Showing papers in "Academic Emergency Medicine in 2003"

Validation of a Verbally Administered Numerical Rating Scale of Acute Pain for Use in the Emergency Department

Abstract: Objectives: Verbally administered numerical rating scales (NRSs) from 0 to 10 are often used to measure pain, but they have not been validated in the emergency department (ED) setting. The authors wished to assess the comparability of the NRS and visual analog scale (VAS) as measures of acute pain, and to identify the minimum clinically significant difference in pain that could be detected on the NRS. Methods: This was a prospective cohort study of a convenience sample of adults presenting with acute pain to an urban ED. Patients verbally rated pain intensity as an integer from 0 to 10 (0 = no pain, 10 = worst possible pain), and marked a 10-cm horizontal VAS bounded by these descriptors. VAS and NRS data were obtained at presentation, 30 minutes later, and 60 minutes later. At 30 and 60 minutes, patients were asked whether their pain was “much less,”“a little less,”“about the same,”“a little more,” or “much more.” Differences between consecutive pairs of measurements on the VAS and NRS obtained at 30-minute intervals were calculated for each of the five categories of pain descriptor. The association between VAS and NRS scores was expressed as a correlation coefficient. The VAS scores were regressed on the NRS scores in order to assess the equivalence of the measures. The mean changes associated with descriptors “a little less” or “a little more” were combined to define the minimum clinically significant difference in pain measured on the VAS and NRS. Results: Of 108 patients entered, 103 provided data at 30 minutes and 86 at 60 minutes. NRS scores were strongly correlated to VAS scores at all time periods (r= 0.94, 95% CI = 0.93 to 0.95). The slope of the regression line was 1.01 (95% CI = 0.97 to 1.06) and the y-intercept was −0.34 (95% CI =−0.67 to −0.01). The minimum clinically significant difference in pain was 1.3 (95% CI = 1.0 to 1.5) on the NRS and 1.4 (95% CI = 1.1 to 1.7) on the VAS. Conclusions: The findings suggest that the verbally administered NRS can be substituted for the VAS in acute pain measurement.

Clinically important change in the visual analog scale after adequate pain control.

Abstract: Objectives: To define the minimum clinically important difference (MCID) for the visual analog scale (VAS) of pain severity by measuring the change in VAS associated with adequate pain control. Methods: The authors conducted a prospective, observational study. Adult emergency department (ED) patients with acute pain (<72 hours) were eligible. Patients rated their pain severity on a 100-mm VAS on presentation and at discharge. Patients were asked if they would accept any analgesic, then if they would accept a parenteral analgesic before treatment. At discharge, they were asked whether they had received adequate pain control. Results: The authors enrolled 143 patients (mean age, 36 years; 54% female). The mean decrease in VAS was -30.0 mm (95% confidence interval [CI] = -36.4 to -23.6) for the 116 of 143 (81%) patients with adequate pain control at discharge vs. -5.7 (95% CI = -11.2 to -0.3) for the 27 with inadequate pain control (p < 0.001). At discharge, the mean VAS was 31.3 mm for those with adequate pain control vs. 55.1 for those without. Mean VAS for the 114 of 143 patients who would accept any analgesics initially was 64.7 vs. 47.1 for the 29 reporting no analgesic need. Initially, 77 patients would accept parenteral analgesics (mean VAS = 72.5 mm). Conclusions: A mean reduction in VAS of 30.0 mm represents a clinically important difference in pain severity that corresponds to patients' perception of adequate pain control. Defining MCID based on adequate analgesic control rather than minimal detectable change may be more appropriate for future analgesic trials, when effective treatments for acute pain exist.

The effect of hospital occupancy on emergency department length of stay and patient disposition.

Abstract: Emergency department (ED) overcrowding is a common problem. Despite a widespread belief that low hospital bed availability contributes to ED overcrowding, there are few data demonstrating this effect. Objectives: To identify the effect of hospital occupancy on ED length of stay for admitted patients and patient disposition. Methods: This was an observational study design using administrative data at a 500-bed acute care teaching hospital. All patients presenting to the ED between April 1993 and June 1999 were included in the study. The predictor variable was daily hospital occupancy. Outcome measures included daily ED length of stay for admitted patients, daily consultation rate, and daily admission rate. The models controlled for the average daily age of ED patients and the average daily “arrival density” index, which adjusts for patient volume and clustering of patient arrivals. Results: The average hospital occupancy was 89.7%. On average 155 patients visited the ED daily; 21% were referred to hospital physicians and 19% were admitted. The median ED length of stay for admitted patients was 5 hours 54 minutes (interquartile range 5 hr 12 min to 6 hr 42 min). Daily ED length of stay for admitted patients increased 18 minutes (95% CI = 12 to 24) when there was an absolute increase in occupancy of 10%. The ED length of stay appeared to increase extensively when hospital occupancy exceeded a threshold of 90%. Consultation and admission rates were not influenced by hospital occupancy. Conclusions: Increased hospital occupancy is strongly associated with ED length of stay for admitted patients. Increasing hospital bed availability might reduce ED overcrowding.

Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath.

Abstract: Patients with altered level of consciousness may be suffering from elevated intracranial pressure (EICP) from a variety of causes. A rapid, portable, and noninvasive means of detecting EICP is desirable when conventional imaging methods are unavailable. Objectives: The hypothesis of this study was that ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) could accurately predict the presence of EICP. Methods: The authors performed a prospective, blinded observational study on emergency department (ED) patients with a suspicion of EICP due to possible focal intracranial pathology. The study was conducted at a large community ED with an emergency medicine residency program and took place over a six-month period. Patients suspected of having EICP by an ED attending were enrolled when study physicians were available. Unstable patients were excluded. ONSD was measured 3 mm behind the globe using a 10-MHz linear probe on the closed eyelids of supine patients, bilaterally. Based on prior literature, an ONSD above 5 mm on ultrasound was considered abnormal. Computed tomography (CT) findings defined as indicative of EICP were the presence of mass effect with a midline shift 3 mm or more, a collapsed third ventricle, hydrocephalus, the effacement of sulci with evidence of significant edema, and abnormal mesencephalic cisterns. For each patient, the average of the two ONSD measurements was calculated and his or her head CT scans were evaluated for signs of EICP. Student's t-test was used to compare ONSDs in the normal and EICP groups. Sensitivity, specificity, and positive and negative predictive values were calculated. Results: Thirty-five patients were enrolled; 14 had CT results consistent with EICP. All cases of CT-determined EICP were correctly predicted by ONSD over 5 mm on US. One patient with ONSD of 5.7 mm in one eye and 3.7 mm in the other on US had a mass abutting the ipsilateral optic nerve; no shift was seen on CT. He was placed in the EICP category on his data collection sheet. The mean ONSD for the 14 patients with CT evidence of EICP was 6.27 mm (95% CI = 5.6 to 6.89); the mean ONSD for the others was 4.42 mm (95% CI = 4.15 to 4.72). The difference of 1.85 mm (95% CI = 1.23 to 2.39 mm) yielded a p = 0.001. The sensitivity and specificity for ONSD, when compared with CT results, were 100% and 95%, respectively. The positive and negative predictive values were 93% and 100%, respectively. Conclusions: Despite small numbers and selection bias, this study suggests that bedside ED US may be useful in the diagnosis of EICP.

