Showing papers in "Academic Emergency Medicine in 2001"
TL;DR: Reliability of the VAS for acute pain measurement as assessed by the ICC appears to be high, and data suggest that the Vas is sufficiently reliable to be used to assess acute pain.
Abstract: Objective: Reliable and valid measures of pain are needed to advance research initiatives on appropriate and effective use of analgesia in the emergency department (ED). The reliability of visual analog scale (VAS) scores has not been demonstrated in the acute setting where pain fluctuation might be greater than for chronic pain. The objective of the study was to assess the reliability of the VAS for measurement of acute pain.
Methods: This was a prospective convenience sample of adults with acute pain presenting to two EDs. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (95% CIs) and a Bland-Altman analysis were used to assess reliability of paired VAS measurements obtained 1 minute apart every 30 minutes over two hours.
Results: The summary ICC for all paired VAS scores was 0.97 [95% CI = 0.96 to 0.98]. The Bland-Altman analysis showed that 50% of the paired measurements were within 2 mm of one another, 90% were within 9 mm, and 95% were within 16 mm. The paired measurements were more reproducible at the extremes of pain intensity than at moderate levels of pain.
Conclusions: Reliability of the VAS for acute pain measurement as assessed by the ICC appears to be high. Ninety percent of the pain ratings were reproducible within 9 mm. These data suggest that the VAS is sufficiently reliable to be used to assess acute pain.
1,616 citations
TL;DR: Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings and its causes are complex and multifactorial.
Abstract: . Objective: To describe the definition, extent, and factors associated with overcrowding in emergency departments (EDs) in the United States as perceived by ED directors. Methods: Surveys were mailed to a random sample of EDs in all 50 states. Questions included ED census, frequency, impact, and determination of overcrowding. Respondents were asked to rank perceived causes using a five-point Likert scale. Results: Of 836 directors surveyed, 575 (69%) responded, and 525 (91%) reported overcrowding as a problem. Common definitions of overcrowding (>70%) included: patients in hallways, all ED beds occupied, full waiting rooms >6 hours/day, and acutely ill patients who wait >60 minutes to see a physician. Overcrowding situations were similar in academic EDs (94%) and private hospital EDs (91%). Emergency departments serving populations ≤250,000 had less severe overcrowding (87%) than EDs serving larger areas (96%). Overcrowding occurred most often several times per week (53%), but 39% of EDs reported daily overcrowding. On a 1-5 scale (±SD), causes of overcrowding included high patient acuity (4.3 ± 0.9), hospital bed shortage (4.2 ± 1.1), high ED patient volume (3.8 ± 1.2), radiology and lab delays (3.3 ± 1.2), and insufficient ED space (3.3 ± 1.3). Thirty-three percent reported that a few patients had actual poor outcomes as a result of overcrowding. Conclusions: Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings. Its causes are complex and multifactorial.
547 citations
TL;DR: A detailed literature and historical record search for support of the "golden hour" concept is discussed, finding none is identified.
Abstract: The term “golden hour” is commonly used to characterize the urgent need for the care of trauma patients This term implies that morbidity and mortality are affected if care is not instituted within the first hour after injury This concept justifies much of our current trauma system However, definitive references are generally not provided when this concept is discussed It remains unclear whether objective data exist This article discusses a detailed literature and historical record search for support of the “golden hour” concept None is identified
429 citations
TL;DR: Patients presenting with cardiac standstill on bedside echocardiogram do not survive to leave the ED regardless of their electrical rhythms, a finding that may be an additional marker for cessation of resuscitative efforts.
Abstract: . Patients presenting in cardiac arrest frequently have poor outcomes despite heroic resuscitative measures in the field. Many emergency medical systems have protocols in place to stop resuscitative measures in the field; however, further predictors need to be developed for cardiac arrest patients brought to the emergency department (ED). Objective: To examine the predictive value of cardiac standstill visualized on bedside ED echocardiograms during the initial presentations of patients receiving cardiopulmonary resuscitation (CPR). Methods: The study took place in a large urban community hospital with an emergency medicine residency program and a high volume of cardiac arrest patients. As part of routine care, all patients arriving with CPR in progress were subject to immediate and brief subxiphoid or parasternal cardiac ultrasound examination. This was followed by brief repeat ultrasound examination during the resuscitation when pulses were checked. A 2.5-MHz phased-array probe was used for imaging. Investigators filled out standardized data sheets. Examinations were taped for review. Statistical analysis included descriptive statistics, positive and negative predictive values, and likelihood ratios. Results: One hundred sixty-nine patients were enrolled in the study. One hundred thirty-six patients had cardiac standstill on the initial echocardiogram. Of these, 71 patients had an identifiable rhythm on monitor. No patient with sonographically identified cardiac standstill survived to leave the ED regardless of his or her initial electrical rhythm. Cardiac standstill on echocardiogram resulted in a positive predictive value of 100% for death in the ED, with a negative predictive value of 58%. Conclusions: Patients presenting with cardiac standstill on bedside echocardiogram do not survive to leave the ED regardless of their electrical rhythms. This finding was uniform regardless of downtime. Although larger studies are needed, this may be an additional marker for cessation of resuscitative efforts.
264 citations
TL;DR: Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument, which reproducibly stratifies patients into five groups with distinct clinical outcomes.
