Faculty Bibliography

BACKGROUND:The assessment of clinical guideline adherence for the evaluation of pulmonary embolism (PE) via computed tomography pulmonary angiography (CTPA) currently requires either labor-intensive, retrospective chart review or prospective collection of PE risk scores at the time of CTPA order. The recording of clinical data in a structured manner in the electronic health record (EHR) may make it possible to automate the calculation of a patient's PE risk classification and determine whether the CTPA order was guideline concordant. OBJECTIVES/OBJECTIVE:The objective of this study was to measure the performance of automated, structured-data-only versions of the Wells and revised Geneva risk scores in emergency department encounters during which a CTPA was ordered. The hypothesis was that such an automated method would classify a patient's PE risk with high accuracy compared to manual chart review. METHODS:We developed automated, structured-data-only versions of the Wells and revised Geneva risk scores to classify 212 emergency department (ED) encounters during which a CTPA was performed as "PE Likely" or "PE Unlikely." We then combined these classifications with D-dimer ordering data to assess each encounter as guideline concordant or discordant. The accuracy of these automated classifications and assessments of guideline concordance were determined by comparing them to classifications and concordance based on the complete Wells and revised Geneva scores derived via abstractor manual chart review. RESULTS:The automatically derived Wells and revised Geneva risk classifications were 91.5% and 92% accurate compared to the manually determined classifications, respectively. There was no statistically significant difference between guideline adherence calculated by the automated scores as compared to manual chart review (Wells: 70.8 vs. 75%, p = 0.33 | Revised Geneva: 65.6 vs. 66%, p = 0.92). CONCLUSION/CONCLUSIONS:The Wells and revised Geneva score risk classifications can be approximated with high accuracy using automated extraction of structured EHR data elements in patients who received a CTPA. Combining these automated scores with D-dimer ordering data allows for the automated assessment of clinical guideline adherence for CTPA ordering in the emergency department, without the burden of manual chart review.

BACKGROUND: Testing for venous thromboembolism (VTE) is associated with cost and risk to patients (e.g. radiation). To assess the appropriateness of imaging utilization at the provider level, it is important to know that provider's diagnostic yield (percentage of tests positive for the diagnostic entity of interest). However, determining diagnostic yield typically requires either time-consuming, manual review of radiology reports or the use of complex and/or proprietary natural language processing software. OBJECTIVES: The objectives of this study were twofold: 1) to develop and implement a simple, user-configurable, and open-source natural language processing tool to classify radiology reports with high accuracy and 2) to use the results of the tool to design a provider-specific VTE imaging dashboard, consisting of both utilization rate and diagnostic yield. METHODS: Two physicians reviewed a training set of 400 lower extremity ultrasound (UTZ) and computed tomography pulmonary angiogram (CTPA) reports to understand the language used in VTE-positive and VTE-negative reports. The insights from this review informed the arguments to the five modifiable parameters of the NLP tool. A validation set of 2,000 studies was then independently classified by the reviewers and by the tool; the classifications were compared and the performance of the tool was calculated. RESULTS: The tool was highly accurate in classifying the presence and absence of VTE for both the UTZ (sensitivity 95.7%; 95% CI 91.5-99.8, specificity 100%; 95% CI 100-100) and CTPA reports (sensitivity 97.1%; 95% CI 94.3-99.9, specificity 98.6%; 95% CI 97.8-99.4). The diagnostic yield was then calculated at the individual provider level and the imaging dashboard was created. CONCLUSIONS: We have created a novel NLP tool designed for users without a background in computer programming, which has been used to classify venous thromboembolism reports with a high degree of accuracy. The tool is open-source and available for download at http://iturrate.com/simpleNLP. Results obtained using this tool can be applied to enhance quality by presenting information about utilization and yield to providers via an imaging dashboard.

Introduction/UNASSIGNED:Emergency department (ED) patient care often hinges on the result of a diagnostic test. Frequently there is a lag time between a test result becoming available for review and physician decision-making or disposition based on that result. We implemented a system that electronically alerts ED providers when test results are available for review via a smartphone- and smartwatch-push notification. We hypothesized this would reduce the time from result to clinical decision-making. Methods/UNASSIGNED:We retrospectively assessed the impact of the implementation of a push notification system at three EDs on time-to-disposition or time-to-follow-up order in six clinical scenarios of interest: chest radiograph (CXR) to disposition, basic metabolic panel (BMP) to disposition, urinalysis (UA) to disposition, respiratory pathogen panel (RPP) to disposition, hemoglobin (Hb) to blood transfusion order, and abnormal D-dimer to computed tomography pulmonary angiography (CTPA) order. All ED patients during a one-year period of push-notification availability were included in the study. The primary outcome was median time in each scenario from result availability to either disposition order or defined follow-up order. The secondary outcome was the overall usage rate of the opt-in push notification system by providers. Results/UNASSIGNED:During the study period there were 6115 push notifications from 4183 ED encounters (2.7% of all encounters). Of the six clinical scenarios examined in this study, five were associated with a decrease in median time from test result availability to patient disposition or follow-up order when push notifications were employed: CXR to disposition, 80 minutes (interquartile range [IQR] 32-162 minutes) vs 56 minutes (IQR 18-141 minutes), difference 24 minutes (p<0.01); BMP to disposition, 128 minutes (IQR 62-225 minutes) vs 116 minutes (IQR 33-226 minutes), difference 12 minutes (p<0.01); UA to disposition, 105 minutes (IQR 43-200 minutes) vs 55 minutes (IQR 16-144 minutes), difference 50 minutes (p<0.01); RPP to disposition, 80 minutes (IQR 28-181 minutes) vs 37 minutes (IQR 10-116 minutes), difference 43 minutes (p<0.01); and D-dimer to CTPA, 14 minutes (IQR 6-30 minutes) vs 6 minutes (IQR 2.5-17.5 minutes), difference 8 minutes (p<0.01). The sixth scenario, Hb to blood transfusion (difference 19 minutes, p=0.73), did not meet statistical significance. Conclusion/UNASSIGNED:Implementation of a push notification system for test result availability in the ED was associated with a decrease in lag time between test result and physician decision-making in the examined clinical scenarios. Push notifications were used in only a minority of ED patient encounters.

