Safe for Discharge: COPD Exacerbations

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The Scope of the Problem

COPD is involved in up to 20% of hospitalizations for adults in the U.S.

While there are studies that aid in evaluation, an acute COPD exacerbation is a clinical diagnosis that is characterized by symptoms which are more severe than the patient’s baseline. This includes, among other symptoms, worsening dyspnea, increased cough and sputum production, worsening wheezing, and increased oxygen requirements.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines note that COPD is the third leading cause of death in the United States.

Who is Safe for Discharge?

The GOLD guidelines recommend admission for these patients:

  • Those significantly worsened from their baseline
  • Patients with a poor response to ED management of their symptoms
  • Patients with significant comorbidities
  • Those with worsening hypoxia or hypercarbia
  • Those who will be unable to cope at home

The DECAF score has been validated and found to outperform other commonly-used stratifying scores such as CURB-65 or APACHE to identify patients at risk of in-hospital or 30-day mortality

A score of 3 or greater is associated with an in-hospital mortality rate of 15%, which rises with increasing DECAF score. Inpatient management is recommended for these patients.

Should these patients be given antibiotics?

There is evidence of benefit for patients who are admitted, but this is less clear for patients with milder exacerbations who are treated as outpatients.

How do we predict FEV1 at the bedside?

This can be difficult – assessing peak flow is a substitute but is highly dependent on the patient’s effort. A patient with a peak flow of 70% of expected or greater is likely safe for discharge. This presumes there are no other indications for admission.

To sum up…

Patients presenting with acute COPD exacerbation who meet the following criteria may be appropriate for outpatient management:

  • No or only mild increase in dyspnea from baseline
  • Minimal increase in baseline hypoxia or hypercarbia
  • Comorbid conditions are well-controlled and do not complicate the acute clinical picture
  • Able to fill prescriptions and care for self at home
  • DECAF score less than 3

Cardiovascular ICU Selective/Elective

Teaching Chief: Kartheek Nagappala MD

Description: Advanced Cardiovascular Critical Care rotation will allow residents to further develop their skills, knowledge and attitudes obtained during their previous rotations, specifically expanding on their critical knowledge to patients that are post cardiac surgery, major vascular surgery, and critically ill due to compromise of their cardiovascular system. The rotation will involve 21-22 12-hour shifts, similar to the EM core ICU experience. 

Availability: Generally available year-round and will occasionally share the experience with an Anesthesia co-rotator.

Scheduling: Schedule to be made by the rotator with final schedule approval by the teaching chief

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Community Emergency Medicine Elective

(PGY-3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Palliative Care Selective/Elective

Teaching Chief: Ryan Howard MD

Description: The Palliative Care Selective or Elective is a 2- or 4-week inpatient rotation designed to expose the rotator to all aspects of inpatient palliative care. Residents will work alongside the palliative director and/or the palliative fellow along with the interdisciplinary palliative team throughout the rotation. The goal is to provide either PGY2 or PGY3 residents with an immersive clinical experience to learn more about inpatient palliative services.

Availability: Generally year-round, those interested in applying to Palliative Fellowship get precedence on the rotation as space is limited

Scheduling: M-F, 8am-5pm, with call shifts if required/desired per Dr. Howard

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Intro and Advanced Pharmacology Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD and Savannah Lail PharmD

Description: A 2 or 4-week rotation where the resident works and learns alongside the ED pharmacists on assigned shifts. The Pharmacology rotation is designed to provide training concerning the application of pharmacology knowledge, pharmaceutics, drug information, medication safety, communication skills, critical thinking, pathophysiology, and therapeutics to the care of patients in an emergency department setting. The advanced rotation is for those who have already had the introductory Pharmacology rotation experience.

Availability: Generally year-round, but must contact PharmD teaching chief prior to choosing the rotation to ensure availability. 

