Publications by authors named "Sean O Henderson"

57 Publications

The Impact of Implementing an Advance Practice Pharmacist-Led Anticoagulation Clinic Within a Correctional Facility.

J Pharm Pract 2019 Dec 9:897190019892120. Epub 2019 Dec 9.

Correctional Health Services, Los Angeles, CA, USA.

Maintaining warfarin in the therapeutic range is clinically challenging and can be made more complex in the correctional health setting. The care of an inmate population is complicated by its episodic and often brief nature in addition to the frequent lack of consistent care prior to incarceration. As part of a process improvement effort, a descriptive study was conducted on a unique pharmacist-led anticoagulation clinic that was initiated in the Los Angeles County jail. The advanced practice pharmacist (APP) used a Collaborative Practice Agreement and had access to a physician supervisor when necessary. The patients who arrived to the jail on warfarin had their doses adjusted by the APP according to their respective international normalized ratio (INR). The primary endpoints were percentage of INR readings within therapeutic range (RR) and time in therapeutic range (TTR). Secondary endpoints included bleeding and thrombotic events. A total of 141 patients were followed by the anticoagulation clinic over the initial 8-month period from September 2017 to April 2018. Indications for warfarin included deep vein thrombosis or pulmonary embolus (67%), mechanical valve (17%), atrial fibrillation (8%), and other (8%). The average RR was 74.1% in the 8 months following APP management, which met the definition of good control (>65%). The TTR was 67% which met the definition of good control (>65%). No bleeding or thrombotic events that required hospitalization occurred. Implementation of an APP-led anticoagulation clinic in a correctional health setting resulted in good INR control as defined in community standards.
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http://dx.doi.org/10.1177/0897190019892120DOI Listing
December 2019

Impact of a Pharmacist-Led Diabetes Clinic in a Correctional Setting.

J Pharm Pract 2019 Nov 19:897190019888075. Epub 2019 Nov 19.

Correctional Health Services, Los Angeles County Department of Health Services, Angeles, CA, USA.

Incarcerated patients often have a high disease burden and poor access to care in the community. In an effort to ensure glycemic control and appropriate initiation of statin therapy for cardiovascular (CV) risk reduction, a pilot program of pharmacist-led diabetes clinic (PLDC) was implemented in a large inner-city jail. A pre-post study was conducted as a quality improvement initiative. Inclusion criteria were inmate-patients (IPs) diagnosed with type 2 diabetes mellitus, treated with oral antidiabetic medications, managed by PLDC, and with at least 2 glycosylated hemoglobin As (HbA). The primary outcome was the change in HbA after PLDC. The secondary outcome was the frequency of statin therapy. A total of 240 IPs met the inclusion criteria. Mean HbA was 8.2% at baseline and 7.6% at the last follow-up encounter, a change of -0.7% (95% confidence interval [CI]: -0.41% to -0.93%). The most dramatic change was seen in the group with the highest initial HbA (HbA ≥ 10%), from a mean baseline HbA of 11.6% to 8.5%, a change of -3.1% (95% CI: -2.5% to -3.7%). IPs with an initial HbA between 7% and 9.9% showed a change in mean HbA from 8.4% to 8.0%, a change of -0.4% (95% CI: -0.1% to -0.7%). Of the 240 included IPs, 141 were not on a statin at baseline. The frequency of statin use increased by 50.4% after PLDC. PLDC significantly improved glycemic control and guideline concordance for CV risk reduction. Adding PLDC to multidisciplinary care teams has the potential to improve population health outcomes for this medically complex, yet underserved patient population.
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http://dx.doi.org/10.1177/0897190019888075DOI Listing
November 2019

Clinical Pharmacist's Role in an Alcohol Detox Unit in a Correctional Setting.

J Pharm Pract 2019 Nov 14:897190019888076. Epub 2019 Nov 14.

Correctional Health Services (CHS), Los Angeles County Department of Health Services (DHS), Los Angeles, CA, USA.

Introduction: Newly incarcerated inmates with chronic alcohol use are at high risk for alcohol withdrawal. This descriptive study aims to describe the role of a clinical pharmacist within an alcohol detoxification unit (ADU) in the Los Angeles County jail that serves nearly 18 000 inmates facility-wide daily.

Methods: This descriptive analysis was conducted from August 2, 2018 through October 31, 2018 within the jail ADU. The pharmacist attended daily assessments on all alcohol detox patients; identified and assessed patients at high risk of severe withdrawal; and initiated, modified, and discontinued withdrawal medication for selected patients. Patients were determined to be high risk of severe withdrawal if they had history of severe withdrawal, any Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) score ≥15, or polysubstance withdrawal.

Results: A total of 1263 patients were admitted to the ADU during the study (average 97 per week). A total of 282 patients were assessed by the pharmacist. Patient assessments included substance use and medication history, CIWA-Ar score, response to pharmacotherapy, and referral to a substance use counselor. Medications were initiated, modified, or discontinued in 148 patients after discussion with a physician. Transfer to an acute care facility occurred in 48 patients. Zero alcohol detox patient deaths occurred during the study.

