Hypercoagulability in COVID-19: A rare case of DIC in SARS-CoV2 in the Emergency Department

Although SARS-CoV2 is increasingly being considered a systemic disease, there have been very few case reports documenting DIC as a rare but fatal consequence of the SARS-CoV2 syndrome. We present our patient scenario as an example of severe COVID sepsis in the ED and DIC. 67-year old nursing home resident with CAD, DM, HTN, and seizures presents to our ED resus room with altered mental status and hypoxia after a reported fall from bed. He was tachycardic to 110 and required a nonrebreather at 15L saturating at 96%. His physical exam revealed GCS 10, no focal neurologic deficits, dry mucous membranes, clear lung sounds, and soft abdomen. He was swabbed for COVID-19, and his 1-view CXR revealed multifocal hazy opacities. ECG showed new T-wave inversions in V2-V3 with prolonged QTc 512. He was empirically treated with vancomycin, ceftriaxone, and flagyl for MRSA/aspiration pneumonia. Prominent labs were as follows: Cr. 1.51 (baseline 0.4), CRP 14.0, ESR 20, WBC 13.9, hemoglobin 13.2, platelets 52, LDH 2005, Tbili 3.0, INR 2.68, PT 27.8, PTT 44, and hs-troponin 1649. Bedside ECHO demonstrated normal LV function but with slightly enlarged RV and mild septal bowing, no pericardial effusion. Although there was concern for pulmonary embolism, he had a severe contrast allergy and therefore could not undergo CTPE. CT head showed 2 small subacute R parietal and cerebellar infarcts, but his encephalopathy was deemed out of proportion to the stroke findings by the neurology team. He was not on any anticoagulants, and his encephalopathy, AKI, thrombocytopenia, and elevated hemolytic labs were concerning for TTP vs. DIC. His DIC panel later revealed D-dimer \u3e20.0 and fibrinogen \u3c60. His COVID-19 PCR swab also resulted as positive. Hematology determined that his elevated coagulation parameters and clear COVID sepsis precipitant were more indicative of DIC. He was given 2U cryoprecipitate and admitted to MICU.DIC is rarely seen in the ED and can be difficult to diagnose, but early detection is paramount to tailoring treatment strategies and as a valuable prognostic indicator at the time of admission. Our patient had presented with multi-organ dysfunction, and this included a pathologic hemostatic system in the form of DIC. Hypercoagulability has been associated with COVID-19, but the progression to DIC in critically ill COVID patients warrants further in-depth research and clinical attention.https://scholarlycommons.henryford.com/merf2020caserpt/1137/thumbnail.jp

Pilot study of a randomized trial to evaluate a Web-based intervention targeting adolescents presenting to the emergency department with acute asthma

Abstract Background Low-income African-American adolescents use preventive medical services less frequently than their White counterparts, indicating a need for effective interventions targeting this group. Puff City is a Web-based, asthma management program for urban adolescents that has been evaluated in high school settings with promising results. The objective of this pilot was to assess the feasibility of initiating Puff City (treatment) in an emergency department setting, thereby informing the conduct of an individual randomized trial to evaluate its effectiveness compared to a generic, Web-based program (control) in preventing subsequent emergency department (ED) visits. Methods Teens aged 13–19 years presenting with acute asthma to two urban EDs within the study period were eligible. Subsequent ED visits were collected using the electronic medical record. A priori indication of a potential intervention effect was p < 0.20. Results Of the 121 teens randomized (65 treatment, 56 control), 86.0% were African-American and 44.6% male, with the mean age = 15.4 years. Computer ownership was reported by 76.8% of teens. Overall, 64.5% of teens completed >3 of 4 sessions and 90% completed the 12-month survey. At 12 months, the treatment group showed a trend toward fewer ED visits than controls (33.8 versus 46.4%), p = 0.15. Conclusions Results indicate the feasibility of enrolling at-risk adolescents in ED settings and set the stage for a large, pragmatic trial using a technology-based intervention to reduce the burden of pediatric asthma. Trial registration ClinicalTrials.gov, NCT01695031https://deepblue.lib.umich.edu/bitstream/2027.42/137647/1/40814_2017_Article_147.pd

