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1.  Reducing Blood Culture Contamination in Community Hospital Emergency Departments: Multicenter Evaluation of a Quality Improvement Intervention 
Objectives
Blood culture contamination is a common and preventable problem in the emergency department (ED). In a previous single-center study, changing the process of ED blood culture collection from the traditional “clean,” nonsterile procedure to a fully sterile procedure with standardized use of sterile gloves, large volume chlorhexidine skin antisepsis, and fenestrated sterile drapes resulted in a substantial reduction in contamination. The objective of the current study was to evaluate the effectiveness of this sterile blood culture collection process for reducing blood culture contamination in two community hospital EDs.
Methods
The authors implemented the sterile blood culture collection process in the ED of two hospitals, including Hospital A, which historically had a contamination rate of approximately 5%, and Hospital B, with a 2.5% historical contamination rate. Using an interrupted times series design and segmented regression analysis to adjust for secular trends and autocorrelation, the monthly percentages of cultures contaminated at each hospital during an intervention period (sterile technique) were compared to a 10-month baseline period immediately preceding implementation (clean technique). At Hospital A, the full sterile blood culture collection process was used throughout the 16-month intervention period. At Hospital B, user feedback indicated poor compliance due to difficulty implementing the fenestrated drape component; therefore, the process was simplified to the modified sterile collection process, in which the fenestrated drape component was dropped and sterile gloves and large volume skin antisepsis were emphasized. Hence, at Hospital B, two intervention periods were compared to the baseline period—the 8-month intervention period 1 (full sterile process) and the subsequent 8-month intervention period 2 (modified sterile process).
Results
Hospital A: During the baseline period 165 / 3417 (4.83%) cultures were contaminated, while 142 / 5238 (2.71%) were contaminated during the intervention period (p < 0.01). In the segmented regression model, the full sterile blood culture collection process was associated with an immediate 2.68% (95% confidence interval [CI]: 1.43% to 3.52%) absolute reduction in contamination and sustained reductions during the entire intervention period. Hospital B: During the baseline, 63/2509 (2.51%) cultures were contaminated. In intervention period 1 with the full sterile process, 51/1865 (2.73%) cultures were contaminated (p=0.65), with segmented regression results showing no changes compared to baseline. After simplification of the process to address poor compliance, the modified sterile process during intervention period 2 was associated with a significant reduction in contamination, with 17/1860 (0.91%) cultures contaminated (p<0.01 compared to baseline). The segmented regression model demonstrated the modified sterile process was associated with an immediate 1.53% (95% CI: 1.00% to 1.88%) absolute reduction in contamination with significant sustained reductions.
Conclusions
Changing the method of blood culture collection from the commonly-used non-sterile technique to a sterile process resulted in significant reductions in blood culture contamination at two community hospital EDs, including one with low baseline contamination. Monitoring the implementation process at both sites was important to identify and overcome operational challenges. At one study site, simplification of the process by removing the fenestrated drape component was a key for successful implementation.
doi:10.1111/acem.12337
PMCID: PMC3984048  PMID: 24628752
2.  ST2 in Emergency Department Patients With Noncardiac Dyspnea 
Objectives:
Serum levels of soluble ST2, a member of the interleukin-1 receptor family, predict mortality in emergency department (ED) patients with dyspnea secondary to acute heart failure and acute coronary syndrome. Elevated levels of ST2 have also been described in pulmonary disease, but it is unclear if these are associated with adverse outcomes. The hypothesis for this study was that elevated ST2 levels would be associated with 180-day mortality and 180-day return ED visits or hospital readmission in patients presenting to the ED with noncardiac causes of dyspnea.
Methods:
This prospective observational cohort study enrolled a convenience sample of patients presenting to a single academic tertiary care ED with a chief complaint of dyspnea. Exclusion criteria included dyspnea due to chest wall trauma, airway obstruction, and known cardiac etiology (new onset heart failure, prior heart failure with current brain natriuretic peptide > 500 pg/mL, presumed ischemic chest pain, elevated troponin, electrocardiogram changes indicating myocardial infarction or ischemia, heart transplant). ST2 levels were measured at ED presentation and compared between those with and without adverse outcomes. Staff were blinded to ST2 levels. Differences between groups were assessed using the Mann-Whitney U test.
