Annals of Emergency Medicine - Articles in Press

Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes - Corrected Proof

2010-02-08

Study objective: Previous studies suggest improved patient outcomes for providers who perform high volumes of complex medical procedures. Out-of-hospital tracheal intubation is a difficult procedure. We seek to determine the association between rescuer procedural experience and patient survival after out-of-hospital tracheal intubation.Methods: We analyzed probabilistically linked Pennsylvania statewide emergency medicine services, hospital discharge, and death data of patients receiving out-of-hospital tracheal intubation. We defined tracheal intubation experience as cumulative tracheal intubation during 2000 to 2005; low=1 to 10 tracheal intubations, medium=11 to 25 tracheal intubations, high=26 to 50 tracheal intubations, and very high=greater than 50 tracheal intubations. We identified survival on hospital discharge of patients intubated during 2003 to 2005. Using generalized estimating equations, we evaluated the association between patient survival and out-of-hospital rescuer cumulative tracheal intubation experience, adjusted for clinical covariates.Results: During 2003 to 2005, 4,846 rescuers performed tracheal intubation. These individuals performed tracheal intubation on 33,117 patients during 2003 to 2005 and 62,586 patients during 2000 to 2005. Among 21,753 cardiac arrests, adjusted odds of survival was higher for patients intubated by rescuers with very high tracheal intubation experience; adjusted odds ratio (OR) versus low tracheal intubation experience: very high 1.48 (95% confidence interval [CI] 1.15 to 1.89), high 1.13 (95% CI 0.98 to 1.31), and medium 1.02 (95% CI 0.91 to 1.15). Among 8,162 medical nonarrests, adjusted odds of survival were higher for patients intubated by rescuers with high and very high tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.55 (95% CI 1.08 to 2.22), high 1.29 (95% CI 1.04 to 1.59), and medium 1.16 (95% CI 0.97 to 1.38). Among 3,202 trauma nonarrests, survival was not associated with rescuer tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.84 (95% CI 0.89 to 3.81), high 1.25 (95% CI 0.85 to 1.85), and medium 0.92 (95% CI 0.67 to 1.26).Conclusion: Rescuer procedural experience is associated with improved patient survival after out-of-hospital tracheal intubation of cardiac arrest and medical nonarrest patients. Rescuer procedural experience is not associated with patient survival after out-of-hospital tracheal intubation of trauma nonarrest patients.

The Importance of “Shrinkage” in Subgroup Analyses - Corrected Proof

Ari M. Lipsky, Marianne Gausche-Hill, Muna Vienna, Roger J. Lewis — 2010-02-08

Study objective: Subgroup analyses examine associations (eg, between treatment and outcome) within subsets of a larger study sample. The traditional approach evaluates the data in each of the subgroups independently. More accurate answers, however, may be expected when the rest of the data are considered in the analysis of each subgroup, provided there are 3 or more subgroups.Methods: We present a conceptual introduction to subgroup analysis that makes use of all the available data and then illustrate the technique by applying it to a previously published study of pediatric airway management. Using WinBUGS, freely available computer software, we perform an empirical Bayesian analysis of the treatment effect in each of the subgroups. This approach corrects the original subgroup treatment estimates toward a weighted average treatment effect across all subjects.Results: The revised estimates of the subgroup treatment effects demonstrate markedly less variability than the original estimates. Further, using these estimates will reduce our total expected error in parameter estimation compared with using the original, independent subgroup estimates. Although any particular estimate may be adjusted inappropriately, adopting this strategy will, on average, lead to results that are more accurate.Conclusion: When multiple subgroups are considered, it is often inadvisable to ignore the rest of the study data. Authors or readers who wish to examine associations within subgroups are encouraged to use techniques that reduce the total expected error.

Cardiopulmonary Resuscitation Interruptions With Use of a Load-Distributing Band Device During Emergency Department Cardiac Arrest - Corrected Proof

2010-02-08

Study objective: Our primary aim is to measure no-flow time and no-flow ratio before and after an emergency department (ED) switched from manual to a load-distributing band mechanical cardiopulmonary resuscitation (CPR) device. Methods: This was a phased, before-after cohort evaluation at an urban tertiary hospital ED. We collected continuous video and chest compression data with the Physiocontrol CodeStat Suite 7.0 for resuscitations during the period just before and after adoption of load-distributing band CPR. All out-of-hospital, nontraumatic cardiac arrest, adult patients were eligible. From February 2007 to July 2008, there were 26 manual and 41 load-distributing band cases. Results: Patients in both phases were comparable in terms of demographics, medical history, witnessed arrest, arrest location, bystander CPR rates, out-of-hospital defibrillation, initial rhythm, and ED defibrillation. The median no-flow time, defined as the sum of all pauses between compressions longer than 1.5 seconds, during the first 5 minutes of resuscitation, was manual CPR 85 seconds (interquartile range [IQR] 45 to 112 seconds) versus load-distributing band 104 seconds (IQR 69 to 151 seconds). The mean no-flow ratio, defined as no-flow time divided by segment length, was manual 0.28 versus load-distributing band 0.40 (difference=−0.12; 95% confidence interval −0.22 to −0.02). However, from 5 to 10 minutes into the resuscitation, median no-flow time was manual 85 seconds (IQR 59 to 151 seconds) versus load-distributing band 52 seconds (IQR 34 to 82 seconds) and mean no-flow ratio manual 0.34 versus load-distributing band 0.21 (difference=0.13; 95% confidence interval 0.02 to 0.24). The average time to apply load-distributing band CPR during this period was 152 seconds. Conclusion: Application of a load-distributing band in the ED is associated with a higher no-flow ratio than manual CPR in the first 5 minutes of resuscitation. We suggest that attention to team training, rapid application of the device to minimize interruption, and feedback from defibrillator and video recordings may be useful to improve resuscitation team performance.

Placing Emergency Care on the Global Agenda - Corrected Proof

Renee Hsia, Junaid Razzak, Alexander C. Tsai, Jon Mark Hirshon — 2010-02-08

Emergency care serves a key function within health care systems by providing an entry point to health care and by decreasing morbidity and mortality. Although primarily focused on evaluation and treatment for acute conditions, emergency care also serves as an important locus of provision for preventive care with regard to injuries and disease progression. Despite its important and increasing role, however, emergency care has been frequently overlooked in the discussion of health systems and delivery platforms, particularly in developing countries. Little research has been done in lower- and middle-income countries on the burden of disease reduction attributable to emergency care, whether through injury treatment and prevention, urgent and emergency treatment of acute conditions, or emergency treatment of complications from chronic conditions. There is a critical need for research documenting the role of emergency care services in reducing the global burden of disease. In addition to applying existing methodologies toward this aim, new methodologies should be developed to determine the cost-effectiveness of these interventions and how to effectively cover the costs of and demands for emergency care needs. These analyses could be used to emphasize the public health and clinical importance of emergency care within health systems as policymakers determine health and budgeting priorities in resource-limited settings.

A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis - Corrected Proof

2010-02-08

Study objective: We assess the diagnostic accuracy of emergency physician–performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical pathology.Methods: We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphy's sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks.Results: Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval [CI] 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%).Conclusion: The test characteristics of emergency physician–performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.

Coronary Artery Calcium Scoring in the Emergency Department: Identifying Which Patients With Chest Pain Can Be Safely Discharged Home - Corrected Proof

2010-02-08

Study objective: Coronary artery calcium scoring (CACS) is a simple and readily available test for identifying coronary artery disease. Our objective is to evaluate whether a CACS of zero will identify chest pain patients who can be safely discharged home, without need for further cardiac testing.Methods: This was a prospective observational cohort study conducted at an urban tertiary care hospital of stable patients presenting to the emergency department (ED) with chest pain of uncertain cardiac cause. Patients with a normal initial troponin level, nonischemic ECG, and no history of coronary artery disease had stress myocardial perfusion imaging (SPECT) and CACS within 24 hours of ED admission. Cardiac events were defined as an acute coronary syndrome during the index hospitalization or in follow-up. CACS results were assessed in relation to SPECT findings and cardiac events.Results: The 1,031 patients enrolled (mean [SD] age 54 [13] years) had a median CACS of 0 (61% with CACS of 0). The frequency of an abnormal SPECT ranged from 0.8% (CACS of 0) to17% (CACS>400). Cardiac events occurred in 32 patients (3.1%) during the index hospitalization (N=28) or after hospital discharge (N=4) (mean 7.4 [3.3] months). Only 2 events occurred in 625 patients with a CACS of 0 (0.3%; 95% confidence interval 0.04% to 1.1%). Thus, 2 of 32 patients with a cardiac event had a CACS of 0 (6%; 95% confidence interval 0.8% to 21%). Both of these patients developed increased troponin levels during their index visit but had normal serial ECG and SPECT study results and no cardiac events at 6-month follow-up.Conclusion: A majority of patients (61% in our sample) evaluated for chest pain of uncertain cardiac cause have a CACS of 0, which predicts both a normal SPECT result and an excellent short-term outcome. Our results suggest that patients with a CACS of 0 can be discharged home, without further cardiac testing.

