Faculty Bibliography

Background: Telemedicine-specific clinical pathways (CPWs), coupled with electronic health record (EHR) order panels, provide an opportunity to ensure evidence and guideline concordant care for conditions at risk for inconsistent diagnoses and management strategies. Standardized provider and patient-facing illness scripts may fill gaps in clinicians"™ communication skills secondary to a training deficit in virtual care delivery. We aimed to implement and assess the impact of a novel care bundle for sinusitis on antimicrobial use, patient satisfaction, clinician satisfaction, and usability in patients with sinusitis. Methods: A sinusitis care bundle (SCB) for virtual urgent care patients included a sinusitis CPW with communication scripts, sinusitis order panels (SOP), and a patient education smart-phrase (SPESP) within visit instructions. Antimicrobial use was assessed during a 15-month period prior to the start of SCB element implementations and 14-months following, using statistical process control charts. Patient satisfaction was measured using Likert-style surveys. Clinician satisfaction was assessed using a novel survey addressing the SCB-targeted domains (decision support, communication, efficiency, usability, and overall satisfaction). Results: There were 69,785 and 64,019 evaluable patients in the pre-care and post-care bundle periods, respectively. Despite a significant increase in patients receiving a sinusitis diagnosis in the post-care bundle period (3.2% pre- vs. 6.2% post-, p < 0.001), antimicrobial prescribing decreased by 3.9% (p < 0.001), with statistical process control evidence of special cause change. There was a 5.1% decrease (p < 0.001) in negative patient survey responses after implementation. Clinician survey revealed substantial agreement in the domains relating to improving communication with patients and/or families, with the highest satisfaction for the SPESP over the SOP. Conclusions: Implementation of a telemedicine care bundle for patients diagnosed with sinusitis can balance multiple elements of quality care. The combination of a clinical care pathway, standardized language, and order panels within the EHR has the potential to improve patient satisfaction and decrease antimicrobial prescribing.

BACKGROUND:During the COVID-19 pandemic, we identified a gap in adequate discharge counseling for COVID-19 patients in the Emergency Department. This was due to high patient volumes and lack of patient education regarding a novel disease. Medical students were also restricted from clinical areas due to safety concerns, compromising their clinical experience. We piloted a novel program in which medical students served as virtual discharge counselors for COVID-19 patients via teleconference. We aimed to demonstrate an impact on patient care by examining the patient bounce back rate as well as assessing medical student education and experience. METHODS:This program was piloted in a tertiary care Emergency Department. Medical student volunteers served as virtual discharge counselors. Students were trained in discharge counseling with a standardized protocol and a discharge script. Eligible patients for virtual discharge counseling were 18 years old or greater with a diagnosis of confirmed or suspected COVID-19 and no impediment precluding them from participating in a telemedicine encounter. Counseling was provided via secure teleconference in the patient's preferred language. Counseling included diagnosis, supportive care with medication dosing, quarantine instructions, return precautions, follow up, and time to ask questions. Duration of counseling was recorded and medical students were anonymously surveyed regarding their experience. RESULTS:Over an 18-week period, 45 patients were counseled for a median of 20 min. The 72-hr ED revisit rate was 0%, versus 4.2% in similarly-matched, not counseled COVID-19 patients. 90% of medical students believed this project increased their confidence when speaking with patients while 80% indicated this was their first telemedicine experience. CONCLUSION/CONCLUSIONS:Our pilot discharge program provided patients with an extensive discharge counseling experience that would not otherwise be possible in an urban ED setting and demonstrated benefit to patient care. Medical students received a safe clinical experience that improved their communication skills.

INTRODUCTION/BACKGROUND:Family presence during emergency resuscitations is increasingly common, but the question remains whether the practice results in psychological harm to the witness. We examine whether family members who witness resuscitations have increased post-traumatic stress disorder (PTSD) symptoms at one month following the event. METHODS:We identified family members of critically ill patients via our emergency department (ED) electronic health record. Patients were selected based on their geographic triage to an ED critical care room. Family members were called a median of one month post-event and administered the Impact of Event Scale-Revised (IES-R), a 22-item validated scale that measures post-traumatic distress symptoms and correlates closely with Diagnostic and Statistical Manual of Mental Disorders-IV criteria for post-traumatic stress disorder (PTSD). Family members were placed into two groups based on whether they stated they had witnessed the resuscitation (FWR group) or not witnessed the resuscitation (FNWR group). Data analyses included chi-square test, independent sample t-test, and linear regression controlling for gender and age. RESULTS:A convenience sample of 423 family members responded to the phone interview: 250 FWR and 173 FNWR. The FWR group had significantly higher mean total IES-R scores: 30.4 vs 25.6 (95% confidence interval [CI], -8.73 to -0.75; P<.05). Additionally, the FWR group had significantly higher mean score for the subscales of avoidance (10.6 vs 8.1; 95% CI, -4.25 to -0.94; P<.005) and a trend toward higher score for the subscale of intrusion (13.0 vs 11.4; 95% CI, -3.38 to .028; P = .054). No statistical significant difference was noted between the groups in the subscale of hyperarousal (6.95 vs 6.02; 95% CI, -2.08 to 0.22; P=.121). All findings were consistent after controlling for age, gender, and immediate family member (spouse, parent, children, and grandchildren). CONCLUSION/CONCLUSIONS:Our results suggest that family members who witness ED resuscitations may be at increased risk of PTSD symptoms at one month. This is the first study that examines the effects of family visitation for an unsorted population of very sick patients who would typically be seen in the critical care section of a busy ED.

