Sadosty, Annie T.

Purpose of review Biphasic anaphylaxis is a well documented complication of anaphylaxis, but it has been inconsistently defined in the literature. Analysis of contemporary studies of biphasic anaphylaxis based on modern definitions is needed. Recent findings The rate of biphasic reactions in contemporary literature ranges from 0.4 to 14.7% depending on the study population. Observational studies have reported risk factors associated with the development of biphasic reactions; however, findings have been inconsistent and of questionable generalizability. Although life-threatening biphasic reactions are rare, up to 50% of biphasic reactions will require treatment with epinephrine. Early epinephrine administration may have a role in prevention of biphasic reactions, but the role of steroids needs further investigation. The optimal duration of observation is yet to be determined. Summary Given the relative rarity of life-threatening biphasic anaphylaxis and the new context of the NIAID/FAAN standardized definition, further research regarding biphasic anaphylaxis is needed to better elucidate the care model for anaphylaxis patients with a focus on: prevention of biphasic reactions; identification of patients at increased risk of a biphasic reaction; determination of appropriate observation strategies for anaphylaxis patients; and patient education and preparation for management of potential biphasic reactions.

AbstractObjectivesThe objectives were to describe lawsuits against providers for failing to order head computed tomography (CT) in cases of head trauma and to determine the potential effects of available clinical decision rules (CDRs) on each lawsuit.MethodsThe authors collected jury verdicts, settlements, and court opinions regarding alleged malpractice for failure to order head CT in the setting of head trauma from 1972 through February 2014 from an online legal research tool (WestlawNext). Data were abstracted onto a standardized data form. The performance of five CDRs was evaluated.ResultsSixty relevant cases were identified (52 adult, eight children). Of 48 cases with known outcomes, providers were found negligent in 10 cases (six adult, four pediatric), settled in 11 cases (nine adult, two pediatric), and were found not liable in 27 cases. In all 10 cases in which providers were found negligent, every applicable CDR studied would have indicated the need for head CT. In all eight cases involving children, the applicable CDR would have suggested the need for head CT or observation.ConclusionsA review of legal cases reported in a major online legal research system revealed 60 lawsuits in which providers were sued for failing to order head CTs in cases of head trauma. In all cases in which providers were found negligent, CT imaging or observation would have been indicated by every applicable CDR.

AbstractObjectivesPatient throughput is an increasingly important cause of emergency department (ED) crowding. The authors previously reported shorter patient length of stay (LOS) when adding a triage liaison provider, which required additional personnel. Here, the objective was to evaluate the effect of moving a fast‐track provider to the triage liaison role.MethodsThis was a prospective observational before‐and‐after study design with predefined outcomes measures. A “standard staffing” situation (where an advanced practice provider staffed treatment rooms in the fast track) was compared with an advanced practice provider performing the triage liaison staffing role, with no additional staff. Eleven intervention (“triage liaison staffing”) days were compared with 11 matched control (“standard staffing”) days immediately preceding the intervention. Total LOS was measured for all adult Emergency Severity Index (ESI) 3, 4, and 5 patients (excluding behavioral health patients), and results were compared using Wilcoxon rank‐sum and chi‐square tests.ResultsA total of 681 patients registered on control days and 599 on intervention days. There was no significant difference in total patient LOS: median = 273 minutes, interquartile range (IQR) 176 to 384 minutes on intervention days versus median = 253 minutes, IQR = 175 to 365 minutes on control days (p = 0.20). There was no difference in left‐without‐being‐seen (LWBS) rates (n = 48, 7% on control days vs. n = 35, 6% on intervention days; p=0.38). Secondary analysis of only ESI 3 patients showed no difference in total LOS between periods (median = 284 minutes, IQR = 194 to 396 minutes on intervention days vs. median = 290 minutes, IQR = 217 to 397 minutes on control days; p = 0.22). There was, however, significantly greater total LOS for ESI 4 and 5 patients during the intervention period (median = 238 minutes, IQR = 124 to 350 minutes on intervention days vs. median = 192 minutes, IQR = 124 to 256 minutes on control days; p = 0.011).ConclusionsThe previously reported benefits on patient LOS and LWBS rates after adding a triage liaison (resource additive) were lost when that provider was moved from fast track to the triage role (resource neutral). While the triage liaison provider role may be a way to improve ED throughput when additional resources are available, as evidenced by our prior study, the triage liaison model itself does not appear to replace the staffing of treatment rooms, as evidenced by this study.

AbstractObjectivesOvercapacity issues plague emergency departments (EDs). Studies suggest that triage liaison providers (TLPs) may shorten patient length of stay (LOS) and reduce the proportion of patients who leave without being seen (LWBS), but these results are not universal. Previous studies used physicians as TLPs. We evaluated whether a physician assistant (PA), acting as a TLP, would shorten LOS and decrease LWBS rates.MethodsThe authors used an observational cohort controlled before‐and‐after study design with predefined outcome measures, comparing 8 pilot days to 8 control days. The TLP evaluated all Emergency Severity Index (ESI) level 3, 4, and 5 patients, excluding pediatric and behavioral health patients.ResultsA total of 353 patients were included on pilot days and 371 on control days. LOS was shorter on pilot days than control days (median [interquartile range {IQR}] = 229 [168 to 303] minutes vs. 270 [187 to 372] minutes, p < 0.001). Waiting room times were similar between pilot and control days (median [IQR] = 69 [20 to 119] minutes vs. 70 [19 to 137] minutes, p = 0.408), but treatment room times were shorter (median [IQR] = 151 [92 to 223] minutes vs. 187 [110 to 254] minutes, p < 0.001). Finally, a lower proportion of patients LWBS on pilot days (1.4% vs. 9.7%, p < 0.001).ConclusionsThe addition of a PA as a TLP was associated with a 41‐minute decrease in median total LOS and a lower proportion of patients who LWBS. The decrease in total LOS is likely attributable to the addition of the TLP, with patients having shorter duration in treatment rooms on pilot days compared to control days.