Annals of Emergency Medicine - Articles in Press

Real-Time Prediction of Waiting Time in the Emergency Department, Using Quantile Regression - Corrected Proof

Yan Sun, Kiok Liang Teow, Bee Hoon Heng, Chee Kheong Ooi, Seow Yian Tay — 2012-05-14

Study objective: Emergency department (ED) waiting times can affect patient satisfaction and quality of care. We develop and validate a model that predicts an individual patient's median and 95th percentile waiting time by using only data available at triage. Methods: From the existing ED information system, we extracted date and time of triage completion, start time of emergency physician consultation, and patient acuity category (1=most urgent, 3=least urgent). Quantile regression was applied for model development and parameter estimation by using visits from January 2011. We assessed absolute prediction error, defined as the median difference between the 50th percentile (median) predicted waiting time and actual waiting time, and the proportion of underestimated prediction, defined as the percentage of patients whose actual waiting time exceeded the 95th percentile prediction. The model was validated retrospectively with June 2010 data and prospectively with data from April to June 2011 after integration with the existing ED information system. Results: The derivation set included 13,200 ED visits; 903 (6.8%) were patient acuity category 1, 5,530 (41.9%) were patient acuity category 2, and 6,767 (51.3%) were patient acuity category 3. The median and 95th percentile waiting times were 17 and 57 minutes for patient acuity category 2 and 21 and 89 minutes for patient acuity category 3, respectively. The final model used predictors of patient acuity category, patient queue sizes, and flow rates only. In the retrospective validation, 5.9% of patient acuity category 2 and 5.4% of category 3 waiting times were underestimated. The median absolute prediction error was 11.9 minutes (interquantile range [IQR] 5.9 to 22.1 minutes) for patient acuity category 2 and 15.7 minutes (IQR 7.5 to 30.1 minutes) for category 3. In prospective validation, 4.3% of patient acuity category 2 and 5.8% of category 3 waiting times were underestimated. The median absolute prediction error was 9.2 minutes (IQR 4.4 to 15.1 minutes) for patient acuity category 2 and 12.9 minutes (IQR 6.5 to 22.5 minutes) for category 3. Conclusion: Using only a few data elements available at triage, the model predicts individual patients' waiting time with good accuracy.

Pain Control in Disaster Settings: A Role for Ultrasound-Guided Nerve Blocks - Corrected Proof

Suzanne C. Lippert, Arun Nagdev, Michael B. Stone, Andrew Herring, Robert Norris — 2012-05-14

Acute pain management for patients sustaining injuries in natural disasters and complex emergencies should be a priority for medical providers. Although there are minimal data examining the modalities and effectiveness of pain control in disaster settings, what data exist reveal practices that would be considered grossly inadequate in a typical emergency department (ED) setting.

A Characterization of Synthetic Cannabinoid Exposures Reported to the National Poison Data System in 2010 - Corrected Proof

2012-05-10

Study objective: Δ-9-Tetrahydrocannabinol homologs have been increasingly abused since their introduction in 2004. Such products were used as a “legal high” for those wishing to experience cannabinoid effects while evading basic drugs-of-abuse testing. We describe a series of exposures to products marketed as synthetic cannabinoids to better characterize the clinical effects in these patients. Methods: All Δ-9-tetrahydrocannabinol homolog exposures reported to the National Poison Data System between January 1, 2010, and October 1, 2010, were extracted with National Poison Data System generic codes and product codes for Δ-9-tetrahydrocannabinol homologs. Only cases involving a single-agent exposure to Δ-9-tetrahydrocannabinol homologs as the major category were analyzed. Descriptive statistics were generated for demographic data, management site, products involved, symptoms, duration of effects, treatments, and severity of clinical effects. Results: During the 9-month study period, there were 1,898 exposures to Δ-9-tetrahydrocannabinol homologs; 1,353 of these cases were single-agent exposures. The mean age was 22.5 years (SD 8.86 years). Most cases were reported in men (n=1,005; 74.3%). The majority of exposures were acute (88.2%; n=1,193). The most common clinical effect was tachycardia (37.7%; n=510). Seizures were reported in 52 patients (3.8%). The majority of clinical effects lasted for fewer than 8 hours (n=711; 78.4%) and resulted in 1,011 non–life-threatening clinical effects (92.9%). The most common therapeutic intervention was intravenous fluids (n=343; 25.3%). There was 1 death (0.1%). Conclusion: The majority of cases were in young men intentionally abusing spice. Most exposures resulted in non–life-threatening effects not requiring treatment, although a minority of exposures resulted in more severe effects, including seizures.

Use of Recreational Drug 1,3-Dimethylethylamine (DMAA) Associated With Cerebral Hemorrhage - Corrected Proof

Paul Gee, Cheryl Tallon, Neil Long, Grant Moore, Ronald Boet, Suzanne Jackson — 2012-05-10

Dimethylamylamine (DMAA) was a forgotten pharmaceutical that was patented in 1944 as a nasal decongestant. DMAA has recently gained popularity as a dietary supplement, with claims of effectiveness as an athletic performance enhancer and weight loss aid. It is also sold as a recreational stimulant drug. DMAA is a sympathomimetic and potent pressor agent. This report describes 3 cases of cerebral hemorrhage in adults after the use of DMAA. The status of this substance as a synthetic or naturally occurring compound is also discussed.

A Comparison of the C-MAC Video Laryngoscope to the Macintosh Direct Laryngoscope for Intubation in the Emergency Department - Corrected Proof

John C. Sakles, Jarrod Mosier, Stephen Chiu, Mari Cosentino, Leah Kalin — 2012-05-07

Study objective: We determine the proportion of successful intubations with the C-MAC video laryngoscope (C-MAC) compared with the direct laryngoscope in emergency department (ED) intubations. Methods: This was a retrospective analysis of prospectively collected data entered into a continuous quality improvement database during a 28-month period in an academic ED. After each intubation, the operator completed a standardized data form evaluating multiple aspects of the intubation, including patient demographics, indication for intubation, device(s) used, reason for device selection, difficult airway characteristics, number of attempts, and outcome of each attempt. Intubation was considered ultimately successful if the endotracheal tube was correctly inserted into the trachea with the initial device. An attempt was defined as insertion of the device into the mouth regardless of whether there was an attempt to pass the tube. The primary outcome measure was ultimate success. Secondary outcome measures were first-attempt success, Cormack-Lehane view, and esophageal intubation. Multivariate logistic regression analyses, with the inclusion of a propensity score, were performed for the outcome variables ultimate success and first-attempt success. Results: During the 28-month study period, 750 intubations were performed with either the C-MAC with a size 3 or 4 blade or a direct laryngoscope with a Macintosh size 3 or 4 blade. Of these, 255 were performed with the C-MAC as the initial device and 495 with a Macintosh direct laryngoscope as the initial device. The C-MAC resulted in successful intubation in 248 of 255 cases (97.3%; 95% confidence interval [CI] 94.4% to 98.9%). A direct laryngoscope resulted in successful intubation in 418 of 495 cases (84.4%; 95% CI 81.0% to 87.5%). In the multivariate regression model, with a propensity score included, the C-MAC was positively predictive of ultimate success (odds ratio 12.7; 95% CI 4.1 to 38.8) and first-attempt success (odds ratio 2.2; 95% CI 1.2 to 3.8). When the C-MAC was used as a video laryngoscope, a Cormack-Lehane grade I or II view (video) was obtained in 117 of 125 cases (93.6%; 95% CI 87.8% to 97.2%), whereas when a direct laryngoscope was used, a grade I or II view was obtained in 410 of 495 cases (82.8%; 95% CI 79.2% to 86.1%). The C-MAC was associated with immediately recognized esophageal intubation in 4 of 255 cases (1.6%; 95% CI 0.4% to 4.0%), whereas a direct laryngoscope was associated with immediately recognized esophageal intubation in 24 of 495 cases (4.8%; 95% CI 3.1% to 7.1%). Conclusion: When used for emergency intubations in the ED, the C-MAC was associated with a greater proportion of successful intubations and a greater proportion of Cormack-Lehane grade I or II views compared with a direct laryngoscope.

