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Simon EL, Abbomerato M, Patel M, Kaylor T, Sanchez J, Krizo J. Virtual access to recovery services for substance use disorder in the emergency department. Am J Emerg Med 2024; 79:225-227. [PMID: 38072731 DOI: 10.1016/j.ajem.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 10/30/2023] [Accepted: 11/17/2023] [Indexed: 04/16/2024] Open
Affiliation(s)
- Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 SR-44, Rootstown, OH 44272, USA.
| | - Micaela Abbomerato
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, OH 44307, USA
| | - Mili Patel
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, OH 44307, USA
| | - Tammy Kaylor
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, OH 44307, USA
| | - Jonathan Sanchez
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, OH 44307, USA
| | - Jessica Krizo
- Cleveland Clinic Akron General, Department of Health Sciences, Akron, OH 44307, USA
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Stenberg R, Goff L, Simon EL. Ultrasound-guided erector spinae nerve block for relief of chest pain from pneumonia in the emergency department. Am J Emerg Med 2024:S0735-6757(24)00180-3. [PMID: 38693022 DOI: 10.1016/j.ajem.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/03/2024] Open
Abstract
Erector spinae plane blocks (ESPB) have shown to provide meaningful chest wall anesthesia and reduce opioid consumption after thoracic surgery. Emergency physicians often use erector spinae plane blocks in the emergency department (ED) for rib fractures when acetaminophen, non-steroidal anti-inflammatory (NSAID), and opioids fail to control pain. They have also demonstrated successful pain management for conditions like herpes zoster, renal colic, burns, and acute pancreatitis for ED patients. With low reported rates of complication and relatively easy landmarks to identify, erector spinae plane blocks are an appealing regional anesthetic technique for emergency physicians to utilize for uncontrolled pain. We present the case of a 58-year-old male presenting to the ED with chest pain from pneumonia which remained unmanageable after acetaminophen, NSAID, and opioid administration. An ultrasound-guided erector spinae plane block was performed in the ED and the patient had a significant reduction in his chest pain.
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Affiliation(s)
- Robert Stenberg
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH 44272, USA
| | - Laine Goff
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH 44272, USA
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH 44272, USA.
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Simon EL, Sherry AC, Rabinowitz J. Metformin-Associated Lactic Acidosis-Is This on Your Radar? J Emerg Med 2024; 66:e530-e533. [PMID: 38423865 DOI: 10.1016/j.jemermed.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/11/2023] [Accepted: 11/23/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Metformin is a biguanide hyperglycemic agent used to manage non-insulin-dependent diabetes mellitus. Adverse reactions include mainly mild gastrointestinal adverse effects, but severe complications, such as metformin-associated lactic acidosis (MALA) can occur. Metformin is excreted renally and, therefore, not recommended in patients with renal impairment. The reported incidence of MALA is 3 cases per 100,000 patient-years. CASE REPORT A 79-year-old woman with a complex medical history, including end-stage renal disease on dialysis and type 2 diabetes, presented to the emergency department (ED) for altered mental status. Prior to arrival, she was found to be hypoglycemic. Her laboratory results were significant for creatinine of 6.56 mg/dL and an anion gap of 52 mmol/L. The venous blood gas revealed a venous pH of 6.857 [reference range (7.32-7.43)], pCO2 of 15.9 mm Hg (40.6-60 mm Hg), HCO3 of 2.7 mmol/L (21-30 mmol/L), lactate of 27 mmol/L (0.5-2 mmol/L), and ammonia of 233 µmol/L. The patient was dialyzed emergently in the ED; repeat laboratory test results showed blood urea nitrogen of 10 mg/dL, creatinine of 1.65 mg/dL, carbon dioxide of 26 mmol/L, and anion gap of 13 mmol/L. The repeat ammonia was 16 µmol/L. The patient's metabolic encephalopathy resolved, and she was discharged home on hospital day 3. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: MALA has a high mortality rate (36%). Laboratory markers have not been found to be a reliable predictor of mortality. Sodium bicarbonate is controversial, but a pH < 7.15 indicates consideration of its use. A pH < 7.1 and a lactate level > 20 mmol/L indicate the need for emergent hemodialysis. Prompt recognition and management in the ED with early hemodialysis can result in good patient outcomes, with a return to their baseline function despite severe laboratory findings.
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Affiliation(s)
- Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | | | - Jeffrey Rabinowitz
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio
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Stenberg R, Septaric K, Simon EL. Ultrasound-guided erector spinae nerve block for relief of endometriosis pain in the emergency department. Am J Emerg Med 2024:S0735-6757(24)00110-4. [PMID: 38514357 DOI: 10.1016/j.ajem.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/16/2024] [Accepted: 03/03/2024] [Indexed: 03/23/2024] Open
Abstract
Endometriosis is a debilitating chronic condition often accompanied by severe pelvic pain and infertility issues. When outpatient medical management is not adequate, controlling pain can be challenging for providers in the acute setting. We report the case of a 23-year-old female with a past medical history of endometriosis who presented to a freestanding emergency department with a chief complaint of 10/10 pelvic pain on a numeric rating scale. She had tried non-steroidal inflammatory medications and heat with no success. The patient had medication intolerances to opioid analgesics and was given ketorolac intramuscularly with no relief of her pain. The emergency physician discussed and offered to perform an erector spinae plane nerve block (ESPB) for pain relief. Ultrasonography was utilized for visualization of landmarks with a curvilinear transducer; a 20-gauge Pajunk® Sonoplex needle was used to inject a total of 100 mg bupivacaine 0.25% without epinephrine along with dexamethasone 10 mg under the bilateral erector spinae fascial planes at the T9 level. Post-procedure, the patient had significant improvement in pain and rated it a 2/10. Utilizing nerve blocks for endometriosis and other chronic pelvic pain in the acute care setting can serve as an effective alternative to opioids. In patients with multiple medication intolerances and for providers navigating pain control in the setting of a nationwide opioid crisis, ESPB blocks can help alleviate acute pain or exacerbations of chronic pain. This case demonstrates the first known use of an ESPB to relieve endometriosis pain in the emergency department.
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Affiliation(s)
- Robert Stenberg
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH 44272, USA
| | - Kristen Septaric
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH 44272, USA
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH 44272, USA.
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Prete S, Abbomerato M, Simon EL. Ovarian torsion masquerading as a ureteral stone. Am J Emerg Med 2024; 76:273.e1-273.e3. [PMID: 38072734 DOI: 10.1016/j.ajem.2023.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/24/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Abdominal pain is the most common complaint within the emergency department (ED) and has many varied etiologies. Some of these conditions can be medical emergencies, including ovarian torsion. While representing just 3% of gynecologic emergencies, ovarian torsion should be considered in all females presenting to the ED with abdominal or pelvic complaints. CASE A 38-year-old G5P5 female with a past medical history significant for ureterolithiasis presented to a freestanding ED with abdominal pain, nausea, and vomiting. She developed sudden onset of right sided abdominal pain radiating to her right flank upon awakening. The initial differential diagnosis was for ureterolithiasis or appendicitis. Her complete blood count (CBC) was normal, and testing for pregnancy, infection, and hematuria was negative. Computed topography (CT) imaging of the abdomen and pelvis revealed a 9 cm adnexal mass, consistent with a possible dermoid cyst. A pelvic ultrasound was ordered which showed a possible ovarian torsion. She was transferred to a tertiary care hospital where she had a laparoscopy with right-sided oophorectomy and salpingectomy performed. DISCUSSION This patient presented with abdominal pain, nausea, and vomiting and was first suspected to have ureterolithiasis or appendicitis. She was found to have an ovarian torsion with a dermoid cyst, which resulted in the loss of her ovary and fallopian tube. This case demonstrates the importance of including gynecologic emergencies in the differential on all female patients presenting with abdominal pain.
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Affiliation(s)
- Spencer Prete
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron GeneralAve., Akron, OH 44307, USA
| | - Micaela Abbomerato
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron GeneralAve., Akron, OH 44307, USA
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron GeneralAve., Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 St. OH-44, Rootstown, OH 44272, USA.
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Simon EL, Krizo J, Septaric K, Citozi E, Smalley CM, Shaffer A, Mangira C, Fertel BS. Computed Tomography Utilization for Patients Presenting with Chest Pain. Am J Emerg Med 2023; 74:100-103. [PMID: 37801999 DOI: 10.1016/j.ajem.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/21/2023] [Accepted: 09/18/2023] [Indexed: 10/08/2023] Open
Abstract
INTRODUCTION Computed tomography (CT) is routinely used in the emergency department (ED) due to its ease of access and its ability to rapidly rule in or out many serious conditions. Freestanding emergency departments (FSEDs) have become increasingly used as an alternative to hospital-based emergency departments (HBEDs). The objective of this study was to investigate if the utilization rate of CT differs between FSEDs and HBEDs for chest pain. METHODS A retrospective evaluation of patients presenting to 17 EDs within a large integrated healthcare system between May 1, 2019 - April 30, 2021 with a chief complaint chest pain. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation. Multiple logistic regression was used to assess the effect of facility on CT utilization for chest pain. RESULTS There were 67,084 patient encounters included in the study. Patients were predominately female (55%), white (61%), and insured through Medicare/Medicaid (59%). After controlling for predictive variables which included Charlson Comorbidity Index, ESI, age, sex, and race, patients who presented to FSEDs with chest pain were less likely to have a CT than those who presented to a HBED (AOR = 0.85, CI (0.81-0.90). CONCLUSION CT scans of the chest are utilized less frequently at FSEDs compared to HBEDs for patient presenting with chest pain.
