Medicine and Health Sciences Commons^™

Anuria Secondary To Bilateral Obstructing Ureteral Stones In The Absence Of Renal Colic., Carolyn A Salter, Christopher Lang, Hernan O Altamar

Emergency Medicine Faculty Publications

BACKGROUND: Obstructing ureteral stones are a rare cause of anuria, which is typically from prerenal or renal etiologies. Classically, obstructive stones cause moderate to severe renal colic. Urolithiasis is rarely considered during evaluation of painless anuria.

CASE PRESENTATION: We present an unusual case of a 73-year-old Caucasian female who presented with anuria and was found to have large bilateral obstructing ureteral stones in the absence of renal colic.

CONCLUSION: Given that patients with obstructive anuria can be asymptomatic, urolithiasis should be considered in all patients presenting with anuria.

A Single Center Observational Study On Emergency Department Clinician Non-Adherence To Clinical Practice Guidelines For Treatment Of Uncomplicated Urinary Tract Infections, Catherine Zatorski, Mark Zocchi, Sara Cosgrove, Cynthia Rand, Gillian Brooks, Larissa May

Emergency Medicine Faculty Publications

Background

The Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidence-based guidelines and broad-spectrum antibiotic overuse is common. Our objective was to determine rates and predictors of inappropriate antimicrobial use in patients with uncomplicated urinary tract infections (UTI) compared to the 2010 International Clinical Practice Guidelines (ICPG).

Methods

A single center, prospective, observational study of patients with uncomplicated UTI presenting to an urban ED between September 2012 and February 2014 that examined ED physician adherence to ICPG when treating uncomplicated UTIs. Clinician-directed antibiotic treatment was compared to the ICPG using a standardized case definition for …

Improving Timeliness For Acute Asthma Care For Paediatric Ed Patients Using A Nurse Driven Intervention: An Interrupted Time Series Analysis., Kathleen Brown, Sabah Iqbal, Su-Lin Sun, Jennifer Fritzeen, James Chamberlain, Paul C. Mullan

Emergency Medicine Faculty Publications

Asthma is the most common chronic paediatric disease treated in the emergency department (ED). Rapid corticosteroid administration is associated with improved outcomes, but our busy ED setting has made it challenging to achieve this goal. Our primary aim was to decrease the time to corticosteroid administration in a large, academic paediatric ED. We conducted an interrupted time series analysis for moderate to severe asthma exacerbations of one to 18 year old patients. A multidisciplinary team designed the intervention of a bedside nurse initiated administration of oral dexamethasone, to replace the prior system of a physician initiated order for oral prednisone. …

Near Misses And Unsafe Conditions Reported In A Pediatric Emergency Research Network, Richard M. Ruddy, James M. Chamberlain, Prashant V. Mahajan, Tomohiko Funai, Karen J. O'Connell, Et Al.

Emergency Medicine Faculty Publications

Objective Patient safety may be enhanced by using reports from front-line staff of near misses and unsafe conditions to identify latent safety events. We describe paediatric emergency department (ED) near-miss events and unsafe conditions from hospital reporting systems in a 1-year observational study from hospitals participating in the Pediatric Emergency Care Applied Research Network (PECARN).

Design This is a secondary analysis of 1 year of incident reports (IRs) from 18 EDs in 2007–2008. Using a prior taxonomy and established method, this analysis is of all reports classified as near-miss (events not reaching the patient) or unsafe condition. Classification included type, …

Do Emergency Department Patients Receive A Pathological Diagnosis? A Nationally-Representative Sample, Leana Wen, Janice A. Espinola, Joshua M. Mosowsky, Carlos A. Camargo

Emergency Medicine Faculty Publications

Introduction: Understanding the cause of patients’ symptoms often requires identifying a pathological diagnosis. A single-center study found that many patients discharged from the emergency department (ED) do not receive a pathological diagnosis. We analyzed 17 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to identify the proportion of patients who received a pathological diagnosis at ED discharge. We hypothesized that many patients do not receive a pathological diagnosis, and that the proportion of pathological diagnoses increased between 1993 and 2009.

