Annals of Emergency Medicine RSS feed: Current Issue. Scope and Stature of the Journal Annals of Emergency Medicine , the official journal of the American College of Emergency Physicians, is an international, peer-reviewed journal dedicated to improving the quality of care by publishing the highest quality science for emergency medicine and related medical specialties. Annals publishes original research, clinical reports, opinion, and educational information related to the practice, teaching, and research of emergency medicine. In addition to general emergency medicine topics, Annals regularly publishes articles on out-of-hospital emergency medical services, pediatric emergency medicine, injury and disease prevention, health policy and ethics, disaster management, toxicology, and related topics. The journal welcomes submissions from international contributors and researchers of all specialties. Although Annals of Emergency Medicine is the official journal of the American College of Emergency Physicians (ACEP) the journal maintains editorial independence from ACEP. Its content is selected by the editorial board and does not necessarily reflect the policies and beliefs of ACEP. Annals continues to be the largest circulation peer review journal in emergency medicine (over 28,000 subscribers, several times its nearest competitor). It is also one of the most accessible to non-subscribing readers, since 6,400 institutions include Annals in their online licenses for ScienceDirect (the world's largest electronic collection of science, technology and medicine full text and bibliographic information). ScienceDirect was utilized for access to Annals articles approximately 658,000 times last year, a 19% increase from the prior year. Annals is also available on the Web (with full text of all articles dating back to its inception), where it received more than 392,000 visitors. Annals is the emergency medicine journal most frequently cited by authors and has the highest impact factor over the years of all 19 journals in the emergency medicine category of the SCI (Science Citation Index). The impact factor (the average number of citations per published article) is the commonest measure of journal influence; the 2010 impact factor for Annals was 4.14, placing it in the top 12% of all 8,005 science and medical journals tracked by the SCI. Not only is Annals most frequently cited, but it is cited more promptly and longer than any other emergency medicine journal (9.5 years, 83% longer than its nearest competitor). In the past 5 years, more than1,200 different journals in the ISI science journal database cited an article in Annals , and in a typical year, Annals articles are cited by more than 400 different scientific journals, most of them from a broad range of specialties outside of emergency medicine. Annals ' articles generate considerable interest in the lay media. From October 2009 through September 2010, there were 5,089 hits in various media outlets, including print, radio and blogs. Major outlets included Wall St. Journal , ABC News, Boston Globe, Business Week, Los Angeles Times, MSNBC, USA Today, New York Times, Modern Healthcare, Washington Post, the AM News, EM News, JEMS, and Reuters Health, as well as many trade publications. Annals is an international journal; 54% of the full text articles accessed via ScienceDirect were downloaded by readers in 93 countries outside the U.S. Our contributors are also international in scope; in 2010 submissions came to us from 46 different countries, with 41% of submissions originating outside the United States, and 25% originating outside North America and Western Europe. The largest volume other than the U.S. was submitted from Taiwan, Canada, Turkey, France, United Kingdom, China, Australia, Korea, Netherlands, Italy, and Japan, in descending order. But the list also includes Brazil, Thailand, Tunisia, India, Iran, Nigeria, and Serbia. We strongly believe we have an obligation to make our journal available to international audiences regardless of their financial resources, and therefore have participated for many years in the HINARI initiative sponsored by large journal publishers ( http://www.healthinternetwork.org/src/eligibility.php ), which makes Annals available free or at greatly reduced cost in low-income countries. http://www.annemergmed.com/?rss=yesElsevier Inc.en © 2011 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved. Annals of Emergency Medicine0196-0644595May 2012 © 2011 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.annemergmed.com/article/PIIS0196064411015411/abstract?rss=yes Study objective: To address concerns about prolonged emergency department (ED) stays from crowding, England mandated that the maximum length of ED stay for 98% of patients be no greater than 4 hours. We evaluate the effect of the mandated ED care intervals in England. Methods: This was a retrospective analysis of ED patient throughput before, during, and after implementation of the target. Fifteen acute hospital trusts' ED data were purposively sampled, including all patient visits during May and June of 2003 to 2006. We compared total time in ED and time to clinician across years, segregating for admitted versus