Scheduling: Variable shifts, 10-shifts per rotation, to be assigned by PharmD teaching chief

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Pulmonary and Ventilator Management Selective/Elective

Teaching Chief: Leland Beggs MD

Description: This is a 4-week rotation based in the ICU, CVICU and ED. Residents will work side-by-side with designated respiratory therapists as well as core faculty physicians. The goal of this rotation is to focus solely on vent management and non-invasive ventilation techniques in patients with a wide variety of disease processes. Residents will be expected to manage vent settings for intubated patients in the ED, ICU and CVICU. Residents on service should gain an in-depth understanding of the events surrounding intubation, including strategies in pre oxygenation as well as the various drugs used for RSI and post intubation sedation. In addition, they will learn when to initiate, and how to manage non-invasive ventilation.

Availability: Generally year-round

Scheduling: M-F, 6am-4pm

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Radiology Selective/Elective

(Two-week experience) 

Teaching Chief: Ashkan Shahkarami MD

Description: The two-week Radiology rotation will provide the resident with an opportunity to learn normal and abnormal radiographic anatomy, recognize radiographic findings of common diseases, understand the indications for commonly ordered imaging studies, and learn the appropriate use of IR procedures. The goal of the rotation is to help the resident become competent in the use of imaging in the evaluation and treatment of disease.

Availability: Generally year-round, but must contact teaching chief before choosing the rotation to ensure availability

Scheduling: M-F, 8am-4pm, or as adjusted by the Radiology attending

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Wilderness Medicine Selective/Elective

Teaching Chief: Various

Description: The one-week wilderness medicine selective is offered twice a year at Kaweah Health, usually once in the Spring and once in the Fall/Winter. If not available during the allocated selective/elective block, previous residents have participated in 4-week experiences in Utah and Redding, CA. Experiences are variable and depend on the chosen course, so for this one touch base with Dr. Sukhija to see what is feasible both locally and away.

Availability: Highly variable, see description above

Scheduling: Highly variable

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Emergency Medicine Admin Selective/Elective

Teaching Chief: Kona Seng DO and Khoa Tu MD

Description: This is 2-4-week rotation in conjunction with the Department of Emergency Medicine Medical Director. The purpose of the ED Administration rotation is to provide an understanding of the administrative components of EM clinical services and operations. This will allow early exposure to ED administration to determine if the resident is interested in the administration and business of emergency medicine. The EM residents will attend all assigned meetings and participate in administrative projects. 

Availability: Generally year-round, will share the rotation with the PGY3 on their core admin rotation

Scheduling: M-F, 9-5pm, or as adjusted by the teaching chiefs

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Patient and Physician Advocacy and Street Medicine Selective/Elective

Teaching Chief: Kunal Sukhija MD, Omar Guzman MD, Lori Winston MD

Description: The Advocacy 2- or 4-week rotation is designed to be a self-directed customizable experience that will provide immersion into various aspects of physician and patient advocacy. The resident will be able to participate in local, state-wide, and national (schedule permitting) advocacy efforts while simultaneously learning about effective strategies to engage community leaders, legislators, and the local constituency. The rotation will offer experiences in both the legislative and community advocacy (the latter will be based in the Street Medicine program). 

Availability: Generally year-round, however certain months tend to be better given the yearly CMA, AMA, CalACEP, ACEP schedules. Touch base with Dr. Sukhija prior to choosing this elective in order to ensure you can get the individualized experience you desire.

Scheduling: Highly variable depending on advocacy events and meetings, Street Medicine tends to hold its events on Friday

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Performance and Quality Improvement (PI/QI) Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD

Description: The Performance Improvement (PI)/Quality Improvement (QI) selective rotation will provide exposure to ongoing PI and QI efforts at KDHCD and provide opportunities for the PGY2 or PGY3 EM resident to become involved in PI/QI projects on an individual, departmental, or institutional level. The resident will join the Emergency Medicine PI director in the regular duties of chart review, M&M conference coordination and presentations, and committee meeting attendance as appropriate. It also offers time for the resident to work on their PI/QI project as part of residency graduation requirements. 