Conclusion: This is a novel role of a pharmacist in a correctional setting. A pharmacist can aid in an ADU by identifying and assessing patients at high risk of severe withdrawal and managing pharmacotherapy. Future studies can examine pharmacist withdrawal management of additional substances.
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http://dx.doi.org/10.1177/0897190019888076DOI Listing
November 2019

Reduction in Jail Emergency Department Visits and Closure After Implementation of On-Site Urgent Care.

J Correct Health Care 2017 Jan;23(1):88-92

1 Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

This descriptive study evaluates the impact of implementation of full service on-site urgent care services at the Los Angeles County Jail (LACJ) by examining the number of patients seen at the referral hospital, Los Angeles County + University of Southern California Medical Center (LAC+USC), and the number of hours that the referral hospital was closed to transfers in the periods before and after the development of the LACJ Urgent Care. The appropriate utilization of public resources is a critical priority for an overburdened county medical health care system. Implementing on-site urgent care staffed by emergency physicians led to reductions in the average number of patients transferred to LAC+USC, the average number of monthly closure hours, and the average days per month when closure to transfer occurred, and a cost savings of some $2 million, primarily in personnel costs.
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http://dx.doi.org/10.1177/1078345816685563DOI Listing
January 2017

Inadequate Sensitivity of Laboratory Risk Indicator to Rule Out Necrotizing Fasciitis in the Emergency Department.

West J Emerg Med 2016 May 26;17(3):333-6. Epub 2016 Apr 26.

University of California Los Angeles, Department of Emergency Medicine, Los Angeles, California.

Introduction: Necrotizing fasciitis (NF) is a life-threatening illness, particularly when surgical debridement is delayed. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed to identify patients at higher risk for NF. Despite limited information in this regard, the LRINEC score is often used to "rule out" NF if negative. We describe the sensitivity of the LRINEC score in emergency department (ED) patients for the diagnosis of NF.

Methods: We conducted a chart review of ED patients in whom coding of hospital discharge diagnoses included NF. We employed standard methods to minimize bias. We used laboratory data to calculate the LRINEC score, and confirmed the diagnosis of NF via explicit chart review. We then calculated the sensitivity of a positive LRINEC score (standardly defined as six or greater) in our cohort. We examined the role of patient characteristics in the performance of the LRINEC score. Finally, we performed sensitivity analyses to estimate whether missing data for c-reactive protein (CRP) results were likely to impact our results.

Results: Of 266 ED patients coded as having a discharge diagnosis of NF, we were able to confirm the diagnosis, by chart review, in 167. We were able to calculate a LRINEC score in only 80 patients (due to absence of an initial CRP value); an LRINEC score of 6 or greater had a sensitivity of 77%. Sensitivity analyses of missing data supported our finding of inadequate sensitivity to rule out NF. In sub-analysis, NF patients with concurrent diabetes were more likely to be accurately categorized by the LRINEC score.

Conclusion: Used in isolation, the LRINEC score is not sufficiently sensitive to rule out NF in a general ED population.
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http://dx.doi.org/10.5811/westjem.2016.2.29069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4899066PMC
May 2016

Aminocaproic Acid and Tranexamic Acid Fail to Reverse Dabigatran-Induced Coagulopathy.

Am J Ther 2016 Nov/Dec;23(6):e1619-e1622

1Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, Los Angeles, CA; 2Department of Emergency Medicine, University of Southern California, Los Angeles, CA; 3University of Southern California, Los Angeles, CA; and 4Department of Emergency Medicine, University of Oklahoma School of Community Medicine, Tulsa, OK.

In recent years, dabigatran has emerged as a popular alternative to warfarin for treatment of atrial fibrillation. If rapid reversal is required, however, no reversal agent has clearly been established. The primary purpose of this manuscript was to evaluate the efficacy of tranexamic acid and aminocaproic acid as agents to reverse dabigatran-induced coagulopathy. Rats were randomly assigned to 6 groups. Each rat received either dabigatran or oral placebo, followed by saline, tranexamic acid, or aminocaproic acid. An activated clotting test was used to measure the coagulopathy. Neither tranexamic acid nor aminocaproic acid successfully reversed dabigatran-induced coagulopathy. In this rodent model of dabigatran-induced coagulopathy, neither tranexamic acid nor aminocaproic acid were able to reverse the coagulopathy.
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http://dx.doi.org/10.1097/MJT.0000000000000216DOI Listing
February 2017

Anticoagulation drug therapy: a review.

West J Emerg Med 2015 Jan 12;16(1):11-7. Epub 2015 Jan 12.

University of Southern California, LA+USC Medical Center, Department of Emergency Medicine, Los Angeles, California.

