2018 LLSA Articles Review. Learning Objectives. Definitions. Evidence in Emergency Medicine. Evidence in Emergency Medicine 11/2/2018

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1 2018 LLSA Articles Review Payal Shah, M.D. 11/05/18 Beaumont Health System Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine Skaugset, LM; et al. Ann Emerg Med 2016: 68; Learning Objectives Interruptions = medical errors + potential harm Review task switching and limitations of human performance Heighten awareness of interruptions Teaching trainees how to effectively task switch Definitions Multitasking: simultaneous performance of two discrete tasks Task Switching: changing between two separate tasks Interruption: original task is returned to after a brief switch Break in task: new task is started as a result of a task switch 3 4 Evidence in Emergency Medicine Focus of literature is on decreasing task switching by decreasing distractions Focus in Emergency Medicine is on frequency of and type of interruption Chisholm et al: 31 distractions in 3 hours Interrupted tasks were less likely to be completed Interrupted tasks were more likely to be completed quickly Evidence in Emergency Medicine Nursing interruptions versus Resident interruptions Resident level-of-training-dependent interruptions Interruptions = Sentinel events Understanding task switching is crucial 5 6 1

2 How the Brain Task Switches Cognitive Load Theory Large task = divide into smaller discrete tasks High rate of task incompletion Difficult to return to a partially completed task External source interruptions leads to at least one more internal interruption Reduction in accuracy of task being performed Increase in rate of error of task being performed Working short term memory versus long-term memory Working short term memory is limited Long term memory is unlimited Cognitive load: mental effort used by working memory Intrinsic load: difficulty of the task itself Extraneous load: how is new information presented Germane load: building of mental structures for later use Chunking is an example 7 8 Multitasking Is the simultaneous performance of two discrete automatic tasks Must be automatic? Perception is multitasking, reality is task switching Effects of Task Switching Each mental switch in task distracts the mind from the primary task Mental delay Prolonged duration of activity Reduced quality Increased workload Time to resume primary task is effected by: Duration Cognitive demand Timing of the interruption 9 10 Effect of Task Switching Ability to return to the primary task: Cues to return Control over the interruption Relatedness of the tasks Complexity of the interruptions Task component incompletion versus task incompletion Heavily distracting environments + Higher patient acuity = Greater risk for error Recommendations for Practice Multitasking is a key skill ABEM certifications, milestones based evaluation Techniques for effective task switching Provider level Practice environment

3 Provider Level Techniques for Task- Switching Prioritize tasks according to acuity Recognize how to delay or redirect an interruption Recognize interruptions that increase risk for error Develop long term memory and decrease cognitive load Use simple mental frameworks Practice Environment Level Techniques for Task Switching Minimize: utilize other ED resources Recognize high risk distraction times Team debriefing = set goals for efficient task completion EMR Optimization: order sets, preference lists Minimize alert fatigue Optimize physical space Signs indicating critical work Department work flow: Redirect routine information Recommendations to Reduce Effects and Risks of Task Switching Decrease external interruptions Educate staff on the danger of interruptions Teach methods to improve task switching Use technology to increase rates of task completion Design department work flow to decrease interruptions How to Develop these Skills for Learners Recognize risks of task switching Sign out rounds, after shift debriefing Deliberate verbalization Allow graduated experiences pertaining to efficient task switching Educate all ED staff on the effect interruptions can have on potential errors Final Thoughts and Future Directions Effective and efficient task switching is a critical skill for successful emergency medicine practice Better understanding of how a clinicians task switching skills develop Understand the effects of EMR Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the ED with Fever Ann Emerg Med 2016; 67:

