Showing papers in "Academic Emergency Medicine in 2011"

Logistic Regression: A Brief Primer

Abstract: Regression techniques are versatile in their application to medical research because they can measure associations, predict outcomes, and control for confounding variable effects. As one such technique, logistic regression is an efficient and powerful way to analyze the effect of a group of independent variables on a binary outcome by quantifying each independent variable's unique contribution. Using components of linear regression reflected in the logit scale, logistic regression iteratively identifies the strongest linear combination of variables with the greatest probability of detecting the observed outcome. Important considerations when conducting logistic regression include selecting independent variables, ensuring that relevant assumptions are met, and choosing an appropriate model building strategy. For independent variable selection, one should be guided by such factors as accepted theory, previous empirical investigations, clinical considerations, and univariate statistical analyses, with acknowledgement of potential confounding variables that should be accounted for. Basic assumptions that must be met for logistic regression include independence of errors, linearity in the logit for continuous variables, absence of multicollinearity, and lack of strongly influential outliers. Additionally, there should be an adequate number of events per independent variable to avoid an overfit model, with commonly recommended minimum "rules of thumb" ranging from 10 to 20 events per covariate. Regarding model building strategies, the three general types are direct/standard, sequential/hierarchical, and stepwise/statistical, with each having a different emphasis and purpose. Before reaching definitive conclusions from the results of any of these methods, one should formally quantify the model's internal validity (i.e., replicability within the same data set) and external validity (i.e., generalizability beyond the current sample). The resulting logistic regression model's overall fit to the sample data is assessed using various goodness-of-fit measures, with better fit characterized by a smaller difference between observed and model-predicted values. Use of diagnostic statistics is also recommended to further assess the adequacy of the model. Finally, results for independent variables are typically reported as odds ratios (ORs) with 95% confidence intervals (CIs).

International perspectives on emergency department crowding.

Abstract: The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom The authors are local emergency care leaders with knowledge of emergency care in their particular countries Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED ED crowding appears to be worsening in many countries despite the presence of universal health coverage Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes

The association between length of emergency department boarding and mortality

Abstract: Objectives: Emergency department (ED) boarding has been associated with several negative patient-oriented outcomes, from worse satisfaction to higher inpatient mortality rates. The current study evaluates the association between length of ED boarding and outcomes. The authors expected that prolonged ED boarding of admitted patients would be associated with higher mortality rates and longer hospital lengths of stay (LOS). Methods: This was a retrospective cohort study set at a suburban academic ED with an annual ED census of 90,000 visits. Consecutive patients admitted to the hospital from the ED and discharged between October 2005 and September 2008 were included. An electronic medical record (EMR) system was used to extract patient demographics, ED disposition (discharge, admit to floor), ED and hospital LOS, and in-hospital mortality. Boarding was defined as ED LOS 2 hours or more after decision for admission. Descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an intensive care unit (ICU), and mortality controlling for comorbidities. Results: There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p < 0.001). Mean hospital LOS also showed an increase with boarding time (p < 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors. Conclusions: Hospital mortality and hospital LOS are associated with length of ED boarding. ACADEMIC EMERGENCY MEDICINE 2011; 18:1324–1329 © 2011 by the Society for Academic Emergency Medicine

Evidence-based diagnostics: adult septic arthritis.

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:782–796 © 2011 by the Society for Academic Emergency Medicine Abstract Background: Acutely swollen or painful joints are common complaints in the emergency department (ED). Septic arthritis in adults is a challenging diagnosis, but prompt differentiation of a bacterial etiology is crucial to minimize morbidity and mortality. Objectives: The objective was to perform a systematic review describing the diagnostic characteristics of history, physical examination, and bedside laboratory tests for nongonococcal septic arthritis. A secondary objective was to quantify test and treatment thresholds using derived estimates of sensitivity and specificity, as well as best-evidence diagnostic and treatment risks and anticipated benefits from appropriate therapy. Methods: Two electronic search engines (PUBMED and EMBASE) were used in conjunction with a selected bibliography and scientific abstract hand search. Inclusion criteria included adult trials of patients presenting with monoarticular complaints if they reported sufficient detail to reconstruct partial or complete 2 × 2 contingency tables for experimental diagnostic test characteristics using an acceptable criterion standard. Evidence was rated by two investigators using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS). When more than one similarly designed trial existed for a diagnostic test, meta-analysis was conducted using a random effects model. Interval likelihood ratios (LRs) were computed when possible. To illustrate one method to quantify theoretical points in the probability of disease whereby clinicians might cease testing altogether and either withhold treatment (test threshold) or initiate definitive therapy in lieu of further diagnostics (treatment threshold), an interactive spreadsheet was designed and sample calculations were provided based on research estimates of diagnostic accuracy, diagnostic risk, and therapeutic risk/benefits. Results: The prevalence of nongonococcal septic arthritis in ED patients with a single acutely painful joint is approximately 27% (95% confidence interval [CI] = 17% to 38%). With the exception of joint surgery (positive likelihood ratio [+LR] = 6.9) or skin infection overlying a prosthetic joint (+LR = 15.0), history, physical examination, and serum tests do not significantly alter posttest probability. Serum inflammatory markers such as white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are not useful acutely. The interval LR for synovial white blood cell (sWBC) counts of 0 × 109–25 × 109/L was 0.33; for 25 × 109–50 × 109/L, 1.06; for 50 × 109–100 × 109/L, 3.59; and exceeding 100 × 109/L, infinity. Synovial lactate may be useful to rule in or rule out the diagnosis of septic arthritis with a +LR ranging from 2.4 to infinity, and negative likelihood ratio (–LR) ranging from 0 to 0.46. Rapid polymerase chain reaction (PCR) of synovial fluid may identify the causative organism within 3 hours. Based on 56% sensitivity and 90% specificity for sWBC counts of >50 × 109/L in conjunction with best-evidence estimates for diagnosis-related risk and treatment-related risk/benefit, the arthrocentesis test threshold is 5%, with a treatment threshold of 39%. Conclusions: Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. Extreme values of sWBC (>50 × 109/L) can increase, but not decrease, the probability of septic arthritis. Future ED-based diagnostic trials are needed to evaluate the role of clinical gestalt and the efficacy of nontraditional synovial markers such as lactate.

