There was a disproportionate increase in ED visits and hospitalizations in the geriatric population compared with the younger population during the IPS. The primary factor of the disproportionate impact on the geriatric population appears to be from indirect effects of the hurricane, mainly due to the subsequent power outages, such as "dialysis," "respiratory device," and "social." Further investigation by chart review may provide more insights to better aid with future disaster preparedness.

Epidemiological data, including prevalence, for cannabinoid hyperemesis syndrome (CHS) remain largely unknown. Without these data, clinicians often describe CHS as 'rare' or 'very rare' without supporting evidence. We seek to estimate the prevalence of CHS in a population of patients presenting to a socio-economically and racially diverse urban Emergency Department of a public hospital. This study consisted of a questionnaire administered to a convenience sample of patients presenting to the ED of the oldest public hospital in the United States. Trained Research Associates (RAs) administered the questionnaire to patients between the ages of 18-49 years who reported smoking marijuana at least 20 days per month. The survey included questions related to CHS symptoms (nausea and vomiting) and Likert scale rankings on eleven symptom relief methods, including 'hot showers'. Patients were classified as experiencing a phenomenon consistent with CHS if they reported smoking marijuana at least 20 days per month and also rated 'hot showers' as five or more on the ten-point symptom relief method Likert scale for nausea and vomiting. Among 2127 patients approached for participation, 155 met inclusion criteria as smoking 20 or more days per month. Among those surveyed, 32.9% (95% CI, 25.5-40.3%) met our criteria for having experienced CHS. If this is extractable to the general population, approximately 2.75 million (2.13-3.38 million) Americans may suffer annually from a phenomenon similar to CHS.

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A previously healthy 56-year-old woman presented to the emergency department with pre-syncopal symptoms that began while she was straining on the toilet. On arrival, the patient complained of a persistent, diffuse abdominal cramping like she ''needed to have a bowel movement.'' She was immediately placed on a monitor. The vitals were: blood pressure 80/50 mmHg, heart rate 60 beats/min, respiratory rate 12/min, oxygen saturation 99% on room air. The physical examination demonstrated a mildly tender epigastrium and brisk peripheral pulses.Bedside emergency ultrasound revealed free fluid in both the splenorenal and hepatorenal views. Two large bore intravenous lines were secured, massive transfusion protocol was initiated, and the patient received two units of O-negative blood. The surgical service was emergently consulted, and the patient was brought for a computed tomography abdomen and pelvis (Fig.

Objective To establish an enterprise initiative for improving health and health care through interoperable electronic health record (EHR) innovations. Materials and Methods We developed a unifying mission and vision, established multidisciplinary governance, and formulated a strategic plan. Key elements of our strategy include establishing a world-class team; creating shared infrastructure to support individual innovations; developing and implementing innovations with high anticipated impact and a clear path to adoption; incorporating best practices such as the use of Fast Healthcare Interoperability Resources (FHIR) and related interoperability standards; and maximizing synergies across research and operations and with partner organizations. Results University of Utah Health launched the ReImagine EHR initiative in 2016. Supportive infrastructure developed by the initiative include various FHIR-related tooling and a systematic evaluation framework. More than 10 EHR-integrated digital innovations have been implemented to support preventive care, shared decision-making, chronic disease management, and acute clinical care. Initial evaluations of these innovations have demonstrated positive impact on user satisfaction, provider efficiency, and compliance with evidence-based guidelines. Return on investment has included improvements in care; over $35 million in external grant funding; commercial opportunities; and increased ability to adapt to a changing healthcare landscape. Discussion Key lessons learned include the value of investing in digital innovation initiatives leveraging FHIR; the importance of supportive infrastructure for accelerating innovation; and the critical role of user-centered design, implementation science, and evaluation. Conclusion EHR-integrated digital innovation initiatives can be key assets for enhancing the EHR user experience, improving patient care, and reducing provider burnout.

