Faculty Bibliography

The left ventricular outflow tract (LVOT) velocity time integral (VTI) is an easily measured echocardiographic stroke volume index analog. Low values predict adverse outcomes in left ventricular failure. We postulate the left ventricular VTI may be a signal of right ventricular dysfunction in acute pulmonary embolism, and therefore a predictor of poor outcomes. We retrospectively reviewed echocardiograms on all Pulmonary Embolism Response Team activations at our institution at the time of pulmonary embolism diagnosis. Low LVOT VTI was defined as ⩽ 15 cm. We examined two composite outcomes: (1) in-hospital death or cardiac arrest; and (2) shock or need for primary reperfusion therapies. Sixty-one of 188 patients (32%) had a LVOT VTI of ⩽ 15 cm. Low VTI was associated with in-hospital death or cardiac arrest (odds ratio (OR) 6, 95% CI 2, 17.9; p = 0.0014) and shock or need for reperfusion (OR 23.3, 95% CI 6.6, 82.1; p < 0.0001). In a multivariable model, LVOT VTI ⩽ 15 remained significant for death or cardiac arrest (OR 3.48, 95% CI 1.02, 11.9; p = 0.047) and for shock or need for reperfusion (OR 8.12, 95% CI 1.62, 40.66; p = 0.011). Among intermediate-high-risk patients, low VTI was the only variable associated with the composite outcome of death, cardiac arrest, shock, or need for reperfusion (OR 14, 95% CI 1.7, 118.4; p = 0.015). LVOT VTI is associated with adverse short-term outcomes in acute pulmonary embolism. The VTI may help risk stratify patients with intermediate-high-risk pulmonary embolism.

Background: The diagnosis of spinal cord compression is often delayed. Classic presentations are frequently variable or absent, leading to a lower clinician index of suspicion. Many patients with compressive lesions do not have the classic signs of rectal or urinary sphincter dysfunction or saddle anesthesia. Signs and symptoms may also evolve over course of an emergency department (ED) encounter. To facilitate rapid diagnosis and treatment of this high morbidity condition, a spinal emergency protocol was developed as part of a quality assurance endeavor.
Method(s): A multi-disciplinary group including emergency medicine, neurology, neurosurgery, and radiology created and implemented a protocol for use in patients presenting to the ED with concern for spinal cord compression. The protocol outlines specific trigger conditions, imaging choices, management strategies, and accountabilities for each involved specialty. All patients presenting to ED who received any spinal MRI from September 2016 to November 2018 were analyzed through chart review to determine whether the spinal emergency protocol was used. Time from MRI order to study start and time from MRI order to MRI read were analyzed for each of these groups. The two sample Wilcoxon test (Mann-Whitney test) was used to evaluate statistical significance.
Result(s): During this time period, 54 patients were evaluated for spinal compressive disease not using the spinal emergency protocol and 24 patients were evaluated using the protocol. The median time from MRI order to initiation of study in patients not on the protocol was 2.75 hours (IQR 1.37-4.37 hours) and for patients on the protocol the median time was 1.58 hours (IQR 1.13-1.97 hours) p value less than 0.01. The median time from MRI order to radiology read for patients not on the protocol was 5.30 hours (IQR 3.59-6.23 hours) and for patients on the protocol was 3.85 hours (IQR 2.72-4.28 hours) p value less than 0.01.
Conclusion(s): The introduction of a spinal emergency protocol led to a significant reduction in the time to the initiation and completion of definitive imaging in this high risk population. While this analysis was conducted at a single site, the implementation of similar protocols in other EDs could lead to reduction in time to diagnosis of spinal cord compression

Background: Older adults visit Emergency Departments (ED) more often and have repeated visits, compared with younger individu-als. Cognitive impairment may drive ED use and may be more preva-lent in ED settings; yet it is often unrecognized, potentially resulting in suboptimal discharge planning. Cognitive screening is not routine ED care and staff are not typically trained in proper procedures.
Method(s): Using a volunteer workforce of college students and recent graduates provides an opportunity for clinical training as cogni-tive screeners and increases opportunities for system change. Volunteers screened for cognitive impairment among English and Spanish speaking patients who were admitted to a large academic ED and were likely to be discharged to home. We targeted patients >= 75 years and requested screening with the MiniCog$sup$

Early palliative care consultation ha the potential to provide comfort to patients and families, and decrease costs and length of stay.