Frequent Users of Emergency Department Services: Gaps in Knowledge and a Proposed Research Agenda

Abstract: Frequent use of emergency department (ED) services is often perceived to be a potentially preventable misuse of resources. The underlying assumption is that similar and more appropriate care can be delivered outside of EDs at a lower cost. To reduce costs and incentivize more appropriate use of services, there have been efforts to design interventions to transition health care utilization of frequent users from EDs to other settings such as outpatient clinics. Many of these efforts have succeeded in smaller trials, but wider use remains elusive for varying reasons. There are also some fundamental problems with the assumption that all or even the majority of frequent ED use is misuse and invoking reasons for that excessive use. These tenuous assumptions become evident when frequent users as a group are compared to less frequent users. Specifically, frequent users tend to have high levels of frequent ED use, have a higher severity of illness, be older, have fewer personal resources, be chronically ill, present for pain-related complaints, and have government insurance (Medicare or Medicaid). Because of the unique characteristics of the population of frequent users, we propose a research agenda that aims to increase the understanding of frequent ED use, by: 1) creating an accepted categorization system for frequent users, 2) predicting which patients are at risk for becoming or remaining frequent users, 3) implementing both ED- and non-ED-based interventions, and 4) conducting qualitative studies of frequent ED users to explore reasons and identify factors that are subject to intervention and explore specific differences among populations by condition, such as mental illness and heart failure.

Measures of Crowding in the Emergency Department: A Systematic Review

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:527–538 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity. Methods: This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that “describe the theory, development, implementation, evaluation, or any other aspect of a ‘crowding measurement/definition’ instrument (qualitative or quantitative)” were included. A ”measurement/definition” instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other). Results: There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria. Conclusions: Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this “crowded” field of measures.

Radiological Imaging of Patients With Suspected Urinary Tract Stones: National Trends, Diagnoses, and Predictors

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:700–707 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Overutilization of computed tomography (CT) is a growing public health concern due to increasing health care costs and exposure to radiation; these must be weighed against the potential benefits of CT for improving diagnoses and treatment plans. The objective of this study was to determine the national trends of CT and ultrasound (US) utilization for assessment of suspected urolithiasis in emergency departments (EDs) and if these trends are accompanied by changes in diagnosis rates for urolithiasis or other significant disorders and hospitalization rates. Methods: This was a retrospective cross-sectional analysis of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1996 and 2007. The authors determined the proportion of patient visits for flank or kidney pain receiving CT or US testing and calculated the diagnosis and hospitalization rates for urolithiasis and other significant disorders. Patient-specific and hospital-level variables associated with the use of CT were examined. Results: Utilization of CT to assess patients with suspected urolithiasis increased from 4.0% to 42.5% over the study period (p 0.05), and admitted to the hospital (approximately 11%, p = 0.49) did not change significantly. The following characteristics were associated with a higher likelihood of receiving a CT scan: male sex (odd ratio [OR] = 1.83, 95% confidence interval [CI] = 1.22 to 2.77), patients presenting with severe pain (OR = 2.96, 95% CI = 1.14 to 7.65), and those triaged in 15 minutes or less (OR = 2.41, 95% CI = 1.08 to 5.37). CT utilization was lower for patients presenting to rural hospitals (vs. urban areas; OR = 0.34, 95% CI = 0.19 to 0.61) and those managed by a nonphysician health care provider (OR = 0.19, 95% CI = 0.07 to 0.53). Conclusions: From 1996 to 2007, there was a 10-fold increase in the utilization of CT scan for patients with suspected kidney stone without an associated change in the proportion of diagnosis of kidney stone, diagnosis of significant alternate diagnoses, or admission to the hospital.

Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:374–384 © 2011 by the Society for Academic Emergency Medicine Abstract Background: Cognitive dysfunction, including dementia and delirium, is prevalent in geriatric emergency department (ED) patients, but often remains undetected. One barrier to reliable identification of acutely or chronically impaired cognitive function is the lack of an acceptable screening tool. While multiple brief screening instruments have been derived, ED validation trials have not previously demonstrated tools that are appropriately sensitive for clinical use. Objectives: The primary objective was to evaluate and compare the Ottawa 3DY (O3DY), Brief Alzheimer’s Screen (BAS), Short Blessed Test (SBT), and caregiver-completed AD8 (cAD8) diagnostic test performance for cognitive dysfunction in geriatric ED patients using the Mini Mental Status Exam (MMSE) as the criterion standard. A secondary objective was to assess the diagnostic accuracy for the cAD8 (which is an informant-based instrument) when used in combination with the other performance-based screening tools. Methods: In an observational cross-sectional cohort study at one urban academic university-affiliated medical center, trained research assistants (RAs) collected patients’ responses on the Confusion Assessment Method for the Intensive Care Unit, BAS, and SBT. When available, reliable caregivers completed the cAD8. The MMSE was then obtained. The O3DY was reconstructed from elements of the MMSE and the BAS. Consenting subjects were non–critically ill, English-speaking adults over age 65 years, who had not received potentially sedating medications prior to or during cognitive testing. Using an MMSE score of ≤23 as the criterion standard for cognitive dysfunction, the sensitivity, specificity, likelihood ratios, and receiver operating characteristic (ROC) area under the curve (AUC) were computed. Venn diagrams were constructed to quantitatively compare the degree of overlap among positive test results between the performance-based instruments. Results: The prevalence of cognitive dysfunction for the 163 patients enrolled with complete data collection was 37%, including 5.5% with delirium. Dementia was self-reported in 3%. Caregivers were available to complete the cAD8 for 56% of patients. The SBT, BAS, and O3DY each demonstrated 95% sensitivity, compared with 83% sensitivity for the cAD8. The SBT had a superior specificity of 65%. No combination of instruments with the cAD8 significantly improved diagnostic accuracy. The SBT provided the optimal overlap with the MMSE. Conclusions: The SBT, BAS, and O3DY are three brief performance-based screening instruments to identify geriatric patients with cognitive dysfunction more rapidly than the MMSE. Among these three instruments, the SBT provides the best diagnostic test characteristics and overlap with MMSE results. The addition of the cAD8 to the other instruments does not enhance diagnostic accuracy.

