Critical analysis of glucose solution efficacy in hypoglycemia treatment in emergency departments

Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED. The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique) and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%. During the baseline period, 321 of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p < 0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% confidence interval [CI] = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period. A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate.

Peripheral tissue oxygenation improves during ED treatment of acute heart failure

To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults. A conceptual model informed, protocol-based systematic review. Emergency Department (ED). Older adults 65 years of age and older. Medline, Embase, CINAHL, and PsycINFO were searched for English-language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi-strategy) and key intervention components present (ie, assessment, referral plus follow-up, and contact both before and after ED discharge ["bridge"]). The effect of ED interventions on clinical (functional status, quality of life [QOL]), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated. A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit. Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.

Crowding in the Emergency Department

Many published reviews and meta-analyses focus on the efficacy of brief alcohol intervention (BAI) within different settings. For the relevance of BAI on public health, it must be shown where it is effective. Recently, a meta-analysis concluded that in primary care BAI reduced alcohol use by about 30 g per week for at least 12 months [1]. The emergency department (ED) is an ideal setting in which to identify and initiate alcohol abuse interventions [2], therefore it becomes important to address the question of effectiveness in that milieu. In this issue of Addiction, Havard and colleagues [3] obtained somewhat modest results from their meta-analysis of ED research evaluating BAI and its impact on alcohol use and associated outcomes. Eleven studies were included, two of which used pooled data of 1174 hazardous drinkers attending ED and found no differences in drinking quantity or frequency between experimental and control groups. The authors found some efficacy of BAI in reducing alcohol-related injuries, using pooled data of 785 patients across three studies, although tests for heterogeneity indicated that pooled effect sizes of heavy drinking frequency and drinking consequences could not be interpreted meaningfully. These data suggest that it may have been a little premature to conduct a meta-analysis. What can be learned from a more qualitative analysis using the systematic review conducted by the authors and information from published literature? Several factors seem likely to influence BAI efficacy in ED, but only some of these have been evaluated in ED and other settings: the patient: age, sex, severity of alcohol use disorder [4], drinking pattern, such as episodic heavy drinking or chronic use, readiness to change [5], injury severity [6], medical condition and its relation to alcohol use; the counsellor: age, sex, training [7], supervision, relationship style including ability to listen empathically, acquired clinical skills, adherence to BAI structure and style; the intervention: content, such as simple advice or more structured techniques (FRAMES), including or withholding feedback, adopting motivational interviewing style and tools, number of sessions [8] and objective, such as reduction in alcohol use and related problems [9], referral to specialized care [10]; the setting: within ED units, issues such as counselling privacy, maximizing use of time while patients are in waiting rooms, and post-discharge, the interest and support of ED and follow-up staff; and the research methodology: outcome measured, inclusion criteria, interval between baseline and follow-up, duration and content of assessment, dropout rate and type II errors due to lack of statistical power. Considering the influence of the above factors, three hypotheses might be explored in ED settings using BAI: (i) it does; (ii) it does not; or (iii) it sometimes does and sometimes does not reduce alcohol use and related consequences. The hypothesis [1] that any BAI reduces alcohol use and problems is not likely, as it implies that effectiveness does not depend on content, style or duration of intervention when in fact many studies indicate that BAI is effective only under certain conditions, e.g. when the patient's ability to change is maximal [11] or when booster sessions are added to the initial intervention [8]. The hypothesis [2] that BAI does not reduce alcohol use and problems is also unlikely, as several studies of BAI in ED point to greater reductions in alcohol use or problems within experimental groups than in controls [8,9,12]. These results, however, may be tempered by an alternative explanation: that observed differences between the experimental and control groups is not due directly to BAI but occurs because of additional attention given the BAI group, which itself suggests a promising field of research concentrating on reactivity to assessment [13]. Probably the most likely hypothesis [4] is that BAI sometimes does and sometimes does not reduce alcohol use, and that the (sometimes) mixed published results are best explained by the heterogeneity of various BAI factors mentioned above. The hypothesis of differential BAI efficacy within particular settings suggests that BAI, first developed in primary care, might not be effective in ED without some modifications. BAI in ED is generally limited to a single contact between patient and counsellor, preventing the development of the therapeutic alliance in primary care. Moreover, ED can be a hectic milieu, with frequent interruptions that could hinder the empathic listening process and limit the motivation of patients to follow through with formal BAI. It is also important to recognize that the content of BAI has evolved over the last 20 years, from the initial belief that very simple, straightforward advice from health-care providers lacking formal training might be sufficient [14] to more systematic and complex interventions requiring longer training and clinical experience [15]. ‘Few answers, many questions’ and the probable hypothesis that BAI sometimes does and sometimes does not reduce alcohol use and problems suggest that future studies should explore systematically the influence of factors related to the patient, counsellor, intervention, setting and research methodology.

