Background: Rising cannabis use poses significant challenges in the administration of general anesthetics, particularly propofol, due to potential alterations in pharmacodynamics caused by tetrahydrocannabinol and its interactions with central nervous system receptors. This systematic review and meta-analysis aims to consolidate the existing literature to quantify propofol requirements in cannabis users, highlighting the complex relationship between cannabis use and anesthetic management. Methods: A systematic search of English-language literature was conducted to identify studies with data on propofol dosing in adult cannabis users. Propofol requirements were defined as the total intraoperative dose needed to achieve and maintain adequate sedation or anesthesia, assessed using parameters like monitoring and procedural tolerance. A random-effects model was used with DerSimonian–Laird estimations for pooled effect sizes and 95% confidence intervals. Heterogeneity was assessed using I2 and Cochran’s Q statistics, and sensitivity analysis was conducted by grouping publications by design, size, and quality. Results: Eight qualified studies were identified with 2268 patients included. Patients who used cannabis were typically younger and more likely to smoke tobacco than non-users. Propofol requirements were significantly higher in cannabis users, who required an average additional dose of 47.33 mg compared to non-users. Subgroup analyses revealed that cannabis users undergoing general anesthesia needed an additional 30.57 mg intraoperatively, while those undergoing sedation for endoscopic procedures required an additional 53.02 mg. Conclusions: These results underscore the need for personalized anesthetic plans to accommodate physiological variations in cannabis users. However, the lack of standardized definitions for propofol requirements and the heterogeneity across studies necessitate caution in interpretation. The observed increase in propofol requirements suggests altered central nervous system sensitivities and receptor changes in cannabis users, emphasizing the need for further research to establish clear definitions, elucidate underlying mechanisms, and refine clinical guidelines for anesthetic management in this population.

High-voltage electrical injuries, especially from lightning strikes, can cause life-threatening complications due to extreme temperature and voltage exposure. While burns and cardiac complications have been widely described, the documentation of metabolic imbalances, particularly hypokalemia, has not been as prevalent. This report focuses on a patient with profound transient hypokalemia following a lightning strike, alongside a review of three similar cases of transient hypokalemia from the literature. Our patient, a previously healthy young man, was struck by lightning and subsequently suffered transient hypokalemia with lower extremity sensory changes, which resolved after the normalization of serum potassium levels. While the exact underlying mechanisms of transient hypokalemia following high-voltage electrical injuries are unknown, we propose a multifactorial mechanism, which includes massive intracellular shifts of potassium due to elevated epinephrine levels and the prevention of potassium efflux through the electrical disruption of voltage-gated potassium channels. Our report underscores the importance of recognizing hypokalemia in patients with high-voltage electrical injuries and contributes to the understanding of the complex mechanisms involved. Further research is necessary to understand the connection between cellular changes induced by high-voltage exposure and their effects on metabolism, particularly in relation to hypokalemia.

Mechanical ventilation is the most common technological support provided to ICU patients, and unplanned extubation is a well-known, associated life-threatening event. Unplanned extubation is generally expressed as the number of unplanned extubations per patient on ventilation or as the number of unplanned extubations per 100 d of mechanical ventilation. The prevalence of unplanned extubations varies widely in the literature. A 2012 systematic review reported rates that ranged from 0.5 to 35.8 (median, 7.3) or from 0.1 to 4.2 unplanned extubations per 100 ventilator days (median, 0.9).1 A 2022 systematic review reported a similar pooled prevalence of 6.7% and incidence density of 1.06 events per 100 ventilator days. In this issue of Respiratory Care, Harbrecht et al2 describe a decade of analysis of unplanned extubation etiology in trauma patients, including the impact of the COVID pandemic. In 2012, the institution identified a "high rate" of unplanned extubation in trauma patients (8.0%; 1.20 per 100 ventilator days).2 In 2013, in response, the authors began to track these events, the reasons for the unplanned extubation, and initiated interventions to mitigate unplanned extubation. They implemented a multidisciplinary multifaceted education and direct feedback program. They continued to track the incidence of unplanned extubation and causes, and incorporated data review into their educational programs and presentations to physician, nurse, and respiratory therapist leadership. In examining the etiology of unplanned extubation, the authors categorized unplanned extubation related to patient factors, mechanical factors, or provider factors. As with previous studies, most cases of unplanned extubation were associated with self-extubation (a patient factor). Patient factor–related unplanned extubations were associated with the lowest rates of re-intubation and more favorable outcomes than other factors. Overall, their program was successful, which demonstrated a reduction of unplanned extubation from their … Correspondence: William E Baker MD, Department of Emergency Medicine, University of Vermont Larner College of Medicine, 111 Colchester Avenue, WP1-106, Burlington, Vermont 05401. E-mail: William.E.Baker{at}uvm.edu