Ten Years of Frequent Users in an Inner City Emergency Department

Introduction:The purpose of this study was to determine if differences could be detected in the presentation patterns and admission rates among frequent emergency department users (FEDU) of an urban emergency department over a 10-year period.Methods: This was an IRB approved, retrospective review of all patients who presented to the ED 5 or more times for 3 distinct time periods: “year 0” 11/98-10/99, “year 5” 11/03–10/04, and “year 10” 11/08–10/9. FEDU were grouped into those with 5–9, 10–14, 15–19, and ≥ 20 visits per year. Variables analyzed included number of visits, disposition, and insurance status. We performed comparisons using Kolmogorov-Smirnov and chi-square tests. A P &lt; 0.05 was considered significant.Results: We found a a 66% increase in FEDU patients over the decade studied, with a significant increase in both the number of FEDU in each visit frequency category over the 3 time periods (P &lt; 0.0001), as well as the total number of visits by each group of FEDU (P &lt; 0.0001). The proportion of FEDU visits for the 5–9 group resulting in admission increased from 25.9% to 29% from year 0 to year 10 (P &lt; 0.001), but not for the other visit groups. In comparing admission rates between FEDU groups, the admission rate for the 5–9 group was significantly higher than the ≥ 20 group for the year 5 time period (P &lt; 0.001) and the year 10 time period (P &lt; 0.001) and showed a similar trend, but not significant, at year 0 (P = 0.052). The overall hospital admission rate for emergency patients over the same time span remained stable at 22-24%. The overall proportion of uninsured FEDU was stable over the decade studied, while the uninsured rate for the overall ED population for the same time periods increased.Conclusion: The results demonstrate the FEDU population is not a homogeneous group of patients. Increased attention to differences among FEDU groups is necessary in order to plan more effective interventions. [West J Emerg Med. 2013;14(3):243–246.

Use of Health Information Technology to Manage Frequently Presenting Emergency Department Patients

Objective: To determine if the effective use of Health Information Technologies (HIT) and the Electronic Medical Record (EMR) affects emergency department (ED) usage in a complicated frequently presenting patient population.Methods: A retrospective, observational study of 45 patients enrolled in our Frequent User Program called Community Resources for Emergency Department Overuse (CREDO) between June 2005 and July 2007. The study was conducted at an urban hospital with greater than 95,000 annual visits. Patients served as their own historical controls. In this pre-post study, the pre-intervention control period was determined by the number of months the patient had been enrolled in the program. The pre- and post-intervention time periods were the same for each patient but varied between patients. The intervention included using HIT to identify the most frequently presenting patients and creating individualized care plans for those patients. The care plans were made available through the EMR to all healthcare providers. Study variables in this study intervention included ED charges, lab studies ordered, number of ED visits, length of stay (LOS), and Total Emergency Department Contact Time (TEDCT), which is the product of the number of visits and the LOS. We analyzed these variables using paired T-tests. This study was approved by the institutional review board.Results: Forty-five patients were enrolled, but nine were excluded for no post enrollment visits; thus, statistical analysis was conducted with n=36. The ED charges decreased by 24% from $64,721 to$49,208 (p=0.049). The number of lab studies ordered decreased by 28% from 1847 to 1328 (p=0.04). The average number of ED visits/patient decreased by 25% from 67.4 to 50.5 (p=0.046). The TEDCT decreased by 39% from 443.7 hours to 270.6 hours (p=0.003).Conclusion: In this pre-post analysis of an intervention targeting ED frequent users, the use of HIT and the EMR to identify patients and store easily accessible care plans significantly reduced ED charges, labs ordered, number of ED visits, and the TEDCT. [West J Emerg Med 2010; 11(4):348-353.

Use of Health Information Technology to Manage Frequently Presenting Emergency Department Patients

Objective: To determine if the effective use of Health Information Technologies (HIT) and the Electronic Medical Record (EMR) affects emergency department (ED) usage in a complicated frequently presenting patient population.Methods: A retrospective, observational study of 45 patients enrolled in our Frequent User Program called Community Resources for Emergency Department Overuse (CREDO) between June 2005 and July 2007. The study was conducted at an urban hospital with greater than 95,000 annual visits. Patients served as their own historical controls. In this pre-post study, the pre-intervention control period was determined by the number of months the patient had been enrolled in the program. The pre- and post-intervention time periods were the same for each patient but varied between patients. The intervention included using HIT to identify the most frequently presenting patients and creating individualized care plans for those patients. The care plans were made available through the EMR to all healthcare providers. Study variables in this study intervention included ED charges, lab studies ordered, number of ED visits, length of stay (LOS), and Total Emergency Department Contact Time (TEDCT), which is the product of the number of visits and the LOS. We analyzed these variables using paired T-tests. This study was approved by the institutional review board.Results: Forty-five patients were enrolled, but nine were excluded for no post enrollment visits; thus, statistical analysis was conducted with n=36. The ED charges decreased by 24% from $64,721 to$49,208 (p=0.049). The number of lab studies ordered decreased by 28% from 1847 to 1328 (p=0.04). The average number of ED visits/patient decreased by 25% from 67.4 to 50.5 (p=0.046). The TEDCT decreased by 39% from 443.7 hours to 270.6 hours (p=0.003).Conclusion: In this pre-post analysis of an intervention targeting ED frequent users, the use of HIT and the EMR to identify patients and store easily accessible care plans significantly reduced ED charges, labs ordered, number of ED visits, and the TEDCT. [West J Emerg Med 2010; 11(4):348-353.