Predictors and Outcomes of Frequent Emergency Department Users

Abstract: Objective: To identify predictors and outcomes associated with frequent emergency department (ED) users. Methods: Cross-sectional intake surveys, medical chart reviews, and telephone follow-up interviews of patients presenting with selected chief complaints were performed at five urban EDs during a one-month study period in 1995. Frequent use was defined by four or more self-reported, prior ED visits. Multivariate logistic regression identified predictors of frequent ED visitors from five domains (demographics, health status, health access, health care preference, and severity of acute illness). Associations between high use and selected outcomes were assessed with logistic regression models. Results: All study components were completed by 2,333 of 3,455 eligible patients (67.5%). Demographics predicting frequent use included being a single parent, single or divorced marital status, high school education or less, and income of less than $10,000 (1995). Health status predictors included hospitalization in the preceding three months, high ratings of psychological distress, and asthma. Health access predictors included identifying an ED or a hospital clinic as the primary care site, having a primary care physician (PCP), and visiting a PCP in the past month. Choosing the ED for free care was the only health preference predictive of heavy use. Illness severity measures were higher in frequent visitors, although these were not independently predictive in the multivariate model. Outcomes correlated with heavy use include increased hospital admissions, higher rates of ED return visits, and lower patient satisfaction, but not willingness to return to the ED or follow-up with a doctor. Conclusions: Frequent ED visits are associated with socioeconomic distress, chronic illness, and high use of other health resources. Efforts to reduce ED visits require addressing the unique needs of these patients in the emergency and primary care settings.

The emergency severity index triage algorithm version 2 is reliable and valid.

Abstract: Objectives: Initial studies have shown improved reliability and validity of a new triage tool, the Emergency Severity Index (ESI), over conventional three-level scales at two university medical centers. After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. The goal of this study was to assess ESI version (v.) 2 reliability and validity at seven emergency departments (EDs) in three states. Methods: In part 1, interrater reliability was assessed using weighted kappa analysis of written training cases and postimplementation by a random sampling of actual patient triages. In part 2, validity was analyzed using a prospective cohort with stratified random sampling at each site. The ESI was compared with outcomes including resource consumption, inpatient admission, ED length of stay, and 60-day all-cause mortality. Results: Weighted kappa analysis of interrater reliability ranged from 0.70 to 0.80 for the written scenarios (n= 3,289) and 0.69 to 0.87 for patient triages (n= 386). Outcomes for the validity cohort (n= 1,042) included hospitalization rates by ESI triage level: level 1, 83%; 2, 67%; 3, 42%; 4, 8%; level 5, 4%. Sixty-day all-cause mortality by triage level was as follows: level 1, 25%; 2, 4%; 3, 2%; 4, 1%; and 5, 0%. Conclusions: ESI v. 2 triage produced reliable, valid stratification of patients across seven sites. ESI triage should be evaluated as an ED casemix identification system for uniform data collection in the United States and compared with other major ED triage methods.

A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department.

Abstract: Objectives: To evaluate the predictive ability of a simple six-item triage risk screening tool (TRST) to identify elder emergency department (ED) patients at risk for ED revisits, hospitalization, or nursing home (NH) placement within 30 and 120 days following ED discharge. Methods: Prospective cohort study of 650 community-dwelling elders (age 65 years or older) presenting to two urban academic EDs. Subjects were prospectively evaluated with a simple six-item ED nursing TRST. Participants were interviewed 30 and 120 days post-ED index visit and the utilization of EDs, hospitals, or NHs was recorded. Main outcome measurement was the ability of the TRST to predict the composite endpoint of subsequent ED use, hospital admission, or NH admission at 30 and 120 days. Individual outcomes of ED use, hospitalization, and NH admissions were also examined. Results: Increasing cumulative TRST scores were associated with significant trends for ED use, hospital admission, and composite outcome at both 30 and 120 days (p < 0.0001 for all, except 30-day ED use, p = 0.002). A simple, unweighted five-item TRST (“lives alone” item removed after logistic regression modeling) with a cut-off score of 2 was the most parsimonious model for predicting composite outcome (AUC = 0.64) and hospitalization at 30 days (AUC = 0.72). Patients defined as high-risk by the TRST (score ≥ 2) were significantly more likely to require subsequent ED use (RR = 1.7; 95% CI = 1.2 to 2.3), hospital admission (RR = 3.3; 95% CI = 2.2 to 5.1), or the composite outcome (RR = 1.9; 95% CI 1.7 to 2.9) at both 30 days and 120 days than the low-risk cohort. Conclusions: Older ED patients with two or more risk factors on a simple triage screening tool were found to be at significantly increased risk for subsequent ED use, hospitalization, and nursing home admission.

Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography.