Abstract: . Objectives: To implement a new five-level emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), into nursing practice, and validate the instrument with a population-based cohort using hospitalization and ED length of stay as outcome measures. Methods: The five-level ESI algorithm was introduced to triage nurses at two university hospital EDs, and implemented into practice with reinforcement and change management strategies. Interrater reliability was assessed by a posttest and by a series of independent paired patient triage assignments, and a staff survey was performed. A cohort validation study of all adult patients registered during a one-month period immediately following implementation was performed. Results: Eight thousand two hundred fifty-one ED patients were studied. Weighted kappa for reproducibility of triage assignments was 0.80 for the posttest (n= 62 nurses), and 0.73 for patient triages (n= 219). Hospitalization was 28% overall and was strongly associated with triage level, decreasing from 5863 (92%) of patients in triage category 1, to 12/739 (2%) in triage category 5. Median lengths of stay were two hours shorter at either triage extreme (high and low acuity) than in intermediate categories. Outcomes followed a-priori predictions. Staff nurses rated the new program easier to use, and more useful as a triage instrument than previous three-level triage. They provided feedback, which resulted in significant revisions to the algorithm and educational materials. Conclusions: Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument. Emergency Severity Index triage reproducibly stratifies patients into five groups with distinct clinical outcomes.
237 citations
TL;DR: A system-change model of IPV ED training was effective in improving staff attitudes and knowledge about battered women and in protocols and staff training, as well as patient information and satisfaction, but change in actual clinical practice was more difficult to achieve and may be influenced by institutional policy.
Abstract: . Objectives: To evaluate a system-change model of training from the Family Violence Prevention Fund and the Pennsylvania Coalition Against Domestic Violence for improving the effectiveness of emergency department (ED) response to intimate partner violence (IPV). Methods: An experimental design with outcomes measured at baseline, 9-12, and 18-24 months post-intervention. Twelve hospitals in Pennsylvania and California with 20,000-40,000 annual ED visits were randomly selected and randomly assigned to experimental and control conditions. Emergency department teams (physician, nurse, social worker) from each experimental hospital and a local domestic violence advocate participated in a two-day didactic information and team planning intervention. Results: The experimental hospitals were significantly higher than the control hospitals on a staff knowledge and attitude measure (F = 5.57, p = 0.019), on all components of the “culture of the ED” system-change indicator (F = 5.72, p = 0.04), and in patient satisfaction (F = 15.43, p < 0.001) after the intervention. There was no significant difference in the identification rates of battered women (F = 0.411, p = 0.52) (although the linear comparison was in the expected direction) in the medical records of the experimental and control hospitals. Conclusions: A system-change model of IPV ED training was effective in improving staff attitudes and knowledge about battered women and in protocols and staff training, as well as patient information and satisfaction. However, change in actual clinical practice was more difficult to achieve and may be influenced by institutional policy.
179 citations
TL;DR: In the study population homelessness was associated with a history of significantly higher rates of infectious disease, ethanol and substance use, psychiatric illness, social isolation, and rates of ED utilization.
Abstract: Objectives To characterize the homeless adult population of an urban emergency department (ED) and study the medical, psychiatric, and social factors that contribute to homelessness. Methods A prospective, case-control survey of all homeless adult patients presenting to an urban, tertiary care ED and a random set of non-homeless controls over an eight-week period during summer 1999. Research assistants administered a 50-item questionnaire and were trained in assessing dentition and triceps skin-fold thickness. Inclusion criteria all homeless adults who consented to participate. Homelessness was defined as being present for any person not residing at a private address, group home, or drug treatment program. Randomly selected controls were concurrently enrolled with a 3:1 homeless:control rate. Exclusion criteria critically ill, injured, or incapacitated patients, or patients Results Two hundred fifty-two homeless subjects and 88 controls were enrolled. Data are presented for homeless vs control patients, and all p-values were 3) 43% vs 18% (OR = 3.3; 95% CI = 1.8 to 6.4); percentage of body fat 16.5% vs 19.7%; hx social isolation (no weekly social contacts) 81% vs 11% (OR = 33.3; 95% CI = 14 to 100); mean number of ED visits/year 6.0 vs 1.6. Conclusions In the study population homelessness was associated with a history of significantly higher rates of infectious disease, ethanol and substance use, psychiatric illness, social isolation, and rates of ED utilization.
177 citations
TL;DR: Use of etomidate in ED patients requiring RSI results in adrenocortical dysfunction, however, cortisol levels remain within normal laboratory levels during this period of dysfunction.
Abstract: Objective To assess adrenocortical function following intravenous etomidate use in emergency department (ED) patients requiring intubation. Methods This was a prospective, randomized, controlled trial of consecutive patients presenting to the ED requiring intubation. Patients were randomized to receive a single bolus induction dose of either 0.05-0.1 mg/kg midazolam (control group) or 0.3 mg/kg etomidate (etomidate group) during a standardized rapid-sequence intubation (RSI) with succinylcholine. The primary outcome variable was adrenocortical function at 4, 12, and 24 hours post-induction as assessed by measured serum cortisol response to exogenous cosyntropin (cosyntropin stimulation test, CST). Fisher's exact test was used to compare CST results between groups. Results Thirty-one patients were enrolled: 8 control, 10 etomidate, and 13 excluded from analysis for either incomplete data or steroid use during the study period. The 4-hour CST results were significantly different between study groups, with a normal response in 100% of control patients vs 30% of etomidate patients (p = 0.004). The 12- and 24-hour CSTs did not differ significantly between groups: normal CST in 100% of control patients at 12 and 24 hours vs 100% and 90% among etomidate patients at 12 and 24 hours, respectively (p = 1.0 at 12 and 24 hours). Measured cortisol levels of patients with abnormal CSTs remained within normal laboratory reference ranges. Conclusion Use of etomidate in ED patients requiring RSI results in adrenocortical dysfunction. However, cortisol levels remain within normal laboratory levels during this period of dysfunction. Adrenocortical dysfunction appears to resolve within 12 hours of a single bolus dose of 0.3 mg/kg etomidate.
