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Surge capacity for optimization of access to hospital beds is a limiting factor in response to catastrophic events. Regional healthcare facilities and supporting local emergency response agencies developed a coalition (the Healthcare Facilities Partnership of South Central Pennsylvania; HCFP-SCPA) to increase regional surge capacity and emergency preparedness for healthcare facilities.
In comparison to baseline measurements, the coalition improved existing areas covered under all 6 objectives documented during a 24-month evaluation period. The HCFP-SCPA successfully increased preparedness and surge capacity through a partnership of regional healthcare facilities and emergency response agencies.
The purpose of this article is to describe an approach to improve surge capacity, in this case for hospital and ED treatment areas. Figure 1The South Central region of Pennsylvania consists of 8 counties (Adams, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Perry, and York), 17 acute care hospitals, emergency medical services (EMS), and county-based emergency management.
The Partnership leveraged the structure of the South Central Pennsylvania Regional Counter-Terrorism Task Force (SCTF), EMAs, and the Emergency Health System Federation (EHSF, regional EMS agency) as important and established entities with an identical geography to that of the HCFP-SCPA with which to formulate planning efforts.
Also in place before the development of the Partnership was the federal Emergency System for Advance Registration of Volunteer Health Professionals Program (ESAR-VHP). After the grant was awarded, personnel from the SCTF, the largest 7 EMS companies, and 11 hospitals within the region were provided the opportunity to participate in specific roles including planning, collaboration, development, and training activities.
Four primary teams were formed within the Partnership to establish modes, mechanisms, procedures, and evaluation techniques to fulfill the goals created for the grant.
Through early Partnership discussions, a consensus was reached that surge capacity would be defined as “the number of adequately staffed beds that can be provided in addition to the normal demand within 2 hours of an incident,” which includes accounting for both inpatient and ED treatment beds. Specific, measurable, achievable, realistic, and time-framed (SMART) objectives were created from the 6 grant objectives.
Inclusive and frequent communication was evaluated as essential for the Partnership to act as 1 cohesive unit. The Partnership conducted regularly scheduled discussions between regional healthcare facilities on shared needs to enhance surge capacity. These alerts were tested, improved, and practiced by using the Comprehensive Hazard and Vulnerability Analysis (HVA), the HSEEP, the pandemic influenza exercise (PanSurge07) assessment, and the PanFlu assessment. To gather effectiveness and outcomes data, brief Web-based surveys and polls, as well as larger hospital and regional exercises, were performed to quantify various outcomes and clarify roles and responsibilities. A SERV-PA administrator at each of the HCFP-SCPA hospital facilities was designated and trained.
The NIMS training requirements were simplified to become more appropriate for the hospital-based participants, and training was made more accessible to all Partnership hospitals, with an online certification process. After several months of information gathering and discussion, the Partnership evaluation and integration team identified 6 gaps in the overall progress and focused on remediating these specific gaps. Outcomes of the Partnership were targeted to be realistic, measurable, time-conscientious, and repeatable so as to be available for implementation by other hospital expanses looking to develop partnerships. Training, policies, and procedures for working with volunteers during a surge were developed or adopted. During the initial HAN alert system exercise, 76% of the hospitals confirmed receipt of HAN alerts and 45% of the personnel within the hospital received the alert. At baseline, an average of 38% of healthcare facilities responded to scheduled weekly alerts on the FRED and 800-MHz systems. Surge capacity was analyzed by a contemporaneous phone survey of cooperating hospitals of the region. During initial review, it was clear that many improvements to the emergency response system were needed in the region. During the granting period, we observed and demonstrated the importance of testing emergency response, not only as a single healthcare entity but also as a regional healthcare system. The members of the partnership were asked to disclose information to the HCFP-SCPA, and much of the data were reliant on this self-reporting.
The Partnership successfully increased preparedness and surge capacity through a coalition of regional healthcare facilities and emergency response agencies.
We would like to thank the members of the Healthcare Facilities Partnership of South Central Pennsylvania and their representatives: Hanover Hospital (Joshua Hale), Gettysburg Hospital (Ron Sterchak), Chambersburg Hospital (Vickie Negley), Waynesboro Hospital (Dan Farner), The New Carlisle Regional Medical Center (Georgeann Laughman), Holy Spirit Hospital (Jason Brown), Pinnacle Health (Christie Muza), Penn State Milton S. 9. US Department of Health and Human Services Assistant Secretary for Preparedness and Response. Direct oral anticoagulants (DOACs) offer a fixed-dose alternative to warfarin for stroke prevention in patients with atrial fibrillation. Department of Clinical Pharmacy Services, University of Massachusetts Medical School, 55 N.
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There have been numerous researches on pgRouting and the use of its algorithms for the shortest path analysis. Song XF, Kono Y, Shibayama M (2004) The development of web mapping application using open source GIS solution, International Symposium on Geoinformatics for Spatial Infrastructure Development in Earth and Allied SciencesSpanaki M, Antoniou B, Tsoulos L (2004) Web mapping and XML technologies, a close relationship. The elderly, defined as 65 years of age and older, are rapidly representing a larger portion of the population in the United States. The etiology of delirium in the elderly is multifactorial as any one or more predisposing and precipitating factors may be involved (Table 1). Commonly noted signs and symptoms for certain ailments are not always evident in the elderly.
Studies involving electroencephalograms, evoked-potential studies, neuroimaging, and other modalities suggest that neurotransmitter abnormalities are associated with delirium.5 At the cellular level, widespread alterations in cerebral metabolic activity with secondary deregulation of neurotransmitter synthesis and metabolism are present. Diagnosing delirium in the elderly requires recognition of the syndrome and a systematic approach (Figure).27 Some patients are obviously delirious. Dementia may be distinguished from delirium (Table 3)28 by the tempo of onset, clinical course, level of attention and consciousness, orientation, and changes in speech patterns.
