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The Discharge Severity Index: Early Research on ED Readmission Risk Assessment

discharge severity index DSI

From Triage to Discharge: As an emergency medicine clinician, you’ve likely become comfortable using the Emergency Severity Index (ESI), a critical tool helping triage patients entering the ED. But what happens when these patients leave your care? How can we anticipate who might need extra support to avoid readmission?

Let’s discuss why ED discharge risk stratification matters, the landscape of existing tools, and introduce a new effort called the Discharge Severity Index (DSI), in the context of this evolving conversation.

History of Emergency Severity Index (ESI)

As emergency medicine clinicians, we’ve all become comfortable with using the ESI. It’s simple, intuitive, and has revolutionized triage since its introduction in the late 1990s. ESI stratifies our incoming patients quickly and reliably based on anticipated resource needs and hospitalization risks, making it easy to decide who gets seen first. Over the years, ESI has gone through multiple iterations to better reflect evolving clinical priorities, workflows, and patient populations [1–4]. It became a living tool that is as dynamic and adaptive as emergency care itself.

However, as powerful as ESI is, it addresses only half the equation: what happens when patients arrive. But what about when they leave?

Discharge: More than a Binary Decision

Currently, ED discharge is largely treated as a binary decision—admit or discharge. But think about admissions: we never treat admissions as simple “yes/no” decisions. Patients can go to observation, a floor bed, step-down units, or the ICU. Each has varying resource needs and follow-up intensities. So why don’t we apply this nuanced thinking to discharge?

ED discharges aren’t straightforward. Almost 14% of patients discharged from EDs return within 30 days, often due to issues that could be preventable with better follow-up [5]. Many face barriers like misunderstanding discharge instructions, inadequate social support, and difficulty accessing outpatient care. We have powerful new follow-up tools available (e.g., nursing callback programs, telehealth, remote patient monitoring) but we often lack a clear, systematic way of figuring out which patients truly need them.

Existing Tools and Their Limitations

Multiple scoring systems have attempted to predict post-discharge adverse outcomes. Some prominent examples include:

  • LACE Score:
    • Length of stay
    • Acuity of admission
    • Comorbidities
    • Emergency visits
  • HOSPITAL Score:
    • Hemoglobin level
    • Oncology diagnosis
    • Sodium level
    • Procedure during hospitalization
    • Index admission type
    • Admissions in previous year
    • Length of stay

Yet, many of these tools weren’t specifically designed for the ED population. Our recent scoping review highlighted significant variability, limited ED-specific validation, and complexity that can hinder practical use [6].

Introducing the Discharge Severity Index (DSI): An Early-Stage Tool

Recognizing this gap, our team developed the DSI, an initial attempt at ED-specific discharge risk stratification. The idea behind DSI is to use straightforward, quickly accessible ED data points to identify patients who might benefit from enhanced follow-up.

Our single-center retrospective study analyzed ED visits, dividing the data into the derivation (75%) and validation (25%) cohorts [7]. We attempted to stratify risk based on the DSI score and measuring their 7-day readmission rates.

Our DSI score was calculated using 5 key clinical factors (0=lowest risk, 7=highest risk):

  1. Age > 65 years = 1 point
  2. Heart rate at discharge > 100 bpm = 1 point
  3. Oxygen saturation at discharge < 96% = 1 point
  4. Length of ED stay > 3 hours = 2 points
  5. Active medications > 5 during hospital stay = 2 points

Here’s what we found:

DSI LevelScore7-day Approximate Readmission Risk
1 (highest risk)6-75%
254%
33–43%
41–21%
5 (lowest risk)0<0.5%

A patient scoring a DSI 1 might benefit from immediate follow-up with telehealth, home health visits, and/or increased outpatient support. Conversely, a DSI 4 or 5 patient might safely manage standard outpatient care with minimal risk.

How is DSI Different Existing Scoring Systems?

Unlike the LACE or HOSPITAL scores, the DSI was built specifically for the ED context. It uses data readily available at discharge, allowing rapid identification of patients who may require more intensive post-discharge follow-up. It’s meant for nursing or automated tools to assign this to the patient, without requiring more provider resources.

But, let’s be clear: the DSI is not perfect. We intentionally started simple (similar to how ESI began) to get people thinking about stratifying discharge risks. For instance:

  • Length of Stay (LOS): Right now, LOS includes waiting room times, boarding delays, and other systems-level issues, making it an imperfect measure of medical complexity.
  • Vital Signs at Discharge Only: Using only discharge vitals doesn’t account for patients who had unstable earlier vitals during their ED stay.
  • Missing Comorbidities: The current DSI doesn’t explicitly factor in comorbidities or past medical history, which we know affect patient outcomes.

Why This Matters to You

It’s important to grasp the complexity behind discharge decisions just as clearly as they understand triage. Discharge isn’t simply sending patients home; it’s anticipating what happens next and appropriately preparing patients to succeed.

Implementing structured discharge risk stratification not only supports better clinical outcomes but also helps teach clinicians to think about care beyond the ED walls. With more accurate identification of high-risk patients, residents can be better prepared to integrate innovative follow-up resources into patient care.

Where do we go from here?

The DSI represents an early, evolving concept. We don’t expect it to be adopted widely and imminently. Rather, we hope it sparks a broader conversation similar to the early years of the ESI. ESI began as a simple triage tool and matured through iterative development, field testing, and adaptation across varied ED environments. It became more robust, nuanced, and integrated into daily clinical operations over time. We envision a similar trajectory for the DSI.

Future iterations of the DSI will undoubtedly incorporate additional clinical variables, operational data, and even social determinants of health. But before we get there, the next step is clear: we must operationalize the DSI and test it in multiple real-world settings. Its utility must be validated not just in theory or retrospective data, but in the dynamic, complex ecosystem of actual emergency departments.

We encourage EM educators and residency programs to join us in refining the conversation about ED discharge stratification.

Whether it’s integrating DSI into discharge planning discussions, piloting it during teaching rounds, or evaluating it in post-discharge follow-up workflows, there is now an opportunity to take this idea from concept to practice for the benefit of our patients.