166 citations
TL;DR: Both the sonographic detection of cardiac activity and ETCO(2) levels higher than 16 torr were significantly associated with survival from ED resuscitation; however, logistic regression analysis demonstrated that prediction of survival using capnography was not enhanced by the addition of cardiac sonography.
Abstract: OBJECTIVE To measure the ability of cardiac sonography and capnography to predict survival of cardiac arrest patients in the emergency department (ED). METHODS Nonconsecutive cardiac arrest patients prospectively underwent either cardiac ultrasonography alone or in conjunction with capnography during cardiopulmonary resuscitation at two community hospital EDs with emergency medicine residency programs. Cardiac ultrasonography was carried out using the subxiphoid view during pauses for central pulse evaluation and end-tidal carbon dioxide (ETCO(2)) levels were monitored by a mainstream capnograph. A post-resuscitation data collection form was completed by each of the participating clinicians in order to assess their impressions of the facility of performance and benefit of cardiac sonography during nontraumatic cardiac resuscitation. RESULTS One hundred two patients were enrolled over a 12-month period. All patients underwent cardiac sonographic evaluation, ranging from one to five scans, during the cardiac resuscitation. Fifty-three patients also had capnography measurements recorded. The presence of sonographically identified cardiac activity at any point during the resuscitation was associated with survival to hospital admission, 11/41 or 27%, in contrast to those without cardiac activity, 2/61 or 3% (p < 0.001). Higher median ETCO(2) levels, 35 torr, were associated with improved chances of survival than the median ETCO(2) levels for nonsurvivors, 13.7 torr (p < 0.01). The multivariate logistic regression model, which evaluated the combination of cardiac ultrasonography and capnography, was able to correctly classify 92.4% of the subjects; however, of the two diagnostic tests, only capnography was a significant predictor of survival. The stepwise logistic regression model, summarized by the area under the receiver operator curve of 0.9, furthermore demonstrated that capnography is an outstanding predictor of survival. CONCLUSIONS Both the sonographic detection of cardiac activity and ETCO(2) levels higher than 16 torr were significantly associated with survival from ED resuscitation; however, logistic regression analysis demonstrated that prediction of survival using capnography was not enhanced by the addition of cardiac sonography.
157 citations
TL;DR: Hospital restructuring was associated with increased ED overcrowding, even after controlling for utilization and patient demographics, and significant seasonality in overcrowding was revealed.
Abstract: Objective: Hospital restructuring often results in fewer inpatient beds, increased ambulatory services, and closures of hospitals or emergency departments (EDs). The authors sought to determine the impact of systematic hospital restructuring on ED overcrowding. Methods: Time series analyses of average monthly overcrowding for EDs in Toronto, Ontario, Canada, from 1991 and 2000 (n ? 20 hospitals, 120 months) were conducted. Autoregression models evaluated the rate of increase of overcrowding before and during systematic restructuring. A secondary analysis included total ED visits, patient age, and sex distribution as covariates. Seasonality was assessed by means of spectral analysis. Results: Severe and moderate overcrowding averaged 3% and 14% of the time each month, respectively, over the whole period. Before restructuring (n ? 74 months), severe and moderate overcrowding averaged 0.5% and 9% per month, respectively; during restructuring (n ? 46 months), the monthly averages were 6% and 23%, respectively. Neither severe nor moderate overcrowding was increasing before restructuring. During restructuring, however, both increased significantly (severe 0.2% per month [p < 0.0001]; moderate 0.5% per month [p < 0.0001]). Similar results were found after controlling for ED utilization. Female gender independently predicted increased overcrowding; older age predicted reduced moderate overcrowding; number of total visits was not a predictor. Spectral analysis revealed significant seasonality in overcrowding. Conclusions: Hospital restructuring was associated with increased ED overcrowding, even after controlling for utilization and patient demographics. Restructuring should proceed slowly to allow time for monitoring of its effects and modification of the process, because the impact of incremental reductions in hospital resources may be magnified as maximum operating capacity is approached.
152 citations
TL;DR: The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years and discusses the impact of cost containment and the emergence of managed care on prevailing views of ED utilization.
Abstract: The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify "inappropriate" ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.
TL;DR: The strategies to reduce ED overcrowding in Rochester in the last decade were those that addressed factors external to the ED such as increased flexibility of inpatient resources; float nurses who responded to acute care needs; and a multidisciplinary team to round in the ED and analyze resource needs.
Abstract: Overcrowding is common in emergency departments (EDs) throughout the United States. The history of ED overcrowding in Rochester, New York, is notable due to its unique health care system that introduced the concepts of managed care as early as the 1950s. An effect of this system was to intentionally restrict resources and allow the issue of access to limit utilization. Overcrowding in EDs was severe in the late 1990s-2000, and became an accepted local standard of care. Objective: To study the strategies to reduce ED overcrowding in Rochester in the last decade. Methods: A descriptive analysis of individual hospital and community efforts to decrease ED overcrowding. Results: Of the strategies tried, those that had little effect on ED overcrowding were based from the ED, such as ambulance diversion. Those that were successful were those that addressed factors external to the ED such as increased flexibility of inpatient resources; float nurses who responded to acute care needs; a transition team (mid-level provider along with registered nurse (RN)/licensed practical nurse) who cared for inpatients boarded in the ED; integrated services across affiliated hospitals/systems; an early alert system that notified key personnel before “code red” criteria were met; and a multidisciplinary team to round in the ED and analyze resource needs. Current community-wide initiatives include precise tracking of code red hours; monitoring patient length of stay (LOS) in the ED and inpatient units; education of physicians and nursing homes regarding ED alternatives; exploration of additional resources for subacute and long-term care; establishing a regional forum to address the nursing shortage; development of an ED triage system to coordinate diversion activities during code red; and consideration of a county-wide state of emergency when needed. Conclusions: Emergency department overcrowding is the end result of a variety of factors that must be addressed system-wide.
