportunity. It is not yet clear if very early intervention by ambulance clinicians prior to arrival at hospital leads to improved clinical outcomes among sepsis patients.

Methods: We systematically searched the electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed up to June 2015. In addition, subject experts were contacted. We adopted the GRADE (grading recommendations assessment, development and evaluation) methodology to conduct the review and follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations to report findings.

Results: Nine studies met the eligibility criteria – one study was a randomized controlled trial while the remaining studies were observational in nature. There was considerable variation in the methodological approaches adopted and outcome measures reported across the studies. Because of these differences, the studies did not answer a unique research question and meta-analysis was not appropriate. A narrative approach to data synthesis was adopted.

Conclusion: There is little robust evidence addressing the impact of prehospital interventions on outcomes in sepsis. That which is available is of low quality and indicates that prehospital interventions have limited impact on outcomes in sepsis beyond improving process outcomes and expediting the patient’s passage through the emergency care pathway. Evidence indicating that prehospital antibiotic therapy and fluid resuscitation improve patient outcomes is currently lacking.

  • 1 supplemental file

Emergency Department Operations

Emergency Department Length of Stay for Maori and European Patients in New Zealand

Introduction: Emergency department length of stay (ED LOS) is currently used in Australasia as aquality measure. In our ED, Maori, the indigenous people of New Zealand, have a shorter ED LOS than European patients. This is despite Maori having poorer health outcomes overall. This study sought to determine drivers of LOS in our provincial New Zealand ED, particularly looking at ethnicity as adetermining factor.

Methods: This was a retrospective cohort study that reviewed 80,714 electronic medical records ofED patients from December 1, 2012, to December 1, 2014. Univariate and multivariate analyses werecarried out on raw data, and we used a complex regression analysis to develop a predictive model of EDLOS. Potential covariates were patient factors, temporal factors, clinical factors, and workload variables(volume and acuity of patients three hours prior to and two hours after presentation by a baselinepatient). The analysis was performed using R studio 0.99.467.

Results: Ethnicity dropped out in the stepwise regression procedure; after adjusting for other factors,a specific ethnicity effect was not informative. Maori were, on average, younger, less likely to receivebloodwork and radiographs, less likely to go to our observation area, less likely to have a generalpractitioner, and more likely to be discharged and to self-discharge; all of these factors decreased theirlength of stay.

Conclusion: Length of stay in our ED does not seem to be related to ethnicity alone. Patient factorshad only a small impact on ED LOS, while clinical factors, temporal factors, and workload variables hadmuch greater influence.

  • 1 supplemental file

Comparison of result times between urine and whole blood point-of-care pregnancy testing

Introduction: Point-of-care (POC) pregnancy testing is commonly performed in the emergency department (ED). One prior study demonstrated equivalent accuracy between urine and whole blood for one common brand of POC pregnancy testing. Our study sought to determine the difference in result times when comparing whole blood versus urine for the same brand of POC pregnancy testing.

Methods: We conducted a prospective, observational study at an urban, academic, tertiary care hospital comparing the turnaround time between order and result for urine and whole blood pregnancy tests collected according to standard protocol without intervention from the investigators. After the blood was collected, the nurse would place three drops onto a Beckman Coulter ICON 25 Rapid HCG bedside pregnancy test and set a timer for 10 minutes. At the end of the 10 minutes, the result and time were recorded on an encoded data sheet and not used clinically. The same make and model analyzer was also used for urine tests in the lab located within the ED. The primary outcome was the difference inmean turnaround time between whole blood in the ED and urine testing in the adjacent lab results. Concordance between samples was assessed as a secondary outcome.

Results: 265 total patients were included in the study. The use of whole blood resulted in a mean time savings of 21 minutes (95% CI 16-25 minutes) when compared with urine (p<0.001). There was 99.6% concordance between results, with one false negative urine specimen with a quantitative HCG level of 81 mIU/L.

Conclusion: Our results suggest that the use of whole blood in place of urine for bedside pregnancy testing may reduce the total result turnaround time without significant changes in accuracy in this singlecenterstudy.

Technology in Emergency Medicine

Body Mass Index is a Poor Predictor of Bedside Appendix Ultrasound Success or Accuracy

Objectives: To determine whether there is a relationship between body mass index (BMI) and success or accuracy rate of BUS for the diagnosis of appendicitis. Methods: Patients 4 years of age and older presenting to the emergency department with suspected appendicitis were eligible.Enrollment was by convenience sampling. After informed consent, BUS wasperformed by trained emergency physicians who had undergone a minimum of 1-hour didactic training on the use of BUS to diagnose appendicitis. Subject outcomes were ascertained by a combination of medical recordreview and telephone follow-up.  Calculated BMI for adults and children were divided into 4 categories(underweight, normal, overweight, obese) according to Centers for Disease Control and Prevention classifications.Results: A total of 125 subjects consented for the study, and 116 of them had adequate image data for final analysis.  Seventy (60%) of the subjects werechildren.  Prevalence of appendicitis was 39%.  Fifty-two (45%) of the BUS studies were diagnostic (successful). Overall accuracy rate was 75%.  Analysis by Chi-square test or Mann Whitney U did not find any significant correlation between BMI category and BUS success. Similarly, there was no significant correlation between BMI category and BUS accuracy.  Same conclusion was reached when children and adults were analyzed separately, or when subjects were dichotomized into underweight/ normal and overweight/ obesecategories.  Conclusion: BMI category alone is a poor predictor of appendix BUS success or accuracy.