Quality of care for joint dislocation in 47 US EDs

Patients receiving naloxone for suspected opioid overdose in the prehospital setting are typically transported to the emergency department (ED) for further evaluation, regardless of Glasgow Coma Scale (GCS). The objective of our study is to determine whether patients with GCS ≥14 after receiving prehospital naloxone received additional doses of naloxone and medical interventions in the ED compared with those with GCS <14 after prehospital naloxone. Our retrospective observational study included patients ≥18 years old treated with naloxone and transported by an inner-city hospital-based Emergency Medical Services (EMS) to its affiliated ED from January 2, 2016 to December 31, 2016. Investigators collected demographic data, prehospital interventions, GCS, ED interventions, and dispositions. Institutional Review Board approval was obtained. The main outcome measures were repeat doses of naloxone and ED interventions. In all, 473 patient encounters were reviewed. Most common route of prehospital naloxone administration was intranasal (68%). Nearly two-thirds (n = 473) of patients had GCS ≥14 upon ED arrival. Repeat naloxone was administered to 3.5% (n = 314) of patients with GCS ≥14 versus 14.6% (n = 159) of patients with GCS <14. ED interventions, such as airway maneuvers, laboratory and radiology testing, and cardiac monitoring, were less common among patients who had improved GCS of 14 or higher (n = 314). There were 8 deaths among patients with GCS <14 (n = 159) and no deaths among patients with GCS ≥14 (n = 314). Patients with GCS score ≥14 after administration of prehospital naloxone are less likely to receive additional naloxone doses and medical interventions in the ED compared with those with a GCS score <14 after prehospital naloxone and may present an invaluable opportunity for the ED to initiate an addiction treatment program for patients with nonfatal overdose.

Mood disorders in the emergency department: the challenge of linking patients to appropriate services

Background: Medical settings such as emergency departments (EDs) present an opportunity to identify and provide services for individuals with substance use problems who might otherwise never receive any form of assessment, referral, or intervention. Although screening, brief intervention, and referral to treatment models have been extensively studied and are considered effective for individuals with alcohol problems presenting in EDs and other medical settings, the efficacy of such interventions has not been established for drug users presenting in EDs. Objectives: This article describes the design of a NIDA Clinical Trials Network protocol testing the efficacy of an screening, brief intervention, and referral to treatment model in medical EDs, highlighting considerations that are pertinent to the design of other studies targeting substance use behaviors in medical treatment settings. Methods: The protocol is described, and critical design decisions are discussed. Results: Design challenges included defining treatment conditions, study population, and site characteristics; developing the screening process; choosing the primary outcome; balancing brevity and comprehensiveness of assessment; and selecting the strategy for statistical analysis. Conclusion: Many of the issues arising in the design of this study will be relevant to future studies of interventions for addictions in medical settings. Scientific Significance: Optimal trial design is critical to determining how best to integrate substance abuse interventions into medical care.

BackgroundThe broad consent (BC) developed by the German Medical Informatics Initiative is a pivotal national strategy for obtaining patient consent to use routinely collected data from electronic health records, insurance companies, contact information, and biomaterials for research. Emergency departments (EDs) are ideal for enrolling diverse patient populations in research activities. Despite regulatory and ethical challenges, obtaining BC from patients in ED with varying demographic, socioeconomic, and disease characteristics presents a promising opportunity to expand the availability of ED data.ObjectiveThis study aimed to evaluate the success rate of obtaining BC through different consenting approaches in a tertiary ED and to explore factors influencing consent and dropout rates.MethodsA single-center prospective observational study was conducted in a German tertiary ED from September to December 2022. Every 30th patient was screened for eligibility. Eligible patients were informed via one of three modalities: (1) directly in the ED, (2) during their inpatient stay on the ward, or (3) via telephone after discharge. The primary outcome was the success rate of obtaining BC within 30 days of ED presentation. Secondary outcomes included analyzing potential influences on the success and dropout rates based on patient characteristics, information mode, and the interaction time required for patients to make an informed decision.ResultsOf 11,842 ED visits, 419 patients were screened for BC eligibility, with 151 meeting the inclusion criteria. Of these, 68 (45%) consented to at least 1 BC module, while 24 (15.9%) refused participation. The dropout rate was 39.1% (n=59) and was highest in the telephone-based group (57/109, 52.3%) and lowest in the ED group (1/14, 7.1%). Patients informed face-to-face during their inpatient stay following the ED treatment had the highest consent rate (23/27, 85.2%), while those approached in the ED or by telephone had consent rates of 69.2% (9/13 and 36/52). Logistic regression analysis indicated that longer interaction time significantly improved consent rates (P=.03), while female sex was associated with higher dropout rates (P=.02). Age, triage category, billing details (inpatient treatment), or diagnosis did not significantly influence the primary outcome (all P>.05).ConclusionsObtaining BC in an ED environment is feasible, enabling representative inclusion of ED populations. However, discharge from the ED and female sex negatively affected consent rates to the BC. Face-to-face interaction proved most effective, particularly for inpatients, while telephone-based approaches resulted in higher dropout rates despite comparable consent rates to direct consenting in the ED. The findings underscore the importance of tailored consent strategies and maintaining consenting staff in EDs and on the wards to enhance BC information delivery and consent processes for eligible patients.Trial RegistrationGerman Clinical Trials Register DRKS00028753; https://drks.de/search/de/trial/DRKS00028753