Abstract: Objectives: Emergency department (ED) bedside echocardiography may offer useful information on cardiac function and volume status. The authors evaluated the accuracy of emergency physician (EP) performance of echocardiography in the assessment of left ventricular ejection fraction (LVEF) and central venous pressure (CVP). Methods: The authors conducted a cross-sectional observational study at an urban teaching ED, involving a convenience sample of patients presenting to the ED between September 2000 and February 2001. Level III– credentialed EP sonographers who had undergone a threehour training session in limited echocardiography, focusing on LVEF and CVP measurement, performed echocardiograms. Vital signs and indication for echocardiography were documented on a study data sheet. LVEF was rated as poor (\30%), moderate (30%–55%), or normal ([55%) and an absolute percentage. Central venous pressure categories included low (\5 cm), moderate (5–10 cm), and high ([10 cm). Formal echocardiograms were obtained within a four-hour window on all patients and interpreted by a staff cardiologist. Correlation analysis was performed using the k correlation coefficient for LVEF and CVP categories and a Pearson correlation coefficient for LVEF measurement. Results: A total of 115 patients were assessed for LVEF, and 94 patients had complete information for CVP. Indications for echocardiography included chest pain (45.1%), congestive heart failure (38.1%), dyspnea (5.7%), and endocarditis (10.6%). Results showed a LVEF correlation of r 2 ¼ 0.712 with 86.1% overall agreement. Subgroup analysis revealed the highest agreement (92.3%) between EP and formal echocardiograms within the normal LVEF category, followed by 70.4% agreement in the poor LVEF category and 47.8% in the moderate LVEF category. Central venous pressure measurements resulted in 70.2% overall raw agreement between EP and formal echocardiograms. Subgroup analysis revealed the highest agreement (83.3%) within the high CVP category followed by 66.6% in the moderate and 20% in the low categories. Conclusions: Experienced EP sonographers with a small amount of focused additional training in limited bedside echocardiography can assess LVEF accurately in the ED. Key words: echocardiography; emergency medicine; left ventricular ejection fraction; inferior vena cava; ultrasound. ACADEMIC EMERGENCY MEDICINE 2003; 10:973–977. Emergency physicians (EPs) routinely are called on to manage critically ill patients who may present with an indeterminate or changing hemodynamic status. Early in the patient’s course, it may be difficult to firmly identify the underlying etiology. At this stage, successful management hinges less on an accurate diagnosis than on a timely determination of the prevailing hemodynamic process. 1 To this end, the

Emergency Medicine Crisis Resource Management (EMCRM): Pilot Study of a Simulation-based Crisis Management Course for Emergency Medicine

Abstract: Objectives: To determine participant perceptions of Emergency Medicine Crisis Resource Management (EMCRM), a simulation-based crisis management course for emergency medicine. Methods: EMCRM was created using Anesthesia Crisis Resource Management (ACRM) as a template. Thirteen residents participated in one of three pilot courses of EMCRM; following a didactic session on principles of human error and crisis management, the residents participated in simulated emergency department crisis scenarios and instructor-facilitated debriefing. The crisis simulations involved a computer-enhanced mannequin simulator and standardized patients. After finishing the course, study subjects completed a horizontal numerical scale survey (1 = worst rating to 5 = best rating) of their perceptions of EMCRM. Descriptive statistics were calculated to evaluate the data. Results: The study subjects found EMCRM to be enjoyable (4.9 ± 0.3) (mean ± SD) and reported that the knowledge gained from the course would be helpful in their practices (4.5 ± 0.6). The subjects believed that the simulation environment prompted realistic responses (4.6 ± 0.8) and that the scenarios were highly believable (4.8 ± 0.4). The participants reported that EMCRM was best suited for residents (4.9 ± 0.3) but could also benefit students and attending physicians. The subjects believed that the course should be repeated every 8.2 ± 3.3 months. Conclusions: The EMCRM participants rated the course very favorably and believed that the knowledge gained would be beneficial in their practices. The extremely positive response to EMCRM found in this pilot study suggests that this training modality may be valuable in training emergency medicine residents.

Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department.

Abstract: Plasma B-type natriuretic peptide (BNP) can reliably identify acute congestive heart failure (CHF) in patients presenting to the emergency department (ED) with acute dyspnea. Heart failure, asthma, and chronic obstructive pulmonary disease (COPD) are syndromes where dyspnea and wheezing are overlapping signs, and hence, these syndromes are often difficult to differentiate. Objective: To determine whether BNP can distinguish new-onset heart failure in patients with COPD or asthma presenting with dyspnea to the ED. Methods: The BNP Multinational Study was a seven-center prospective study of 1,586 adult patients presenting to the ED with acute dyspnea who had blinded BNP levels measured on arrival with a rapid, point-of-care device. This study evaluated the 417 patients with no previous history of heart failure and a history of asthma or COPD as a subgroup from the 1,586 adult patients in the BNP Multinational Study. The reference standard for CHF was adjudicated by two independent cardiologists, also blinded to BNP results, who reviewed all clinical data and standardized CHF scores. Results: A total of 417 subjects (mean age 62.2 years, 64.4% male) had a history of asthma or COPD without a history of CHF. Of these, 87/417 (20.9%, 95% CI = 17.1% to 25.1%) were found to have CHF as the final adjudicated diagnosis. The emergency physicians identified a minority, 32/87 (36.8%), of these patients with CHF. The mean BNP values (± SD) were 587.0 ± 426.4 and 108.8 ± 221.3 pg/mL for those with and without CHF (p < 0.0001). At a cutpoint of 100 pg/mL, BNP had the following decision statistics: sensitivity 93.1%, specificity 77.3%, positive predictive value 51.9%, negative predictive value 97.7%, accuracy 80.6%, positive likelihood ratio 4.10, and negative likelihood ratio 0.09. If BNP would have been added to clinical judgment (high ≥ 80% probability of CHF), at a cutpoint of 100 pg/mL, 83/87 (95.4%) of the CHF subjects would have been correctly diagnosed. Multivariate analysis found BNP to be the most important predictor of CHF (OR = 12.1, 95% CI = 5.4 to 27.0, p < 0.0001). In the 87 subjects found to have CHF, 39.0%, 22.2%, and 54.8% were taking angiotensin-converting enzyme inhibitors (ACEIs), beta-blockers (BBs), and diuretics on a chronic basis, respectively. Conclusions: The yield of adding routine BNP testing in patients with a history of asthma or COPD in picking up newly diagnosed CHF is approximately 20%. This group of patients presents a substantial therapeutic opportunity for the initiation and chronic administration of ACEI and BB therapy, as well as other CHF management strategies.

Emergency medicine animal research: does use of randomization and blinding affect the results?

Abstract: Objectives: It has been shown that human clinical trials that lack randomization (RND) or blinding (BLD) often overestimate the magnitude of treatment effects. However, no studies have evaluated the effect of RND and BLD on animal research. The authors' objectives were to determine the proportion of animal studies presented at a national academic emergency medicine meeting that utilize randomization, blinding, or both; and to determine whether failure to employ these techniques changes the likelihood of observing a difference between treatment groups. Methods: Two trained researchers reviewed abstracts presented at the 1997–2001 Society for Academic Emergency Medicine (SAEM) annual meetings using a standard data collection sheet. Studies that used an animal or cell line, compared two or more study groups, and measured an effect caused by the intervention or drugs were included. Studies were classified as randomized (RND+) if any part of the experiment involved random assignment of subjects to treatment groups, blinded (BLD+) if any assessment of the outcome was made by an investigator blinded to treatment group, and outcome-positive (Outcome+) if any difference between the study groups met the author's definition of significant. Following the initial review, differences in classification were resolved by consensus. The association between outcome and study methodology (RND, BLD or both) was measured using odds ratios (ORs) with 95% confidence intervals (95% CIs). Results: A total of 2,592 studies were published as abstracts. Three hundred eighty-nine were animal studies, and 290 of these studies had two or more study groups. RND− and BLD− studies were more likely to be Outcome+ than RND+ or BLD+ studies (OR = 3.4; 95% CI = 1.7 to 6.9 and OR = 3.2; 95% CI = 1.3 to 7.7, respectively). When studies that used both RND and BND were compared with studies that used neither, the OR for a positive study was 5.2 (95% CI = 2.0 to 13.5). Conclusions: These results suggest that animal studies that do not utilize RND and BLD are more likely to report a difference between study groups than studies that employ these methods.