Let’s build upon this first step, creating tools that are practical, teachable, and clinically meaningful. Together, we can ensure that the decision to discharge is just as thoughtful, nuanced, and patient-focused as the decision to admit.

References

  1. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Reliability and validity of a new five-level triage instrument. Acad Emerg Med 2000;7(3):236–42.
  2. Wuerz RC, Travers D, Gilboy N, Eitel DR, Rosenau A, Yazhari R. Implementation and refinement of the emergency severity index. Acad Emerg Med 2001;8(2):170–6.
  3. Eitel DR, Travers DA, Rosenau AM, Gilboy N, Wuerz RC. The emergency severity index triage algorithm version 2 is reliable and valid. Acad Emerg Med 2003;10(10):1070–80.
  4. Elshove-Bolk J, Mencl F, van Rijswijck BTF, Simons MP, van Vugt AB. Validation of the Emergency Severity Index (ESI) in self-referred patients in a European emergency department. Emerg Med J 2007;24(3):170–4.
  5. Characteristics of 30-Day All-Cause Hospital Readmissions, 2016-2020 [Internet]. [cited 2025 Jul 7].
  6. Jaffe TA, Wang D, Loveless B, et al. A Scoping Review of Emergency Department Discharge Risk Stratification. West J Emerg Med 2021;22(6):1218–26. PMID 34787544
  7. Kijpaisalratana N, El Ariss AB, Balk A, et al. Development and validation of the discharge severity index for post-emergency department hospital readmissions. Am J Emerg Med. 2025;94:125-132. doi:10.1016/j.ajem.2025.04.045. PMID 40288325
By |2025-08-09T13:19:36-07:00Aug 14, 2025|Administrative, Beyond the Abstract|
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When Research Meets Social Media Expertise: Lessons from the PECARN-ALiEM Partnership

PECARN - ALiEM partnership twitter X
From Pipe Dream to Proven Strategy: How a 4-year partnership between PECARN and ALiEM created a replicable framework for evidence-based research dissemination

Sometimes the best collaborations begin with simple questions. Following Dr. Nathan Kuppermann’s grand rounds presentation in 2018, I had the opportunity to discuss an idea with him as PECARN’s Steering Committee Chair: might there be untapped potential in using social media platforms like Twitter to amplify PECARN’s research impact? Five years later, that initial conversation has grown into a reality with a systematic approach and measurable outcomes.

Social media is not just about fads and marketing. In fact, it represents the foreseeable future for information dissemination, even in scientific research, because it meets learners and providers where they already are. Rather than hoping clinicians would stumble upon publications in traditional journals, we should actively bring the research to the platforms they frequently check.

Why Organizational Social Media Requires Strategic Planning

Organizational social media for research dissemination can’t just “do social media.” This endeavor requires fundamentally different approaches than personal academic accounts. While individual faculty might share insights casually or build personal brands, research organizations need systematic frameworks that ensure consistency, maintain academic rigor, and deliver measurable impact.

The critical distinction: institutional social media isn’t about intuition or viral content—it demands rigorous planning, dedicated resources, and iterative optimization based on analytics. Just as we wouldn’t launch a research study without proper methodology and oversight, we shouldn’t approach organizational research dissemination without strategic frameworks and quality control systems.

The Partnership Model: When Research Meets Social Media Expertise

Our approach began with recognizing a fundamental truth: most research organizations lack the specialized expertise needed for effective social media presence. Rather than building these capabilities from scratch, PECARN partnered with ALiEM, leveraging our existing social media infrastructure and experience. What started as an experimental collaboration became a four-year case study, which we recently published in JMIR Formative Research [1]. We share our processes, outcomes, and lessons learned to provide a replicable framework and roadmap for other research organizations considering similar initiatives on Twitter/X (or alternative social media platforms).

The Foundation: Building Sustainable Infrastructure

Organizational Inputs:

  • Research Organization (PECARN) – content expertise and credibility
  • Social Media Experts (ALiEM) – Twitter/X platform knowledge and audience understanding
  • Funding & Leadership Support – executive champions and resource allocation
  • Technical Infrastructure – analytics tools, scheduling platforms, communication systems

The 5-Person Dream Team:

  • Content Writers (2): Physician-researchers who understand both clinical context and platform constraints
  • Peer Reviewers (2): Quality control experts ensuring academic rigor
  • Account Monitors (2): Daily engagement specialists building community
  • Analytics Manager (1): Data scientist tracking performance and optimization
  • Graphic Designer (1): Visual content specialist (added after 2 years based on data)

We created 2-person teams for key roles to ensure sustainability and backup coverage. Faculty have competing priorities, and redundancy ensures consistent output despite scheduling challenges.

pecarn ALiEM twitter X partnership research dissemination architect

What the Numbers Taught Us

The key to our success wasn’t guesswork—it was rigorous analytics tracking and iterative evidence-based improvement. Over the 4 years (2020-23), 569 tweets were published, 99 PECARN journal publications were featured, and we grew an audience of over 2,000 followers.

Tweet-Level Analytics: The Strategy Elements That Actually Work

Through multiple linear regression analysis, we identified 3 characteristics with statistically significant impact on both impressions and engagement:

  1. Polls (β = 0.278): Our most impactful discovery was that interactive polls became our strongest engagement driver. we used polls to introduce clinical scenarios related to featured research, allowing audiences to test their knowledge before revealing study findings.
  2. Graphics (β = 0.195): Professional graphics significantly boosted engagement, leading us to add a dedicated graphic designer to the team after 2 years. This wasn’t cosmetic—it was a data-driven personnel decision.
  3. URL Links (β = 0.173): Links to full articles didn’t just drive traffic; they contributed to increased Altmetric Attention Scores, providing measurable academic impact beyond social media metrics.