Results:
Of the 82 patients enrolled, 45 (55%) were female, 48 (59%) were African American, and 34 (42%) were hospitalized. The most frequent ED or hospital diagnosis was chronic obstructive pulmonary disease (COPD) or asthma, in 29 (35%) patients. At 180 days, 36 of 81 patients (44%) had return ED visits, 21 of 81 patients (26%) were readmitted, and five of 82 patients (6%) were deceased. Median ST2 level was 227 ng/mL in patients who died versus 32 ng/mL in those who survived (difference = 195 ng/mL, 95% confidence interval [CI] = 48 to 342 ng/mL, p = 0.006). Median ST2 level was 59 ng/mL in readmitted patients versus 31 ng/mL in nonreadmitted patients (difference = 28 ng/mL, 95% CI = −3 to 60 ng/mL, p = 0.036). Median ST2 levels were 41 ng/mL in patients with return ED visits versus 31 ng/mL in those without return visits (difference = 10 ng/mL, 95% CI = −10 to 20 ng/mL, p = 0.23).
Conclusions:
Patients with noncardiac dyspnea who died or required readmission to the hospital within 180 days had higher levels of ST2 compared with nonadmitted survivors. Further research into ST2 as a prognostic tool in pathologic processes not involving the heart, such as pulmonary disease, is warranted.
doi:10.1111/acem.12250
PMCID: PMC3973176  PMID: 24165288
3.  Marked Reduction in Length of Stay for Patients with Psychiatric Emergencies after Implementation of a Co-Management Model 
Objectives
Patients with psychiatric emergencies often spend excessive time in an emergency department (ED) due to limited inpatient psychiatric bed capacity. The objective was to compare traditional resident consultation with a new model (co-management) to reduce length of stay for patients with psychiatric emergencies. The costs of this model were compared to those of standard care.
Methods
This was a before-and-after study conducted in the ED of an urban academic medical center without an inpatient psychiatry unit from January 1, 2007 through December 31, 2009. Subjects were all adult patients seen by ED clinicians and determined to be a danger to self or others, or gravely disabled. At baseline, psychiatry residents evaluated patients and made therapeutic recommendations after consultation with faculty. The co-management model was fully implemented in September 2008. In this model, psychiatrists directly ordered pharmacotherapy, regularly monitored effects, and intensified efforts toward appropriate disposition. Additionally, increased attending-level involvement expedited focused evaluation and disposition of patients. An interrupted time series analysis was used to study the effects of this intervention on length of stay for all psychiatric patients transferred for inpatient psychiatric care. Secondary outcomes included average number of hours on ambulance diversion per month, and the average number of patients who left without being seen from the ED.
Results
One thousand eight hundred eighty-four patient visits were considered. Compared to the pre-intervention phase, median length of stay for patients transferred for inpatient psychiatric care decreased by about 22% (p-value < 0.0005, 95% CI = 15% to 28%) in the post-intervention phase. Ambulance diversion hours increased by about 40 hours per month (p-value 0.008, 95% CI = 11 to 69 hours) and the average number of patients who left without being seen decreased by about 26 per month (p-value 0.106; 95% CI = -60 to 5.9 visits per month) in the post-intervention phase.
Conclusions
A co-management model was associated with a marked reduction in the length of stay for this patient population.
doi:10.1111/acem.12105
PMCID: PMC3671493  PMID: 23701340
4.  Variation in the Type, Rate, and Selection of Patients for Out-of-hospital Airway Procedures Among Injured Children and Adults 
Objectives
The objective was to compare the type, rate, and selection of injured patients for out-of-hospital airway procedures among emergency medical services (EMS) agencies in 10 sites across North America.