In the Child With Gastroenteritis Who Is Unable to Tolerate Oral Fluids, Are There Effective Alternatives to Intravenous Hydration? - Corrected Proof

Lisa T. Barker — 2012-05-07

Nasogastric hydration is an effective alternative to intravenous hydration when oral hydration fails. MEDLINE, EMBASE, the Cochrane library, Global Health, and CINAHL inclusive through December 2009 were searched. Key references from included articles were also reviewed.

The Unappreciated Challenges of Between-Unit Handoffs: Negotiating and Coordinating Across Boundaries - Corrected Proof

Brian Hilligoss, Michael D. Cohen — 2012-05-07

Although interest in studying and improving handoffs has grown considerably in recent years, a general tendency to treat handoff as a single type of activity has resulted in overlooking important variation and in understudying one consequential type: between-unit handoffs. Using the admission handoff between emergency departments and inpatient services as an example, this conceptual article identifies 2 distinguishing structural features of between-unit transitions and demonstrates how these features create negotiation and coordination challenges that are further complicated by several contextual factors. Between-unit handoffs are distinguished from within-unit handoffs because the former are triggered by patient conditions as opposed to shift schedules and entail working across organizational boundaries rather than within them. Consequently, between-unit handoffs are challenged by several contextual factors, including interprofessional differences, unequal distributions of power among units, frequent lack of established relationships among the involved parties, infrequent face-to-face communication, a lack of awareness of the other unit's state, and the fact that responsibility and control of patients are transferred separately. Implications for improvement are discussed.

Dopamine Versus Norepinephrine for the Treatment of Septic Shock EBEM Commentators - Corrected Proof

John P. Sandifer, Alan E. Jones — 2012-05-07

Dopamine administration is associated with a higher incidence of arrhythmias and increased risk of death compared with norepinephrine in the treatment of septic shock. The search included MEDLINE, EMBASE, Scopus databases, and the Cochrane registry of clinical trials (through June 30, 2011). Google Scholar, clinical trials.org, controlled-trials.com, and abstracts of major congresses (2005 to 2010) were also searched.

Patient and Practice-Related Determinants of Emergency Department Length of Stay for Patients With Psychiatric Illness - Corrected Proof

2012-05-04

Study objective: To identify patient and clinical management factors related to emergency department (ED) length of stay for psychiatric patients. Methods: This was a prospective study of 1,092 adults treated at one of 5 EDs between June 2008 and May 2009. Regression analyses were used to identify factors associated with ED length of stay and its 4 subcomponents. Secondary analyses considered patients discharged to home and those who were admitted or transferred separately. Results: The overall mean ED length of stay was 11.5 hours (median 8.2 hours). ED length of stay varied by discharge disposition, with patients discharged to home staying 8.6 hours (95% confidence interval 7.7 to 9.5 hours) and patients transferred to a hospital outside the system of care staying 15 hours (95% confidence interval 12.7 to 17.6 hours) on average. Older age and being uninsured were associated with increased ED length of stay, whereas race, sex, and homelessness had no association. Patients with a positive toxicology screen result for alcohol stayed an average of 6.2 hours longer than patients without toxicology screens, an effect observed primarily in the periods before disposition decision. Diagnostic imaging was associated with an average 3.2-hour greater length of stay, prolonging both early and late components of the ED stay. Restraint use had a similar effect, leading to a length of stay 4.2 hours longer than that of patients not requiring restraints. Conclusion: Psychiatric patients spent more than 11 hours in the ED on average when seeking care. The need for hospitalization, restraint use, and the completion of diagnostic imaging had the greatest effect on postassessment boarding time, whereas the presence of alcohol on toxicology screening led to delays earlier in the ED stay. Identification and sharing of best practices associated with each of these factors would provide an opportunity for improvement in ED care for this population.

Does Cardiac Computed Tomography Angiography Identify Patients at Low Risk for Cardiovascular Events? - Corrected Proof

J. Adam Oostema, Brady Wilkinson — 2012-05-04

Patients with suspected coronary artery disease who have normal cardiac computed tomography (CT) angiography results are at very low risk of death, myocardial infarction, or coronary revascularization.

Head Computed Tomography Use in the Emergency Department for Mild Traumatic Brain Injury: Integrating Evidence Into Practice for the Resident Physician - Corrected Proof

Melinda J. Morton, Frederick K. Korley — 2012-04-30

There is a large gap between the recommendations of high-quality evidence-based guidelines and use of this evidence in routine patient care. The 2001 Institute of Medicine report titled Crossing the Quality Chasm reported that clinicians' adherence to well-established evidence is “highly uneven.” Multiple barriers to acceptance and implementation of evidence exist, including lack of awareness or familiarity, variable agreement, questioning of self-efficacy and outcome, and inertia. Given that emergency departments (EDs) manage millions of patients each year, improving evidence uptake and reducing variability in resource use will potentially yield significant benefits in terms of efficacy of care and cost-effectiveness. One example in which there is a potential gap in uptake of evidence in emergency medicine is use of head computed tomography (CT) scans in patients with mild traumatic (TBI) brain injury.

Simulating Various Levels of Clinical Challenge in the Assessment of Clinical Procedure Competence - Corrected Proof

2012-04-30

Study objective: Immersive simulation is increasingly used for competency assessment of emergency physicians. This group's concept of hybrid simulation (HS) (combining simulated patients and part-task trainers (a simulator that simulates a limited component of a clinical procedure) to create a multimodal clinical context) requires clinicians to integrate technical and nontechnical skills in a holistic clinical performance for assessment. It also offers the potential to provide authentic simulation of a given clinical procedure across multiple levels of challenge. The aims of this study are to systematically design and validate 2 patient-focused HS scenarios (each combining a simulated patient with a part-task simulator) for assessment of the management of a commonly encountered problem in an emergency department (ED) at different levels of clinical challenge, and to explore the effect of level of challenge of the HS scenario on physicians' performance. Methods: A simple (HS1) and a complex (HS2) HS scenario (based on the management of a patient with a traumatic skin laceration within the ED) was developed according to expert opinion through cognitive task analysis. Interns and emergency medicine residents (stratified into expert and novice groups according to experience) were recruited to participate in both scenarios. Participants were randomized to perform either the HS1 or HS2 scenario first. Participants completed a questionnaire for face validity (realism of simulation) and content validity (comprehensiveness of simulation). Performances were assessed by 2 independent raters using validated rating tools modified to the needs of this study: the Modified Objective Structured Assessment of Technical Skills–Task Specific Checklist, the Objective Structured Assessment of Technical Skills–Global Rating Score, and the Direct Observation of Procedural Skills. Results: Ten novice and 10 expert clinicians completed both scenarios. Mean face and content validity ratings were high for both HS1 (mean 4.4 [SD 0.52] and 4.2 [SD 0.48], respectively) and HS2 scenarios (mean 4.5 [SD 0.35] and 4.3 [SD 0.43], respectively). In HS1, no difference was found between experts' and novices' Modified Objective Structured Assessment of Technical Skills–Task Specific Checklist, Objective Structured Assessment of Technical Skills–Global Rating Score, and Direct Observation of Procedural Skills ratings. Experts performed significantly better than novices in HS2 in terms of the 3 tools' ratings. Novices' Modified Objective Structured Assessment of Technical Skills–Task Specific Checklist and Direct Observation of Procedural Skills ratings were significantly worse in HS2 compared with HS1, but no difference was found with the Objective Structured Assessment of Technical Skills–Global Rating Score. No statistical difference was found in experts' Modified Objective Structured Assessment of Technical Skills–Task Specific Checklist, Objective Structured Assessment of Technical Skills–Global Rating Score, and Direct Observation of Procedural Skills ratings between HS2 and HS1 scenarios. Conclusion: Recreating clinical challenge is an important consideration in the design of simulation-based assessment of procedural skills of clinicians. In this study, we have demonstrated a systematic approach to developing HS scenarios, which may be able to recreate various levels of clinical challenge for purpose of assessment of procedural skills.