A Novel Curriculum for Ophthalmology Training of Emergency Medicine Residents (COPTER)

Background: Emergency Medicine (EM) physicians must effectively manage ophthalmologic emergencies, yet many EM residencies teach Ophthalmology via the traditional off-service rotation model. Training during medical school is limited and variable. Objectives: Replacing an apprenticeship model of ophthalmology training with an innovative longitudinal curriculum may improve EM residents\u27 competency in treating eye complaints. Methods: The Curriculum for Ophthalmology Training of Emergency Medicine Residents (COPTER) is designed to cover all the Ophthalmology content in the Model of EM over 18 months. It consists of three, 4-hour sessions employing didactics and hands-on training in diagnosis, equipment use, and procedures. A knowledge test was administered to 16 PGY1 EM residents before and immediately after participation in COPTER session 1; the test was re-administered 8 months later (before session 2) to assess knowledge retention. These residents also completed a survey at the end of PGY1 to assess self-perceived competency in the diagnosis and management of select ophthalmologic complaints. The same survey was administered to 16 upper-class residents who had completed a 2-week ophthalmology rotation during their PGY1 year ( Pre-COPTER ) and was re-administered after they completed one session of COPTER ( Mixed Curriculum. ) Paired t-test and Wilcoxon Rank Sum test were used to analyze the data. Results: Residents displayed improved knowledge immediately after a COPTER Session (p=0.0012 compared to pretest), and this improvement was sustained 8 months later (p=0.0261). There was a statistically signifcant increase in self-perceived competency in evaluating medical eye complaints (p=0.0493) and in acute glaucoma management (p=0.0221) between the Pre-COPTER and the Mixed Curriculum. Conclusions: An innovative, multi-modal ophthalmology curriculum improved EM resident knowledge of the diagnosis and management of ophthalmologic emergencies. When compared to an apprenticeship/rotation model, this curriculum also enhanced self-reported competency in managing medical eye complaints. COPTER may improve the care of patients with ophthalmologic emergencies. [Table Presented]

Initiating an online asthma management program in urban emergency departments: the recruitment experience.

BACKGROUND: The emergency department could represent a means of identifying patients with asthma who could benefit from asthma interventions. OBJECTIVE: To assess the initiation of a Web-based tailored asthma intervention in the emergency department of 2 urban tertiary care hospitals. METHODS: In addition to awareness strategies for emergency department staff (eg, attending nursing huddles, division meetings, etc), recruitment experiences are described for 2 strategies: (1) recruitment during an emergency department visit for acute asthma and (2) recruitment from patient listings (mail or telephone). Patient enrollment was defined as baseline completion, randomization, and completion of the first of 4 online sessions. RESULTS: Of 499 eligible patients 13 to 19 years old visiting the emergency department for asthma during the study period, 313 (63%) were contacted in the emergency department (n = 65) or by mail or telephone (n = 350). Of these, 121 (38.6%) were randomized. Mean age of the study sample was 15.4 years and 88.4% were African American. Refusal rates for emergency department recruitment and mail or telephone were 18.5% (12 of 65) and 16.6% (58 of 350), respectively. On average, emergency department enrollment took 44 to 67 minutes, including downtime. When surveyed, emergency department providers were more positive about awareness activities and emergency department recruitment than were research staff. CONCLUSION: Emergency department recruitment was feasible but labor intensive. Refusal rates were similar for the 2 strategies. Targeting patients with acute asthma in the emergency department is one way of connecting with youth at risk of future acute events

83 Utilization of Ultrasound in Resuscitation Rooms in an Urban Level 1 Trauma Center

Study Objectives: The resuscitation rooms of emergency departments (EDs) are resource rich rooms that are fast paced and costly to maintain and operate. Often times, point-of-care ultrasound (POCUS) is used in ED resuscitation rooms as one of the resources for immediate diagnosis, to assist medical decision making, and aid the course of treatment. Unfortunately, failure of POCUS documentation along with the lack of patient charges may result in the possible loss of hospital revenue. The primary objective of the study is to assess the effects of educating residents on the importance of documenting POCUS procedures in resuscitation rooms into the patient chart and saving the image(s) to the US machine. Secondary objectives include assessing the types of patients utilizing the POCUS in resuscitation rooms, evaluating the documentation of procedures of POCUS, and to identify potential improvement in billing and revenue capture. Methods: This is an observational cohort study. 467 patients were included prior to resident education on US documentation and 498 patients were included post education. Documentation of ultrasound use and whether images were saved to QPATHE were summarized by counts, percentages, and 95% confidence intervals. Chi-square tests were used for the comparison between pre- and post-resident education and the t-test was used for the continuous variable. Significance was inferred at

Spergularia rubra (L.) J. & C.Presl. (BR0000010099483)

Belgium Herbarium image of Meise Botanic Garden