discharged patients and young versus old patients, using a random-effects regression model and adjusting for hospital clustering. Results: We analyzed 735,588 ED visits. The proportion of patients seen and treated within 4 hours improved from 83.9% to 96.3%. Adjusted total length of ED stay from 2003 to 2006 increased by 8.6 minutes for all patients and 30 minutes for admissions; time to physician improved by 1 minute for all patients. The proportion of patients leaving the ED during the last 20 minutes before 4 hours increased from 4.7% of all patients in 2003 to 8.4% in 2006. Admitted patients were more likely than discharged ones to leave the ED in the last 20 minutes, and the relative likelihood increased each year after 2003, with incidence rate ratio 1.04 (95% confidence interval [CI] 0.78 to 1.39), 1.39 (95% CI 1.05 to 1.82), and 1.55 (95% CI 1.19 to 2.20) for 2004, 2005, and 2006, respectively. An increasing proportion of elderly patients were in the last 20-minute departure interval each year compared with younger patients (in 2003 7.4% versus 4.1%; in 2006 17.3% versus 6.3%). Conclusion: The introduction of a time target reduced the proportion of patients staying greater than 4 hours. More patients departed within 20 minutes of the target 4-hour interval after the mandate, notably, the elderly. Time Patients Spend in the Emergency Department: England's 4-Hour Rule—A Case of Hitting the Target but Missing the Point?Suzanne Mason, Ellen J. Weber, Joanne Coster, Jennifer Freeman, Thomas Locker10.1016/j.annemergmed.2011.08.017Annals of Emergency Medicine 59, 5 (2012)2011-11-16Annals of Emergency Medicine2011-11-16595S0196-0644(11)X0018-5Health Policy341349http://www.annemergmed.com/article/PIIS0196064411015587/abstract?rss=yes [Ann Emerg Med. 2012;59:350.] A 22-year-old previously healthy man was transferred to the authors' hospital 7 hours after sustaining injuries from a high-pressure power washer. The device malfunctioned while in use, and as the patient struck the nozzle on the ground, the spray caused the nozzle to turn toward his open mouth for approximately 3 seconds. He complained of severe neck pain and odynophagia. At a different hospital, he was evaluated and diagnostic imaging was obtained. On arrival at our institution, the vital signs were normal, and physical examination result was notable for a wound in the posterior oropharynx without active bleeding and exquisite tenderness to light palpation of the soft tissues of the neck, without crepitus or deformity ().Man With Oropharyngeal TraumaJeffrey N. Siegelman, Ilana Warsofsky, Brittani N. Loukas, Christian Arbelaez10.1016/j.annemergmed.2011.09.010Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Images in Emergency Medicine350350http://www.annemergmed.com/article/PIIS0196064411015447/abstract?rss=yes Optimizing resource use, eliminating waste, aligning provider incentives, reducing overall costs, and coordinating the delivery of quality care while improving outcomes have been major themes of health care reform initiatives. Recent legislation contains several provisions designed to move away from the current fee-for-service payment mechanism toward a model that reimburses providers for caring for a population of patients over time while shifting more financial risk to providers. In this article, we review current approaches to episode of care development and reimbursement. We describe the challenges of incorporating emergency medicine into the episode of care approach and the uncertain influence this delivery model will have on emergency medicine care, including quality outcomes. We discuss the limitations of the episode of care payment model for emergency services and advocate retention of the current fee-for-service payment model, as well as identify research gaps that, if addressed, could be used to inform future policy decisions of emergency medicine health policy leaders. We then describe a meaningful role for emergency medicine in an episode of care setting. Episodes of Care: Is Emergency Medicine Ready?Jennifer L. Wiler, Dennis Beck, Brent R. Asplin, Michael Granovsky, John Moorhead, Randy Pilgrim, Jeremiah D. Schuur10.1016/j.annemergmed.2011.08.020Annals of Emergency Medicine 59, 5 (2012)2011-09-29Annals of Emergency Medicine2011-09-29595S0196-0644(11)X0018-5Health Policy351357http://www.annemergmed.com/article/PIIS0196064411016623/abstract?rss=yes Study objective: Emergency department (ED) closures threaten community access to emergency services, but few data exist to describe factors associated with closure. We evaluate factors associated with ED closure in California and seek to determine whether hospitals serving more vulnerable populations have a higher rate of ED closure. Methods: This was a retrospective cohort study of California hospital EDs between 1998 and 2008, using hospital- and patient-level data from the California Office of Statewide Health Planning and Development (OSHPD), as well as OSHPD patient discharge data. We examined the effects of hospital and patient factors on the hospital's likelihood of ED closure by using Cox proportional hazards models. Results: In 4,411 hospital-years of observation, 29 of 401 (7.2%) EDs closed. In a model adjusted for total