Comparative Effectiveness of Care Coordination Interventions in the Emergency Department: A Systematic Review - Corrected Proof

Elyse B. Katz, Emily R. Carrier, Craig A. Umscheid, Jesse M. Pines — 2012-04-30

Study objective: To conduct a systematic review on the effectiveness of emergency department (ED)–based care coordination interventions. Methods: We reviewed any randomized controlled trial or quasi-experimental study indexed in MEDLINE, CINAHL, Web of Science, Cochrane, or Scopus that evaluated the effectiveness of ED-based care coordination interventions. To be included, interventions had to incorporate information from previous visits, provide educational services on continuing care, provide post-ED treatment plans, or transfer information to continuing care providers. Studies had to quantify information transfer or report ED revisits, hospitalizations, or follow-up rates. Randomized controlled trial quality was assessed with the Jadad score. Results: Of 23 included articles, 14 were randomized controlled trials and 9 were quasi-experimental studies. Randomized controlled trial quality ranged from 2 to 3 on a 5-point scale. The majority of the studies (17) were conducted at a single center. Of nineteen studies that developed post-ED plans, 12 were effective in improving follow-up rates or reducing repeated ED visits. Four studies found paradoxically higher ED visit rates. Of 4 that used educational services for continuing care, 2 were effective. Of the 2 evaluating information transfer, 1 was effective. One study assessed incorporating information from other sites and found higher rates of information transfer, but utilization was not studied. Conclusion: The majority of ED-based care coordination interventions focus on interfacing with outpatient providers, and about two thirds have been effective in increasing follow-up rates or reducing repeated ED utilization. Other types of interventions have shown similar effectiveness, but fewer have been studied.

Emergency Department Patients' Preferences for Technology-Based Behavioral Interventions - Corrected Proof

2012-04-30

Study objective: To assess emergency department (ED) patients' preferences for technology-based behavioral interventions, and the demographic factors associated with these preferences. Methods: A cross-sectional survey of a random sample of urban ED patients (⩾13 years) from a representative sample of shifts, with oversampling of adolescents/young adults (aged 13 to 24 years). Participants self-administered the survey about baseline technology use, concerns about technology-based interventions, and preferred intervention format for 7 behavioral health topics. We performed descriptive statistics and multivariate logistic regression (controlling for demographics and then additionally for baseline technology use) to identify factors differentially associated with technology preference for each behavioral topic. Results: Of patients presenting during research assistant shifts, 1,429 (≈59%) were screened and 664 (68.2% of eligible) consented to participate. Mean age was 31 years (SD 0.69); 54.5% were female, 64.1% were white, 23.2% were Hispanic, and 46.6% reported low income. Baseline use of computers (91.2%), Internet (70.7%), social networking (66.9%), mobile phones (95.0%), and text messaging (73.8%) was high. Participants reported interest in receiving interventions on each behavioral topic. Ninety percent preferred a technology-based intervention for at least 1 topic. Patients expressed greatest concerns about Internet (51.5%) and social networking (57.6%), particularly about confidentiality. Adjusting for sex, race, ethnicity, and income, younger age associated with preference for technology-based interventions for unintentional injuries (odds ratio 0.63 for technology preference if adult versus youth; 95% confidence interval 0.45 to 0.89) and peer violence (odds ratio 0.63 if adult; 95% confidence interval 0.43 to 0.92). Additionally adjusting for baseline technology usage, only baseline usage was associated with preference for technology-based interventions. Conclusion: ED patients reported high baseline technology use, high interest in behavioral health interventions, and varying preferences for technology-based interventions. Future studies should address actual feasibility and acceptability of technology-based interventions in a more generalized population and ways to alleviate concerns about these interventions.

Does the Use of Recombinant Factor VIIA Reduce Morbidity or Mortality in Nonhemophiliac Patients? - Corrected Proof

Steven Sattler, Adam Schwartz — 2012-04-30

There is no prophylactic or therapeutic benefit to the use of recombinant factor VIIa (rFVIIa) as a hemostatic agent in nonhemophiliac patients. Cochrane Injuries Group Specialized Register, The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, NBS Systematic Review Initiative RCT Database, Latin American and Caribbean Health Sciences Literature, KoreaMed, IndMed, PakMediNet, mRCT, ClinicalTrials.gov, and the WHO ICTRP Database were searched. The authors also searched references in review articles and attempted to identify the gray literature by contacting trialists.

Are Benzodiazepines Effective for Alcohol Withdrawal? - Corrected Proof

Timothy J. Schaefer, John W. Hafner — 2012-04-30

When compared with placebo, benzodiazepines offer significant benefit in preventing alcohol withdrawal seizures. The authors searched Cochrane Drugs and Alcohol Group' Register of Trials, PubMed, EMBASE, CINAHL, the American Economic Association's electronic bibliography, the reference lists of relevant articles, and relevant conference proceedings and contacted investigators for unpublished or incomplete trial information.

Prevalence of Bicycle Helmet Use by Users of Public Bikeshare Programs - Corrected Proof

2012-04-30

Study objective: Public bikeshare programs are becoming increasingly common in the United States and around the world. These programs make bicycles accessible for hourly rental to the general public. We seek to describe the prevalence of helmet use among adult users of bikeshare programs and users of personal bicycles in 2 cities with recently introduced bikeshare programs (Boston, MA, and Washington, DC). Methods: We performed a prospective observational study of adult bicyclists in Boston, MA, and Washington, DC. Trained observers collected data during various times of the day and days of the week. Observers recorded the sex of the bicycle operator, type of bicycle, and helmet use. All bicycles that passed a single stationary location in any direction for a period of between 30 and 90 minutes were recorded. Results: There were 43 observation periods in 2 cities at 36 locations; 3,073 bicyclists were observed. There were 562 (18.3%; 95% confidence interval [CI] 16.4% to 20.3%) bicyclists riding shared bicycles. Overall, 54.5% of riders were unhelmeted (95% CI 52.7% to 56.3%), although helmet use varied significantly with sex, day of use, and type of bicycle. Bikeshare users were unhelmeted at a higher rate compared with users of personal bicycles (80.8% versus 48.6%; 95% CI 77.3% to 83.8% versus 46.7% to 50.6%). Logistic regression, controlling for type of bicycle, sex, day of week, and city, demonstrated that bikeshare users had higher odds of riding unhelmeted (odds ratio [OR] 4.4; 95% CI 3.5 to 5.5). Men had higher odds of riding unhelmeted (OR 1.6; 95% CI 1.4 to 1.9), as did weekend riders (OR 1.3; 95% CI 1.1 to 1.6). Conclusion: Use of bicycle helmets by users of public bikeshare programs is low. As these programs become more popular and prevalent, efforts to increase helmet use among users should increase.

Patients With Rib Fractures Do Not Develop Delayed Pneumonia: A Prospective, Multicenter Cohort Study of Minor Thoracic Injury - Corrected Proof

2012-04-30

Study objective: Patients admitted to emergency departments (EDs) for minor thoracic injuries are possibly at risk of delayed pneumonia. We aimed to evaluate the incidence of delayed pneumonia post–minor thoracic injury and the associated risk factors. Methods: A prospective, multicenter cohort study was conducted in 4 Canadian EDs, from November 2006 to November 2010. All consecutive patients aged 16 years and older with minor thoracic injury who were discharged from the ED were screened for eligibility. Uniform clinical and radiologic evaluations were performed on the initial ED visit and were repeated at weeks 1 and 2. Relative risk analyses quantified incidence with comparison by age, sex, smoking status, alcohol intoxication, pulmonary comorbidity, ability to cough atelectasis, pain level, and number of rib fractures. Results: Of the 1,057 participants recruited, 347 (32.8%) had at least 1 rib fracture, 87 (8.2%) had asthma, and 36 (3.4%) had chronic obstructive pulmonary disease. Only 6 patients (0.6%; 95% confidence interval 0.24% to 1.17%) developed pneumonia during the follow-up period. The relative risk for patients with preexistent pulmonary disease and radiologically proven rib fractures was 8.6 (P=.045; 95% confidence interval 1.05 to 70.9). Sex, smoking habit, initial atelectasis, ability to cough, and alcohol intoxication were not significantly associated with delayed pneumonia. Conclusion: This prospective cohort study of nonhospitalized patients with minor thoracic injuries revealed a low incidence of delayed pneumonia. Nonetheless, our results support tailored follow-up for asthmatic or chronic obstructive pulmonary disease patients with rib fracture.

