A 65-year-old woman with a history of hypertension and diabetes mellitus presented with a 1-day onset of chest pain, shortness of breath, and dizziness. Vital signs were significant for hypoxia, with a room air saturation of 80%, heart rate of 118 beats per minute, and BP of 175/115 mm Hg. CT angiogram of the chest showed a large saddle pulmonary embolism with right ventricular strain; the decision was made to administer IV alteplase, 100 mg, for thrombolysis.After thrombolysis, the patient's cardiopulmonary status improved. However, over the next 2 hours, the patient experienced vision loss in the right eye with associated pain and headache. Fundoscopic examination performed by the Ophthalmology Department revealed a fixed, nonreactive right pupil with severely elevated (immeasurably high) intraocular pressures. Dilated examination showed choroidal elevation with vitreous hemorrhage; however, the examination was limited because of nuclear sclerosis and hemorrhagic material.In conjunction with the Ophthalmology Department, point-of-care ultrasound scanning of the right orbit was performed by the critical care team (Video 1).Question: Based on the clinical scenario and ultrasound findings, what is the most likely diagnosis of this patient?
patients directly admitted to the ICU. Respiratory rate, heart rate, and temperature do not discriminate between those who require transfer and those who do not. Patients who require unplanned transfers have longer hospitalizations and require intubation more often than patients directly admitted to the ICU. 552
Importance A same-day ophthalmic urgent care clinic can provide efficient eye care, a rich educational environment, and can improve patient experience. Objective The aim of this study was to systematically evaluate volume, financial impact, care metrics, and the breadth of pathology of urgent new patient encounters based on their site of initial presentation. Design, Setting, and Participants A retrospective analysis was performed on consecutive urgent new patient evaluations in our same-day triage clinic at the Henkind Eye Institute at Montefiore Medical Center between February 2019 and January 2020. The cohort of patients who presented directly to this urgent care clinic were referred to as the “TRIAGE” group. Patients who initially presented to an emergency department (ED), and were subsequently referred to our triage clinic, are referred to as the “ED + TRIAGE” group. Main Outcomes and Measures Visits were evaluated on a variety of metrics, including diagnosis, duration, charge, cost, and revenue. Furthermore, return to the ED or inpatient admission was documented. Results Of 3,482 visits analyzed, 2,538 (72.9%) were in the “TRIAGE” group. Common presenting diagnoses were ocular surface disease (n = 486, 19.1%), trauma (n = 342, 13.5%; most commonly surface abrasion n = 195, 7.7%), and infectious conjunctivitis (n = 304, 12.0%). Patients in the “TRIAGE” group, on average, were seen 184.6% faster (158.2 vs. 450.2 minutes) than patients in the “ED + TRIAGE” group (p < 0.001). The “ED + TRIAGE” group were furthermore found to generate 442.1% higher charges ($870.20 vs. 4717.70) and were associated with 175.1% higher cost ($908.80 vs. 330.40) per patient. The hospital was found to save money when noncommercially insured patients with ophthalmic complaints presented to the triage clinic instead of the ED. Patients seen in the triage clinic had a low rate of readmission to the ED (n = 42, 1.2%). Conclusions and Relevance A same-day ophthalmology triage clinic provides efficient care, while providing a rich learning environment for residents. Less wait time with direct access to subspecialist care can help improve quality, outcome, and satisfaction metrics.
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