4 Clinical questions to answer: Well-appearing, immunocompetent 2 month-2 year old with fever, are there clinical predictors of patients at risk for UTI? For the above undergoing urine testing, which lab testing method to diagnose UTI should be used? Clinical questions to answer: Well-appearing, immunocompetent 2 month-2 year old with fever, are there clinical predictors of risk for pneumonia and obtaining a CXR? Well-appearing, immunocompetent full term infants age 1 month-3 months presenting with fever, are there clinical predictors of risk for meningitis and obtaining CSF studies? Fever = most common chief complaint in ED Determine well-appearing febrile child with serious bacterial illness, versus febrile child with benign illness Many factors to consider Fever without a source Acute onset, duration < 1 week, absence of localizing signs Diagnosis of SBI=positive culture result Prepneumococcal vaccine era Risk of SBI highest in age 3-28 days Risk of bacteremia in well appearing 3 mo-36 mo was associated with fever or fever+wbc>15,000 Most common organisms(strep, HiB) Advent of pneumococcal/hib vaccine Decline of bacteremia to less than 2% Other organisms, types of infections have emerged Most common SBI now is UTI in <2 mo No single screening test or algorithm for identification of SBI has been universally accepted The focus of this clinical policy applies to infants/children >28 days but less than 2 years old Methodology Expert review from: Emergency Physicians, AAP, AAFP, ACEP PEM Committee Classes of Evidence Goal of the Clinical Policies Committee Goal of the guidelines Patient criteria: Physicians working in an ED Healthy, term, immunized, infants/children Excludes neonates, high-risk populations

5 Critical Questions Critical Questions 1) Well-appearing, immunocompetent 2mo- 2yo with fever>38.0c, are there clinical factors that identify at risk patients for UTI Level C: females<12 months; uncircumcised males; non-black; fever>39; negative test for respiratory pathogens; no obvious source of infection 373 articles identified 26 selected for further review 2 studies included for this question 2) Well appearing febrile 2mo to 2yo undergoing urine testing, which lab testing method should be used for UTI? Level B: Positive urine LE, nitrites, leukocyte count, or Gram s stain Level C: Obtain urine culture when starting antibiotics; if dipstick is negative but UTI is still suspected, obtain urine culture 492 articles identified 109 selected for further review 10 studies included for this question Critical Questions 3) Well appearing febrile 2mo-2yo with fever>38c, are there clinical predictors that identify patients at risk for pneumonia for whom CXR should be obtained? Level B: If no other obvious source of infection, consider CXR if cough, hypoxia, rales, fever>39c, fever>2days, tachycardia/tachypnea out of proportion to fever present Level C: if well-appearing, with wheezing/high likelihood of bronchiolitis, DO NOT order CXR 473 articles identified 64 selected further review 9 studies included for this question Critical Questions Well-appearing, full term 1mo-3mo with fever>38 are there predictors that identify patients at risk for meningitis from whom CSF should be obtained? Level C: No predictors, but consider Level C: If diagnosed with viral illness, can defeer LP if low risk for meningitis. If deferred, hold abx unless other source identified. Admission, close PCP or ED follow up needed 661 articles identified 68 selected further review 1 study included for this question Imaging Foreign Bodies: Ingested, Aspirated, and Inserted ED Providers = first point of contact Review: epidemiology, presentation, anatomy, imaging, entry mechanism, management and intervention Tseng HJ, et al. Ann Emerg Med 2015; 66:

6 Background: Radiography Radiography=key Radiopacity: intrinsic feature of the object Radiopaque=more radiopaque than the surrounding tissue Radiographic visibility: depends on surrounding structures Depends on size, opacity, anatomic location, body habitus, surrounding structures Background: Radiography Measuring foreign bodies on radiographs depends on: Distance of object from radiographic cassette Technique Body habitus Can use calibration techniques Background: Ultrasound Background: Ultrasound Anatomic evaluation without radiation Superficial foreign body = use linear probe Deeper foreign body = use curvilinear probe Composition dependent on imaging: Posterior shadowing Dark shadows deep to the structure Wood Plastic Stone Ring-down artifacts Bright echogenic lines extending posteriorly Glass Metal Background: Fluoroscopy Real-time radiography Patient must follow commands Requires interpreting radiologist Background: CT Helps to evaluate radiolucent foreign bodies and related complications Hounsfield units: 0=water +40=blood +1000=bone -1000=air

