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RCH EMERGENCY PHYSICIAN CQI CLINICAL SURVEY

RCH EMERGENCY PHYSICIAN CQI CLINICAL SURVEY. Clinical Survey. 35 of 36 CEPA members responded GOAL: Get to know what others are doing with respect to referrals, practice patterns, etc. May be a useful tool in the development of future educational sessions Not all questions were answered

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RCH EMERGENCY PHYSICIAN CQI CLINICAL SURVEY

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  1. RCH EMERGENCY PHYSICIAN CQI CLINICAL SURVEY

  2. Clinical Survey • 35 of 36 CEPA members responded • GOAL: Get to know what others are doing with respect to referrals, practice patterns, etc. • May be a useful tool in the development of future educational sessions • Not all questions were answered • Most questions were generic • Some questions were not entirely fair • Forced into limited answers • Many different patient variables exist

  3. GOAL: • Move towards either having 2nd EP present or at least making them aware of procedural sedation.

  4. COMMENTS RE PLAIN FILM VS. CT CERVICAL SPINE • Pre-test probability is a major factor. • Depends on mechanism of injury, age, body habitus. • CT scan in older patients (> 50 yrs), obese patients (anticipate poor / difficult to interpret plain films) or high risk mechanism. • Younger patients with low risk mechanism – use clinical decision rule; usually start with plain films.

  5. Standard of Care for TBI Patients SHOULD ALL PATIENTS WITH A SIGNIFICANT TRAUMATIC BRAIN INJURY BE SEEN BY A NEUROSURGEON PRIOR TO DISCHARGE IRREGARDLESS OF WHICH HOSPITAL THEY PRESENT TO?? SIGNIFICANT TBI = ANY BLOOD PRESENT ON CT SCAN (SAH, SMALL SDH) +/- SKULL #

  6. IVT FOR PYELONEPHRITIS - comments • Need to consider other factors – age, medical co-morbidities, abnormal urologic anatomy, immunocompromised • Consider IVT for pts with past hx of antibiotic resistance or recurrence • IVT for pts with pyelo and known kidney stone

  7. IVT FOR CELLULITIS - comments • Use clinical gestalt • Size of the involved area – IVT for larger areas • Location of involvement • IVT if suspicious of poor compliance or loss to follow up

  8. ANTIBIOTICS FOR UNCOMPLICATED ABCESS - comments • Usually put them on antibiotics for a few days only • Use of Septra may decrease the rate of re-infection if MRSA • Gradually switching to not using antibiotics in these patients

  9. DOES THE ROUTINE CULTURE OF AN UNCOMPLICATED ABCESS CHANGE THE TREATMENT IN ANY WAY? • COST VS. BENEFIT • MAY INFLUENCE TREATMENT OF FUTURE INFECTIONS

  10. IS IT TIME TO LOOK (AGAIN) AT NURSE INITIATED ORDERS FOR OTHER PROBLEMS? • XRAYS FOR BONY INJURIES • PAIN CONTROL • ABDOMINAL PAIN • PEDIATRIC FEVER • PEDIATRIC LACERATIONS • DYSPNEA with FEVER • VAGINAL BLEEDING

  11. WHY SIGN UP FOR PATIENTS? • Nursing staff (and other EP’s) knows who is responsible for individual patients • Keeps track of where your patients are in the Dept • If you are going to check their EMR / PCI anyways; why not sign up for them? • Easier transfer of care to another physician • Wireless ER in the future • “Paperless” ER???

  12. WHY SIGN UP FOR PATIENTS? GOAL: Our group needs to make a better effort in signing up for patients on Meditech. With the move to a Wireless ED and a “paperless” ED; the expectation is that the signup rate for our group would be 100%

  13. Troponin Use in Low Risk Patients • Timing of biomarker testing is critical; sensitivity of a single troponin for MI within the first hour of symptoms is 10% to 45% and increases to more than 90% at 8 or more hours. • Retrospective study of 588 low-risk patients with nondiagnosticECGs and negative troponins drawn 6 to 9 hours after symptom onset reported a 0.3% rate of adverse events and no deaths at 30 days.

  14. Atrial Fibrillation and Flutter in the EDStiell et al; Can. Journal of Cardiology; 2011 • We recommend that synchronized electrical cardioversion or pharmacologic cardioversion may be used when a decision is made to cardiovert patients in the emergency department. (Strong Recommendation, Moderate-Quality Evidence). • We suggest that antiarrhythmic drugs may be used to pretreat patients before electrical cardioversion in ED in order to decrease early recurrence of AF and to enhance cardioversion efficacy (Conditional Recommendation, Low-Quality Evidence).

  15. Atrial Fibrillation and Flutter in the EDStiell et al; Can. Journal of Cardiology; 2011 RECOMMENDATION We recommend that electrical cardioversion may be conducted in the ED with 150-200 joules biphasic waveform as the initial energy setting (Strong Recommendation, Low-Quality Evidence). Values and preferences. This recommendation places a high value on the avoidance of repeated shocks and the avoidance of ventricular fibrillation that can occur with synchronized cardioversion of AF at lower energy levels. It is recognized that the induction of VF is a rare but easily avoidable event.

  16. CLINICAL SURVEY - SUMMARY • Gained some perspective on what other EP’s are doing • Critical assessment of your own practice • Develop some group expectations • Possible future educational sessions • Initiation and cessation of IV therapy • Atrial fib in the ER • Use of troponins in low risk chest pain pts. • Nurse initiated orders in the ER

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