Pilot Study to Determine the Utility of Point-of-care Ultrasound in the Assessment of Difficult Laryngoscopy

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:754–758 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Prediction of difficult laryngoscopy in emergency care settings is challenging. The preintubation clinical screening tests may not be applied in a large number of emergency intubations due to the patient’s clinical condition. The objectives of this study were 1) to determine the utility of sonographic measurements of thickness of the tongue, anterior neck soft tissue at the level of the hyoid bone, and thyrohyoid membrane in distinguishing difficult and easy laryngoscopies and 2) to examine the association between sonographic measurements (thickness of tongue and anterior neck soft tissue) and difficult airway clinical screening tests (modified Mallampati score, thyromental distance, and interincisor gap). Methods: This was a prospective observational study at an academic medical center. Adult patients undergoing endotracheal intubation for an elective surgical procedure were included. The investigators involved in data collection were blinded to each other’s assessments. Demographic variables were collected preoperatively. The clinical screening tests to predict a difficult airway were performed. The ultrasound (US) measurements of tongue and anterior neck soft tissue were obtained. The laryngoscopic view was graded using Cormack and Lehane classification by anesthesia providers on the day of surgery. To allow for comparisons between difficult airway and easy airway groups, a two-sided Student’s t-test and Fisher’s exact test were employed as appropriate. Spearman’s rank correlation coefficients were used to examine the association between screening tests and sonographic measurements. Results: The mean (±standard deviation [SD]) age of 51 eligible patients (32 female, 19 male) was 53.1 (±13.2) years. Six of the 51 patients (12%, 95% confidence interval [CI] = 3% to 20%) were classified as having difficult laryngoscopy by anesthesia providers. The distribution of laryngoscopy grades for all subjects was 63, 25, 4, and 8% for grades 1, 2, 3, and 4, respectively. In this study, 83% of subjects with difficult airways were males. No other significant differences were noted in the demographic variables and difficult airway clinical screening tests between the two groups. The sonographic measurements of anterior neck soft tissue were greater in the difficult laryngoscopy group compared to the easy laryngoscopy group at the level of the hyoid bone (1.69, 95% CI = 1.19 to 2.19 vs. 1.37, 95% CI = 1.27 to 1.46) and thyrohyoid membrane (3.47, 95% CI = 2.88 to 4.07 vs. 2.37, 95% CI = 2.29 to 2.44). No significant correlation was found between sonographic measurements and clinical screening tests. Conclusions: This pilot study demonstrated that sonographic measurements of anterior neck soft tissue thickness at the level of hyoid bone and thyrohyoid membrane can be used to distinguish difficult and easy laryngoscopies. Clinical screening tests did not correlate with US measurements, and US was able to detect difficult laryngoscopy, indicating the limitations of the conventional screening tests for predicting difficult laryngoscopy. ACADEMIC EMERGENCY MEDICINE 2011; 18:1–5 © 2011 by the Society for Academic Emergency Medicine

Review of modeling approaches for emergency department patient flow and crowding research.

Abstract: Emergency department (ED) crowding is an international phenomenon that continues to challenge operational efficiency. Many statistical modeling approaches have been offered to describe, and at times predict, ED patient load and crowding. A number of formula-based equations, regression models, time-series analyses, queuing theory-based models, and discrete-event (or process) simulation (DES) models have been proposed. In this review, we compare and contrast these modeling methodologies, describe the fundamental assumptions each makes, and outline the potential applications and limitations for each with regard to usability in ED operations and in ED operations and crowding research.

A Prospective Comparison of Procedural Sedation and Ultrasound-guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:922–927 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Emergency physicians (EPs) are beginning to use ultrasound (US) guidance to perform regional nerve blocks. The primary objective of this study was to compare length of stay (LOS) in patients randomized to US-guided interscalene block or procedural sedation to facilitate reduction of shoulder dislocation in the emergency department (ED). The secondary objectives were to compare one-on-one health care provider time, pain experienced by the patient during reduction, and patient satisfaction between the two groups. Methods: This was a prospective, randomized study of patients presenting to the ED with shoulder dislocation. The study was conducted at an academic Level I trauma center ED with an annual census of approximately 80,000. Patients were eligible for the study if they were at least 18 years of age and required reduction of a shoulder dislocation. A convenience sample of patients was randomized to either traditional procedural sedation or US-guided interscalene nerve block. Procedural sedation was performed with etomidate as the sole agent. Interscalene blocks were performed by hospital-credentialed EPs using sterile technique and a SonoSite MicroMaxx US machine with a high-frequency linear array transducer. Categorical variables were evaluated using Fisher’s exact test, and continuous variables were analyzed using the Wilcoxon rank sum test. Results: Forty-two patients were enrolled, with 21 patients randomized to each group. The groups were not significantly different with respect to sex or age. The mean (±SD) LOS in the ED was significantly higher in the procedural sedation group (177.3 ± 37.9 min) than in the US-guided interscalene block group (100.3 ± 28.2 minutes; p < 0.0001). The mean (±SD) one-on-one health care provider time was 47.1 (±9.8) minutes for the sedation group and 5 (±0.7) minutes for the US-guided interscalene block group (p < 0.0001). There was no statistically significant difference between the two groups in patient satisfaction or pain experienced during the procedure. There were no significant differences between groups with respect to complications such as hypoxia or hypotension (p = 0.49). Conclusions: In this study, patients undergoing shoulder dislocation reduction using US-guided interscalene block spent less time in the ED and required less one-on-one health care provider time compared to those receiving procedural sedation. There was no difference in pain level or satisfaction when compared to procedural sedation patients.