Methods:Using the NHAMCS data from 1993-2009, we analyzed visits of patients age ≥18 years, …

Emergency Department Ultrasound Probe Infection Control: Challenges And Solutions, Hamid A. Shokoohi, Paige Armstrong, Ryan Tansek

Emergency Medicine Faculty Publications

Point-of-care ultrasound (US) has become a cornerstone in the diagnosis and treatment of patients in the emergency department (ED). Despite the beneficial impact on patient care, concern exists over repeat use of probes and the role as a vector for pathogen transmission. US probes are used for various applications, with the level of infection risk, based on the Spaulding Classification, ranging from noncritical with common practice to semicritical with endocavitary probes. To date, the most closely studied organisms are Staphylococcus aureus and human papilloma virus. Current evidence does confirm probe colonization but has not established a causative role in human …

Educational Technology Improves Ecg Interpretation Of Acute Myocardial Infarction For Medical Students And Emergency Medicine Residents, Ali Pourmand, Mary Tanski, Steven Davis, Hamid A. Shokoohi, Raymond Lucas, Fareen Zaver

Emergency Medicine Faculty Publications

Introduction: Asynchronous online training has become an increasingly popular educational format in the new era of technology-based professional development. We sought to evaluate the impact of an online asynchronous training module on the ability of medical students and emergency medicine (EM) residents to detect electrocardiogram (ECG) abnormalities of an acute myocardial infarction (AMI).

Methods: We developed an online ECG training and testing module on AMI, with emphasis on recognizing ST elevation myocardial infarction (MI) and early activation of cardiac catheterization resources. Study participants included senior medical students and EM residents at all postgraduate levels rotating in our emergency department (ED). …

Do Emergency Department Patients Receive A Pathological Diagnosis? A Nationally-Representative Sample., Leana S. Wen, Janice A. Espinola, Joshua M. Mosowsky, Carlos A. Camargo

Emergency Medicine Faculty Publications

Introduction

Understanding the cause of patients’ symptoms often requires identifying a pathological diagnosis. A single-center study found that many patients discharged from the emergency department (ED) do not receive a pathological diagnosis. We analyzed 17 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to identify the proportion of patients who received a pathological diagnosis at ED discharge. We hypothesized that many patients do not receive a pathological diagnosis, and that the proportion of pathological diagnoses increased between 1993 and 2009.

Methods

Using the NHAMCS data from 1993–2009, we analyzed visits of patients age ≥18 years, discharged …

Solving The Worldwide Emergency Department Crowding Problem - What Can We Learn From An Israeli Ed?, Jesse M Pines, Steven L Bernstein

Emergency Medicine Faculty Publications

ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED …

Treatment Failure Outcomes For Emergency Department Patients With Skin And Soft Tissue Infections, Larissa S. May, Mark S. Zocchi, Catherine Zatorski, Jeanne A. Jordan, Richard E. Rothman, Chelsea Ware

Emergency Medicine Faculty Publications

Introduction: Skin and soft tissue infections (SSTIs) are commonly evaluated in the emergency department (ED). Our objectives were to identify predictors of SSTI treatment failure within one week post-discharge in patients with cutaneous abscesses, as well as to identify predictors of recurrence within three months in that proportion of participants. Methods: This was a sub-analysis of a parent study, conducted at two EDs, evaluating a new, nucleic acid amplification test (NAAT) for Staphylococcus aureus in ED patients. Patients≥18 years receiving incision and drainage (I and D) were eligible. Patient-reported outcome data on improvement of fever, swelling, erythema, drainage, and pain …

Mental Health Disorders In Child And Adolescent Survivors Of Post-War Landmine Explosions., Mohammad Ali Hemmati, Hamid Shokoohi, Mehdi Masoumi, Shahriar Khateri, Mohammadreza Soroush, Ehsan Modirian, Mahtab Poor Zamany Nejat Kermany, Maryam Hosseini, Batool Mousavi

Emergency Medicine Faculty Publications

BACKGROUND: To describe the mental health status of 78 child and adolescent survivors of post-war landmine explosions.