Association Between Repeated Intubation Attempts and Adverse Events in Emergency Departments: An Analysis of a Multicenter Prospective Observational Study - Corrected Proof

2012-04-30

Study objective: Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events. Methods: We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation. Results: Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1). Conclusion: In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events.

Are Thrombolytics Indicated for Pulmonary Embolism? - Corrected Proof

Melinda J. Morton, Rodney Omron — 2012-04-20

There is a lack of evidence to support the routine administration of thrombolytics for the undifferentiated pulmonary embolism patient. The Cochrane Peripheral Vascular Diseases Review Group searched their Specialized Register in April 2009 and CENTRAL in The Cochrane Library through issue 2, 2009. The authorship group also hand searched private databases and bibliographies of relevant articles.

Do Febrile Infants Aged 60 to 90 Days With Bronchiolitis Require a Septic Evaluation? - Corrected Proof

Anand Swaminathan, Jeffrey Hom — 2012-04-20

Febrile infants younger than 90 days and with bronchiolitis have very low rates of serious bacterial infection. The authors searched the National Library of Medicine Medline database (to December 2010). In addition, the bibliographies of these studies were searched for studies not otherwise identified.

Electrocardiographic Differentiation of Early Repolarization From Subtle Anterior ST-Segment Elevation Myocardial Infarction - Corrected Proof

2012-04-20

Study objective: Anterior ST-segment elevation myocardial infarction (STEMI) can be difficult to differentiate from early repolarization on the ECG. We hypothesize that, in addition to ST-segment elevation, T-wave amplitude to R-wave amplitude ratio (T-wave amplitudeavg/R-wave amplitudeavg), and R-wave amplitude in leads V2 to V4, computerized corrected QT interval (QTc) and upward concavity would help to differentiate the 2. We seek to determine which ECG measurements best distinguish STEMI versus early repolarization. Methods: This was a retrospective study of patients with anterior STEMI (2003 to 2009) and early repolarization (2003 to 2005) at 2 urban hospitals, one of which (Minneapolis Heart Institute) receives 500 STEMI patients per year. We compared the ECGs of nonobvious (“subtle”) anterior STEMI with emergency department noncardiac chest pain patients with early repolarization. ST-segment elevation at the J point and 60 ms after the J point, T-wave amplitude, R-wave amplitude, QTc, upward concavity, J-wave notching, and T waves in V1 and V6 were measured. Multivariate logistic regression modeling was used to identify ECG measurements independently predictive of STEMI versus early repolarization in a derivation group and was subsequently validated in a separate group. Results: Of 355 anterior STEMIs identified, 143 were nonobvious, or subtle, compared with 171 early repolarization ECGs. ST-segment elevation was greater, R-wave amplitude lower, and T-wave amplitudeavg/R-wave amplitudeavg higher in leads V2 to V4 with STEMI versus early repolarization. Computerized QTc was also significantly longer with STEMI versus early repolarization. T-wave amplitude did not differ significantly between the groups, such that the T-wave amplitudeavg/R-wave amplitudeavg difference was entirely due to the difference in R-wave amplitude. An ECG criterion based on 3 measurements (R-wave amplitude in lead V4, ST-segment elevation 60 ms after J-point in lead V3, and QTc) was derived and validated for differentiating STEMI versus early repolarization, such that if the value of the equation ([1.196 x ST-segment elevation 60 ms after the J point in lead V3 in mm]+[0.059 x QTc in ms]–[0.326 x R-wave amplitude in lead V4 in mm]) is greater than 23.4 predicted STEMI and if less than or equal to 23.4, it predicted early repolarization in both groups, with overall sensitivity, specificity, and accuracy of 86% (95% confidence interval [CI] 79, 91), 91% (95% CI 85, 95), and 88% (95% CI 84, 92), respectively, with positive likelihood ratio 9.2 (95% CI 8.5 to 10) and negative likelihood ratio 0.1 (95% CI 0.08 to 0.3). Upward concavity, upright T wave in V1 or T wave, in V1 greater than T wave in V6, and J-wave notching did not provide important information. Conclusion: R-wave amplitude is lower, ST-segment elevation greater, and QTc longer for subtle anterior STEMI versus early repolarization. In combination with other clinical data, this derived and validated ECG equation could be an important adjunct in the diagnosis of anterior STEMI.

Individual Interactive Instruction: An Innovative Enhancement to Resident Education - Corrected Proof

Dena A. Reiter, Daniel J. Lakoff, N. Seth Trueger, Kaushal H. Shah — 2012-04-20

[Ann Emerg Med. 2012;■■:■■■.] Individual interactive instruction (previously called asynchronous learning) is defined as individualized learning away from groups of similar-level learners, which allows learners to consume material at their own pace on their own timetable. This is in contrast to synchronous learning, a more traditional teaching style in which learners are all presented the same topic in a group setting.

Are There Pharmacologic Agents That Safely and Effectively Treat Post–Lumbar Puncture Headache? - Corrected Proof

Benton R. Hunter, Rawle A. Seupaul — 2012-04-20

Although intravenous caffeine has demonstrated efficacy for post–lumbar puncture headache in patients who have received spinal anesthesia, its efficacy and safety remain uncertain in patients presenting to the emergency department (ED) after a typical diagnostic lumbar puncture.

Do Decongestants, Antihistamines, and Nasal Irrigation Relieve the Symptoms of Sinusitis in Children? - Corrected Proof

Jeffrey Hom — 2012-04-20

The effects of decongestants, antihistamines, and nasal irrigation for children receiving a diagnosis of sinusitis are unknown. The Cochrane Register of Controlled Trials (CENTRAL) was searched up to May 2010. In addition, EMBASE was searched from 1950 to January 2010. Last, MEDLINE was combined with CENTRAL, using a Cochrane highly sensitive strategy, to search for additional trials.

A Is for Airway: A Pediatric Emergency Department Challenge - Corrected Proof

Steven M. Green — 2012-04-20

SEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2006;■■:■■■.]

From Comparative Effectiveness Research to Patient-Centered Outcomes Research: Integrating Emergency Care Goals, Methods, and Priorities - Corrected Proof

Zachary F. Meisel, Brendan G. Carr, Patrick H. Conway — 2012-04-20

Federal legislation placed comparative effectiveness research and patient-centered outcomes research at the center of current and future national investments in health care research. The role of this research in emergency care has not been well described. This article proposes an agenda for researchers and health care providers to consider comparative effectiveness research and patient-centered outcomes research methods and results to improve the care for patients who seek, use, and require emergency care. This objective will be accomplished by (1) exploring the definitions, frameworks, and nomenclature for comparative effectiveness research and patient-centered outcomes research; (2) describing a conceptual model for comparative effectiveness research in emergency care; (3) identifying specific opportunities and examples of emergency care–related comparative effectiveness research; and (4) categorizing current and planned funding for comparative effectiveness research and patient-centered outcomes research that can include emergency care delivery.