Detailed history-taking may also require interviewing multiple people, including the prehospital providers who evaluated and transported the patient to the ED, family members, and other caregivers. A thorough physical examination is essential, especially if the cause of delirium is not obvious.
Standard questions should assess orientation to person, time, place, and self, as well as 3-item recall. The physical examination should continue in a head-to-toe systematic fashion with a keen eye toward findings that may mark an underlying precipitant condition.
Ancillary testing should be ordered as indicated by clinical examination, and usually include blood oxygen saturation, complete blood count, chemistry panel, urinalysis, and a chest radiograph.
Finally, additional studies worth considering are: arterial blood gas (hypercarbia, hypoxia), thyroid function tests (hypothyroid and hyperthyroid), liver function tests (liver failure, encephalopathy), blood alcohol level, drug levels (intoxication), toxin screens (overdose), rapid plasma reagin test (syphilis), vitamin B12 and folic acid (metabolic deficiencies) levels, and carbon monoxide level (hypoxia, poisoning)4,15 (Figure). Initial management of the delirious patient should start with the standard assessment of airway, breathing, circulation, and, if indicated, cervical spine precautions.
For elderly patients with hyperactive delirium, chemical restraints may be required to complete the examination, perform vital tests or procedures, or for personal safety. When providing analgesia, morphine should be used judiciously since any associated dysphoria, respiratory depression, and hepatic encephalopathy may be more pronounced in elderly patients.
Younger patients with delirium are more likely to be diagnosed as well as to recover fully, although mild cognitive dysfunction may linger for some time.
Delirium in elderly patients can manifest subtly and often may be the only sign of an underlying serious and potentially life-threatening illness. Emergency physicians should also be cognizant that many delirious elderly patients warrant and benefit from admission. Pain is the leading cause of emergency department (ED) visits for patients with sickle cell disease (SCD) [1]. Barriers to rapid and appropriate care of VOE in the ED are multifactorial and include systems-based limitations, such as acuity of the ED census, staffing limitations (eg, nurse-to-patient ratios), and facility limitations (eg, room availability) [6]. Gaps and variations in quality of care contribute to poor outcomes for patients with SCD [20,21].
This ED QI initiative was implemented at Children’s Hospital & Research Center Oakland, an urban free-standing pediatric hospital that serves a demographically diverse population. A multidisciplinary team consisting of ED staff and sickle cell center staff drafted a nursing-driven protocol for the assessment and management of acute pain associated with VOE, incorporating elements from a protocol in use by another WISCH collaborative member.
We selected performance measures from the bank developed by the WISCH team to track improvement and evaluate progress. The WISCH project coordinator reviewed records of visits to the ED for a baseline period of 6 months and post-order set implementaton.
All biostatistical analyses were conducted using Stata 9.2 (StataCorp, College Station, TX). Secondary analyses were conducted to evaluate whether mean pain scores were significantly different over the course of the ED visit for the 78 unique patients seen post order set implementation. For metric 3, percentage of visits with initial pain assessment within 30 minutes of triage, a model was not developed to assess the changes over time given that 100% of visits post order set implementation had the initial pain assessment within 30 minutes of triage, with the exception of one visit in September 2012 (Figure 2).
It can be seen in Figure 2 that staff performance on 3 of the 4 metrics (with the exception of initial analgesic within 30 minutes of triage) began to improve prior to implementing the order set. We performed secondary analyses to determine if performance on our first metric, mean time from triage to first analgesic dose, was associated with any improvement on the third pain assessment for the patients enrolled post order set implementation. We demonstrated that a QI initiative to improve acute pain management resulted in more timely assessment and treatment of pain in pediatric patients with SCD.
Another strategy that we used to insure that the changes we observed would be sustained was to create a multidisciplinary team to build knowledge, skills, and new practices, including learning from other WISCH grantees and the NICHQ coordinating center [23].
A previous study of a multi-institutional QI initiative aimed at improving acute SCD pain management for adult patients in the ED was unable to demonstrate an improvement in time to administration of initial analgesic [26]. We did not find that the QI intervention resulted in decreased admissions to the inpatient unit, with 68% of visits resulting in admission.
The project could not have been undertaken were it not for a small but determined multidisciplinary team of individuals who were personally invested in seeing the project come to fruition. Although protocol-driven interventions are designed to provide a certain degree of uniformity of care, the protocol was not designed nor utilized in such a way that it superseded the best medical judgment of the treating clinicians. With the goal of further reducing the time to administration of first analgesic dose in the ED setting, intranasal fentanyl will be utilized in our ED as the initial drug of choice for patients who do not object to or have a contraindication to its use. Implementation of a QI initiative in the ED has led to expeditious care for pediatric patients with SCD presenting with VOE.
Greg Kierce gives a tour of the Jersey City Office of Emergency Management & Homeland Security on Summit Avenue on Thursday, Oct.
Greg Kierce gives a tour of the Jersey City Office of Emergency Management & Homeland Security on Summit Avenue on Thursday, Oct. Medical facilities, communication tools, manpower, and resource reserves exist to respond to these events.
The coalition focused on 6 objectives: (1) increase awareness of capabilities and assets, (2) develop and pilot test advanced planning and exercising of plans in the region, (3) augment written medical mutual aid agreements, (4) develop and strengthen partnership relationships, (5) ensure National Incident Management System compliance, and (6) develop and test a plan for effective utilization of volunteer healthcare professionals.