Predicting hospital admissions at emergency department triage using routine administrative data.

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:844–850 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: To be able to predict, at the time of triage, whether a need for hospital admission exists for emergency department (ED) patients may constitute useful information that could contribute to systemwide hospital changes designed to improve ED throughput. The objective of this study was to develop and validate a predictive model to assess whether a patient is likely to require inpatient admission at the time of ED triage, using routine hospital administrative data. Methods: Data collected at the time of triage by nurses from patients who visited the ED in 2007 and 2008 were extracted from hospital administrative databases. Variables included were demographics (age, sex, and ethnic group), ED visit or hospital admission in the preceding 3 months, arrival mode, patient acuity category (PAC) of the ED visit, and coexisting chronic diseases (diabetes, hypertension, and dyslipidemia). Chi-square tests were used to study the association between the selected possible risk factors and the need for hospital admission. Logistic regression was applied to develop the prediction model. Data were split for derivation (60%) and validation (40%). Receiver operating characteristic curves and goodness-of-fit tests were applied to the validation data set to evaluate the model. Results: Of 317,581 ED patient visits, 30.2% resulted in immediate hospital admission. In the developed predictive model, age, PAC status, and arrival mode were most predictive of the need for immediate hospital inpatient admission. The c-statistic of the receiver operating characteristic (ROC) curve was 0.849 (95% confidence interval [CI] = 0.847 to 0.851). The goodness-of-fit test showed that the predicted patients’ admission risks fit the patients’ actual admission status well. Conclusions: A model for predicting the risk of immediate hospital admission at triage for all-cause ED patients was developed and validated using routinely collected hospital data. Early prediction of the need for hospital admission at the time of triage may help identify patients deserving of early admission planning and resource allocation and thus potentially reduce ED overcrowding.

Seventy‐two‐hour Returns May Not be a Good Indicator of Safety in the Emergency Department: A National Study

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:390–397 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to measure the association between returns to an emergency department (ED) within 72 hours and resource utilization, severity of illness, mortality, and admission rate. Methods: This was a retrospective, cross-sectional analysis of ED visits using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1998 to 2006. Cohorts were patients who had been seen in the ED within the past 72 hours versus those without the prior visit. A multivariate model was created to predict adjusted-resource utilization and mortality or admission rate. Results: During the study period, there were 218,179 ED patient visits and a 3.2% 72-hour return rate. Patients with Medicare (3.5%) and without insurance (3.5%) were more likely to return within 72 hours. Visits associated with alcohol (4.1%), low triage acuity (4.0%), or dermatologic conditions (5.9%) were more likely to return. Seventy-two-hour return visits used fewer resources (5.0 [±0.1] vs. 5.5 [±0.1] tests, medications, procedures), were less likely to be Level I triage acuity (17% vs. 20%), and had a similar admission rate (13% vs. 13%) as those not seen within 72 hours. The sample size was too small to evaluate mortality. Conclusions: Patients who return to the ED within 72 hours do not use more resources, are not more severely ill, and do not have a higher hospital admission rate than those who had not been previously seen. These findings do not support the use of 72-hour returns as a quality or safety indicator. A more refined variation such as 72-hour returns resulting in admission may have more value.

Pan-Asian Resuscitation Outcomes Study (PAROS): rationale, methodology, and implementation.

Abstract: Disease-based registries can form the basis of comparative research to improve and inform policy for optimizing outcomes, for example, in out-of-hospital cardiac arrest (OHCA). Such registries are often lacking in resource-limited countries and settings. Anecdotally, survival rates for OHCA in Asia are low compared to those in North America or Europe, and a regional registry is needed. The Pan-Asian Resuscitation Outcomes Study (PAROS) network of hospitals was established in 2009 as an international, multicenter, prospective registry of OHCA across the Asia-Pacific region, to date representing a population base of 89 million in nine countries. The network's goal is to provide benchmarking against established registries and to generate best practice protocols for Asian emergency medical services (EMS) systems, to impact community awareness of prehospital emergency care, and ultimately to improve OHCA survival. Data are collected from emergency dispatch, ambulance providers, emergency departments, and in-hospital collaborators using standard protocols. To date (March 2011), there are a total of 9,302 patients in the database. The authors expect to achieve a sample size of 13,500 cases over the next 2 years of data collection. The PAROS network is an example of a low-cost, self-funded model of an Asia-Pacific collaborative research network with potential for international comparisons to inform OHCA policies and practices. The model can be applied across similar resource-limited settings.

Validation and refinement of the difficult intravenous access score: a clinical prediction rule for identifying children with difficult intravenous access.