TL;DR: In this paper, a comparison study measuring the impact of FT vs no FT on ED length-of-stay (LOS) was carried out in an urban county teaching hospital, where patients presenting to the registration desk between 9 AM and 9 PM on 16 consecutive Mondays (August 2 to November 15, 1999).
Abstract: Objective: To determine whether faculty triage (FT) activities can shorten emergency department (ED) length of stay (LOS). Methods: This was a comparison study measuring the impact of faculty triage vs no faculty triage on ED LOS. It was set in an urban county teaching hospital. Subjects were patients presenting to the registration desk between 9 AM and 9 PM on 16 consecutive Mondays (August 2 to November 15, 1999). On eight Mondays, an additional faculty member was stationed at the triage desk. He or she was asked to expedite care by rapid evaluation orders for diagnostic studies and basic therapeutic interventions, and by moving serious patients to the patient care areas. He or she was not provided with detailed instructions or protocols. The ED LOS, time of registration (TIMEREG), inpatient admission status (ADMIT), x-ray utilization (XRAY), total patients registered each day between 9 AM and 9 PM (TOTREG), and patients who left without being seen (LWBS) were determined using an ED information system. The LOS was analyzed in relation to FT, ADMIT, and XRAY by the Mann-Whitney U test. The LOS was related to TIMEREG and TOTREG by simple linear regression. Stepwise multiple linear regression models to predict LOS were generated using all the variables. Results: Patients without FT (n? 814) had a mean LOS of 445 minutes. Patients with FT (n? 920) had a mean LOS of 363 minutes. Mean difference in LOS was -82 minutes (95% CI ? -111 to -53), a reduction of 18%. The LOS was also related to: ADMIT +203 minutes (95% CI ? 168 to 238), TOTREG -2.7 min/additional patient registered (95% CI ? -1.15 to -4.3), and TIMEREG +0.14 min/min since 9 AM (95% CI ? 0.07 to 0.21). The LWBS was reduced by 46% with FT. In multiple regression analysis, ADMIT, FT, TIMEREG, and XRAY were all related to LOS, but the model explained only a small part of variance (adjusted R2? 0.093). The faculty cost is estimated to be 11.98/patient. Conclusions: Faculty triage offers a moderate increase in efficiency at this ED, albeit with relatively high cost.
TL;DR: A national, multicenter IRB process might streamline ethical review and warrants further consideration, as well as insight into the advantages and disadvantages of local IRB review.
Abstract: . Multicenter clinical trials require approval by multiple local institutional review boards (IRBs). The Multicenter Airway Research Collaboration mailed a clinical trial protocol to its U.S. investigators and 44 IRBs ultimately reviewed it. Objective: To describe IRB responses to one standard protocol and thereby gain insight into the advantages and disadvantages of local IRB review. Methods: Two surveys were mailed to participants, with telephone follow-up of nonrespondents. Survey 1 was mailed to 82 investigators across North America. Survey 2 was mailed to investigators from 44 medical centers in 17 U.S. states. Survey 1 asked about each investigator's local IRB (e.g., frequency of meetings, membership), whereas survey 2 asked about IRB queries and concerns related to the submitted clinical trial. Results: Both surveys had 100% response rate. Investigators submitted applications a median of 58 days (interquartile range [IQR], 40-83) after receipt of the protocol, and IRB approval took an additional 38 days (IQR, 26-62). Although eight applications were approved with little or no changes, IRBs requested an average of 3.5 changes per site. Changes involved study logistics and supervision for 45%, the research process for 43%, and the consent form for 91%. Despite these numerous requests, all eventually approved the basic protocol, including inclusion criteria, intervention, and data collection. Conclusions: The IRBs showed extreme variability in their initial responses to a standard protocol, but ultimately all gave approval. Almost all IRBs changed the consent form. A national, multicenter IRB process might streamline ethical review and warrants further consideration.
TL;DR: Patients with presenting complaints related to seizures are frequent in the ED population and make considerable demands on EMS and ED resources, and more than a fourth of patients with seizure-related presentations required hospitalization.
Abstract: . Objectives: Patients with seizure disorders are common in the emergency department (ED), yet little is known regarding the management of these patients. This study was performed to define the frequency of patients with seizure disorders in the ED patient population and to determine possible seizure etiologies, characteristics of diagnostic activities, treatments, and dispositions. Methods: Twelve EDs monitored all patients with a chief complaint related to seizure disorders presenting over 18.25 days (5% of the calender year) in late 1997. Retrospective chart review was used to gather specific data regarding these consecutive cases. Results: Of the 31,508 patients who presented to these 12 EDs during the study period, 368 (1.2%) had complaints related to seizures. Three hundred sixty-two charts were available for analysis and make up the study population. Two hundred fifty-seven (71%) utilized emergency medical services (EMS) for transport and care. Advanced care, including intravenous access, laboratory work, cardiac monitoring, or oxygen administration, was utilized in 304 (84%) patients. Antiepileptic drugs were given in 199 (55%) patients. Ethanol withdrawal or low antiepileptic drug levels were implicated as contributing factors in 177 (49%) of patients. New-onset seizures were thought to be present in 94 (26%) patients. Status epilepticus occurred in only 21 (6%) patients. Ninety-eight (27%) of all patients were admitted to the hospital. Conclusions: Patients with presenting complaints related to seizures are frequent in the ED population and make considerable demands on EMS and ED resources. Six percent of patients with seizure-related presentations were in status epilepticus and more than a fourth of all patients required hospitalization.
TL;DR: To identify mTBI patients at low and high risk of PCS by comparing the predictive values of variables generated by logistic regression (LR) and recursive partitioning (RP), which expanded the number of patients able to be classified as high/low risk.