Historically, most patients who required parenteral anticoagulation received heparin, whereas those patients requiring oral anticoagulation received warfarin. Due to the narrow therapeutic index and need for frequent laboratory monitoring associated with warfarin, there has been a desire to develop newer, more effective anticoagulants. Consequently, in recent years many novel anticoagulants have been developed. The emergency physician may institute anticoagulation therapy in the short term (e.g. heparin) for a patient being admitted, or may start a novel anticoagulation for a patient being discharged. Similarly, a patient on a novel anticoagulant may present to the emergency department due to a hemorrhagic complication. Consequently, the emergency physician should be familiar with the newer and older anticoagulants. This review emphasizes the indication, mechanism of action, adverse effects, and potential reversal strategies for various anticoagulants that the emergency physician will likely encounter.
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http://dx.doi.org/10.5811/westjem.2014.12.22933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307693PMC
January 2015

Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission.

Ann Emerg Med 2014 Aug 13;64(2):167-75. Epub 2013 Nov 13.

Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA.

Study Objective: Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes.

Methods: This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction.

Results: Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction.

Conclusion: An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.
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http://dx.doi.org/10.1016/j.annemergmed.2013.10.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4019722PMC
August 2014

Death notification in the emergency department: survivors and physicians.

West J Emerg Med 2013 Mar;14(2):181-5

Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.

When patients die in the emergency department (ED), emergency physicians (EP) must disclose the bad news to family members. The death is often unexpected and the act of notification can be difficult. Many EPs have not been trained in the skill of communicating death to family members. This article reviews the available literature regarding ED death notification training and proposes future directions for educational interventions to improve physician communication in ED death disclosure.
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http://dx.doi.org/10.5811/westjem.2012.10.14193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628479PMC
March 2013

Electrocardiogram changes in Thyrotoxic Periodic Paralysis.

West J Emerg Med 2012 Dec;13(6):512-3

Los Angeles County USC Medical Center, USC Keck School of Medicine, Department of Emergency Medicine, Los Angeles, California.

Thyrotoxic periodic paralysis (TPP) attacks are characterized as recurrent, transient episodes of muscle weakness that range from mild weakness to complete flaccid paralysis. Episodes of weakness are accompanied by hypokalemia, which left untreated can lead to life-threatening arrhythmias (6). In this case study, we followed a patient's potassium levels analyzing how they correlate with electrocardiogram changes seen while treating his hypokalemia and ultimately his paralysis.
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http://dx.doi.org/10.5811/westjem.2011.11.12127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3555582PMC
December 2012

Reversal of thienopyridine-induced platelet dysfunction following desmopressin administration.

J Med Toxicol 2013 Jun;9(2):139-43

Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, Los Angeles, CA, 90033, USA.

Adenosine diphosphate (ADP)-receptor antagonists are widely used for thrombus prevention, although reversing their platelet dysfunction is difficult. This study evaluated the ability of desmopressin to reverse clopidogrel-induced platelet dysfunction. Sprague-Dawley rats received either clopidogrel (30 mg/kg) or placebo, followed 4 h later by saline or desmopressin (0.15, 0.3, or 0.6 μg/kg). Bleeding times and platelet aggregation studies were subsequently performed. A bleeding time >25 min was considered "prolonged." The median bleeding time for clopidogrel-exposed rats was 21 min, vs. 6 min for controls (p < 0.01). Progressively higher doses of 1-deamino-8-D-arginine vasopressin (DDAVP) were associated with a reduced number of rats with prolonged bleeding time (p = 0.001). Higher doses of DDAVP were also associated with a reduction in the median (IQR) bleeding time; 29 (13.5-30) min in rats receiving clopidogrel without DDAVP vs. 19 (12-28) min in rats receiving clopidogrel and 0.6 μg/kg DDAVP. The step-wise dosing of DDAVP resulted in a 54 % reduction in meeting the endpoint of prolonged bleeding time (OR 0.46; p = 0.025; 95 % CI 0.23-0.91). Platelet aggregation was observed in all control rats, but only some of those clopidogrel-treated rats who received 0.6 μg/kg DDAVP. In this model of an ADP-receptor antagonist, DDAVP results in partial reversal of clopidogrel-induced platelet dysfunction.
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http://dx.doi.org/10.1007/s13181-012-0275-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657025PMC
June 2013

The implementation of therapeutic hypothermia in the emergency department: a multi-institution case review.

Ther Hypothermia Temp Manag 2012 Sep;2(3):138-43

1 Keck School of Medicine of the University of Southern California , Los Angeles, California.

Background: The use of therapeutic hypothermia (TH) is a burgeoning treatment modality for post-cardiac arrest patients.

Objectives: We performed a retrospective chart review of patients who underwent post-cardiac arrest TH at eight different institutions across the United States. Our objectives were to assess how TH is currently being implemented in emergency departments and to examine the feasibility of conducting TH research using multi-institution prospective data.

Methods: A total of 94 cases were identified in a 3-year period and submitted for review by participating institutions of the Peri-Resuscitation Consortium. Of those, seven charts were excluded for missing data. Two independent reviewers performed the data abstraction. Results were subsequently compared, and discrepancies were resolved by a third reviewer. We assessed patient demographics, initial presenting rhythm, time until TH initiation, duration of TH, cooling methods and temperature reached, survival to hospital discharge, and neurological status on discharged.