METHODS: Child and adolescent survivors of landmine explosions who were younger than 18 years old at the time of the study were identified and enrolled in this study. The mental health status of the participants was assessed by general health assessment and psychiatric examinations. Psychiatric assessment and diagnosis were undertaken using the Diagnostic and Statistical Manual for mental disorders (DSM-IV) criteria. A psychiatrist visited and interviewed each survivor and identified psychiatric disorders.

RESULTS: Seventy-eight child and adolescent survivors with a mean age of …

Telepsychiatric Assessment Of A Mariner Expressing Suicidal Ideation., Alexander Lee, Neal Sikka, Francis O'Connell, Allen Dyer, Keith Boniface, James Betz

Emergency Medicine Faculty Publications

This case report highlights the successful use of telepsychiatric consultation by secure video chat to remotely assess a mariner expressing suicidal ideation. As a result of this intervention, telemedicine providers initiated psychiatric stabilisation while the mariner was still aboard the vessel, determined that he was safe for repatriation under the care of qualified medical escorts, and facilitated admission to a psychiatric facility near his home in the United States. Mental health emergencies are a significant cause of morbidity and mortality among mariners. Telepsychiatry is a validated method of establishing a psychiatric diagnosis and disposition as well as assessing risk of …

Clinical Management Of Skin And Soft Tissue Infections In The U.S. Emergency Departments, Rakesh Mistry, Daniel J. Shapiro, Monika Goyal, Theoklis Zaoutis, Jeffrey Gerber, Catherine Liu, Adam L. Hersh

Emergency Medicine Faculty Publications

Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft-tissue infections (SSTI) in the United States. A nearly three-fold increase in SSTI visit rates had been documented in the nation's emergency departments (ED). The objective of this study was to determine characteristics associated with ED performance of incision and drainage (I+D) and use of adjuvant antibiotics in the management of skin and soft tissue infections (SSTI).

METHODS:

Cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a nationally representative database of ED visits from 2007-09. Demographics, rates of I+D, and adjuvant antibiotic …

Trends In Antibiotic Resistance In Coagulase-Negative Staphylococci In The United States, 1999 To 2012, Larissa S. May, Eili Y. Klein, Richard E. Rothman, Ramanan Laxminarayan

Emergency Medicine Faculty Publications

Coagulase-negative staphylococci (CoNS) are important bloodstream pathogens that are typically resistant to multiple antibiotics. Despite the concern about increasing resistance, there have been no recent studies describing the national prevalence of CoNS pathogens. We used national resistance data over a period of 13 years (1999 to 2012) from The Surveillance Network (TSN) to determine the prevalence of and assess the trends in resistance for Staphylococcus epidermidis, the most common CoNS pathogen, and all other CoNS pathogens. Over the course of the study period, S. epidermidis resistance to ciprofloxacin and clindamycin increased steadily from 58.3% to 68.4% and from 43.4% to …

High Dose Insulin Therapy, An Evidence Based Approach To Beta Blocker/Calcium Channel Blocker Toxicity, Christina Woodward, Ali Pourmand, Maryann Mazer-Amirshahi

Emergency Medicine Faculty Publications

Poison-induced cardiogenic shock (PICS) as a result of beta-blocker (?-blocker) or calcium channel blocker (CCB) overdose is a common and potentially life-threatening condition. Conventional therapies, including fluid resuscitation, atropine, cardiac pacing, calcium, glucagon, and vasopressors often fail to improve hemodynamic status. High-dose insulin (HDI) is an emerging therapeutic modality for PICS. In this article, we discuss the existing literature and highlight the therapeutic success and potential of HDI. Based on the current literature, which is limited primarily to case series and animal models, the authors conclude that HDI can be effective in restoring hemodynamic stability, and recommend considering its use …

Do Emergency Department Patients Receive A Pathological Diagnosis? A Nationally Representative Sample., Leana S. Wen, Janice A. Espinola, Joshua M. Kosowsky, Carlos A. Camargo Jr

Emergency Medicine Faculty Publications

No abstract provided.