Enhanced communications between the hospital coalition, and real-time exercises, were used to provide evidence of improved preparedness for putative mass casualty incidents. Furthermore, national-level exercises such as “Dark Winter” and the Homeland Security Exercise and Evaluation Program (HSEEP) have repeatedly exposed areas where the need for improvement in response is clear.3–7 For political leaders, health officials, hospital leaders, and emergency management officials, upholding public confidence in their respective institutions before, during, and after a catastrophic event is crucial. The timely availability of these treatment areas is crucial for all seriously ill and injured patients, and for the public’s health, when a mass casualty incident (MCI) occurs. The region is composed of both rural and micro and metro urban areas, and has a hospital capacity and capability that ordinarily serves the needs of these communities (Figure 1). The SCTF’s mission is to deliver a comprehensive and sustainable regional “all-hazards” emergency preparedness program that addresses planning, prevention, response, and recovery for events in South Central Pennsylvania that exceed local capabilities. It consists of more than 200 quick response services, basic life support services, and advanced life support services. The ESAR-VHP (a product of HHS in response to volunteer-related complications on September 11, 2001) is a registration program of healthcare professionals who will potentially volunteer their efforts in the event of a mass casualty event.
The project contracted with additional key partners to provide both technical assistance and outcomes measurements.
These teams were (1) education and development, (2) technology and simulation, (3) evaluation and integration, and (4) surge enhancement. The Healthcare Facilities Partnership of South Central Pennsylvania is composed of personnel from 17 hospitals, emergency medical service (EMS), and emergency management agencies (EMA) in the region. Two specific tools were implemented to enhance contact during meetings and to immediately collaborate on data and information: a desktop-sharing tool and a toll-free number.
Emphasis was based on frequent development, reduced dependency on face-to-face meetings, and growth of mutual understanding of hospital-based procedures.
These systems were the Facility Resource Emergency Database (FRED) system, an 800-MHz radio system, and the Health Alert Network (HAN) system. The Partnership also established triggers for activating those systems and created an “ideal communication” flow chart for the South Central Pennsylvania region. On the secured access portion of the portal, members of the Partnership are able to share information about the surge capability of their particular hospital.
To develop a library of low-cost repeatable training exercises, 3 computer simulations were created: a pandemic influenza outbreak (gradual and persistent surge simulation), mass casualty blast incident (sudden surge simulation), and a hospital evacuation scenario (“reverse” surge simulation). All participating healthcare facilities reviewed, enhanced, and agreed upon updated MMAAs that now included the availability of volunteers (SERV-PA). The administrators were given responsibility and oversight for volunteer alerts and organization of volunteers during an actual event. The gaps were identified as requirement for (1) increased capacity through staffing and alternative care sites, (2) improved efficiency through preparedness standardization, (3) decompression of hospitals by working with alternative care sites, (4) development of command and control and NIMS compliance, (5) development of improved transportation planning, and (6) enhanced surge capacity through broader participation. Progress was evaluated by the completion of the 59 SMART objectives (Table) and tested through implementation of 17 brief regional exercises. The 3 computer-based simulations were created and used throughout the region as an education tool. Seventeen regional data gathering and assessment exercises were conducted during the time period of the grant.
Fifteen of 17 hospitals appointed SERV-PA managers and all were sufficiently trained by the end of the granting period. This should lead to a greater ability for hospitals to meaningfully participate in disaster response. In all, 50% of hospitals were responding to the 800-MHz alert system, and 62% of hospitals were using the FRED alert system (31% used both systems). This was performed by using the Health Alert Network and Web portal communications as an alerting activity, followed by a teleconference documenting capacity for surge at 0700 and 1500 hours at each facility. Many systems that were expected to respond to MCI and other surge emergencies, such as NIMS, MMAAs, and ESAR-VHP, were in existence but not functioning optimally.
In particular, it is important for key jurisdictions within a healthcare region to practice communication in order for a flow of information to go from the initial dispatch to all of the key jurisdictions that need to respond, including hospitals.
Although the South Central Pennsylvania region has many communities, hospital facilities, and demographics that are similar to other regions, no 2 points across the country are the same.
Furthermore, we rely on the partners to uphold preparedness and surge quality after the end of the grant period.
At baseline, the healthcare facilities in our region of Pennsylvania had the ability to accommodate 10 critically ill patients. Hershey Medical Center (Scott Freeden), Good Samaritan Health System (Kim Crosson), Heart of Lancaster Regional Medical Center (Scott Marks), Ephrata Community Hospital (Gloria Jean Maser Fluck), Lancaster Regional Medical Center (Walter Roth), Lancaster General Hospital (Jeffery Manning), York Memorial Hospital (Lisa Ziegler), and York Hospital (Kevin Arthur). Homeland security exercise and evaluation program, volume I: HSEEP overview and exercise program management. However, there is minimal evidence to guide the management of bleeding in patients taking a DOAC. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.
Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban: a randomised crossover ex vivo study in healthy volunteers. In: ALENEX’07 (ed) Proceedings of the 2007 SIAM workshop on algorithm engineering and experiments.
7th AGILE International Conference on Geographic Information Science, GreeceYin F, Feng M (2009) A WebGIS framework for vector geospatial data sharing based on open source projects, Proceedings of the 2009 International Symposium on Web Information Systems and Applications (WISA’09), Nanchang, pp. Numerous studies have observed that emergency physicians often fail to identify and diagnose delirium in the elderly.


Delirium may manifest itself clinically in the hyperactive, the hypoactive, or the mixed form.11 The hyperactive form is identified by agitation, increased vigilance, and hallucinations. As compared to a younger, healthier patient, an elderly patient can enter a delirious state when exposed to a simple noxious insult or precipitating event. For example, an elderly patient may be experiencing respiratory difficulty, but not have dyspnea or tachypnea, or an acute myocardial infarction without the expected classic complaint of chest pain.