Results: The majority of cases had initial cardiac rhythms of asystole or pulseless electrical activity (55.2%), followed by ventricular tachycardia or fibrillation (34.5%). The inciting cardiac rhythm was unknown in 10.3% of cases. Time to initiation of TH ranged from 0 to 783 minutes with a mean time of 99 minutes (SD=132). Length of TH ranged from 25 to 2,171 minutes with a mean time of 1,191 minutes (SD=536). The average minimum temperature achieved was 32.5°C, with a range from 27.6°C to 36.7°C (SD=1.5°C). Of the 87 charts reviewed, 29 (33.3%) of the patients survived to hospital discharge.

Conclusion: The implementation of TH across the country is extremely varied with no universally accepted treatment. While our study is limited by sample size, it illustrates some compelling trends. A large, prospective, multicenter trial or registry is necessary to elucidate further the optimal parameters for TH and its benefit in various population subsets.
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http://dx.doi.org/10.1089/ther.2012.0015DOI Listing
September 2012

End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest.

Prehosp Disaster Med 2011 Jun;26(3):148-50

Department of Emergency Medicine, University of Southern California, Los Angeles, CA, USA.

Objective: The objective of this study was to evaluate initial end-tidal CO2 (EtCO2) as a predictor of survival in out-of-hospital cardiac arrest.

Methods: This was a retrospective study of all adult, non-traumatic, out-of-hospital, cardiac arrests during 2006 and 2007 in Los Angeles, California. The primary outcome variable was attaining return of spontaneous circulation (ROSC) in the field. All demographic information was reviewed and logistic regression analysis was performed to determine which variables of the cardiac arrest were significantly associated with ROSC.

Results: There were 3,121 cardiac arrests included in the study, of which 1,689 (54.4%) were witnessed, and 516 (16.9%) were primary ventricular fibrillation (VF). The mean initial EtCO2 was 18.7 (95%CI = 18.2-19.3) for all patients. Return of spontaneous circulation was achieved in 695 patients (22.4%) for which the mean initial EtCO2 was 27.6 (95%CI = 26.3-29.0). For patients who failed to achieve ROSC, the mean EtCO2 was 16.0 (95%CI = 15.5-16.5). The following variables were significantly associated with achieving ROSC: witnessed arrest (OR = 1.51; 95%CI = 1.07-2.12); initial EtCO2 >10 (OR = 4.79; 95%CI = 3.10-4.42); and EtCO2 dropping <25% during the resuscitation (OR = 2.82; 95%CI = 2.01-3.97).The combination of male gender, lack of bystander cardiopulmonary resuscitation, unwitnessed collapse, non-vfib arrest, initial EtCO2 ≤10 and EtCO2 falling > 25% was 97% predictive of failure to achieve ROSC.

Conclusions: An initial EtCO2 >10 and the absence of a falling EtCO2 >25% from baseline were significantly associated with achieving ROSC in out-of-hospital cardiac arrest. These additional variables should be incorporated in termination of resuscitation algorithms in the prehospital setting.
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http://dx.doi.org/10.1017/S1049023X11006376DOI Listing
June 2011

Excited delirium.

West J Emerg Med 2011 Feb;12(1):77-83

University of California, San Diego School of Medicine.

Excited (or agitated) delirium is characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting. It is typically associated with the use of drugs that alter dopamine processing, hyperthermia, and, most notably, sometimes with death of the affected person in the custody of law enforcement. Subjects typically die from cardiopulmonary arrest, although the cause is debated. Unfortunately an adequate treatment plan has yet to be established, in part due to the fact that most patients die before hospital arrival. While there is still much to be discovered about the pathophysiology and treatment, it is hoped that this extensive review will provide both police and medical personnel with the information necessary to recognize and respond appropriately to excited delirium.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378PMC
February 2011

Excited Delirium Syndrome (ExDS): defining based on a review of the literature.

J Emerg Med 2012 Nov 25;43(5):897-905. Epub 2011 Mar 25.

Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California 92103, USA.

Background: Patients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include hyperthermia, "superhuman" strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as "Excited Delirium" deaths.

Objectives: This article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations.

Discussion: Excited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both.

Conclusions: Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.
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http://dx.doi.org/10.1016/j.jemermed.2011.02.017DOI Listing
November 2012

A standardized Code Blue Team eliminates variable survival from in-hospital cardiac arrest.

J Emerg Med 2012 Jan 26;42(1):74-8. Epub 2011 Feb 26.

Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California 90033, USA.

Background: Recent studies suggest that time of day affects survival from in-hospital cardiac arrest. Lower survival rates are observed during nights and on weekends, except in areas with consistent physician care, such as the Emergency Department. Since 1997, our hospital has utilized a standard, hospital-wide "Code Blue Team" (CBT) to respond to cardiac arrests at any time. This team is always led by an emergency physician, and includes specially trained nurses.

Objective: To assess if time of day or week affects survival from in-hospital cardiac arrest when a trained, consistent, emergency physician-led CBT is implemented.

