Objectives: Because of overcrowding and limited critical care resources, critically ill patients in the emergency department may spend hours to days awaiting transfer to the ICU. In these patients, often termed “ICU boarders,” delayed ICU transfer is associated with poor outcomes. We implemented an emergency department–based, electronic ICU monitoring system for ICU boarders. Our aim was to investigate the effect of this initiative on morbidity, mortality, and ICU usage. Design: Single-center, retrospective cohort study. Setting: Nonprofit, tertiary care, teaching hospital with greater than 100,000 emergency department visits per year. Patients: Emergency department patients with admission orders for the medical ICU, who spent more than 2 hours boarding in the emergency department after being accepted for admission to the medical ICU, were included in the study. Interventions: None. Measurements and Main Results: During the study period, a total of 314 patients were admitted to the medical ICU from the emergency department, 214 of whom were considered ICU boarders with a delay in medical ICU transfer over 2 hours. Of ICU boarders, 115 (53.7%) were enrolled in electronic ICU telemonitoring (electronic ICU care), and the rest received usual emergency department care (emergency department care). Age, mean illness severity (Acute Physiology and Chronic Health Evaluation IVa scores), and admitting diagnoses did not differ significantly between ICU boarders receiving electronic ICU care and emergency department care. Forty-one electronic ICU care patients (36%) were ultimately transitioned to a less intensive level of care in lieu of ICU admission while still in the emergency department, compared with zero patients in the emergency department care group. Among all ICU boarders transferred to the ICU, in-hospital mortality was lower in the electronic ICU care cohort when compared with the emergency department care cohort (5.4% vs 20.0%; adjusted odds ratio, 0.08). Conclusions: In critically ill patients awaiting transfer from the emergency department to the medical ICU, electronic ICU care was associated with decreased mortality and lower ICU resource utilization.

Objective The objective of this study was to evaluate whether trimester-specific D-dimer levels or the modified Wells score (MWS) is a useful risk stratification tool to exclude pregnant women at low risk of pulmonary embolism (PE) from diagnostic imaging. Study Design This is a prospective and retrospective cohort study. Pregnant women who underwent diagnostic imaging for suspected PE were prospectively enrolled. D-dimer serum levels were drawn, and a MWS was assigned. Pregnant women diagnosed with a PE before study launch who underwent diagnostic imaging and had a D-dimer level drawn were also evaluated. Results In this study, 17 patients were diagnosed with a PE and 42 patients had no PE on diagnostic imaging. Sixteen out of 17 patients with a PE versus 11 out of 42 without PE had an abnormal D-dimer level (p = 0.001). Four patients with a PE versus zero without a PE had an abnormal MWS (p = 0.005). The combination of a trimester-specific D-dimer level along with the MWS was abnormal in all 17 patients with a documented PE versus 11/42 (26.2%) patients without a documented PE (p = 0.001). Conclusion A combination of trimester-specific D-dimer levels along with a MWS can be used in pregnancy to triage women into a low-risk category for PE and thereby avoid radiation exposure in a majority of pregnant patients.

ObjectivesOur objective was to compare outcomes of discharge disposition, need for additional medications, and restraint use for patients who received inhaled loxapine compared with patients receiving traditional antipsychotic drugs in the emergency department (ED).MethodsA retrospective chart review was conducted on all patients who presented to the ED with agitation and received antipsychotic therapy, including loxapine, ziprasidone, or haloperidol from December 1, 2014, through October 31, 2016.ResultsThe mean time from physician assignment to medical clearance was 7.9 hours for patients treated with inhaled loxapine versus 10.3 hours for controls (P < 0.01). Those who received inhaled loxapine were given significantly less benzodiazepines as additional rescue medications as compared with other antipsychotic medications (P < 0.01, 35.2% vs 65.1%). Additionally, restraints were utilized less frequently in the loxapine group (P < 0.01, 1.8% vs 19.8%).ConclusionsTreating patients with agitation due to psychotic episodes in an ED setting with inhaled loxapine versus haloperidol or ziprasidone was associated with significantly improved treatment outcomes, suggesting that inhaled loxapine may be a more effective and rapid treatment option.

