Volume 17, Issue 1, January 2016.
Niels Rathlev, MD, et al.

Introduction: There is a paucity of literature supporting the use of electronic alerts for patients
with high frequency emergency department (ED) use. We sought to measure changes in opioid
prescribing and administration practices, total charges and other resource utilization using electronic
alerts to notify providers of an opioid-use care plan for high frequency ED patients.
Methods: This was a randomized, non-blinded, two-group parallel design study of patients who
had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical
electronic health records participated. Patients were randomized into “Care Plan” versus “Usual Care
groups”. Between the years before and after randomization, we compared as primary outcomes
the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and
administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED
visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging
[MRI]) studies, and 5) inpatient admissions.
Results: A total of 40 patients were enrolled. For ED and inpatients in the “Usual Care” group, the
proportion of morphine mg equivalents received in the post-period compared with the pre-period was
15.7%, while in the “Care Plan” group the proportion received in the post-period compared with the
pre-period was 4.5% (ratio=0.29, 95% CI [0.07-1.12]; p=0.07). For discharged patients in the “Usual
Care” group, the proportion of morphine mg equivalents prescribed in the post-period compared with
the pre-period was 25.7% while in the “Care Plan” group, the proportion prescribed in the post-period
compared to the pre-period was 2.9%. The “Care Plan” group showed an 89% greater proportional
change over the periods compared with the “Usual Care” group (ratio=0.11, 95% CI [0.01-0.092];
p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT
or MRI or inpatient admissions.
Conclusion: Electronic care plans were associated with an incremental decrease in opioids (in
morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED
use.

Volume 17, Issue 1, January 2016.
Michael Gottlieb, MD, et al.

Introduction: Most emergency physicians routinely obtain shoulder radiographs before and after
shoulder dislocations. However, currently there is limited literature demonstrating how frequently
new fractures are identified on post-reduction radiographs. The primary objective of this study
was to determine the frequency of new, clinically significant fractures identified on post-reduction
radiographs with a secondary outcome assessing total new fractures identified.
Methods: We conducted a retrospective chart review using appropriate International Classification
of Diseases, 9th Revision (ICD-9) codes to identify all potential shoulder dislocations that were
reduced in a single, urban, academic emergency department (ED) over a five-year period. We
excluded cases that required operative reduction, had associated proximal humeral head or shaft
fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted
separately by two study investigators with disagreements settled by consensus among three
investigators. Images from indeterminate cases were reviewed by a radiology attending physician
with musculoskeletal expertise. The primary outcome was the percentage of new, clinically
significant fractures defined as those altering acute ED management. Secondary outcomes included
percentage of new fractures of any type.
Results: We identified 185 total patients meeting our study criteria. There were no new,
clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI
[3.3%-10.7%]) total new fractures identified, all of which were without clinical significance for
acute ED management.
Conclusion: Post-reduction radiographs do not appear to identify any new, clinically significant
fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED
setting for shoulder dislocations.