Believing Is Seeing - Corrected Proof

Robert L. Wears, Lewis S. Nelson — 2010-02-05

SEE RELATED ARTICLES, P.■■■. [Ann Emerg Med. 2010;■■:■■■.]

Catheterization Laboratory Activation: More About the Drawing Than the Balloons - Corrected Proof

Deborah B. Diercks, Judd E. Hollander — 2010-02-01

SEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2009;■■:■■■.]

Further Illumination of the Test Threshold Approach in the Care of Emergency Department Patients With Symptoms of Pulmonary Embolism - Corrected Proof

Jeffrey A. Kline — 2010-02-01

SEE RELATED ARTICLE, P. ■■■. [Ann Emerg Med. 2010;■■:■■■.]

The Development of Civilian Emergency Medical Care During an Insurgency: Current Status and Future Outlook in Iraq - Corrected Proof

Ross I. Donaldson, Tariq Hasson, Sharaf Aziz, Waleed Ansari, Gerald Evans — 2010-01-25

We review the development of civilian out-of-hospital and hospital-based emergency medical care in Iraq, focusing on the non-Kurdish regions. Emergency medicine in the country has made encouraging steps during the last several years, including the establishment of national emergency medicine policy, the training of out-of-hospital caregivers, the education of physicians currently working in Iraqi emergency departments, and the development of emergency medicine residency programs, among others. The utilization of a national Emergency Medicine Working Group has been a key resource in the development of emergency medicine in the country, a strategy we recommend to others aiding low- and middle-income nations.

Drive-Through Medicine: A Novel Proposal for Rapid Evaluation of Patients During an Influenza Pandemic - Corrected Proof

Eric A. Weiss, Jessica Ngo, Gregory H. Gilbert, James V. Quinn — 2010-01-18

Study objective: During a pandemic, emergency departments (EDs) may be overwhelmed by an increase in patient visits and will foster an environment in which cross-infection can occur. We developed and tested a novel drive-through model to rapidly evaluate patients while they remain in or adjacent to their vehicles. The patient's automobile would provide a social distancing strategy to mitigate the person-to-person spread of infectious diseases.Methods: We conducted a full-scale exercise to test the feasibility of a drive-through influenza clinic and measure throughput times of simulated patients and carbon monoxide levels of staff. We also assessed the disposition decisions of the physicians who participated in the exercise. Charts of 38 patients with influenza-like illness who were treated in the Stanford Hospital ED during the initial H1N1 outbreak in April 2009 were used to create 38 patient scenarios for the drive-through influenza clinic.Results: The total median length of stay was 26 minutes. During the exercise, physicians were able to identify those patients who were admitted and discharged during the real ED visit with 100% accuracy (95% confidence interval 91% to 100%). There were no significant increases of carboxyhemoglobin in participants tested.Conclusion: The drive-through model is a feasible alternative to a traditional walk-in ED or clinic and is associated with rapid throughput times. It provides a social distancing strategy, using the patient's vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases.

Health Information Exchange, Biosurveillance Efforts, and Emergency Department Crowding During the Spring 2009 H1N1 Outbreak in New York City - Corrected Proof

2010-01-18

Novel H1N1 influenza spread rapidly around the world in spring 2009. Few places were as widely affected as the New York metropolitan area. Emergency departments (EDs) in the region experienced daily visit increases in 2 distinct temporal peaks, with means of 36.8% and 60.7% over baseline in April and May, respectively, and became, in a sense, the “canary in the coal mine” for the rest of the country as we braced ourselves for resurgent spread in the fall. Biosurveillance efforts by public health agencies can lead to earlier detection, potentially forestalling spread of outbreaks and leading to better situational awareness by frontline medical staff and public health workers as they respond to a crisis, but biosurveillance has traditionally relied on manual reporting by hospital administrators when they are least able: in the midst of a public health crisis. This article explores the use of health information exchange networks, which enable the secure flow of clinical data among otherwise unaffiliated providers across entire regions for the purposes of clinical care, as a tool for automated biosurveillance reporting. Additionally, this article uses a health information exchange to assess H1N1's effect on ED visit rates and discusses preparedness recommendations and lessons learned from the spring 2009 H1N1 experience across 11 geographically distinct EDs in New York City that participate in the health information exchange.

Emergency Department Care in the United States: A Profile of National Data Sources - Corrected Proof

2010-01-15

Study objective: Emergency departments (EDs) are an integral part of the US health care system, and yet national data sources on the care received in the ED are poorly understood, thereby limiting their usefulness for analyses. We provide a comparison of data sources that can be used to examine utilization and quality of care in the ED nationally.Data sources and comparisons: This article compares 7 data sources available in 2005 for conducting analyses of ED encounters: the American Hospital Association Annual Survey DatabaseTM, Hospital Market Profiling Solution©, National Emergency Department Inventory, Nationwide Emergency Department Sample, National Hospital Ambulatory Medical Care Survey, National Electronic Injury Surveillance System–All-Injury Program, and the National Health Interview Survey. In addition to describing the type and scope of data collection, available characteristics, and sponsor of the ED data sources, we compare (where possible) estimates of the total number of EDs, national and regional volume of ED visits, national and regional admission rates (percentage of ED visits resulting in hospital admission), patient characteristics, hospital characteristics, and reasons for visit generated by the various data sources.Major findings: The different data sources yielded estimates of the number of EDs that ranged from 4,609 to 4,884 and the number of ED encounters from more than 109 million to more than 116 million. Admission rates across data sources varied from 12.0% to 15.3%. Although comparisons of the 7 data sources were somewhat limited by differences in available information and operational definitions, variation in estimates of utilization and patterns of care existed by region, expected payer, and patient and hospital characteristics. The rankings and estimates of the top 5 first-listed conditions seen in the ED are relatively consistent between the 2 data sources with diagnoses, although the Nationwide Emergency Department Sample estimates 1.3 to 5.8 times more ED visits for each chronic and acute all-listed condition examined relative to the National Hospital Ambulatory Medical Care Survey.Conclusion: Each of the data sources described in this article has unique advantages and disadvantages when used to examine patterns of ED care, making the different data sources appropriate for different applications. Analysts should select a data source according to its construction and should bear in mind its strengths and weaknesses in drawing conclusions based on the estimates it yields.

A Prospective Observational Study of Medication Errors in a Tertiary Care Emergency Department - Corrected Proof

Asad E. Patanwala, Terri L. Warholak, Arthur B. Sanders, Brian L. Erstad — 2010-01-15

Study objective: We determine the rate and severity of medication errors, as well as factors associated with error occurrence in the emergency department (ED).Methods: This was a prospective observational study conducted between May 1, 2008, and February 1, 2009. The pharmacist observer was present in the ED for 28 shifts (12 hours each). Information was collected on the medication use process by observing the activities of nurses caring for the patients. Errors were categorized by severity. Logistic regression was used to analyze factors associated with a risk of medication error.Results: The observer identified 178 medication errors in 192 patients during the data collection period. At least 1 error occurred in 59.4% of patients, and 37% of patients overall had an error that reached them. No errors in the study resulted in permanent harm to the patient or contributed to initial or prolonged hospitalization; however, interventions were performed to prevent patient harm that likely influenced the severity of error. Errors categorized according to stage were prescribing (53.9%), transcribing (10.7%), dispensing (0.6%), and administering (34.8%). Variables predictive of medication errors were boarded patient status (odds ratio [OR] 2.15; 95% confidence interval [CI] 1.03 to 4.5), number of medication orders (OR 1.25; 95% CI 1.12 to 1.39), number of medications administered (OR 1.22; 95% CI 1.07 to 1.38), and nursing employment status (less error if full time) (OR 0.37; 95% CI 0.16 to 0.86).Conclusion: Medication errors in the ED are common, and most errors occur in the prescribing and administering phases. Boarded patient status, increasing number of medications orders, increasing number of medications administered, and part-time nursing status are associated with an increased risk of medication error.

