This may reflect random variation or purposeful decline in opioid prescribing influenced by the significant attention recently brought on by the “opioid epidemic.” The providers were not notified of removal of the default quantity; therefore, it is less likely that the intervention itself influenced the decrease in number of prescriptions. The data on prescribing patterns from the ED in recent years are limited, and it is unknown if there has been a widespread decline in prescribing patterns over this same time period.As a retrospective analysis, unmeasured confounders may have influenced our analysis. Factors that were not studied may have influenced opioid prescribing patterns. These include the physician’s perception of pain intensity, the age of the patient, the provider’s experience level, and the diagnosis at the time of discharge. Furthermore, it is unknown whether the increased variation post-intervention really represents true individual prescribing variation. Further evaluation would be required to analyze each individual provider’s prescribing patterns before and after the intervention to determine whether they each exhibited the same increase in variability as the entire group or if, after removal of the default quantity, each provider relied on his/her own individual default quantity for each patient regardless of painful condition. Other potential explanations for the findings observed were not studied directly. One potential confounder is a change in the patient population or ED providers during the study period, which may have influenced prescribing habits. Comparing patient acuity in the period before and after the intervention demonstrates similar Emergency Severity Index scores and admission rates. This suggests similar patient characteristics in the pre and post-intervention period. The total number of Level I and II trauma activations and ED visits for adult patients was lower in the post-intervention period as expected,cannabis hydroponic set up given the duration of the post-intervention period was shorter.
Although it appears that prescribing patterns may have been more appropriate after elimination of default quantity, this assumption was not directly tested. Changes in provider mix may also account for differences in opioid prescribing during the post-intervention period. Although this was not studied directly, there was minimal turnover among the provider group during the study period with a total of one hire and two departures of full-time faculty during the combined time periods. Further studies would be needed to determine which factors influence physician-prescribing patterns of opioid analgesics for specific, painful conditions including analysis of pain scores.Frequent users of emergency departments have been the subject of substantial research given the implications for resource utilization, healthcare costs, and ED crowding.A unique subset of frequent ED users are those who present to the ED repeatedly for acute alcohol intoxication.As ED visits for acute alcohol intoxication are increasing,9 the burden of alcohol-related frequent users will be important to Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota explore. Existing studies describing frequent ED users often cite alcohol-use disorders as a common comorbidity and a precipitant for their disproportionate utilization of emergency services.Despite this established association, there is a paucity of data describing the encounters and individuals who frequently use the ED for alcohol intoxication, or the extent to which they use the ED for other reasons. The purpose of this study was to describe this population and their ED encounters.This was a retrospective, observational, cohort study of ED patients presenting for acute alcohol intoxication from 2012 to 2016. It was approved by the institutional review board. The study hospital is a county ED with an annual volume of 100,000 visits and 7,000 visits for alcohol intoxication. The ED has a 16-bed area within the department that clusters all intoxication encounters. The purpose of this area is to treat patients who are in the department for intoxication at patients who ared to treat complicated medical or trauma patients who also happen to be intoxicated from alcohol.
Patients are selected for treatment in this area at the discretion of triage nurses, paramedics , and the emergency physicians. All alcohol intoxication encounters are seen in this particular area of the ED, but there is occasional overflow to other parts of the ED if these rooms are full. All patients who are treated in one of these rooms are entered into the electronic medical record using the chief complaint “altered mental status.” We included adults if they presented to the ED for alcohol intoxication during the study period. These patients were identified using the EMR by querying for all visits where the chief complaint was “altered mental status ng for ir initial ED room was within the intoxication section of the ED. Patients were excluded if their breath alcohol concentration was zero. The variables for analyses were chosen a priori. We selected them if they were hypothesized to be relevant to the study population and if they were readily available in the EMR. A data analyst who was blinded to the purpose of the study obtained the following variables without any manual chart abstraction: age, gender, race/ethnicity, insurance status, primary care physician, medical/ psychiatric comorbidities, breath alcohol concentration, testing obtained , chemical sedation administered, ED disposition, and length of stay. Additional data for each frequent user was manually abstracted from the chart by another investigator ; these included counts of ED visits that were not for alcohol intoxication, hospital admissions, and visits to a separate psychiatric services ED. Multiple definitions for ED frequent users exist in the literature, ranging from 3-20 visits per 12-month period.For this study,hydroponic system for cannabis we elected to use the upper limit of this range and categorize an alcohol- related frequent user as greater than 20 visits for acute alcohol intoxication in the previous 12 months, in order to describe the highest-user cohort possible. Non-frequent users were those who did not meet this criterion. After we identified the frequent-user cohort, we analyzed encounter characteristics for those with a frequent-user designation during that visit compared to those without. For analysis of patient characteristics and demographics, duplicate observations were excluded. The patient encounter that was retained for demographic analysis was the most recent encounter during the study period.
