The American journal of emergency medicine
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The Centers for Medicare and Medicaid Services introduced the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) as a national quality measure in October 2015. The purpose of SEP-1 is to facilitate the efficient, effective, and timely delivery of high-quality care to patients presenting along the spectrum of sepsis severity. ⋯ Overall, there were no clinically or statistically meaningful changes in fluid volume resuscitation strategies for suspected septic shock patients following SEP-1. Broad mandates may not be effective tools for promoting practice change in the ED setting. Further research investigating barrier to changes in practice patterns surrounding fluid administration and other SEP-1 bundle elements is warranted.
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Despite projections of an oversupply of residency-trained emergency medicine physicians by 2030 and amidst intensifying national debate over Nurse Practitioner (NP) qualifications to practice independently and unsupervised, NPs are increasingly staffing Emergency Departments (EDs) as hospitals seek to contain costs while simultaneously expanding services. We sought to characterize NP practice in the ED by examining NP independent billing by level of severity of illness, and relationship to practice authority, State Medicaid expansion status, and rurality. ⋯ As a proportion of the providers independently billing in the ED, NPs are increasingly managing higher acuity patients as evidenced by billing percentage of the highest acuity CPT codes (99284 and 99285). During the same time period, ED MDs decreased their billing in the same categories. Current employment of NPs in the ED may not be fulfilling its original vision to care for the lower acuity patients in order to allow MDs to care for the more acutely and critically ill patients, and to increase the services for underserved populations in rural areas, those over age 65, and those with limited English language proficiency. Future research should investigate ED policies resulting in NPs as opposed to MDs seeing patients with greater severity codes.
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This case demonstrates a complex patient presenting with diagnosis of pulmonary embolism. He received heparin therapy, then subsequently found to have an intracranial hemorrhage, which rapidly progressed, leading to patient demise. Through this case, the reader should better understand the therapeutic conundrums in critical PE patients and complications of anticoagulation.
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Paroxysmal Supraventricular Tachycardia (SVT) is an arrhythmia with sudden onset and termination, characterized by a fast heart rate and a narrow QRS complex. There are several remedies that have been described to convert the SVT, such as the Valsalva maneuver, holding the breath for a few seconds, or putting cold water on the face. ⋯ This device is named "Forced Inspiratory Suction and Swallow Tool" (FISST) and is branded as "HiccAway," which is primarily designed to stop hiccups and is available as an over-the-counter tool. It works by drinking water forcibly through a pressure valve, and it follows "Bernoulli's Principle": applications of the law of conservation energy.
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We evaluated the sensitivity, specificity, predictive values, and likelihood ratios of hip effusion and/or iliopsoas hematoma on point-of-care ultrasound (POCUS) performed by ultrasound fellows and fellowship trained emergency providers to identify hip fractures in emergency department (ED) patients with a high suspicion of hip fracture. ⋯ In a convenience sample of ED patients with high clinical suspicion for hip fracture, the presence of a hip effusion and/or iliopsoas hematoma on POCUS performed by expert emergency ultrasonographers showed high sensitivity in diagnosing patients with a hip fracture.