Prospective Double-Blinded Study of Abdominal-Pelvic Computed Tomography Guided by the Region of Tenderness: Estimation of Detection of Acute Pathology and Radiation Exposure Reduction - Corrected Proof

2010-01-14

Study objective: Computed tomography (CT) is increasingly used for emergency department (ED) patients with abdominal tenderness. CT-related radiation contributes to 2% of US cancers. We hypothesized that in the ED patient with nontraumatic abdominal tenderness, the tender region accurately delineates acute pathology. z axis–restricted CT guided by this region could detect pathology while reducing radiation dose.Methods: This was a prospective double-blinded observational trial with informed consent and was institutional review board–approved and registered with ClinicalTrials.gov. A convenience sample of ED patients undergoing abdominal CT was recruited, excluding pregnant women, patients with altered mental status or abdominal sensation, preverbal children, and patients with abdominal trauma or surgery in the previous month. Before standard CT, physicians demarcated the tender region with labels invisible to radiologists on abdominal windows. Radiologists blinded to the tender region recorded cephalad-caudad limits of pathology on CT. Personnel blinded to pathology location recorded label positions on lung windows. Two hypothetical CT strategies were then explored: CT restricted to the tender region and CT from the cephalad skin marker to the lower caudad limit of the usual CT. The percentage of the pathologic region contained within the extent of the 2 hypothetical z axis restricted CTs was calculated. z axis reduction, which is linearly related to radiation reduction, from the restricted CTs was determined.Results: One hundred two subjects were enrolled, 93 with complete data for analysis. Fifty-one subjects had acute pathology on CT. CT limited to the tender region would reduce z axis (radiation exposure) by 69% (95% confidence interval [CI] 60% to 78%). All acute pathology was included within these boundaries in 17 of the 51 abnormal cases (33%; 95% CI 22% to 47%). CT from the cephalad marker through the caudad abdomen and pelvis would reduce z axis (radiation exposure) by 38% (95% CI 29% to 48%). All acute pathology was included within these boundaries in 36 of 51 abnormal cases (71%; 95% CI 57% to 81%). With both strategies 1 and 2, the pathologic region was at least partially included within the CT region in the majority of cases (84% and 92%, respectively).Conclusion: CT with z axis restriction based on abdominal tenderness could reduce radiation exposure but with a potentially unacceptably high rate of misdiagnosis, using our current methods. Further prospective study may be warranted to determine the diagnostic utility of partially visualized pathology.

Testing Low-Risk Patients for Suspected Pulmonary Embolism: A Decision Analysis - Corrected Proof

2010-01-11

Study objective: The Pulmonary Embolism Rule-out Criteria (PERC) identifies low-risk patients who are treated in the emergency department for suspected pulmonary embolism and for whom testing may be deferred. The purpose of this study is to develop a decision model to determine whether certain elements not included in the PERC methodology could better estimate the testing threshold for pulmonary embolism (ie, the pretest probability below which a patient should not be tested for pulmonary embolism). In addition, we determine which risks and benefits of pulmonary embolism evaluation and treatment have the greatest effect on the testing threshold.Methods: We built decision models of low-risk patients with suspected pulmonary embolism, as determined by the PERC. We obtained model inputs from the literature or by using clinical judgment when data were unavailable. One-way sensitivity analysis derived the testing threshold, and 2-way sensitivity analysis was used to determine the main drivers of the testing threshold.Results: We found an average testing threshold of 1.4% across all age and sex cohorts. Two-way sensitivity analysis demonstrated that risk of major bleeding from anticoagulation, mortality from contrast-induced renal failure, risk of cancer from computed tomography scan, and mortality from both treated and untreated pulmonary embolism had the greatest effects on the testing threshold.Conclusion: We found a testing threshold for the PERC similar to that calculated by the Pauker and Kassirer method, using somewhat different assumptions. The 5 major drivers for the testing threshold are variables for which there is a paucity of literature to assess accurately for low-risk patients.

The Effect of Removal of Point-of-Care Fecal Occult Blood Testing on Performance of Digital Rectal Examinations in the Emergency Department - Corrected Proof

Nathan J. Cleveland, Michael Yaron, Adit A. Ginde — 2010-01-11

Study objective: We determine whether removing point-of-care fecal occult blood testing from the emergency department (ED) is associated with a decrease in documented digital rectal examinations.Methods: We performed a retrospective observational chart review study examining documented digital rectal examinations, before and after removal of a point-of-care fecal occult blood test, on all adult patients who presented to our ED with chief complaints that were likely to warrant a fecal occult blood test (intervention-sensitive). We studied the 6 months immediately before and after switching from bedside fecal occult blood testing to immunohistochemical laboratory fecal occult blood testing. We compared the results with those from a similar cohort of patients who presented during the same period, with chief complaints that would warrant a digital rectal examination for reasons other than fecal occult blood test (intervention-insensitive).Results: A total of 4,981 and 5,557 patients met our inclusion criteria during the before and after intervention periods, respectively. We observed an overall reduction of 10% (95% confidence interval [CI] 8% to 12%) in digital rectal examinations in patients with intervention-sensitive chief complaints. The largest relative decreases in digital rectal examinations were observed in patients with chief complaints of abdominal pain, nausea/vomiting, and diarrhea. Smaller decreases were observed in gastrointestinal bleeding, constipation, and rectal problem. There was an overall reduction of 3% (95% CI 0% to 5%) in documented digital rectal examinations in intervention-insensitive chief complaints. After controlling for all covariates, digital rectal examinations decreased in the postintervention period for intervention-sensitive (odds ratio 0.44 [95% CI 0.39 to 0.50]) and, to a lesser extent, for intervention-insensitive (odds ratio 0.67 [95% CI 0.52 to 0.86]) conditions.Conclusion: Removal of point-of-care fecal occult blood test from our ED was associated with a reduction in digital rectal examinations, particularly among chief complaints that may require fecal occult blood testing.

Clinical Features From the History and Physical Examination That Predict the Presence or Absence of Pulmonary Embolism in Symptomatic Emergency Department Patients: Results of a Prospective, Multicenter Study - Corrected Proof

2010-01-04

Study objective: Prediction rules for pulmonary embolism use variables explicitly shown to estimate the probability of pulmonary embolism. However, clinicians often use variables that have not been similarly validated, yet are implicitly believed to modify probability of pulmonary embolism. The objective of this study is to measure the predictive value of 13 implicit variables. Methods: Patients were enrolled in a prospective cohort study from 12 centers in the United States; all had an objective test for pulmonary embolism (D-dimer, computed tomographic angiography, or ventilation-perfusion scan). Clinical features including 12 predefined previously validated (explicit) variables and 13 variables not part of existing prediction rules (implicit) were prospectively recorded at presentation. The primary outcome was venous thromboembolism (pulmonary embolism or deep venous thrombosis), diagnosed by imaging up to 45 days after enrollment. Variables with adjusted odds ratios from logistic regression with 95% confidence intervals not crossing unity were considered significant. Results: Seven thousand nine hundred forty patients (7.2% venous thromboembolism positive) were enrolled. Mean age was 49 years (SD 17 years) and 67% were female patients. Eight of 13 implicit variables were significantly associated with venous thromboembolism; those with an adjusted odds ratio (OR) greater than 1.5 included non-cancer-related thrombophilia (OR 1.99), pleuritic chest pain (OR 1.53), and family history of venous thromboembolism (OR 1.51). Implicit variables that predicted no venous thromboembolism outcome included substernal chest pain, female sex, and smoking. Nine of 12 explicit variables predicted a positive outcome of venous thromboembolism, including patient history of pulmonary embolism or deep venous thrombosis in the past, unilateral leg swelling, recent surgery, estrogen, hypoxemia, and active malignancy. Conclusion: In symptomatic outpatients being considered for possible pulmonary embolism, non-cancer-related thrombophilia, pleuritic chest pain, and family history of venous thromboembolism increase probability of pulmonary embolism or deep venous thrombosis. Other variables that are part of existing pretest probability systems were validated as important predictors in this diverse sample of US emergency department patients.