Abstract: BACKGROUND Up to 50% of patients with minor traumatic brain injury (mTBI) develop postconcussion syndrome (PCS). A decision rule to stratify risk for PCS is needed. OBJECTIVE To identify mTBI patients at low and high risk of PCS by comparing the predictive values of variables generated by logistic regression (LR) and recursive partitioning (RP). METHODS This was a prospective, observational study of 69 mTBI patients aged >16 years presenting to the emergency department of a university teaching hospital. Minor TBI was defined as loss of consciousness 24 on the Hopkins Verbal Learning A (HVLA) (by LR) and in 9% of those injured in sports scoring >22 on HVLA (RP). High risk: PCS occurred in 89% of women scoring <9 on the Digit Span test (LR) and in 92% of those injured via falls or motor vehicle collision scoring <11.5 on HVLB2 (RP). CONCLUSIONS Despite the high incidence of PCS, we were able to identify a low-risk subgroup with an average PCS risk of <10% and a high-risk subgroup with a PCS risk of approximately 90%. Combining results from LR and RP expanded the number of patients able to be classified as high/low risk. Prospective validation is necessary.
TL;DR: The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.
Abstract: A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.
TL;DR: An ED-managed ACU can have significant impact on ED overcrowding and ambulance diversion, and it need not be located proximate to the ED.
Abstract: Objective: To determine the impact of an inpatient, emer- gency department (ED)-managed acute care unit (ACU) on ED over- crowding and use of ambulance diversion. Methods: Descriptive ob- servational study with prospectively collected data from a 14-bed ACU recently opened remote from the main ED. Rates of patients who left without being seen (LWBS) and ambulance diversion frequency and duration were adjusted for ED patient volumes and compared with those for the period immediately before the ACU was opened and with those for a matching time period during the previous year. Results: There were 1,589 patients seen in the ACU during the first ten weeks of operation, representing about 14.5% of the ED volume (10,871). About 33% could be classified as post-ED management, 20% as ad- mission processing, and the rest as primary evaluation. The number of patients who LWBS decreased from 10.1% of the ED census two weeks prior to opening of the ACU, and from 9.4% during the previous year, to 5.0% (range 4.2%-6.2%) during the ensuing ten weeks post opening. Ambulance diversion was a mean of 6.7 hours per 100 pa- tients before the unit opened and 5.6 hours per 100 patients during the same time in the previous year, and decreased to 2.8 hours per 100 patients after the unit opened (p < 0.05, respectively). A six-month pre- and two-month post-examination revealed that the mean monthly hours of ambulance diversion for the ED decreased by 40% (202 hours vs 123 hours) (p < 0.05) in contrast to a mean increase of 44% (186 hours vs 266 hours) (p < 0.05) experienced by four proximate hospitals. Conclusions: An ED-managed ACU can have significant impact on ED overcrowding and ambulance diversion, and it need not be located proximate to the ED. Key words: emergency; emergency department overcrowding; observation medicine; ambulance diversion; emergency department operations. ACADEMIC EMERGENCY MEDICINE 2001; 8:1095-1100
TL;DR: Rates of SBI in this multi-institution population of children with first-time simple febrile seizures were low and are consistent with those published in the literature for feBrile children without seizures.
Abstract: Objective To describe the rates of serious bacterial illness (SBI) in children presenting to emergency departments (EDs) with first-time uncomplicated febrile seizures. Methods The ED visits from seven Chicago metropolitan area hospitals (two tertiary pediatric EDs, five community general EDs) for all pediatric patients seen between July 1995 and December 1997 with a discharge diagnosis including the term "seizure" were retrospectively identified. Records of patients who met criteria for simple, first-time febrile seizure were reviewed (age 6-60 months; temperature > or =38.0 degrees C; single, generalized, tonic-clonic seizure Results Four hundred fifty-five children were identified who had first-time simple febrile seizures. The study participants had a mean age of 21 months and a mean temperature of 39.6 degrees C, and 64% were male. Seventy-three percent were seen in a community hospital setting. Blood cultures were obtained for 315 children (69%). Four children (1.3% [95% CI = 0.1% to 2.5%]) were bacteremic, all with Streptococcus pneumoniae; the rate of bacteremia did not differ in the subset at highest risk for bacteremia (6-36 months, temperature >39 degrees C). No demographic or laboratory data distinguished the bacteremic children from those with negative blood cultures. One hundred seventy-one children (38%) had urine cultures obtained; 5.9% [95% CI = 2.4% to 9.4%] of the cultures grew >100,000 colony-forming units/mL of a single pathogenic organism. One hundred thirty-five children (30%) had cerebrospinal fluid cultures performed. None of these cultures grew a bacterial pathogen [95% CI = 0% to 2.2%]. Two hundred eight children (45.7%) had chest x-rays performed; 12.5% [95% CI = 10.2% to 14.8%] (n = 26) of the x-rays were read as consistent with pneumonia by the radiologist at the treating institution. None of the blood cultures performed on children with abnormal radiographs were positive (cultures drawn on 23 of 26 patients, 88%). Stool cultures were performed on 14 children (3.1%); two cultures (14.3% [95% CI = 0% to 32.6%]) grew a bacterial pathogen, both Shigella. Conclusions Rates of SBI in this multi-institution population of children with first-time simple febrile seizures were low and are consistent with those published in the literature for febrile children without seizures.
TL;DR: Both patient and wound characteristics of traumatic lacerations have an influence on the likelihood of infection, and this knowledge may be valuable for determining whether various methods of wound cleansing, debridement, and repair can improve the outcome of patients with traumaticLacerations.