Determinants of Emergency Department Visits by Older Adults: A Systematic Review

Abstract: Objectives: To conduct a systematic review of the literature on the determinants of hospital emergency department (ED) visits by elders, using a modification of the Andersen behavioral model of health services, adapted to explain ED utilization. Methods: Relevant articles were identified through MEDLINE and a search of reference lists and personal files. Studies of populations aged 65 or older in which ED visits were a study outcome were included if they were: original, not restricted to a particular medical condition, written in English or French, and investigated one or more determinants. Data were abstracted and checked by two authors using a standard protocol. Results: Fourteen studies (reported in 15 articles) were reviewed, 10 community-based and four using clinical samples. Among ten studies that measured multiple determinants, determinants reported from multivariate analyses included measures of need (perceived and evaluated health status, prior utilization), predisposing factors (health beliefs and sociodemographic variables), and enabling factors (physician availability, regular source of care, family resources, geographical access to services). Conclusions: Need is usually the primary determinant of ED visits in older people. Controlling for need, predisposing and enabling factors that promote access to primary medical care are associated with reduced ED utilization.

Development and Validation of a New Index to Measure Emergency Department Crowding

Abstract: OBJECTIVES To develop a quantitative measure of emergency department (ED) crowding and busyness. METHODS A five-week study in spring 2002 in an urban teaching ED compared a new index (the Emergency Department Work Index [EDWIN]) with attending physician and nurse ratings of crowding. EDWIN is defined as summation operator n(i)t(i)/N(a)(B(T)-B(A)), where n(i) = number of patients in the ED in triage category i, t(i) = triage category, N(a) = number of attending physicians on duty, B(T) = number of treatment bays, and B(A) = number of admitted patients in the ED. The triage system used is the Emergency Severity Index (ESI), which was modified by reversing the ranking of triage categories; that is, an ESI score of 1 represented the least acute patient and 5 the sickest. EDWIN was calculated every two hours in a convenience sample of 60 eight-hour shifts. With each measurement, the charge attending physician and nurse estimated how busy/crowded the ED was, using a Likert scale. Nurse and physician assessments were averaged and compared with EDWIN scores. Data were analyzed with SPSS 10.0 (SPSS Inc., Chicago, IL). RESULTS A total of 2,647 patients aged 18 years and older were assessed at 225 time points over 35 consecutive days. Nurses and physicians showed good interrater agreement of crowding assessment (weighted kappa 0.61, 95% confidence interval = 0.53 to 0.69). Median EDWIN scores and interquartile ranges (IQRs) when the ED was rated as not busy, average, and very busy were 1.07 (IQR = 0.80 to 1.55), 1.55 (IQR = 1.16 to 1.93), and 1.83 (IQR = 1.42 to 2.45) (p < 0.001). The ED was on diversion for 17 time blocks (6.5% of all blocks), with a median EDWIN of 2.77 (IQR = 1.83 to 3.63), compared with an EDWIN of 1.45 (IQR = 1.05 to 2.00) when not on diversion (p < 0.001). EDWIN scores correlated weakly with various process-of-care measures chosen as secondary end points. CONCLUSIONS EDWIN correlated well with staff assessment of ED crowding and diversion. The index can be programmed into tracking software for use as a "dashboard" to alert staff when the ED is approaching crisis. If validated across other sites, EDWIN may provide a tool to compare crowding levels among different EDs.

Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting.

Abstract: OBJECTIVE: To determine the rate of unrecognized endotracheal tube misplacement when performed by emergency medical services (EMS) personnel in a mixed urban and rural setting. METHODS: The authors conducted a prospective, observational analysis of out-of-hospital endotracheal intubations (EIs) performed by EMS personnel serving a mixed urban, suburban, and rural population. From July 1, 1998, to August 30, 1999, emergency physicians assessed and recorded the position of out-of-hospital EIs using auscultation, direct laryngoscopy, infrared CO(2) detectors, esophageal detector devices, and chest x-ray. The state EMS database also was reviewed to determine the number of EIs involving patients transported to the authors' medical center and paramedic assessment of success for these encounters. RESULTS: A total of 167 out-of-hospital EIs were recorded, of which 136 (81%) were deemed successful by EMS personnel. Observational forms were completed for 109 of the 136 patients who arrived intubated to the emergency department. Of the studied patients, 12% (13 of 109) were found to have misplaced endotracheal tubes. For the patients with unrecognized improperly placed tubes, 9% (10 of 109) were in the esophagus, 2% (2 of 109) were in the right main stem, and 1% (1 of 109) were above the cords. Paramedics serving urban and suburban areas did not perform significantly better (p < 0.05) than intermediate-level providers serving areas that are more rural. CONCLUSIONS: The incidence of unrecognized misplacement of endotracheal tubes by EMS personnel may be higher than most previous studies, making regular EMS evaluation and the out-of-hospital use of devices to confirm placement imperative. The authors were unable to show a difference in misplacement rates based on provider experience or level of training.

