Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department.

This clinical policy from the American College of Emergency Physicians addresses key issues in opioid management in adult patients presenting to the emergency department. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? (2) In adult patients experiencing an acute painful condition, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (3) In adult patients with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (4) In adult patients with an acute episode of pain being discharged from the emergency department, do the harms of a short concomitant course of opioids and muscle relaxants/sedative-hypnotics outweigh the benefits? Evidence was graded and recommendations were made based on the strength of the available data.

High Scan Volume with Low Positive Scan Rate in Highest Utilizers: Computed Tomography Pulmonary Angiography in the Emergency Department.

Background: We examined utilization patterns and predictors of computed tomography pulmonary angiography (CTPA) results in the emergency department (ED).

Objectives: We retrospectively determined ED CTPA positive scan rate (PSR) among ED attendings based on a system that grouped attendings into scan quantity categories through >100.

Methods: We manually reviewed all scans ordered in 2017 in EDs in a multisite medical system.

Future technology-enabled care for diabetes and hyperglycemia in the hospital setting.

Patients with diabetes are increasingly common in hospital settings where optimal glycemic control remains challenging. Inpatient technology-enabled support systems are being designed, adapted and evaluated to meet this challenge. Insulin pump use, increasingly common in outpatients, has been shown to be safe among select inpatients.

Lower Abdominal Pain.

Although most frequently presenting with lower abdominal pain, appendicitis, colitis, and diverticulitis can cause pain throughout the abdomen and can cause peritoneal and retroperitoneal symptoms. Evaluation and management of lower intestinal disease requires a nuanced approach by the emergency physician, sometimes requiring computed tomography, ultrasonography, MRI, layered imaging, shared decision making, serial examination, and/or close follow-up. Once a presumed or confirmed diagnosis is made, appropriate treatment is initiated, and may include surgery, antibiotics, and/or steroids.

THE SYNERGY TO ENABLE GLYCEMIC CONTROL FOLLOWING EMERGENCY DEPARTMENT DISCHARGE PROGRAM FOR ADULTS WITH TYPE 2 DIABETES: STEP-DIABETES.

Objective: To evaluate a diabetes (DM) care delivery model among hyperglycemic adults with type 2 DM being discharged from the emergency department (ED) to home. The primary hypothesis was that a focused education and medication management intervention would lead to a greater short-term improvement in glycemic control compared to controls.

Methods: A 4-week, randomized controlled trial provided antihyperglycemic medications management using an evidence-based algorithm plus survival skills diabetes self-management education (DSME) for ED patients with blood glucose (BG) levels ≥200 mg/dL.

Synergy to reduce emergency department visits for uncontrolled hyperglycemia.

Purpose: The purpose of this pilot study was to evaluate the safety and preliminary efficacy of a treatment algorithm and education intervention for the management of patients with type 2 diabetes and hyperglycemia presenting to the emergency department (ED) and stable enough to be discharged home.

Methods: Urban hospital ED patients (n = 86) with BG ≥ 200 mg/dL were enrolled in a 4-week prospective, nonrandomized pilot intervention with historic self-controls. Follow-up visits occurred at 12 to 72 hours, 2 and 4 weeks, and 6 months.