False-Negative FAST Examination: Associations With Injury Characteristics and Patient Outcomes - Corrected Proof

2012-04-19

Study objective: Focused assessment with sonography in trauma (FAST) is widely used for evaluating patients with blunt abdominal trauma; however, it sometimes produces false-negative results. Presenting characteristics in the emergency department may help identify patients at risk for false-negative FAST result or help the physician predict injuries in patients with a negative FAST result who are unstable or deteriorate during observation. Alternatively, false-negative FAST may have no clinical significance. The objectives of this study are to estimate associations between false-negative FAST results and patient characteristics, specific abdominal organ injuries, and patient outcomes. Methods: This was a retrospective cohort study including consecutive patients who presented to an urban Level I trauma center between July 2005 and December 2008 with blunt abdominal trauma, a documented FAST, and pathologic free fluid as determined by computed tomography, diagnostic peritoneal lavage, laparotomy, or autopsy. Physicians blinded to the study purpose used standardized abstraction methods to confirm FAST results and the presence of pathologic free fluid. Multivariable modeling was used to assess associations between potential predictors of a false-negative FAST result and false-negative FAST result and adverse outcomes. Results: During the study period, 332 patients met inclusion criteria. Median age was 32 years (interquartile range 23 to 45 years), 67% were male patients, the median Injury Severity Score was 27 (interquartile range 17 to 41), and 162 (49%) had a false-negative FAST result. Head injury was positively associated with false-negative FAST result (odds ratio [OR] 4.9; 95% confidence interval [CI] 1.5 to 15.7), whereas severe abdominal injury was negatively associated (OR 0.3; 95% CI 0.1 to 0.5). Injuries to the spleen (OR 0.4; 95% CI 0.24 to 0.66), liver (OR 0.36; 95% CI 0.21 to 0.61), and abdominal vasculature (OR 0.17; 95% CI 0.07 to 0.38) were also negatively associated with false-negative FAST result. False-negative FAST result was not associated with mortality (OR 0.89; 95% CI 0.42 to 1.9), prolonged ICU length of stay (relative risk 0.88; 95% CI 0.69 to 1.12), or total hospital length of stay (relative risk 0.92; 95% CI 0.76 to 1.12). However, patients with false-negative FAST results were substantially less likely to require therapeutic laparotomy (OR 0.31; 95% CI 0.19 to 0.52). Conclusion: Patients with severe head injuries and minor abdominal injuries were more likely to have a false-negative than true-positive FAST result. On the other hand, patients with spleen, liver, or abdominal vascular injuries are less likely to have false-negative FAST examination results. Adverse outcomes were not associated with false-negative FAST examination results, and in fact patients with false-negative FAST result were less likely to have a therapeutic laparotomy. Further studies are needed to assess the strength of these findings.

Quality of Registration for Clinical Trials Published in Emergency Medicine Journals - Corrected Proof

Christopher W. Jones, Timothy F. Platts-Mills — 2012-04-16

Study objective: In 2005, the International Committee of Medical Journal Editors established clinical trial registration as a requirement for articles submitted to member journals, with the goal of improving the transparency of clinical research. The objective of this study is to characterize the registration of clinical trials published in emergency medicine journals. Methods: Randomized trials involving human subjects and published between June 1, 2008, and May 31, 2011 in the 5 emergency medicine journals with the highest impact factors were included. We assessed the clarity of registered primary outcomes, timing of registration relative to patient enrollment, and consistency between registered and published outcomes. Results: Of the 123 trials included, registry entries were identified for 57 (46%). Of the 57 registered studies, 45 (79%) were registered after the initiation of subject enrollment, 9 (16%) had registered outcomes that were unclear, and 26 (46%) had discrepancies between registered and published outcomes. Only 5 studies were registered before patient enrollment with a clear primary outcome that was consistent with the published primary outcome. Annals of Emergency Medicine was the only journal in which the majority of trials were registered. Conclusion: Current compliance with clinical trial registration guidelines is poor among trials published in emergency medicine journals.

Emergency Department Patient Acuity Varies by Age - Corrected Proof

Steven M. Green — 2012-04-16

Study objective: A previous single-region study has suggested that acuity varies by patient age in ways that may affect subspecialty critical care skills retention. This study seeks to independently confirm or refute these findings by using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a large nationally representative database of emergency department (ED) visits. Methods: Using 8 years of NHAMCS data composed of 288,199 ED visits, the following 6 measures of patient acuity were weighted and graphically stratified by patient age: triage category, hospital admission, critical care unit admission, death in the ED, cardiopulmonary resuscitation, and tracheal intubation. Their relative frequency was then compared between adults and children (<18 years). Results: All measures of acuity increased with age and were higher in adults versus children: highest triage category odds ratio 1.3, hospital admission odds ratio 4.2, critical care unit admission odds ratio 4.5, death in the ED odds ratio 5.8, cardiopulmonary resuscitation odds ratio 4.7, and tracheal intubation odds ratio 2.5. Conclusion: This analysis of a large, nationally representative ED sample found substantial age-based differences in patient acuity that can inform discussion about subspecialty critical care skills retention.

A Brief Intervention Reduces Hazardous and Harmful Drinking in Emergency Department Patients - Corrected Proof

2012-03-30

Study objective: Brief interventions have been shown to reduce alcohol use and improve outcomes in hazardous and harmful drinkers, but evidence to support their use in emergency department (ED) patients is limited. The use of research assessments in studies of brief interventions may contribute to uncertainty about their effectiveness. Therefore we seek to determine (1) if an emergency practitioner-performed Brief Negotiation Interview or a Brief Negotiation Interview with a booster reduces alcohol consumption compared with standard care; and (2) the impact of research assessments on drinking outcomes using a standard care-no-assessment group. Methods: We randomized 889 adult ED patients with hazardous and harmful drinking. A total of 740 received an emergency practitioner–performed Brief Negotiation Interview (n=297), a Brief Negotiation Interview with a 1-month follow-up telephone booster (Brief Negotiation Interview with booster) (n=295), or standard care (n=148). We also included a standard care with no assessments (n=149) group to examine the effect of assessments on drinking outcomes. Primary outcomes analyzed with mixed-models procedures included past 7-day alcohol consumption and 28-day binge episodes at 6 and 12 months, collected by interactive voice response. Secondary outcomes included negative health behaviors and consequences collected by telephone surveys. Results: The reduction in mean number of drinks in the past 7 days from baseline to 6 and 12 months was significantly greater in the Brief Negotiation Interview with booster (from 20.4 [95% confidence interval {CI} 18.8 to 22.0] to 11.6 [95% CI 9.7 to 13.5] to 13.0 [95% CI 10.5 to 15.5]) and Brief Negotiation Interview (from 19.8 [95% CI 18.3 to 21.4] to 12.7 [95% CI 10.8 to 14.6] to 14.3 [95% CI 11.9 to 16.8]) than in standard care (from 20.9 [95% CI 18.7 to 23.2] to 14.2 [95% CI 11.2 to 17.1] to 17.6 [95% CI 14.1 to 21.2]). The reduction in 28-day binge episodes was also greater in the Brief Negotiation Interview with booster (from 7.5 [95% CI 6.8 to 8.2] to 4.4 [95% CI 3.6 to 5.2] to 4.7 [95% CI 3.9 to 5.6]) and Brief Negotiation Interview (from 7.2 [95% CI 6.5 to 7.9] to 4.8 [95% CI 4.0 to 5.6] to 5.1 [95% CI 4.2 to 5.9]) than in standard care (from 7.2 [95% CI 6.2 to 8.2] to 5.7 [95% CI 4.5 to 6.9] to 5.8 [95% CI 4.6 to 7.0]). The Brief Negotiation Interview with booster offered no significant benefit over the Brief Negotiation Interview alone. There were no differences in drinking outcomes between the standard care and standard care–no assessment groups. The reductions in rates of driving after drinking more than 3 drinks from baseline to 12 months were greater in the Brief Negotiation Interview (38% to 29%) and Brief Negotiation Interview with booster (39% to 31%) groups than in the standard care group (43% to 42%). Conclusion: Emergency practitioner–performed brief interventions can reduce alcohol consumption and episodes of driving after drinking in hazardous and harmful drinkers. These results support the use of brief interventions in ED settings.