A Prospective, Randomized Trial of Intravenous Prochlorperazine Versus Subcutaneous Sumatriptan in Acute Migraine Therapy in the Emergency Department - Corrected Proof

2010-01-04

Study objective: Intravenous (IV) prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine patients presenting to the emergency department (ED).Methods: In this randomized, double-blind, placebo-controlled trial, after providing written informed consent, patients presenting to the ED with a chief complaint of migraine received a 500-mL bolus of IV saline solution and either 10 mg prochlorperazine with 12.5 mg diphenhydramine IV plus saline solution placebo subcutaneously or saline solution placebo IV plus 6 mg sumatriptan subcutaneously. Pain intensity was assessed with 100-mm visual analog scales (visual analog scale at baseline and every 20 minutes for 80 minutes). The primary outcome was change in pain intensity from baseline to 80 minutes or time of ED discharge if subjects remained in the ED for fewer than 80 minutes after treatment. Sedation and nausea were assessed every 20 minutes with visual analog scale scales, and subjects were contacted within 72 hours to assess headache recurrence.Results: Sixty-eight subjects entered the trial, with complete data for 66 subjects. Baseline pain scores were similar for the prochlorperazine/diphenhydramine and sumatriptan groups (76 versus 71 mm). Mean reductions in pain intensity at 80 minutes or time of ED discharge were 73 mm for the prochlorperazine/diphenhydramine group and 50 mm for those receiving sumatriptan (mean difference 23 mm; 95% confidence interval 11 to 36 mm). Sedation, nausea, and headache recurrence rates were similar.Conclusion: IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine.

Intramuscular Cobinamide Sulfite in a Rabbit Model of Sublethal Cyanide Toxicity - Corrected Proof

2010-01-04

Study objective: Exposure to cyanide in fires and industrial exposures and intentional cyanide poisoning by terrorists leading to mass casualties is an ongoing threat. Current treatments for cyanide poisoning must be administered intravenously, and no rapid treatment methods are available for mass casualty cyanide exposures. Cobinamide is a cobalamin (vitamin B12) analog with an extraordinarily high affinity for cyanide that is more water-soluble than cobalamin. We investigate the use of intramuscular cobinamide sulfite to reverse cyanide toxicity–induced physiologic changes in a sublethal cyanide exposure animal model and determine the ability of an intramuscular cobinamide sulfite injection to rapidly reverse the physiologic effects of cyanide toxicity.Methods: New Zealand white rabbits were given 10 mg sodium cyanide intravenously over 60 minutes. Quantitative diffuse optical spectroscopy and continuous-wave near-infrared spectroscopy monitoring of tissue oxyhemoglobin and deoxyhemoglobin concentrations were performed concurrently with blood cyanide level measurements and cobinamide levels. Immediately after completion of the cyanide infusion, the rabbits were injected intramuscularly with cobinamide sulfite (n=6) or inactive vehicle (controls, n=5).Results: Intramuscular administration led to rapid mobilization of cobinamide and was extremely effective at reversing the physiologic effects of cyanide on oxyhemoglobin and within deoxyhemoglobin extraction. Recovery time to 63% of their baseline values in the central nervous system occurred within a mean of 1,032 minutes in the control group and 9 minutes in the cobinamide group, with a difference of 1,023 minutes (95% confidence interval 116 to 1,874 minutes). In muscle tissue, recovery times were 76 and 24 minutes, with a difference of 52 minutes (95% confidence interval 7 to 98 minutes). RBC cyanide levels returned toward normal significantly faster in cobinamide sulfite–treated animals than in control animals.Conclusion: Intramuscular cobinamide sulfite rapidly and effectively reverses the physiologic effects of cyanide poisoning, suggesting that a compact cyanide antidote kit can be developed for mass casualty cyanide exposures.

A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behaviors - Corrected Proof

2010-01-04

Study objective: Ohio recently instituted an online prescription monitoring program, the Ohio Automated Rx Reporting System (OARRS), to monitor controlled substance prescriptions within Ohio. This study is undertaken to identify the influence of OARRS data on clinical management of emergency department (ED) patients with painful conditions.Methods: This prospective quasiexperimental study was conducted at the University of Toledo Medical Center Emergency Department during June to July 2008. Eligible participants included ED patients with painful conditions. Patients with acute injuries were excluded. After clinical evaluation, and again after presentation of OARRS data, providers answered a set of questions about anticipated pain prescription for the patient. Outcome measures included changes in opioid prescription and other potential factors that influenced opioid prescription.Results: Among 179 participants, OARRS data revealed high numbers of narcotics prescriptions filled in the most recent 12 months (median 7; range 0 to 128). Numerous providers prescribed narcotics for patients (median 3 per patient; range 0 to 40). Patients had filled narcotics prescriptions at different pharmacies (mean [SD] 3.5 [4.4]). Eighteen providers are represented in the study. Four providers treated 63% (N=114) of the patients in the study. After review of the OARRS data, providers changed the clinical management in 41% (N=74) of cases. In cases of altered management, the majority (61%; N=45) resulted in fewer or no opioid medications prescribed than originally planned, whereas 39% (N=29) resulted in more opioid medication than previously planned.Conclusion: The use of data from a statewide narcotic registry frequently altered prescribing behavior for management of ED patients with complaints of nontraumatic pain.

Defining the Emergency Care Sensitive Condition: A Health Policy Research Agenda in Emergency Medicine - Corrected Proof

2010-01-04

[Ann Emerg Med. 2009;■■:■■■.] After the Institute of Medicine's (IOM) report on health care quality almost a decade ago, the medical community has focused on improving the delivery of high-quality medical care in the United States. The federal government, as the largest payer for health care, has attempted to incentivize high-quality care through programs such as the Centers for Medicare & Medicaid Services Physician Quality Reporting Initiative program (available online at http://www.cms.hhs.gov/PQRI). Some of these measures specifically address emergency care, including aspirin during the emergency department (ED) stay for acute myocardial infarction; assessment of vital signs, oxygen saturation, mental status, and prompt delivery of appropriate antibiotics for community-acquired pneumonia; tissue plasminogen activator considered for patients with diagnosis of ischemic stroke, whose time from symptom onset to arrival is less than 3 hours; and 12-lead ECG performed for nontraumatic chest pain or syncope in patients aged 40 years and older. The desire to decrease errors and increase quality is not contentious, but many emergency physicians reject the notion that quality can be measured by focusing on a small set of clinical interventions.

Attrition From Emergency Medicine Clinical Practice in the United States - Corrected Proof

Adit A. Ginde, Ashley F. Sullivan, Carlos A. Camargo — 2009-12-25

Study objective: We estimate the annual attrition from emergency medicine clinical practice.Methods: We performed a cross-sectional analysis of the American Medical Association's 2008 Physician Masterfile, which includes data on all physicians who have ever obtained a medical license in at least 1 US state. We restricted the analysis to physicians who completed emergency medicine residency training or who obtained emergency medicine board certification. We defined attrition as not being active in emergency medicine clinical practice. Attrition was reported as cumulative and annualized rates, with stratification by years since training graduation. Death rates were estimated from life tables for the US population.Results: Of the 30,864 emergency medicine–trained or emergency medicine board-certified physicians, 26,826 (87%) remain active in emergency medicine clinical practice. Overall, type of attrition was 45% to non–emergency medicine clinical practice, 22% retired, 14% administration, and 10% research/teaching. Immediate attrition (<2 years since training graduation) was 6.5%. The cumulative attrition rates from 2 to 15 years postgraduation were stable (5% to 9%) and thereafter were progressively higher, with 18% having left emergency medicine clinical practice at 20 years postgraduation and 25% at 30 years postgraduation. Annualized attrition rates were highest for the first 5 years postgraduation and after 40 years postgraduation; between 5 and 40 years, the rates remained low (<1%). The overall annual attrition rate from emergency medicine clinical practice, including estimated death rate, was approximately 1.7%.Conclusion: Despite the high stress and demands of emergency medicine, overall attrition remains low and compares favorably with that of other medical specialties. These data have positive implications for the emergency physician workforce and are important for accurate estimation of and planning for emergency physician workforce needs.

