RESUMEN
We report a case of contrast-inducted Steven Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN). The patient had received parenteral iopamidol and oral iohexol five days prior. The patient's chief complaint at the Emergency Department (ED) presentation was shortness of breath and blisters throughout body. Upon arrival, the patient was awake, alert, and oriented with a blood pressure (BP) of 166/68, heart rate (HR) of 117 beats per minute, respiratory rate (RR) of 22 breaths per minute and oxygen saturation of 94% on room air. A review of systems was unremarkable with the exception of chills, fatigue and rash. Physical exam was significant for right eye edema/crusting, hemorrhagic bullae, and maculopapular rash. The patient's initial laboratory results were significant for platelets (PLT) of 549 and absolute neutrophil count (ANC) 8.48 × 10(3)/mcL, neutrophils 84.2%, and lymphocytes 10%. Complete metabolic panel was normal with serum creatinine 0.77 mg/dL. The patient was initially treated with diphenhydramine, methylprednisolone, ondansetron, sodium chloride, lorazepam and oxycodone-acetaminophen. Hemotology/Oncology and Trauma/Burn consult identified possible SJS/TEN and the patient was transferred to another facility for dermatologic/burn follow up.
Asunto(s)
Medios de Contraste/efectos adversos , Síndrome de Stevens-Johnson/etiología , Tomografía Computarizada por Rayos X/efectos adversos , Femenino , Humanos , Persona de Mediana Edad , Síndrome de Stevens-Johnson/diagnósticoRESUMEN
This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.
Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Pase de Guardia/estadística & datos numéricos , Estudios Transversales , Humanos , Internado y Residencia/estadística & datos numéricos , Encuestas y Cuestionarios , Estados UnidosRESUMEN
OBJECTIVES: The objective of this study is to present an algorithm for improving the safety and effectiveness of transitions of care (ToC) in the emergency department (ED). METHODS: This project was undertaken by the Council of Emergency Medicine Residency Directors (CORD) Transitions of Care Task Force and guided by the six-step Kern model for curriculum development. A targeted needs assessment in survey form was designed using a modified Delphi method among the CORD ToC Task Force. The survey was designed for four subgroups within the ED: emergency medicine (EM) residency program directors, EM academic chairpersons, EM residents, and EM nurses. Members from nationally recognized EM organizations assisted in the development of each respective survey, including the Academic Affairs Committee of the American College of Emergency Physicians, the leadership of the Emergency Medicine Residents' Association (EMRA), and the leadership of Emergency Nurses Association (ENA). The surveys contained questions about current handoff practices and asked participants to rate the importance of key logistical and informational parameters within a ToC. Survey validity was achieved through content validity, item analysis, format familiarity, and electronic scoring. The surveys of program directors and academic chairpersons were distributed through the CORD listserv, the resident survey was distributed via EMRA correspondents, and the nurse survey was distributed through the ENA listserv. Following survey collection, the ToC Task Force convened and used the data to assess handoff practices and deficiencies. The Task Force developed recommendations for a ToC algorithm that was then piloted by medical educators in their institutions. These educators shared their experiences with senior department members in a phone interview. This informant feedback was used to address deficiencies in the algorithm and finalize the recommendations from the CORD Task Force. RESULTS: The surveys for program directors (n = 147), academic chairpersons (n = 99), residents (n = 194), and nurses (n = 902) were electronically scored. Handoff education in the form of structured workshops or classes was typically not offered, with only 10.9% of residents and 9.0% of nurses reporting that they received such training. The majority (93.9%) of EM academic chairpersons stated that assessments of handoff proficiency were not conducted within their programs. Computerized handoff was the most popular assistive tool among all surveyed groups. Handoff parameters that were rated as "important" and "extremely important" included uninterrupted time and space to perform the handoff, identification of "high-risk" handoffs, and the opportunity for questions and clarification from the handoff recipient. The developed handoff algorithm consisted of five steps: 1) setting the stage, 2) assembling the team, 3) identification of high-risk patients, 4) shift sign-out, and 5) closing the loop. CONCLUSIONS: The authors present specific guidelines for an algorithm-based approach to transitioning care within the ED. This algorithm is based on surveys of perceived deficiencies and emphasizes informational and logistical parameters within a ToC. Standardizing the process of the ToC may allow for future research on the link between effective ToC and patient outcomes.