Surprisingly, emojis showed a negative correlation with engagement in our academic audience. We hypothesize that these emojis may have not resonated with our academic and healthcare professions audience— a reminder that strategies must be tailored to the desired audience.

research dissemination architect pecarn ALiEM twitter X

Lessons Learned for Building Research Dissemination Architecture

1. Analytics Are Non-Negotiable

Don’t guess about what works. Track impressions, engagement, click-through rates, and downstream academic metrics. What gets measured gets optimized.

2. Quality Control Maintains Credibility

Our peer review process for each tweet provided academic rigor for accuracy and quality, treating social media content with the same methodological care we apply to research publications. This approach strengthened PECARN’s digital credibility and built trustworthiness with our professional audience who expect evidence-based content even in 280 characters.

3. Team Redundancy Ensures Sustainability

Faculty have complex schedules. Build systems that work despite individual availability challenges.

4. Visual Content Isn’t Optional

Professional graphics aren’t “nice to have”—they’re proven engagement drivers in the era of information overload. They are worth the investment.

New Academic Role: Research Dissemination Architect

What began as grassroots FOAM (Free Open Access Medical education) with individual bloggers and social media educators has evolved into something more substantial: the emergence of the “Research Dissemination Architect” as a legitimate, potentially funded position within academic institutions and research organizations.

This represents a fundamental shift in how we think about knowledge translation careers. We’re no longer talking about faculty “doing social media on the side”—we’re talking about dedicated professional positions with specific expertise, measurable outcomes, and institutional recognition. Our recent publication in JMIR Formative Research documents our journey in this evolution. The ALiEM-PECARN partnership wasn’t just about Twitter success; it was about demonstrating that research dissemination can be a systematic, professional discipline worthy of institutional investment and academic recognition.

Conclusion

The PECARN-ALiEM partnership demonstrates that academic rigor and social media success aren’t mutually exclusive—they’re synergistic when approached systematically. Through this collaboration, we’ve contributed to establishing systematic approaches to research dissemination as a pathway toward accelerated knowledge translation.

Research Dissemination Architects represent an emerging career pathway that bridges traditional academic expertise with digital communication skills. As medical education continues evolving toward digital-first approaches, faculty who develop competency in evidence-based social media are positioning themselves at the forefront of this evolution. The framework we’ve developed offers one approach to professional research dissemination. As more organizations experiment with similar roles, we’ll undoubtedly see diverse models emerge, each contributing to our collective understanding of effective academic digital scholarship.

We hope our experience can inform others exploring this space. Whether you adapt our specific approach or develop entirely different methods, the opportunity to advance how research reaches its intended audiences has never been greater.

Reference

  1. Hooley GC, Magana JN, Woods JM, et al. Research Dissemination Strategies in Pediatric Emergency Care Using a Professional Twitter (X) Account: A Mixed Methods Developmental Study of a Logic Model Framework. JMIR Form Res. 2025;9:e59481. Published 2025 Jun 24. doi:10.2196/59481. PMID 40554778
By |2025-07-05T13:21:28-07:00Jul 5, 2025|Academic, Beyond the Abstract, Medical Education, Research, Social Media & Tech|
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Tranq dope (fentanyl-xylazine combination): A new horizon in opioid withdrawal treatment

tranq dope xylazine syringe opioid

‘Dope’ is no longer heroin in an increasing number of our communities. The biggest change has been the gradual replacement of diacetylmorphine (heroin) by fentanyl and other synthetic opioids. Due in large part to the proliferation of anonymous chemical factories able to produce industrial volumes of inexpensive synthetic opioids without opium or other controlled precursors, fentanyl spilled into the United States, Canada, and Europe, heroin soon fell to market forces [1, 2]. Along the same time, a veterinary sedative, xylazine, became popular in Puerto Rico in individuals who used injection drugs [3]. An alpha-2 receptor agonist mechanistically similar to clonidine, dexmedetomidine, and tetrahydrozoline, xylazine made its way to the U.S. and settled in the metropolitan areas of the Northeast, especially my community, Philadelphia. The combination of the two now represents more than 98% of samples tested by the City of Philadelphia and has been given the moniker ‘tranq dope’ [4]. 

Case

A patient arrives via EMS from the bus station complaining of fever, vomiting, and back pain. Their back has worsened significantly over the past 24 hours with radiation down the left leg. They report insufflating ‘a bundle’ of tranq dope per day. They report occasional cocaine and amphetamine use more than 72 hours ago, but no other substances. They report an allergy to ‘bupe,’ describing a prior episode of ‘precipitated withdrawal’ when given buprenorphine, despite already withdrawing.

Vital signs

  • T 39.5C
  • BP 180/90
  • HR 140
  • RR 24 (oxygen saturation 99% room air)

Exam

  • General: Diaphoresis, piloerection, psychomotor agitation, and actively vomiting
  • Eyes: Dilated pupils
  • Cardiac: No murmur
  • Back: Focal tenderness at L1 and L2
  • Neurologic: L hip flexion weakness
  • Extremities:
    • Several necrotic, ulcerative wounds on their arms and legs without secondary signs of infection
    • Lymphedema of distal arms and legs with early venous stasis changes

Breaking down the case

“A Bundle”

  • Understanding how much patients use can help us understand how likely their withdrawal is to be severe.
  • Our experience: A Philadelphia Bundle is 14 bags, most other cities are 10 bags. One bag has been approximated anywhere from 25-100 morphine milligram equivalents (MME), meaning use of a bundle (or two) a day is equivalent to use of hundreds to thousands of MME, vastly more than has ever been encountered in human history. Anyone using “bundles” (or more than a few bags per day) is at risk of significant withdrawal if they abruptly stop.
  • Clinical impact: This patient is likely having severe symptoms of withdrawal from cessation of their regular use.

