Overcoming stagnant flow: A scoping review of vertical movement in the emergency department

OBJECTIVES

Improving emergency department (ED) patient flow has plagued many hospitals worldwide. "Vertical" flow improves throughput by maximizing use of chairs and waiting areas instead of beds. This process, however, is inconsistently described in the literature. The objective of this study was to collate existing evidence of successful vertical care programs.

METHOD

A scoping review was conducted within several databases utilizing key search terms to capture relevant traditional and gray literature. All articles were uploaded into Covidence (n = 1000). After duplicates were removed, remaining abstracts were initially screened by two reviewers (n = 731). Records identified by at least one reviewer subsequently underwent a two-reviewer full-text screening for inclusion (n = 46). This process yielded 36 articles. Finally, each record underwent data extraction by two independent study members and any inconsistencies were resolved by a third study member. Extracted data included 21 predetermined variables. Descriptive statistics were used to summarize results.

RESULTS

Of the 36 included articles, most were published from the United States (91.7%), after 2014 (55.6%), and as a peer-reviewed article or abstract/conference proceeding (86.1%). While every article discussed some aspect of vertical flow, most (77.8%) were observational studies. Only half of the studies reported details of staffing and/or physical resources. A variety of challenges and success strategies were described, with several themes identified. Positive outcomes were reported by most articles (86%), although measurement of outcomes varied with the two most common being length of stay (69.4%) and arrival-to-provider time (55.6%).

CONCLUSIONS

The findings of this scoping review provide the first summative report of existing literature on vertical flow processes within the ED setting. Despite different measurable outcomes and varied processes, most articles support the use of vertical flow to improve throughput.

Technology and Transplants: Troubleshooting Insulin Pumps and Pancreas Transplants in the Emergency Department

Diabetes management has continued to evolve with new treatments and technology. This article discusses the approach to evaluation and management of two distinctive subsets of patients: (1) patients who manage their diabetes with an insulin pump (artificial pancreas) and (2) patients who have received a pancreas transplant. The most current literature is reviewed and pearls and pitfalls distinctive to these two patient populations are discussed. Relevant diagnostics are reviewed with emphasis on recognition of complications faced in the emergency department management of these unique patient populations.

44-year-old Man with Hemoptysis and Hypoxemic Respiratory Failure: A Case Report

INTRODUCTION

Hemoptysis can be a highly alarming presentation in the emergency department (ED). Even seemingly minor cases may represent potentially lethal underlying pathology. It requires thorough evaluation and careful consideration of a broad differential diagnosis.

CASE PRESENTATION

A 44-year-old man presented to the ED with a concern of hemoptysis in the setting of recent fever and myalgias.

DISCUSSION

This case takes the reader through how to approach the differential diagnosis and diagnostic work-up of hemoptysis in the ED setting and then reveals the surprising final diagnosis.

A Narrative Review of the Evaluation and Management of Liver Transplant Complications in the Emergency Department

BACKGROUND

Liver transplant recipients are prone to both short-term and long-term complications and may present to any emergency department.

OBJECTIVE

This narrative review summarized key aspects of liver transplantation and reviewed the major complications that may result in emergency department presentation.

DISCUSSION

Liver transplantation is the only curative therapy for end-stage liver disease and the liver is the second most commonly transplanted solid organ. With nearly 100,000 living liver transplant recipients in the United States, these patients no longer present exclusively to transplantation centers. Critical complications may manifest with a variety of subtle signs and symptoms that must be considered by the emergency physician. Appropriate evaluation often includes laboratory analysis and imaging. Treatment may be time-sensitive and is variable depending on the specific complication.

CONCLUSIONS

Emergency physicians in all settings must be prepared to evaluate and treat liver transplant recipients who present with potential graft- and life-threatening complications.

Balancing Efficiency and Access: Discouraging Emergency Department Boarding in a Global Budget System

Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its “capitation” payment system (also known as “global budget”), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland’s system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals’ ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland’s model that should also prove instructive for a variety of emerging alternative payment mechanisms.

Association of Resident Shift Length with Procedural Complications

BACKGROUND

Training programs for resident physicians struggle to balance the need for clinical experience with the impact of fatigue on patient safety. The length of shifts worked by emergency medicine (EM) residents is likely an important determinant of resident fatigue.

OBJECTIVE

Assess the impact of a longer clinical shift on procedural competency.

METHODS

We conducted a retrospective chart review of arterial line placements, central venous catheterizations, tube thoracostomies, endotracheal intubations, and lumbar punctures performed by EM residents working 12-h shifts in the emergency department of an academic medical center over an academic year. We compared complication rates between procedures performed in the first 8 vs. the last 4 h of a 12-h shift. Procedures without complication were defined as successful on first-pass attempt and without a downstream mechanical or medical complication. Multivariable modified Poisson regression was used to simultaneously control for possible confounders affecting procedure success.