Objectives: To identify correlates of alcohol related assault injury in the city centre of a European capital city, with particular reference to emergency department (ED) and police interventions, and number...

Prehospital assessment of illness and injury severity with the National Advisory Committee for Aeronautics (NACA) score and hospital pre-arrival notification of a patient who is likely to need intensive care unit (ICU) or intermediate care unit (IMC) admission are both common in Germany's physician-staffed emergency medical services (EMS) system. This study aimed at comparing the prehospital evaluation of severity of disease or injuries by EMS physicians and the subsequent clinical treatment in unselected emergency department (ED) patients. This study involved a prospective observational analysis of patients transported to the ED of an academic level I hospital escorted by an EMS physician over a period of 6 months (February-July 2011). The physician's qualification and the patient's NACA score were documented and the EMS physician was asked to predict whether the patient would need hospital admission and, if so, to the general ward, IMC or ICU. After the ED treatment, discharge or admission, outcome and length of hospital and ICU or IMC stay were documented. A total of 378 mostly non-trauma patients (88 %) treated by experienced EMS physicians could be enrolled. The number of patients discharged from the ED decreased, while the number of patients admitted to the ICU increased with higher NACA scores. Prehospital prediction of discharge or admission, IMC or ICU treatment by EMS physicians was accurate in 47 % of the patients. In 40 % of patients a lower level of care was sufficient while 12 % needed treatment on a higher level of care than that predicted by EMS physicians. Of the patients 39 % who were predicted to be discharged after ED treatment, were admitted to hospital and 48 % of patients predicted to be admitted to the IMC were admitted to the general ward. Patients predicted to be admitted to the ICU were admitted to the ICU in 75 %. Higher NACA scores were associated with increased mortality and a longer hospital IMC or ICU length of stay, but significant differences were only found between patients with NACA V versus VI scores or patients predicted to be treated on the IMC versus the ICU. Prehospital NACA scores indicate the need for inpatient treatment, but neither hospital discharge or admission nor need of IMC or ICU admission after initial ED treatment could be sufficiently predicted by EMS physicians. Thus, hospital prenotification in order to predispose IMC or ICU capacities does not seem to be useful in cases where an ED can reassess admitted EMS patients.

Many patients with unhealthy alcohol use (UAU) access health care in emergency departments (EDs). Scalable supports, such as SMS text messaging interventions, are acceptable and feasible to enhance care delivery for many health issues, including substance use. Further, SMS text messaging interventions have been shown to improve patient outcomes related to alcohol consumption (eg, reduced consumption compared to no intervention, basic health information, or drink tracking), but they are rarely offered in clinical settings. This paper describes a mixed methods study using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. The goal of this study was to use a stakeholder-engaged mixed methods design to assess barriers and facilitators to the implementation of SMS text messaging interventions for UAU in EDs with a focus on the recipient's characteristics, the innovation's degree of fit within the existing practice, and the unique nature of the inner and outer context. This study was conducted in a large health system in the northeastern United States. We examined electronic health record data on alcohol screening in 17 EDs; surveyed 26 ED physician chairpersons on implementation feasibility, acceptability, and appropriateness; and interviewed 18 ED staff and 21 patients to understand barriers and facilitators to implementation. Interviews were analyzed according to the i-PARIHS framework to assess recipient characteristics, innovation degree of fit, and inner and outer context. Electronic health record data revealed high variability in alcohol screening completion (mean 73%, range 35%-93%), indicating potential issues in identifying patients eligible to offer the intervention. The 26 ED chair surveys revealed a relatively high level of implementation confidence (mean 4, SD 0.81), acceptability (mean 4, SD 0.71), and appropriateness (mean 3.75, SD 0.69) regarding the UAU SMS text messaging intervention; feasibility (mean 3.5, SD 0.55) had the lowest mean, indicating concerns about integrating the text intervention in the busy ED workflow. Staff were concerned about staff buy-in and adding additional discussion points to already overwhelmed patients during their ED visit but saw the need for additional low-threshold services for UAU. Patients were interested in the intervention to address drinking and health-related goals. ED visits involving UAU have increased in the United States. The results of this formative study on barriers and facilitators to the implementation of UAU SMS text messaging interventions in EDs indicate both promise and caution. In general, we found that staff viewed offering such interventions as appropriate and acceptable; however, there were concerns with feasibility (eg, low alcohol risk screening rates). Patients also generally viewed the SMS text messaging intervention positively, with limited drawbacks (eg, slight concerns about having time to read messages). The results provide information that can be used to develop implementation strategies that can be tested in future studies.