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:1129–1134 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The difficult intravenous access (DIVA) score, a proportionally weighted four-variable (vein palpability, vein visibility, patient age, and history of prematurity) clinical rule, has been developed to predict failure of intravenous (IV) placement in children. This study sought to externally validate and refine the DIVA score. Methods: Patients undergoing peripheral IV placement by pediatric emergency department (ED) nurses were enrolled. The outcome of interest was defined as failure of cannulation on first attempt. Proposed refinement predictor variables include history of newborn intensive care unit (NICU) stay, operator experience characteristics (years since graduation, years of pediatric nursing experience, and IVs started per month), and skin shade. Adjusted multivariate models were constructed using logistic regression. Receiver operating characteristic (ROC) curves were constructed and areas under the curve (AUC) calculated for each model. Results: A total of 366 subjects were enrolled (mean age = 5.4 years, SD ± 5.6 years) and of them, 118 (32.2%) subjects failed the first IV attempt. The original four-variable model tested in this data set resulted in an AUC of 0.72 (95% confidence interval [CI] = 0.67 to 0.78). Patients with a DIVA score of 4 or greater had more than 50% likelihood of failed first IV attempt. A three-variable rule (vein palpability, vein visibility, and patient age) was evaluated and found to possess similar discriminating ability (AUC = 0.72, 95% CI = 0.67 to 0.78). Conclusions: This study validated the previously derived four-variable DIVA score. A simpler three-variable rule was as predictive of failed IV placement on first attempt as the four-variable rule. Validation in nonpediatric EDs is needed to thoroughly evaluate generalizability.

National study of emergency department observation services

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:959–965 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to describe patient and facility characteristics of emergency department (ED) observation services in the United States. Methods: The authors analyzed the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Characteristics of EDs with observation units (OUs) were compared to those without, and patients with a disposition of ED observation were compared to those with a “short-stay” (<48 hour) hospital admission. Results are descriptive and without formal statistical comparisons for this observational analysis. Results: An estimated 1,746 U.S. EDs (36%) reported having OUs, of which 56% are administratively managed by ED staff. Fifty-two percent of hospitals with ED-managed OUs are in an urban location, and 89% report ED boarding, compared to 29 and 65% of those that do not have an OU. The admission rate is 38% at those with ED-managed OUs and 15% at those without OUs. Of the 15.1% of all ED patients who are kept in the hospital following an ED visit, one-quarter are kept for either a short-stay admission (1.8%) or an ED observation admission (2.1%). Most (82%) ED observation patients were discharged from the ED. ED observation patients were similar to short-stay admission patients in terms of age (median = 52 years for both, interquartile range = 36 to 70 years), self-pay (12% vs. 10%), ambulance arrival (37% vs. 36%), urgent/emergent triage acuity (77% vs. 74%), use of ≥1 ED medication (64% vs.76%), and the most common primary chief complaints and primary diagnoses. Conclusions: Over one-third of U.S. EDs have an OU. Short-stay admission patients have similar characteristics as ED observation patients and may represent an opportunity for the growth of OUs.

The interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients.

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:98–101 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Inferior vena cava ultrasound (IVC-US) is a noninvasive bedside tool to assess intravascular volume status. This study set out to investigate the interrater reliability of IVC-US by bedside clinician sonographers and determine whether alternative methods of IVC-US such as B-mode and visual estimation are equally reliable to traditional M-mode. Methods: A convenience sample of adult emergency department (ED) patients was prospectively enrolled. Each patient underwent IVC-US by two different emergency physicians (EPs), each of whom first performed visual estimation of IVC percent collapse and of volume status, followed by caliper measurements in M-mode and B-mode. EPs were blinded to patient data and to the other sonographer’s results. For each technique, interrater reliability was determined between the two EPs’ assessments using intraclass correlation coefficients (ICC) for continuous data and Cohen’s weighted kappa for categorical data. In addition, analysis was performed on M-mode diameter measurements to determine the relationship between sonographer and patient characteristics on interrater reliability. Results: Five EPs performed 92 US exams on 46 patients. Using M-mode, the ICC for maximum IVC diameter was 0.81 (95% confidence interval [CI] = 0.67 to 0.89), and for minimum diameter was 0.77 (95% CI = 0.62 to 0.87). There were no statistically significant differences between the caliper methods used for IVC measurements (M-mode diameter, B-mode diameter, or B-mode area). Agreement for visually estimated IVC collapse (0.60, 95% CI = 0.36 to 0.76) was similar to agreement for calculated M-mode IVC collapse index (0.52, 95% CI = 0.27 to 0.71). Cohen’s weighted kappa for volume status based on visual estimation of IVC filling (size, shape, and collapse) was 0.64 (95% CI = 0.53 to 0.73). ICC values for M-mode diameter measurements were significantly higher in studies involving patients who were noneuvolemic and studies in which sonographers had each performed at least five prior IVC-US. Conclusions: Emergency physicians’ US measurements of IVC diameter have a high degree of interrater reliability. IVC percent collapse by visual estimation or based on caliper measurements have lower, but still moderate to good reliability. The use of the visual estimation technique should be considered by clinicians who have learned to obtain measured parameters of IVC filling because it is equally reliable to traditional M-mode and can be performed more rapidly.

Delirium in Older Emergency Department Patients Is an Independent Predictor of Hospital Length of Stay

Abstract: Delirium is an underrecognized public health problem affecting 8% to 10% of older emergency department (ED) patients1–3 This form of organ dysfunction incurs a significant economic burden, costing the United States health care system up to an estimated $152 billion per year in direct and indirect charges4 A large proportion of these costs are likely driven by prolonged hospitalizations observed in delirious patients5–8 However, most studies of delirium patients have been conducted in the inpatient setting, and their findings may have limited validity to the ED Enrollment in these previous studies typically occurred within 24 to 48 hours after admission, and patients who were delirious in the hospital setting may not have been delirious in the ED Conversely, because delirium can resolve within 24 hours in up to 51% of patients,9 patients classified as nondelirious in the hospital may have been delirious in the ED Currently, there are limited data on the consequences of delirium in the ED, especially in regard to its association with hospital length of stay (LOS) As result, we sought to determine if delirium in the ED is associated with prolonged hospital LOS in older patients