Patients who present without overt delirium pose a more difficult diagnostic challenge, especially when information or patient corroboration is limited. It is critical to ascertain the patient’s cognitive baseline, the recent sequence of events, any history of similar problems or prior episodes, new medications (including prescribed medications, dietary supplements, and over-the-counter agents), and any history of alcohol use or substance abuse. As with any patient, observation of the patient’s general behavior should be conducted as subtle or obvious abnormalities in breathing, walking, and reactions to activity or conversations in the room may be noted. An electrocardiogram should also be obtained because there is a higher risk of silent myocardial infarction in the elderly population.16 Elderly patients with cognitive dysfunction warrant special consideration as to whether or not they should undergo a lumbar puncture.
Intravenous access, cardiac monitoring, and simultaneous screening for readily reversible causes, such as hypoglycemia, hypoxia, and excessive opioid use should be initiated. As already noted, elderly patients with delirium generally do not fare as well and usually experience a persistent decline in their baseline level of functioning. Numerous studies have revealed that emergency physicians are not proficient at recognizing and diagnosing delirium in elderly patients or that they believe the condition is a normal process of aging. As the number of elderly patients presenting to EDs continues to increase, emergency physicians must strive to better appreciate, identify, and manage delirium in the elderly.
Geriatric emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of Emergency Care in the U.S.
A QI framework provided us with unique challenges but also invaluable lessons as we address our objective of decreasing the quality gap in SCD medical care. In the United States, 78% of the nearly 200,000 annual ED visits for SCD are for a complaint of pain [1].
Previous negative experiences in the ED can lead patients and families to delay seeking care or avoid the ED altogether despite severe VOE pain [16]. To help address these inequities, the Working to Improve Sickle Cell Healthcare (WISCH) project began in 2010 to improve care and outcomes for patients with SCD.
The protocol called for the immediate triage and assessment of all patients with SCD who presented with moderate to severe pain suggestive of VOE.
Providers gave input into the flow of the order set and wording, for example, clarifying language around when to draw a blood culture and how to re-dose the second and third analgesic doses.
These performance measures included (1) mean time from triage to first analgesic dose, (2) percentage of patients that received their first dose of analgesic within 30 minutes of triage, (3) percentage of patients who had a pain assessment performed within 30 minutes of triage, and (4) percentage of patients re-assessed within 30 minutes after the first dose of analgesic had been administered. Demographic data (age, gender), clinical data (hemoglobin type), pain scores, utilization data (number of ED visits during the study period), and data pertaining to the metrics chosen from the WISCH measurement bank were extracted from each eligible patient’s ED chart after the visit was completed. Descriptive statistics computed at 2 time-points (pre and post order set implementation) were utilized to examine means, standard deviations and percentages. A multivariable mixed linear model, for the outcome of the third pain score, was used to assess the associations with prior scores and to control for potential covariates (age, gender, number of ED visits, hemoglobin type) that were determined in advance.
The protocol was implemented in July 2012 and was utilized during 165 ED visits (91% of eligible visits) through April 2013. Significant improvements from baseline were achieved and sustained over a 10-month period in all 4 targeted metrics. We recognize that simply raising awareness and educating staff about the importance of timely and appropriate assessment and treatment of acute sickle cell related pain in the ED might be a potential confounder of our results.
We modified and adapted the intervention to our specific context [25]; although the outline of the order set was influenced by our WISCH colleagues, the final order set was structured to be consistent with other protocols within our institution. Our study with pediatric patients was able to demonstrate a clinically meaningful decrease in the time to administration of first parenteral analgesic. In a recent pediatric SCD study, hospital admissions for pain control accounted for 78% of all admissions and 70% of readmissions within 30 days [28]. Previous researchers [28] have emphasized the importance of coupling provider education with standardized order sets in efforts to improve the care of patients with SCD.
The identification of physician and nurse champions who were enthusiastic about the project, invested in its conduct, and committed to its success was a cornerstone of the project’s success. Deviations from the protocol were permissible when they were felt to be in the patient’s best interest.
Collection of data from patients and family members is being undertaken to assess consumer satisfaction with the ED QI initiative. A multidisciplinary approach, ongoing staff education, and commitment to the initiative have been necessary to sustain the improvements. Further support came from a grant from the Health Resources and Services Administration Sickle Cell Disease Treatment Demonstration Project Grant No.
However, these factors may not be optimally functioning to generate an effective and efficient surge response. This can be done by increasing preparedness for public health emergencies, largely those that require the ability to treat a large influx of patients (surge capacity). Within this region, a total of 17 acute care hospitals became members of the Partnership, which was supported by a federal grant from September 1, 2007, to August 8, 2009, inclusive of 2 no-cost extensions to the initial award.
The SCTF, supported primarily by grants from the Department of Homeland Security, is organized into approximately 10 functional groups and committees.
ESAR-VHP expedites the volunteer’s verification of identity, licenses, credentials, and accreditations. Each of the 59 SMART objectives created by the Partnership included a description of how to measure or document the objective, and the person or persons who took the lead to implement each, and provided a deadline for completion.
The desktop–sharing program (Webinar, Web-based seminar) was fully interactive, which allowed all attendees to present, respond to, and discuss information in real time. FRED is an Internet-based system that alerts facilities in the event of a crisis or situation that may warrant a coordinated response.
These flat-screen, computer-based simulations incorporated the HVA, PanSurge07, and PanFlu assessment results for at-risk medical populations. The HCFP-SCPA carried out a week-long recruiting event to encourage volunteers to register at each regional facility. Along with this, the Partnership launched a Web-based portal with a public and secure access to facilitate communication between partners and with the public. Incident scene operations may require emergency operations center (EOC) support for MCIs of significant magnitude. After each was performed, the partnership evaluated and reviewed the results to identify limitations in the region as a whole and within each Partnership facility.
