Background Because clinicians fear missing occult cervical-spine injuries, they obtain cervical radiographs for nearly all patients who present with blunt trauma. Previous research suggests that a set of clinical criteria (decision instrument) can identify patients who have an extremely low probability of injury and who consequently have no need for imaging studies. Methods We conducted a prospective, observational study of such a decision instrument at 21 centers across the United States. The decision instrument required patients to meet five criteria in order to be classified as having a low probability of injury: no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury. We examined the performance of the decision instrument in 34,069 patients who underwent radiography of the cervical spine after blunt trauma. Results The decision instrument identified all but 8 of the 818 patients who had cervical-spine injury (sensitivity, 99.0 ...

https://www.nejm.org/doi/pdf/10.1056/NEJM200007133430203

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.

/pdf/validity-of-a-set-of-clinical-criteria-to-rule-out-injury-to-2crvqdfcia.pdf

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma

Background— Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non–ST-segment elevation acute coronary syndromes (NSTE ACS) and how different treatments affect outcomes. Methods and Results— Using data from 400 US hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37 813 (87.3%) white and 5504 (12.7%) black patients. Black patients were younger; were more li...

Racial Variations in Treatment and Outcomes of Black and White Patients With High-Risk Non–ST-Elevation Acute Coronary Syndromes Insights From CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?)

Emergency department crowding: A point in time

Background: The causes of unscheduled returns to the emergency department (ED) within 72 hours of discharge are unclear. A study was undertaken to identify factors associated with this quality care indicator. Methods: 250 cases and 250 controls from the ED were prospectively studied. Outcomes measured were unscheduled returns, post-ED destination, and patient dissatisfaction. Possible medical errors (in diagnosis, treatment, prognosis or patient information) and errors in follow up care were identified. Other factors examined included chief complaint at presentation, discharge diagnosis, level of triage, category of treating physician, observation or not, application of emergency treatment, ancillary studies, accessibility to ED, ED time band or work shift, day of the week, past medical history, and demographic data (age, sex, educational level and economic status). Results: The main factor associated with unscheduled returns was error in prognosis (odds ratio 18.62, 95% CI 9.60 to 36.09). Advanced age and a chief complaint of dyspnoea were also associated with unscheduled returns and with admission to hospital. Post-ED destination worsened by 0.61 (95% CI 0.33 to 0.90) with diagnostic errors and by 0.60 (95% CI 0.30 to 0.90) with errors in follow up care. Patient dissatisfaction increased by 0.68 (95% CI 0.55 to 0.80) with information errors, by 0.63 (95% CI 0.17 to 1.09) with errors in follow up care, and by 0.52 (95% CI 0.09 to 0.94) with diagnostic errors. Conclusion: Unscheduled returns are associated with medical errors in prognosis, treatment, follow up care, and information. A worse post-ED destination is associated with these medical errors and patient factors (dyspnoea and advanced age). Patient dissatisfaction is associated with medical errors, level of triage or care zone, patient educational level and ED time work shift. Most of these factors are modifiable.

/pdf/unscheduled-returns-to-the-emergency-department-an-outcome-2lx2fhcr5e.pdf

Paul Hogan

Papers

A study of the workforce in emergency medicine: 1999.