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Affiliation(s)
- Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307, USA.
| | - Jessica Krizo
- Department of Health Sciences, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307, USA
| | - Kristen Septaric
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 SR-44, Rootstown, OH 44272, USA
| | - Enri Citozi
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307, USA
| | - Courtney M Smalley
- Emergency Services Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Austin Shaffer
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307, USA
| | - Caroline Mangira
- Emergency Services Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Baruch S Fertel
- Emergency Services Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA; Enteprise Safety, Quality & Patient Experience, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
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Fertel BS, Pozuelo L, Kirschling S, Worley S, Simon EL, Muir M, Smalley CM. Universal suicide screening in emergency departments across a large healthcare system. Am J Emerg Med 2023; 72:127-131. [PMID: 37523993 DOI: 10.1016/j.ajem.2023.06.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/04/2023] [Accepted: 06/28/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Suicidal ideation is a common complaint in Emergency Departments (EDs) across the United States (US) and is an important preventable cause of death. Consequently, current Joint Commission guidelines require screening high-risk patients and those with behavioral health needs for suicide. Accordingly, we implemented universal suicide screening for all patients presenting to EDs in our healthcare system and sought to describe the characteristics of the identified "high-risk" patients. We also sought to determine whether universal suicide screening was feasible and what its impact was on ED length of stay (LOS). METHODS All ED encounters in the healthcare system were assessed. Data were collected from February 1, 2020, through June 30, 2022. All patients aged 18 and over were screened using the Columbia Suicide Severity Rating Scale (C-SSRS) and categorized as no risk, low risk, moderate risk, and high risk. Encounters were then grouped into 'high risk" and "not high risk," defined as no, low, and moderate risk patients. Data collected included gender, discharge disposition, LOS, and insurance status. RESULTS A total of 1,058,735 patient encounter records were analyzed. The "high risk" group (n = 11,359; 10.7%) was found to have a higher proportion of male patients (50.9 vs 43.7%) and government payors (71.6 vs. 67.1%) and a higher ED LOS [medians 380 min vs. 198 min] than the not high-risk group (p ≤0.001). Those with suicidal ideation comprised 0.73-1.58% of ED encounters in a given month. A secondary analysis of 2,255,616 ED encounter records from January 2019 - June 30, 2022, revealed that 40,854 (1.81%) encounters required 1:1 observation. The proportion of 1:1 observations in 2019, the year before implementation, was 1.91%. Using a non-inferiority margin of 25%, we found that the proportion of 1:1 patients in 2020, the year following implementation, was non-inferior to (no worse than) the previous year at 2.09% and decreased from 2021 to 2022 (1.69% and 1.57% respectively). CONCLUSION Implementing universal suicide screening in all EDs within a healthcare system is feasible. The percentage of patients who screened high risk was under 5% of the overall ED population. While the median LOS was longer for "high-risk" patients than for the general ED population, it was not excessively so. Adequate staffing to properly maintain the safety of these patients is paramount.
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Affiliation(s)
- Baruch S Fertel
- Quality & Patient Safety New York - Presbyterian Hospital, Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, United States of America
| | - Leopoldo Pozuelo
- Center for Behavioral Health, Cleveland Clinic, Cleveland, OH, United States of America
| | - Sarah Kirschling
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Clecveland, OH, United States of America
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Northeast Ohio Medical University, United States of America.
| | - McKinsey Muir
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America
| | - Courtney M Smalley
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
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Iheonunekwu C, Krasnoschlik NJ, Schramm J, Shundry N, Simon EL. Spontaneous Expulsive Suprachoroidal Hemorrhage. Am J Emerg Med 2023; 70:210.e1-210.e3. [PMID: 37349235 DOI: 10.1016/j.ajem.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Spontaneous Expulsive Suprachoroidal Hemorrhage (SESCH) is an extremely rare phenomenon that leads to atraumatic spontaneous globe rupture. Only a handful of SESCH cases have been reported worldwide, primarily in developing countries. Risk factors associated with SESCH include uncontrolled hypertension, previous eye surgery, glaucoma, atherosclerosis, advanced age, and corneal damage. CASE REPORT We report a case of expulsive suprachoroidal hemorrhage in a ninety-seven-year-old female. The patient presented to the emergency department with painful bleeding from her right eye. She denied any trauma or injury to the eye. She denied any use of anticoagulation. Physical examination showed a right ocular hematoma with mild active bleeding. She had exophthalmos and proptosis with extrusion of the ocular structures. A computed tomography scan of the orbits demonstrated right globe rupture with diffuse hemorrhage. Ophthalmology was consulted, and the patient subsequently had an evisceration of her right eye. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous expulsive choroidal hemorrhage is exceedingly rare. SESCH predominantly affects diseased eyes in the elderly. Early recognition of impending globe rupture in patients who present with suprachoroidal hemorrhage is necessary and requires prompt ophthalmology consultation. Emergency physicians must be aware that an atraumatic open globe can occur and requires immediate evaluation by an ophthalmologist and emergent repair in the operating suite.
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Affiliation(s)
- Chizite Iheonunekwu
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA.
| | | | - Jorgi Schramm
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA
| | - Nicholas Shundry
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 SR-44, Rootstown, OH 44272, USA
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Smalley CM, Simon EL, Muir MR, Fertel BS. A Real-World Experience: Retrospective Review of Point-of-Care Ultrasound Utilization and Quality in Community Emergency Departments. West J Emerg Med 2023; 24:685-692. [PMID: 37527388 PMCID: PMC10393449 DOI: 10.5811/westjem.58965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/24/2023] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION Point-of-care ultrasound (POCUS) is commonly used in the emergency department (ED) as a rapid diagnostic tool. Emergency medicine (EM) has been an early adopter of POCUS with indications expanding over the last 10 years. While the literature describes widespread use among academic sites, there is little data on clinical POCUS utilization at non-academic EDs. We sought to describe community emergency physician (EP) use of POCUS by quantifying the number and type of studies performed, characteristics of the performing physician, and quality metrics. METHODS Prior to the study period, all EPs underwent a standardized training and credentialing program. A retrospective review of all POCUS studies across 11 non-academic EDs from October 1, 2018-September 30, 2020 was performed by fellowship-trained physicians, who identified physician, exam type, and residency graduation year. The studies were then cross-referenced with quality review reports that assessed image acquisition, image interpretation, and image labeling. We performed descriptive statistics. RESULTS During the study period, 5,099 POCUS studies were performed by 170 EPs. Exams most frequently performed were cardiac (24%), focused assessment of sonography in trauma (21.7%), and pregnancy (16.2%). Recent EM residency graduates (<10 years) were higher utilizers of POCUS with a group mean of 1.3 exams per 100 patients. Of the studies done, 86% had no quality issues. CONCLUSION Community POCUS demonstrates a heavy focus on core exams performed by recent EM residency graduates with minimal quality issues after a standardized training program. This study is the first to quantify actual community POCUS use in multiple EDs and may impact credentialing and skills maintenance requirements.
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Affiliation(s)
- Courtney M Smalley
- Cleveland Clinic Health System, Emergency Services Institute, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
- Northeast Ohio Medical University, Rootstown, Ohio
| | - McKinsey R Muir
- Cleveland Clinic Health System, Emergency Services Institute, Cleveland, Ohio
| | - Baruch S Fertel
- Columbia University Vagelos College of Physicians and Surgeons, Department of Emergency Medicine, New York, New York
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Simon EL, Smalley CM, Muir M, Mangira CM, Pence R, Wahi-Singh B, Delgado F, Fertel BS. Agitation Management in the Emergency Department with Physical Restraints: Where Do These Patients End Up? West J Emerg Med 2023; 24:454-460. [PMID: 37278796 DOI: 10.5811/westjem.59466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/15/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION Agitation is frequently encountered in the emergency department (ED) and can range from psychomotor restlessness to overt aggression and violent behavior. Among all ED patients, 2.6% present with agitation or become agitated during their ED visit. We aimed to determine ED disposition for patients requiring agitation management with physical restraints. METHODS This was a retrospective cohort of all adult patients who presented to one of 19 EDs in a large integrated healthcare system and received agitation management with physical restraints between January 1, 2018-December 31, 2020. Categorical variables are presented as frequency and percentages, and continuous variables are presented as medians and interquartile range. RESULTS There were 3,539 patients who had agitation management with physical restraints included in this study. In total 2,076 (58.8%) were admitted to the hospital (95% CI [confidence interval] 0.572-0.605), and of those 81.4% were admitted to a primary medical floor and 18.6% were medically cleared and admitted to a psychiatric unit. Overall, 41.2% were able to be medically cleared and discharged from the ED. Mean age was 40.9 years, 2,140 were male (59.1%), 1,736 were White (50.3%), and 1,527 (43%) were Black. We found 26% had abnormal ethanol, (95% CI 0.245-0.274) and 54.6% had an abnormal toxicology screen (95% CI 0.529-0.562). A significant number were administered a benzodiazepine or antipsychotic in the ED (88.44%) (95% CI 0.874-0.895). CONCLUSION The majority of patients who had agitation management with physical restraints were admitted to the hospital; of those patients, 81.4% were admitted to a primary medical floor and 18.6% were admitted to a psychiatric unit.
