Although the absolute improvement in quality scores was modest , the intervention resulted in the communication of approximately 100 pieces of additional information, any of which had the potential to improve the handoff process. A recent survey of EM residency programs in the U.S. found poor adherence to standardized ED-to- inpatient handoff practices,and our study was no exception. In the post-intervention period, the SBAR-DR format was used for only 30% of verbal hand offs and the written template was used for 50%. The reason for this was likely multi-factorial and related to both methodological and cultural barriers. Although the pilot study involved the institution’s largest admitting service, EPs performed admission hand offs with other admitting teams not included in the study. Having to shift between different handoff strategies may have limited EPs’ ability to acclimatize and integrate SBAR-DR into their daily practice. The adoption of the written handoff note also may have been hindered by the additional charting time required. Additionally, having fewer senior EM residents in the post-intervention cohort may have negatively impacted our post-intervention scores, as we found this group showed significant improvement in both handoff quality score and global rating scale. This supports prior research, which has found that residents’ ability to integrate handoff information may improve with experience.Additionally, handoff practices are an engrained part of a specialty’s culture. Although our study group included faculty and resident physician champions from IM and EM, we may not have fostered adequate buy-in from practicing providers to change practice routines.
As institutions implement changes to inter-unit hand offs and care transitions, they need to address cultural complacency and build coalitions among affected members of the healthcare team.Possible solutions includeinter-disciplinary communication training,cannabis grow table which could give physicians an opportunity to practice standardized hand offs with one another, while also mitigating future conflicts via improved inter-personal engagement.Endorsement from senior physician leadership could also facilitate provider buy-in and adherence. Finally, the Joint Commission Center for Transforming Health care’s Targeted Solutions Tool® has shown promise in improving handoff communication by facilitating targeted needs assessment of local handoff practices, data collection, and quality improvement intervention.Cannabis is the most widely used illicit substance in the United States. In 2014, 22.2 million Americans 12 years of age and older reported current cannabis use.The rapidly changing political landscape surrounding cannabis use has the potential to increase these numbers dramatically.In addition, as of 2017 California, seven other states and the District of Columbia have legalized recreational use of marijuana.The incidence of CHS and other marijuana related emergency department visits has increased significantly in states where marijuana has been legalized.A study published in 2016 evaluating the effects of cannabis legalization on EDs in the state of Colorado found that visits for cyclic vomiting—which included CHS in this study—have doubled since legalization.Despite the syndrome’s increasing prevalence, many physicians are unfamiliar with its diagnosis and treatment. CHS is marked by symptoms that can be refractory to standard antiemetics and analgesics.Notwithstanding increasing public health concerns about a national opioid epidemic and emerging guidelines advocating non-opioid alternatives for management of painful conditions, these patients are frequently treated with opioids.
In light of the public health implications of a need to reduce opioid use when better alternatives exist, this paper describes the current state of knowledge about CHS and presents a novel model treatment guideline that may be useful to front line emergency physicians and other medical providers who interface with these patients. The expert consensus process used to develop the model guideline is also described.CHS is a condition defined by symptoms including significant nausea, vomiting, and abdominal pain in the setting of chronic cannabis use.7 Cardinal diagnostic characteristics associated with CHS include regular cannabis use, cyclic nausea and vomiting, and compulsive hot baths or showers with resolution of symptoms after cessation of cannabis use. Cyclical vomiting syndrome is a related condition consisting of symptoms of relentless vomiting and retching. While CHS patients present with similar symptoms to those with CVS, associated cannabis use is required to make the diagnosis. CHS patients present to the ED with non-specific symptoms that are similar to other intra-abdominal conditions. These patients command substantial ED and hospital resources. In a small multi-center ambispective cohort study by Perrotta et al., the mean number of ED visits and hospital admissions for 20 suspected CHS patients identified over a two-year period was 17.3 ± 13.6 and 6.8 ± 9.4 respectively.These patients frequently undergo expensive and non-diagnostic abdominal imaging studies. In the Perrotta study,cannabis drying trays the mean number of abdominal computed tomography scans and abdominal/ pelvic ultrasounds per patient was 5.3 ± 4.1 and 3.8 ± 3.6 respectively. In addition to a contribution to ED crowding by unnecessary prolonged stays to perform diagnostic testing, patients are exposed to potential side effects of medications, peripheral intravenous lines, and procedures such as endoscopies and abdominal surgeries.