Trade-offs Caused by Batching Inpatient Admissions from Emergency Departments In “To Batch or Not to Batch? Impact of Admission Batching on Emergency Department Boarding Time and Physician Productivity,” Feizi and coauthors tackle the important problem of identifying causes of emergency department (ED) boarding with the goal of identifying a managerial lever to reduce it. They investigate the impact of batching admissions of ED patients. The authors empirically show that batching occurs frequently at the end of shifts when physicians wrap up their tasks. Interestingly, Feizi et al. find a trade-off. Batching improves individual physician productivity, which explains its prevalence. However, it increases boarding times, an outcome that negatively impacts patients and the hospital. A counterfactual analysis comparing empirical results to theoretical queuing models finds that eliminating batching reduces boarding times by 15%. The paper highlights that boarding can be reduced by physicians completing admissions work as it occurs rather than delaying to the end of shift.

Mitigating the rise and spread of contaminants is a major challenge faced during any contagious disease outbreak. In densely occupied areas, such as a breakroom, the risk of cross-contamination between healthy and infected individuals is significantly higher, thereby increasing the risk of further spread of infectious diseases. In this study, a high fidelity transient fluid solver and Lagrangian particle-based method were used to predict the airflow distribution and contaminant transmission inside a detailed 3D virtual twin of an emergency hospital breakroom. The solver efficiently captured the contaminants emitted simultaneously from multiple talking occupants as well as their propagation inside the breakroom. The influence of airflow distribution on the aerosol spread inside the breakroom for two different air conditioning vent positions was demonstrated with all occupants and with reduced occupants. The baseline simulation with all occupants in the breakroom showed a higher risk of contamination overall as well as between adjacent occupants. It was observed that there was a 26% reduction in the contaminants received by the occupants with the proposed modified vent arrangement and a 70% reduction with the scenarios considering a reduced number of occupants. Furthermore, the fomite deposition and cross-contamination between adjacent humans significantly changed with different ventilation layouts. Based on the simulation results, areas with higher contaminant concentrations were identified, providing information for the positioning of UV lights in the breakroom to efficiently eliminate/reduce the contaminants.

In areas with limited access to critical care services, the intensivist's reach can be expanded by removing the silo of the ICU and providing care wherever the patient is located. The University of Vermont Health Network includes a tertiary care center, two community hospitals, and three critical access hospitals, and often experiences limited ICU bed availability. The community hospitals have ICU services; however, only the tertiary site has consistent staffing for many subspeciality services. For example, the University of Vermont Medical Center is the only Vermont hospital to offer inpatient dialysis services or continuous electroencephalogram. The tertiary center ICU beds can be occupied by patients with brief ICU needs, but who remain in the ICU due to constraints in system throughput. The critical care transition (CCT) service was created in October 2022 to provide critical care consults for patients outside of the ICU. CCT serves the tertiary care ED and hospital wards, and provides peer-to-peer support for emergency physicians at the rural network EDs via telehealth. Dual-boarded emergency medicine/critical care medicine (EM/CCM) physicians provide the consults and offer procedural assistance within the tertiary care site. By increasing this access to critical care consults - independent of patient location - the long-term goals are to reduce short (<24-hour) ICU admissions, reduce the rates of transfer declines to the ICU due to capacity, decrease the time to evaluation by the intensivist for critically ill patients, and improve patient-centered measures of quality, such as inter-facility transfers and mortality. Short-term measures of success included demonstration of value and sustainability through either cost avoidance or revenue generation, favorable staff satisfaction evaluated via surveys, and successful deployment of telehealth to support rural network providers. The authors present the pilot phase of this care delivery model in a rural setting. Work is ongoing to expand and improve the ways in which critical care can be effectively delivered where and when needed. The initial 9 months of coverage, through August 2023, suggest improved access to ICU care, mitigation of avoidable high-cost services, and positive feedback from staff in the management of complex patients. The service, which started with just two EM/CCM physicians (limited, sporadic shifts, 60% full-time equivalent [FTE]) was approved in April 2023 for full-time staffing of one shift per day (2.3 FTEs) with a goal to continue data collection for evaluation of long-term objectives, continued rapid cycle improvement testing to increase patient volumes, and expanded use of telehealth opportunities throughout the network. This model of a peri-ICU consult service, focused on critical care anywhere, utilized the same physicians to concurrently support patients and providers outside of an ICU in multiple health care settings. The health system has demonstrated the feasibility of implementing a creative solution to complex health care delivery challenges.