Methods: This is an analysis of prospectively collected data on initial survival rates (return of spontaneous circulation >20 min) of all cardiac arrests that were managed by the CBT from 2000 to 2008. Cardiac arrests were also subcategorized based on initial cardiac rhythm. Survival rates were compared according to time of day or week.

Results: A total of 1692 cardiac arrests were included. There was no significant difference in the overall rate of initial survival between day/evening vs. night hours (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.83-1.29), or between weekday vs. weekend hours (OR 1.10, 95% CI 0.85-1.38). This held true for all cardiac rhythms.

Conclusion: At our institution, there is no significant difference in survival from cardiac arrest when a standardized "Code Blue Team" is utilized, regardless of the time of day or week.
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http://dx.doi.org/10.1016/j.jemermed.2010.10.023DOI Listing
January 2012

Diagnostic accuracy of point-of-care testing for diabetic ketoacidosis at emergency-department triage: {beta}-hydroxybutyrate versus the urine dipstick.

Diabetes Care 2011 Apr 9;34(4):852-4. Epub 2011 Feb 9.

Department of Clinical Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Objective: In the emergency department, hyperglycemic patients are screened for diabetic ketoacidosis (DKA) via a urine dipstick. In this prospective study, we compared the test characteristics of point-of-care β-hydroxybutyrate (β-OHB) analysis with the urine dipstick.

Research Design And Methods: Emergency-department patients with blood glucose ≥250 mg/dL had urine dipstick, chemistry panel, venous blood gas, and capillary β-OHB measurements. DKA was diagnosed according to American Diabetes Association criteria.

Results: Of 516 hyperglycemic subjects, 54 had DKA. The urine dipstick had a sensitivity of 98.1% (95% CI 90.1-100), a specificity of 35.1% (30.7-39.6), a positive predictive value of 15% (11.5-19.2), and a negative predictive value of 99.4% (96.6-100) for DKA. Using the manufacturer-suggested cutoff of >1.5 mmol/L, β-OHB had a sensitivity of 98.1% (90.1-100), a specificity of 78.6% (74.5-82.2), a positive predictive value of 34.9% (27.3-43), and a negative predictive value of 99.7% (98.5-100) for DKA.

Conclusions: Point-of-care β-OHB and the urine dipstick are equally sensitive for detecting DKA (98.1%). However, β-OHB is more specific (78.6 vs. 35.1%), offering the potential to significantly reduce unnecessary DKA work-ups among hyperglycemic patients in the emergency department.
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http://dx.doi.org/10.2337/dc10-1844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3064039PMC
April 2011

Use of therapeutic hypothermia in postcardiac arrest patients by emergency departments.

Ther Hypothermia Temp Manag 2011 ;1(1):23-7

1 Department of Emergency Medicine, Keck School of Medicine of the University of Southern California , Los Angeles, California.

Since 2003, resuscitation guidelines have recommended the use of induced hypothermia as a therapy for patients who achieve return of spontaneous circulation after cardiac arrest from ventricular fibrillation. The aim of this study was to survey emergency physicians across the United States on their use of therapeutic hypothermia (TH) after cardiac arrest. An 18-question survey was e-mailed to a sample of emergency physicians. Fifty-eight respondents completed the survey. Most (71%) were associated with an emergency medicine residency training program. Annual census ranged from 12,000 to >170,000 visits. TH is used by the majority (69%) of respondents, 79% of which report the presence of a formal institutional protocol. The majority of respondents use TH in arrest rhythms including but not limited to ventricular fibrillation, and 21% begin the process in the prehospital setting. To induce hypothermia, a majority of respondents use commercial cooling products. The average time to target temperature was 95 minutes. The majority of respondents report a goal temperature between 32°C and 34°C. A shivering protocol is used by 76% of respondents, and as a first line medication, 46% use benzodiazepines. For those who do not use TH or do not have a protocol in place, the reasons cited include "too expensive," "too difficult to implement," and "not enough science to warrant it." In this sample of practicing emergency physicians, TH after cardiac arrest is not being used as described in the original literature. Although awareness and implementation of TH have increased, there appears to be a wide variation in the application of this therapy.
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http://dx.doi.org/10.1089/ther.2010.0004DOI Listing
April 2014

Emergency department ultrasound by nurse practitioners.

J Am Acad Nurse Pract 2010 Jul;22(7):352-5

Department of Emergency Medicine, Keck/USC School of Medicine, Los Angeles, California 90033, USA.

Purpose: Bedside ultrasound (u/s) examinations by emergency physicians (EPs) have been integrated into clinical emergency medicine (EM) training programs and the efficacy and success of an introductory u/s training course, based on established guidelines, has been previously described. We used this same course to teach EM nurse practitioners (NPs) bedside u/s and then assessed the adequacy of NP ultrasonography 1 year following the course.

Data Sources: Five NPs were included in a standardized 16-h EM u/s training program. Subsequently, the NPs were asked to print consecutive u/s images representative of their clinical assessments. A single qualified EP reviewer assessed images for adequacy.