BACKGROUND: Traumatic brain injuries are common and costly to hospital systems. Most of the guidelines on management of traumatic brain injuries are taken from the Brain Trauma Foundation Guidelines. This is a review of the current literature discussing the evolving practice of traumatic brain injury.DATA SOURCES: A literature search using multiple databases was performed for articles published through September 2012 with concentration on meta-analyses, systematic reviews, and randomized controlled trials. RESULTS:The focus of care should be to minimize secondary brain injury by surgically decompressing certain hematomas, maintain systolic blood pressure above 90 mmHg, oxygen saturations above 93%, euthermia, intracranial pressures below 20 mmHg, and cerebral perfusion pressure between 60-80 mmHg. CONCLUSION:Much is still unknown about the management of traumatic brain injury. The current practice guidelines have not yet been sufficiently validated, however equipoise is a major issue when conducting randomized control trials among patients with traumatic brain injury.

Introduction It is difficult to determine illness severity for coronavirus disease 2019 (COVID-19) patients, especially among stable-appearing emergency department (ED) patients. We evaluated patient outcomes among ED patients with a documented ambulatory oxygen saturation measurement. Methods This was a retrospective chart review of ED patients seen at New York University Langone Health during the peak of the COVID-19 pandemic in New York City. We identified ED patients who had a documented ambulatory oxygen saturation. We studied the outcomes of high oxygen requirement (defined as >4 liters per minute) and mechanical ventilation among admitted patients and bounceback admissions among discharged patients. We also performed logistic regression and compared the performance of different ambulatory oxygen saturation cutoffs in predicting these outcomes. Results Between March 15–April 14, 2020, 6194 patients presented with fever, cough, or shortness of breath at our EDs. Of these patients, 648 (11%) had a documented ambulatory oxygen saturation, of which 165 (24%) were admitted. Notably, admitted and discharged patients had similar initial vital signs. However, the average ambulatory oxygen saturation among admitted patients was significantly lower at 89% compared to 96% among discharged patients (p<0.01). Among admitted patients with an ambulatory oxygen saturation, 30% had high oxygen requirements and 8% required mechanical ventilation. These rates were predicted by low ambulatory oxygen saturation (p<0.01). Among discharged patients, 50 (10%) had a subsequent ED visit resulting in admission. Although bounceback admissions were predicted by ambulatory oxygen saturation at the first ED visit (p<0.01), our analysis of cutoffs suggested that this association may not be clinically useful. Conclusion Measuring ambulatory oxygen saturation can help ED clinicians identify patients who may require high levels of oxygen or mechanical ventilation during admission. However, it is less useful for identifying which patients may deteriorate clinically in the days after ED discharge and require subsequent hospitalization.

BackgroundThe Veterans Health Administration COVID-19 (VACO) Index incorporates age, sex, and pre-existing comorbidity diagnoses readily available in the electronic health record (EHR) to predict 30-day all-cause mortality in both inpatients and outpatients infected with SARS-CoV-2. We examined the performance of the Index using data from Yale New Haven Hospital (YNHH) and national Medicare data overall, over time, and within important patient subgroups.Methods and findingsWith measures and weights previously derived and validated in a national Veterans Healthcare Administration (VA) sample, we evaluated the accuracy of the VACO Index for estimating inpatient (YNHH) and both inpatient and outpatient mortality (Medicare) using area under the receiver operating characteristic curve (AUC) and comparisons of predicted versus observed mortality by decile (calibration plots). The VACO Index demonstrated similar discrimination and calibration in both settings, over time, and among important patient subgroups including women, Blacks, Hispanics, Asians, and Native Americans. In sensitivity analyses, we allowed component variables to be re-weighted in the validation datasets and found that weights were largely consistent with those determined in VA data. Supplementing the VACO Index with body mass index and race/ethnicity had no effect on discrimination.ConclusionAmong COVID-19 positive individuals, the VACO Index accurately estimates risk of short-term mortality among a wide variety of patients. While it modestly over-estimates risk in recent intervals, the Index consistently identifies those at greatest relative risk. The VACO Index could identify individuals who should continue practicing social distancing, help determine who should be prioritized for vaccination, and among outpatients who test positive for SARS-CoV-2, indicate who should receive greater clinical attention or monoclonal antibodies.