ED visits, hospital discharges, trauma center and teaching status, ownership, operating margin, and urbanicity, hospitals with more black patients (hazard ratio [HR] 1.41 per increase in proportion of blacks by 0.1; 95% confidence interval [CI] 1.16 to 1.72) and Medi-Cal recipients (HR 1.17 per increase in proportion insured by Medi-Cal by 0.1; 95% CI 1.02 to 1.34) had higher risk of ED closure, as did for-profit institutions (HR 1.65; 95% CI 1.13 to 2.41). Conclusion: The population served by EDs and hospitals' profit model are associated with ED closure. Whether our findings are a manifestation of poorer reimbursement in at-risk EDs is unclear. System-Level Health Disparities in California Emergency Departments: Minorities and Medicaid Patients Are at Higher Risk of Losing Their Emergency DepartmentsRenee Y. Hsia, Tanja Srebotnjak, Hemal K. Kanzaria, Charles McCulloch, Andrew D. Auerbach10.1016/j.annemergmed.2011.09.018Annals of Emergency Medicine 59, 5 (2012)2011-11-17Annals of Emergency Medicine2011-11-17595S0196-0644(11)X0018-5Health Policy358365http://www.annemergmed.com/article/PIIS019606441101763X/abstract?rss=yesSEE RELATED ARTICLE, P. 358. [Ann Emerg Med. 2012;59:366-368.]Singularities, Odds Ratios, and Significance: California Emergency Department Closures and Los AngelesWilliam Wesley Fields10.1016/j.annemergmed.2011.10.024Annals of Emergency Medicine 59, 5 (2012)2011-12-12Annals of Emergency Medicine2011-12-12595S0196-0644(11)X0018-5Health Policy366368http://www.annemergmed.com/article/PIIS0196064411017987/abstract?rss=yes Study objective: The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED). Methods: This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables. Results: A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%). Conclusion: Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities. A Prospective, Multicenter Study of Pharmacist Activities Resulting in Medication Error Interception in the Emergency DepartmentAsad E. Patanwala, Arthur B. Sanders, Michael C. Thomas, Nicole M. Acquisto, Kyle A. Weant, Stephanie N. Baker, Erica M. Merritt, Brian L. Erstad10.1016/j.annemergmed.2011.11.013Annals of Emergency Medicine 59, 5 (2012)2012-01-09Annals of Emergency Medicine2012-01-09595S0196-0644(11)X0018-5Patient Safety369373http://www.annemergmed.com/article/PIIS0196064411019792/abstract?rss=yesSEE RELATED ARTICLE, P. 369. [Ann Emerg Med. 2012;59:374-375.]Work, Visible and InvisibleRobert L. Wears10.1016/j.annemergmed.2011.12.018Annals of Emergency Medicine 59, 5 (2012)2012-01-16Annals of Emergency Medicine2012-01-16595S0196-0644(11)X0018-5Patient Safety374375http://www.annemergmed.com/article/PIIS0196064411018075/abstract?rss=yes Study objective: Nontechnical skills are “the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance.” Our research team developed and evaluated the task of developing and validating a behavioral marker system for the observational assessment of emergency physicians' nontechnical skills. Methods: The development of the tool was divided into 3 phases and used triangulation of data from a number of sources. During phase 1, a provisional assessment tool was developed according to published literature and curricula. Phase 2 used analysis of staff interviews and field observations to determine whether the skill list contained any significant omissions. These studies were also used to identify behavioral markers linked to nontechnical skills in the context of the emergency department (ED) and establish whether skills included in the tool were observable. Phase 3 involved evaluating the content validity index of exemplar behaviors, using a survey of experts. Results: A behavioral marker system was developed that comprised 12 emergency medicine–specific nontechnical skills, grouped into 4 categories. Content validity was assessed with a survey of 148 emergency medicine staff, and 75% of items achieved the recommended content validity index greater than 0.75. Data from the survey enabled further refinement of the behavioral markers to produce a final version of the tool. Conclusion: Although further evaluative studies are needed, this behavioral marker system provides a structured approach to the assessment and training of nontechnical skills in the ED. Development and Validation of a Tool to Assess Emergency Physicians' Nontechnical SkillsLynsey Flowerdew, Ruth Brown, Charles Vincent, Maria Woloshynowych10.1016/j.annemergmed.2011.11.022Annals of Emergency Medicine 59, 5 (2012)2012-03-19Annals of Emergency Medicine2012-03-19595S0196-0644(11)X0018-5Patient Safety376385.e4http://www.annemergmed.com/article/PIIS0196064411018063/abstract?rss=yes Study objective: Understanding the nontechnical skills specifically applicable to the emergency department (ED) is essential to facilitate training and more broadly consider interventions to reduce error. The aim of this scoping review is to first identify and then explore in depth the nontechnical skills linked to safety in the ED. Methods: The review was conducted in 2 stages. In stage 1, online databases were searched for published empirical studies linking nontechnical skills to safety and performance in the ED. Articles were analyzed to identify key ED nontechnical