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Affiliation(s)
- Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
| | | | - McKinsey Muir
- Cleveland Clinic, Patient Quality and Safety, Cleveland, Ohio
| | | | - Rylee Pence
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
| | - Bhanu Wahi-Singh
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
| | | | - Baruch S Fertel
- Cleveland Clinic, Patient Quality and Safety, Cleveland, Ohio
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Downs T, Jacquet J, Disch J, Kolodychuk N, Talmage L, Krizo J, Simon EL, Meehan A, Stenberg R. Large-scale Implementation of Fascia Iliaca Compartment Blocks in an Emergency Department. West J Emerg Med 2023; 24:384-389. [PMID: 37278790 DOI: 10.5811/westjem.58793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/09/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION A robust body of literature supports the use of fascia iliaca compartment blocks (FICB) for improving outcomes in hip fractures, especially in the geriatric population. Our objective in this project was to implement consistent pre-surgical, emergency department (ED) FICB for hip fracture patients and to address barriers to implementation. METHODS With the support of a multidisciplinary team, including orthopedic surgery and anesthesia, a core team of emergency physicians developed and implemented a departmentwide FICB training and credentialing program. The goal was to have 80% of all emergency physicians credentialed to provide pre-surgical FICB to all hip fracture patients seen in the ED who met the criteria. Following implementation, we assessed approximately one year of data on hip fracture patients presenting to the ED. We evaluated whether or not they were eligible for FICB and, if so, whether or not they received it. RESULTS Emergency physician education has resulted in 86% of clinicians credentialed to perform FICB. Of 486 patients presenting for hip fracture, 295 (61%) were considered eligible for a block. Of those eligible, (54%) consented and underwent a FICB in the ED. CONCLUSION A collaborative, multidisciplinary effort is vital for success. The primary barrier to achieving a higher percentage of eligible patients receiving blocks was the deficit of emergency physicians initially credentialed. Continuing education is ongoing, including credentialing and early identification of patients eligible for the fascia iliaca compartment block.
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Affiliation(s)
- Tony Downs
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
| | - Joshua Jacquet
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
| | - Jno Disch
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
| | - Nicholas Kolodychuk
- Cleveland Clinic Akron General, Department of Orthopedic Surgery, Akron, Ohio
| | - Lance Talmage
- Cleveland Clinic Akron General, Department of Anesthesia, Akron, Ohio
| | - Jessica Krizo
- Cleveland Clinic Akron General, Department of Health Sciences, Akron, Ohio
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
| | - Anita Meehan
- Cleveland Clinic Akron General, Department of Nursing, Akron, Ohio
| | - Robert Stenberg
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, Ohio
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Griffin G, Krizo J, Mangira C, Simon EL. The impact of COVID-19 on emergency department boarding and in-hospital mortality. Am J Emerg Med 2023; 67:5-9. [PMID: 36773378 PMCID: PMC9884607 DOI: 10.1016/j.ajem.2023.01.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic has been challenging for healthcare systems in the United States and globally. Understanding how the COVID-19 pandemic has impacted emergency departments (EDs) and patient outcomes in a large integrated healthcare system may help prepare for future pandemics. Our primary objective was to evaluate if there were changes to ED boarding and in-hospital mortality before and during the COVID-19 pandemic. METHODS This was a retrospective cohort study of all patients ages 18 and over who presented to one of 17 EDs (11 hospital-based; 6 freestanding) within our healthcare system. The study timeframe was March 1, 2019- February 29, 2020 (pre-pandemic) vs. March 1, 2020-August 31, 2021 (during the pandemic). Categorical variables are described using frequencies and percentages, and p-values were obtained from Pearson chi-squared or Fisher's exact tests where appropriate. In addition, multiple regression analysis was used to compare ED boarding and in-hospital mortality pre-pandemic vs. during the pandemic. RESULTS A total of 1,374,790 patient encounters were included in this study. In-hospital mortality increased by 16% during the COVID-19 Pandemic AOR 1.16(1.09-1.23, p < 0.0001). Boarding increased by 22% during the COVID-19 pandemic AOR 1.22(1.20-1.23), p < 0.0001). More patients were admitted during the COVID-19 pandemic than prior to the pandemic (26.02% v 24.97%, p < 0.0001). Initial acuity level for patients presenting to the ED increased for both high acuity (13.95% v 13.18%, p < 0.0001) and moderate acuity (60.98% v 59.95%, p < 0.0001) during the COVID-19 pandemic. CONCLUSION The COVID-19 pandemic led to increased ED boarding and in-hospital mortality.
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Affiliation(s)
- Gregory Griffin
- Cleveland Clinic Akron General Department of Emergency Medicine, 1 Akron General Ave., Akron, OH 44307, USA
| | - Jessica Krizo
- Cleveland Clinic Akron General Department of Research, 1 Akron General Ave. Akron, OH 44307, USA
| | - Caroline Mangira
- Cleveland Clinic Akron General Department of Research, 1 Akron General Ave. Akron, OH 44307, USA
| | - Erin L. Simon
- Cleveland Clinic Akron General Department of Emergency Medicine, 1 Akron General Ave., Akron, OH 44307, USA,Northeast Ohio Medical University, 4209 St, OH-44, Rootstown, OH 44272, USA,Corresponding author at: Cleveland Clinic Akron General Department of Emergency Medicine, 1 Akron General Ave., Akron, OH 44307, USA
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13
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Simon EL, Crouse B, Wilson M, Muir M, Sayles S, Ramos C, Phelan MP. Evaluation of missed influenza vaccination opportunities in the emergency department. Am J Emerg Med 2023; 68:59-63. [PMID: 36933335 DOI: 10.1016/j.ajem.2023.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/19/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Seasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018-2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data. METHODS This was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 - April 30) over a two-years, 2018-2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity. RESULTS A total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions. CONCLUSION Patients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.
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Affiliation(s)
- Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave., Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 SR-44, Rootstown, OH 44272, USA.
| | - Bethany Crouse
- Northeast Ohio Medical University, 4209 SR-44, Rootstown, OH 44272, USA; Cleveland Clinic Akron General, Department of Pharmacy, 1 Akron General Ave., Akron, OH 44307, USA
| | - Mackenzie Wilson
- Northeast Ohio Medical University, 4209 SR-44, Rootstown, OH 44272, USA
| | - McKinzey Muir
- Emergency Services Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Stephen Sayles
- Emergency Services Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Chris Ramos
- Emergency Services Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Michael P Phelan
- Emergency Services Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
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Stenberg RT, Nelson J, Rabinowitz J, Simon EL. Spontaneous Hyphema and Vitreous Hemorrhage Causing Secondary Glaucoma in a Patient on Apixaban. J Emerg Med 2023; 64:359-362. [PMID: 36863910 DOI: 10.1016/j.jemermed.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/10/2022] [Accepted: 12/13/2022] [Indexed: 03/04/2023]
Abstract
BACKGROUND Spontaneous hyphema is the rare occurrence of hemorrhage within the anterior chamber of the eye without a predisposing traumatic event. Hyphema can be associated with acute elevations in intraocular pressure in up to 30% of cases, which poses a significant risk for permanent vision loss if not quickly recognized and treated in the emergency department (ED). Anticoagulant and antiplatelet medications have been previously associated with cases of spontaneous hyphema; however, there are limited reports of hyphema with associated acute glaucoma in a patient taking a direct oral anticoagulant. Due to the limited data of reversal therapies for direct oral anticoagulants in intraocular hemorrhage, these patients pose a challenge in deciding whether to reverse anticoagulation in the ED. CASE REPORT We present a case of a 79-year-old man on apixaban anticoagulation therapy who presented to the ED with spontaneous painful vision loss in the right eye with associated hyphema. Point-of-care ultrasound revealed an associated vitreous hemorrhage, and tonometry was significant for acute glaucoma. As a result, the decision was made to reverse the patient's anticoagulation with four-factor activated prothrombin complex concentrate. Why Should an Emergency Physician Be Aware of This? This case is an example of acute secondary glaucoma due to a hyphema and vitreous hemorrhage. There is limited evidence regarding anticoagulation reversal in this setting. A second site of bleeding was identified by utilization of point-of-care ultrasound, which led to the diagnosis of a vitreous hemorrhage. This allowed for shared decision-making between the emergency physician, ophthalmologist, and patient regarding the risks and potential benefits of the reversal of anticoagulation. Ultimately, the patient decided to have his anticoagulation reversed to try and preserve vision.
