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: 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.