More than 500 SERV-PA volunteers had been added within the region since the start of the project. At baseline in 2007, it was determined that total regional surge capacity for critical adult patients was 10 or less and for critical pediatric patients, 2 or less. It was clear to the Partnership that without significant practice and troubleshooting, the path of communication did not move rapidly from the initial dispatch to all of the event catchment hospitals. Simulation training with the regional facilities is a priority and is crucial to sustain regional disaster preparedness. Each region has individual requirements, restrictions, and resources, which may differ from ours. Although we believe that our partners are dedicated to emergency preparedness and increasing surge capacity, the incident of fraudulence is possible. At the conclusion of the study, the Partnership has practiced a regional response to a large surge event and has found an increase in capacity that exceeds 100 patients. We would also like to thank Osteopathic Hospital, The Lebanon Veterans Affairs Medical Center, The University Physicians Group-Fishburn, the University Physicians Group-Middletown, and The South Central Pennsylvania Regional Counter-Terrorism Task Force.
We retrospectively evaluated the acute management of major bleeding in this patient population at a large, tertiary academic medical center. SIAMBruce M (2000) PostgreSQL: introduction and concepts, Addison-WesleyChoosumrong S, Raghavan V, Delucchi L, Yoshida V (2014) Implementation of dynamic routing as a web service for emergency routing decision planning. 124–127Yongtaek and Hyunmyung (2005) A shortest path algorithm for real road network based on path overlap.
These studies also suggest that even when emergency physicians recognized delirium, they still may not have fully appreciated the import of the diagnosis. Although multiple neurotransmitters have been implicated, the most prominent agent in the development of delirium is acetylcholine. Most etiologies of delirium may be uncovered by a guided history and physical examination, with special emphasis on medication history, combined with focused ancillary testing and a search for occult infection.5 An important caveat to remember is that a delirious person may be oriented to person, place, and time, but that apparent alertness and orientation do not preclude delirium. The course usually does not fluctuate throughout the day, and inattention and disorientation are not usually observed until the latter stages of dementia.
Delirious patients are easily distracted and have difficulty maintaining focus and performing simple repetitive tasks, such as counting backwards from 100 by 7s or reciting the days of the week or months backwards. The areas tested are: orientation, registration, attention and calculation, recall, and language and praxis. The classic meningeal findings of fever, headache, and stiff neck are often absent.16,32 A retrospective chart review studied the utility of lumbar puncture (LP) to detect meningitis in elderly patients with altered mental status, including those afebrile on presentation. The views expressed are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the US Government. Leibovich, MD, Fernando Barreda, BS, Anne Marsh, MD, Ginny Gildengorin, PhD, and Claudia R.
Guidelines for the management of sickle cell vaso-occlusive pain episodes (VOE) suggest prompt initiation of parenteral opioids, use of effective opioid doses, and repeat opioid doses at frequent intervals [2–4].
Biases and misunderstandings amongst providers about sickle cell pain and adequate medication dosing may also play a role [11–13]. Patients report frustration with the lack of consideration that they receive for their reports of pain, perceived insensitivity of hospital staff, inadequate analgesic administration, staff preoccupation with concerns of drug addiction, and an overall lack of respect and trust [17–19]. WISCH is a collaborative quality improvement (QI) project funded by the Health Resources and Services Administration (HRSA) that has the goal to use improvement science to improve outcomes for patients with SCD across the life course (Ed note: see Editorial by Oyeku et al in this issue). Moderate to severe pain was defined as a pain score of ? 5 on a numeric scale of 0 to 10, where 0 = no pain and 10 = the worst pain imaginable. Our aims were to have 80% of patients assessed and given pain medications within 30 minutes of triage, and to have 80% of patients re-assessed within 30 minutes after having received their first dose of an analgesic, within 12 months of implementing our intervention.
If patients were admitted, their length of hospitalization was extracted from their inpatient medical record.
The 2 time-points were initially compared at the visit level of measurement, using Student’s t tests corrected for unequal variances where necessary for continuous variables and chi-square analyses for categorical variables, to evaluate if there was an improvement in timely triage, assessment, and treatment of acute VOE pain for all ED visits pre and post order set implementation. There were no statistically significant differences in demographic or clinical characteristics between the 55 patients whose charts were reviewed prior to implementing the order set and the 78 unique patients treated thereafter. For metric 4, 3 of the months post order set implementation had 100% of visits re-assessed within 30 minutes of the first IV pain medication (Figure 2). There was no significant change in the percentage of patients admitted to the inpatient unit. However, changes were sustained for 10 months post order set implementation and beyond, with no evidence that the performance on the target metrics is drifting back to baseline levels.
The factors that account for the discrepant findings between these studies are likely multifactorial. The investigators found that use of a SCD analgesic protocol including patient-controlled analgesia (PCA) improved quality of care as well as hospital readmission rates within 30 days (from 28% to 11%). Although we did not offer monthly formal education to our providers, the immediate follow-up when there were protocol deviations most likely served as teaching moments. These champions played an essential role in engaging staff interest in the project and oversaw the practicalities of implementing a new protocol in the ED. The study did not control for confounding variables such as disease severity, how long the patient had been in pain prior to coming to the ED, nor did we assess therapeutic interventions the patient had utilized at home prior to seeking out care in the ED. Recognizing that the ED management of acute pain addresses only one aspect of sickle cell pain, we are looking at ways to more comprehensively address pain. Our success can provide a template for other QI initiatives in the ED that translate to improved patient care for other diseases. Emergency department visits made by patients with sickle cell disease: a descriptive study, 1999-2007.
Pain management in adults with sickle cell disease in a medical center emergency department. A comparison of analgesic management for emergency department patients with sickle cell disease and renal colic.