Defining Frequent Use: The Numbers No Longer Count - Corrected Proof

Ellen J. Weber — 2012-03-26

SEE RELATED ARTICLE, P. ■■■. [Ann Emerg Med. 2012;■■:■■■.]

Ibuprofen Prevents Altitude Illness: A Randomized Controlled Trial for Prevention of Altitude Illness With Nonsteroidal Anti-inflammatories - Corrected Proof

2012-03-22

Study objective: Acute mountain sickness occurs in more than 25% of the tens of millions of people who travel to high altitude each year. Previous studies on chemoprophylaxis with nonsteroidal anti-inflammatory drugs are limited in their ability to determine efficacy. We compare ibuprofen versus placebo in the prevention of acute mountain sickness incidence and severity on ascent from low to high altitude. Methods: Healthy adult volunteers living at low altitude were randomized to ibuprofen 600 mg or placebo 3 times daily, starting 6 hours before ascent from 1,240 m (4,100 ft) to 3,810 m (12,570 ft) during July and August 2010 in the White Mountains of California. The main outcome measures were acute mountain sickness incidence and severity, measured by the Lake Louise Questionnaire acute mountain sickness score with a diagnosis of ≥ 3 with headache and 1 other symptom. Results: Eighty-six participants completed the study; 44 (51%) received ibuprofen and 42 (49%) placebo. There were no differences in demographic characteristics between the 2 groups. Fewer participants in the ibuprofen group (43%) developed acute mountain sickness compared with those receiving placebo (69%) (odds ratio 0.3, 95% confidence interval 0.1 to 0.8; number needed to treat 3.9, 95% confidence interval 2 to 33). The acute mountain sickness severity was higher in the placebo group (4.4 [SD 2.6]) than individuals receiving ibuprofen (3.2 [SD 2.4]) (mean difference 0.9%; 95% confidence interval 0.3% to 3.0%). Conclusion: Compared with placebo, ibuprofen was effective in reducing the incidence of acute mountain sickness.

An Overview of the Adaptive Designs Accelerating Promising Trials Into Treatments (ADAPT-IT) Project - Corrected Proof

2012-03-19

Randomized clinical trials, which aim to determine the efficacy and safety of drugs and medical devices, are a complex enterprise with myriad challenges, stakeholders, and traditions. Although the primary goal is scientific discovery, clinical trials must also fulfill regulatory, clinical, and ethical requirements. Innovations in clinical trials methodology have the potential to improve the quality of knowledge gained from trials, the protection of human subjects, and the efficiency of clinical research. Adaptive clinical trial methods represent a broad category of innovations intended to address a variety of long-standing challenges faced by investigators, such as sensitivity to previous assumptions and delayed identification of ineffective treatments. The implementation of adaptive clinical trial methods, however, requires greater planning and simulation compared with a more traditional design, along with more advanced administrative infrastructure for trial execution. The value of adaptive clinical trial methods in exploratory phase (phase 2) clinical research is generally well accepted, but the potential value and challenges of applying adaptive clinical trial methods in large confirmatory phase clinical trials are relatively unexplored, particularly in the academic setting. In the Adaptive Designs Accelerating Promising Trials Into Treatments (ADAPT-IT) project, a multidisciplinary team is studying how adaptive clinical trial methods could be implemented in planning actual confirmatory phase trials in an established, National Institutes of Health–funded clinical trials network. The overarching objectives of ADAPT-IT are to identify and quantitatively characterize the adaptive clinical trial methods of greatest potential value in confirmatory phase clinical trials and to elicit and understand the enthusiasms and concerns of key stakeholders that influence their willingness to try these innovative strategies.

Errors of Medical Interpretation and Their Potential Clinical Consequences: A Comparison of Professional Versus Ad Hoc Versus No Interpreters - Corrected Proof

Glenn Flores, Milagros Abreu, Cara Pizzo Barone, Richard Bachur, Hua Lin — 2012-03-19

Study objective: To compare interpreter errors and their potential consequences in encounters with professional versus ad hoc versus no interpreters. Methods: This was a cross-sectional error analysis of audiotaped emergency department (ED) visits during 30 months in the 2 largest pediatric EDs in Massachusetts. Participants were Spanish-speaking limited-English-proficient patients, caregivers, and their interpreters. Outcome measures included interpreter error numbers, types, and potential consequences. Results: The 57 encounters included 20 with professional interpreters, 27 with ad hoc interpreters, and 10 with no interpreters; 1,884 interpreter errors were noted, and 18% had potential clinical consequences. The proportion of errors of potential consequence was significantly lower for professional (12%) versus ad hoc (22%) versus no interpreters (20%). Among professional interpreters, previous hours of interpreter training, but not years of experience, were significantly associated with error numbers, types, and potential consequences. The median errors by professional interpreters with greater than or equal to 100 hours of training was significantly lower, at 12, versus 33 for those with fewer than 100 hours of training. Those with greater than or equal to 100 hours of training committed significantly lower proportions of errors of potential consequence overall (2% versus 12%) and in every error category. Conclusion: Professional interpreters result in a significantly lower likelihood of errors of potential consequence than ad hoc and no interpreters. Among professional interpreters, hours of previous training, but not years of experience, are associated with error numbers, types, and consequences. These findings suggest that requiring at least 100 hours of training for interpreters might have a major impact on reducing interpreter errors and their consequences in health care while improving quality and patient safety.

Lung Carcinoma Presenting With Pathologic Femur Fracture and False-Positive Pregnancy Test Result - Corrected Proof

Brandon C. Maughan, Achyut Kamat — 2012-03-19

β-Human chorionic gonadotropin (βhCG) assays are routinely used to test for pregnancy. However, βhCG may be elevated in conditions other than pregnancy. We describe a case of metastatic lung adenocarcinoma presenting with a pathologic femur fracture and a false-positive urine pregnancy test. Lung cancer is the most common nongestational malignancy that produces βhCG among reproductive-age women. Emergency physicians should consider this rare cause of a positive pregnancy test result in women who deny recent sexual intercourse, especially if the patient is older than 40 years, has a history of tobacco use, or presents with respiratory complaints.

Update: Antiemetics for Vomiting Associated With Acute Gastroenteritis in Children - Corrected Proof

Ben Carter, Rawle A. Seupaul — 2012-03-19

Oral or intravenous ondansetron is an effective treatment for the management of children with vomiting from acute gastroenteritis. This was an update of a previous Cochrane review. The authors of the review searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to July 2005), and EMBASE (1980 to July 2005). They also hand searched published abstracts from relevant conference proceedings and contacted content experts for unpublished data. This search was rerun up to July 2010, yielding 3 additional trials and 3 ongoing studies. There were no language restrictions.

