Applying Topical Anesthetic on Pediatric Lacerations in the Emergency Department: A Quality Improvement Project

OBJECTIVES

Caring for pediatric lacerations in the emergency department (ED) is typically painful because of irrigation and suturing. To improve this painful experience, we aimed to increase the use of a topical anesthetic, Eutectic Mixture of Local Anesthetics (EMLA) on eligible pediatric lacerations with an attainable, sustainable, and measurable goal of 60%. The baseline rate of applying topical anesthetic to eligible lacerations was 23% in our ED. We aimed to increase the use of topical anesthetics on eligible pediatric lacerations to a measurable goal of 60% within 3 months of implementing our intervention.

METHODS

We conducted a prospective, single-center, interrupted time series, ED quality improvement project from November 2019 to July 2020. A multidisciplinary team of physicians and nurses performed a cause-and-effect analysis identifying 2 key drivers: early placement of EMLA and physician buy-in on which we built our Plan, Do, Study, and Act (PDSA) cycles. We collected data on number of eligible patients receiving EMLA, as well as patient and physician feedback via phone calls within 2 days after encounter. Balancing measures included ED length of stay (LOS), patient and physician satisfaction with EMLA, and adverse effects of EMLA.

RESULTS

We needed 3 PDSA cycles to reach our goal of 60% in 3 months, which was also maintained for 5 months. The PDSA cycles used educational interventions, direct provider feedback about noncompliance, and patient satisfaction results obtained via phone calls. Balancing measures were minimally impacted: 75% good patient satisfaction, no adverse events but an increase in LOS of patients who received EMLA compared with those who did not (1.79 ± 0.66 vs 1.41 ± 0.83 hours, P < 0.001). The main reasons for dissatisfaction for physicians were the increased LOS and the preference for procedural sedation or intranasal medications.

CONCLUSIONS

With a few simple interventions, our aim of applying EMLA to 60% of eligible pediatric lacerations was attained and maintained.

Electronic medical record implementation in the emergency department in a low-resource country: Lessons learned

OBJECTIVE

There is paucity of information regarding electronic medical record (EMR) implementation in emergency departments in countries outside the United States especially in low-resource settings. The objective of this study is to describe strategies for a successful implementation of an EMR in the emergency department and to examine the impact of this implementation on the department's operations and patient-related metrics.

METHODS

We performed an observational retrospective study at the emergency department of a tertiary care center in Beirut, Lebanon. We assessed the effect of EMR implementation by tracking emergency departments' quality metrics during a one-year baseline period and one year after implementation. End-user satisfaction and patient satisfaction were also assessed.

RESULTS

Our evaluation of the implementation of EMR in a low resource setting showed a transient increase in LOS and visit-to-admission decision, however this returned to baseline after around 6 months. The bounce-back rate also increased. End-users were satisfied with the new EMR and patient satisfaction did not show a significant change.

CONCLUSIONS

Lessons learned from this successful EMR implementation include a mix of strategies recommended by the EMR vendor as well as specific strategies used at our institution. These can be used in future implementation projects in low-resource settings to avoid disruption of workflows.

Characteristics and dispositional determinants of psychiatric emergencies in a University Hospital in Beirut

Mental health problems are common in Lebanon, and so are psychiatric emergencies. In order to show the characteristics of psychiatric emergencies in Lebanon along with their dispositional determinants, we conducted this retrospective, single-center, chart-review study of patients who presented to the Emergency Department between July 1, 2016 until December 31, 2016 and required an official psychiatrist consultation. Our sample included 195 patients of all age groups. The most common diagnosis was depression (75 patients) followed by anxiety (61 patients). 107 patients (54.8%) required admission for adequate treatment; however only 72 (67.3%) of those were actually admitted, and the rest (32.7%) left the hospital against medical advice. Increased hospital admission was associated with being a female (OR = 3.042), having family history of psychiatric disease (OR = 2.040) and having suicidal ideations (OR = 12.949). In a country that has inadequate health coverage, financial coverage can also be a determining factor in whether or not patients get the admission they need.

Serum lactate is an independent predictor of hospital mortality in critically ill patients in the emergency department: a retrospective study

Background

Elevated lactate has been found to be associated with a higher mortality in a diverse patient population. The aim of the study is to investigate if initial serum lactate level is independently associated with hospital mortality for critically ill patients presenting to the Emergency Department.

Methods

Single-center, retrospective study at a tertiary care hospital looking at patients who presented to the Emergency Department (ED) between 2014 and 2016. A total of 450 patients were included in the study. Patients were stratified to lactate levels: <2 mmol/L, 2-4 mmol/L and >4 mmol/L. The primary outcome was in-hospital mortality. Secondary outcomes included 72-h hospital mortality, ED and hospital lengths of stay.

Results

The mean age was 64.87 ± 18.08 years in the <2 mmol/L group, 68.51 ± 18.01 years in the 2-4 mmol/L group, and 67.46 ± 17.67 years in the >4 mmol/L group. All 3 groups were comparable in terms of age, gender and comorbidities except for diabetes, with the 2-4 mmol/L and >4 mmol/L groups having a higher proportion of diabetic patients. The mean lactate level was 1.42 ± 0.38 (<2 mmol/L), 2.72 ± 0.55 (2-4 mmol/L) and 7.18 ± 3.42 (>4 mmol/L). In-hospital mortality was found to be 4 (2.7%), 18(12%) and 61(40.7%) patients in the low, intermediate and high lactate groups respectively. ED and hospital length of stay were longer for the >4 mmol/L group as compared to the other groups. While adjusting for all variables, patients with intermediate and high lactate had 7.13 (CI 95% 2.22–22.87 p = 0.001) and 29.48 (CI 95% 9.75–89.07 p = <0.001) greater odds of in-hospital mortality respectively.

Discussion

Our results showed that for all patients presenting to the ED, a rising lactate value is associated with a higher mortality. This pattern was similar regardless of patients’ age, presence of infection or blood pressure at presentation.

Conclusion

Higher lactate values are associated with higher hospital mortalities and longer ED and hospital lengths of stays. Initial ED lactate is a useful test to risk-stratify critically ill patients presenting to the ED.