The Wounds

  • Common among patients who use xylazine, the necrotic and exudative wounds are still not fully understood [5-8], but are likely due in part to direct cytotoxic effects of the drug and its impurities, as well as possible nutritional deficiencies common in those with dependence.
  • Our experience: Oddly, though injection drug use is certainly associated with wound location, injection use is not required for their development, and they have been noted in patients who solely insufflate or smoke their substances. While superinfection is common due to the myriad social determinants of health challenges individuals who use these drugs face in trying to care for them — when the wounds look uninfected, they typically are and respond better to local wound care, nutritional support, and long-term monitoring than obligatory IV antibiotics or surgical debridement. The wounds themselves may not be infected or require surgical management themselves, but can act as an entry point to deeper infections. We treat with wound care and reserve surgical management only for limbs that are no longer viable. IV antibiotics do not help treat the wounds unless there is evidence of other skin/soft tissue infection (City of Philadelphia’s excellent wound care guide).
  • Clinical impact: The case patient’s wounds were cleaned and dressed with petroleum jelly based wound ointments and enzymatic salves for the necrotic portions. Inpatient wound care teams provided long-term support and a nutrition consult ordered protein, micronutrient, and vitamin supplementation.

Lymphedema (Puffy Hands & Feet)

  • Our experience: After we noted a cohort of admissions for suspected endocarditis were found to be reassuringly negative, we noted this physical exam finding as strikingly common. Evaluation for nephrotic syndrome due to viral hepatitis, endocarditis, venous thromboembolism or other cause of chronic lymphedema is reasonable.
  • Clinical impact: The patient’s DVT ultrasounds were negative. A trans-esophageal echocardiogram showed a normal ejection fracture, normal right ventricular function, and no vegetations.

Bupe Allergy

  • Buprenorphine induction has been the mainstay of emergency department treatment of opioid use disorder for more than a decade [11, 12].
  • Our experience: It was not long ago that we instructed our staff that: ‘COWS >8, give ’em 8 (mg of buprenorphine).’ We witnessed our prior protocols become ineffective, even at very large doses (16 mg over 2 hours with adjuncts) in patients who were already in severe withdrawal. Similarly, dramatic but idiosyncratic episodes of ‘precipitated withdrawal’ were noted in some patients who had used tranq dope in the past 48-72 hours. Patients with moderate withdrawal became dramatically worse within short periods, noted both in the community and in our department [13, 14]. Confounding this is a high-quality analysis in an area with high fentanyl and unknown xylazine intensity not demonstrating this phenomenon [15]. Akin to real-life ghost stories told by patients, the risk is not insignificant, and the concern warranted by patients. We have seen cases of esophageal rupture from vomiting and stress cardiomyopathy in association with these phenomena. While fentanyl is more lipophilic than other opioids, and a depot effect may play a role in long term users, this condition, its pathophysiology, and its relation to xylazine or other contaminants remains unknown.
  • Clinical impact: Rather than arguing with the patient about the likelihood of this phenomenon occurring and whether this is a true allergy, the patient is informed that they do not need to immediately start treatment to receive care in the hospital. That discussion can be deferred until the patient is stable, the risk of such an event is mitigated, and other medications can be given for their withdrawal symptoms and pain.

Multi-Substance Use

  • Substances such as cocaine, amphetamines, and benzodiazepines often are used concurrently, which can confound the management plan. Urine/serum toxicology screening can show additional substances that they don’t know they’ve been using, which can help them receive recovery services when medically stable. Of note, screening is often required for insurance approval for substance use treatment.
  • Our experience: Traditionally, ED physicians do not like ordering urine drug screens (UDS). Whether due to the non-specific nature of the results, a low likelihood of changing management, or a genuine concern that ordering UDS is a form of stigmatizing patients, it has been a change of practice for us to encourage ordering (and provide EHR decision support) for UDS testing in patients who use drugs. Bundled ordering has not only opened our eyes to the use patterns in our community, but has streamlined the referral to substance use treatment for thousands of patients in our health system. Pairing fentanyl screening to our standard UDS has also allowed us to see the ubiquity of its use; patients are now routinely screening negative for conventional opiates despite using enormous amounts of tranq dope.
  • Clinical impact: For the patient case, the UDS was negative for conventional opiates but positive for cocaine. You call the lab and request fentanyl testing, which is a send-out test. A social worker stops you in the hall and thanks you for ordering the UDS as they go see the patient.

How to Think About This Case of Tranq Dope Withdrawal

The patient is likely experiencing opioid withdrawal [MDCalc Clinical Opioid Withdrawal Scale (COWS) score] and some degree of xylazine withdrawal. We recently published a retrospective observational study of a novel implementation medication order set for fentanyl & xylazine withdrawal, which provide insights into managing this case [16].

1. Xylazine withdrawal is controversial.

There are no prospectively developed or articulated xylazine withdrawal scales. Some experts wonder if what we deem xylazine withdrawal is actually due in large part to the large doses of synthetic opioids consumed, or due to coexisting stimulant withdrawal. We have certainly seen patients who have pain which is controlled and still have psychomotor agitation and sympathetic activation, leading some to require ICU admission for dexmedetomidine and/or ketamine infusion. In our study, we used COWS alone in the ED, which does utilize restlessness, anxiety, and tachycardia as part of the formula, as the sole evaluation tool for tranq dope withdrawal.

2. Medication opioid use disorder (MOUD) induction needs to be done carefully.

We advocate for an approach that uses low dose (or micro-induction) of buprenorphine. We use a product that contains solely buprenorphine at a range of low doses, called Belbuca. This allows us to administer a safe dose of buprenorphine. This low dose initiation strategy did not result in any cases of precipitated withdrawal, and still provided kappa opioid receptor antagonism, which is postulated to help modulate psychological components of dependence.

Alternatively, one can cut the 2 mg Suboxone (buprenorphine + naloxone combination) strips into 4 pieces after waiting for a longer washout period (72-96 hours of abstinence from non-medical opioids) before starting the induction. Or one can start methadone induction.

3. Short-acting, full mu agonist opioids are part of the solution.

In our study, we administer full mu agonists for tranq dope withdrawal, but others in our community also use a combination of short and long-acting full mu agonists.