Conclusions: Five NPs reported 229 u/s examinations, two of which were excluded as nondiagnostic over the 2-month study period. There were 32 inadequate images and 27 "positive" findings. All the positives were correct. Totals per provider were 104, 58, 49, 13, and 3 u/s assessments with 83%, 95%, 84%, 77%, and 100% adequacy of images, respectively. Of the 32 inadequate images, 18 of these were incomplete focused assessment with sonography for trauma (FAST) examinations with a reading of negative for free fluid.

Implications For Practice: NPs are able to perform focused u/s with a high degree of accuracy, and a 16-h guideline-based course serves as a good introductory foundation.
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http://dx.doi.org/10.1111/j.1745-7599.2010.00518.xDOI Listing
July 2010

The utility of serial peak flow measurements in the acute asthmatic being treated in the ED.

Am J Emerg Med 2010 Feb;28(2):221-3

Department of Emergency Medicine, Keck/USC School of Medicine, Los Angeles, CA 90033, USA.

Background: Peak flow is used extensively in emergency departments (EDs) to both assess asthma patient's status on arrival as well as to document clinical improvement during treatment. Many algorithms suggest serial peak expiratory flow (PEF) measurements during an ED stay.

Objective: The aim of the study was to assess the contribution of serial PEF in describing the overall improvement of asthmatics over the course of an ED visit for acute exacerbation of their asthma.

Methods: This was a prospective institutional review board-approved study of mild/moderate asthmatics presenting to an inner-city ED serving a large Latino population. Peak expiratory flow was measured before treatment (baseline PEF) and after each inhaled treatment (PEF post RX#1, PEF post RX#2, PEF post RX#3) while in the ED.

Results: One hundred consecutive patients made up this study cohort. The change from baseline PEF to PEF #1 represented 86% (95% confidence interval [CI], 76%-96%) of the total improvement experienced by these patients with asthma. The change from PEF post RX#1 to PEF post RX#2 represented 7.5% (95% CI, -4.2% to 26%) of the total improvement and PEF post RX#2 to PEF post RX#3 represented 8.6% (95% CI, -1% to 34%) of the total PEF improvement seen.

Limitation: No correlation between outcome and PEF% of predicted was made or implied.

Conclusion: The improvement in PEF seen after the first ED inhaled therapy appears to describe most of the total improvement seen in asthmatic patients. Subsequent PEFs provided little additional information.
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http://dx.doi.org/10.1016/j.ajem.2008.10.031DOI Listing
February 2010

EMS and managed care: the Los Angeles experience.

Prehosp Emerg Care 2010 Apr-Jun;14(2):245-9

Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Patients belonging to a managed care organization (MCO) who call 9-1-1 are typically transported to their MCO facility only if it is also the closest emergency department (ED). As past medical records and close follow-up are unavailable at the non-MCO facility, unnecessary workups and/or admissions may result.

Objective: To examine the safety and feasibility of preferentially transporting MCO patients to the closest MCO ED rather than the closest ED.

Methods: This was a retrospective review over a 52-month period comparing all patients transported by ambulance to an MCO ED when that destination was not the closest ED (targeted group) with all other transported patients. If the MCO facility was not the closest ED, then the emergency medical services (EMS) provider would be reimbursed an additional fee beyond the routine ambulance charges. The primary outcome measure was the additional ambulance transport time. The secondary outcome measure was mortality within the first 24 hours.

Results: There were 15,938 patients transported under this program from July 2000 through December 2004 for whom outcome data were available. Of these, 10,532 (66%) were transported by advanced life support (ALS) ambulance. The mean (+/- standard deviation) transport time to the hospital for all targeted patients transported during the study interval was 10.4 minutes (+/-3.2 minutes) compared with 8.6 minutes (+/-2.1 minutes) for all transported patients (p < 0.001). No patient required ventilatory support in the field. Twelve (0.1%) patients died during the subsequent hospital admission and, after a blinded chart review, none of the deaths were deemed to be preventable or likely to have resulted from additional transport time.

Conclusion: Our study suggests that paramedic transport of MCO patients to the nearest MCO hospital in lieu of the nearest ED is safe and feasible. Given the potential benefits to patient care, this program should be evaluated in other EMS systems.
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http://dx.doi.org/10.3109/10903120903537197DOI Listing
June 2010

Racial/ethnic differences in bystander CPR in Los Angeles, California.

Ethn Dis 2009 ;19(4):401-6

Department of Emergency Medicine, Keck/USC School of Medicine, Los Angeles, CA, USA.

Background: Bystander CPR (BCPR) has been demonstrated to improve rates of return of spontaneous circulation, survival to hospital admission, and quality of life in survivors. While previous studies have shown that African Americans are less likely to receive BCPR than Caucasians even after adjusting for variables such as socioeconomic status, BCPR rates in Latinos have not been reported.

Objective: To describe BCPR rates in an urban African American and Latino population as compared to Caucasians.