The Impact Of A Large-Scale Power Outage On Hemodialysis Center Operations, Mahshid Abir, Sophia Jan, Lindsay Jubelt, Raina M. Merchant, Nicole Lurie

Emergency Medicine Faculty Publications

INTRODUCTION:

On June 29, 2012, mid-Atlantic storms resulted in a large-scale power outage affecting up to three million people across multiple (US) states. Hemodialysis centers are dependent on electricity to provide dialysis care to end-stage renal disease patients. The objective of thisstudy was to determine how the power outage impacted operations in a sample of hemodialysis centers in the impacted regions.

METHODS:

The sample consisted of all hemodialysis centers located in the District of Columbia and a total of five counties with the largest power losses in West Virginia, Virginia, and Maryland. A semi-structured interview guide was developed, and …

Depression Is Associated With Repeat Emergency Department Visits In Patients With Non-Specific Abdominal Pain, Andrew C. Meltzer, Benjamin Bregman, Janice Blanchard

Emergency Medicine Faculty Publications

Introduction: Patients with abdominal pain often return multiple times despite no definitive diagnosis. Our objective was to determine if repeat emergency department (ED) use among patients with non-specific abdominal pain might be associated with a diagnosis of moderate to severe depressive disorder.

Methods: We screened 987 ED patients for major depression during weekday daytime hours from June 2011 through November 2011 using a validated depression screening tool, the PHQ-9. Each subject was classified as either no depression, mild depression or moderate/ severe depression based on the screening tool. Within this group, we identified 83 patients with non-specific abdominal pain by …

Creation And Implementation Of An Emergency Medicine Education And Training Program In Turkey: An Effective Educational Intervention To Address The Practitioner Gap, Jennifer Whitfield Bellows, Katherine A. Douglass, Atilla Ridvan, Jeffrey Smith, G. Bobby Kapur

Emergency Medicine Faculty Publications

Background

The specialty of Emergency Medicine has enjoyed recognition for nearly 20 years in Turkey. However, the majority of underserved and rural Turkish emergency departments are staffed by general practitioners who lack formal training in the specialty and have few opportunities to increase emergency medicine-specific knowledge and skills.

Methods

To address this “practitioner gap,” the authors developed a four-phase comprehensive emergency medicine education and training program for general practitioners practicing in government hospitals in Turkey.

Results

From April 2006 until June 2009, 42 courses were taught by 62 trainers across seven regions in Turkey. A total of 2,262 physicians were …

A Risk Score For Identifying Methicillin-Resistant Staphylococcus Aureus In Patients Presenting To The Hospital With Pneumonia., Andrew F. Shorr, Daniela E. Myers, David B. Huang, Brian H. Nathanson, Matthew F. Emons, Marin H. Kollef

Emergency Medicine Faculty Publications

Background

Methicillin-resistant Staphylococcus aureus (MRSA) represents an important pathogen in healthcare-associated pneumonia (HCAP). The concept of HCAP, though, may not perform well as a screening test for MRSA and can lead to overuse of antibiotics. We developed a risk score to identify patients presenting to the hospital with pneumonia unlikely to have MRSA.