In our study protocol, dosing started at oxycodone 10 mg PO (update: I now recommend 20 mg) or hydromorphone 2 mg IV for more severe cases. These doses do not come close to replacing their daily opioid use. Some patients require re-dosing in the ED. Most admitted patients end up on patient-controlled analgesia (PCA) pumps early in their course of admission when their use patterns are severe (≥ 1 bundle/day).

4. Acknowledge that short-acting opioids are insufficient on their own.

In our study order set, we intentionally incorporated the concepts of potentiation and synergism to stretch the effects of short-acting opioids (oxycodone PO or hydromorphone IV) while also treating the associated symptoms of opioid and xylazine withdrawal. We also incorporated:

  • Ketamine
  • Neuroleptic medications (droperidol IV and olanzapine ODT)
  • Alpha 2 agonists (tizanidine and guanfacine)
  • Diphenhydramine
  • Lactated ringers IV solution

Differentiation was based on severity, presence of an IV, and concern for prolongation of the QTc >450 msec (Table 1).

We did not use clonidine, despite its known alpha agonist utility in opioid withdrawal, due to the undifferentiated nature of our patients receiving the pathways, not wanting to give an antihypertensive agent to patients who sometimes are experiencing shock and other critical illness. Clonidine is often added back to their regimens inpatient as their vital signs tolerate.

When patients received treatment with one of our four our pathways, there was an association with a significant decrease in post-treatment COWS scores and the risk of patient-directed discharge (renamed from ‘against medical advice’ disposition to remove the stigmatizing connotation [17]) .

Pathway ConditionBupre-norphineOpioidAnti-psychoticAlpha 2 AgonistKetamineDiphen-hydramineLactated Ringers IV Fluids
1. Mild (or no IV) AND normal QTc150 mcg buccalOxycodone 10 mg PO liquidOlanzapine 5 mg PO ODTTizanidine 4 mg PO–––
2. Mild (or no IV) AND prolonged/ unknown QTcGuanfacine 2 mg PO–––
3. Severe AND normal QTcHydromorphone 2 mg IVDroperidol 2.5 mg IVPTizanidine 4 mg PO0.15 mg/kg up to 15 mg (rounded to nearest 5 mg) IVP over 2 minutes25 mg IVP1L bolus
4. Severe AND prolonged/ unknown QTcOlanzapine 10 mg PO ODTGuanfacine 2 mg PO
Table 1. Multimodal medication options for fentanyl-xylazine withdrawal management in London et al. 2024 study [16]. Prolonged QTc was defined as >450 msec.

5. Treatment protocol update: Adding gabapentin with concurrent stimulant use

In our study, more than 70% of our patients used multiple substances, including cocaine and amphetamines [16]. Because the withdrawal syndromes from stimulants can also produce anxiety and sympathetic activation, we have now added GABAergic medications (gabapentin 300 mg PO) to our pathways, given the commonality of coexisting stimulant use disorders.

6. When all else fails, choose harm reduction.

Even in the best-case scenarios, some patients may not be able or willing to stay for their full treatment. While we may not convince them, it does not mean we cannot make a positive contribution to their health. Consider the following discharge adjuncts to give the patient:

  • Nasal naloxone
  • Fentanyl test strips
  • Wound care supplies
  • Safe injection equipment
  • Connection to syringe service programs or other community groups (which are both likely less expensive than the hospital and less traumatizing for patients)

Case Conclusion: Tranq dope withdrawal and spinal epidural abscess

For the patient with back pain and severe tranq dope withdrawal symptoms, you order the following:

  • Buprenorphine 150 mcg buccal
  • Hydromorphone 2 mg IV
  • Ketamine 10 mg IV
  • Olanzapine 10 mg ODT
  • Tizanidine 4 mg PO
  • Diphenhydramine 25 mg IV
  • Gabapentin 300 mg PO (given UDS being for cocaine)
  • IV fluids 1 L bolus

With an unknown QTc interval, you avoid droperidol IV. Your patient ultimately is diagnosed with a spinal epidural abscess requiring operative care. Post-operatively, the care team includes an addiction medicine consultant and certified recovery specialist (an individual with lived experience of addiction, who advocates for and connects others to recovery services; also called peer recovery specialists or recovery coaches [20, 21]).

The patient’s buprenorphine doses are titrated up as their pain stimulus decreases. They are also given screening exams for viral hepatitis, HIV and STIs, and are offered PrEP (pre-exposure prophylaxis for HIV). Despite myriad challenges due to out of state insurance, the patient is connected with a rehabilitation center that provides both physical and substance recovery services. A dedicated addiction and medical bridge clinic is available to the patient following their rehabilitation stay, connecting them to long term care, including treatment for their newly diagnosed hepatitis C. They reconnect with family and community members who were lost to them, building a sustainable support system.

Last Words

Substance use disorders (SUD) are similar to other chronic relapsing medical conditions such as diabetes mellitus, congestive heart failure/cardiomyopathy, chronic obstructive pulmonary disorder, and cancer. While all share a combination of genetic, developmental, and cognitive risk factors, only SUD has been demonized societally as a behavioral failure, rather than just another consequence of cascading social and medical determinants of health.

Treating patients with SUD can be incredibly challenging, especially without a foundation in trauma-informed care principles [20]. Stigma occurs on both sides of the therapeutic relationship, and the poor coping strategies that lead individuals to use injection drugs can malign even tolerant clinicians in such highly charged situations. Strategies to mitigate these challenges include adding certified recovery specialists to care teams, standardizing/improving withdrawal management, and having a holistic addiction medicine team that can provide patient-centered, tailored MOUD and comorbidity guidance.

We are now seeing further contamination in our drug supply, such as other veterinary sedatives (such as medetomidine), novel benzodiazepines (such as bromazolam) and even an industrial solvent (called BTMPS or Tinuvin 770). Psychosis is now being witnessed with naloxone reversal in some cases, and the impact of these novel contaminants on withdrawal syndromes and wounds remain unknown.

If this is reaching your community and you have additional questions, feel free to contact me. I am happy to help how I can.