Adult emergency department patients with sickle cell pain crisis: a learning collaborative model to improve analgesic management.
Evaluation and treatment of sickle cell pain in the emergency department: paths to a better future.
The impact of race and disease on sickle cell patient wait times in the emergency department. Treatment and prevention of pain due to vaso-occlusive crises in adults with sickle cell disease: an educational void. The association of provider communication with trust among adults with sickle cell disease. Pain management and symptoms of substance dependence among patients with sickle cell disease.
Understanding the causes of problematic pain management in sickle cell disease: evidence that pseudoaddiction plays a more important role than genuine analgesic dependence. Experiences of hospital care and treatment seeking for pain from sickle cell disease: qualitative study.
Hemoglobinopathy Learning Collaborative: using quality improvement (QI) to achieve equity in health care quality, coordination, and outcomes for sickle cell disease.
Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management. Multi-modal intervention and prospective implementation of standardized sickle cell pain admission orders reduces 30-day readmission rate. It consists of representatives from 16 hospitals, the Office of Public Health Preparedness, 8 county EMAs, and other critical entities required for public health and safety for a population of about 2 million people. The EHSF also works to improve preparedness and recruitment and provides regional resources that can be deployed in the event of a required response.
In the state of Pennsylvania, ESAR-VHP is known as The State Emergency Registry of Volunteers in Pennsylvania (SERV-PA). Teams met regularly to discuss current developments and to further the goals as set forth by the HCFP as a whole. It provides information about the emergency and enables facilities to report about available resources. The portal also kept a central repository for information regarding availability of equipment, similar to that of the National Hospital Available Beds for Emergencies and Disasters System developed by the Agency for Healthcare Research and Quality.
The SERV-PA program was advertised on the Partnership Web site and at several of the hospitals in the region to further encourage volunteer enrollment. A regional “ideal communication flow chart” (Figure 3) was created and trigger points for surge response were identified and agreed upon to further strengthen communication. The EMAs are then responsible for producing a Pennsylvania Emergency Incident Reporting System (PEIRS) report. This compares favorably with the 600 volunteers that were available statewide at the beginning of the Partnership. 2, 100% of the hospitals confirmed receipt of the alert and 47% of the personal within the hosptials confirmed receipt.
At the conclusion of the grant, all hospitals had the 800-MHz radio, wired and monitored continually, and had practiced receiving the FRED alert. The computer-based simulation added additional interactive and qualitative data and measurements that exceeded previous real-time exercises, such as tabletops. Similarly, while we feel that improvement in hospital personnel participation is a result of participation in, and actions of, the HCFP-SCPA, the possibility exists that subjects improve or modify an aspect of their behavior that is being experimentally measured in response to the fact that they are being studied. We would also like to thank Nancy Flint, Carla Perry, Shannon Harrington, and Lee Groff for their help. We evaluated various strategies of management including dialysis, transfusions, pharmacologic agents, surgical intervention, and reinitiation of anticoagulation.


The increasing pervasiveness of natural disasters is drawing people to pay more attention to quick emergency response and planning. Geoinformatics, International Journal ofDonnelly FP (2010) Evaluating open source GIS for libraries. J East Asia Soc Transportation Stud 6:1426–1438Zhan FB (1997) Three fastest shortest path algorithms on real road networks. Delirium is not a normal manifestation of aging and, often, is the only sign of a serious underlying medical condition. Often, this leads the caregiver or practitioner to believe that the patient is doing fine due to the lack of any sign of discomfort or distress. Delirium is frequently caused by anticholinergic drugs, and increased serum anticholinergic activity has been demonstrated in delirious elderly patients.5,22,23Elevated serotonin levels have been identified in patients with sepsis, hepatic encephalopathy, serotonin syndrome, and psychedelic drug ingestion. Eliciting a more subtle presentation may require more substantial questioning.11 Unfortunately, early or evolving baseline dementia may complicate initial evaluation. A demented individual’s speech may be marked by parsimony, anomia, or even aphasia, while a delirious person will talk incoherently, illogically, and have dysnomia. To offset this limitation, the patient’s category fluency (eg, name as many animals as possible in 1 minute) and phonemic fluency (eg, name as many words beginning with the letter “F” in 1 minute) should be tested. However, if not diagnosed and treated promptly, delirium in elderly patients is associated with strikingly elevated morbidity and mortality rates. These provider biases often lead to undertreatment of the pain, which in turn can lead to pseudoaddiction (drug-seeking behavior due to inadequate treatment) and a cycle of increased ED and inpatient utilization [14,15].
Patients also perceive a lack of knowledge of SCD and its treatments on the part of ED staff [7]. As one of the HRSA-WISCH grantee networks, we undertook a QI project designed to decrease the quality gap in SCD medical care by creating and implementing a protocol for ED pain management for pediatric patients. Exclusion criteria included a chief complaint of pain not considered secondary to VOE (eg, trauma, fracture).
Prior to implementation of the order set, over 90% of ED staff (nurses, residents and attendings), hematology attendings, and fellows participated in in-service training on the new protocol, its rationale, and expectations for the intervention.
To account for trends and possible correlations across the months post order set implementation, we ran a mixed linear model with repeated measures over time to compare visits during all months post order set implementation with the baseline months, for metric 1, time from triage to first pain medication. While we also achieved our goal to have 80% of patients re-assessed within 30 minutes after having received their first dose of an analgesic, we fell short in the percent who received their initial pain medication within 30 minutes of triage (52.7% versus goal of 80%).
Education and awareness-raising alone rarely result in sustained application of clinical practice guidelines [22]. These teaching moments also surfaced when some ED and hematology providers expressed concerns about the risk for oversedation with the rapid reassessment of pain and re-dosing of pain medications.
