Objectives More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele‐intake at the time of presentation would reduce LWBS rates and ED throughput measures. Methods We conducted a before‐and‐after study at an urban community hospital. The intervention was use of a tele‐intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele‐intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24‐hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6‐month tele‐intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. Results Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24‐hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele‐intake providers thought tele‐intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in‐person triage. Of the receiving physicians, most agreed with statements that tele‐intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%). Conclusions Remote tele‐intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.

Study Objectives: The United States is in the midst of an opioid epidemic. Of more than 42,000 opioid deaths in 2016, 40% were related to prescription medications. Emergency department (ED) visit prescriptions may provide the initial exposure for many patients who subsequently misuse or develop opioid use disorder (OUD). Physician prescribing patterns can vary extensively, however ED physicians are among the top 5 opioid prescribers in all medical specialties in almost all age groups. It is well documented that a larger quantity of tablets or prolonged prescription duration is associated with increased risk of chronic opioid use. Electronic health records (EHR) allow for implementation of active and passive interventions that may influence provider behavior, specifically the ability to set prescription preferences on the departmental level. We tested the hypothesis that decreasing the number of pills in our ED prescribing preference settings would decrease the duration of prescriptions and number of tablets for opioid medications prescribed by our providers.Methods: A pre-post study design was performed between 4/1/17 and 4/30/18 using all opioid prescriptions made through EPIC Corporation's 2015 ASAP EHR module in 2 EDs. Prior to the intervention, which occurred on 1/28/18, opioid prescriptions had the EHR default prescription settings, which varied in number of pills and durations. Using the CDC guidelines for opioid prescribing, all opioid entries were given defaults under 50 milligram morphine equivalents per day and supplies were only for 3-days. Opioid prescriptions, their dosages and total pills dispensed were abstracted using the institutional reporting software Qlik. Our outcome measures were rates of prescription attributes that were consistent with CDC guidelines. Chi-square and Mann Whitney test were used to determine statistical significance.Results: During the study period, there were 78,416 discharged patients, of whom 731 (0.093%) received opioid prescriptions. 503 (69%) of these prescriptions were for >3 days of therapy. Comparing the pre period to the post period there was a reduction in the median number of all opioid prescriptions per month (56 [IQR, 49.9-62.2] to 47 [IQR,[45][46][47][48][49], p ¼ 0.014). There was also a reduction in the proportion of prescriptions lasting >3 days (80% [95% CI, 76.5-83.1%] to 19.3% [95% CI, 13.2-27.1%], p<0.001), as well as a reduction in median number of pills dispensed (12 [IQR,[8][9][10][11][12][13][14][15][16] to 8 [IQR, 6-10], p<0.001).When isolating the 3 months pre and post intervention there was no difference in the median number of overall opioid prescriptions. However, there was a reduction in proportion of prescriptions lasting >3 days (70 .5% [95% CI, 62.6-77.4%] to 19.3% [95% CI, 13.2-27.1%], p<0.001), as well as the median number of pills dispensed (11 [IQR,.5] to 8 [IQR, 6-10] p<0.001).Conclusions: Modification of departmental EHR prescription preference settings can substantially alter prescribing patterns for opioid prescriptions in the ED. ...

Stingray envenomation is a common occurrence. X-ray evaluation of stingray wounds is an unnecessarily misunderstood diagnostic concept. We present the case of a patient stung by a stingray with a prolonged and complicated course and permanent disability due to a retained barb. The patient had undergone multiple medical evaluations before an X-ray was obtained.

Waardenburg syndrome (WS) is an autosomal-dominant neural crest cell disorder phenotypically characterized by hearing impairment and disturbance of pigmentation. A presence of dystopia canthorum is indicative of WS type 1, caused by loss of function mutation in the PAX3 gene. In contrast, type 2 WS (WS2) is characterized by normally placed medial canthi and is genetically heterogeneous; mutations in MITF (microphthalmia associated transcription factor) associated with WS2 have been identified in some but not all affected families. Here, we report on a three-generation Indian family with a point mutation in the MITF gene causing WS2. This mutation, initially reported in a Northern European family, creates a stop codon in exon 7 and is predicted to result in a truncated protein lacking the HLH-Zip or Zip structure necessary for normal interaction with its target DNA motif. Comparison of the phenotype between the two families demonstrates a significant difference in pigmentary disturbance of the eye. This family, with the first documented case of two unrelated WS2 families harboring identical mutations, provides additional evidence for the importance of genetic background on the clinical phenotype.

Waardenburg syndrome (WS) is an autosomal-dominant neural crest cell disorder phenotypically characterized by hearing impairment and disturbance of pigmentation. A presence of dystopia canthorum is indicative of WS type 1, caused by loss of function mutation in the PAX3 gene. In contrast, type 2 WS (WS2) is characterized by normally placed medial canthi and is genetically heterogeneous; mutations in MITF (microphthalmia associated transcription factor) associated with WS2 have been identified in some but not all affected families. Here, we report on a three-generation Indian family with a point mutation in the MITF gene causing WS2. This mutation, initially reported in a Northern European family, creates a stop codon in exon 7 and is predicted to result in a truncated protein lacking the HLH-Zip or Zip structure necessary for normal interaction with its target DNA motif. Comparison of the phenotype between the two families demonstrates a significant difference in pigmentary disturbance of the eye. This family, with the first documented case of two unrelated WS2 families harboring identical mutations, provides additional evidence for the importance of genetic background on the clinical phenotype.