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Affiliation(s)
- Robert T Stenberg
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Jacob Nelson
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Des Moines University College of Osteopathic Medicine, Des Moines, Iowa
| | - Jeffrey Rabinowitz
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
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15
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Simon EL, Wahi-Singh B, Fertel BS, Weber L, Krizo J, Mangira C, Smalley CM. Patients utilizing emergency medical services - Does facility type matter? Am J Emerg Med 2023; 68:38-41. [PMID: 36924750 DOI: 10.1016/j.ajem.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/15/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Emergency departments (EDs) play a critical role in the US healthcare system. As freestanding EDs (FSEDs) are integrated into the acute care landscape, local EMS providers are transporting to these facilities, which may be closer in proximity and provide faster turnaround times. We hypothesized that patients transported via EMS to a freestanding ED required fewer tests and are admitted less frequently than those transported to a HBED. Our objective was to compare testing frequency and admission rates between patients transported via EMS to a FSED vs. HBED. METHODS This was a retrospective cohort study of all patients who presented within a large integrated hospital system via EMS to one of 10 HBEDs or one of 6 FSEDs between April 1, 2020 - May 1, 2021. Categorical variables are presented as frequencies and percentages and comparisons between groups were obtained using chi squared tests. Continuous variables are presented as mean and standard deviation and p-values comparing groups were obtained using t-tests. Multiple logistic regression was used to assess the effect of ED type on admission status, labs ordered, and testing performed. RESULTS A total of 123,120 encounters were included in our study. Mean age at the FSEDs was 59.9 vs. 61.3 at the HBEDs. At the FSEDs 55.6% (n = 4675) were female vs. 53.0% (n = 60,809) at the HBEDs. At the FSEDs 82.0% (n = 6805) were White vs. 60.7% (n = 68,430) at the HBEDs. We found 50.0% (n = 3974) had Medicare at the FSEDs vs 50.9% (n = 55,372) at the FSEDs. At the FSEDs, 69.5% (n = 5846) had bloodwork vs. 82.4% (n = 94,512) at the HBEDs; 68.3% (n = 5745) had an x-ray at the FSEDs vs. 70.7% (n = 81,089) at the HBEDs; 40.1% (n = 3370) had a CT scan at the FSEDs vs. 44.9% (n = 51,503) at the HBEDs; and 40.6% (n = 3412) were admitted at the FSEDs vs. 56.1% (n = 64,355) at the HBEDs. After controlling for Charlson Comorbidity Index, acuity, age, gender, sex, insurance and race, patients in FSEDs were 35% less likely to be admitted as compared to HBEDs. CONCLUSION Patients brought in via EMS to a FSED were less likely to have blood work, x-ray, or CT scan, and were less likely to be admitted to the hospital than those transported to a HBED.
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Affiliation(s)
- Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA; Northeast Ohio Medical University, 4209 SR-44, Rootstown, OH 44272, USA.
| | - Bhanu Wahi-Singh
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA
| | - Baruch S Fertel
- Emergency Services Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA; Enteprise Safety, Quality & Patient Experience, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Luke Weber
- Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA
| | - Jessica Krizo
- Department of Health Sciences, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA
| | - Caroline Mangira
- Department of Health Sciences, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH 44307, USA
| | - Courtney M Smalley
- Emergency Services Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA
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16
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Yocum AD, Patel M, Palocko B, Simon EL. Primary Neurologic Symptoms: Have You Considered Pernicious Anemia? J Emerg Med 2023; 64:217-219. [PMID: 36739174 DOI: 10.1016/j.jemermed.2022.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/06/2022] [Accepted: 10/21/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Vitamin B12, or cobalamin, is a nutrient that is vital for metabolic function. Absorption of ingested B12 is dependent on intrinsic factor, which is secreted by parietal cells within the stomach. Pernicious anemia is caused by an intrinsic factor deficiency or autoantibodies against intrinsic factor. The presence of parietal cell antibodies can destroy parietal cells, which can also lead to a deficiency in intrinsic factor. Both lead to megaloblastic anemia caused by vitamin B12 deficiency. The typical presentation of pernicious anemia includes fatigue, pale appearance, tingling sensation, depression, alterations to vision and smell, urinary incontinence, psychotic episodes, and weakness. The most effective treatment for pernicious anemia is intramuscular B12. CASE REPORT A 27-year-old woman with a history of vitiligo presented to the emergency department (ED) with bilateral lower extremity weakness, clumsiness, numbness, and tingling. Physical examination revealed ataxia, no sensation below her umbilicus, decreased strength, and hyperreflexia in both lower extremities. Complete blood count in the ED revealed low hemoglobin and hematocrit and elevated mean corpuscular volume, concerning for pernicious anemia. Further laboratory testing upon inpatient admission revealed a low vitamin B12 level and parietal cell antibodies in the blood. The patient's pernicious anemia was treated with intramuscular vitamin B12 injections, which led to near complete resolution of her symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early suspicion and detection of pernicious anemia in the ED can prevent serious and permanent hematologic and neurologic damage and the development of other autoimmune disorders.
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Affiliation(s)
- Andrew D Yocum
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Mili Patel
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Bradley Palocko
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
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17
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Grossman M, See AP, Mannix R, Simon EL. Complete Neurological Recovery After Emergency Burr Hole Placement Utilizing EZ-IO® for Epidural Hematoma. J Emerg Med 2022; 63:557-560. [DOI: 10.1016/j.jemermed.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/04/2022] [Indexed: 12/05/2022]
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18
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Merrill R, Septaric K, Simon EL. Acute Cholecystitis With Situs Inversus Totalis. J Emerg Med 2022; 62:e77-e79. [PMID: 35067391 DOI: 10.1016/j.jemermed.2021.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Rebecca Merrill
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Kristen Septaric
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
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19
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Prete S, McShannic JD, Fertel BS, Simon EL. Acute transverse myelitis progressing to permanent quadriplegia following COVID-19 infection. Am J Emerg Med 2022; 56:391.e1-391.e3. [PMID: 35248410 PMCID: PMC8864811 DOI: 10.1016/j.ajem.2022.02.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
- Spencer Prete
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America
| | - Joseph D McShannic
- Northeast Ohio Medical University, Rootstown, OH, United States of America
| | - Baruch S Fertel
- Emergency Services Institute Cleveland Clinic Foundation, Enterprise Quality and Safety, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States of America
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America.
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20
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Engineer RS, Podolsky SR, Fertel BS, Grover P, Jimenez H, Simon EL, Smalley CM. A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool. Pediatr Emerg Care 2021; 37:e1670-e1674. [PMID: 29768294 DOI: 10.1097/pec.0000000000001501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool. METHODS A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013. RESULTS The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group. CONCLUSION A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.
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Affiliation(s)
- Rakesh S Engineer
- From the Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH
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21
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Watkins K, Griffin G, Septaric K, Simon EL. Myocarditis after BNT162b2 vaccination in a healthy male. Am J Emerg Med 2021; 50:815.e1-815.e2. [PMID: 34229940 PMCID: PMC8238643 DOI: 10.1016/j.ajem.2021.06.051] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 02/01/2023] Open
Abstract
Myocarditis following mRNA COVID-19 vaccination has recently been reported to health authorities in the United States and other countries. Cases predominately occur in young adult males within four days following the second dose of either the Moderna (mRNA-1273) or Pfizer-BioNTech (BNT162b2) vaccines. Although the number of cases reported have been small in comparison with the large number of people vaccinated, myocarditis may be a rare adverse reaction to the COVID-19 vaccination that is now only becoming apparent due to the widespread use of the vaccine. In this article, we present a case of a 20-year-old male with no prior medical history who presented to the emergency department (ED) with chest pain. He had received the BNT162b2 vaccine two days prior to his presentation to the ED. The patient had an elevated troponin at 89 ng/L which increased on repeat examination. His electrocardiogram showed diffuse concave ST segment elevations and a later MRI confirmed the diagnosis of myocarditis. Based on these findings, the patient was diagnosed with myocarditis. The patient had a previous infection with SARS-CoV-2 approximately two months prior to the onset of his symptoms, but since he had fully recovered before the time of his presentation to the ED, it is unlikely that the infection caused the myocarditis. To our knowledge, this is the first published case of myocarditis following BNT162b3 vaccination.
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Affiliation(s)
- Kevin Watkins
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America
| | - Gregory Griffin
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America
| | - Kristen Septaric
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America.