Confusion About Epinephrine Dosing Leading to Iatrogenic Overdose: A Life-Threatening Problem With a Potential Solution - Corrected Proof

Manreet Kanwar, Charlene B. Irvin, John J. Frank, Kathryn Weber, Howard Rosman — 2009-12-25

Epinephrine is indicated for various medical emergencies, including cardiac arrest and anaphylaxis, but the dose and route of administration are different for each indication. For anaphylaxis, it is given intramuscularly at a low dose, whereas for cardiac arrest a higher dose is required intravenously. We encountered a patient with suspected anaphylaxis who developed transient severe systolic dysfunction because of inappropriately received cardiac arrest dose, ie, larger dose given as an intravenous push. Three additional patients who experienced potentially lethal cardiac complications after receiving inappropriately higher doses intravenously were also identified. These iatrogenic errors resulted from underlying confusion by physicians about proper dosing of epinephrine for anaphylaxis. The risk of error was amplified by the need for rapid decisionmaking in critically ill anaphylactic patients. An e-mail survey of local hospitals in southeast Michigan revealed that 6 of 7 hospitals did not stock prefilled intramuscular dose syringes for emergency use in anaphylaxis. At our institution, we have introduced prefilled and appropriately labeled intramuscularly dosed epinephrine syringes in crash carts, which are easily distinguished from intravenously dosed epinephrine syringes. In this Concepts article, we describe the clinical problem of inadvertent epinephrine overdose and propose a potential solution. Epinephrine must be clearly packaged and labeled to avoid inappropriate usage and unnecessary, potentially lethal complications in patients with anaphylaxis.

Ondansetron Use in the Pediatric Emergency Department and Effects on Hospitalization and Return Rates: Are We Masking Alternative Diagnoses? - Corrected Proof

2009-12-25

Study objective: We evaluate the effect of ondansetron use in cases of suspected gastroenteritis on the proportion of hospital admissions and return visits and assess whether children who receive ondansetron on their initial visit to the pediatric emergency department (ED) for suspected gastroenteritis return with an alternative diagnosis more frequently than those who did not receive ondansetron.Methods: This is a retrospective review of visits to 2 tertiary care pediatric EDs with an International Classification of Diseases, Ninth Revision diagnosis of vomiting or gastroenteritis. A logistic regression model was developed to determine the effect of ondansetron use during the initial pediatric ED visit on hospital admission, return to the pediatric ED within 72 hours, and admission on this return visit. For patients who returned within 72 hours and were admitted, hospital discharge records were reviewed. The proportions of alternative diagnoses, defined as a hospital discharge diagnosis that was not a continuation of gastroenteritis or vomiting, were compared between the groups.Results: During the 3-year study period (2005 to 2007), 34,117 patients met study criteria. Ondansetron was used for 19,857 (58.2%) of these patients on their initial pediatric ED visit. After controlling for differences between the groups, patients who received ondansetron were admitted on their initial visit less often: odds ratio (OR) 0.47 (95% confidence interval [CI] 0.42 to 0.53). However, those who received ondansetron were more likely to return to the pediatric ED within 72 hours (OR 1.45; 95% CI 1.27 to 1.65) and be admitted on the return visit (OR 1.74; 95% CI 1.39 to 2.19). The proportions of alternative diagnoses at hospital discharge were not significantly different in the group that received ondansetron on the initial pediatric ED visit (14.9%) compared with the group that did not (22.4%) (absolute difference 7.5% [95% CI –0.5% to 16.4%).Conclusion: Ondansetron use in the pediatric ED reduces hospital admissions for suspected gastroenteritis and vomiting. However, children who receive ondansetron in the pediatric ED appear more likely to return to the pediatric ED and be admitted on this return visit than their counterparts. Furthermore, the use of ondansetron does not appear to be associated with increased risks of masking serious diagnoses in children.

Nasogastric Aspiration: A Useful Tool in Some Patients With Gastrointestinal Bleeding - Corrected Proof

Robert S. Anderson, Michael D. Witting — 2009-12-23

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.

Just Say No: Gastric Aspiration and Lavage Rarely Provide Benefit - Corrected Proof

Abbe Pitera, John Sarko — 2009-12-23

Gastric aspiration is routinely used to assist in the diagnosis and management of patients with known or suspected gastrointestinal hemorrhage. However, this practice provides little reliable information and is associated with complications such as pain, aspiration, and pneumothorax. Because of this, the use of routine gastric aspiration to diagnose and evaluate gastrointestinal hemorrhage in emergency department (ED) patients should be abandoned.

Effective Clinical Teaching by Residents in Emergency Medicine - Corrected Proof

John E. Houghland, Jeffrey Druck — 2009-12-23

The pace, level of patient acuity, and time constraints of the emergency department (ED) can limit teaching interactions between senior residents and the medical students and junior residents they supervise. Personal interaction between residents and learners (medical students and junior residents) is often limited to a brief presentation and discussion of the patient, easily making teaching an afterthought. Thus, the ED can seem like a less than ideal venue for effective clinical teaching by emergency medicine residents. The scenario below represents a missed opportunity for teaching in the ED.

Patient Identification Errors Are Common in a Simulated Setting - Corrected Proof

2009-12-23

Study objective: We evaluate the frequency and accuracy of health care workers verifying patient identity before performing common tasks.Methods: The study included prospective, simulated patient scenarios with an eye-tracking device that showed where the health care workers looked. Simulations involved nurses administering an intravenous medication, technicians labeling a blood specimen, and clerks applying an identity band. Participants were asked to perform their assigned task on 3 simulated patients, and the third patient had a different date of birth and medical record number than the identity information on the artifact label specific to the health care workers' task. Health care workers were unaware that the focus of the study was patient identity.Results: Sixty-one emergency health care workers participated—28 nurses, 16 technicians, and 17 emergency service associates—in 183 patient scenarios. Sixty-one percent of health care workers (37/61) caught the identity error (61% nurses, 94% technicians, 29% emergency service associates). Thirty-nine percent of health care workers (24/61) performed their assigned task on the wrong patient (39% nurses, 6% technicians, 71% emergency service associates). Eye-tracking data were available for 73% of the patient scenarios (133/183). Seventy-four percent of health care workers (74/100) failed to match the patient to the identity band (87% nurses, 49% technicians). Twenty-seven percent of health care workers (36/133) failed to match the artifact to the patient or the identity band before performing their task (33% nurses, 9% technicians, 33% emergency service associates). Fifteen percent (5/33) of health care workers who completed the steps to verify patient identity on the patient with the identification error still failed to recognize the error.Conclusion: Wide variation exists among health care workers verifying patient identity before performing everyday tasks. Education, process changes, and technology are needed to improve the frequency and accuracy of patient identification.

Do Emergency Physicians Attribute Drug-Related Emergency Department Visits to Medication-Related Problems? - Corrected Proof

2009-12-11

Study objective: Adverse drug events represent the most common cause of preventable nonsurgical adverse events in medicine but may remain undetected. Our objective is to determine the proportion of drug-related visits emergency physicians attribute to medication-related problems.Methods: This prospective observational study enrolled adults presenting to a tertiary care emergency department (ED) during 12 weeks. Drug-related visits were defined as ED visits caused by adverse drug events. The definition of adverse drug event was varied to examine both narrow and broad adverse drug event classification systems. Clinical pharmacists evaluated all patients for drug-related visits, using standardized assessment algorithms, and then followed patients until hospital discharge. Interrater agreement for the clinical pharmacist diagnosis of drug-related visit was assessed. Emergency physicians, blinded to the clinical pharmacist opinion, were interviewed at the end of each shift to determine whether they attributed the visit to a medication-related problem. An independent committee reviewed and adjudicated all cases in which the emergency physicians' and clinical pharmacists' assessments were discordant, or either the emergency physician or clinical pharmacist was uncertain. The primary outcome was the proportion of drug-related visits attributed to a medication-related problem by emergency physicians.Results: Nine hundred forty-four patients were enrolled, of whom 44 patients received a diagnosis of the narrowest definition of an adverse drug event, an adverse drug reaction (4.7%; 95% confidence interval [CI] 3.5% to 6.2%). Twenty-seven of these were categorized as medication-related by emergency physicians (61.4%; 95% CI 46.5% to 74.3%), 10 were categorized as uncertain (22.7%; 95% CI 12.9% to 37.1%), and 7 categorized as a non-medication-related problem (15.9%; 95% CI 8.0% to 29.5%). Seventy-eight patients (8.3%; 95% CI 6.7% to 10.2%) received a diagnosis of an adverse drug event caused by an adverse drug reaction, a drug interaction, drug withdrawal, a medication error, or noncompliance. Emergency physicians attributed 49 of these to a medication-related problem (62.8%; 95% CI 51.7% to 72.7%), were uncertain about 15 (19.2%; 95% CI 12.0% to 29.4%), and attributed 14 to non-medication-related problems (17.9%; 95% CI 11.0% to 27.9%). Twenty-five of 29 (86.2%; 95% CI 69.3% to 94.4%) adverse drug events not considered medication related by emergency physicians were rated at least moderate in severity.Conclusion: A significant proportion of drug-related visits are not deemed medication related by emergency physicians. Drug-related visits not attributed to medication-related problems by emergency physicians may be missed in ongoing outpatient adverse drug event surveillance programs intended to develop strategies to enhance drug safety. Further research is needed to determine what the effect may be of not attributing adverse drug events to medication-related problems.