Short-axis versus long-axis approaches for teaching ultrasound-guided vascular access on a new inanimate model

Abstract: Objectives: To determine whether a short-axis (SA) or long-axis (LA) ultrasound (US) approach to guidance for line placement results in faster vascular access for novice US users. Also, to assess if there was a difference in the number of skin penetrations and needle redirections between the two guidance techniques. Methods: This was a prospective, randomized, observational study of emergency medicine (EM) residents at a Level I trauma center. A gelatin dessert and dietary fiber supplement mixture, providing a realistic US image, were placed inside a synthetic arm skin that is used for training phlebotomists and contains a rubber vein filled with red fluid at a depth of 1.5 cm. After a 30-minute tutorial on US-guided vascular access, EM residents were randomized to one of two groups. Group one attempted SA first and then the LA. Group two tried LA first followed by the SA. Time from skin break to vein cannulation, number of skin breaks and needle redirections, and difficulty of access on a 10-point Likert scale as reported by residents were recorded. Statistical analysis included paired Student's t-test with 95% confidence intervals (95% CIs). Results: Seventeen EM residents participated. The mean times to vein cannulation in SA and LA were 2.36 minutes (95% CI = 1.15 to 3.58) and 5.02 minutes (95% CI = 2.90 to 7.13), respectively (p = 0.03). The mean numbers of skin breaks for SA and LA were 4.18 (95% CI = 1.18 to 7.17) and 5.76 (95% CI = 1.83 to 9.69), respectively (p = 0.49). The mean numbers of needle redirections in the SA and LA were 13.71 (95% CI = 4.51 to 22.89) and 18.17 (95% CI = 7.95 to 28.40), respectively (p = 0.51). The mean difficulty scores for SA and LA were 3.99 (95% CI = 2.42 to 5.67) and 5.86 (95% CI = 4.32 to 7.40), respectively (p = 0.17). Conclusions: Novice US users obtain vascular access faster with an SA approach on an inanimate model.

Bench to bedside: electrophysiologic and clinical principles of noninvasive hemodynamic monitoring using impedance cardiography.

Abstract: The evaluation of the hemodynamic state of the severely ill patient is a common problem in emergency medicine. While conventional vital signs offer some insight into delineating the circulatory pathophysiology, it is often impossible to determine the true clinical state from an analysis of blood pressure and heart rate alone. Cardiac output measurements by thermodilution have been the criterion standard for the evaluation of hemodynamics. However, this technology is invasive, expensive, time-consuming, and impractical for most emergency department environments. Impedance cardiography (ICG) is a noninvasive method of obtaining continuous measurements of hemodynamic data such as cardiac output that requires little technical expertise. ICG technology was first developed by NASA in the 1960s and is based on the idea that the human thorax is electrically a nonhomogeneous, bulk conductor. Variation in the impedance to flow of a high-frequency, low-magnitude alternating current across the thorax results in the generation of a measured waveform from which stroke volume can be calculated by a modification of the pulse contour method. To adequately judge the possible role of this technology in the practice of emergency medicine, it is important to have a sufficient understanding of the basic scientific principles involved as well as the clinical validity and limitations of the technique.

Profiles in patient safety: emergency care transitions.

Abstract: A 59-year-old man presented to the emergency department (ED) with the chief complaint of "panic attacks." In total, he was evaluated by 14 faculty physicians, 2 fellows, and 16 residents from emergency medicine, cardiology, neurology, psychiatry, and internal medicine. These multiple transitions were responsible, in part, for the perpetuation of a failure to accurately diagnose the patient's underlying medical illness. The case illustrates the discontinuity of care that occurs at transitions, which may threaten the safety and quality of patient care. Considerable effort must be directed at making transitions effective and safe. Recommendations to improve transitions include a heightened awareness of cognitive biases operating at these vulnerable times, improving team situational awareness and communication, and exploring systems to facilitate effective transfer of relevant data.

The Effect of Race/Ethnicity and Desirable Social Characteristics on Physicians' Decisions to Prescribe Opioid Analgesics

Abstract: Objective: Racial/ethnic disparities in physician treatment have been documented in multiple areas, including emergency department (ED) analgesia. The purpose of this study was to determine if physicians were predisposed to different treatment decisions based on patient race/ethnicity and if physicians’ treatment predispositions changed when socially desirable information about the patient (occupation, socioeconomic status, and relationship with a primary care physician) was made explicit. Methods: The authors developed three clinical vignettes designed to engage physicians’ decision-making processes. The patient’s race/ethnicity was included. Each vignette randomly included or omitted explicit socially desirable information. The authors mailed 5,750 practicing emergency physicians three clinical vignettes and a one-page questionnaire about demographic and practice characteristics. Chi-square tests of significance for bivariate analyses and multiple logistic regression were used for multivariate analyses. Results: A total of 2,872 (53%) of the 5,398 potential physician subjects participated. Patient race/ethnicity had no effect on physician prescription of opioids at discharge for African Americans, Hispanics, and whites: absolute differences in rates of prescribing opioids at discharge were less than 2% for all three conditions presented. Making socially desirable information explicit increased the prescribing rates by 4% (95% CI ¼ 0.1% to 8%) for the migraine vignette and 6% (95% CI ¼ 3% to 8%) for the back pain vignette. Conclusions: Patient race/ethnicity did not influence physicians’ predispositions to treatment plans in clinical vignettes. Even knowing that the patient had a high-prestige occupation and a primary care provider only minimally increased prescribing of opioid analgesics for conditions with few objective findings. Key words: emergency department; analgesia prescription; race/ethnicity; usual source of care; communication; access. ACADEMIC EMERGENCY MEDICINE 2003; 10:1239–1248.

Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years.

Abstract: Determination of the presence of an abdominal aortic aneurysm (AAA) is essential in the management of the symptomatic emergency department (ED) patient. Objectives: To identify whether emergency ultrasound of the abdominal aorta (EUS-AA) by emergency physicians could accurately determine the presence of AAA and guide ED disposition. Methods: This was a prospective, observational study at an urban ED with more than 100,000 annual patient visits with consecutive patients enrolled over a two-year period. All patients suspected to have AAA underwent standard ED evaluation consisting of EUS-AA, followed by a confirmatory imaging study or laparotomy. AAA was defined as any measured diameter greater than 3 cm. Demographic data, results of confirmatory testing, and patient outcome were collected by retrospective review. Results: A total of 125 patients had EUS-AA performed over a two-year period. The patient population had the following characteristics: average age 66 years, male 54%, hypertension 56%, coronary artery disease 39%, diabetes 22%, and peripheral vascular disease 14%. Confirmatory tests included radiology ultrasound, 28/125 (22%); abdominal computed tomography, 95/125 (76%); abdominal magnetic resonance imaging, 1/125 (1%); and laparotomy, 1/125 (1%). AAA was diagnosed in 29/125 (23%); of those, 27/29 patients had AAA on confirmatory testing. EUS-AA had 100% sensitivity (95% CI ¼ 89.5 to 100), 98% specificity (95% CI ¼ 92.8 to 99.8), 93% positive predictive value (27/29), and 100% negative predictive value (96/96). Admission rate for the study group overall was 70%. Immediate operative management was considered in 17 of 27 (63%) patients with AAA; ten patients were taken to the operating room. Conclusions: EUS-AA in a symptomatic population for AAA is sensitive and specific. These data suggest that the presence of AAA on EUS-AA should guide urgent consultation. Emergency physicians were able to exclude AAA regardless of disposition from the ED. Key words: abdominal aortic aneurysm (AAA); emergency ultrasound (EUS); emergency physician; accuracy. ACADEMIC EMERGENCY MEDICINE 2003; 10:867‐871.

Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study.

Abstract: Objectives: To determine if a focused transthoracic echocardiography (TTE) training course would improve the accuracy of completion and interpretation of a goal-directed TTE by emergency medicine residents. Methods: This was a prospective, observational, educational study of the impact of a focused training course on the change in physician performance on pre- and postcourse examinations testing competency in goal-directed TTE defined by five criteria: 1) image orientation, 2) anatomy identification, 3) chamber size grading, 4) ventricular function estimation, and 5) pericardial effusion identification. Subjects included were emergency medicine residents with between ten and 20 hours of noncardiac ultrasound didactics and between 20 and >150 proctored noncardiac ultrasound examinations. All underwent five hours of focused echocardiography didactics and one hour of proctored practical echocardiography training designed and implemented by an emergency physician ultrasound director and a cardiologist. Before the start of the training course, participants completed two examinations: 1) written 23-question test on the above concepts and 2) performance of a TTE on a healthy subject testing 16 elements that define a properly performed examination. After the training course, participants again completed both examinations. Results: A total of 21 emergency medicine residents qualified for and underwent standardized testing and training. The percentage correct on the precourse written examination was 54% (95% CI = 50% to 59%), and the postcourse examination score was 76% (95% CI = 71% to 80%) (p < 0.005, paired t-test). The percentage correct on the precourse practical examination was 56% (95% CI = 51% to 60%), and the postcourse examination score was 94% (95% CI = 91% to 96%) (p < 0.005). Conclusions: A focused six-hour echocardiography training course significantly improved emergency medicine residents' percentage scores on both written and practical examinations testing essential components required for correct goal-directed TTE performance and interpretation.

Ethnic and racial disparities in emergency department care for mild traumatic brain injury.

Abstract: OBJECTIVES: To identify racial, ethnic, and gender disparities in the emergency department (ED) care for mild traumatic brain injury (mTBI). METHODS: A secondary analysis of ED visits in the National Hospital Ambulatory Medical Care Survey for the years 1998 through 2000 was performed. Cases of mTBI were identified using ICD-9 codes 800.0, 800.5, 850.9, 801.5, 803.0, 803.5, 804.0, 804.5, 850.0, 850.1, 850.5, 850.9, 854.0, and 959.01. ED care variables related to imaging, procedures, treatments, and disposition were analyzed along racial, ethnic, and gender categories. The relationship between race, ethnicity, and selected ED care variables was analyzed using multivariate logistic regression with control for associated injuries, geographic region, and insurance type. RESULTS: The incidence of mTBI was highest among men (590/100,000), Native Americans/Alaska Natives (1026.2/100,000), and non-Hispanics (391.1/100,000). After controlling for important confounders, Hispanics were more likely than non-Hispanics to receive a nasogastric tube (OR, 6.36; 95% CI = 1.2 to 33.6); nonwhites were more likely to receive ED care by a resident (OR, 3.09; 95% CI = 1.9 to 5.0) and less likely to be sent back to the referring physician after ED discharge (OR, 0.47; 95% CI = 0.3 to 0.9). Men and women received equivalent ED care. CONCLUSIONS: There are significant racial and ethnic but not gender disparities in ED care for mTBI. The causes of these disparities and the relationship between these disparities and post-mTBI outcome need to be examined. Language: en

The status of bedside ultrasonography training in emergency medicine residency programs.

Abstract: Bedside ultrasonography (BU) is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. In the past decade, several organizations in EM have issued position statements on the use of this technology. Program training content is currently driven by the recently published “Model of the Clinical Practice of Emergency Medicine,” which includes BU as a necessary skill. Objective: The authors sought to determine the current status of BU training in EM residency programs. Methods: A survey was mailed in early 2001 to all 122 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs. The survey instrument asked whether BU was currently being taught, how much didactic and hands-on training time was incorporated into the curriculum, and what specialty representation was present in the faculty instructors. In addition, questions concerning the type of tests performed, the number considered necessary for competency, the role of BU in clinical decision making, and the type of quality assurance program were included in the survey. Results: A total of 96 out of 122 surveys were completed (response rate of 79%). Ninety-one EM programs (95% of respondents) reported they teach BU, either clinically and/or didactically, as part of their formal residency curriculum. Eighty-one (89%) respondents reported their residency program or primary hospital emergency department (ED) had a dedicated ultrasound machine. BU was performed most commonly for the following: the FAST scan (focused abdominal sonography for trauma, 79/87%); cardiac examination (for tamponade, pulseless electrical activity, etc., 65/71%); transabdominal (for intrauterine pregnancy, ectopic pregnancy, etc., 58/64%); and transvaginal (for intrauterine pregnancy, ectopic pregnancy, etc., 45/49%). One to ten hours of lecture on BU was provided in 43%, and one to ten hours of hands-on clinical instruction was provided in 48% of the EM programs. Emergency physicians were identified as the faculty most commonly involved in teaching BU to EM residents (86/95%). Sixty-one (69%) programs reported that EM faculty and/or residents made clinical decisions and patient dispositions based on the ED BU interpretation alone. Fourteen (19%) programs reported that no formal quality assurance program was in place. Conclusions: The majority of ACGME-accredited EM residency programs currently incorporate BU training as part of their curriculum. The majority of BU instruction is done by EM faculty. The most commonly performed BU study is the FAST scan. The didactic component and clinical time devoted to BU instruction are variable between programs. Further standardization of training requirements between programs may promote increasing standardization of BU in future EM practice.

Comparison of the rapid emergency medicine score and APACHE II in nonsurgical emergency department patients.