skills. In stage 2, these key skills were used to generate additional key words, which enabled a second search of the literature to be undertaken and expand on the evidence available for review. Results: In stage 1, 11 articles were retrieved for data analysis and 9 core emergency medicine nontechnical skills were identified. These were communicating, managing workload, anticipating, situational awareness, supervising and providing feedback, leadership, maintaining standards, using assertiveness, and decisionmaking. In stage 2, a secondary search, using these 9 skills and related terms, uncovered a further 21 relevant articles. Therefore, 32 articles were used to describe the main nontechnical skills linked to safety in the ED. Conclusion: This article highlights the challenges of reviewing a topic for which the terms are not clearly defined in the literature. A novel methodological approach is described that provides a structured and transparent process for reviewing the literature in emerging areas of interest. A series of literature reviews focusing on individual nontechnical skills will provide a clearer understanding of how the skills identified contribute to safety in the ED. Identifying Nontechnical Skills Associated With Safety in the Emergency Department: A Scoping Review of the LiteratureLynsey Flowerdew, Ruth Brown, Charles Vincent, Maria Woloshynowych10.1016/j.annemergmed.2011.11.021Annals of Emergency Medicine 59, 5 (2012)2012-03-19Annals of Emergency Medicine2012-03-19595S0196-0644(11)X0018-5Patient Safety386394http://www.annemergmed.com/article/PIIS0196064411006561/abstract?rss=yes Study objective: Using a national sample of emergency department (ED) visits, we aim to describe use of CBC, computed tomography (CT), and pain medication among ED visits in which appendicitis was diagnosed. We describe use trends over time and identify use differences between adults and children. Methods: The ED component of the National Hospital Ambulatory Medical Care Survey was analyzed for 1992 through 2006, comprising a sample of 447,011 visits (representing an estimated total of approximately 1.5 billion visits), from which a sample of 1,088 patients (representing an estimated 3.7 million patients) received a diagnosis of appendicitis. The frequency of CBC and CT use and frequency of pain medication administration were determined. Survey-adjusted regression analyses were used to determine the probability of a patient receiving CBC, CT, or pain medication. Use was compared between adults and children. Results: During the course of the study, from 1996 to 2006, the percentage of patients with appendicitis who received a CT scan increased from 6.3% (95% confidence interval [CI] 0% to 15.3%) to 69% (95% CI 55.5% to 81.7%) for adults and from 0% to 59.8% (95% CI 31.6% to 87.9%) for children. CBC use for adults increased from 77.2% (95% CI 62.9% to 91.5%) to 92.8% (95% CI 85.8% to 99.7%) and decreased from 89.1% (95% CI 74.9% to 100.0%) to 68.4% (95% CI 41.9% to 94.9%) for children. The use of pain medications increased from 24.8% (95% CI 11.3% to 38.4%) to 69.9% (95% CI 56.7% to 83.1%) for adults and from 27.2% (95% CI 5.7% to 48.8%) to 42.8% (95% CI 18.1% to 67.5%) for children. The proportion of children who received parenteral narcotics (13.7% [95% CI 9.3% to 18.0%]) was less than that of adults (23% [95% CI 18.9% to 27.1%]). Conclusion: CT use has increased for patients with appendicitis over time, and CBC use remains high. There has been an increase in analgesic administration, but more than half of all patients with appendicitis had not received pain medication over the course of the entire study period. Children received fewer parenteral narcotics than adults and appeared to be preferentially treated with nonparenteral nonnarcotic analgesics. Increasing Computed Tomography Use for Patients With Appendicitis and Discrepancies in Pain Management Between Adults and Children: An Analysis of the NHAMCSDaniel S. Tsze, Lisa M. Asnis, Roland C. Merchant, Siraj Amanullah, James G. Linakis10.1016/j.annemergmed.2011.06.010Annals of Emergency Medicine 59, 5 (2012)2011-08-01Annals of Emergency Medicine2011-08-01595S0196-0644(11)X0018-5Pediatrics395403http://www.annemergmed.com/article/PIIS0196064411004860/abstract?rss=yesThere is inadequate evidence to support the routine use of rapid viral testing to reduce antibiotic use in pediatric emergency departments. The authors searched the Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library, 2009, issue 1) which contains the Acute Respiratory Infection Group's Specialized Register, MEDLINE (1950 to April Week 3, 2009), EMBASE (1988 to Week 16, 2009), MEDLINE In-Process and other Non-Indexed Citations (April 27, 2009), HealthStar (1966 to 2009), BIOSIS Previews (1969 to 2009), CAB Abstracts (1973 to 2007), CBCA Reference (1970 to 2007), and Proquest Dissertations and Theses (1861 to 2009).Can Rapid Viral Testing in the Emergency Department Reduce Antibiotic Use in Children?Lee Wilbur, Rawle A. Seupaul10.1016/j.annemergmed.2011.04.037Annals of Emergency Medicine 59, 5 (2012)2011-06-20Annals of Emergency Medicine2011-06-20595S0196-0644(11)X0018-5Pediatrics404405http://www.annemergmed.com/article/PIIS0196064412001229/abstract?rss=yes [Ann Emerg Med. 2012;59:406-407.] The problem of boarding emergency department (ED) patients is multifactorial, with causes that span the entire health care delivery system. Boarding is a major patient safety issue. To optimize patient care, it is critical to reduce the boarding of pediatric patients awaiting inpatient bed placement, as well as the overall length of stay of patients treated and discharged. By reducing patient boarding, treatment of patients in nontreatment areas such as hallways can be limited, and the number of patients leaving before evaluation or completion of medical treatment can be reduced. Approaches used to achieve these goals include: Boarding of Pediatric Patients in the Emergency Department10.1016/j.annemergmed.2012.01.032Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Pediatrics406407http://www.annemergmed.com/article/PIIS0196064411007219/abstract?rss=yes Study objective: We sought to test the effectiveness of an intervention designed to replace multivitamin infusions with alternative vitamin therapies when treating emergency department (ED) patients who present with alcohol-related illnesses. Most patients presenting to the ED with alcohol-related illnesses are not vitamin deficient, and thus the routine use of multivitamin infusions may be unnecessary. Methods: We created an educational document that included background literature, the costs of administering multivitamin infusions, and recommended alternative vitamin therapies. We then educated each emergency physician and changed the default electronic physician order entry in EPIC to an alternative vitamin treatment. Results: There were no differences in monthly alcohol-related ED visits between the preintervention (June 2008 to May 2009; mean 204; SD 17) and postintervention (June 2009 to May 2010; mean 217; SD 20) periods. A mean of 32 (SD 3.6) multivitamin infusions was administered each month preintervention; the postintervention mean was 1.1 (SD 2.7) multivitamin infusions per month. The difference was 31 multivitamin infusions per month (95% confidence interval 28 to 34 infusions). The overall percentage of patients receiving vitamin therapy after the intervention was approximately half that of those receiving multivitamin infusions before, 6.8% (SD 2.4%) versus 16% (SD 2.0%), difference 8.7% (95% confidence interval 6.8% to 11%). Conclusion: Our educational and order entry intervention was effective in changing physician vitamin prescribing behavior in ED patients with an alcohol-related illness. Implementing Evidence-Based Changes in Emergency Department Treatment: Alternative Vitamin Therapy for Alcohol-Related IllnessesBrett Faine, Mark Nunge, Gerene Denning, Andrew Nugent10.1016/j.annemergmed.2011.06.021Annals of Emergency Medicine 59, 5 (2012)2011-08-01Annals of Emergency Medicine2011-08-01595S0196-0644(11)X0018-5General Medicine408412http://www.annemergmed.com/article/PIIS0196064410018366/abstract?rss=yes Opposing authors provide succinct, authoritative discussions of controversial issues in emergency medicine. Authors are provided the opportunity to review and comment on opposing presentations. Each topic is accompanied by an Editor's Note that summarizes important concepts. Participation as an authoritative discussant is by invitation only, but suggestions for topics and potential authors can be submitted to the section editors.Intravenous Multivitamins (“Banana Bags”) for Emergency Patients Who May Have Nutritional DeficitsKenneth Darren Katz10.1016/j.annemergmed.2010.12.004Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5General Medicine413414http://www.annemergmed.com/article/PIIS0196064411017719/abstract?rss=yesThe empiric administration of vitamins and supplements to all alcoholic patients in the emergency department (ED) should be abandoned. Potential harm from their administration, albeit rare, includes allergic reactions and vitamin toxicity from recurrent infusions. Other negative consequences include unnecessary intravenous access, potential for hematologic transmission of disease, cost of products, and staff satisfaction with administration of a “banana bag.”Multivitamin “Banana Bags” Provide Little Value in Emergency Department PatientsFrank LoVecchio10.1016/j.annemergmed.2011.11.007Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5General Medicine414415http://www.annemergmed.com/article/PIIS0196064412002831/abstract?rss=yes The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency training programs and the residents in those programs. We present the 2012 annual report on the status of US emergency medicine training programs. Report on Residency Training Information (2011-2012), American Board of Emergency MedicineRebecca Smith-Coggins, Michael L. Carius, Robert E. Collier, Francis L. Counselman, Terry Kowalenko, Catherine A. Marco, Robert L. Muelleman, Robert C. Korte, Research Committee10.1016/j.annemergmed.2012.03.014Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Education416424http://www.annemergmed.com/article/PIIS0196064411005178/abstract?rss=yes[Ann Emerg Med. 2012;59:425-431.] The breadth of emergency medicine and the rapid growth in relevant research makes an ability to assess new research