Abstract: Background: Most of our knowledge of laceration management comes from studies in animal models or patients with closure of sterile postoperative surgical incisions. Traumatic laceration management has not been well studied. Objective: To determine which characteristics of traumatic lacerations were associated with the development of wound infection. Methods: A cross-sectional study of consecutive patients with traumatic lacerations repaired over a four-year period was conducted. Structured closed-question data sheets were prospectively completed at the time of laceration repair and suture removal. Infection was determined at the time of suture removal. Multivariate modeling was used to determine the adjusted odds ratio (OR) of infection. Results: Five thousand five hundred twenty-one patients were enrolled; 195 patients developed an infection (3.5%). An increased likelihood of wound infection was associated with age (adjusted OR per year, 1.01; 95% CI = 1.0 to 1.02); history of diabetes mellitus (adjusted OR 6.7; 95% CI = 1.7 to 26.4); laceration width (adjusted OR 1.05 per mm; 95% CI = 1.02 to 1.08); and presence of foreign body (adjusted OR 2.6; 95% CI = 1.3 to 5.2). Laceration location on the head/neck was associated with a decreased risk of infection (adjusted OR 0.28; 95% CI = 0.18 to 0.45). Conclusions: Both patient and wound characteristics of traumatic lacerations have an influence on the likelihood of infection. This knowledge may be valuable for determining whether various methods of wound cleansing, debridement, and repair can improve the outcome of patients with traumatic lacerations.
TL;DR: Out-of-hospital cardiac arrest survival in suburban and rural Indiana did not improve after police were equipped with AEDs, likely related to poor police response.
Abstract: . Objective: To assess the out-of-hospital cardiac arrest (OHCA) survival advantage after providing police with automated external defibrillators (AEDs) in rural and suburban Indiana. Methods: An observational evaluation was conducted in six Indiana counties (population: 464,741) before (retrospective) and after (prospective) training and equipping police with AEDs. The primary outcome evaluated was survival to hospital discharge for all cases of ventricular tachycardia/ventricular fibrillation (VT/VF) OHCA. Other factors evaluated include age, gender, race, arrest location, witnessed arrest, bystander cardiopulmonary resuscitation, response intervals, and survival to discharge for all OHCAs. Results are reported using chi-square, Student's t-test, and logistic regression. Results: Police were equipped with 112 AEDs, increasing total defibrillator capability by 43.2%. During the study period, AED-equipped police responded prior to emergency medical services (EMS) in 26 of 388 cases (6.7%). The time intervals from 911 call-to-scene and 911 call-to-shock were shortened by 1.6 minutes (95% confidence interval [95% CI] = 0.0 to 3.1, p = 0.05) and 4.8 minutes (95% CI = 1.3 to 8.3, p = 0.008), respectively, with police response as compared with EMS response. Survival to hospital discharge for VT/VF OHCA was 15.0% (3/20) in cases in which police responded first and 10.0% (16/160) in cases in which EMS responded first (relative risk [RR] 0.63, 95% CI = 0.17 to 2.39, p = 0.45). Survival to hospital discharge for VT/VF OHCA did not improve from the prestudy period (16/204, 7.8%) to after police AED availability (19/180, 10.6%) (RR 0.72, 95% CI = 0.36 to 1.45, p = 0.38). Conclusions: Out-of-hospital cardiac arrest survival in suburban and rural Indiana did not improve after police were equipped with AEDs, likely related to poor police response.
TL;DR: The prevalence of TL injuries in ED blunt trauma patients undergoing TL radiographs is 6.3%, and the most commonly injured area of the TL spine is the thoracolumbar junction.
Abstract: Objective To evaluate the prevalence, distribution, and demographics of thoracolumbar (TL) spine injuries following blunt trauma. Methods Prospective, cross-sectional study of a consecutive sample of all blunt trauma patients presenting initially to the emergency department (ED) of a Level 1 trauma center and undergoing thoracic and/or lumbar spine radiography from August 1997 to November 1998. The age, sex, and mechanism of injury of each patient as well as location and type of spine injury were recorded for those patients with vertebral fractures, dislocations, or subluxations. Results Two thousand four hundred four blunt trauma patients were enrolled. Vertebral injuries were identified in 152 individuals (6.3%, 95% CI = 5.4% to 7.4%). Two hundred sixty distinct anatomic levels of injury were identified in these 152 individuals. Of these 260 injuries, 42 (16.2%) occurred at L1, 38 (14.6%) at L2, 29 (11.1%) at L3, and 27 (10.4%) at T12, making these the most commonly injured vertebrae. Injuries were most common (34 patients) in those aged 30-39 years and were least common (12 patients) in those under 18 years. Compression fractures (52%) were the most common injury in the thoracic spine, while transverse process fractures (48%) were the most common injuries in the lumbar spine. Conclusions The prevalence of TL injuries in ED blunt trauma patients undergoing TL radiographs is 6.3%. The most commonly injured area of the TL spine is the thoracolumbar junction.
TL;DR: The combination of two risk stratification modalities for ED chest pain patients (Goldman risk < or =4% and cTnI < or=0.3 ng/mL) did not identify a subgroup ofchest pain patients at <1% risk for death, acute myocardial infarction, or revascularization within 30 days.
Abstract: Background Accurate identification of low-risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably risk-stratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk-stratify patients but have not identified a subset safe for ED release. Objective To test the hypothesis that ED chest pain patients with a Goldman risk of Methods A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase-MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow-up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/coronary artery bypass grafting) within 30 days. Results Of 2,322 patients evaluated, 998 had both a Goldman risk Conclusions The combination of two risk stratification modalities for ED chest pain patients (Goldman risk
TL;DR: Compared with an industry consent form, a shortened version, focusing on Food and Drug Administration and Department of Health and Human Services informed consent guidelines, allowed patients to retain more information in the immediate postconsent period.