Abstract: The severity of illness was scored in a cohort of 11751 non-surgical patients presenting at the Emergency Department (ED) during 12 consecutive months and followed for 4.7 years. The scoring system Rapid Acute Physiology score (RAPS) (including blood pressure, respiratory rate, pulse rate and Glasgow coma scale) was calculated for all arrivals at the ED. The RAPS system was also additionally developed by including the peripheral oxygen saturation and patient age, resulting in the new Rapid Emergency Medicine Score, (REMS). REMS was superior to RAPS in predicting in-hospital mortality according to ROC-curve analysis. An increase of one point in the 26 point REMS scale was associated with an Odds ratio of 1.40 for in-hospital death (95% CI 1.36-1.45, p<0.0001). Similar results were obtained in the major patient groups (chest pain, stroke, coma, dyspnea and diabetes). The association between REMS and length of stay in hospital was modest. Charlson Co-morbidity Index could add prognostic information to REMS in a long-term (4.7 years), but not in a short-term perspective (3 and 7 days). REMS was shown to be as powerful a predictor of in-hospital mortality as the more complicated APACHE II. REMS at the ED could also predict long-term mortality (4.7 years) in the total cohort (Hazard ratio 1.26, p<0.0001).REMS is a potentially useful prognostic tool for non-surgical patients at the ED, regarding both in-hospital and long-term mortality. It is less complicated to use than APACHE II and has equal predictive accuracy.

Multivariate predictors of failed prehospital endotracheal intubation.

Abstract: Objectives: Conventionally trained out-of-hospital rescuers (such as paramedics) often fail to accomplish endotracheal intubation (ETI) in patients requiring invasive airway management. Previous studies have identified univariate variables associated with failed out-of-hospital ETI but have not examined the interaction between the numerous factors impacting ETI success. This study sought to use multivariate logistic regression to identify a set of factors associated with failed adult out-of-hospital ETI. Methods: The authors obtained clinical and demographic data from the Prehospital Airway Collaborative Evaluation, a prospective, multicentered observational study involving advanced life support (ALS) emergency medical services (EMS) systems in the Commonwealth of Pennsylvania. Providers used standard forms to report details of attempted ETI, including system and patient demographics, methods used, difficulties encountered, and initial outcomes. The authors excluded data from sedation-facilitated and neuromuscular blockade-assisted intubations. The main outcome measure was ETI failure, defined as failure to successfully place an endotracheal tube on the last out-of-hospital laryngoscopy attempt. Logistic regression was performed to develop a multivariate model identifying factors associated with failed ETI. Results: Data were used from 45 ALS systems on 663 adult ETIs attempted during the period June 1, 2001, to November 30, 2001. There were 89 cases of failed ETI (failure rate 13.4%). Of 61 factors potentially related to ETI failure, multivariate logistic regression revealed the following significant covariates associated with ETI failure (odds ratio; 95% confidence interval; likelihood ratio p-value): presence of clenched jaw/trismus (9.718; 95% CI = 4.594 to 20.558; p < 0.0001); inability to pass the endotracheal tube through the vocal cords (7.653; 95% CI = 3.561 to 16.447; p < 0.0001); inability to visualize the vocal cords (7.638; 95% CI = 3.966 to 14.707; p < 0.0001); intact gag reflex (7.060; 95% CI = 3.552 to 14.033; p < 0.0001); intravenous access established prior to ETI attempt (3.180; 95% CI = 1.640 to 6.164; p = 0.0005); increased weight (ordinal scale) (1.555; 95% CI = 1.242 to 1.947; p = 0.0001); and electrocardiographic monitoring established prior to ETI attempt (0.199; 95% CI = 0.084 to 0.469; p = 0.0003). This model was the most parsimonious of the models evaluated and demonstrated good fit (Hosmer-Lemeshow test p = 0.471) and discrimination (area under ROC curve = 0.906). There were no significant interaction terms. Conclusions: The authors used multivariate logistic regression to identify a set of factors associated with failure to accomplish ETI in adult out-of-hospital patients. Findings from this analysis could provide the basis for clinical protocols or decision rules aimed at minimizing the incidence of out-of-hospital ETI failure.

Bispectral electroencephalographic analysis of patients undergoing procedural sedation in the emergency department

Abstract: Objective: To determine whether there is a correlation between the level of sedation achieved during procedural sedation (PS) in the emergency department as determined by bispectral electroencephalographic (EEG) analysis (BIS) and the rate of respiratory depression (RD), the patient's perception of pain, recall of the procedure, and satisfaction. Methods: This was a prospective observational study conducted in an urban county hospital of adult patients undergoing PS using propofol, methohexital, etomidate, and the combination of fentanyl and midazolam. Consenting patients were monitored by vital signs, pulse oximetry, nasal-sample end-tidal carbon dioxide (ETCO 2 ), and BIS monitors during PS. Respiratory depression (RD) was defined as an oxygen saturation 10 mm Hg, or an absent ETCO 2 waveform at any time during the procedure. After the procedure, patients were asked to complete three 100-mm visual analog scales (VASs) concerning their perception of pain, recall of the procedure, and satisfaction with the procedure. Patients were divided into four groups based on the lowest BIS score recorded during the procedure, group 1, >85; group 2, 70-85; group 3, 60-69; group 4, <60. Rates of RD and VAS outcomes were compared between groups using chi-square statistics. Results: One hundred eight patients were enrolled in the study. No serious adverse events were noted. RD was seen in three of 14 (21.4%) of the patients in group 1, seven of 34 (20.6%) in group 2, 16 of 26 (61.5%) in group 3, and 18 of 34 (52.9%) in group 4. The rate of RD in patients in group 2 was not significantly different from that in group 1 (p = 0.46). The rate of RD in group 2 was significantly lower than that in groups 3 (p = 0.0003) and 4 (p = 0.006). For the VAS data, when group 1 was compared with the combined groups 2, 3, and 4, it had significantly higher rates of pain (p = 0.003) and recall (p = 0.001), and a dissatisfaction rate (p = 0.085) that approached significance. When groups 2, 3, and 4 were compared with chi-square test, there was not a significant difference in pain (p = 0.151), recall (p = 0.27), or satisfaction (p = 0.25). Conclusions: Patients with a lowest recorded BIS score between 70 and 85 had the same VAS outcomes as more deeply sedated patients and the same rate of RD as less deeply sedated patients. This range of scores represented the optimally sedated patients in this study.

Incidence of traumatic lumbar puncture.

Abstract: Objective: To determine the incidence of traumatic lumbar puncture (LP). Methods: A retrospective study was conducted at an urban, university tertiary care referral center with 50,000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1,000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics. Results: Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%)were traumatic,using acutoffof1,000RBCsintube1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p , 0.025). Similarly, using a cutoff of 1,000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p ¼ 0.1). The incidence of ‘‘champagne taps’’ (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p , 0.01). Conclusions: The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1,000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital. Key words: lumbar puncture; subarachnoid hemorrhage; traumatic tap. ACADEMIC EMERGENCY MEDICINE 2003; 10:151‐154.