Medication Errors Recovered by Emergency Department Pharmacists - Corrected Proof

2009-12-11

Study objective: We assess the impact of emergency department (ED) pharmacists on reducing potentially harmful medication errors.Methods: We conducted this observational study in 4 academic EDs. Trained pharmacy residents observed a convenience sample of ED pharmacists' activities. The primary outcome was medication errors recovered by pharmacists, including errors intercepted before reaching the patient (near miss or potential adverse drug event), caught after reaching the patient but before causing harm (mitigated adverse drug event), or caught after some harm but before further or worsening harm (ameliorated adverse drug event). Pairs of physician and pharmacist reviewers confirmed recovered medication errors and assessed their potential for harm. Observers were unblinded and clinical outcomes were not evaluated.Results: We conducted 226 observation sessions spanning 787 hours and observed pharmacists reviewing 17,320 medications ordered or administered to 6,471 patients. We identified 504 recovered medication errors, or 7.8 per 100 patients and 2.9 per 100 medications. Most of the recovered medication errors were intercepted potential adverse drug events (90.3%), with fewer mitigated adverse drug events (3.9%) and ameliorated adverse drug events (0.2%). The potential severities of the recovered errors were most often serious (47.8%) or significant (36.2%). The most common medication classes associated with recovered medication errors were antimicrobial agents (32.1%), central nervous system agents (16.2%), and anticoagulant and thrombolytic agents (14.1%). The most common error types were dosing errors, drug omission, and wrong frequency errors.Conclusion: ED pharmacists can identify and prevent potentially harmful medication errors. Controlled trials are necessary to determine the net costs and benefits of ED pharmacist staffing on safety, quality, and costs, especially important considerations for smaller EDs and pharmacy departments.

Predicting Survival After Out-of-Hospital Cardiac Arrest: Role of the Utstein Data Elements - Corrected Proof

2009-11-30

Study objective: Survival after out-of-hospital cardiac arrest depends on the links in the chain of survival. The Utstein elements are designed to assess these links and provide the basis for comparing outcomes within and across communities. We assess whether these measures sufficiently predict survival and explain outcome differences.Methods: We used an observational, prospective data collection, case-series of adult persons with nontraumatic out-of-hospital cardiac arrest from December 1, 2005, through March 1, 2007, from the multisite, population-based Resuscitation Outcomes Consortium Epistry–Cardiac Arrest. We used logistic regression, receiver operating curves, and measures of variance to estimate the extent to which the Utstein elements predicted survival to hospital discharge and explained outcome variability overall and between 7 Resuscitation Outcomes Consortium sites. Analyses were conducted for all emergency medical services–treated cardiac arrests and for the subset of bystander-witnessed patient arrests because of presumed cardiac cause presenting with ventricular fibrillation or ventricular tachycardia.Results: Survival was 7.8% overall (n=833/10,681) and varied from 4.6% to 14.7% across Resuscitation Outcomes Consortium sites. Among bystander-witnessed ventricular fibrillation or ventricular tachycardia, survival was 22.1% overall (n=323/1459) and varied from 12.5% to 41.0% across sites. The Utstein elements collectively predicted 72% of survival variability among all arrests and 40% of survival variability among bystander-witnessed ventricular fibrillation. The Utstein elements accounted for 43.6% of the between-site survival difference among all arrests and 22.3% of the between-site difference among the bystander-witnessed ventricular fibrillation subset.Conclusion: The Utstein elements predict survival but account for only a modest portion of outcome variability overall and between Resuscitation Outcomes Consortium sites. The results underscore the need for ongoing investigation to better understand characteristics that influence cardiac arrest survival.

Hydroxocobalamin and Sodium Thiosulfate Versus Sodium Nitrite and Sodium Thiosulfate in the Treatment of Acute Cyanide Toxicity in a Swine (Sus scrofa) Model - Corrected Proof

2009-11-30

Study objective: Cyanide can cause severe hypotension with acute toxicity. To our knowledge, no study has directly compared hydroxocobalamin and sodium nitrite with sodium thiosulfate in an acute cyanide toxicity model. Our objective is to compare the return to baseline of mean arterial blood pressure between 2 groups of swine with acute cyanide toxicity and treated with hydroxocobalamin with sodium thiosulfate or sodium nitrite with sodium thiosulfate.Methods: Twenty-four swine were intubated, anesthetized, and instrumented (continuous arterial and cardiac output monitoring) and then intoxicated with a continuous cyanide infusion until severe hypotension. The animals were divided into 2 arms of 12 each and then randomly assigned to intravenous hydroxocobalamin (150 mg/kg)+sodium thiosulfate (413 mg/kg) or sodium nitrite (10 mg/kg)+sodium thiosulfate (413 mg/kg) and monitored for 40 minutes after start of antidotal infusion. Twenty animals were needed for 80% power to detect a significant difference in outcomes (α 0.05). Repeated measures of analysis of covariance and post hoc t test were used for determining significance.Results: Baseline mean weights, time to hypotension (31 minutes 3 seconds versus 28 minutes 6 seconds), and cyanide dose at hypotension (5.6 versus 5.9 mg/kg) were similar. One animal in the hydroxocobalamin group and 2 animals in the sodium nitrite group died during antidote infusion and were excluded from analysis. Hydroxocobalamin resulted in a faster return to baseline mean arterial pressure, with improvement beginning at 5 minutes and lasting through the conclusion of the study (P<.05). No statistically significant difference was detected between groups for cardiac output, pulse rate, systemic vascular resistance, or mortality at 40 minutes postintoxication. Mean cyanide blood levels (4.03 versus 4.05 μg/mL) and lactate levels (peak 7.9 versus 8.1 mmol/L) at hypotension were similar. Lactate levels (5.1 versus 4.48 mmol/L), pH (7.40 versus 7.37), and base excess (−0.75 versus 1.27) at 40 minutes were also similar.Conclusion: Hydroxocobalamin with sodium thiosulfate led to a faster return to baseline mean arterial pressure compared with sodium nitrite with sodium thiosulfate; however, there was no difference between the antidote combinations in mortality, serum acidosis, or serum lactate.

External Validation of the San Francisco Syncope Rule in the Canadian Setting - Corrected Proof

2009-11-30

Study objective: Syncope is a common disposition challenge for emergency physicians. Among the risk-stratification instruments available, only the San Francisco Syncope Rule is rigorously developed. We evaluate its performance in Canadian emergency department (ED) syncope patients.Methods: This retrospective review included patients aged 16 years or older who fulfilled the definition of syncope (transient loss of consciousness with complete recovery) and presented to a tertiary care ED during an 18-month period. We excluded patients with ongoing altered mental status, alcohol/illicit drug use, seizure, and head and severe trauma. Patient characteristics, 5 predictors for the rule (history of congestive heart failure, hematocrit level <30%, abnormal ECG characteristics, shortness of breath, and triage systolic blood pressure <90 mm Hg), and outcomes (as per the original study) were extracted.Results: Of 915 visits screened, 505 were included. Forty-nine (9.7%) visits were associated with serious outcomes. The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%). Including monitor abnormalities in the ECG variable would improve sensitivity to 96% (47/49 outcomes; 95% CI 87% to 99%). Although physicians failed to predict 2 deaths, the rule would have predicted all 3 deaths that occurred after ED discharge. Implementing the rule in our setting would increase the admission rate from 12.3% to 69.5%.Conclusion: In this retrospective Canadian study, the San Francisco Syncope Rule performed with comparable sensitivity but significantly poorer specificity than previously reported. Implementing the rule would significantly increase admission rates. Further studies to either refine the San Francisco Syncope Rule or develop a new rule are needed.