Hydroxocobalamin and Epinephrine Both Improve Survival in a Swine Model of Cyanide-Induced Cardiac Arrest - Corrected Proof

2012-03-19

Study objective: To determine whether hydroxocobalamin will improve survival compared with epinephrine and saline solution controls in a model of cyanide-induced cardiac arrest. Methods: Forty-five swine (38 to 42 kg) were tracheally intubated, anesthetized, and central venous and arterial continuous cardiovascular monitoring catheters were inserted. Potassium cyanide was infused until cardiac arrest developed, defined as mean arterial pressure less than 30 mm Hg. Animals were treated with standardized mechanical chest compressions and were randomly assigned to receive one of 3 intravenous bolus therapies: hydroxocobalamin, epinephrine, or saline solution (control). All animals were monitored for 60 minutes after cardiac arrest. Additional epinephrine infusions were used in all arms of the study after return of spontaneous circulation for systolic blood pressure less than 90 mm Hg. A sample size of 15 animals per group was determined according to a power of 80%, a survival difference of 0.5, and an α of 0.05. Repeated-measure ANOVA was used to determine statistically significant changes between groups over time. Results: Baseline weight, time to arrest, and cyanide dose at cardiac arrest were similar in the 3 groups. Coronary perfusion pressures with chest compressions were greater than 15 mm Hg in both treatment groups indicating sufficient compression depth. Zero of 15 (95% confidence interval [CI] 0% to 25%) animals in the control group, 11 of 15 (73%; 95% CI 48% to 90%) in the hydroxocobalamin group, and 11 of 15 (73%; 95% CI 48% to 90%) in the epinephrine group survived to the conclusion of the study (P<.001). The proportion of animals with return of spontaneous circulation at 5 minutes was 4 of 15 (27%; 95% CI 10% to 52%), and that of return of spontaneous circulation at 10 minutes was 11 of 15 (73%; 95% CI 48% to 90%) in the 2 treatment groups. Additional epinephrine infusion after return of spontaneous circulation was administered for hypotension in 2 of 11 (18%; 95% CI 4% to 48%) hydroxocobalamin animals and in 11 of 11 (100%; 95% CI 70% to 100%) of the epinephrine animals (P<.001). At 60 minutes, serum lactate was significantly lower in the hydroxocobalamin group compared with the epinephrine group (4.9 [SD 2.2] versus 12.3 [SD 2.2] mmol/L), and the pH was significantly higher (7.34 [SD 0.03] versus 7.15 [SD 0.07]). Serial blood cyanide levels in the hydroxocobalamin group were also lower than that of the epinephrine group from cardiac arrest through the conclusion of the study. Conclusion: Intravenous hydroxocobalamin and epinephrine both independently improved survival compared with saline solution control in our swine model of cyanide-induced cardiac arrest. Hydroxocobalamin improved mean arterial pressure and pH, decreased blood lactate and cyanide levels, and decreased the use of rescue epinephrine therapy compared with that in the epinephrine group.

Alcohol and Drug Use Disorders Among Adults in Emergency Department Settings in the United States - Corrected Proof

2012-03-19

Study objective: Improving identification and treatment for substance use disorders is a national priority, but data about various drug use disorders encountered in emergency departments (EDs) are lacking. We examine past-year substance use and substance use disorders (alcohol, 9 drug classes) among adult ED users. Prevalences of substance use and substance use disorders among ED nonusers are calculated for reference purposes. Methods: Using data from the 2007 to 2009 National Surveys on Drug Use and Health, we assessed substance use disorders among noninstitutionalized adults aged 18 years or older who responded to standardized survey questions administered by audio computer-assisted self-interviewing methods. Results: Of all adults (N=113,672), 27.8% used the ED in the past year. ED users had higher prevalences than ED nonusers of coexisting alcohol and drug use (15.2% versus 12.1%), drug use (any drug, 16.9% versus 13.0%; marijuana, 12.1% versus 9.7%; opioids, 6.6% versus 4.1%), and alcohol or drug disorders (11.0% versus 8.5%). Among substance users, the ED group on average spent more days using drugs than the non-ED group; ED users manifested higher conditional rates of substance use disorders than ED nonusers (alcohol or drugs, 15.9% versus 11.7%; marijuana, 16.6% versus 13.2%; cocaine, 33.2% versus 22.3%; opioids, 20.6% versus 10.0%; stimulants, 18.6% versus 9.2%; sedatives, 35.0% versus 4.4%; tranquilizers, 12.4% versus 5.2%). Regardless of ED use status, substance-using young adults, men, and less-educated adults showed increased odds of having a substance use disorder. Conclusion: Drug use is prevalent and combined with high rates of drug use disorders among drug users treated in the ED.

Diagnosis of Intussusception by Physician Novice Sonographers in the Emergency Department - Corrected Proof

Antonio Riera, Allen L. Hsiao, Melissa L. Langhan, T. Rob Goodman, Lei Chen — 2012-03-19

Study objective: We investigate the performance characteristics of bedside emergency department (ED) ultrasonography by nonradiologist physician sonographers in the diagnosis of ileocolic intussusception in children. Methods: This was a prospective, observational study conducted in a pediatric ED of an urban tertiary care children's hospital. Pediatric emergency physicians with no experience in bowel ultrasonography underwent a focused 1-hour training session conducted by a pediatric radiologist. The session included a didactic component on sonographic appearances of ileocolic intussusception, review of images with positive and negative results for intussusceptions, and a hands-on component with a live child model. On completion of the training, a prospective convenience sample study was performed. Children were enrolled if they were to undergo diagnostic radiology ultrasonography for suspected intussusception. Bedside ultrasonography by trained pediatric emergency physicians was performed and interpreted as either positive or negative for ileocolic intussusception. Ultrasonographic studies were then performed by diagnostic radiologists, and their results were used as the reference standard. Test characteristics (sensitivity, specificity, positive and negative predictive values) and likelihood ratios were calculated. Results: Six pediatric emergency physicians completed the training and performed the bedside studies. Eighty-two patients were enrolled. The median age was 25 months (range 3 to 127 months). Thirteen patients (16%) received a diagnosis of ileocolic intussusception by diagnostic radiology. Bedside ultrasonography had a sensitivity of 85% (95% confidence interval [CI] 54% to 97%), specificity of 97% (95% CI 89% to 99%), positive predictive value of 85% (95% CI 54% to 97%), and negative predictive value of 97% (95% CI 89% to 99%). A positive bedside ultrasonographic result had a likelihood ratio of 29 (95% CI 7.3 to 117), and a negative bedside ultrasonographic result had a likelihood ratio of 0.16 (95% CI 0.04 to 0.57). Conclusion: With limited and focused training, pediatric emergency physicians can accurately diagnose ileocolic intussusception in children by using bedside ultrasonography.

Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review - Corrected Proof

2012-03-19

Study objective: Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED). Methods: We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success. Results: We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. Conclusion: Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries - Corrected Proof

Paul T. Cheung, Jennifer L. Wiler, Robert A. Lowe, Adit A. Ginde — 2012-03-14

Study objective: We compare the association between barriers to timely primary care and emergency department (ED) utilization among adults with Medicaid versus private insurance. Methods: We analyzed 230,258 adult participants of the 1999 to 2009 National Health Interview Survey. We evaluated the association between 5 specific barriers to timely primary care (unable to get through on telephone, unable to obtain appointment soon enough, long wait in the physician's office, limited clinic hours, lack of transportation) and ED utilization (≥1 ED visit during the past year) for Medicaid and private insurance beneficiaries. Multivariable logistic regression models adjusted for demographics, socioeconomic status, health conditions, outpatient care utilization, and survey year. Results: Overall, 16.3% of Medicaid and 8.9% of private insurance beneficiaries had greater than or equal to 1 barrier to timely primary care. Compared with individuals with private insurance, Medicaid beneficiaries had higher ED utilization overall (39.6% versus 17.7%), particularly among those with barriers (51.3% versus 24.6% for 1 barrier and 61.2% versus 28.9% for ≥2 barriers). After adjusting for covariates, Medicaid beneficiaries were more likely to have barriers (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 1.30 to 1.52) and higher ED utilization (adjusted OR 1.48; 95% CI 1.41 to 1.56). ED utilization was even higher among Medicaid beneficiaries with 1 barrier (adjusted OR 1.66; 95% CI 1.44 to 1.92) or greater than or equal to 2 barriers (adjusted OR 2.01; 95% CI 1.72 to 2.35) compared with that for individuals with private insurance and barriers. Conclusion: Compared with individuals with private insurance, Medicaid beneficiaries were affected by more barriers to timely primary care and had higher associated ED utilization. Expansion of Medicaid eligibility alone may not be sufficient to improve health care access.

Early Administration of Systemic Corticosteroids Reduces Hospital Admission Rates for Children With Moderate and Severe Asthma Exacerbation - Corrected Proof

2012-03-12

Study objective: The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes. Methods: We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders. Results: Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval −1.3 to −0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score. Conclusion: In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness.