References

  1. Reuter P, Pardo B, Taylor J. Imagining a fentanyl future: Some consequences of synthetic opioids replacing heroin. International Journal of Drug Policy. 2021 Aug 1;94:103086. PMID 33423915
  2. Pesce A, Bevins N, Tran K, Thomas R, Jensen K. Changing Landscape of Fentanyl/Heroin Use and Distribution. Annals of Clinical and Laboratory Science. 2023 Jan 1;53(1):140-2. PMID 36889767
  3. Torruella RA. Xylazine (veterinary sedative) use in Puerto Rico. Substance Abuse Treatment, Prevention, and Policy. 2011 Dec;6:1-4. PMID 21481268
  4. Education, T.C.F.F.S.R. Drug Checking Quarterly Report (Q3 2022). Philadelphia, Pennsylvania, USA. 2022; 06/26/2023.
  5. Wei J, Wachuku C, Berk-Krauss J, Steele KT, Rosenbach M, Messenger E. Severe cutaneous ulcerations secondary to xylazine (tranq): a case series. JAAD Case Reports. 2023 Jun 1;36:89-91. PMID 37274146
  6. Sloan B. This month in JAAD Case Reports: August 2023: Xylazine and skin necrosis. Journal of the American Academy of Dermatology. 2023 Aug 1;89(2):231. DOI:
  7. Papudesi BN, Malayala SV, Regina AC. Xylazine toxicity. 2023 [book]. PMID 37603662
  8. Rose L, Kirven R, Tyler K, Chung C, Korman AM. Xylazine-induced acute skin necrosis in two patients who inject fentanyl. JAAD Case Reports. 2023 Jun 1;36:113-5. PMID 37288443
  9. Bishnoi A, Singh V, Khanna U, Vinay K. Skin ulcerations caused by xylazine: A lesser-known entity. Journal of the American Academy of Dermatology. 2023 Aug 1;89(2):e99-102. PMID 37054812
  10. Janardan A, Ayoub M, Khan H, Jha P, Dhariwal MS. Mysteriously puffy extremities: an unintended consequence of intravenous drug abuse. Cureus. 2022 May;14(5). PMID 35774687
  11. D’Onofrio G, Chawarski MC, O’Connor PG, et al. Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention. Journal of general internal medicine. 2017 Jun;32:660-6. PMID 28194688
  12. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015 Apr 28;313(16):1636-44. PMID 25919527
  13. Sue KL, Cohen S, Tilley J, Yocheved A. A Plea From People Who Use Drugs to Clinicians: New Ways to Initiate Buprenorphine Are Urgently Needed in the Fentanyl Era. J Addict Med. 2022;16(4):389-391. PMID 35020693.
  14. Starting Bupe From Fentanyl Can Be a Nightmare. Microdosing Methods Help, 2020.
  15. D’Onofrio G, Hawk KF, Perrone J, et al. Incidence of precipitated withdrawal during a multisite emergency department–initiated buprenorphine clinical trial in the era of fentanyl. JAMA Network Open. 2023 Mar 1;6(3):e236108-. PMID 36995717
  16. London K, Li Y, Kahoud JL, et al. Tranq Dope: Characterization of an ED cohort treated with a novel opioid withdrawal protocol in the era of fentanyl/xylazine [published correction appears in Am J Emerg Med. 2024 Oct 8:S0735-6757(24)00523-0. doi: 10.1016/j.ajem.2024.10.006]. Am J Emerg Med. Published online September 4, 2024. doi:10.1016/j.ajem.2024.08.036. PMID 39260041.
  17. Lee CD, Mello MM, Bradfield O, Beach MC. Discharging Patients Against Medical Advice. N Engl J Med. 2023;388(13):1230-1232. doi:10.1056/NEJMclde2210118. PMID 36988605
  18. Vakkalanka P, Lund BC, Arndt S, et al. Association Between Buprenorphine for Opioid Use Disorder and Mortality Risk. Am J Prev Med. 2021;61(3):418-427. doi:10.1016/j.amepre.2021.02.026. PMID 34023160
  19. London K, Matsubara J, Christianson D, Gillingham J, Reed MK (September 12, 2024) Descriptive Analysis of Emergency Department Patients With Substance Use Disorders As Seen by Peer Recovery Specialists in Philadelphia. Cureus 16(9): e69274. DOI
  20. Bartholow LAM, Huffman RT. The Necessity of a Trauma-Informed Paradigm in Substance Use Disorder Services. J Am Psychiatr Nurses Assoc. 2023;29(6):470-476. PMID 34334012
By |2024-10-24T12:19:35-07:00Oct 30, 2024|Beyond the Abstract, Tox & Medications|
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Reading from the Silver Linings Playbook: The ALiEM Connect Project

ALiEM Connect graduation

It feels like yesterday that we were sheltered-in-place, staring at our computers, wondering, “So now what?” 

As COVID-19 paused all in-person educational sessions, the early morning residency conference we used to begrudgingly join quickly became something that we profoundly missed. While we can now be “present” while wearing sweatpants and a button-down shirt, we miss the human connection. Many of us would gladly even suffer through traffic just to be a part of this morning conference tradition.

As educators and innovators, we know what a disruptive force the COVID-19 pandemic has been to the medical community. It has strained our medical and healthcare systems and has irrevocably altered our day-to-day lives. Without a doubt, the pandemic also changed how we delivered educational content to our learners over the past year.

Scholars have written about how likely this pandemic will likely precipitate the much-needed digital transformation of healthcare and health professions education that many of us have expected and hoped for. But while some of these innovations are born out of necessity, they may also inadvertently isolate us from the experiential aspects of education and human interaction that provide meaning to our work. For the ALiEM team, we cherish the opportunity to be part of some of these significant innovative and positive “disruptions,” further aligning our goal of creating an impactful and fulfilling academic life in emergency medicine. 