Comparison of an Informally Structured Triage System, the Emergency Severity Index, and the Manchester Triage System to Distinguish Patient Priority in the Emergency Department

Abstract: Objectives: The objective was to compare the validity of an existing informally structured triage system with the Emergency Severity Index (ESI) and the Manchester Triage System (MTS). Methods: A total of 900 patients were prospectively triaged by six trained triage nurses using the three systems. Triage ratings of 421 (48%) patients treated only by emergency department (ED) physicians were compared with a reference standard determined by an expert panel. The percentage of undertriage, the sensitivity, and the specificity for each urgency level were calculated. The relationship between urgency level, resource use, hospitalization, and length of stay (LOS) in the 900 triaged patients was determined. Results: The percentage of undertriage using the ESI (86 of 421; 20%) was significantly higher than in the MTS (48 of 421; 11%). When combining urgency levels 4 and 5, the percentage of undertriage was 8% for the informally structured system (ISS), 14% for the ESI, and 11% for the MTS. In all three systems, sensitivity for all urgency levels was low, but specificity for levels 1 and 2 was high (>92%). Sensitivity and specificity were significantly different between ESI and MTS only in urgency level 4. In all 900 patients triaged, urgency levels across all systems were associated with significantly increased resource use, hospitalization rate, and LOS. Conclusions: All three triage systems appear to be equally valid. Although the ESI showed the highest percentage of undertriage and the ISS the lowest, it seems preferable to use a verifiable, formally structured triage system. ACADEMIC EMERGENCY MEDICINE 2011; 18:822‐829 a 2011 by the Society for Academic Emergency Medicine

Feasibility of nonmydriatic ocular fundus photography in the emergency department: Phase I of the FOTO-ED study.

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:928–933 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Examination of the ocular fundus is imperative in many acute medical and neurologic conditions, but direct ophthalmoscopy by nonophthalmologists is underutilized, poorly performed, and difficult without pharmacologic pupillary dilation The objective was to examine the feasibility of nonmydriatic fundus photography as a clinical alternative to direct ophthalmoscopy by emergency physicians (EPs) Methods: Adult patients presenting to the emergency department (ED) with headache, acute focal neurologic deficit, diastolic blood pressure ≥ 120 mm Hg, or acute visual change had ocular fundus photographs taken by nurse practitioners using a nonmydriatic fundus camera Photographs were reviewed by a neuroophthalmologist within 24 hours for findings relevant to acute ED patient care Nurse practitioners and patients rated ease, comfort, and speed of nonmydriatic fundus photography on a 10-point Likert scale (10 best) Timing of visit and photography were recorded by automated electronic systems Results: A total of 350 patients were enrolled There were 1,734 photographs taken during 230 nurse practitioner shifts Eighty-three percent of the 350 patients had at least one eye with a high-quality photograph, while only 3% of patients had no photographs of diagnostic value Mean ratings were ≥ 87 (standard deviation [SD] ≤ 19) for all measures The median photography session lasted 19 minutes (interquartile range [IQR] = 13 to 29 minutes), typically accounting for less that 05% of the patient’s total ED visit Conclusions: Nonmydriatic fundus photography taken by nurse practitioners is a feasible alternative to direct ophthalmoscopy in the ED It is performed well by nonphysician staff, is well-received by staff and patients, and requires a trivial amount of time to perform

Comparison of Celox-A, ChitoFlex, WoundStat, and Combat Gauze Hemostatic Agents Versus Standard Gauze Dressing in Control of Hemorrhage in a Swine Model of Penetrating Trauma

Abstract: Objectives: Uncontrolled hemorrhage remains one of the leading causes of trauma deaths and one of the most challenging problems facing emergency medical professionals Several hemostatic agents have emerged as effective adjuncts in controlling extremity hemorrhage However, a review of the current literature indicates that none of these agents have proven superior under all conditions and in all wound types This study compared several hemostatic agents in a lethal penetrating groin wound model where the bleeding site could not be visualized Methods: A complex groin injury with a small penetrating wound, followed by transection of the femoral vessels and 45 seconds of uncontrolled hemorrhage, was created in 80 swine The animals were then randomized to five treatment groups (16 animals each) Group 1 was Celox-A (CA), group 2 was combat gauze (CG), group 3 was Chitoflex (CF), group 4 was WoundStat (WS), and group 5 was standard gauze (SG) dressing Each agent was applied with 5 minutes of manual pressure Hetastarch (500 mL) was infused over 30 minutes Hemodynamic parameters were recorded over 180 minutes Primary endpoints were attainment of initial hemostasis and incidence of rebleeding Results: Overall, no difference was found among the agents with respect to initial hemostasis, rebleeding, and survival Localizing effects among the granular agents, with and without delivery mechanisms, revealed that WS performed more poorly in initial hemostasis and survival when compared to CA

The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:111–120 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to examine the effectiveness of triage liaison physicians (TLPs) on mitigating the effects of emergency department (ED) overcrowding. Methods: Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, HealthSTAR, Dissertation Abstracts, and ABI/INFORM Global), controlled trial registry websites, conference proceedings, study references, contact with experts in the field, and correspondence with authors were used to identify potentially relevant TLP studies. Intervention studies in which a TLP was used to influence ED overcrowding metrics (length of stay [LOS] in minutes, physician initial assessment [PIA], and left without being seen [LWBS]) were included in the review. Two reviewers independently conducted data extraction and assessed the citation relevance, inclusion, and study quality. For continuous outcomes, weighted mean differences (WMD) were calculated and reported with corresponding 95% confidence intervals (CIs). For dichotomous variables, individual and pooled statistics were calculated as relative risk (RR) with 95% CI. Results: From 14,446 potentially relevant studies, 28 were included in the systematic review. Thirteen were journal publications, 12 were abstracts, and three were Web-based articles. Most studies employed before–after designs; 23 of the 28 studies were considered of weak quality. Based on the statistical pooling of data from two randomized controlled trials (RCTs), TLP resulted in shorter ED LOS compared to nurse-led triage (WMD = −36.85 min; 95% CI = −51.11 to –22.58). One of these RCTs showed a significant reduction in the PIA associated to TLP presence (WMD = −30.00 min; 95% CI = −56.91 to –3.09); the other RCT showed no change in LWBS due to a CI that included unity (RR = 0.82; 95% CI = 0.67 to 1.00). Conclusions: While the evidence summarized here suggests that to have a TLP is an effective intervention to mitigate the effects of ED overcrowding, due to the weak research methods identified, more research is required before its widespread implementation.