Triage is the first step of emergency care, where patients are classified based on their urgency and their anticipated resource usage. Although triage nurses follow a standard classification algorithm, worker judgement plays a significant part in how urgent patients are perceived. In this paper, our goal is twofold: First, we evaluate whether downstream congestion affects prioritization. Specifically, we test whether workload in the treatment area of the emergency department (ED) affects under-triage, defined as perceiving a patient as being less urgent than they truly are. Second, we test the impact of under-triage on patient flow and quality of care. To determine a patient’s true urgency level, and subsequently, define under-triage, we develop a deep-learning model that is trained using information collected during triage. We find that under-triage has a U-shaped relationship with ED workload; it decreases up to the 84th percentile of workload, but increases thereafter. We also find that a one standard deviation increase in under-triage increases patients’ disposition time, room-to-departure times and risk of 30-day readmission by 11.2%, 13.4% and 27%, respectively. From an academic perspective, our work contributes to the healthcare and behavioral operations literature by demonstrating how workload affects customer classification, and quantifying the effects of under-triage. From a practical perspective, our predictive model achieves state-of-the-art performance, and can be employed in hospitals and EDs to assist in patient triage. Also, our results assist managers in making staffing decisions to balance the costs of under-triage.

Abstract Background The impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts’ 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED). Methods We obtained Medicare Fee for Service claims records (2007–2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients (“reference ED”). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients (“safety-net ED”). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states. Results Our study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (− 2.7 percentage point; 95% CI, − 4.5 to − 1.0) and Black (− 4.1 percentage point; 95% CI, − 6.2 to − 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, − 2.3 to − 0.2). Conclusion Massachusetts ambulance diversion ban was associated with a reduction in the proportion of White and Black EMS patients being transported to the most frequent ED destination for White patients, highlighting the role of non-proximity factors in EMS transport destination.

Introduction: Influenza vaccination is a recommended tool in preventing influenza-related illnesses, medical visits, and hospitalizations. With many patients remaining unvaccinated each year, the Emergency Department (ED) represents a unique opportunity to provide vaccinations to patient not yet vaccinated. However, busy urban safety-net EDs maybe challenged to safely execute such a vaccination program. The aim of this quality improvement project was to assess influenza vaccination feasibility in the ED and improve influenza vaccination rates in our community. Methods: The quality improvement work-group, comprised of ED physicians, nurses, and pharmacists, designed and implemented an influenza vaccination protocol that aligned with the ED workflow. The outcome measure was the total number of patients vaccinated per month and per influenza season. Process measures included the type of influenza vaccine administered and type of care area within ED. Balancing measures were also included. Results: Following the initiative, a total of 337 patients received influenza vaccinations in the ED between September 1, 2018 and December 31, 2020 compared to none during the previous influenza season. With each influenza season, the number of vaccinated patients increased from 61 to 134 and 142, respectively. The average age of the patients was 48.23 +/- 15.29, 52.89 +/- 15.91, and 44.92 +/- 18.97 years old. Most patients received the vaccination while roomed in the high acuity section of the adult ED. No adverse effects or automated dispensing cabinet stockouts were observed. Conclusion: Our structured program indicates that influenza vaccine administration to eligible patients is feasible in a busy urban safety-net ED. Piloting new and further developing existing ED-based influenza vaccination programs have the potential to significantly benefit public health. (C) 2021 Elsevier Inc. All rights reserved.

Background and Objectives: The aim of this quality improvement project was to decrease the percentage of emergency department (ED) patients admitted with blood glucose (BG) level above 250 mg/dL to less than 20%. Methods: A work group comprised physicians, pharmacists, and endocrinologists collaborated to standardize management of ED hyperglycemia. Plan-Do-Study-Act cycles included education, monitoring of patients with BG level above 200 mg/dL, and development of an ED-specific insulin protocol. Results: Following the initiative, 24.8% fewer patients were admitted with BG level above 250 mg/dL. The average admission BG level was reduced by 65.8 mg/dL, creating a significant shift toward improved average BG level. No difference was seen in hospital mortality, hospital length of stay, ED length of stay, hypoglycemia, or inhospital diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome, Conclusion: Implementation of a standardized hyperglycemia treatment protocol along with pharmacist interventions reduced average admission BG and the percentage of patients with BG level above 250 mg/dL on admission.