findings particularly important for emergency physicians. Improvements in the treatment of acute myocardial infarction, evolution of thrombolytic use in acute stroke, and the demise of military antishock trousers for traumatic shock provide examples of the dynamic relationship between emergency medicine research and clinical practice. The purpose of this article is to provide an overview of common research limitations and flaws relevant to emergency medicine. We explain and provide published examples of problems related to external validity, experimenter bias, publication bias, straw man comparisons, incorporation bias, randomization, composite outcomes, clinical importance versus statistical significance, and disease-oriented versus patient-oriented outcomes.Understanding Commonly Encountered Limitations in Clinical Research: An Emergency Medicine Resident's PerspectiveChristopher W. Jones, Timothy F. Platts-Mills10.1016/j.annemergmed.2011.05.024Annals of Emergency Medicine 59, 5 (2012)2011-08-05Annals of Emergency Medicine2011-08-05595S0196-0644(11)X0018-5Education425431.e11http://www.annemergmed.com/article/PIIS0196064411017999/abstract?rss=yesAlbumin use during resuscitation of patients with sepsis may decrease mortality compared with other fluid solutions. Until additional studies are published, clinicians should consider albumin use an option during the initial resuscitation of patients with sepsis.Does Resuscitation With Albumin-Containing Solutions Improve Mortality in Sepsis?Brian J. Tollefson, Alan E. Jones10.1016/j.annemergmed.2011.11.014Annals of Emergency Medicine 59, 5 (2012)2011-12-09Annals of Emergency Medicine2011-12-09595S0196-0644(11)X0018-5Infectious Disease432433http://www.annemergmed.com/article/PIIS0196064412001552/abstract?rss=yes[Centers for Disease Control and Prevention. Carbapenem-resistant Klebsiella pneumoniae associated with a long-term-care facility—West Virginia, 2009–2011. MMWR Morb Mortal Wkly Rep. 2011;60:1418-1420.]Carbapenem-Resistant Klebsiella pneumoniae Associated With a Long-Term-Care Facility—West Virginia, 2009-2011Centers for Disease Control and Prevention10.1016/j.annemergmed.2012.02.010Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Infectious Disease434436http://www.annemergmed.com/article/PIIS0196064412001564/abstract?rss=yes[Ann Emerg Med. 2012;59;436-437.] As quickly as the armamentarium of available antibiotics has expanded, bacteria have evolved mechanisms of resistance. Multidrug-resistant ogranisms (MDROs) are challenging and costly to treat. The spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) as described in this article and other enterobacteriaceae (CRE) have been described worldwide. Emergence of CRE represents a global public health threat with implications for empiric antimicrobial therapy and infection control practices in emergency departments (EDs).CommentarySophie Terp, Matthew Waxman10.1016/j.annemergmed.2012.02.011Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Infectious Disease436437http://www.annemergmed.com/article/PIIS0196064411016064/abstract?rss=yes[Ann Emerg Med. 2012;59:438-439.] It's this texting thing. I'll walk into the exam room and there's a kid, maybe 8 or 9 years old, sitting on theIt's This Texting ThingVladimir Svesko10.1016/j.annemergmed.2011.09.015Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Change of Shift438439http://www.annemergmed.com/article/PIIS019606441200251X/abstract?rss=yes Overuse of antibiotics for upper respiratory tract infections is common. The article by Garbutt et al contributes further evidence that antibiotics provide little benefit for most patients with uncomplicated acute rhinosinusitis. Some Think Antibiotics are Candy, But We Know They're NotSukhjit S. Takhar, David L. Schriger, Tyler W. Barrett10.1016/j.annemergmed.2012.03.005Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Annals of Emergency Medicine Journal Club440441http://www.annemergmed.com/article/PIIS019606441101537X/abstract?rss=yes [Ann Emerg Med. 2012;59:442.] A 7-month-old boy presented to the emergency department with an obvious head injury after a witnessed fall from standing onto a carpeted floor. He did not lose consciousness or vomit after the incident. A left-sided skull deformity was observed on examination ().Infant With Head InjuryJack Nicolet, Casey Z. MacVane10.1016/j.annemergmed.2011.08.014Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Images in Emergency Medicine442442http://www.annemergmed.com/article/PIIS019606441101554X/abstract?rss=yes[Ann Emerg Med. 2012;59:e9-e10.] A 34-year-old woman presented to the emergency department with a 3-week history of a soft tissue mass in the right lower abdominal quadrant. Physical examination revealed a painless swelling in the right iliac fossa. Her general condition was good, and she was not febrile. Laboratory tests indicated a WBC count of 11,200/mm3 and erythrocyte sedimentation rate of 40μmm/hour. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) were performed ().A Woman With Painless Swelling in the Right Lower Abdominal QuadrantAhmet Pergel, Ahmet Fikret Yucel, Ibrahim Aydin, Dursun Ali Sahin10.1016/j.annemergmed.2011.08.023Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Images in Emergency Medicinee9e10http://www.annemergmed.com/article/PIIS019606441200296X/abstract?rss=yesDrs. Schultz and Annas spark debate on a critical issue. As the originator of the term “crisis standard of care” in 2008 (before the Institute of Medicine established guidance, renaming it crisis standards of care), I would like to correct some misperceptions.Crisis Standard of Care Is Altered Care, Not an Altered StandardKristi L. Koenig10.1016/j.annemergmed.2012.03.026Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Correspondence443444http://www.annemergmed.com/article/PIIS0196064411018683/abstract?rss=yesWe thank Dr. Koenig for her comments. Rather than clarifying the issue, however, her comments may confuse the debate further. The difference between the standard of care and protocols designed to allocate scarce resources in disasters is crucial. The standard of care is metric to judge the behavior and decisions of physicians to determine whether they are acceptable and appropriate. Resource allocation protocols provide guidance to physicians on how to allocate care during times of scarcity, such as disasters. The 2 are distinct and have different purposes.In replyCarl H. Schultz, George J. Annas10.1016/j.annemergmed.2011.11.028Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Correspondence444445http://www.annemergmed.com/article/PIIS0196064411019846/abstract?rss=yesThe recent study by Kocher et al is one of several documenting a striking increase in the use of computed tomography (CT) in emergency department (ED) patients during the past decade. Their study analyzes CT utilization by the patient's presenting complaint and finds particularly eye-popping growth in CT utilization for certain common clinical presentations: abdominal pain, flank pain, chest pain, and shortness of breath. CT utilization rates increased 10 times or more from 1996 to 2007.The Truth About the Increase in Computed Tomography UtilizationDavid T. Schwartz10.1016/j.annemergmed.2011.11.043Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Correspondence445446http://www.annemergmed.com/article/PIIS0196064411019834/abstract?rss=yesI agree with both of Dr. Schwartz's main points. First, he rightly emphasizes that the growth in imaging use is largely due to its enormous success as a diagnostic aid and so implies that criticizing that growth is somewhat self-contradictory; it is widely used because it is so useful. (Just imagine the headlines if use had not grown so rapidly: “Doctors Ignore Lifesaving Technologies!”) Second, I agree with him that there is clearly a risk that the Centers for Medicare & Medicaid Services, especially given their track record in this regard, might do something stupid when it examines this growth; unfortunately, they are likely to take what actions they will, regardless of supporting or refuting publications.In replyRobert L. Wears10.1016/j.annemergmed.2011.12.022Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Correspondence446446http://www.annemergmed.com/article/PIIS0196064411019858/abstract?rss=yesWe appreciate the important historical perspective that Dr. Schwartz's observations bring to the discussion on changes in computed tomography (CT) use in the emergency department (ED) over time. There are several narratives that can be told about the near-universal diffusion of this powerful diagnostic technology into the standard practice of emergency medicine, many of which we tried to identify in our article.In replyKeith E. Kocher, Brahmajee K. Nallamothu10.1016/j.annemergmed.2011.12.023Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Correspondence446448http://www.annemergmed.com/article/PIIS0196064411017732/abstract?rss=yesIn March issue of Annals, Peleg and Kellermann initiate a complex and important debate about the international response to catastrophic earthquakes. The authors make the significant point that a dispassionate and objective evaluation of the benefits and cost-effectiveness for humanitarian aid such as urban search and rescue teams sent from outside the disaster zone is needed. No matter how quickly resources are mobilized, factors related to communications, politics, and logistics dictate a delay of some time. This delay could be hours but more likely days or longer; hence, the mantra of “prepare to be self-sufficient for the first 48 to 72 hours after a major disaster.”Medical Relief After Earthquakes: Don't Forget the Local Response!Kristi L. Koenig, Carl H. Schultz10.1016/j.annemergmed.2011.10.026Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Correspondence448448http://www.annemergmed.com/article/PIIS0196064412003617/abstract?rss=yes In the March 2012 issue, the letter by Koenig, “Crisis Standard of Care Is Altered Care, Not an Altered Standard,” Volume 59, Issue 3, pages 237-238, was erroneously published. We are publishing it again with the corresponding reply.Correction Notice10.1016/j.annemergmed.2012.04.001Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Correspondence448448http://www.annemergmed.com/article/PIIS0196064411018798/abstract?rss=yesWhen a new reference book is released, the question is always, do I need to add this book to my library? This is especially true with the advent of