Methods: A retrospective analysis of the Cardiac Arrest Resuscitation Evaluation in Los Angeles (CARE-LA) database combined with the California Death Statistical Master File (CDSMF). The combined database included location, race/ethnicity/ethnic background, witnessed status, socioeconomic status, and other variables that have previously been associated with differing rates of BCPR.

Results: There were 814 individuals included in the final study group (53% Caucasian, 28% African American, 19% Latino). African Americans and Latinos were younger than the Caucasians, had more events in the home and had a bystander CPR rate of 13% compared to 24% for the Caucasians (OR=0.47 (95%CI: 0.30-0.74) for African Americans and OR=0.48 (95%CI:0.28-0.80) for the Latinos). Bystander CPR was found to be an independent predictor of survival to hospital discharge and, after adjustment, Latino ethnicity was associated with lower rates of bystander CPR (OR 0.45 (95%CI:0.22-0.92)).

Conclusion: After adjusting for other variables, Latinos in Los Angeles receive bystander CPR at approximately half the rate of Caucasians.
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March 2010

Supraglottic laryngeal mass.

West J Emerg Med 2009 Nov;10(4):298-9

Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791740PMC
November 2009

Xanthogranulomatous pyelonephritis presentation in the ED: a case report.

Am J Emerg Med 2009 Nov;27(9):1175.e1-3

University of Southern California Keck School of Medicine, Los Angeles, CA, USA.

Xanthogranulomatous pyelonephritis (XGP) is a slowly progressive, chronic kidney infection. It presents with nonspecific symptoms and is definitively diagnosed by surgical examination. Xanthogranulomatous pyelonephritis must be differentiated in the emergency department (ED) from acutely progressive conditions, such as emphysematous pyelonephritis, which require immediate intervention. Xanthogranulomatous pyelonephritis requires nephrectomy; however, emergent kidney removal is not crucial. The low prevalence and nonspecific presentation of XGP increase the importance of recognizing common risk factors and comorbidities, such as type 2 diabetes, hyperlipidemia, and untreated urinary tract infections. Computed tomography (CT) scan is crucial in XGP assessment and should be obtained quickly upon presentation.
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http://dx.doi.org/10.1016/j.ajem.2009.01.028DOI Listing
November 2009

Left ventricular hypertrophy may be transient in the emergency department.

West J Emerg Med 2009 Aug;10(3):140-3

Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA.

Background: While research has established that the bedside electrocardiogram (ECG) is an insensitive test for the presence or absence of left ventricular hypertrophy (LVH), the finding, when present, is thought to be reproducible.

Objective: To assess the reproducibility of serial ECGs done in the emergency department (ED) with regard to the presence or absence of LVH.

Method: A prospective study on consecutive patients admitted to an ED-run cardiac observation unit. A single reviewer collected and scored ECGs for the presence of LVH, using three established criteria (Cornell, Sokolow-Lyon and Romhilt-Estes). Demographic and medical history was also collected.

Results: Over a three-year time period, 295 patients were enrolled; 132 males and 163 females with a mean age of 54.4 years (range, 19-89 years). The prevalence of LVH ranged from 11-14% and the agreement among all three criteria was fair (kappa = 0.325). Using the Cornell criteria, 33 patients had ECG#1 consistent with LVH. Of the patients meeting LVH criteria on ECG #1, only 15 retained their diagnosis of LVH on ECG#2 (i.e. 55% of the LVH identified in ECG#1 was not seen in ECG#2). Additionally, nine patients developed an ECG diagnosis of LVH between ECG#1 and ECG#2. In total, 27 (nine percent of the total) had ECG measurements that changed between ECG#1 and ECG#2. We made similar findings with the Sokolow-Lyon and Romhilt-Estes criteria. The results were not modified by gender, blood pressure or medication use.

Conclusion: The finding of LVH on ECG was not very reproducible during serial measurements on the same person during a single 24-hour observation period.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729211PMC
August 2009

Use of the trendelenburg position in the porcine model improves carotid flow during cardiopulmonary resuscitation.

West J Emerg Med 2008 Nov;9(4):206-11

Northridge Hospital, Northridge California.

Background: Cardiopulmonary resuscitation (CPR) is now widely used as a treatment for ventricular fibrillation, though numerous studies have shown the outcome of standard CPR to be dismal. Alternative methods of CPR, including interposed abdominal compression, constant aortic occlusion, and the use of intrathoracic pressure regulator, have been shown to increase cardiac output and affect the mortality rate of CPR.

Objectives: Here we suggest the Trendelenburg position as yet another method of increasing cardiac output and therefore improving the effectiveness of chest compressions. We hypothesized that the use of the Trendelenburg position during CPR would increase cardiac output as measured by carotid blood flow.

Methods: We anaesthetized six pigs and measured their pre-arrest carotid flow rate for two minutes. We then induced ventricular fibrillation in those pigs and performed open-chest CPR on them. Post-arrest carotid blood flow was measured for two minutes each at 0 (supine position), 10, 20, and 30 degrees of head-down tilt in each pig. The mean carotid flow for each degree of tilt was compared to mean carotid flow at 0 degrees of tilt using a paired student t-test.