Inadvertent knotting of urethral catheters and enteric feeding tubes is a rare complication in pediatric patients. If a small flexible tube is used and advanced too far, upon withdrawal, the catheter may knot in the bladder. Surgical intervention for retrieval is required in most cases. We present a case of a 26-day-old female neonate who was catheterized with a 5 French enteric feeding tube, which was later removed in the emergency department with gentle traction alone. After removal, a knot was noted at the tip. It is important for emergency physicians to be aware of this complication, because this particular size feeding tube is most susceptible to kinking inside of the urinary tract.

OBJECTIVES/OBJECTIVE:Dyspnea is a common emergency department (ED) condition, which may be caused by pleural effusion and other thoracic diseases. We present data on a new sonographic marker, the extension of the thoracic spine sign, for diagnosis of pleural effusion. METHODS:In this prospective study, we enrolled a convenience sample of undifferentiated patients who underwent computed tomography (CT) of the abdomen or chest, which was performed as part of their emergency department evaluations. Patients underwent chest sonography to assess the utility of the extension of the thoracic spine sign for diagnosing pleural effusion. The point-of-care sonographic examinations were performed and interpreted by emergency physicians who were blinded to information in the medical records. Sonographic results were compared to radiologists' interpretations of the CT results, which were considered the criterion standard. RESULTS:Forty-one patients were enrolled, accounting for 82 hemithoraces. Seven hemithoraces were excluded from the analysis due to various limitations, leaving 75 hemithoraces for the final analysis. The median time for completion of the sonographic examination was 3 minutes. The sensitivity and specificity for extension of the thoracic spine were 73.7% (95% confidence interval [CI], 48.6%-89.9%) and 92.9% (95%CI, 81.9%-97.7%), respectively. Overall, there were 5 hemithoraces with false-negative results when using the extension sign. Of those 5 cases, 4 were found to have trace pleural effusions on CT. When trace pleural effusions were excluded in a subgroup analysis, the sensitivity and specificity of extension of the thoracic spine were 92.9% (95% CI, 64.2%-99.6%) and 92.9% (95% CI, 81.9%-97.7%). CONCLUSIONS:We found the extension of the thoracic spine sign to be an excellent diagnostic tool for clinically relevant pleural effusion.

STUDY OBJECTIVE/OBJECTIVE:We assess and compare the analgesic efficacy and safety of subdissociative intravenous-dose ketamine with morphine in emergency department (ED) patients. METHODS:This was a prospective, randomized, double-blind trial evaluating ED patients aged 18 to 55 years and experiencing moderate to severe acute abdominal, flank, or musculoskeletal pain, defined as a numeric rating scale score greater than or equal to 5. Patients were randomized to receive ketamine at 0.3 mg/kg or morphine at 0.1 mg/kg by intravenous push during 3 to 5 minutes. Evaluations occurred at 15, 30, 60, 90, and 120 minutes. Primary outcome was reduction in pain at 30 minutes. Secondary outcome was the incidence of rescue analgesia at 30 and 60 minutes. RESULTS:Forty-five patients per group were enrolled in the study. The primary change in mean pain scores was not significantly different in the ketamine and morphine groups: 8.6 versus 8.5 at baseline (mean difference 0.1; 95% confidence interval -0.46 to 0.77) and 4.1 versus 3.9 at 30 minutes (mean difference 0.2; 95% confidence interval -1.19 to 1.46; P=.97). There was no difference in the incidence of rescue fentanyl analgesia at 30 or 60 minutes. No statistically significant or clinically concerning changes in vital signs were observed. No serious adverse events occurred in either group. Patients in the ketamine group reported increased minor adverse effects at 15 minutes post-drug administration. CONCLUSION/CONCLUSIONS:Subdissociative intravenous ketamine administered at 0.3 mg/kg provides analgesic effectiveness and apparent safety comparable to that of intravenous morphine for short-term treatment of acute pain in the ED.

BACKGROUND:Pyocele is a rare emergent urologic condition that requires rapid recognition and treatment to prevent testicular loss. Cases of pediatric pyocele have not been previously reported in the emergency medicine literature. CASE REPORT/METHODS:We describe a case of a 6-week-old male who presented to the emergency department for a sepsis evaluation. The patient displayed subtle scrotal findings but had an otherwise benign physical examination. Subsequent sonographic imaging suggested a possible scrotal abscess and surgical exploration revealed a pyocele. A literature review of previously reported cases of patients with pyocele is also presented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A pyocele is a rare cause of both an acute scrotum and neonatal fever. It is important for emergency physicians to consider this entity when evaluating pediatric patients with fever, particularly those with symptoms related to the scrotum.