Emergency department quality: an analysis of existing pediatric measures.

Abstract: Objectives: The Institute of Medicine (IOM) has recommended the development of national standards for the measurement of emergency care performance. The authors undertook this study with the goals of enumerating and categorizing existing performance measures relevant to pediatric emergency care. Methods: Potential performance measures were identified through a survey of 1) the peer-reviewed literature, 2) websites of organizations and societies pertaining to quality improvement, and 3) emergency department (ED) directors. Performance measures were enumerated and categorized, using consensus methods, on three dimensions: 1) the IOM quality domains; 2) Donabedian’s structure ⁄process ⁄outcome framework; and 3) general, cross-cutting, or disease-specific measures. Results: A total of 405 performance measures were found for potential use for pediatric emergency care. When categorized by IOM domain, nearly half of the measures were related to effectiveness, while only 6% of measures addressed patient-centeredness. In the Donabedian dimension, 67% of measures were categorized as process measures, with 29% outcome and 4% structure measures. Finally, 31% of measures were general measures relevant to every ED visit. Although 225 measures (55%) were diseasespecific, the majority (56%) of these measures related to only five common conditions. Conclusions: A wide range of performance measures relevant to pediatric emergency care are available. However, measures lack a systematic and comprehensive approach to evaluate the quality of care provided. ACADEMIC EMERGENCY MEDICINE 2011; 18:519‐526 a 2011 by the Society for Academic Emergency Medicine

Telesimulation: An Innovative and Effective Tool for Teaching Novel Intraosseous Insertion Techniques in Developing Countries

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:420–427 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Telesimulation is a novel concept coupling the principles of simulation with remote Internet access to teach procedural skills. This study’s objective was to determine if telesimulation could be used by pediatricians in Toronto, Ontario, Canada, to teach a relatively new intraosseous (IO) insertion technique to physicians in Africa. Methods: One simulator was located in Toronto and the other in Gaborone, Botswana. Instructors and trainees could see one another, see inside each other’s simulators, and communicate in real time. Learner’s opinions and skills were evaluated. Before and after the curriculum, physicians completed a self-assessment questionnaire, a multiple-choice test, and during session 3, a demonstration of competence using an IO infusion system was timed and scored locally and via the Internet. Results: Twenty-two physicians participated. The scores on the pretest ranged from 1 to 12 out of 15. The range of scores on the posttest was 10 to 15 out of 15. The mean (±SD) score on pre- and post–multiple choice testing increased by +5 (±2.75; 95% confidence interval [CI] for mean difference = 3.92 to 6.35). Based on McNemar’s chi-square test, physicians reported a significant improvement in their comfort and knowledge inserting IO needles (p < 0.01), familiarity with the EZ-IO infusion system (p < 0.01), and knowledge handling the IO equipment (p < 0.01). Postintervention, all physicians reported that telesimulation teaching was a worthwhile experience, and 95% felt more prepared to manage pediatric resuscitation. There was no evidence of a difference in scoring or timing of IO insertion tasks whether measured locally or remotely (mean ± SD score difference = −0.11 ± 1.22 [95% CI = −0.66 to 0.43]; mean ± sd time difference = 0.01 ± 0.15 seconds [95% CI = −0.06 to 0.08 seconds]). Conclusions: Telesimulation is a novel method for teaching procedural skills. The session improved physicians’ knowledge, self-reported confidence, and comfort level in inserting the IO needle. Accurate scoring is possible via the Internet. This modality offers potential for teaching other procedural skills over distances.

Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support?

Abstract: Objectives: Dizziness is a common presenting complaint to the emergency department (ED), and emergency physicians (EPs) consider these presentations a priority for decision support. Assessing for nystagmus and defining its features are important steps for any acute dizziness decision algorithm. The authors sought to describe nystagmus documentation in routine ED care to determine if nystagmus assessments might be an important target in decision support efforts. Methods: Medical records from ED visits for dizziness were captured as part of a surveillance study embedded within an ongoing population-based cohort study. Visits with documentation of a nystagmus assessment were reviewed and coded for presence or absence of nystagmus, ability to draw a meaningful inference from the description, and coherence with the final EP diagnosis when a peripheral vestibular diagnosis was made. Results: Of 1,091 visits for dizziness, 887 (81.3%) documented a nystagmus assessment. Nystagmus was present in 185 of 887 (20.9%) visits. When nystagmus was present, no further characteristics were recorded in 48 of the 185 visits (26%). The documentation of nystagmus (including all descriptors recorded) enabled a meaningful inference about the localization or cause in only 10 of the 185 (5.4%) visits. The nystagmus description conflicted with the EP diagnosis in 113 (80.7%) of the 140 visits that received a peripheral vestibular diagnosis. Conclusions: Nystagmus assessments are frequently documented in acute dizziness presentations, but details do not generally enable a meaningful inference. Recorded descriptions usually conflict with the diagnosis when a peripheral vestibular diagnosis is rendered. Nystagmus assessments might be an important target in developing decision support for dizziness presentations. ACADEMIC EMERGENCY MEDICINE 2011; 18:619‐626 a 2011 by the Society for Academic Emergency Medicine

Test Characteristics of Focused Assessment of Sonography for Trauma for Clinically Significant Abdominal Free Fluid in Pediatric Blunt Abdominal Trauma

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:477–482 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT. Methods: This was a prospective observational study of consecutive children (0–17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery. Results: The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%). Conclusion: In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.