Racial and Ethnic Disparities in Pediatric Appendicitis Rupture Rate

Abstract: Objectives: To determine if there are racial/ethnic differences in the rates of appendiceal rupture among the children of two large states. Because rupture is primarily due to delayed diagnosis, differences would suggest disparities in timely access to quality emergency care. Methods: This was an observational, cross-sectional analysis of full-year samples of acute appendicitis cases from California and New York children 4 to 18 years old. Racial/ethnic groups were compared for risk of appendiceal rupture adjusted for biological factors both before and after adjustment for the following socioeconomic, hospital, and admission characteristics: income, insurance, hospital type, and admission source. Results were interpreted in light of census data on the proportion of immigrants in each racial/ethnic group. Results: Compared with white children with acute appendicitis, Hispanic and Asian children have higher odds of rupture in California, whereas Asian and black/African American children have higher odds in New York. These differences roughly parallel the within-state proportion of immigrant children in these groups. Adjustments for family, socioeconomic, and hospital characteristics attenuate but do not eliminate disparities. Conclusions: The authors found evidence of significant racial/ethnic disparities in rate of appendiceal rupture, an important and preventable outcome, in two large but dissimilar states. Immigrant groups may be most at risk for delayed emergency care. Future research should focus on immigration and acculturation as risk factors for appendicitis rupture in children.

Is total out-of-hospital time a significant predictor of trauma patient mortality?

Abstract: Objective: To determine if there is an association between total out-of-hospital time and trauma patient mortality. Methods: A retrospective review was performed of a convenience sample of consecutive medical records for all admitted patients transported by helicopter or ambulance from the scene of injury to the regional trauma center. Descriptive and univariate analyses were conducted to determine which variables were associated with patient mortality and total out-of-hospital time. Multiple predictors logistic regression was used to determine if total out-ofhospital time was associated with trauma patient outcome, while controlling for the variables associated with trauma patient mortality. Results: Of the 2,925 patients who were transported from the scene, 1,877 met the inclusion criteria. Six percent (116) did not survive. The multiple predictors model included CUPS (critical, unstable, potentially unstable, stable) status, patient age, Injury Severity Score, Revised Trauma Score, and total out-of-hospital time as predictors of mortality. Total out-of-hospital time (odds ratio 0.987; p ¼ 0.092) was the only variable not found to be a significant predictor of mortality. Conclusions: Providerassigned CUPS status, patient age, Injury Severity Score, and Revised Trauma Score all were significant predictors of trauma patient mortality. Total out-of-hospital time was not associated with mortality. Key words: wounds; trauma; injury; emergency medicine services; time; triage. ACADEMIC EMERGENCY MEDICINE 2003; 10:949‐954.

Racial and ethnic disparities in the clinical practice of emergency medicine.

Abstract: There is convincing evidence that racial and ethnic disparities exist in the provision of health care, including the provision of emergency care; and that stereotyping, biases, and uncertainty on the part of health care providers all contribute to unequal treatment. Situations, such as the emergency department (ED), that are characterized by time pressure, incomplete information, and high demands on attention and cognitive resources increase the likelihood that stereotypes and bias will affect diagnostic and treatment decisions. It is likely that there are many as-yet-undocumented disparities in clinical emergency practice. Racial and ethnic disparities may arise in decisions made by out-of-hospital personnel regarding ambulance destination, triage assessments made by nursing personnel, diagnostic testing ordered by physicians or physician-extenders, and in disposition decisions. The potential for disparate treatment includes the timing and intensity of ED therapy as well as patterns of referral, prescription choices, and priority for hospital admission and bed assignment. At a national roundtable discussion, strategies suggested to address these disparities included: increased use of evidence-based clinical guidelines; use of continuous quality improvement methods to document individual and institutional disparities in performance; zero tolerance for stereotypical remarks in the workplace; cultural competence training for emergency providers; increased workforce diversity; and increased epidemiologic, clinical, and services research. Careful scrutiny of the clinical practice of emergency medicine and diligent implementation of strategies to prevent disparities will be required to eliminate the individual behaviors and systemic processes that result in the delivery of disparate care in EDs.

A Risk Score to Predict Arrhythmias in Patients with Unexplained Syncope

Abstract: Objectives: To develop and validate a risk score predicting arrhythmias for patients with syncope remaining unexplained after emergency department (ED) noninvasive evaluation. Methods: One cohort of 175 patients with unexplained syncope (Geneva, Switzerland) was used to develop and cross-validate the risk score; a second cohort of 269 similar patients (Pittsburgh, PA) was used to validate the system. Arrhythmias as a cause of syncope were diagnosed by cardiac monitoring or electrophysiologic testing. Data from the patient’s history and 12-lead emergency electrocardiography (ECG) were used to identify predictors of arrhythmias. Logistic regression was used to identify predictors for the risk-score system. Risk-score performance was measured by comparing the proportions of patients with arrhythmias at various levels of the score and receiver operating characteristic (ROC) curves. Results: The prevalence of arrhythmic syncope was 17% in the derivation cohort and 18% in the validation cohort. Predictors of arrhythmias were abnormal ECG (odds ratio [OR]: 8.1, 95% confidence interval [CI] ¼ 3.0 to 22.7), a history of congestive heart failure (OR: 5.3, 95% CI ¼ 1.9 to 15.0), and age older than 65 (OR: 5.4, 95% CI ¼ 1.1 to 26.0). In the derivation cohort, the risk of arrhythmias ranged from 0% (95% CI ¼ 0 to 6) in patients with no risk factors to 6% (95% CI ¼ 1t o 15) for patients with one risk factor, 41% (95% CI ¼ 26 to 57) for patients with two risk factors, and 60% (95% CI ¼ 32 to 84) for those with three risk factors. In the validation cohort, these proportions varied from 2% (95% CI ¼ 0 to 7) with no risk factors to 17% (95% CI ¼ 10 to 27) with one risk factor, 35% (95% CI ¼ 24 to 46) with two risk factors, and 27% (95% CI ¼ 6 to 61) with three risk factors. Areas under the ROC curves ranged from 0.88 (95% CI ¼ 0.84 to 0.91) for the derivation cohort to 0.84 (95% CI ¼ 0.77 to 0.91) after crossvalidation within the same cohort and 0.75 (95% CI ¼ 0.68 to 0.81) for the external validation cohort. Conclusions: In patients with unexplained syncope, a risk score based on clinical and ECG factors available in the ED identifies patients at risk for arrhythmias. Key words: unexplained syncope; arrhythmia; risk factor; scoring system. ACADEMIC EMERGENCY MEDICINE 2003; 10:1312–1317.