smart phones, iPads, and Internet-capable computers so readily available in every emergency department (ED) to make medical information on the Web so easily obtainable. In regard to this book, Current Diagnosis and Treatment Emergency Medicine, the answer is yes. This book has more than 1,000 pages of information yet maintains a size that is compact and easy to store. It is filled with helpful pictures and diagrams despite its compact size.Mitch Charles10.1016/j.annemergmed.2011.11.038Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5Book and Media Reviews449449http://www.annemergmed.com/article/PIIS0196064412002995/abstract?rss=yesTable of Contents10.1016/S0196-0644(12)00299-5Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5FrontmatterA3A3http://www.annemergmed.com/article/PIIS0196064412003010/abstract?rss=yesEditors10.1016/S0196-0644(12)00301-0Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5FrontmatterA13A15http://www.annemergmed.com/article/PIIS0196064412003034/abstract?rss=yesWhat's Coming in Annals ● June 201210.1016/S0196-0644(12)00303-4Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5FrontmatterA16A16http://www.annemergmed.com/article/PIIS0196064412002570/abstract?rss=yes Emergency physicians are under increasing pressure to reduce the number of computed tomography (CT) scans they perform because recent studies reveal just how much they have come to rely on advanced imaging studies: CT scan use in the emergency department (ED) has increased nearly 6-fold during the past 15 years.Emergency Department Computed Tomography Use Under Fire: Emergency Physicians Defend Imaging PracticesJan Greene10.1016/j.annemergmed.2012.03.008Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5News and PerspectiveA17A19http://www.annemergmed.com/article/PIIS0196064412002582/abstract?rss=yesProposals by the American Council on Graduate Medical Education (ACGME) to limit entry into its fellowships to physicians whose clinical training has been in ACGME programs and to require that some osteopathic internship years be repeated has roiled the osteopathic community, some of whom see it as a first step toward gaining increasing control over all of postgraduate medical education.ACGME Tightens Postgraduate Training Entry Requirements: Doctors of Osteopathic Medicine, International Medical Graduates Most AffectedLee Cearnal10.1016/j.annemergmed.2012.03.009Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5News and PerspectiveA19A22http://www.annemergmed.com/article/PIIS019606441200306X/abstract?rss=yesAnnals adheres to the International Committee of Medical Journal Editor's specific requirements regarding authorship (see www.icmje.org). On behalf of all authors, I verify that all listed authors meet the www.icmje.org authorship requirements. ❒ Yes ❒ No, explain in cover letterRequired Conflict of Interest Information from Authors10.1016/S0196-0644(12)00306-XAnnals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5FrontmatterA23A23http://www.annemergmed.com/article/PIIS0196064412003083/abstract?rss=yesAnnals of Emergency Medicine is the official publication of the American College of Emergency Physicians (www.acep.org). The journal is provided to all ACEP members as a membership benefit. For information about becoming an ACEP member, contact ACEP's member services department at the address below. For your convenience, a postage-paid card for obtaining membership information is included in every issue of the journal.Information for Readers10.1016/S0196-0644(12)00308-3Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5FrontmatterA24A24http://www.annemergmed.com/article/PIIS0196064412003885/abstract?rss=yes2012 ED Leadership Forum. May 2, 2012. New York, NY. Sponsor: NY Chapter ACEP. Fee: $240.00 – $315.00. Contact: JoAnne Tarantelli, 1130 Crosspointe Ln Ste 10B, Webster, NY, 14580. Email: nyacep@nyacep.org. 585-872-2417. (6.5)Calendar10.1016/S0196-0644(12)00388-5Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5FrontmatterA29A43http://www.annemergmed.com/article/PIIS0196064412003897/abstract?rss=yesAds and complete payments must be received in writing by the issue's deadline date. These deadlines apply to insertions, cancellations, and changes. Classified 2012 Advertising Rates & Information: New Value-Added Feature—Your Ad Online at no Additional Cost!10.1016/S0196-0644(12)00389-7Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5FrontmatterA44A44http://www.annemergmed.com/article/PIIS0196064412003903/abstract?rss=yes MAINE: MAINE COAST: MEDICAL DIRECTOR - State-of-the-art community hospital seeking BC, experienced ER physician w/leadership skills. Combination of administrative hours & clinical shifts. New ED w/20,000 visits per/yr. Excellent salary, benefits, vacation, CME, relocation, signing-bonus. Beautiful scenic Maine coast, surrounded by Acadia National Park. Exceptional year-round recreational, cultural, educational resources. Nearby international airport; University of Maine campus. Contact: Susan Edson, 207-866-5680; SEdson@nehs.net; www.HealthSearchNewEngland.com.Classified10.1016/S0196-0644(12)00390-3Annals of Emergency Medicine 59, 5 (2012)2012-05-01Annals of Emergency Medicine2012-05-01595S0196-0644(11)X0018-5FrontmatterA45A58