Factors Influencing Physician Treatment Strategies in Crotaline Snake Envenomation

BACKGROUND: Crotaline snake envenomation is a potentially serious medical condition that affects thousands of Americans each year. There continues to be variation in treatment practices by physicians in the United States despite guidelines establishing the use of antivenom and supportive care as the mainstays for treating crotaline snake envenomation. METHODS: This study sought to determine associations between physician treatment strategies, snake identification (ID), venom effects, bite location and patient presentation. A cross-sectional review of electronic medical records (EMR) for patients diagnosed with venomous snake bites from July 1, 2014 to August 31, 2019 was completed. Data collected from the EMR included: patient demographics, transfer information, length of hospital and ICU stays, snake ID, bite site, progression of local tissue effects, additional clinical and lab results, patient comorbidities and complications, and provider treatment strategy. RESULTS: Of the 83 patients who met inclusion criteria, 68 patients (81.9%) received antivenom. None of the 15 patients who were under observation (no antivenom) for treatment went to the ICU. These patients experienced the shortest hospital stays (H(2)=16.76, p<0.001). Hospital stays were longest for patients envenomated by an identified rattlesnake or cottonmouth compared to patients envenomated by an unknown snake or copperhead (H(2)=14.32, p<0.05). Rattlesnake envenomations used more vials of antivenom than copperhead envenomations (H(2)=8.76, p=0.01). In a regression model of treatment strategy, progression of local tissue effects was the only statistically significant predictor of receiving antivenom while other independent variables including snake ID, patient age, hemotoxicity, systemic symptoms, site of the snakebite, and patient comorbidities were not significant predictors. Lastly, there was a statistically significant association between treatment strategy and opioid prescription, with 77.9% of patients who received antivenom also receiving an opioid for pain management vs. 33.3% of patients under observation (no antivenom) who received opioids (Fisher Exact Probability Test, p=0.001). CONCLUSION: Envenomated patients are likely to be treated with antivenom if there was progression of local tissue effects. For patients in this study who were bitten by copperheads and unknown snakes, close observation without antivenom administration had favorable outcomes including shorter hospital stays and likely decreased hospital costs.N

Improving Primary Care Follow-Up After Pediatric Hospitalization

BACKGROUND: Transitioning patient care to primary care physicians after pediatric hospitalization plays a critical role in children’s health. Follow-up appointments are an ideal time to provide education, address concerns, and arrange for continuity of care. This quality improvement (QI) study aimed to improve the percentages of primary care clinic follow-up within 7 days of hospital discharge. METHODS: Using the Plan-Do-Study-Act (PDSA) Model for Improvement, a multidisciplinary team examined pre-implementation data for patients discharged from the children’s hospital in February 2018. Electronic medical record (EMR) review was performed to determine if follow-up appointments were scheduled and attended within 7 days of discharge. Four week PDSA cycles were then completed by the medical residents, pediatric hospitalists and a care transition coordinator. Cycle 1 (n=25) involved developing an EMR-based shared patient list to identify all patients needing follow-up. In Cycle 2 (n=69), monthly standardized resident education was implemented to optimize use of the shared patient list. In Cycle 3 (n=81), a discharge appointment template was used to schedule appointments for patients discharged on weekends. RESULTS: Percent of appointments scheduled increased throughout the PDSA cycles from baseline (baseline - 60%; cycle 1 - 72%; cycle 2 - 74%; cycle 3 - 85%), as well as percent of appointments attended (baseline - 56%; cycle 1 - 56%; cycle 2 - 61%; cycle 3 - 70%) with p<0.001. Clinic follow-up was lower for patients with chronic illnesses but did improve from cycle 1 (42%) to cycle 3 (67%). The percentage of appointments scheduled for weekend discharges was not significantly different from weekday discharges, and increased from baseline over the course of the PDSA cycles. CONCLUSION: The number of follow-up appointments both scheduled and attended increased throughout the study, suggesting that the QI measures implemented were effective. Further interventions will focus on patient and system barriers to appointment attendance.N

Impact of Electronic Health Record Systems on Prescribing Errors in Pediatric Clinics

Medication errors are commonly reported in the pediatric population. While evidence supports the use of e-prescribing to prevent certain errors, prescribing with an electronic health record (EHR) system is not devoid of errors. Furthermore, the majority of EHRs are not equipped with functionalities addressing pediatric needs. This study analyzes three unique EHRs in three pediatric clinics. It describes the functionality of each system and identifies errors found in e-prescribed prescriptions. Finally, the study estimates the proportion of e-prescribing errors that could have been avoided if those EHRs had met requirements set by the American Academy of Pediatrics (AAP). The number of prescriptions reviewed for Clinics 1, 2, and 3, respectively, were: 477, 408, and 633 with total error rates of 13.2%, 8.8%, and 6.6%. The clinic EHRs included 21%, 26%, and 47% of the AAP pediatric requirements for safe and effective e-prescribing for children. If all AAP elements had been included in the EHRs, over 83% of errors in the examined e-prescriptions could have been prevented. This study demonstrates that EHR systems used by many pediatric clinic practices do not meet the standard set forth by the AAP. To ensure our most vulnerable population is better protected, it is imperative that medical technology tools adequately consider pediatric needs during development and that this is reflected in selected EHR systems

Acute Renal Failure Secondary to Inadvertent Propylene Glycol Overdose with Single-Day High-Dose Vitamin D (Stosstherapy)

Globally, there has been increasing attention paid to vitamin D deficiency and its treatment. Vitamin D stosstherapy with high-dose ergocalciferol in a single day is reemerging as a potential treatment option. We present an as yet unreported complication of acute renal injury due to propylene glycol toxicity in a 7-month infant treated with vitamin D stosstherapy. The product label for the vitamin D used for this patient states it is dissolved in propylene glycol (PG), but the amount is not listed on this or other US ergocalciferol liquid products that contain PG. Caution should be used when considering vitamin D stosstherapy with liquid ergocalciferol products available in the United States