Research priorities for palliative and end-of-life care in the emergency setting.

Abstract: Palliative care focuses on the physical, spiritual, psychological, and social care from diagnosis to cure or death of a potentially life-threatening illness. When cure is not attainable and end of life approaches, the intensity of palliative care is enhanced to deliver the highest quality care experience. The emergency department (ED) frequently cares for patients and families during the end-of-life phase of the palliative care continuum. The intersection between palliative care and emergency care continues to be more clearly defined. Currently, there is a mounting body of evidence to guide the most effective strategies for improving palliative and end-of-life care in the ED. In a workgroup session at the 2009 Agency for Healthcare Research and Quality (AHRQ)/American College of Emergency Physicians (ACEP) conference "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach," four key research questions arose: 1) which patients are in greatest need of palliative care services in the ED, 2) what is the optimal role of emergency clinicians in caring for patients along a chronic trajectory of illness, 3) how does the integration and initiation of palliative care training and services in the ED setting affect health care utilization, and 4) what are the educational priorities for emergency clinical providers in the domain of palliative care? Workgroup leaders suggest that these four key questions may be answered by strengthening the evidence using six categories of inquiry: descriptive, attitudinal, screening, outcomes, resource allocation, and education of clinicians.

The Role of Triage Nurse Ordering on Mitigating Overcrowding in Emergency Departments: A Systematic Review

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:1349–1357 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to examine the effectiveness of triage nurse ordering (TNO) on mitigating the effect of emergency department (ED) overcrowding. Methods: Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, HealthSTAR, Dissertation Abstracts, ABI/INFORM Global), controlled trial registry websites, conference proceedings, study references, experts in the field, and correspondence with authors were used to identify potentially relevant studies. Interventional studies in which TNO was used to influence ED overcrowding metrics (length of stay [LOS] and physician initial assessment [PIA]) were included in the review. Two reviewers independently assessed study eligibility and methodologic quality. Mean differences were calculated and reported with corresponding 95% confidence intervals (CIs). Results: From more than 14,000 potentially relevant studies, 14 were included in the systematic review. Most were single-center ED studies; the overall quality was rated as weak, due to methodologic deficiencies and variable outcome reporting. TNO was associated with a 37-minute mean reduction (95% CI = −44.10 to −30.30 minutes) in the overall ED LOS in one randomized clinical trial (RCT); a 51-minute mean reduction (95% CI = −56.3 to −45.5 minutes) was observed in non-RCTs. When applied to injured subjects with suspected fractures, TNO interventions reduced ED LOS by 20 minutes (95% CI = −37.5 to −1.9 minutes) in three RCTs and by 18 minutes (95% CI = −23.2 to −13.2) in two non-RCTs. No significant reduction in PIA was observed in two RCTs. Conclusions: Overall, TNO appears to be an effective intervention to reduce ED LOS, especially in injury and/or suspected fracture cases. The available evidence is limited by small numbers of studies, weak methodologic quality, and incomplete reporting. Future studies should focus on a better description of the contextual factors surrounding these interventions and exploring the impact of TNO on other indicators of productivity and satisfaction with health care delivery.

Comparison of Serial Qualitative and Quantitative Assessments of Caval Index and Left Ventricular Systolic Function During Early Fluid Resuscitation of Hypotensive Emergency Department Patients

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:912–921 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to determine whether serial bedside visual estimates of left ventricular systolic function (LVF) and respiratory variation of the inferior vena cava (IVC) diameter would agree with quantitative measurements of LVF and caval index in hypotensive emergency department (ED) patients during fluid challenges. The authors hypothesized that there would be moderate inter-rater agreement on the visual estimates. Methods: This prospective observational study was performed at an urban, regional ED. Patients were eligible for enrollment if they were hypotensive in the ED as defined by a systolic blood pressure (sBP) of <100 mm Hg or mean arterial pressure of ≤65 mm Hg, exhibited signs or symptoms of shock, and the treating physician intended to administer intravenous (IV) fluid boluses for resuscitation. Sonologists performed a sequence of echocardiographic assessments at the beginning, during, and toward the end of fluid challenge. Both caval index and LVF were determined by the sonologist in qualitative then quantitative manners. Deidentified digital video clips of two-dimensional IVC and LVF assessments were later presented, in random order, to an ultrasound (US) fellowship–trained emergency physician using a standardized rating system for review. Statistical analysis included both descriptive statistics and correlation analysis. Results: Twenty-four patients were enrolled and yielded 72 caval index and LVF videos that were scored at the bedside prior to any measurements and then reviewed later. Visual estimates of caval index compared to measured caval index yielded a correlation of 0.81 (p < 0.0001). Visual estimates of LVF compared to fractional shortening yielded a correlation of 0.84 (p < 0.0001). Inter-rater agreement of respiratory variation of IVC diameter and LVF scores had simple kappa values of 0.70 (95% confidence interval [CI] = 0.56 to 0.85) and 0.46 (95% CI = 0.29 to 0.63), respectively. Significant differences in mean values between time 0 and time 2 were found for caval index measurements, the visual scores of IVC diameter variation, and both maximum and minimum IVC diameters. Conclusions: This study showed that serial visual estimations of the respiratory variation of IVC diameter and LVF agreed with bedside measurements of caval index and LVF during early fluid challenges to symptomatic hypotensive ED patients. There was moderate inter-rater agreement in both visual estimates. In addition, acute volume loading was associated with detectable acute changes in IVC measurements.