Methods

We identified patients admitted with pneumonia (Apr 2005 – Mar 2009) at 62 hospitals in the US. We only included patients with lab evidence of bacterial infection (e.g., positive respiratory secretions, blood, or pleural cultures or urinary antigen testing). We determined variables independently associated with the …

Rapid 13(C) Urea Breath Test To Identify Helicobacter Pylori Infection In Emergency Department Patients With Upper Abdominal Pain, Andrew C. Meltzer, Rebecca Pierce, Derek A.T. Cummings, Jesse M. Pines, Larissa May, Meaghan A. Smith, Joseph Marcotte, Melissa L. Mccarthy

Emergency Medicine Faculty Publications

Introduction: In emergency department (ED) patients with upper abdominal pain, management includes ruling out serious diseases and providing symptomatic relief. One of the major causes of upper abdominal pain is an ulcer caused by Helicobacter pylori (H. pylori), which can be treated and cured with antibiotics. We sought to estimate the prevalence of H. pylori infection in symptomatic patients using a convenience sample at a single urban academic ED and demonstrate the feasibility of ED-based testing.

Methods: We prospectively enrolled patients with a chief complaint of pain or discomfort in the upper abdomen for 1 year from February …

Patient-Driven Resource Planning Of A Health Care Facility Evacuation, Bruno P. Petinaux, Kabir Yadav

Emergency Medicine Faculty Publications

Introduction: The evacuation of a health care facility is a complex undertaking, especially if done in an immediate fashion, ie, within minutes. Patient factors, such as continuous medical care needs, mobility, and comprehension, will affect the efficiency of the evacuation and translate into evacuation resource needs. Prior evacuation resource estimates are 30 years old.

Methods: Utilizing a cross-sectional survey of charge nurses of the clinical units in an urban, academic, adult trauma health care facility (HCF), the evacuation needs of hospitalized patients were assessed periodically over a two-year period.

Results: Survey data were collected on 2,050 patients. Units with patients …

Pathogen-Specific Risk Of Chronic Gastrointestinal Disorders Following Bacterial Causes Of Foodborne Illness, Chad K. Porter, Daniel Choi, Brooks Cash, Mark Pimentel, Joseph Murray, Larissa May, Mark S. Riddle

Emergency Medicine Faculty Publications

Background

The US CDC estimates over 2 million foodborne illnesses are annually caused by 4 major enteropathogens: non-typhoid Salmonella spp., Campylobacter spp., Shigella spp. and Yersinia enterocoltica. While data suggest a number of costly and morbid chronic sequelae associated with these infections, pathogen-specific risk estimates are lacking. We utilized a US Department of Defense medical encounter database to evaluate the risk of several gastrointestinal disorders following select foodborne infections.

Methods

We identified subjects with acute gastroenteritis between 1998 to 2009 attributed to Salmonella(nontyphoidal) spp., Shigella spp., Campylobacter spp. or Yersinia enterocolitica and matched each with up to 4 …

Broadening Access To Medical Care During A Severe Influenza Pandemic: The Cdc Nurse Triage Line Project., Lisa M. Koonin, Dan Hanfling

Emergency Medicine Faculty Publications

The impact of a severe influenza pandemic could be overwhelming to hospital emergency departments, clinics, and medical offices if large numbers of ill people were to simultaneously seek care. While current planning guidance to reduce surge on hospitals and other medical facilities during a pandemic largely focuses on improving the “supply” of medical care services, attention on reducing “demand” for such services is needed by better matching patient needs with alternative types and sites of care. Based on lessons learned during the 2009 H1N1 pandemic, the Centers for Disease Control and Prevention and its partners are currently exploring the acceptability …

Asynchronous Web-Based Learning, A Practical Method To Enhance Teaching In Emergency Medicine, Ali Pourmand, Raymond Lucas, Mehdi Nouraie

Emergency Medicine Faculty Publications

Objective: To compare medical knowledge acquisition among emergency medicine (EM) residents who attend weekly core content lectures with those absent but asynchronously viewing the same lectures in a Web-based electronic platform.