The Backstory

As a remote team working across continents, the ALiEM team has thrived on digital connection for over a decade. With excellent collaborators and volunteers representing different parts of the world, our daily operations require us to stay connected and work asynchronously to achieve our goals and deliverables. When the lockdowns hit, we leveraged its impact on physical distancing and leaned into connecting with each other even more! They say “chance favors the prepared mind,” and there we were, already on Slack and yearning for the opportunity to harness the power of teamwork using our shared passions, individual creative strengths, and enthusiastic and supportive emojis. There were moments of creating, moments of celebration, and moments of simply being with each other – often through an evening #WifiAndWine.

By the Ides of March 2020, an auspicious time indeed, we knew we were at a turning point. Our friends and work families had been working on the front lines combating the pandemic locally, gathering PPE, and studying the effects of a virus we knew next to nothing about. New information was coming in daily, and the signal-to-noise ratio was low. In some ways, to escape the disruptions going on all around us, we banded together to focus our unique energies toward creating something as novel as the virus itself in the realm of free open-access medical education.

At a time where everyone was feeling alone, we asked ourselves how we could support the joy of learning from and with each other? In truly whirlwind fashion, the first ALiEM Connect conference went from idea to execution in less than 2 weeks, a record-breaking time even for ALiEM. Thank especially to the American Board of Emergency Medicine for sponsoring these events.

We recently made it to the semi-finals at the CORD/ACEP Innovator of the Year competition, where we shared the below video capturing the fun, collaboration, and innovative outcome of our efforts. Oh, and the familiar ratatat of Slack.

Making this a Multiple Win

The secret sauce of the ALiEM team is that we have a diverse group of people, each of whom brings their own perspective and that we are able to share with one another liberally. Dr. Michelle Lin encouraged an environment that is psychologically safe and supportive since the inception of the ALiEM enterprise. It is out of this space that our diverse team was able to successfully bring a massively successful project to fruition amid a global pandemic. What started as a small brainstorming session blossomed into ALiEM Connect – 3 distinct remote conferences featuring nationally-recognized educators and thought leaders enjoyed by residents across the country.

It’s difficult to express as a linear narrative, but looking back, it seems as though our team divided into unique roles without a second thought. Just like a production company, we had the front and back of the house. Those in the front made sure to help get people in the seats to watch; stage managers and coordinators ensured that every part of each of the ALiEM Connect experiences was phenomenally smooth. We had talented individuals who acted as hosts and speakers to ensure that each of these experiences was top-notch and engaging. In the back, Drs. Mary Haas, Yusuf Yilmaz, and Teresa Chan sprung quickly into action to create a program evaluation strategy for our ALiEM Connect program, including a formal institutional review board exemption! All the while, testing and vetting platforms and methods to distribute the material were ongoing. We built upon each technological skill, learned new platforms, and trialed different features. We had barely decided on an open, free, and accessible platform (which was, in fact, no individual platform but an amalgamation of many!) before sending out the invites.

But the fun didn’t stop there! We’re the “academic” life in emergency medicine! How could we not also share our results with the traditional academic community? Within days of finishing our first ALiEM Connect experience, our program evaluation team generated the scaffolding of a manuscript to put together our thoughts and analyze the evaluation data collected. We harnessed the power of metrics from social media platforms (YouTube, Slack, Twitter), website analytics, and end-user experiences. Harnessing all of these analytics and communicating the right message with our academic medicine community was important to inform and help others to replicate similar approaches to their residents. Our team used ready to use metrics which came from YouTube analytics. But we did not stop there as we needed more reports of how the residents and programs interacted during the Connect events in the backchannel, Slack. We developed Python supported software to export and analyze all the messages happening in separate channels. We developed a “Emoji Cloud” to see how the reactions happened, and closely analyzed the messages during the event.

Given the true novelty of the experience, we figured we might as well shoot for the moon, as they say, by submitting our innovation description paper to Academic Medicine. After all, even if they didn’t accept it, we might get some constructive reviews, to say the least. As innovators, we are comfortable with the possibility of failure. We understand the value of the saying, “You miss 100% of the shots you don’t take,” and were prepared to accept “no” as an answer. With that, we took a calculated risk, making use of the same collaborative strategy to craft a manuscript, and clicked submit.

…And we’re glad we took that shot! We are excited to share that what we sent was indeed accepted and express our gratitude for the chance to share our low-cost approach to a large-scale, nationwide residency conference! You may read the Published Ahead-of-Print version of our paper.

Moral of the story…

You might be asking yourself, “What’s the moral of the story here? Of course, with enough academics and experts, yeah, you got a paper published. Cool…” But the papers aren’t the point. In fact, during the COVID-19 pandemic, more papers have been published than ever before – more research is being done, and our whole field is changing. The point is… this is how we got to ENJOY the academic life during a pandemic! We made lemonade (and several other desserts!) out of the lemons we were handed. New knowledge comes from thinking big and trying new things. Turns out, sometimes you also have to write about those experiences and share them with others.

As emergency physicians, we know we’re good in a crisis. But this experience reminded us that by surrounding ourselves with amazing people, we could get a surprising amount of work done (at record speed) and have a fantastically memorable time along the way. The moral of this story is that when you bring great people together and give them a chance to get to know each other, magic happens. ALiEM Connect happens. And we impact more people than we can possibly meet at the touch of our keyboards. We are so grateful for the chance to work alongside all the wonderful people at each of our institutions every day. Still, also, we are indebted to those who are our digital family. Thank you to all of you who make initiatives like ALiEM Connect possible. Academic life in emergency medicine is all about bringing a great team together.

So is the ALiEM team.

By |2021-04-23T11:02:57-07:00Apr 26, 2021|Academic, Beyond the Abstract, Education Articles, Medical Education, Professional Development, Social Media & Tech|
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Social Medicine in the Emergency Department: Not all conditions can be treated with medicines

social medicine emergency department homeless

On the day we met Jane, a woman in her 70’s with diabetes and mobility impairment, she was visiting an Emergency Department (ED) for the 50th time in the past year. Jane was experiencing homelessness and spent much of her day riding public transportation in her wheelchair. Bystanders, often concerned for her health after noticing she had an episode of incontinence, would call 911 after which Jane would be brought to the nearest ED.