Abstract: OBJECTIVE Informed consent is a required part of clinical research. Industry consent forms may be complex and difficult to understand. A comparison was performed between a standard, industry consent form (IF) and a modified, shortened version of the same form (MF) to determine which allows the patient to retain more information in the immediate postconsent period. METHODS This was a prospective, randomized study performed in an urban, county teaching emergency department (ED). A convenience sample (based on the availability of one of two research assistants being present in the ED) of 100 patients with a history of asthma seen in the ED were enrolled. After reading the consent form, 50 MF and 50 IF patients were given a postconsent test to determine how much information was retained. Mean differences in test scores between the IF and MF were determined. RESULTS The population had a mean age (+/-SD) of 39.4 +/- 12.1 years (range 18-80); 52% were female. The overall score for the study population was 9.6 (+/-2.0), range 2-12 (maximum 12). The MF score was 10.6 (+/-1.4) vs the IF score of 8.6 (+/-2.1); mean difference = 2.0 (95% CI = 1.3 to 2.7, p < 0.0001). The MF group had significantly more correct answers than the IF group with the following questions (MF%, IF%; mean difference in proportions with 95% CIs): purpose (96, 70; 26, 95% CI = 12 to 40); randomization (78, 44; 34, 95% CI = 16 to 52); study duration (94, 70; 24, 95% CI = 10 to 38); risks (92, 74; 18, 95% CI = 4 to 32); benefits (94, 78; 16, 95% CI = 3 to 29); alternative treatments (88, 70; 18, 95% CI = 2 to 34); confidentiality (98, 88; 10, 95% CI = 0.2 to 20); and voluntary participation (74, 54; 20, 95% CI = 2 to 38). Adverse event compensation had the poorest correct rate (54, 38; 13, 95% CI = -6 to 32). Subsequently, after taking the postconsent test, 98% wrote that they read the entire MF, while only 68% wrote that they read the entire IF (mean difference in proportions 30%, 95% CI = 17% to 43%). CONCLUSIONS Compared with an industry consent form, a shortened version, focusing on Food and Drug Administration and Department of Health and Human Services informed consent guidelines, allowed patients to retain more information in the immediate postconsent period.
TL;DR: Intravenous etomidate can be administered safely and effectively to provide appropriate conscious sedation for short, painful ED procedures.
Abstract: . Objective: To determine the safety and effectiveness of intravenous (IV) etomidate for the sedation of patients undergoing painful procedures in the emergency department (ED). Methods: A two-part feasibility study for ED patients receiving IV etomidate for painful ED procedures was undertaken. In the initial phase, a retrospective series of patients receiving etomidate for ED procedural sedation was considered. This phase served as the basis for a descriptive, prospective feasibility study of consecutive ED patients. During the second phase, patients were evaluated for complications related to IV etomidate sedation or the procedure performed. Immediately following the procedure, the physician was asked to complete a data collection sheet documenting the patient's etomidate dose, the number of doses required to complete the procedure, the analgesic used, the complications of the procedure, and the patient's procedural recall. Results: Intravenous etomidate was administered to nine patients during the initial study phase and 51 during the prospective, descriptive phase. Indications for sedation included dislocation reduction (25), cardioversion (7), fracture reduction (20), abscess incision and drainage (4), foreign body removal (3), and chest thoracostomy (1). Physicians used 0.1-mg/kg IV bolus etomidate. A mean of 1.6 doses of etomidate was used to complete procedures (range 1-3 doses). Of the 60 patients in both study groups, 59 (98%) achieved adequate sedation by physician's assessment. Procedural success was documented for 56 patients (93%). There were 12 complications reported: oxygen desaturation below 90% (5), myoclonus (4), vomiting (1), pain with injection (1), and a brief bradycardic episode (1). No patient required assistance with ventilation or endotracheal intubation. Conclusions: Intravenous etomidate can be administered safely and effectively to provide appropriate conscious sedation for short, painful ED procedures.
TL;DR: Droperidol was more effective than prochlorperazine in relieving pain associated with benign headaches in emergency department patients and no significant or persisting morbidity was detected.
Abstract: Objective To compare the efficacy of droperidol with that of prochlorperazine for the treatment of benign headaches in emergency department (ED) patients. Methods Prospective, randomized clinical trial in an urban ED. Patients were given either droperidol, 5 mg intramuscular (IM) or 2.5 mg intravenous (IV), or prochlorperazine, 10 mg IM or 10 mg IV. Measurements included side effects and the patient's pain perception as measured on a 100-mm visual analog scale (VAS) at baseline, 30, and 60 minutes after the medication was given. Data were analyzed using chi-square, two-tailed t-tests, and two-way analysis of variance (ANOVA) when appropriate. Results During an eight-month period, 168 patients were enrolled. Eighty-two (48.8%) of the patients received droperidol; 86 (51.2%) received prochlorperazine. In the droperidol group, 49 (59.6%) received IM administration and 33 (40.4%) IV. In the prochlorperazine group, 57 (66.3%) received IM administration and 29 (33.7%) IV. Sixty minutes after the medication, the mean decrease in the VAS scores was 81.4% for droperidol and 66.9% for prochlorperazine (p = 0.001). At 30 minutes, 60.9% of the patients receiving droperidol and 44.2% of the patients receiving prochlorperazine had obtained at least a 50% reduction in their VAS scores (p = 0.09). At 60 minutes, 90.2% of the patients receiving droperidol and 68.6% of the patients receiving prochlorperazine had at least a 50% reduction in their VAS scores (p = 0.017). No difference between IM dosing and IV dosing was detected. Side effects, including dystonia, akathisia, and decreased level of consciousness, were seen in 15.2% of the patients receiving droperidol and 9.61% of the patients receiving prochlorperazine. No significant or persisting morbidity was detected. Conclusions Droperidol was more effective than prochlorperazine in relieving pain associated with benign headaches.