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22
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Stenberg R, Mancini G, Guthrie T, Simon EL. Intraocular mass as first presenting symptom of metastatic squamous cell lung cancer. Am J Emerg Med 2021; 50:814.e1-814.e2. [PMID: 34275680 DOI: 10.1016/j.ajem.2021.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/20/2021] [Indexed: 11/29/2022] Open
Abstract
Lung cancer is one of the leading causes of cancer related mortality worldwide. Currently, it is the third most common cancer behind prostate and breast cancer. Approximately 85% of all lung cancers are non-small-cell lung cancers (NSCLC). Adenocarcinoma and squamous cell carcinoma are the most common subtypes, accounting for 50% and 30% of NSCLC cases, respectively. Lung cancer is often initially found on chest x-rays and diagnosed via biopsy of the lesion. It is often diagnosed at the time of advanced or metastatic disease. The majority of lung cancers metastasize to locations such as bone, brain, adrenal glands and liver. Multiple case reports have been reported with ocular metastases, such as the choroid, iris and retina. We present a 87-year-old women whose initial emergency department presentation of squamous cell type lung cancer was an intraocular mass. To our knowledge this is the first reported case of this presentation and diagnosis within the emergency department setting.
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Affiliation(s)
- Robert Stenberg
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, Northeast Ohio Medical University, Rootstown, United States of America
| | - Gregory Mancini
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, Northeast Ohio Medical University, Rootstown, United States of America
| | - Tim Guthrie
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, Medical College of Wisconsin-Green Bay Campus, Green Bay, WI., United States of America
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, Northeast Ohio Medical University, Rootstown, United States of America.
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23
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Winot S, Hill AC, Simon EL. A Case Report You Can't Make Up: A Bladder Foreign Body. J Emerg Med 2021; 61:73-75. [PMID: 33972134 DOI: 10.1016/j.jemermed.2021.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Scott Winot
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Andrew C Hill
- Ohio University Heritage College of Osteopathic Medicine, Warrensville Heights, Ohio
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
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24
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Fertel BS, Milk J, Simon EL, Muir MR, Smalley CM. COVID-19 vaccine adverse reactions bring patients to emergency departments. Am J Emerg Med 2021; 54:302-303. [PMID: 33994051 PMCID: PMC8101000 DOI: 10.1016/j.ajem.2021.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 10/25/2022] Open
Affiliation(s)
- Baruch S Fertel
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America; Enterprise Quality and Patient Safety, Cleveland Clinic Health System, Cleveland, OH, United States of America.
| | - Jason Milk
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America.
| | - Erin L Simon
- Department of Emergency Medicine, Akron General Medical Center, Akron, OH, United States of America; Northeast Ohio Medical University (NEOMED), Rootstown, OH, United States of America
| | - McKinsey R Muir
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America
| | - Courtney M Smalley
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
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25
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Simon EL. International Federation for Emergency Medicine global research primer. Afr J Emerg Med 2021; 11:211. [PMID: 33680744 PMCID: PMC7910179 DOI: 10.1016/j.afjem.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Erin L. Simon
- Corresponding author: Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America.
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Smalley CM, Meldon SW, Simon EL, Muir MR, Delgado F, Fertel BS. Emergency Department Patients Who Leave Before Treatment Is Complete. West J Emerg Med 2021; 22:148-155. [PMID: 33856294 PMCID: PMC7972384 DOI: 10.5811/westjem.2020.11.48427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Emergency department (ED) patients who leave before treatment is complete (LBTC) represent medicolegal risk and lost revenue. We sought to examine LBTC return visits characteristics and potential revenue effects for a large healthcare system. Methods This retrospective, multicenter study examined all encounters from January 1–December 31, 2019 at 18 EDs. The LBTC patients were divided into left without being seen (LWBS), defined as leaving prior to completed medical screening exam (MSE), and left subsequent to being seen (LSBS), defined as leaving after MSE was complete but before disposition. We recorded 30-day returns by facility type including median return hours, admission rate, and return to index ED. Expected realization rate and potential charges were calculated for each patient visit. Results During the study period 626,548 ED visits occurred; 20,158 (3.2%) LBTC index encounters occurred, and 6745 (33.5%) returned within 30 days. The majority (41.7%) returned in <24 hours with 76.1% returning in 10 days and 66.4% returning to index ED. Median return time was 43.3 hours, and 23.2% were admitted. Urban community EDs had the highest 30-day return rate (37.8%, 95% confidence interval, 36.41–39.1). Patients categorized as LSBS had longer median return hours (66.0) and higher admission rates (29.8%) than the LWBS cohort. There was a net potential realization rate of $9.5 million to the healthcare system. Conclusion In our system, LSBS patients had longer return times and higher admission rates than LWBS patients. There was significant potential financial impact for the system. Further studies should examine how healthcare systems can reduce risk and financial impacts of LBTC patients.
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Affiliation(s)
- Courtney M Smalley
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Stephen W Meldon
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Erin L Simon
- Akron General Medical Center, Department of Emergency Medicine, Akron, Ohio.,Northeast Ohio Medical University (NEOMED), Rootstown, Ohio
| | - McKinsey R Muir
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, Ohio
| | - Fernando Delgado
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, Ohio
| | - Baruch S Fertel
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.,Cleveland Clinic Health System, Enterprise Quality and Patient Safety, Cleveland, Ohio
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Yocum AD, Dennison JL, Simon EL. Esophageal Obstruction and Death in a Nonverbal Patient. J Emerg Med 2021; 60:e109-e113. [PMID: 33583613 DOI: 10.1016/j.jemermed.2020.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/15/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND There are more than 100,000 cases of esophageal foreign body in the United States each year. Most cases resolve spontaneously; however, complete esophageal obstruction is a medical emergency. Patients with developmental disabilities are at high risk, because a large percentage of this population is effected by dysphagia, pica, tooth loss, or impulsive swallowing. In some cases, the diagnosis of esophageal foreign body can be made clinically, with the typical presentation including coughing, inability to tolerate secretions, drooling, vomiting, and dysphagia. In other instances, imaging is needed to confirm the diagnosis. CASE REPORT A nonverbal adult patient with history of mental retardation and dysphagia presented to the emergency department (ED) after a choking episode with persistent coughing. An x-ray study of the chest showed mild opacity at the left lung base and she was discharged with antibiotics. She returned to the ED that day with worsening symptoms suggestive of aspiration pneumonia. A computed tomography scan of the chest revealed numerous cylindrical objects in the esophagus, later identified as crayons. At least 28 crayons were removed via 3 endoscopies. During this time, the patient developed aspiration pneumonia, respiratory distress, and septic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Delayed recognition of foreign body puts patients at risk for esophageal perforation, aspiration, airway compromise, infection, sepsis, and death. In nonverbal patients presenting with upper respiratory symptoms, it is especially important to consider esophageal foreign body in the differential diagnosis, because this group is high risk for missed diagnosis and complications secondary to the foreign body.
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Affiliation(s)
- Andrew D Yocum
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Jennifer L Dennison
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Lake Erie College of Osteopathic Medicine at Seton Hill, Greensburg, Pennsylvania
| | - Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
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Smalley CM, Simon EL, Muir MR, Delgado F, Fertel BS. Point-of-Care Ultrasound Training and Credentialing for mid-late Career Emergency Physicians: Is it worth it? POCUS J 2021; 6:56-57. [PMID: 36895662 PMCID: PMC9979911 DOI: 10.24908/pocus.v6i2.14891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Point-of-care ultrasound (POCUS) is becoming more prevalent in community emergency medicine (EM) practice with the current American College of Emergency Physician guidelines recommending POCUS training for all graduates from United States based residency programs as well as support for POCUS privileging by the American Medical Association. However, in a recent survey of nonacademic EDs, it was found that most providers lack US training, credentialing, and quality assurance (QA) assessments of their POCUS studies. In 2017, our healthcare system embarked on a system-wide credentialing process for POCUS to credential community physicians with little to no POCUS training.
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Smalley CM, Baskin BE, Simon EL, Meldon SW, Muir MR, Borden BL, Trentanelli K, Fertel BS. Ongoing Professional Practice Evaluation for Emergency Medicine Physicians in a Large Health Care System. Jt Comm J Qual Patient Saf 2020; 47:318-326. [PMID: 33358572 DOI: 10.1016/j.jcjq.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Ongoing professional practice evaluation (OPPE) is designed to identify professional practice trends that affect quality and safety of practicing physicians. Focused professional practice evaluation (FPPE) is employed when physician nonconformance is identified. The goal of this novel OPPE initiative was threefold: (1) meet The Joint Commission's accreditation standards, (2) assess documentation for compliance and risk, and (3) maintain procedural competency to provide optimal patient care. METHODS A quality assurance project with OPPE program development was initiated in 18 emergency departments across a large health care system. First, a monthly comprehensive peer review meeting assessed cases across the system for medicolegal risk. Physicians with reasonable practice concerns were identified and referred to FPPE. Second, a standardized OPPE chart review was performed biannually by a quality assurance committee assessing all physician charts for clinical care, medicolegal risk, and quality. Last, completion of a procedure lab every three years was required to maintain competency. OUTCOMES For systemwide peer review in 2019, 47 cases were referred and 12.8% had quality concerns. For standardized OPPE chart review, 221 physicians were reviewed on 1,219 charts on the following metrics: insufficient medical decision making, diagnoses not medical/legally supported, and charts with red flags. Nine physicians (4.1%) and 17 charts (1.4%) were deficient in all three measures, and 8 physicians (3.6%) had deficiencies in ≥ 50% of their charts. For procedure lab competency, 19.0% of physicians completed the lab in 2019 with no quality concerns. CONCLUSION A structured OPPE algorithm can aid large health care systems in identifying deviations from practice standards for which additional FPPE can be beneficial.