On the day Jane came to our ED, our multidisciplinary ED-based Social Medicine team was asked to help in her care. She was very thin, her clothes were wet from rain, and her belongings were falling from the plastic bags draped on the back of her wheelchair.  Our team sat with Jane to understand what type of help that she wanted — she was hungry, she hadn’t had stable access to food for months, and her bottom was painful as she had developed wounds from spending hours sitting in soiled clothes. That day, our team provided her with a sandwich and hot coffee, brought her a set of clean, dry clothes, and built enough rapport with her to interest her in moving indoors to a nearby respite center. Over the ensuing months, Jane gained back her strength, she established care with a primary care physician and improved her diabetes control, her wounds healed, and she built a relationship with a case manager who helped her to move into long-term housing. And, as a secondary outcome, her use of acute care services dropped substantially – she had less than 5 ED visits and no hospitalizations in the following year.  Caring for Jane and watching what happened next was a lesson for all of us about the impact of addressing medical and social needs together.

What is an ED Social Medicine team?

We formed the ED Social Medicine team in 2017 to support ED clinicians and help better meet the complex medical, behavioral health, and social needs of ED patients. A brief description of our work was recently published in JAMA [1], which provides one potential roadmap to medical and social care integration in the ED. A few core components of this work include:

  1. Asking patients about their self-identified social needs – Meeting a patient’s psychosocial needs allows them to better engage with medical care.
  2. Supporting ED clinicians in the care of patients with complex behavioral health and social needs – The ED and acute care system cannot function optimally in a silo. The Social Medicine team is multi-disciplinary and includes hospital-based social workers, nurses, pharmacists, care coordinators, AND strong partnerships with ambulatory health care clinicians and community-based organizations essential to the safe discharge and successful care of ED patients with complex social needs.
  3. Considering how to best promote the individual patient’s health and independence while preserving access to acute care for all patients – Medical, social, and behavioral health resources in the community are often more robust than we might realize; clinicians and patients both win by better understanding the landscape of care and resources available in the community. Leveraging available community resources also allows the ED and inpatient hospital to be preserved for patients with the most emergent medical conditions.

Integrating the medical, behavioral, and social care for your patient

Treatment of medical conditions without consideration of underlying social needs will be less effective, more costly, and may lead to moral distress for both patients and providers. We all want to feel that we are treating the patient so that they will do as well as possible in their life outside the hospital — to address not just the immediate medical issue, but the things that are fundamental challenges in their lives.

For instance, when we are treating a patient in the ED with diabetes, homelessness, and social isolation, prescribing medication to treat hyperglycemia may be the most straightforward solution, but it is unlikely to be maximally effective without ensuring the patient can do the following:

  • Afford the medication
  • Get to the pharmacy
  • Read the label and administer the medication
  • Access affordable food
  • Obtain transportation to follow up medical appointments
  • Find a stable place to live
  • Connect with social support in their community

These can seem daunting, and it may not be possible to improve all of these issues during the ED visit, but there are effective interventions to try to help patients experiencing complex social needs. As related to the example above:

  • Arrange a conversation with a social worker to assess and address the patient’s social needs
  • Dispense discharge medications directly from the ED
  • Ask the pharmacist to consider how to make dosing easier such as a medi-set or special labeling for patients who speak a primary language other than English, or have visual impairment or low literacy
  • Facilitate the next check up in primary care or other medical care by making an appointment or providing a warm handoff
  • Provide printed information about social and community resources such as meal kitchens, food pantries, housing programs and community groups (such as support groups, faith communities and cultural organizations)

No matter what the problem, a first step is always to ask the patient what support they need in order to be successful.

Call to action for social medicine

  1. Partner up: We encourage you to understand the underlying social needs of your patients and work with partners, such as your ED social workers and community social services, to help meet those needs. The ED visit can be an opportunity to go beyond healthcare, and help our patients realize optimal health.
  2. Ask the patient: At the frontline, we recommend asking your patients about their primary concerns and social needs, and doing what you can to help.
  3. Form a team: If you want to go a step further, form a team and develop partnerships with staff in your ED (e.g., social workers) and outside your health setting (e.g., community based organizations) to understand a system problem (e.g., access to medications, food or emergency housing) more deeply. Talk to your patients to get their input and recommendations. Then, use quality improvement techniques to improve the care of that problem in service to your patients.
  4. Look upstream: If you want to work upstream of direct care, join or form a group to understand a problem at the community level and advocate for increased social services available to your organization and community.

More resources

If you want to learn more or get more involved in the Social Emergency Medicine space:

 

References

  1. Chase J, Bilinski J, Kanzaria HK. Caring for Emergency Department Patients With Complex Medical, Behavioral Health, and Social Needs. JAMA. 2020;324(24):2550-2551. doi:10.1001/jama.2020.17017

Photo by Ev on Unsplash

By |2021-01-13T17:57:01-08:00Jan 22, 2021|Beyond the Abstract, Emergency Medicine|
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Beyond the Abstract | Resident Motivations and Experiences in Listening to Educational Podcasts

Podcasts are all the rage these days, and it is not surprising that some residents spend more time with podcasts than any other educational resource.​1–3​ But why? And how do podcasts fit with other forms of learning, like lectures, textbooks, and clinical teaching?

In our recent article published in Academic Medicine, we explored these questions. Using qualitative interviews and analysis, we identified 3 overarching themes that shed light on residents’ podcast listening behaviors and the tensions with which listeners wrestled.​4​

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By |2019-10-30T21:00:09-07:00Sep 27, 2019|Beyond the Abstract, Research, Social Media & Tech|
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Beyond the Abstract: A Return to Work Policy for New Resident Parents

More women than men entered medical school in the United States for the first time in 2017. Will this generation also set new trends in parenting during their training? One study suggests that 40% of female residents plan to have a child while in residency.1

Can our graduate medical education system withstand even a modest increase in the number of resident parents? Can your hospital?

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By |2019-04-18T15:05:11-07:00Mar 19, 2019|Beyond the Abstract, Wellness|
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