A spirit of collaboration, teamwork, and good communication between all involved parties was also critical. Individualized outpatient pain management plans are being created and patients and families are being encouraged and empowered to become active partners with their sickle cell providers in their own care. A QI framework provided us with unique challenges but also invaluable lessons as we addressed our objective to improve outcomes for patients with SCD across the life course.
The views expressed in this publication do not necessarily reflect the views of WISCH, NICHQ, or HRSA. The response to this model (Figure 2) for completing the work was received favorably by members of the Partnership and this proved an efficient means of task management for its overall goals. Attendees of Webinar meetings were able to communicate verbally during sessions by calling into a phone conference.
The 800-MHz radio is a system implemented by the Pennsylvania Department of Health as a means to alert and communicate in the event of failure of primary communication methods.
On the public portion of the Web site, the Partnership created a way to communicate with the region’s communities about preparedness efforts and emergency situations.
Following recruitment, the SERV-PA system was tested to determine how many new volunteers were generated. Information on the PEIRS report is passed through the Pennsylvania Emergency Management Agency (PEMA), to the Pennsylvania Department of Health (DOH), to the Emergency Health Services Federation (EHSF), and then to the hospitals who will be receiving the patients. After exercises, self-reported capacity for the responding hospitals showed an average regional hospital surge capacity of 342 beds over the baseline of 3,192 beds (a 10.7% regional increase with surge capacity). We would like to thank Christopher Hatzi and Dennis Damore of Crisis Simulations International, LLC (CSI). We also assessed length of intensive care unit and hospital stay, mortality, and laboratory markers for coagulation. The availability of disaster-centric applications will aid in the process of decision making by offering solutions when disaster struck. International ICST Conference on Theory and Practice of Algorithms in Computer Systems, LNCS 6595, SpringerSchultes D (2008) Route planning in road networks.
This article will review the significance, definition, and principal features of delirium so that emergency physicians may better appreciate, recognize, evaluate, and manage delirium in the elderly.
Delirium was identified to be an independent risk factor of increased mortality, and especially significant if underlying dementia was absent.12 Cognitive impairment is not considered a normal part of the aging process.
Unfortunately, the hypoactive form is more common and generally portends a poorer prognosis.
Dysnomia (the inability to name objects correctly) and dysgraphia (impaired writing ability) are 2 of the most sensitive indicators of delirium.16 In summary, the hallmark of delirium is the acute onset (hours to days) of changes in attention and cognition.
They may also manifest memory impairment, especially short-term, and the inability to assimilate new information. Both pediatric and adult patients with SCD experience delays in the initiation of analgesics and are routinely undertreated with respect to opioid dosing [5–8]. Other barriers to effective management are technical in nature, such as difficulty in establishing timely intravenous (IV) access.
Goals of the project were to improve the timely and appropriate assessment and treatment of acute VOE in the ED. Nursing staff were empowered to initiate the protocol upon triage and asked to alert a physician immediately to the presence of a patient requiring management on the protocol. If significant differences were found, we used Dunnett’s method of multiple comparisons to determine which months differed from baseline. Although the length of stay in the ED decreased, no change was observed in the percentage of patients who required admission to the inpatient unit. We collaborated with NICHQ and other HRSA-WISCH grantees to systematically implement improvement science to ensure that the changes that we observed were indeed improvements and would be sustained [23] by first changing the system of care in the ED by introducing a standard order set [24,25].
Our team has discussed the potential for starting the PCA in the ED and we should build on our success to focus on specific care that patients receive beyond their initial presentation.
Although rare, some parents also expressed that their child was being treated too vigorously with opioids. At the same time, we incorporated input from the treating ED and hematology clinicians using PDSA cycles as we were refining our protocol. We believe that sharing baseline data and monthly progress via run charts (graphs of data over time) with ED and sickle cell center staff and with consumer representatives enhanced the pace and focus of the project [23]. Although our initial efforts have focused on our pediatric patients, an additional aim of our project is to broaden the scope of our ED QI initiative to include community hospitals in the region that serve adult patients with SCD.
Using the Webinar with phone, meetings could be held and “attended” by all parties, regardless of their location within the 8 counties (approximately 13,303 km2).
HAN is a national system developed by the Center for Disease Control that alerts facilities of any health threat using Web- and satellite-based technologies, and then links organizations critical for preparedness and response to said events. To achieve faster situational awareness for hospitals, the 911 service now directly contacts local hospitals in the event of a significant occurrence for which surge is possible.
After these surge capacity exercises, we were able to demonstrate the following increases in hospital beds: 25% increase in adult floor beds, 37% increase in critical care beds, 27% increase in ED beds, and a total regional increase of 24%. These activities were supported in part by a grant from the Department of Health and Human Services, Office of Preparedness and Emergency Operations, Division of National Healthcare Preparedness Programs, grant No. This publication provides an important literature review of trials and case reports regarding the emergent reversal of DOACs. Dabigatran etexilate—a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity.
Despite various possibilities of pgRouting for path analysis, a little research is done, on its usages for emergency managements.
38, Part IIGilberto C et al (2010) Free and open source GIS: will there ever be a Geo-Linux? Technology, Karlsruhe Institute ofSingh PS, Chutia D, Sudhakar S (2012) Development of a web based GIS application for spatial natural resources information system using effective open source software and standards. As a result, emergency physicians should recognize delirium, even if subtle, as a medical emergency. In the mixed form of delirium, characteristics from both the hyperactive and hypoactive forms are manifested.
Disorganized thought processes and speech (disjointed or incoherent speech, an unclear or illogical progression of ideas), sleep-wake cycle disturbances, and perceptual disturbances may also be reported or observed. Even after controlling for race, the delays in time to analgesic administration experienced by patients with SCD exceed the delays encountered by patients who present to the ED with other types of pain [5,9].