7 Esophageal foreign bodies: 1500 deaths annually 10-20% require intervention Majority in pediatrics: 6mo-6yo, usually accidental Adult ingestions: Intentional Signs and symptoms Asymptomatic after passage into the GE junction Esophageal foreign bodies: Most common location of impaction is the upper esophagus at the cricopharyngeus muscle Other sites include: aortic arch, left main bronchus, GE junction, pylorus, duodenal C-loop, ileocecal valve Endoscopy Allows diagnosis and intervention Sharp foreign bodies=emergent removal from esophagus Urgent removal from stomach or duodenum If past duodenum, then surgical removal if symptomatic or failure to progress after 3 days Blunt objects Plastic bread bag clip Symptomatic >2.5cm wide; >6cm long Coins In esophagus: If asymptomatic then can be observed for 24 hours Button Batteries Emergent removal from esophagus Once in stomach, follow Button batteries >2cm Lithium batteries=badness Cylindrical batteries=not an issue Remove if remains after 48 hours Multiple magnets Devastating complications Urgent removal Illicit drugs CT with IV contrast can help to detect body packets Recommendation is against removal unless symptomatic or failure to progress Foreign body aspiration Adults: Right bronchial tree Pediatrics: Proximal smaller tracheal diameter Diagnose with bronchoscopy and laryngoscopy Non-life threatening 2 view CXR/neck x-ray/lateral decubitus views

8 Insertion Foreign Bodies Rectal and GU 45 year old; Males>Females Autoeroticism, assault, fecal impaction treatment, body stuffing, concealing weapons Delayed presentation to ED due to embarrassment Imaging before DRE Predictors of failure for transanal extraction Summary of Foreign Bodies of Entry Know the clinical implications Know the chemical properties Know the anatomic location Know your radiology consultation modalities Know what is emergent Managing Suicidal Patients in the Emergency Department Caring for ED patient with suicidal ideation is challenging Betz ME, et al. Ann Emerg Med 2016; 67: Identification of Suicidal Patients The Joint Commission requires suicide screening and assessment for patients with a primary emotional or behavioral presenting symptoms General Approach Acute emotional pain empathetic patientcentered care Providers, overcome your own areas of discomfort Asking about suicide does not incite or encourage suicidal behavior Obtain information from appropriate collateral sources

9 Precautions Suicide Risk Assessment Thorough evaluation in ED Protect the patient from any self harm while in the ED. First attempt verbal de-escalation Consider a written ED policy on the care of suicidal patients that the patient can be provide with Aims to determine treatment Inexact science Risk stratification Low risk: no plan or intent, no prior attempts, no history of mental illness or substance abuse, no agitation Use the 6 question Decision Support tool Majority of suicidal patients do need a comprehensive risk assessment Suicide Risk Assessment Adequate risk assessment=cognitive participation by the patient Substance abuse and chronic alcohol raise the risk of suicide Comprehensive assessments are typically done by mental health consultants Resources include the SAFE-T Thrombotic Microangiopathies Suicide Assessment Five-step Evaluation and Triage (SAFE-T) Step-wise evaluation of a patient s risk and protective factors, thoughts/plans of suicide to estimate overall risk ED Based Interventions Patient education and safety planning Personalized plans with warning signs, follow-up, and emergency contacts Step by step mechanisms for coping and help seeking Rapid referral for follow up Enlisting help from family or friends Counseling to reduce home access to lethal means Guns have the highest suicide case fatality rate Disposition Psychiatric admission Voluntary preferred Involuntary with adherence to state laws Outpatient management Use the above planning strategies Utilize caring contacts National Suicide Prevention Hotline

10 Conclusion Provide focused medical assessment Perform a suicide risk assessment Determine need for mental health consultation Determine if hospitalization is needed Consider Brief ED Interventions 55 10