Check the Head: Emergency Ultrasound Diagnosis of Fetal Anencephaly

Background: Early pregnancy complaints in emergency medicine are common. Emergency physicians increasingly employ ultrasound in the evaluation of these complaints. As a result, it is likely that rare, though important, diagnoses will be encountered. We report a case of fetal anencephaly diagnosed by bedside emergency ultrasound in a patient presenting with first trimester vaginal bleeding.

Case Report: A 33 year-old patient at 10 weeks gestation presented with vaginal bleeding. After initial history and physical examination, a bedside ultrasound was performed. The emergency physician noted the abnormal appearance of the fetal cranium and anencephaly was suspected. This finding was confirmed by a consultative high-resolution fetal ultrasound. Making the diagnosis at the point of care allowed earlier detection, and more comprehensive maternal counseling about pregnancy options. This particular patient underwent elective abortion which was able to be performed at an earlier gestation, decreasing maternal risk.  If this diagnosis would not have been recognized by the emergency physician at the point of care, it may not have been diagnosed until the second trimester, and lower risk maternal options would not have been available.

  • 1 supplemental video

Diagnostic Acumen

Pneumorrhachis Secondary From Sacral Decubitus Ulcer

An elderly woman with a chronic decubitus sacral ulcer presented to the emergency department with sepsis. A computed tomography of her abdomen showed diffuse gas extending throughout the thoracolumbar spinal canal. Pneumorrhachis is a rare radiographic finding defined as gas within the spinal canal. There are many causes of pneumorrhachis ranging from trauma to infection. In this case the pneumorrhachis was caused by direct spread of gas-forming organisms from vertebral osteomyelitis. Emergency physicians should know about the implication of gas in the spinal canal in the setting of sepsis.

Don’t Forget What You Can’t See: A Case of Ocular Syphilis

This case describes an emergency department (ED) presentation of ocular syphilis in a human immunodeficiency virus (HIV) infected patient. This is an unusual presentation of syphilis and one that emergency physicians should be aware of. The prevalence of syphilis has reached epidemic proportions since 2001 with occurrences primarily among men who have sex with men (MSM). This is a case of a 24-year-old male who presented to our ED with bilateral painless vision loss. The patient’s history and ED workup were notable for MSM, positive rapid plasmin reagin (RPR) and HIV tests and fundus exam consistent with ocular syphilis, specifically uveitis. Ocular manifestations of syphilis can present at any stage of syphilis. The 2010 Centers for Disease Control and Prevention guidelines now recommend that ocular syphilis be treated as neurosyphilis regardless of the lumbar puncture results. There is a paucity of emergency medicine literature on ocular syphilis. For emergency physicians it is important to be aware of iritis, uveitis, or chorioretinitis as ocular manifestations of neurosyphilis especially in this high-risk population and to obtain RPR and HIV tests in the ED to facilitate early diagnosis, and treatment and to prevent irreversible vision loss.


Increasing Completion Rate of an M4 Emergency Medicine Student End-of-Shift Evaluation Using a Mobile Electronic Platform and Real-Time Completion

Introduction: Medical students on an emergency medicine rotation are traditionally evaluated at the end of each shift with paper-based forms, and data are often missing due to forms not being turned in or completed. Because students’ grades depend on these evaluations, change was needed to increase form rate of return. We analyzed a new electronic evaluation form and modified completion process to determine if it would increase the completion rate without altering how faculty scored student performance.

Methods: During fall 2013, 29 faculty completed paper N=339 evaluations consisting of seven competencies for 33 students. In fall 2014, an electronic evaluation form with the same competencies was designed using an electronic platform and completed N=319 times by 27 faculty using 25 students’electronic devices. Feedback checkboxes were added to facilitate collection of common comments. Data was analyzed with IBM® SPSS® 21.0 using multi-factor analysis of variance with the students’ globalrating (GR) as an outcome. Inter-item reliability was determined with Cronbach alpha.

Results: There was a significantly higher completion rate (p=0.001) of 98% electronic vs. 69% paperforms, lower (p=0.001) missed GR rate (1% electronic. vs 12% paper), and higher mean scores(p=0.001) for the GR with the electronic (7.0±1.1) vs. paper (6.8±1.2) form. Feedback check boxes were completed on every form. The inter-item reliability for electronic and paper forms was each alpha=0.95.

Conclusion: The use of a new electronic form and modified completion process for evaluating students at the end of shift demonstrated a higher faculty completion rate, a lower missed data rate, a higher global rating and consistent collection of common feedback. The use of the electronic form and the process for obtaining the information made our end-of-shift evaluation process for students more reliable and provided more accurate, up-to-date information for student feedback and when determining student grades.