TL;DR: Four calculations are proposed using real-time data for accurately diagnosing an ED with potential for failing both as a safety net and as a source for quality health care.
Abstract: Although much work has been done evaluating causes for increased demand for emergency department (ED) services, few ways are available to help determine that an individual ED is overcrowded. Four calculations are proposed using real-time data for accurately diagnosing an ED with potential for failing both as a safety net and as a source for quality health care. The bed ratio (BR) accounts for the number of patients in relation to the available treatment spaces. The BR is obtained by adding the current number of ED patients to the predicted arrivals minus the predicted departures and dividing the result by the total number of treatment spaces. The acuity ratio (AR) measures the relative burden of illness in the ED. The AR is the average triage category of all patients in the ED. The provider ratio (PR) determines the volume of patients that can be evaluated and treated by the physician providers. The PR is found by dividing the arrivals per hour by the sum of the average patients per hour usually disposed for each provider on duty. From these ratios, the demand value (DV) is calculated, which gives an overall measure of current demand. The DV is found by taking the sum of the BR and PR and multiplying by the AR. A DV of more than 7 should initiate a specific assessment of the individual ratios in order to accurately diagnose the problem and institute action. Based on the values, predetermined processes can be instituted to help remedy the overcrowded situation. Trended over time, the ratios can provide the data needed for better resource assessment, planning, and allocation.
TL;DR: Using a prediction equation for the number of patients seeking urgent care allowed for improved accuracy in staffing patterns with associated improvement in measures of patient satisfaction.
Abstract: . Objective: To develop a prediction equation for the number of patients seeking urgent care. Methods: In the first phase, daily patient volume from February 1998 to January 1999 was matched with calendar and weather variables, and stepwise linear regression analysis was performed. This model was used to match staffing to patient volume. The effects were measured through patient complaint and “left without being seen” rates. The second phase was undertaken to develop a model to account for the continual yearly increase in patient volume. For this phase daily patient volume from February 1998 to April 2000 was used; the patient volume from May 2000 to July 2000 was used as a validation set. Results: First-phase prediction equation was: daily patient volume = 66.2 + 11.1 January + 4.56 winter + 47.2 Monday + 37.3 Tuesday + 35.6 Wednesday + 28.2 Thursday + 24.2 Friday + 7.96 Saturday + 10.1 day after a holiday. This equation accounted for 75.2% of daily patient volume (p < 0.01). Inclusion of significant weather variables only minimally improved the predictive ability (r2= 0.786). The second-phase final model was: daily patient volume = 57.2 + 0.035 Newdate + 52.0 Monday + 44.2 Tuesday + 39.2 Wednesday + 30.2 Thursday + 26.5 Friday + 10.9 Saturday + 12.2 February + 3.9 March, which accounted for 72.7% of the daily variation (p < 0.01). The model predicted the patient volume in the validation set within ±11%. When the first-phase model was used to predict patient volume and thus staffing, the percentage of patients who left without being seen decreased by 18.5% and the number of patient complaints dropped by 30%. Conclusions: Use of a prediction equation allowed for improved accuracy in staffing patterns with associated improvement in measures of patient satisfaction.
TL;DR: The authors describe the Andersen behavioral model of health services use and suggest it as a useful theoretical framework for emergency medicine researchers who are interested in studying these issues.
Abstract: In virtually every community in this nation, the emergency department (ED) is an integral part of the health care safety net, often serving as the only available point of access to the health care system for many vulnerable and disenfranchised individuals. The authors present a brief overview of the March 2000 report released by the Institute of Medicine that described and assessed the current status of the nation's health care safety net. The authors discuss the role of the ED as a safety net provider and as a window onto the status of the rest of the health care system. The authors describe the Andersen behavioral model of health services use and suggest it as a useful theoretical framework for emergency medicine researchers who are interested in studying these issues.
TL;DR: This study suggests that EPs using bedside ultrasonography are able to accurately diagnose patients presenting with acute scrotal pain and appear able to differentiate between surgical emergencies, such as testicular torsion, and other etiologies.
Abstract: UNLABELLED Acute scrotal pain is not a rare emergency department (ED) complaint Traditional reliance on medical history and physical examination can be precarious as signs and symptoms can overlap in various etiologies of acute scrotal pain OBJECTIVE To determine the accuracy with which emergency physicians (EPs) using bedside ultrasonography are able to evaluate patients presenting to the ED with acute scrotal pain METHODS The study was performed at an urban community hospital ED with a residency program and an annual census of 70,000 A retrospective chart review identified 36 patients who presented with complaints of acute scrotal pain and were evaluated by EPs using bedside ultrasound A 50- or 75-MHz linear-array transducer with color and power Doppler capability was used to scan the scrotum Patients were seen between July 1998 and September 1999 Diagnoses were verified by radiology or surgery Sensitivity and specificity with 95% confidence intervals were calculated RESULTS The EP ultrasound examinations agreed with confirmatory studies for 35 of 36 patients, resulting in a sensitivity of 95% (95% CI = 078 to 099) and a specificity of 94% (95% CI = 072 to 099) Diagnoses included three testicular torsions, six cases of epididymitis, four cases of orchitis, one testicular fracture, three hernias, three hydroceles, and 15 normal examinations One case of epididymitis was misdiagnosed as an epididymal mass CONCLUSIONS This study suggests that EPs using bedside ultrasonography are able to accurately diagnose patients presenting with acute scrotal pain In addition, they appear able to differentiate between surgical emergencies, such as testicular torsion, and other etiologies