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Simon EL, Osei-Ampofo M, Wachira BW, Kwan J. Getting accepted - Successful writing for scientific publication: a Research Primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S154-S157. [PMID: 33304800 PMCID: PMC7718457 DOI: 10.1016/j.afjem.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 11/09/2022] Open
Abstract
Clear and precise writing is a vital skill for healthcare providers and those involved in global emergency care research. It allows one to publish in scientific literature and present oral and written summaries of their work. However, writing skills for publishing are rarely part of the curriculum in the healthcare education system. This review gives you a step-by-step guide on how to successfully write for scientific publication following the IMRaD principle (Introduction, Methods, Results, and Discussion) with every part supporting the key message. There are specific benefits of writing for publication that justify the extra work involved. Any lessons learned about improving global emergency care delivery can be useful to emergency clinicians. The end result can lead to changing others' practice and pave the way for further research.
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DeVos E, Simon EL, Aluisio A. Funding sources for research: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S130-S134. [PMID: 33304795 PMCID: PMC7718450 DOI: 10.1016/j.afjem.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 08/30/2020] [Accepted: 09/12/2020] [Indexed: 11/25/2022] Open
Abstract
Research is a fundamental component of the development of quality emergency care systems. Developing qualified professionals and programs to conduct emergency care research is essential to understanding epidemiology in low resource settings. This leads to evaluating research outcomes, developing clinical practice guidelines and program implementation. This paper aims to introduce the reader to opportunities for research funding at various stages of one's career. We will discuss concepts necessary to obtain funding for research, a crucial step towards initiating a research program. The chapter further describes competitive funding mechanisms including governmental agencies, foundations and private industry along with organisations that offer funding for global health and emergency care research. We describe categories of grants specific to a stage of an investigator's career, developing a team for a proposal and the grant application process.
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Totten V, Simon EL, Jalili M, Sawe HR. Acquiring data in medical research: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S135-S139. [PMID: 33304796 PMCID: PMC7718444 DOI: 10.1016/j.afjem.2020.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 08/08/2020] [Accepted: 09/05/2020] [Indexed: 11/19/2022] Open
Abstract
Without data, there is no new knowledge generated. There may be interesting speculation, new paradigms or theories, but without data gathered from the universe, as representative of the truth in the universe as possible, there will be no new knowledge. Therefore, it is important to become excellent at collecting, collating and correctly interpreting data. Pre-existing and new data sources are discussed; variables are discussed, and sampling methods are covered. The importance of a detailed protocol and research manual are emphasized. Data collectors and data collection forms, both electronic and paper-based are discussed. Ensuring subject privacy while also ensuring appropriate data retention must be balanced.
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Affiliation(s)
- Vicken Totten
- Kaweah Delta Health Care District (KDHCD), KDHCD Department of Emergency Medicine, Visalia, CA, USA
- Corresponding author.
| | - Erin L. Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, USA
| | - Mohammad Jalili
- Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hendry R. Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Taylor DM, Hodkinson PW, Khan AS, Simon EL. Research skills and the data spreadsheet: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S140-S144. [PMID: 33304797 PMCID: PMC7718460 DOI: 10.1016/j.afjem.2020.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/23/2020] [Accepted: 05/06/2020] [Indexed: 10/25/2022] Open
Abstract
The specialty of Emergency Medicine continues to expand and mature worldwide. As a relatively new specialty, the body of research that underpins patient management in the emergency department (ED) setting needs to be expanded for optimum patient care. Research in the ED, however, is complicated by a number of issues including limited time and resources, urgency for some therapeutic investigations and interventions, and difficulties in obtaining truly informed patient consent. Notwithstanding these issues, many of the fundamental principles of medical research apply equally to ED research. In all medical disciplines, data needs to be collected, collated and stored for analysis and a data spreadsheet is employed for this purpose. Like other aspects of clinical research, the use of the data spreadsheet needs to be exacting and appropriate. This research primer explores the choice of available spreadsheets and a range of principles for their best-practice use. It is deliberately, not an exhaustive review of the subject. However, we aim to explore basic principles and some of the most accessible and widely used data spreadsheets.
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Simon EL, Smalley CM, Meldon SW, Borden BL, Briskin I, Muir MR, Suchan A, Delgado F, Fertel BS. Procedural frequency: Results from 18 academic, community and freestanding emergency departments. J Am Coll Emerg Physicians Open 2020; 1:1669-1675. [PMID: 33392575 PMCID: PMC7771730 DOI: 10.1002/emp2.12238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/05/2020] [Accepted: 08/10/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Emergency physicians must maintain procedural skills, but clinical opportunities may be insufficient. We sought to determine how often practicing emergency physicians in academic, community and freestanding emergency departments (EDs) perform 4 procedures: central venous catheterization (CVC), tube thoracostomy, tracheal intubation, and lumbar puncture (LP). METHODS This was a retrospective study evaluating emergency physician procedural performance over a 12-month period. We collected data from the electronic records of 18 EDs in one healthcare system. The study EDs included higher and lower volume, academic, community and freestanding, and trauma and non-trauma centers. The main outcome measures were median number of procedures performed. We examined differences in procedural performance by physician years in practice, facility type, and trauma status. RESULTS Over 12 months, 182 emergency physicians performed 1582 of 2805 procedures (56%) and supervised (resident, nurse practitioner or physician assistant) an additional 1223 of the procedures they did not perform (43%). Median (interquartile range) physician performance for each procedure was CVC 0 [0, 2], tube thoracostomy 0 [0, 0], tracheal intubation 3 [0.25, 8], and LP 0 [0, 2]. The percentage of emergency physicians who did not perform at least one of each procedure during the 1-year time frame ranged from 25.3% (tracheal intubation) to 76.4% (tube thoracostomy). Physicians who work at high-volume EDs (>50,000 visits per year) performed nearly twice as many tracheal intubations, CVCs, and LPs than those at low-volume EDs or freestanding EDs when normalized per 1000 visits. Years out of training were inversely related to total number of procedures performed. Emergency physicians at trauma centers performed almost 3 times as many tracheal intubations and almost 4 times as many CVCs compared to non-trauma centers. CONCLUSION In a large healthcare system, regardless of ED type, emergency physicians infrequently performed the 4 procedures studied. Physicians in high-volume EDs, trauma centers, and recent graduates performed more procedures. Our study adds to a growing body of research that suggests clinical frequency alone may be insufficient for all emergency physicians to maintain competency.
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Affiliation(s)
- Erin L. Simon
- Department of Emergency MedicineCleveland Clinic Akron GeneralAkronOhioUSA
- Northeast Ohio Medical UniversityRootstownOhioUSA
| | - Courtney M. Smalley
- Cleveland Clinic Lerner College of MedicineCleveland Clinic Emergency Services InstituteClevelandOhioUSA
| | - Stephen W. Meldon
- Cleveland Clinic Lerner College of MedicineCleveland Clinic Emergency Services InstituteClevelandOhioUSA
| | - Bradford L. Borden
- Cleveland Clinic Lerner College of MedicineCleveland Clinic Emergency Services InstituteClevelandOhioUSA
| | - Isaac Briskin
- Cleveland Clinic Emergency Services InstituteClevelandOhioUSA
| | | | - Andrew Suchan
- Department of Emergency MedicineCleveland Clinic Akron GeneralAkronOhioUSA
- Northeast Ohio Medical UniversityRootstownOhioUSA
| | - Fernando Delgado
- Cleveland ClinicCleveland Clinic Emergency Services InstituteOhioUSA
| | - Baruch S. Fertel
- Enterprise Quality and Safety, Cleveland Clinic Lerner College of MedicineEmergency Services Institute Cleveland Clinic FoundationClevelandOhioUSA
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Dark C, Canellas M, Mangira C, Jouriles N, Simon EL. Estimates of throughput and utilization at freestanding compared to low-volume hospital-based emergency departments. J Am Coll Emerg Physicians Open 2020; 1:1297-1303. [PMID: 33392536 PMCID: PMC7771828 DOI: 10.1002/emp2.12318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Our investigation compared throughput metrics and utilization measures for freestanding emergency departments (FSEDs) versus hospital-based emergency departments (HBEDs) of similar volumes in the United States. METHODS This study is a cross sectional survey of 183 FSEDs and 317 HBEDs located across the United States using the Emergency Department Benchmarking Alliance (EDBA) Database. We measured common emergency department (ED) throughput metrics. Primary outcomes included overall length of stay, length of stay for admitted, and length of stay for treated and released patients. Outcomes were weighted based on the proportion of ED volume per facility as per a prior pilot study. Multiple linear regression analysis was used to adjust for measured differences between FSEDs and HBEDs. The variables that were controlled for in regression analysis included geographic location of the ED (urban, suburban, and rural), percent of high acuity capacity, ED volume, percentage of patients arriving via emergency medical services (EMS), and percentage of pediatric patients. RESULTS Nationally, the median length of stay in minutes (104.2 vs 140.0), length of stay for treated and released patients (98.6 vs 122.9), door-to-bed (4.0 vs 8.0), door-to-doctor (11.0 vs 16.0), percentage of patients admitted through the ED (4.0 vs 11.0), and percentage of patients leaving the ED without being seen (LWBS) (0.9 vs 1.5), were significantly lower at FSEDs compared to HBEDs (P < 0.0001 for all comparisons). Length of stay for admitted patients (265.9 vs 241.8) and median boarding time (96.8 vs. 71.3) were significantly lower in HBEDs compared to FSEDs. X-ray, computed tomography, and ECG utilization per 100 patients was significantly lower at the FSEDs compared to HBEDs. Multiple linear regression analysis demonstrated that the length of stay for treated and released patients was 8.67 minutes shorter for FSEDs as compared to HBEDs (95% confidence interval [CI] = -1.4 to -16.0). The length of stay for admitted patients was 44 minutes longer for FSEDs as compared to HBEDs (95% CI = 25.5 to 63.0). CONCLUSIONS In this study of similarly sized EDs in the United States, throughput metrics for FSEDs tended to be significantly shorter from the arrival of the patient until their departure, except for patients requiring hospital admission. For measures favoring FSEDs, throughput times range from 20%-50% shorter than HBEDs.