Introduction: The objective of this study was to compare airway management technique, performance, and peri-intubation complications during the novel coronavirus pandemic (COVID-19) using a single-center cohort of patients requiring emergent intubation. Methods: We retrospectively collected data on non-operating room (OR) intubations from February 1-April 23, 2020. All patients undergoing emergency intubation outside the OR were eligible for inclusion. Data were entered using an airway procedure note integrated within the electronic health record. Variables included level of training and specialty of the laryngoscopist, the patient's indication for intubation, methods of intubation, induction and paralytic agents, grade of view, use of video laryngoscopy, number of attempts, and adverse events. We performed a descriptive analysis comparing intubations with an available positive COVID-19 test result with cases that had either a negative or unavailable test result. Results: We obtained 406 independent procedure notes filed between February 1-April 23, 2020, and of these, 123 cases had a positive COVID-19 test result. Residents performed fewer tracheal intubations in COVID-19 cases when compared to nurse anesthetists (26.0% vs 37.4%). Video laryngoscopy was used significantly more in COVID-19 cases (91.1% vs 56.8%). No difference in first-pass success was observed between COVID-19 positive cases and controls (89.4% vs. 89.0%, p = 1.0). An increased rate of oxygen desaturation was observed in COVID-19 cases (20.3% vs. 9.9%) while there was no difference in the rate of other recorded complications and first-pass success. Discussion: An average twofold increase in the rate of tracheal intubation was observed after March 24, 2020, corresponding with an influx of COVID-19 positive cases. We observed adherence to society guidelines regarding performance of tracheal intubation by an expert laryngoscopist and the use of video laryngoscopy.

OBJECTIVE Guidelines recommend emergency medical services (EMS) patients to be transported to the nearest appropriate emergency department (ED). Our objective was to estimate the prevalence of EMS transport to an ED other than the nearest ED ("potential bypassing"). DATA SOURCES Illinois Prehospital Patient Care Report Data of EMS transports (7/2019 to 12/2019). DATA COLLECTION/EXTRACTION METHODS We identified all EMS ground transports with an advanced life-support (ALS) paramedic to an ED for patients aged 21 and older. Using street address of incident location, we performed geocoding and driving route analyses and obtained estimated driving distance and time to the destination ED and alternative EDs. MAIN OUTCOME AND MEASURES Our main outcomes were dichotomous indicators of potential bypassing of the nearest ED based on distance and time. As secondary outcomes we examined potential bypassing indicators based on excess driving distance and time. STUDY DESIGN We used Poisson regression models to obtain adjusted relative rates of potential bypassing indicators by acuity level, primary impression, patient demographics and geographic characteristics. PRINCIPAL FINDINGS Our study cohort of 361,051 EMS transports consisted of 5.8% critical, 37.2% emergent and 57.0% low acuity cases transported to 222 EDs. The observed rate of potential bypassing was approximately 34 percent of cases for each acuity level. Treating the cardiovascular primary impression code group as the reference case, we found small to no differences in potential bypassing rates across other primary impression code groups of all acuity levels, with the exception of critical acuity trauma cases for which potential bypassing rate was 64 percent higher (incidence rate ratio = 1.64, 95% confidence interval, 1.54 to 1.74). Compared to zip codes with one ED within a 5-mile vicinity, potential bypassing was higher in areas with no ED or multiple EDs within a 5-mile vicinity. CONCLUSION Approximately one-third of EMS transports potentially bypassed the nearest ED. EMS transport destination may be motivated by factors other than proximity. This article is protected by copyright. All rights reserved.