Use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation, termed eCPR, offers the prospect of improving survival with good neurological function after cardiac arrest. After death, ECMO can also be used for enhanced preservation of abdominal and thoracic organs, designated normothermic regional perfusion (NRP), before organ recovery for transplantation. To optimize resuscitation and transplantation outcomes, healthcare networks in Portugal and Italy have developed cardiac arrest protocols that integrate use of eCPR with NRP. Similar dissemination of eCPR and its integration with NRP in the USA raise novel ethical issues due to a non-nationalized health system and an opt-in framework for organ donation, as well as other legal and cultural factors. Nonetheless, eCPR investigations are ongoing, and both eCPR and NRP are selectively employed in clinical practice. This paper delineates the most pressing relevant ethical considerations and proposes recommendations for implementation of protocols that aim to promote public trust and reduce conflicts of interest. Transparent policies should rely on protocols that separate lifesaving from organ preservation considerations; robust, centralized eCPR data to inform equitable and evidence-based allocations; uniform practices concerning clinical decision-making and resource utilization; and partnership with community stakeholders, allowing patients to make decisions about emergency care that align with their values. Proactively addressing these ethical and logistical challenges could enable eCPR dissemination and integration with NRP protocols in the USA, with the potential to maximize lives saved through both improved resuscitation with good neurological outcomes and increased organ donation opportunities when resuscitation is unsuccessful or not in accordance with individuals' wishes.

CASE PRESENTATION/METHODS:We describe a case of left internal jugular central venous access with rare malpositioning into the internal mammary vein. Despite various confirmatory measures at the time of placement including ultrasonography of the internal jugular vein, as well as blood gas analysis consistent with venous blood by oxygen saturation and good venous flow in all three ports of the catheter, subsequent imaging confirmed misplacement into the internal mammary vein. DISCUSSION/CONCLUSIONS:Central venous access is a frequently used procedure by emergency physicians for a variety of indications. Emergency physicians must be facile with both the technical process of central venous catheter placement, as well as possible pitfalls and complications of the procedure. Common complications, such as bleeding, pneumothorax, arterial injury, infection, and hematomas, are usually well known; less frequently encountered is malposition of the catheter despite seemingly appropriate placement.

BACKGROUND/UNASSIGNED:Severe acetaminophen (APAP) poisoning can result in fulminant hepatic failure and abnormal tests of coagulation. Although the international normalized ratio (INR) may be elevated, the actual hemostatic status of patients with APAP-induced hepatotoxicity is unknown. Few studies exist investigating the clinical use of thromboelastography (TEG) to evaluate the hemostatic status in the setting of APAP-induced hepatotoxicity. METHODS/UNASSIGNED:We performed a retrospective review of patients who were admitted for APAP toxicity and received TEG testing at a single transplant center. RESULTS/UNASSIGNED:Nine patients had detectable APAP concentrations and exhibited elevated aspartate and alanine aminotransferase activities. Seven had thrombocytopenia. TEG revealed a decreased median alpha angle and maximum amplitude but other values were within the normal reference range. DISCUSSION/UNASSIGNED:Based on our study of APAP-induced hepatotoxicity, TEG showed a decreased rate of fibrin formation and cross-linking, as well as reduced clot strength. These findings suggest that patients with APAP-induced hepatotoxicity and thrombocytopenia have a theoretically increased bleeding risk as demonstrated by both elevated INR and abnormal TEG values. However, these TEG findings are more likely related to thrombocytopenia rather than directly to APAP-induced hepatotoxicity. Further studies should be performed to elucidate the potential role of TEG in various stages of APAP-induced hepatotoxicity.

INTRODUCTION/BACKGROUND:Novel long-acting lipoglycopeptide antibiotics allow for the treatment and discharge of selected emergency department (ED) patients with cellulitis who require intravenous antibiotics. Telehealth systems have shown success in remote management of dermatologic conditions; we implemented a telehealth follow-up program for patients diagnosed with cellulitis in the ED, treated with single-dose dalbavancin, and discharged. METHODS:This was a prospective, multi-center observational study. Patients were included based on clinical criteria and ability to complete follow-up using a smartphone and enroll in an online care portal. We examined the rate of successful telehealth follow-up at 24- and 72-hour intervals from discharge. We also examined the ED return rate within 14 days, reviewed any visits to determine cause of return, and for admission. RESULTS:55 patients were enrolled. 54/55 patients completed at least one telehealth follow up encounter (98.2%). 13 patients (23.6%) had a return ED visit within 14 days; no patients required admission for worsening cellulitis. Patient engagement in the telehealth program decreased over time; there was an approximately 11% decrease in engagement between the 24 and 72-hour follow-up call, and a 15% decrease in engagement between the 24 and 72-hour image upload. Patients over 65 had a lower rate of image upload (31%) than younger patients (80.6%). DISCUSSION/CONCLUSIONS:A telehealth follow-up system for discharged emergency department patients with cellulitis demonstrated high rates of engagement. In these patients who -may have otherwise required admission for intravenous antibiotics, telehealth-facilitated outpatient management resulted in a low ED return rate and no inpatient admissions for cellulitis.