Grand Rounds Recap 7/6/2016
/Operations Update with Dr. Palmer
Good to Great
STEMI: Door to EKG times <10 min
Stroke: Door to Doc: <10 min (Good Job!)
Door to Stroke Team: <15 min
Door to CT Start: <25 min
Door to CT Read: <45 min (Use the “Code Stroke” Head CT)
Door to needle (tPa): <60 min (Coming soon: <45 min)
Sepsis: Aggressive Resuscitation
Early, appropriate antibiotics
Lactate screening & trending-- (See Hidden Curriculum)
OB Stat: For use is a baby is / has come unexpectedly... check the call sheets around the ED
Leadership Curriculum with Dr. Stettler et al.
Three tier approach to teaching leadership that we participate in at UC:
In Grand Rounds: for everyone (come to Leadership Academy Planning Committee Meetings)
Academies: for self-selected groups (Education & Operations)
Mentored Projects: for individuals (One-on-one, focused on self-reflection and self-improvement)
Health Literacy with Dr. Axelson
Those who are classified as health illiterate are more likely to use the Emergency Department
You are the 1% from an educational perspective, remember that your patients are typically not
Safe to assume that your patients are reading at a 5th grade reading level, make your default instructions at this level
Pre-populated discharge instructions in the ED are written at high school reading level, "Easy-to-Read" at a middle school reading level
Use the dot phrase .edhealthliteracy for instructions written in a 5th grade reading level
Danecdote: The ED is not our patients' natural environment, remember how easy it is to be lost outside your comfort zone
Cognitive Bias with Dr. Hill
Traditional ED thinking:
Thinking Fast (Template recognition & Pattern matching)
Thinking Slow (What could this be?)
Recognition-Primed Decision Making: People don't consider all options when they don't have time, they just go with the first thing they think of.
See Dr. Hill's podcast regarding cognitive biases here
HIV Updates with Dr. Lyons
Who should we be screening?
⅛ people with HIV do not know they have the disease (13%)
Transmission reduces by 96% just based on diagnosing patients with HIV
HIV is a problem of disparity: minorities (African-Americans & MSM)
Symptom driven testing
Acute HIV: 96% of people presenting with acute HIV had fevers, 70% had pharyngitis
Consider in patients with: thrush, recurrent infection of any kind, lymphadenopathy, herpes, encephalopathy
If it is for diagnostic purposes (signs/symptoms of disease, will change management for the patient): order the lab test
Targeted screening
African American, homeless, IV drug use, alcoholic, prison, STI/pregnancy, MSM (Call EIP if available, order lab test if not)
Universal screening
Not here yet
Pre-exposure Prophylaxis (PrEP)
Taken correctly, its highly efficacious: >90% for transmission via sex; >70% for IVDU
Who should use this?
Those at risk of sexual transmission: Relationship with HIV+ partner, non-monogamous but partner known to be HIV-, MSM with unprotected anal intercourse or STD in last 6 mo
Those at risk for transmission via IVDU: Sharing needles in the last 6 months
Post-exposure Prophylaxis
Needle sticks happen (don’t recap needles)
Local practice pattern: EmergencyKT.com. Dr. Lyons recommends the New York Department of Health for their practice patterns.
Risk assessment after exposure:
Find out status of source patient (Ohio Law says consent is not required if infection control or designee finds that provider/EMS/peace officer has significant exposure while rendering care): Risks, prior testing history, epidemiology
Exposure Factors: Deep injury (OR 15), Visibly contaminated with blood, Needle placed in source patient vasculature, Source patient with advanced HIV, Mucocutaneous exposures (who knows?)
Exposed Patient Factors: Do they have the disease already? Pregnant? Other contraindications to the drugs themselves?
Does PEP work? Case control studies say yes, Monkey studies say yes
Initiation PEP
Lab testing of exposed: CBC, renal, hepatic (now in 2 weeks), HIV testing (baseline, 6wks, 4mo)
Drugs: toxicity & drug interactions, cost and access to drugs, 3 drug regimen (consider resistance), timing and adherence for 30 days
nPEP (non-occupational post exposure prophylaxis): in general, if they are exposed through a sexual exposure-- they should be on PEP
New Positive HIV Dx
Reactive test results: draw confirmatory test results but assume this is real
*You must disclose results if you order the test *(not necessarily you, but the patient has to be told)
Follow-up is Essential, Partner Issues are Essential
Ohio law surrounding disclosure: Individual who knows “shall” disclose to any other person with whom the individual intends to share needles, engage in sexual conduct (we are not required to tell partner/spouse)
ODH says: Ask partner to step out and ask the patient-- “Do you want to share this with your partner?” and then go from there.