RESULTS

We identified 548 eligible procedures: 307 performed in the first 8 h of a 12-h shift and 241 in the last 4 h. The complication rate across all procedures was higher in the last 4 h of the shift (pooled risk ratio 1.41, 95% confidence interval 1.18-1.67). This effect persisted when adjusting for potential confounders (adjusted risk ratio 1.42, 95% confidence interval 1.19-1.69).

CONCLUSION

Overall, complication rates of included procedures performed by EM residents were higher during the last 4 vs. first 8 h of a 12-h shift. Training programs should consider the impact of resident fatigue on patient safety when making work schedules.

Traumatic Injuries to the Spinal Cord and Peripheral Nervous System

Both blunt and penetrating trauma can cause injuries to the peripheral and central nervous systems. Emergency providers must maintain a high index of suspicion, especially in the setting of polytrauma. There are 2 major classifications of peripheral nerve injuries (PNIs). Some PNIs are classically associated with certain traumatic mechanisms. Most closed PNIs are managed conservatively, whereas sharp nerve transections require specialist consultation for urgent repair. Spinal cord injuries almost universally require computed tomography imaging; some require emergent magnetic resonance imaging. Providers should work to minimize secondary injury. Surgical specialists are needed for closed reduction, surgical decompression, or stabilization.

37-year-old Transgender Man with Fevers, Dysuria, and Sudden Decompensation

Introduction

Patients in the emergency department may experience sudden decompensation despite initially appearing stable.

Case Presentation

A 37-year-old transgender man presented to the emergency department (ED) with several months of fevers, myalgias, and weight loss. The patient acutely became febrile, tachycardic, and hypotensive after an initially reassuring assessment in the ED.

Discussion

This case takes the reader through the differential diagnosis and work-up of the decompensating patient initially presenting with subacute symptoms.

55-year-old Male with Exertional Dyspnea

INTRODUCTION

Dyspnea is a common presenting complaint for many patients in the emergency department.

CASE PRESENTATION

A 55-year-old man with type I diabetes presented to the emergency department with one month of intermittent palpitations and dyspnea. His lungs were clear to auscultation, and his chest radiograph was normal.

DISCUSSION

This case takes the reader through the differential diagnosis and systematic work-up of dyspnea with discussion of the diagnostic study, which ultimately led to this patient's diagnosis and successful treatment.

Prepacked naloxone administration for suspected opioid overdose in the era of illicitly manufactured fentanyl: a retrospective study of regional poison center data

Background: Prepacked naloxone kits (PNKs) are frequently used to reverse opioid intoxication. It is unknown if the presence of illicitly manufactured fentanyl and its analogs (IMFs) in heroin supply is affecting the PNK doses given by laypersons. We investigated the trend of PNK dose administered to reverse opioid toxicity in suspected/undifferentiated opioid intoxication.Methods: We retrospectively reviewed PNK administrations reported to the Maryland Poison Center between 1 January 2015 and 15 October 2017. Primary outcome was the mean PNK dose administered to reverse opioid-induced central nervous system and ventilatory depression. Secondary outcomes included the reversal rate of opioid toxicity, patient disposition, and survival rate.Results: Our analysis involved 1139 PNK administrations. The mean age of subjects was 34.3 years; 68.8% (n = 781) were male. Ventilatory depression was present in 98.2% (n = 958) of cases, and 97% (n = 1097) were unresponsive. Law enforcement administered the majority of PNK (91.0%; n = 1035); the primary route was intranasal (97.9%; n = 1051). Toxicity was reversed in 79.2% (n = 886) of overdose victims after a mean PNK dose of 3.12 mg. EMS personnel gave 291 subjects additional naloxone (mean: 2.2 mg), reversing opioid toxicity in 94.2% (n = 254). Between 2015 and 2017, the mean PNK dose increased from 2.12 to 3.63 mg (p < .0001) while the reversal rate decreased from 82.1% to 76.4% (p = .04). One hundred and eighty-two patients (15.9%) refused transport; of those transported to a hospital, 73.4% (n = 569) were treated and released and 12.4% (n = 96) required hospitalization. Ninety-six percent (n = 1092) of the subjects survived. Forty subjects were pronounced dead at the scene. Fentanyl or its analog was detected in 36 of 55 opioid-related deaths (65.5%).Conclusions: PNK administration reversed toxicity in the majority of patients with undifferentiated opioid intoxication. Between 2015 and 2017, increasing doses of PNK were administered but the reversal rate decreased. These trends are likely multifactorial, including increasing availability of IMFs.