For all comparisons, we calculated differences in means or proportions with associated 95% confidence intervals. We checked a subset of 20 charts to confirm accuracy of data abstraction.Frequent users for alcohol intoxication are a unique subset of frequent ED users who merit attention given increasing numbers of alcohol-related visits nationally.9 In this study, we identified 325 patients with 11,370 encounters for alcohol intoxication over a five-year period, where some individuals used the ED for alcohol intoxication more than 100 times in a year. In this study, we identified several variables that differed for frequent users compared to non-frequent users. First, there were comparatively higher rates of medical and psychiatric comorbidities among alcohol- related frequent users. This finding reiterates the complexity of this population, and the fact that any of these “routine” visits have the potential for clinical decompensation and may require resources beyond the scope of simple observation for intoxication. We also identified differences in demographics , as well as differences regarding health insurance status. In contrast, several variables were not different among the two groups; namely, diagnostic workups were similar between the groups, but interpretation of this finding is limited by practice patterns at our institution, where workups tend to be minimal for most alcohol intoxication encounters. Another important finding in this study was the low admission rate among frequent users. While it is not unexpected that presentations for alcohol intoxication would result in low admission rates , it does illustrate a potential barrier in caring for this population. In other studies describing frequent users for other general medical complaints, admission rates are reported to be as high as 40%.3 In those cases, interventions can be implemented as inpatients, and resources can be initiated during admissions. In the population we describe, since admissions are so uncommon, the responsibility may be on ED personnel to identify these patients, as they will not be addressed by an inpatient team. In our cohort of alcohol-related frequent users, we identified some concerning features regarding primary care access and utilization. Less than half of the frequent-user population had primary care physicians, and only 4% were participants in a coordinated primary care program intended for the hospital’s greatest utilizers. We believe that this is an important gap in coverage for a very high-needs population. This finding also contrasts the general ED frequent-user literature, where most describe primary care access as over 90%.Our institution does not appear to be identifying alcohol-related frequent users for primary care services as effectively as those who use the ED for other problems. Possible explanations for this gap in coverage could include a lack of readiness for healthcare accountability, or a struggle maintaining primary care relationships in the setting of ongoing substance abuse. We were unable to determine the prevalence of important social stressors such as homelessness, employment, or government assistance in this cohort, but addressing these stressors in future will play an important role in assisting this population.
Multiple social services interventions have been proposed for frequent ED users, such as case management and referral programs, but these have been shown to have variable rates of success.One study conducted in our community investigated use of case management and demographic-specific housing referrals among 92 chronic inebriates. While the study found that the healthcare costs decreased pre vs. post intervention, ED visits did not decrease.Oxygen desaturation below 70% puts patients at risk for dysrhythmia, hemoglobin decompensation, hypoxic brain injury, and death.The challenge for emergency physicians is to secure an endotracheal tube rapidly without critical hypoxia or aspiration.1 Preoxygenation prior to intubation extends the duration of “safe apnea” , to allow for placement of a definitive airway.Below that level, oxygen offloading from hemoglobin enters the steeper portion of the oxyhemoglobin dissociation curve, and can decrease to critical levels of oxygen saturation within seconds.Alveoli will continue to take up oxygen even without diaphragmatic movements or lung expansion. Within some of the larger airways, turbulent flow could generate a cascade of turbulent vortex flows extending into smaller airways.Denitrogenation involves using oxygen to wash out the nitrogen contained in lungs after breathing room air, resulting in a larger alveolar oxygen reservoir. When breathing room air , 450 mL of oxygen is present in the lungs of an average healthy adult. When a patient breathes 100% oxygen, this washes out the nitrogen, increasing the oxygen in the lungs to 3,000 mL. EPs and emergency medical services use several devices to deliver oxygen or increased airflow to patients in respiratory need. Nasal cannula is used primarily for apneic oxygenation rather than pre-oxygenation. Previous recommendations were to place high-flow nasal cannula with an initial oxygen flow rate of 4 L/min, then increase to 15 L/min to provide apneic oxygenation once the patient is sedated. A nasal cannula can be placed above the face mask until just prior to attempting laryngoscopy, at which point it is placed in the nares to facilitate apneic oxygenation. The standard non-rebreather mask delivers only 60% to 70% inspired oxygen at oxygen flow rates of 15 L/ min. The FiO2 can be improved by connecting the NRB to 30-60 L/min oxygen flows from rates of 15 L/min. The use of NRBs is limited in patients with high inspiratory flow rates as FiO2 may be decreased due to NRB design. Some devices with effective seals and valves will collapse onto the patients face at high inspiratory flow rates causing transient airway obstruction. A bag-valve mask may approximate an anesthesia circuit for preoxygenation. BVMs vary in performance according to the type of BVM device, spontaneous ventilation vs. positive pressure ventilation, and the presence of a positive end-expository pressure valve. During spontaneous ventilation the patient must produce sufficient negative inspiratory pressures to activate the inspiratory valve. The negative pressures generated within the mask may lead to entrapment of room air and lower FiO2 during pre oxygenation. A BVM’s performance increases during spontaneous breathing by administering high-flow oxygen, using a PEEP valve, and assisting spontaneous ventilations with positive pressure ventilations in synchrony with the patient’s spontaneous inspiratory efforts. Continuous positive airway pressure improves oxygenation by increasing functional residual capacity by reversing pulmonary shunting through the recruitment of poorly ventilated lung units.