Availability: Generally year-round

Scheduling: Variable depending on meetings and current on-going projects

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Public Health Elective (PGY3 only)

(PGY3 only)

Teaching Chief: Karen Haught MD MPH, Tulare County Public Health Director

Description: This is a 4-week rotation with the Tulare Public Health Department designed to expose the rotator to all aspects of public health. Residents will work alongside the Tulare Public Health Director and/or the epidemiologist throughout the rotation. The goal is to provide PGY3 residents exposure to the role of the local public health department in the community. Residents will be expected to work at the Tulare Public Health Department and contribute to a community health project of the resident’s choice.

Availability: Generally year-round, though an interested resident should first contact Dr. Haught prior to selecting this experience (Dr. Sukhija will help you with contact information)

Scheduling: M-F, 9-5, though historically it’s been less than this as independence is given to work on the resident’s chosen project

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Research Selective/Elective

Teaching Chief: Chris Patty DNP, Director of Research

Description: The goal of the resident research rotation (2 or 4 weeks) is to improve the resident’s understanding of how new knowledge is created and translated into practice.  At the end of the rotation, the resident will present a deliverable which demonstrates ACGME competencies in knowledge development and translation. Many residents choose this rotation in order to work on their chosen Scholarly Activity as part of residency graduation requirements. 

Availability: Generally year-round, the resident must contact the director of research 4-weeks prior to the rotation in order to state deliverables and set up the rotational requirements.

Scheduling: Variable, generally self-directed independent work

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Simulation and Education Selective/Elective

Teaching Chief: Kim Sokol MD

Description: This is a 4-week rotation includes developing simulation scenarios, teaching simulation-based educational sessions, and assisting in daily operations in the simulation center. The rotation’s purpose is to develop skills associated with teaching. The rotation will provide an introduction to simulation with multiple adjuncts such as high and low-fidelity mannequins, task trainers, and the use of standardized patients.  A basic understanding of simulation-based education and debriefing will be taught along with basic principles associated with adult education. The resident must choose teaching shifts as their clinical experience.

Availability: Generally year-round

Scheduling: Variable, to be determined with the teaching chief prior to the rotation start date

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Teaching Elective with Dr. Stanley

(PGY3 only)

Teaching Chief: Michael Stanley DO

Description: This 4-week rotation is a highly-desired advanced elective rotation for PGY3 EM residents. It is intended only for those residents who are serious about improving their ability to teach AND lead. This rotation is as much about leadership as it is about teaching because both utilize the same skill sets. Residents will gain knowledge in effective communication techniques while learning about the underlying psychology of teaching, learning, and leadership.

Availability: Generally year-round

Scheduling: 12 10-hour shifts to be scheduled in accordance with Dr. Stanley’s clinical schedule, along with didactics (also to be scheduled with Dr. Stanley prior to the start date). If Dr. Stanley has less than 12 shifts, then the remainder can be completed with either Dr. Oldroyd, Dr. Sokol, or Dr. Alexeeva.

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Advanced Ultrasound Selective/Elective

Teaching Chief: John Hipskind MD

Description: This 4-week rotation is designed to augment the resident’s diagnostic (and therapeutic) skills in relation to the ultrasound, and to explore more advanced US modalities such as TEE. The resident will gain experience with nerve blocks, enhanced approaches to the core EM ultrasound studies, and explore novel ways to use the ultrasound in the ED setting. They will work alongside the teaching chief as well as the ultrasound fellows.

Scheduling: The expectation is to be scanning daily M-F, with weekends off. Due to PGY1 EM rotators and the popularity of this selective/elective, there may be many residents on rotation, and thus scheduling must be in conjunction with Mia Zavinovich and Dr. Hipskind prior to the start of the rotation. 

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International & Global Medicine Elective

(PGY3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Patient Callbacks and PBLI form

Patient callback instuctions - complete 12/block when you are on the emergency medicine service

PBLI form - complete 4/year to reflect & self-evaluate your patient care

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