While treating physicians often administer opioid analgesics and antiemetics, symptom relief is rarely achieved with this strategy. In fact, there is evidence to suggest opioids may exacerbate symptoms.The pathophysiology of CHS is unclear.Paradoxically, there are long-recognized antiemetic effects of cannabis, thus leading to its approved use for treatment of nausea and vomiting associated with chemotherapy and appetite stimulation in HIV/AIDS patients. The factors leading to the development of CHS among only a portion of chronic marijuana users are not well understood. Basic science research has identified two main cannabinoid receptors: CB1 and CB2 , with CB1 receptors primarily in the central nervous system, and CB2 receptors primarily in peripheral tissues. This categorization has recently been challenged and researchers have identified CB1 receptors in the gastrointestinal tract.Activity at the CB1 receptor is believed to be responsible for many of the clinical effects of cannabis use, including those related to cognition, memory, and nausea/vomiting.Scientists hypothesize that CHS may be secondary to dysregulation of the endogenous cannabinoid system by desensitization or down regulation of cannabinoid receptors.Some investigators have postulated that disruption of peripheral cannabinoid receptors in the enteric nerves may slow gastric motility, precipitating hyperemesis.Relief of CHS symptoms with very hot water has highlighted a peripheral tissue receptor called TRPV1 , a G-protein coupled receptor that has been shown to interact with the endocannabinoid system, but is also the only known capsaicin receptor.This has led some to advocate for the use of topical capsaicin cream in the management of acute CHS.Sorensen et al. identified seven diagnostic frameworks, with significant overlap among characteristics listed by the various authors; however, there was no specific mention of how many of the above features are required for diagnosis. Those with the highest sensitivity include at least weekly cannabis use for greater than one year, severe nausea and vomiting that recurs in cyclic patterns over months usually accompanied by abdominal pain, resolution of symptoms after cannabis cessation, and compulsive hot baths/showers with symptom relief. Clinicians should consider other causes of abdominal pain, nausea and vomiting to avoid misdiagnosis. Abdominal pain is classically generalized and diffuse in nature. CHS is primarily associated with inhalation of cannabis, though it is independent of formulation and can be seen with incineration of plant matter , vaporized formulations , waxes or oils, and synthetic cannabinoids. At the time of this writing, there have been no reported cases associated with edible marijuana. Episodes generally last 24-48 hours, but may last up to 7-10 days. Patients who endorse relief with very hot water will sometimes report spending hours in the shower.Many of these patients will have had multiple presentations to the ED with previously negative workups, including laboratory examinations and advanced imaging.Clinicians should assess for the presence of CHS in otherwise healthy, young, non-diabetic patients presenting with a previous diagnosis of gastroparesis. Laboratory test results are frequently non-specific. If patients present after a protracted course of nausea and vomiting, there may be electrolyte derangements, ketonuria, or other signs of dehydration. Mild leukocytosis is common.
If patients deny cannabis use but suspicion remains high, a urine drug screen should be considered. Imaging should be avoided, especially in the setting of a benign abdominal examination, as there are no specific radiological findings suggestive of the diagnosis.Per the expert consensus guideline, once the diagnosis of CHS has been made and there is a low suspicion for other acute diagnoses, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to employ as first line treatment.While this recommendation is made based on very limited data including a few small case series, capsaicin is inexpensive, has a low risk side-effect profile, makes mechanistic sense, and is well tolerated.Conversely, there are no data demonstrating efficacy of opioids for CHS. Capsaicin 0.075% can be applied to the abdomen or the backs of the arms. If the patients can identify regions of their bodies where hot water provides symptom relief, those areas should be prioritized for capsaicin application. Patients should be advised that capsaicin may be uncomfortable initially, but then should rapidly mimic the relief that they receive with hot showers. Additionally patients must be counseled to avoid application near the face, eyes, genitourinary region, and other areas of sensitive skin, not to apply capsaicin to broken skin, and not to use occlusive dressings over the applied capsaicin. Patients can be discharged home with capsaicin, advising application three or four times a day as needed. If capsaicin is not readily available, but there is a shower available in the ED, patients can be advised to shower with hot water to provide relief. Educate patients to use caution to avoid thermal injury, as there are reports of patients spending as long as four hours at a time in hot showers.11 Other possible therapeutic interventions include administration of antipsychotics such as haloperidol 5 mg IV/IM or olanzapine 5 mg IV/IM or ODT, which have been described to provide complete symptom relief in case reports.Conventional antiemetics, including antihistamines , serotonin antagonists , dopamine antagonists , and benzodiazepines can be used, though reports of effectiveness are mixed.Provide intravenous fluids and electrolyte replacement as indicated. Avoid opioids if the diagnosis of CHS is certain. Clinicians should inform patients that their symptoms are directly related to continued use of cannabis. They should further advise patients that immediate cessation of cannabis use is the only method that has been shown to completely resolve symptoms. Reassure patients that symptoms resolve with cessation of cannabinoid use and that full resolution can take anywhere from 7-10 days of abstinence.Educate patients that symptoms may return with re-exposure to cannabis. Provide clear documentation in the medical record to assist colleagues with confirming a diagnosis, as these patients will frequently re present to the ED.Due to the growing opioid epidemic in the U.S., there is widespread interest in using prescription drug monitoring systems to curb prescription drug abuse. PDMPs are statewide databases used by physicians, pharmacists, and law enforcement to obtain data about controlled-drug prescriptions, with the goal of detecting substance-use disorders, drug-seeking behaviors, and reducing patient risks of adverse drug events. While almost all U.S. states have PDMPs, they vary in design and implementation.In this paper, we review the history, evidence, and adoption of best practice guidelines in state PDMPs with a focus on how to best deploy PDMPs in emergency departments. Specifically, we analyze the current PDMP model and provide recommendations for PDMP developers and EDs to help meet the informational needs of ED providers with the goal of better detection and prevention of prescription drug abuse.The U.S. accounts for roughly 80% of opioid use worldwide, and misuse – such as the recreational use of opioids – is a significant problem.Every 19 minutes in the U.S. someone dies from an unintentional drug overdose, the majority from opioids.From 1997 to 2007 the average milligram -per-year use of prescription per person of opioids in the U.S. increased 402%, from 74 mg to 369 mg. Meanwhile, an estimated seven million people above the age of 12 use opioids and other prescription medications for non therapeutic purposes annually.These non-medical uses of opioids are linked to 700,000 ED visits yearly.Along with treating the consequences of opioid-related illness and overdose, EDs are often a location used by some patients as a source for opioid prescriptions.