Pregnancy Testing in Women of Reproductive Age in US Emergency Departments, 2002 to 2006: Assessment of a National Quality Measure - Corrected Proof

Jeremiah D. Schuur, Sarah A. Tibbetts, Jesse M. Pines — 2009-11-23

Study objective: We assess performance and explore definitions for a new emergency department (ED) quality measure: the proportion of women aged 14 to 50 years who have abdominal pain and receive pregnancy testing (aimed at detecting ectopic pregnancy).Methods: We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) (2002 to 2006) to test trends and predictors of the new measure, using both restrictive and broad definitions from the International Classification of Diseases, Ninth Revision (ICD-9) and reason-for-visit codes, and determine the proportion of women with ectopic pregnancy who had undergone pregnancy testing. For comparison, we conducted a detailed chart review in 4 US hospitals among patients who visited the ED in 2006.Results: Using a broad ICD-9 definition for inclusion in NHAMCS, 2.13 million women aged 14 to 50 years with abdominal pain visited an ED annually between 2002 and 2006. Of those, 33.0% (95% confidence interval [CI] 30.5% to 35.5%) received pregnancy testing. Testing rates were materially stable, regardless of the definition used (broad or restrictive ICD-9 or reason-for-visit code). Among women with an ICD-9 diagnosis of ectopic pregnancy, 55.6% (95% CI 43.7% to 67.6%) had a documented pregnancy test. In the chart review, among 200 women aged 14 to 50 years and with abdominal pain, 89.4% (95% CI 85.0% to 94.0%) were eligible for the measure; of those, 93.9% (95% CI 90.3% to 97.4%) received testing.Conclusion: Analysis of national ED survey data demonstrated a large performance gap for a new pregnancy testing quality measure, whereas focused chart review at 4 sites showed a smaller gap. Given these discrepancies, additional study is recommended before the widespread implementation of the pregnancy testing measure as an assessment of ED performance.

Emergency Physician Perceptions of Patient Safety Risks - Corrected Proof

David P. Sklar, Cameron S. Crandall, Timothy Zola, Ron Cunningham — 2009-10-26

Study objective: Although national standards to address patient safety exist, their relevance to emergency department (ED) patient safety is unclear. We survey practicing emergency physicians to assess their perceptions of the relative importance of patient safety concerns and how these varied by urban/rural location and practice characteristics.Methods: We developed and analyzed electronically collected survey data that assessed emergency physician perceptions of patient safety risks. American College of Emergency Physicians (ACEP) members rated 16 patient safety concerns with a 5-point Likert scale.Results: Of 2,507 emergency physician respondents, 1,114 (44%) practiced in urban, 1,056 (42%) in suburban, and 337 (13%) in rural settings. Crowding from inpatient boarding (mean Likert scale score 4.3), availability of specialty consultation (mean 4.1), and nursing shortages (mean 3.9) were the greatest concerns. Rural respondents ranked consultant availability (mean 4.3), lack of follow-up after ED care (mean 3.8), and nurse shortages (mean 3.8) as top concerns. Crowding was the greatest concern for suburban (mean 4.3) and urban emergency physicians (mean 4.5) but was ranked seventh by rural emergency physicians (mean 3.5). Crowding was perceived as a greater problem as hospital size, ED volume, and the percentage of patients who left without being seen increased, regardless of practice location.Conclusion: In this sample of practicing emergency physicians, rural emergency physicians' patient safety concerns differ from those of their urban/suburban counterparts. For urban/suburban emergency physicians, crowding is the greatest safety concern; for rural emergency physicians, consultant availability was the greatest concern. Emergency physicians' greatest concerns are not routinely measured and reported as part of national patient safety benchmarking programs.

Pool Chemical Blast Injury - Corrected Proof

Brian W. Shippert — 2009-10-26

Swimming pools are one of the most popular forms of recreation in the United States. Pool-related injuries may produce significant morbidity and mortality, and those related to pool chemicals are of particular importance. The majority of injuries associated with pool chemicals are respiratory, with the remainder composed mainly of dermal exposures. There are few case reports about injuries from pool chemicals, and the potential for significant injury from blast force is presented here.

Should Capnographic Monitoring Be Standard Practice During Emergency Department Procedural Sedation and Analgesia? Pro and Con - Corrected Proof

Steven M. Green, Jay Pershad — 2009-10-12

SEE RELATED ARTICLE, P. ■■■. [Ann Emerg Med. 2009;■■:■■■.]

Does End Tidal CO2 Monitoring During Emergency Department Procedural Sedation and Analgesia With Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled Trial - Corrected Proof

Kenneth Deitch, Jim Miner, Carl R. Chudnofsky, Paul Dominici, Daniel Latta — 2009-09-25

Study objective: We determine whether the use of capnography is associated with a decreased incidence of hypoxic events than standard monitoring alone during emergency department (ED) sedation with propofol.Methods: Adults underwent ED propofol sedation with standard monitoring (pulse oximetry, cardiac and blood pressure) and capnography and were randomized into a group in which treating physicians had access to the capnography and a blinded group in which they did not. All patients received supplemental oxygen (3 L/minute) and opioids greater than 30 minutes before. Propofol was dosed at 1.0 mg/kg, followed by 0.5 mg/kg as needed. Capnographic and SpO2 data were recorded electronically every 5 seconds. Hypoxia was defined as SpO2 less than 93%; respiratory depression, as end tidal CO2 (etco2) greater than 50 mm Hg, etco2 change from baseline of 10%, or loss of the waveform.Results: One hundred thirty-two subjects were evaluated and included in the final analysis. We observed hypoxia in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%). Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds).Conclusion: In adults receiving ED propofol sedation, the addition of capnography to standard monitoring reduced hypoxia and provided advance warning for all hypoxic events.

Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort - Corrected Proof

2009-09-24

Study objective: The first hour after the onset of out-of-hospital traumatic injury is referred to as the “golden hour,” yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality.Methods: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ≥15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders.Results: There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings.Conclusion: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

An Evaluation of the Accuracy of Emergency Physician Activation of the Cardiac Catheterization Laboratory for Patients With Suspected ST-Segment Elevation Myocardial Infarction - Corrected Proof

2009-09-23

Study objective: Current recommendations indicate that emergency physicians should activate cardiac catheterization laboratory personnel by a single page for ST-segment elevation myocardial infarction (STEMI) patients. We assessed the accuracy of emergency physician cardiac catheterization laboratory activations, angiographic findings, outcomes, and treatment times among patients with and without STEMI.Methods: We classified the appropriateness and outcomes of consecutive emergency physician STEMI pages between June 2006 and September 2008. Emergency physician activations of the cardiac catheterization laboratory were classified according to the findings of the initial ECG compared with cardiology interpretation for the presence of STEMI and presence of coronary disease.Results: During a 27-month period, emergency physician activation of the cardiac catheterization laboratory occurred 249 times. There were 188 (76%) patients with a true STEMI, of whom 13 did not receive emergency angiography. Of the 37 (15%) patients who had ECG findings meeting STEMI criteria and who ultimately did not have myocardial necrosis and underwent emergency angiography, 12 had significant disease and 5 had revascularization performed. Eleven patients had ECGs concerning for but not meeting STEMI criteria; all had emergency angiography (n=11) or received a diagnosis of non-STEMI (n=6). Only 13 patients were considered as having received unnecessary cardiac catheterization laboratory activations (5.2%) in which emergency angiography was not performed and myocardial infarction was excluded.Conclusion: A significant number of emergency physician STEMI cardiac catheterization laboratory activations are for patients who did not meet standard STEMI criteria. However, most had ECG findings and symptoms that lead to emergency angiography, had significant disease, or were diagnosed with non-STEMI. Only a small percentage of patients received unnecessary cardiac catheterization laboratory activations. Our findings support current recommendations for emergency physician cardiac catheterization laboratory activation for potential STEMI patients.