The protocol called for IV pain medication to be administered within 10 minutes of the patient being roomed, with re-evaluation at 20-minute intervals and re-dosing of pain medication based on the patient’s subsequent pain rating.
Physicians were asked to make the immediate pain relief of patients with VOE a top priority. For metrics 2 through 4, we ran linear models with a binary outcome, a logit link function and using general estimating equations to determine trends and to account for correlations over time. The mean number of visits was 1.5 visits per patient with a range of 1–8 visits, both pre and post order set implementation.
A secondary analysis showed that mean pain scores significantly decreased over the course of the ED visit, from severe to moderate intensity. We put a system into place to track use of the order set and to work with providers almost immediately if deviations were observed, to understand and overcome any barriers to the order set implementation. Education for providers should include the importance of alternative methods of administration of opioids, including subcutaneous and intranasal routes, to avoid delays when IV access is difficult. Further, we introduced pain action planning into outpatient care and need to continue to improve positive patient self-management strategies to ensure more seamless transition of pain management between home, ED, and inpatient settings. Our project highlighted the element of stigma that still accompanies the use of opioids for SCD pain management. We believe that our process enhanced buy-in from participating providers and clarified any issues that needed to be addressed in our setting, resulting in accelerated and sustained quality improvement.
We had a dedicated person managing our data in real time through our HRSA funding, thus the project might not be generalizable to other institutions that do not have such staffing or access to the technology to allow project progress to be closely monitored by stakeholders. This significantly reduced travel costs and allowed partners to complete their other regular duties with less interruption to their everyday workflow. These local hospitals then contact regional hospitals capable of creating a Facility Resource Emergency Database (FRED) alert that notifies all hospitals in the region.
However, no increase in pediatric capacity could be created regionally without changing the Department of Health regulations on designated use of adult and pediatric beds. It was created in 2012 prior to many of the contemporary trials and case reports, but provides recommendations on how to manage emergent reversal of DOACs.
Most of the existing research focus on its usability on finding the shortest path based on some cost. There may be a misperception of the environment with poorly formed delusions and hallucinations. These disparities warrant efforts designed to improve the delivery of quality care to patients with SCD.
Systems in the ED and in the sickle cell center were aligned with the hospital’s QI initiatives [23].
It is possible that negative provider attitudes converge with the documented increase in patient visits during the young adult years [27].
In subsequent practice sessions, verifiable alternative care expansion and personnel availability were shown to produce more than 3,600 low-acuity, staffed evaluation and treatment rooms for surge capacity enhancement within the region. In our paper, we have done an extensive path analysis to give the shortest and alternate path based on different disaster conditions affecting road networks such as occurrence of sudden floods and single and multiple obstructions of road segments due to landslides. This may set up a challenging feedback loop wherein these vulnerable young adults are faced with greater stigma and consequently receive lower quality care, even when there is an attempt to carry out a standardized protocol.
These exercises asked hospital organizations to identify usable, staffed clinical areas that could be directed to care for patients needing education, immunization, and low-acuity visits but not requiring services only available within the affiliated hospital.
No patients required dialysis and two patients who experienced subarachnoid hemorrhages needed surgical interventions. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events (ACTIVE W): a randomised controlled trial. The multidisciplinary QI team had regular email contact and monthly meetings to review progress and concerns. These sessions assumed that the ESAR-VHP was used to augment staffing of available beds (ie, movement of providers assured between hospital organizations), that memorandum of understandings between hospital organizations resulted in enhanced coordination between overloaded and other hospital organizations, and that staffed beds for low-acuity patients could provide a load of 4 patients per treatment room per hour. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. Therapeutic anticoagulation was restarted during admission on six patients; two were restarted on their original anticoagulant, while four received an alternative agent. 38, Part IIJeannette Sutton and Kathleen Tierney (2006) Disaster preparedness: concepts, guidance, and research. Patients treated for a non-intracranial major bleed while taking a DOAC at our institution have been managed with supportive care alone without the need for concentrated coagulation factors. Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): a randomised double-blind trial. Dabigatran, rivaroxaban, or apixaban versus enoxaparin for thromboprophylaxis after total hip or knee replacement: systematic review, meta-analysis, and indirect treatment comparisons. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Letter by Marlu et al regarding article, “reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects”. This publication provides guidance to the management of patients with bleeding complications who are on DOACs, as well as identifying evidence to support reversal strategies. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Reversal of dabigatran-induced bleeding with a prothrombin complex concentrate and fresh frozen plasma. This trial was the first trial in humans studying the reversal of laboratory markers for coagulation with prothrombin complex concentrate in patients who had taken DOACs.
Rectal bleeding and hemostatic disorders induced by dabigatran etexilate in 2 elderly patients.
Although it was studied in healthy male volunteers, this study shows efficacy with reversal of rivaroxaban and questionable efficacy with reversal of dabigatran. Acute-onset severe gastrointestinal tract hemorrhage in a postoperative patient taking rivaroxaban after total hip arthroplasty: a case report. Neurosurgical complications of direct thrombin inhibitors–catastrophic hemorrhage after mild traumatic brain injury in a patient receiving dabigatran.
Spontaneous splenic hemorrhage after initiation of dabigatran (Pradaxa) for atrial fibrillation. Epidural hematoma and intraoperative hemorrhage in a spine trauma patient on Pradaxa (dabigatran).
Recombinant factor VIIa (rFVIIa) and hemodialysis to manage massive dabigatran-associated postcardiac surgery bleeding.
Dabigatran-induced gastrointestinal bleeding in an elderly patient with moderate renal impairment.



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