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Affiliation(s)
- Cedric Dark
- Henry J.N. Taub Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | - Maureen Canellas
- Department of Emergency MedicineUniversity of Massachusetts Memorial Medical CenterWorcesterMassachusettsUSA
| | - Caroline Mangira
- Department of ResearchCleveland Clinic Akron GeneralAkronOhioUSA
| | - Nick Jouriles
- Department of Emergency MedicineNortheast Ohio Medical UniversityRootstownOhioUSA
| | - Erin L. Simon
- Cleveland Clinic Akron General Department of Emergency MedicineNortheast Ohio Medical UniversityRootstownOhioUSA
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Yocum AD, Bacharach D, Simon EL. An unusual presentation and treatment of a hemorrhaging plexiform neurofibroma. Am J Emerg Med 2020; 44:479.e3-479.e4. [PMID: 33221111 DOI: 10.1016/j.ajem.2020.10.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/31/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrew D Yocum
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH. Northeast Ohio Medical University, Rootstown, OH, USA
| | - Dana Bacharach
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH. Lake Erie College of Osteopathic Medicine at Seton Hill, Greensburg, PA, USA
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH. Northeast Ohio Medical University, Rootstown, OH, USA.
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Graham CA, Simon EL, Knott J. Study design: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S115-S119. [PMID: 33304793 PMCID: PMC7718464 DOI: 10.1016/j.afjem.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/06/2020] [Accepted: 10/11/2020] [Indexed: 11/26/2022] Open
Abstract
Study design is critical to ensure that research questions are answered in an appropriate and rational manner for all aspects of health, but particularly in emergency care. Appropriate study design selection is one of the most critical decisions to make at the earliest stage of a research project; once this is clear, much of the methodology and sample size estimations should be straightforward. Selection of an appropriate study design is fundamental to good research and deserves careful consideration at the outset of any research project. The classic gold standard for study design is the double-blind randomised clinical trial, but it is often not possible to achieve this ideal in the busy clinical emergency environment or with the resources available. Descriptive studies are common in emergency care; they include retrospective clinical records reviews, prospective cohort studies and case-control studies. Case reports and surveys can be a useful introduction to research for novice researchers. When sufficient empirical evidence on a topic exists, results of similar studies can be combined in systematic reviews and/or meta-analyses to pool the results from multiple studies to determine stronger evidence for or against an intervention or treatment, but these techniques require specialist expertise and statistical skills.
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Affiliation(s)
- Colin A. Graham
- Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong Special Administrative Region
- Corresponding author.
| | - Erin L. Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, USA
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Jonathan Knott
- University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Smalley CM, Simon EL, Meldon SW, Muir MR, Briskin I, Crane S, Delgado F, Borden BL, Fertel BS. The impact of hospital boarding on the emergency department waiting room. J Am Coll Emerg Physicians Open 2020; 1:1052-1059. [PMID: 33145557 PMCID: PMC7593429 DOI: 10.1002/emp2.12100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Patient boarding in the emergency department (ED) is a significant issue leading to increased morbidity/mortality, longer lengths of stay, and higher hospital costs. We examined the impact of boarding patients on the ED waiting room. Additionally, we determined whether facility type, patient acuity, time of day, or hospital occupancy impacted waiting rooms in 18 EDs across a large healthcare system. METHODS This was a retrospective multicenter study that included all ED encounters between January 1, 2018, and September 30, 2019. Encounters with missing Emergency Severity Index (ESI) level were excluded. ESI levels were defined as high (ESI 1,2), middle (ESI 3), and low (ESI 4,5). Spearman correlation coefficients measured the relationship between boarded patients and number of patients in ED waiting room. A multivariable mixed effects model identified drivers of this relationship. RESULTS A total of 1,134,178 encounters were included. Spearman correlation coefficient was significant between number of patients in the ED waiting room and patient boarding (0.54). For every additional patient boarded/hour, the number of patients waiting/hour in the waiting room increased by 8% (95% confidence interval [CI] = 1.08-1.09). The number of patients waiting for a room/hour was 2.28 times higher for middle than for high acuity. The number of patients in waiting room slightly decreased as hospital occupancy increased (95% CI = 0.997-0.997). CONCLUSION Number of patients in ED waiting room are directly related to boarding times and hospital occupancy. ED waiting room times should be considered as not just an ED operational issue, but an aspect of hospital throughput.
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Affiliation(s)
- Courtney M. Smalley
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityClevelandOhioUSA
| | - Erin L. Simon
- Department of Emergency MedicineAkron General Medical CenterAkronOhioUSA
- Northeast Ohio Medical University (NEOMED)RootstownOhioUSA
| | - Stephen W. Meldon
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityClevelandOhioUSA
| | - McKinsey R. Muir
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
| | - Isaac Briskin
- Department of Quantitative Health SciencesCleveland Clinic Health SystemClevelandOhioUSA
| | - Steven Crane
- Department of Emergency MedicineAkron General Medical CenterAkronOhioUSA
| | - Fernando Delgado
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
| | - Bradford L. Borden
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityClevelandOhioUSA
| | - Baruch S. Fertel
- Cleveland Clinic Health SystemEmergency Services InstituteClevelandOhioUSA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityClevelandOhioUSA
- Enterprise Quality and Patient SafetyCleveland Clinic Health SystemClevelandOhioUSA
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Bitter CC, Ngabirano AA, Simon EL, Taylor DM. Principles of research ethics: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S125-S129. [PMID: 32837877 PMCID: PMC7423570 DOI: 10.1016/j.afjem.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/17/2020] [Accepted: 07/11/2020] [Indexed: 12/15/2022] Open
Abstract
Ethical oversight in the form of review boards and research ethics committees provide protection for research subjects as well as guidance for safe conduct of studies. As the number of collaborative emergency care research studies carried out in low- and middle-income countries increases, it is crucial to have a shared understanding of how ethics should inform choice of study topic, study design, methods of obtaining consent, data management, and access to treatment after closure of the study. This paper describes the basic principles of Western research ethics - respect for persons, beneficence, and justice - and how the principles may be contextualized in different settings, by researchers of various backgrounds with different funding streams. Examples of lapses in ethical practice of research are used to highlight best practices.
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Affiliation(s)
- Cindy C. Bitter
- Saint Louis University School of Medicine, Division of Emergency Medicine, St. Louis MO, USA
| | - Annet Alenyo Ngabirano
- Aga Khan University, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Erin L. Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, USA
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - David McD. Taylor
- University of Melbourne, Department of Medicine, Parkville, Victoria, Australia
- Austin Health, Heidelburg, Victoria, Australia
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Defabio AC, Scott TR, Stenberg RT, Simon EL. Guillain-Barré syndrome in a patient previously diagnosed with COVID-19. Am J Emerg Med 2020; 45:154-155. [PMID: 33041119 PMCID: PMC7402368 DOI: 10.1016/j.ajem.2020.07.074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 12/30/2022] Open
Abstract
As the COVID-19 pandemic continues to progress, the medical community is rapidly trying to identify complications and patterns of disease to improve patient outcomes. In a recent systematic review, it has been reported that isolated cases of Guillain-Barre Syndrome (GBS) have occurred secondary to COVID-19 infection. GBS is defined as a rare, but potentially fatal, immune mediated disease of peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and 2015 in Latin America. While several cases of GBS secondary to COVID-19 infection have been reported in Italy, only one case has been reported in the United States (US). The reported case in the US was a 54- year old male. We present a case of GBS secondary to a COVID-19 infection and believe this to be the first documented female case in the US and the second documented case in the US overall. The presented case aims to supplement the existing body of knowledge and to assist clinicians in managing complications of COVID-19.