The available routes of administration commonly used for medications and fluids in the acute care setting are generally limited to oral, intravenous, or intraosseous routes, but in many patients, particularly in the emergency or critical care settings, these routes are often unavailable or time-consuming to access. A novel device is now available that offers an easy route for administration of medications or fluids via rectal mucosal absorption (also referred to as proctoclysis in the case of fluid administration and subsequent absorption). Although originally intended for the palliative care market, the utility of this device in the emergency setting has recently been described. Specifically, reports of patients being treated for dehydration, alcohol withdrawal, vomiting, fever, myocardial infarction, hyperthyroidism, and cardiac arrest have shown success with administration of a wide variety of medications or fluids (including water, aspirin, lorazepam, ondansetron, acetaminophen, methimazole, and buspirone). Device placement is straightforward, and based on the observation of expected effects from the medication administrations, absorption is rapid. The rapidity of absorption kinetics are further demonstrated in a recent report of the measurement of phenobarbital pharmacokinetics. We describe here the placement and use of this device, and demonstrate methods of pharmacokinetic measurements of medications administered by this method.

Study Objective: Nonsuicidal self-injury (NSSI), the deliberate destruction of one's body tissue (eg, self-cutting, burning) without suicidal intent, has consistent rates ranging from 14% to 24% among youth and young adults. Moreover, youth who enact NSSI are at risk for repeated NSSI, interpersonal difficulties, additional psychiatric symptoms, and, in some cases, suicide. With more youth using videosharing Web sites (YouTube), this study will examine the accessibility and content of nonsuicidal self-injury videos online.Methods: This is a retrospective content analysis study. Using YouTube's search engine, data was collected by searching for videos on YouTube using the key words "self-injury" and "self-harm." Videos were identified and viewed between October 2014 and December 2014. Standardized forms were used for data abstraction. Beyond coding for video purposes, video tones (eg, educational, encouraging, angry) were also examined. Many videos may have more than 1 NSSI method depicted; many may also have more than 1 body location. Viewers' comments from the NSSI videos on YouTube were examined as an index of viewer response using two coding rubrics, one for the global nature of comments and one for recovery-oriented themes. All videos were analyzed independently by 2 researchers and disagreements resolved by an arbitrator. Descriptive statistics and frequency tables were used to describe research findings. Interrater reliability was determined using the Kappa score.Results: During the 3-month study period, 92 YouTube videos of depicting NSSI were identified. The videos were collectively viewed over 10 million times; the mean number of views per video was 236,811. These videos were marked as a "favorite" a total of 224,734 times with an average of 2470 times per video. Specifically, 84% of videos had visual depictions (eg, photographs) of NSSI. Overall, cutting was the most commonly depicted NSSI method, followed by self-embedding, burning, and then, less frequently, acts including hitting, biting, skin picking, and wound interference. Forty videos (43%) featured a live person (ie, character videos) and 52 were non-character videos. Noncharacter videos depicted more graphic NSSI imagery and multiple NSSI methods (eg, cutting, burning). The majority of the people (88%) identified in the videos were Caucasian; 84% were female. The estimated age of participants was 10 to 15 years in 23% of the videos, 16-20 years in 59%, and > 20 years old in 18%. Only 27 of these videos (29%) posted trigger-warnings, intended to warn users that Web site content may trigger NSSI. The majority of NSSI videos had informational content (ie, presented NSSI facts) and/or "melancholic/hopeless" (ie, emphasized emotional pain) messages. Responses consisted of viewers sharing their own NSSI experiences (41%), validating or praising uploaders for their videos (22%), or encouraging the uploader (13%). Few discussed or mentioned NSSI recovery; most comments indicated that the individual was still injuring.Conclusions: The depiction of NSSI ...