Results: We found an increase of up to 1.4-fold in carotid blood flow during CPR in the Trendelenburg position, though only 20 and 30 degrees of Trendelenburg showed a statistically significant increase from the 0 degrees of tilt in pigs.

Conclusion: The Trendelenburg position can lead to increased blood flow through the carotid arteries during CPR in this pig model. Future studies should investigate whether this increased blood flow through the carotid arteries leads to improved brain perfusion and better neurologic outcomes.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672278PMC
November 2008

Images in emergency medicine: traumatic pneumocephalus.

West J Emerg Med 2008 May;9(2):123

Keck School of Medicine of the University of Southern California.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672246PMC
May 2008

Point: diagnostic radiation: why aren't we stopping (or at least slowing down)?

Authors:
Sean O Henderson

West J Emerg Med 2008 May;9(2):118-9

Keck School of Medicine of the University of Southern California.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672243PMC
May 2008

The presence of an Emergency Airway Response Team and its effects on in-hospital Code Blue.

J Emerg Med 2009 Feb 28;36(2):116-20. Epub 2008 Mar 28.

Department of Emergency Medicine, Keck/USC School of Medicine, Los Angeles, California, USA.

The survival rate from in-hospital cardiac arrest due to pulseless electrical activity (PEA)/asystole in our institution was higher than expected (70%). It was the impression of the Emergency Department-led Code Blue Team (CBT) that many of these patients were actually suffering respiratory arrests before their cardiac events. To address this, the facility developed an early intervention team focused on early airway intervention-the Emergency Airway Response Team (EART). The objective of this study was to assess the effect of early intervention in patients during the "pre-Code Blue" period, specifically with regard to airway stabilization. Our hypothesis was that there would be fewer CBT calls (cardiac arrests) due to PEA and asystole and that the survival from these events would decrease. This was a retrospective review of all cardiac arrests responded to by the CBT and EART for a period of 2 years. Charts were reviewed for the initial presenting rhythm (as defined by the Utstein Format) and event survival for the 12-month period immediately before and immediately after the establishment of the EART (Time Periods 1 and 2, respectively). The total number of CBT calls decreased by 15%, return of spontaneous circulation from any rhythm decreased by 9%, and survival to discharge decreased by 8% (p = non-significant). The number of CBT calls specifically for asystole/PEA decreased by 8%. Deaths in hospital were significantly associated with Period 2 (odds ratio 1.84; 95% confidence interval 1.03-3.28) after adjusting for age, gender, and presenting rhythms. The total number of CBT calls decreased slightly with the creation of the Emergency Airway Response Team. Return of spontaneous circulation and survival to hospital discharge after cardiac arrest due to asystole/PEA were significantly decreased, suggesting early intervention may have benefit.
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http://dx.doi.org/10.1016/j.jemermed.2007.10.022DOI Listing
February 2009

A prospective clinical trial evaluating urinary 5-hydroxyindoleacetic acid levels in the diagnosis of acute appendicitis.

Am J Emerg Med 2008 Mar;26(3):282-6

Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA.

Background: To improve the diagnostic accuracy of identifying acute appendicitis, imaging modalities, such as ultrasound and the computed tomography scan, are used in combination with the history and physical examination. There is no reliable single laboratory marker to assist with this diagnosis. During inflammation, enterochromaffin cells in the appendix secrete serotonin, and 5-hydroxyindoleacetic acid (5-HIAA), a serotonin metabolite excreted in urine, has been found to be elevated in patients presenting with acute appendicitis.

Objective: The aim of this study was to measure the urinary 5-HIAA concentrations of patients presenting with symptoms of acute appendicitis to determine the sensitivity and specificity of urinary 5-HIAA levels for diagnosing acute appendicitis.

Methods: 5-HIAA was quantitatively measured by high-performance liquid chromatography in the spot urine of 100 healthy individuals, aged 18 to 70 years, who presented to the emergency medicine department with a clinical picture of acute appendicitis. Urine concentration results were correlated to the gold standard of histopathologic reports of removed appendices. The sensitivity, specificity, and their 95% confidence intervals were derived.

Results: Of the 100 patients presenting with symptoms consistent with acute appendicitis, 72 had appendectomies and 2 had cholecystectomies. The remaining 26 patients were discharged after hospital observation. A total of 64 patients were found to have appendicitis: 52 had acute appendicitis, whereas 12 had perforated and/or gangrenous (nonacute) appendices. The acute appendicitis group had a mean urinary 5-HIAA level of 19.31 micromol/L, slightly lower than the 23.10 micromol/L of the patients with gangrenous/perforated appendicitis. The group without appendicitis had a urinary 5-HIAA value of 17.27 micromol/L. Using the lowest of previously reported cutoffs, we calculated the sensitivity and specificity of this test for acute appendicitis as 63% and 33%, respectively.

Conclusion: Urinary 5-HIAA level is not a good diagnostic tool for determining acute appendicitis.
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http://dx.doi.org/10.1016/j.ajem.2007.05.012DOI Listing
March 2008