A common practice in busy emergency departments (EDs) is to admit patients from the waiting area to hallway beds as the regular beds fill up. Using data from a large ED, we first perform a causal analysis to quantify the impact of hallway placement on wait times and quality of care, defined by ED length of stay (LOS) and likelihood of adverse outcomes. We find that patients placed in a hallway bed experience a 20 minute (28%) lower door-to-doctor time (delay from arrival to first being seen by a caregiver). This reduction is 50 minutes (76%) for low-acuity patients who are treated in a fast-track area, which is isolated from the rest of the ED. However, hallway patients experience an average of 25 minutes (16.1%) and 18 minutes (9.2%) longer disposition time, and LOS, respectively. Moreover, we find that hallway patients are 20% more likely to experience an adverse outcome. Next, we perform a counterfactual analysis using a data-driven simulation of the ED to find better hallway usage policies. We find that a pooling policy, where hallway beds are used only if all regular beds are full, has the greatest impact on reducing wait times albeit at the cost of slightly higher hallway utilization. Also, too little or too much wait tolerance for rooming patients may result in under- or over-utilization of the hallway space, both of which are detrimental to ED average throughput times and wait times.

Intranasal naloxone is used to treat patients with respiratory and central nervous system depression that is known or suspected to be caused by an opioid overdose. This video demonstrates the administration of intranasal naloxone.

Introduction: Current recommendations for diagnostic imaging for moderately to severely ill patients with suspected coronavirus disease 2019 (COVID-19) include chest radiograph (CXR). Our primary objective was to determine whether lung ultrasound (LUS) B-lines, when excluding patients with alternative etiologies for B-lines, are more sensitive for the associated diagnosis of COVID-19 than CXR. Methods: This was a retrospective cohort study of all patients who presented to a single, academic emergency department in the United States between March 20 and April 6, 2020, and received LUS, CXR, and viral testing for COVID-19 as part of their diagnostic evaluation. The primary objective was to estimate the test characteristics of both LUS B-lines and CXR for the associated diagnosis of COVID-19. Our secondary objective was to evaluate the proportion of patients with COVID-19 that have secondary LUS findings of pleural abnormalities and subpleural consolidations. Results: We identified 43 patients who underwent both LUS and CXR and were tested for COVID-19. Of these, 27/43 (63%) tested positive. LUS was more sensitive (88.9%, 95% confidence interval (CI), 71.1-97.0) for the associated diagnosis of COVID-19 than CXR (51.9%, 95% CI, 34.0-69.3; p = 0.013). LUS and CXR specificity were 56.3% (95% CI, 33.2-76.9) and 75.0% (95% CI, 50.0-90.3), respectively (p = 0.453). Secondary LUS findings of patients with COVID-19 demonstrated 21/27 (77.8%) had pleural abnormalities and 10/27 (37%) had subpleural consolidations. Conclusion: Among patients who underwent LUS and CXR, LUS was found to have a higher sensitivity than CXR for the evaluation of COVID-19. This data could have important implications as an aid in the diagnostic evaluation of COVID-19, particularly where viral testing is not available or restricted. If generalizable, future directions would include defining how to incorporate LUS into clinical management and its role in screening lower-risk populations.

Quality assurance (QA) of care in the emergency department encompasses activities ensuring that the care provided meets applicable standards. Health care delivery is complex and many factors affect quality of care. Thus, quantification of health care quality is challenging, especially with regard to attribution of outcomes to various factors contributing to such care. A critical component of the process of QA is determination of quality health care and the concept of (unjustified) deviation from the reference applicable standard of care.

Scholars assert that firms with a strong entrepreneurial orientation (EO) should enjoy an advantage in foreign market entry. However, extant theory, particularly the dominant logic and adaptation frameworks, as well as supporting empirical research outside the domain of foreign market entry, suggests that the positive impact of a strong EO on foreign market entry is likely to be situational. Per the dynamic capabilities perspective, the authors first propose that marketing program adaptation (MPA) is a mediator of the EO-foreign market entry relationship. They further propose two moderators of the EO-MPA relationship, both of which are related to foreign market uncertainty: cultural distance (which increases uncertainty but is known prior to entry) and unanticipated events (which increases uncertainty but by definition are not known prior to entry). A study of 245 US MNCs supports the thesis that MPA is strongly related to foreign market entry success and that EO is an important contributor to foreign entry success when cultural distance is high and unanticipated events occur during launch but is less relevant in the opposite scenarios. There are important implications for firms entering foreign markets.

Key Points Question Are racial/ethnic minorities who use emergency medical services transported to the same emergency department as white residents living in the same zip code? Findings In this cohort study of 864 750 Medicare enrollees from 4175 zip codes, the proportion of white patients transported to the reference (or most frequent) emergency department destination was high (61.3%), compared with the proportion of black patients (difference of −5.3%) and Hispanic patients (difference of −2.5%). Meaning This study suggests that emergency department destination is substantially different on the basis of the race/ethnicity of patients living in the same zip code.