Does Computed Tomography Rule Out Clinically Significant Cervical Spine Injuries in Patients With Obtunded or Intubated Blunt Trauma? - Corrected Proof

Jonathan Kirschner, Rawle A. Seupaul — 2012-03-12

Cervical spine computed tomography (CT) is highly sensitive and may reliably exclude unstable injuries in patients with obtunded or intubated blunt trauma. The authors searched MEDLINE (1966 to 2009), EMBASE (1980 to 2009), and bibliographies of included trials, limiting the search to English-language articles.

At Risk of Undertriage? Testing the Performance and Accuracy of the Emergency Severity Index in Older Emergency Department Patients - Corrected Proof

2012-03-09

Study objective: We test predictive validity, interrater reliability, and diagnostic accuracy of the Emergency Severity Index in older emergency department (ED) patients and identify reasons for inadequate triage. Methods: We analyzed data of patients aged 65 years or older who were included in a prospective, single-center cohort study. Predictive validity was assessed by investigating associations of resources, disposition, length of stay, and mortality with Emergency Severity Index levels. Diagnostic accuracy was tested by calculating sensitivity and specificity of Emergency Severity Index level 1 for the prediction of a lifesaving intervention. For the assessment of interrater reliability, 2 experts independently reviewed the triage nurses' notes. Agreement was estimated as raw agreement and as Cohen's weighted κ. Results: In total, 519 older patients were included. Emergency Severity Index level was associated with resource consumption (Spearman's ρ=–0.449; 95% confidence interval [CI] −0.519 to −0.379), disposition (Kendall's τ=–0.452; 95% CI −0.516 to −0.387), ED length of stay (Kruskal-Wallis χ2=92.5; df=4; P<.001), and mortality (log-rank χ2=37.04; df=3; P<.001). The sensitivity of the Emergency Severity Index to predict lifesaving interventions was 0.462 (95% CI 0.232 to 0.709), and the specificity was 0.998 (95% CI 0.989 to 1.000). Interrater reliability between experts was high (raw agreement 0.917, 95% CI 0.894 to 0.944; Cohen's weighted κw=0.934, 95% CI 0.913 to 0.954). Undertriage occurred in 117 cases. Main reasons were neglect of high-risk situations and failure to appropriately interpret vital signs. Conclusion: In our study, older patients were at risk for undertriage. However, our results suggest that the Emergency Severity Index is reliable and valid for triage of older patients.

Observational Studies of Patients in the Emergency Department: A Comparison of 4 Sampling Methods - Corrected Proof

2012-03-09

Study objective: We evaluate the ability of 4 sampling methods to generate representative samples of the emergency department (ED) population. Methods: We analyzed the electronic records of 21,662 consecutive patient visits at an urban, academic ED. From this population, we simulated different models of study recruitment in the ED by using 2 sample sizes (n=200 and n=400) and 4 sampling methods: true random, random 4-hour time blocks by exact sample size, random 4-hour time blocks by a predetermined number of blocks, and convenience or “business hours.” For each method and sample size, we obtained 1,000 samples from the population. Using χ2 tests, we measured the number of statistically significant differences between the sample and the population for 8 variables (age, sex, race/ethnicity, language, triage acuity, arrival mode, disposition, and payer source). Then, for each variable, method, and sample size, we compared the proportion of the 1,000 samples that differed from the overall ED population to the expected proportion (5%). Results: Only the true random samples represented the population with respect to sex, race/ethnicity, triage acuity, mode of arrival, language, and payer source in at least 95% of the samples. Patient samples obtained using random 4-hour time blocks and business hours sampling systematically differed from the overall ED patient population for several important demographic and clinical variables. However, the magnitude of these differences was not large. Conclusion: Common sampling strategies selected for ED-based studies may affect parameter estimates for several representative population variables. However, the potential for bias for these variables appears small.

Ketamine-Propofol Combination (Ketofol) Versus Propofol Alone for Emergency Department Procedural Sedation and Analgesia: A Randomized Double-Blind Trial - Corrected Proof

2012-03-09

Study objective: We determine whether a 1:1 mixture of ketamine and propofol (ketofol) for emergency department (ED) procedural sedation results in a 13% or more absolute reduction in adverse respiratory events compared with propofol alone. Methods: Participants were randomized to receive either ketofol or propofol in a double-blind fashion. Inclusion criteria were aged 14 years or older and American Society of Anesthesiology class 1 to 3 status. The primary outcome was the number and proportion of patients experiencing an adverse respiratory event as defined by the Quebec Criteria. Secondary outcomes were sedation consistency, efficacy, and time; induction time; and adverse events. Results: A total of 284 patients were enrolled, 142 per group. Forty-three (30%) patients experienced an adverse respiratory event in the ketofol group compared with 46 (32%) in the propofol group (difference 2%; 95% confidence interval −9% to 13%; P=.80). Three ketofol patients and 1 propofol patient received bag-valve-mask ventilation. Sixty-five (46%) patients receiving ketofol and 93 (65%) patients receiving propofol required repeated medication dosing or progressed to a Ramsay Sedation Score of 4 or less during their procedure (difference 19%; 95% confidence interval 8% to 31%; P=.001). Six patients receiving ketofol were treated for recovery agitation. Other secondary outcomes were similar between the groups. Patients and staff were highly satisfied with both agents. Conclusion: Ketofol for ED procedural sedation does not result in a reduced incidence of adverse respiratory events compared with propofol alone. Induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol.

How Accurate Are Clinical Decision Rules for Pediatric Minor Head Injury? - Corrected Proof

Kelly Medwid, Gene G. Couri — 2012-03-09

The Pediatric Emergency Care Applied Research Network (PECARN) decision rule is very sensitive for detecting clinically important brain injury in children with minor head trauma.

Evidence From the Scene: Paramedic Perspectives on Involvement in Out-of-Hospital Research - Corrected Proof

2012-03-05

Study objective: In the context of calls to develop better systems for out-of-hospital clinical research, we seek to understand paramedics' perceptions of involvement in research and the barriers and facilitators to that involvement. Methods: This was a qualitative study using semistructured focus groups with 58 United Kingdom paramedics and interviews with 30 US firefighter-paramedics. The study focused on out-of-hospital research (trials of out-of-hospital treatment for stroke), whereby paramedics identified potential study subjects or obtained consent and administered study treatment in the field. Data were analyzed with a thematic and discourse approach. Results: Three key themes emerged as significant facilitators and barriers to paramedic involvement in research: patient benefit, professional identity and responsibility, and time. Paramedics showed willingness and capacity to engage in research but also some reticence because of the perceived sacrifice of autonomy and challenge to their identity. Paramedics work in a time-sensitive environment and were concerned that research would increase time taken in the field. Conclusion: Awareness of these perspectives will help with development of out-of-hospital research protocols and potentially facilitate greater participation.

Hyperthermia and Multiorgan Failure After Abuse of “Bath Salts” Containing 3,4-Methylenedioxypyrovalerone - Corrected Proof

Heather A. Borek, Christopher P. Holstege — 2012-03-05

“Bath salts” are being increasingly used as drugs of abuse. These products have been found to contain a variety of compounds, including 3,4-methylenedioxypyrovalerone (MDPV). We present a case of a 25-year-old man who injected bath salts and acutely developed severe agitation, hyperthermia, and tachycardia. Despite aggressive early medical management, including dialysis, he progressed to multiorgan system failure, although he ultimately recovered after a prolonged hospital course. The only chemical substance detected on comprehensive toxicologic testing was MDPV, a synthetic cathinone analogue. According to our case, MDPV abuse may result in adverse multisystem organ effects, including rhabdomyolysis, cardiac injury, hepatic injury, and renal failure. It is unknown whether these end-organ effects were due to direct cellular toxicity induced by MDPV or a result of the patient's marked agitation and hyperthermia. Acute management should focus on the rapid identification of organ injury and appropriate supportive care.