Subjects and Methods: During the study period all EM residents attending or absent from weekly educational conferences were given a quiz on the covered material. During Phase 1, absentees were not given supplemental educational content for missed lectures. During Phase 2, absentees were sent a link to an online multimedia module containing an audiovisual recording of the actual missed lecture with presentation slides. Scores between attendees and absentees during …

Bedside Teaching On Time To Disposition Improves Length Of Stay For Critically-Ill Emergency Departments Patients, Ali Pourmand, Raymond Lucas, Jesse M. Pines, Hamid Shokoohi, Kabir Yadav

Emergency Medicine Faculty Publications

Introduction: We tested the effect of a brief disposition process intervention on residents’ time to disposition and emergency department (ED) length of stay (LOS) in high acuity ED patients.

Methods: This was a quasi-experimental study design in a single teaching hospital where ED residents are responsible for administrative bed requests for patients. Enrollment was performed for intervention and control groups on an even-odd day schedule. Inclusion criteria were ED patients triaged as Emergency Severity Index (ESI) 1 and 2. In the intervention group, the attending physician prompted the resident to make the disposition immediately after the evaluation of resuscitation patients. …

Reducing Ambulance Diversion At Hospital And Regional Levels: Systematic Review Of Insights From Simulation Models, M. Kit Delgado, Lesley J. Meng, Mary P. Mercer, Jesse M. Pines, Douglas K. Owens, Gregory S. Zaric

Emergency Medicine Faculty Publications

Introduction: Optimal solutions for reducing diversion without worsening emergency department (ED) crowding are unclear. We performed a systematic review of published simulation studies to identify: 1) the tradeoff between ambulance diversion and ED wait times; 2) the predicted impact of patient flow interventions on reducing diversion; and 3) the optimal regional strategy for reducing diversion.

Methods: Data Sources: Systematic review of articles using MEDLINE, Inspec, Scopus. Additional studies identified through bibliography review, Google Scholar, and scientific conference proceedings. Study Selection: Only simulations modeling ambulance diversion as a result of ED crowding or inpatient capacity problems were included. Data extraction: Independent …

The Treatment Of Cutaneous Abscesses: Comparison Of Emergency Medicine Providers' Practice Patterns, Gillian Schmitz, Tress Goodwin, Adam Singer, Chad S. Kessler, David Bruner, Hollyn Larabee, Larissa S. May, Samuel D. Luber, Justin Williams, Rahul Bhat

Emergency Medicine Faculty Publications

INTRODUCTION:

Cutaneous abscesses are commonly treated in the emergency department (ED). Although incision and drainage (I&D) remains the standard treatment, there is little high-quality evidence to support additional interventions such as pain control, type of incision, and use of irrigation, wound cultures, and packing. Although guidelines exist to support clinician management of abscesses, they do not clearly specify these additional interventions. This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting.

METHODS:

Four hundred and seventy-four …

Perceptions Of Emergency Department Crowding In The Commonwealth Of Pennsylvania, Jesse M. Pines, Joshua A. Isserman, John J. Kelly

Emergency Medicine Faculty Publications

Introduction: The state of emergency department (ED) crowding in Pennsylvania has not previously been reported.

Methods: We assessed perceptions of ED crowding by surveying medical directors/chairs from Pennsylvania EDs in the spring of 2008.

Results: A total of 106 completed the questionnaire (68% response rate). A total of 83% (86/104) agreed that ED crowding was a problem; 26% (27/105) reported that at least half of admitted patients boarded for more than 4 hours. Ninety-eight percent (102/104) agreed that patient satisfaction suffers during crowding and 79% (84/106) stated that quality suffers. Sixty-five percent (68/105) reported that crowding had worsened during the …

False Passage To The Trachea After Emergency Intubation In A Victim Of Near Hanging, Ali Pourmand, Hamid A. Shokoohi

Emergency Medicine Faculty Publications

Emergency medicine physicians should have enough knowledge and experience to deal with emergent and traumatic difficult airway. In this paper, we present a case of near hanging with neck soft tissue injury, tracheal and esophageal rupture that is complicated by a displaced intubation and false passage to the trachea.