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Affiliation(s)
- Alexandria C Defabio
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America
| | - Thomas R Scott
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America
| | - Robert T Stenberg
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America.
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41
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Simon EL, Wainblat EG, Krizo JA, Smalley CM, Fertel BS. Septic Sacroiliitis caused by Serratia marcescens. Am J Emerg Med 2020; 38:2758.e5-2758.e8. [PMID: 32527605 DOI: 10.1016/j.ajem.2020.05.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/24/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, USA; Northeast Ohio Medical University, Rootstown, Ohio, USA.
| | - Ethan G Wainblat
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, USA; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Jessica A Krizo
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, USA; Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Courtney M Smalley
- Cleveland Clinic Emergency Services Institute, Cleveland Clinic Lerner College of Medicine Cleveland, OH, USA
| | - Baruch S Fertel
- Emergency Services Institute Cleveland Clinic Foundation, Enterprise Quality and Safety, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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Heaney AI, Griffin GD, Simon EL. Newly diagnosed diabetes and diabetic ketoacidosis precipitated by COVID-19 infection. Am J Emerg Med 2020; 38:2491.e3-2491.e4. [PMID: 32536476 PMCID: PMC7274947 DOI: 10.1016/j.ajem.2020.05.114] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 05/30/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- Ashley I Heaney
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America
| | - Gregory D Griffin
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America.
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Smalley CM, Malone DA, Meldon SW, Borden BL, Simon EL, Muir MR, Fertel BS. The impact of COVID-19 on suicidal ideation and alcohol presentations to emergency departments in a large healthcare system. Am J Emerg Med 2020; 41:237-238. [PMID: 32505472 PMCID: PMC7263212 DOI: 10.1016/j.ajem.2020.05.093] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/29/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Courtney M Smalley
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America.
| | - Donald A Malone
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America; Department of Psychiatry and Psychology, Neurological Institute, Center for Behavioral Health, Cleveland Clinic Health System, Cleveland, OH, United States of America
| | - Stephen W Meldon
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
| | - Bradford L Borden
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
| | - Erin L Simon
- Department of Emergency Medicine, Akron General Medical Center, Akron, OH, United States of America; Northeast Ohio Medical University (NEOMED), Rootstown, OH, United States of America
| | - McKinsey R Muir
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America
| | - Baruch S Fertel
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America; Enterprise Quality and Patient Safety, Cleveland Clinic Health System, Cleveland, OH, United States of America
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Carpenter CR, Hollong B, Simon EL, Graham CA. Analysing the literature: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S100-S105. [PMID: 33304790 PMCID: PMC7718467 DOI: 10.1016/j.afjem.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/02/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022] Open
Abstract
Effective critical appraisal of medical research requires training and practice. Evidence-based medicine provides a framework for standardised review of manuscripts of nearly any research design. Online resources and communities exist to provide free access to electronic search engines and critical appraisal of emergency medicine and non-emergency medicine research. An emerging array of Free Online Open Access medical education (FOAMed) resources also provide opportunities to observe Evidence-based medicine critical appraisal in written or audio format and to actively participate as a learner. This chapter will highlight accessible resources that provide both methodological background and virtual mentoring for readers to develop EBM skills.
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Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med 2020; 38:1978.e1-1978.e3. [PMID: 32425319 PMCID: PMC7227523 DOI: 10.1016/j.ajem.2020.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/08/2020] [Indexed: 01/13/2023] Open
Affiliation(s)
- Michael H Morales
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America
| | - Candace L Leigh
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America
| | - Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America.
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Knott JC, Taylor DM, Simon EL. Conference presentations: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S158-S160. [PMID: 33304801 PMCID: PMC7718443 DOI: 10.1016/j.afjem.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/27/2020] [Accepted: 05/06/2020] [Indexed: 11/17/2022] Open
Abstract
Presenting research at a conference is an opportunity to disseminate the findings, network with other researchers, and to develop your academic track record. Although every conference will have some local differences, there are common approaches to presenting your research in the best manner. This will differ depending on whether it is an oral or a poster presentation. This research primer aims to support researchers in the early stages of their careers to undertake the best possible presentation. Presentations, both oral and poster, follow general principles that apply everywhere. Conference presentations provide an opportunity for authors to get known and to identify potential future collaborators. Consideration should be given to the conference both in terms of the audience to be addressed, and the resources available.
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Affiliation(s)
- Jonathan C. Knott
- Emergency Research, Royal Melbourne Hospital, Grattan St, Parkville, Victoria, Australia
- Centre for Integrated Critical Care, University of Melbourne, Victoria, Australia
- Corresponding author at: Emergency Department, Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia.
| | - David McD Taylor
- Emergency Research, Austin Hospital, Studley Rd, Heidelberg, Victoria, Australia
- Centre for Integrated Critical Care, University of Melbourne, Victoria, Australia
| | - Erin L. Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, Ohio 44307, United States of America
- Associate Professor Northeast Ohio Medical University, 4209 State Route 44, Rootstown, Ohio 44272, United States of America
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Simon EL, Shakya S, Smalley CM, Muir M, Podolsky SR, Fertel BS. Same provider, different location: Variation in patient satisfaction scores between freestanding and hospital-based emergency departments. Am J Emerg Med 2020; 38:968-974. [PMID: 31956050 DOI: 10.1016/j.ajem.2020.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 01/01/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patient satisfaction scores have become quality benchmarks for hospitals, are publicly reported, and are often tied to financial incentives. We determined whether patient satisfaction scores for individual emergency medicine providers varied according to the clinical setting. METHODS We obtained patient satisfaction survey results from January 1, 2018 to December 31, 2018 for patients treated at 6 freestanding (FED) and 11 hospital-based emergency departments (HBED). Differences in mean score by ED facility were tested for significance. Mean score differences with 95% confidence intervals are presented. Univariate and multivariable logistic regression analysis was conducted to predict the odds of receiving different scores by type of ED facility and adjusted for patient and provider demographics and ED length of stay. RESULTS Sixty-six providers with 3743 total surveys were analyzed: FED (n = 1974) and HBED (n = 1769). Overall satisfaction scores were higher for FED compared to HBED surveys 1.13 [95% CI, 1.0-1.3]. In multivariable logistic regression, we found patients seen at the FEDs were 42% more likely to rate providers courtesy as "very good" compared to patients seen at a HBED [OR: 1.42, 95% CI (0.94-2.15)]. Similarly, patients from FEDs showed increased likelihood to rate providers as "very good" for keeping patients informed about treatment [OR: 1.70, 95% CI (1.21-2.39)], took time to listen to patients [OR: 1.66, 95% CI (0.72-1.60)] and concerned for patient's comfort [OR: 1.54, 95% CI (1.12-2.12)]. CONCLUSION Individual providers, who practice at both types of facilities, consistently received higher satisfaction ratings from patients at FEDs compared to HBEDs.
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Affiliation(s)
- Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America.
| | - Sunita Shakya
- Cleveland Clinic Akron General, Akron, OH, United States of America; Kent State University, Kent, OH, United States of America
| | - Courtney M Smalley
- Cleveland Clinic Emergency Services Institute, Cleveland, OH, United States of America
| | - McKinsey Muir
- Cleveland Clinic Emergency Services Institute, Cleveland, OH, United States of America
| | - Seth R Podolsky
- Cleveland Clinic Emergency Services Institute, Cleveland, OH, United States of America
| | - Baruch S Fertel
- Cleveland Clinic Emergency Services Institute, Cleveland, OH, United States of America
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Simon EL, Shakya S, Muir M, Fertel BS. Differences in patient population and length of stay between freestanding and hospital-based emergency departments. Am J Emerg Med 2019; 37:1738-1742. [DOI: 10.1016/j.ajem.2019.05.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/30/2019] [Accepted: 05/30/2019] [Indexed: 11/28/2022] Open
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Ross CH, Singh P, Simon EL. Hemorrhagic Soft Tissue Upper Airway Obstruction From Brodifacoum-Contaminated Synthetic Cannabinoid. J Emerg Med 2019; 57:47-50. [DOI: 10.1016/j.jemermed.2019.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/27/2019] [Accepted: 03/04/2019] [Indexed: 10/26/2022]
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50
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Hallas O, Yocum A, Jackson D, Simon EL. Uveitis and acute glaucoma as first presenting symptoms of sarcoidosis in a healthy male. Am J Emerg Med 2018; 36:2133.e5-2133.e6. [DOI: 10.1016/j.ajem.2018.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/07/2018] [Indexed: 12/28/2022] Open
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