BackgroundRefining and individualizing treatment of acute pain in the emergency department (ED) is a high priority, given that painful complaints are the most common reasons for ED visits. Few tools exist to objectively measure pain perception in the ED setting. We speculated that variation in perception of fixed painful stimuli would explain individual variation in reported pain and response to treatment among ED patients.Materials and methodsIn three studies, we 1) describe performance characteristics of brief quantitative sensory testing (QST) in 50 healthy volunteers, 2) test effects of 10 mg oxycodone versus placebo on QST measures in 18 healthy volunteers, and 3) measure interindividual differences in nociception and treatment responses in 198 ED patients with a painful complaint during ED treatment. QST measures adapted for use in the ED included pressure sensation threshold, pressure pain threshold (PPT), pressure pain response (PPR), and cold pain tolerance (CPT) tests.ResultsFirst, all QST measures had high inter-rater reliability and test–retest reproducibility. Second, 10 mg oxycodone reduced PPR, increased PPT, and prolonged CPT. Third, baseline PPT and PPR revealed hyperalgesia in 31 (16%) ED subjects relative to healthy volunteers. In 173 (88%) ED subjects who completed repeat testing 30 minutes after pain treatment, PPT increased and PPR decreased (Cohen’s dz 0.10–0.19). Verbal pain scores (0–10) for the ED complaint decreased by 2.2 (95% confidence intervals [CI]: 1.9, 2.6) (Cohen’s dz 0.97) but did not covary with the changes in PPT and PPR (r=0.05–0.13). Treatment effects were greatest in ED subjects with a history of treatment for anxiety or depression (Cohen’s dz 0.26–0.43) or with baseline hyperalgesia (Cohen’s dz 0.40–0.88).ConclusionQST reveals individual differences in perception of fixed painful stimuli in ED patients, including hyperalgesia. Subgroups of ED patients with hyperalgesia and psychiatric history report larger treatment effects on ED pain and QST measures.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common cause for emergency department (ED) visits. Still, large scale studies that assess the management of AECOPD in the ED are limited. Our aim was to evaluate treatment characteristics of AE-COPD in the ED on a national scale. A prospective study as part of the COPD Israeli survey, conducted between 2017 and 2019, in 13 medical centers. Patients hospitalized with AECOPD were included and interviewed. Clinical data related to their ED and hospital stay were collected. 344 patients were included, 38% females, mean age of 70 ± 11 years. Median (IQR) time to first ED treatment was 59 (23–125) minutes and to admission 293 (173–490) minutes. Delayed ED treatment (> 1 h) was associated with older age (p = 0.01) and lack of a coded diagnosis of COPD in hospital records (p = 0.01). Long ED length-of-stay (> 5 h) was linked with longer hospitalizations (p = 0.01). Routine ED care included inhalations of short-acting bronchodilators (246 patients, 72%) and systemic steroids (188 patients, 55%). Receiving routine ED care was associated with its continuation during hospitalization (p < 0.001). In multivariate analysis, predictors for patients not receiving routine care were obesity (adjusted odds ratio 0.5, 95% CI 0.3–0.8, p = 0.01) and fever (AOR 0.3, 95% CI 0.1–0.6, p < 0.01), while oxygen saturation < 91% was an independent predictor for ED routine treatment (AOR 3.6, 95% CI 2.1–6.3, p < 0.01). Our findings highlight gaps in the treatment of AECOPD in the ED on a national scale, with specific predictors for their occurrence.