Observation Medicine in the Journals

In this series we will look articles and abstracts both inside and beyond the emergency medicine journals related to observation medicine. While these may or may not change care, I hope to provide information on pertinent topics you may have otherwise missed.

On tap in this issue:

• Safety of a brief emergency department observation protocol for patients with presumed fentanyl overdose
• Evaluating the emergency department observation unit for the management of hyperglycemia in adults
• How the availability of observation status affects emergency physician decision making
• Biphasic anaphylactic reactions and emergency department observation times

Safety of a brief emergency department observation protocol for patients with presumed fentanyl overdose¹

This was based on an administrative record review rather than prospective data. Looking at just over 1,000 cases most patients with presumed uncomplicated fentanyl overdose most went home. They do note one of these patients did die within 24 hours. None developed new medical issues while being observed in the ED. One was admitted from the ED. Over 80% received naloxone in the field and approximately two percent required a repeat dose in the ED. It is important to note this was not an observation unit protocol but rather patients observed within the ED.

Evaluating the emergency department observation unit for the management of hyperglycemia in adults²

A retrospective chart review was performed of observation patients placed in observation for hyperglycemia (>/= 300 md/dl). Nearly 84% of the patients were managed in and discharged from the ED observation unit. Approximately 5-6% of the patients returned for glucose related issues to the ED within 30 days (hyperglycemia, hypoglycemia, or diabetic ketoacidosis). This suggests these patients can be adequately managed for their acute episode in the ED observation unit. It should be noted the mean HbA1c was 12.1 mmol/mol indicating unknown or poorly controlled diabetes on presentation.

How the availability of observation status affects emergency physician decision making³

This was a semi-structured interview survey of emergency physicians. It found observation can relax decision making constraints on ED providers. Clear protocols are important to avoid placement for diagnostic uncertainty.

Biphasic anaphylactic reactions and emergency department observation times⁴

This was a literature review looking at biphasic anaphylaxis to evaluate for evidence to support the 4-6 hour observation time for post anaphylaxis patients. The mean time to onset of a biphasic reaction was greater than 8 hours (Range 1-72 hours). Small studies showed steroids decreased biphasic reaction however the articles pulled by this study did not show conclusive evidence. Factors associated with higher probability of biphasic reaction were prolonged time (>60 minutes) between symptom onset and epinephrine administration or anaphylaxis requiring multiple doses of epinephrine.

References

1. Scheuermeye FX, DeWitt C, Christenson J, et al. Safety of a brief emergency department observation protocol for patients with presumed fentanyl overdose. Ann Emerg Med. 2018;72:1-8.e1
2. Crilly CJ, Allen AJ, Amaton TM, et al. Evaluating the emergency department observation unit for the management of hyperglycemia in adults. Am J Emerg Med. 2018;36:1975-9.
3. Wright B, Martin GP, Ahmed A. How the availability of observation status affects emergency physician decision making. Ann Emerg Med. 2018;72:401-9.
4. Robinson C. Biphasic anaphylactic reactions and emergency department observation times. George Washington School of Medicine and Health Sciences Poster Presentation. Spring 2018

Robert M. Bramante, MD, FACEP
Good Samaritan Hospital Medical Center