12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism - Corrected Proof

2009-09-22

Study objective: Acute pulmonary embolism can produce abnormalities on ECG that reflect severity of pulmonary hypertension. Early recognition of these findings may alter the estimated pretest probability of pulmonary embolism and prompt more aggressive treatment before hemodynamic instability ensues, but it is first important to test whether these findings are specific to patients with pulmonary embolism. We hypothesize that ECG findings consistent with pulmonary hypertension would be observed more frequently in patients with pulmonary embolism.Methods: Secondary analysis of a prospective, observational cohort of emergency department patients who were tested for pulmonary embolism. ECGs were ordered at clinician's discretion and interpreted at presentation.Results: Six thousand forty-nine patients had an ECG, 354 (5.9%) of whom were diagnosed with pulmonary embolism. The frequency, positive likelihood ratio (LR+) and 95% confidence interval (CI) of each predictor were as follows: S1Q3T3 8.5% with pulmonary embolism versus 3.3% without pulmonary embolism (LR+ 3.7; 95% CI 2.5 to 5.4); nonsinus rhythm, 23.5% versus 16.6% (LR+ 1.4; 95% CI 1.2 to 1.7); inverted T waves in V1 to V2, 14.4% versus 8.1% (LR+ 1.8; 95% CI 1.3 to 2.3); inversion in V1 to V3, 10.5% versus 4.0% (LR+ 2.6; 95% CI 1.9 to 3.6); inversion in V1 to V4, 7.3% versus 2.0% (LR+ 3.7; 95% CI 2.4 to 5.5); incomplete right bundle branch block, 4.8% versus 2.8% (LR+ 1.7; 95% CI 1.0 to 2.7); tachycardia (pulse rate >100 beats/min), 28.8% versus 15.7% (LR+ 1.8; 95% CI 1.5 to 2.2). Likelihood ratios and specificities were similar when patients with previous cardiopulmonary disease were excluded from analysis.Conclusion: Findings of acute pulmonary hypertension were infrequent overall but were observed more frequently in patients with the final diagnosis of pulmonary embolism compared with patients who do not have pulmonary embolism.

Should I Consider Treating Patients With Acute Cardiogenic Pulmonary Edema With Noninvasive Positive-Pressure Ventilation? - Corrected Proof

Rawle A. Seupaul — 2009-08-21

[Ann Emerg Med. 2009;■■:■■■.] This is a systematic review abstract, a regular feature of the Annals' Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area.

Bedside Ultrasonography to Identify Hip Effusions in Pediatric Patients - Corrected Proof

Rebecca L. Vieira, Jason A. Levy — 2009-08-21

Study objective: We determine whether pediatric emergency physicians can use bedside ultrasonography to accurately identify hip effusions in pediatric patients.Methods: This was a prospective study conducted in the emergency department (ED) of an urban tertiary care freestanding pediatric hospital. A convenience sample of children younger than 18 years and who required hip ultrasonography as part of their ED evaluation was enrolled. Pediatric emergency physicians with focused ultrasonographic training performed bedside ultrasonography on patients' symptomatic and contralateral hips and categorized the findings as “effusion” or “no effusion,” according to a priori definitions. Physicians rated their confidence for each bedside ultrasonographic result on a scale of 1 (not confident) to 5 (very confident). Bedside ultrasonographic results were compared with the radiology department's ultrasonographic results, which were considered the criterion standard. Standard performance metrics (sensitivity, specificity, and positive and negative predictive values) were calculated.Results: Three physicians enrolled patients. Twenty-eight patients were enrolled, and 55 hips were studied. In all hips (both symptomatic and contralateral), bedside ultrasonography had a sensitivity of 80% (95% confidence interval [CI] 51% to 95%), a specificity of 98% (95% CI 85% to 99%), a positive predictive value of 92% (95% CI 62% to 99%), and a negative predictive value of 93% (95% CI 79% to 98%). In the 28 symptomatic hips, bedside ultrasonography had a sensitivity of 85% (95% CI 54% to 97%), a specificity of 93% (95% CI 66% to 99%), a positive predictive value of 92% (95% CI 60% to 99%), and negative predictive value of 88% (95% CI 60% to 98%). When physician self-rated confidence was high, the sensitivity of bedside ultrasonography in symptomatic hips was 90% (95% CI 54% to 99%), the specificity was 100% (95% CI 70% to 100%), the positive predictive value was 100% (95% CI 63% to 100%), and the negative predictive value was 92% (95% CI 62% to 99%).Conclusion: With focused training, pediatric emergency physicians were able to use bedside ultrasonography to identify hip effusions in pediatric ED patients.

Tongue Engorgement Associated With Prolonged Use of the King-LT Laryngeal Tube Device - Corrected Proof

Joshua B. Gaither, Jessica Matheson, Aaron Eberhardt, Christopher B. Colwell — 2009-08-21

We report a case of massive tongue engorgement associated with the placement of a laryngeal tube device (King Airway-LTS-D EMS). Our patient developed isolated, massive lingual swelling approximately 3 hours after the out-of-hospital placement of a laryngeal tube. Swelling resolved 2 days later in the ICU after fiberoptic-guided exchange of the laryngeal tube for an endotracheal tube. It is most likely that the observed swelling was due to obstruction of venous drainage from the tongue by the oropharyngeal balloon. Other etiologies for lingual swelling such as angioedema cannot be definitively ruled out but are less likely to have caused the patient's tongue engorgement.

Preventing Falls in Community-Dwelling Older Adults - Corrected Proof

Christopher R. Carpenter — 2009-07-21

[Ann Emerg Med. 2009;■■:■■■.] This is a systematic review abstract, a regular feature of the Annals' Evidenced-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary from an emergency physician knowledgeable in the subject area.

Emergency Department Bedside Ultrasonographic Measurement of the Caval Index for Noninvasive Determination of Low Central Venous Pressure - Corrected Proof

2009-06-26

Study objective: Among adult emergency department (ED) patients undergoing central venous catheterization, we determine whether a greater than or equal to 50% decrease in inferior vena cava diameter is associated with a central venous pressure of less than 8 mm Hg.Methods: Adult patients undergoing central venous catheterization were enrolled in a prospective, observational study. Inferior vena cava inspiratory and expiratory diameters were measured by 2-dimensional bedside ultrasonography. The caval index was calculated as the relative decrease in inferior vena cava diameter during 1 respiratory cycle. The correlation of central venous pressure and caval index was calculated. The sensitivity, specificity, and positive and negative predictive values of a caval index greater than or equal to 50% that was associated with a central venous pressure less than 8 mm Hg were estimated.Results: Of 73 patients, the median age was 63 years and 60% were women. Mean time and fluid administered from ultrasonographic measurement to central venous pressure determination were 6.5 minutes and 45 mL, respectively. Of the 73 participants, 32% had a central venous pressure less than 8 mm Hg. The correlation between caval index and central venous pressure was –0.74 (95% confidence interval [CI] –0.82 to –0.63). The sensitivity of caval index greater than or equal to 50% to predict a central venous pressure less than 8 mm Hg was 91% (95% CI 71% to 99%), the specificity was 94% (95% CI 84% to 99%), the positive predictive value was 87% (95% CI 66% to 97%), and the negative predictive value was 96% (95% CI 86% to 99%).Conclusion: Bedside ultrasonographic measurement of caval index greater than or equal to 50% is strongly associated with a low central venous pressure. Bedside measurements of caval index could be a useful noninvasive tool to determine central venous pressure during the initial evaluation of the ED patient.

Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient - Corrected Proof

Myto Duong, Stephen Markwell, John Peter, Stephen Barenkamp — 2009-05-01

Study objective: Emergency department visits for skin and soft tissue infections are increasing with the discovery of community-acquired methicillin-resistant Staphylococcus aureus. Whether abscesses treated surgically also require antibiotics is controversial. There are no published pediatric randomized controlled trials evaluating the need for antibiotics in skin abscess management. We determine the benefits of antibiotics in surgically managed pediatric skin abscesses.Methods: This was a double-blind, randomized, controlled trial. Pediatric patients were randomized to receive 10 days of placebo or trimethoprim-sulfamethoxazole after incision and draining. Follow-up consisted of a visit/call at 10 to 14 days and a call at 90 days. Primary outcome was treatment failure at the 10-day follow-up. Secondary outcome was new lesion development at the 10- and 90-day follow-ups. Noninferiority of placebo relative to trimethoprim-sulfamethoxazole for primary and secondary outcomes was assessed.Results: One hundred sixty-one patients were enrolled, with 12 lost to follow-up. The failure rates were 5.26% (n=4/76) and 4.11% (n=3/73) in the placebo and antibiotic groups, respectively, yielding a difference of 1.15, with a 1-sided 95% confidence interval (CI) (1.15% to 6.8%). Noninferiority was established with an equivalence threshold of 7%. New lesions occurred at the 10-day follow-up: 19 on placebo (26.4%) and 9 on antibiotics (12.9%), yielding a difference of 13.5, with 95% 1-sided CI (13.5% to 24.3%). At the 3-month follow-up, 15 of 52 (28.8%) in the placebo group and 13 of 46 (28.3%) in the antibiotic group developed new lesions. The difference was 0.58, with 95% 1-sided CI (0.5% to 15.6%).Conclusion: Antibiotics are not required for pediatric skin abscess resolution. Antibiotics may help prevent new lesions in the short term, but further studies are required.