Methods
The authors analyzed a consecutive patient, prospective cohort registry of injured adults and children with an out-of-hospital advanced airway attempt, collected from December 1, 2005, through February 28, 2007, by 181 EMS agencies in 10 sites across the United States and Canada. Advanced airway procedures were defined as orotracheal intubation, nasotracheal intubation, supraglottic airway, or cricothyrotomy. Airway procedure rates were calculated based on age-specific population values for the 10 sites and the number of injured patients with field physiologic abnormality (systolic blood pressure of ≤90 mm Hg, respiratory rate of <10 or >29 breaths / min, Glasgow Coma Scale [GCS] score of ≤12). Descriptive measures were used to compare patients between sites.
Results
A total 1,738 patients had at least one advanced airway attempt and were included in the analysis. There was wide variation between sites in the types of airway procedures performed, including orotracheal intubation (63% to 99%), supraglottic airways (0 to 27%), nasotracheal intubation (0 to 21%), and cricothyrotomy (0 to 2%). Use of rapid sequence intubation (RSI) varied from 0% to 65%. The population-adjusted rates of field airway intervention (by site) ranged from 1.2 to 22.8 per 100,000 adults and 0.2 to 4.0 per 100,000 children. Among trauma patients with physiologic abnormality, some sites performed airway procedures in almost 50% of patients, while other sites used these procedures in fewer than 10%. There was also large variation in demographic characteristics, physiologic measures, mechanism of injury, mode of transport, field cardiopulmonary resuscitation, and unadjusted mortality among airway patients.
Conclusions
Among 10 sites across North America, there was wide variation in the types of out-of-hospital airway procedures performed, population-based rates of airway intervention, and the selection of injured patients for such procedures.
doi:10.1111/j.1553-2712.2009.00604.x
PMCID: PMC3954116  PMID: 20053248
trauma; emergency medical services; out-of-hospital; airway; intubation; epidemiology
5.  A Qualitative Assessment of Emergency Department Patients’ Knowledge, Beliefs, Attitudes, and Acceptance towards Revised HIV Testing Strategies 
Objectives
The objective of this study was to explore emergency department (EDs) patient’s knowledge, beliefs, attitudes, and acceptability towards revised human immunodeficiency virus (HIV) testing recommendations.
Methods
Participants were recruited in proportion to the racial, sex, and ethnic makeup of the study ED. Interviewers presented participants with a stimulus followed by questions about opt-out consent, elimination of separate written consent, and curtailed counseling. Three investigators coded all transcripts using an iterative coding strategy until thematic saturation was achieved.
Results
Thirty-four semi-structured, in-depth, individual interviews were conducted, including five with patients ages 13 to 17 years, and five with Spanish-speaking patients. Nineteen (56%) participants were women. The mean age was 31 years (SD ±12 years). Most were Hispanic (38%), or African American/black (44%). Only one (2.9%) participant knew about the revised testing recommendations. Participants believed opt-out consent would result in increased testing, but this was confounded by misunderstanding of the consent process: “so the opt-out is, you basically don’t have a choice.” Participants thought eliminating separate written consent was a positive change but that it could result in people being tested without their knowledge. Attitudes diverged over curtailed counseling, but participants felt patients “should have options” for counseling because “everybody isn’t the same.”
Conclusions
Emergency department patients were unaware of revised HIV testing recommendations. Most felt opt-out consent and elimination of separate written consent were positive changes but could result in a patient being tested without his or her knowledge. The response to curtailed counseling was polarized but participants agreed on the need to accommodate personal preferences. This information may be useful to when designing ED-based HIV testing programs.
doi:10.1111/acem.12090
PMCID: PMC3607454  PMID: 23517261
7.  Reduction in Observation Unit Length of Stay with Coronary Computed Tomography Angiography Depends on Time of Emergency Department Presentation 
Objectives
Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS, and if there are disparities in testing modality use, based upon the time of patient presentation to the ED.
Methods
The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hrs. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using four hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race.
Results
Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (IQR 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After adjusting for age, race, and sex, patients presenting between 08:00 and 11:59 hrs not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing.
Conclusions
In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hrs. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.
doi:10.1111/acem.12094
PMCID: PMC3607957  PMID: 23517254
8.  Providers' Perceptions Of The Factors Influencing The Implementation Of The New York State Mandatory HIV Testing Law In Two Urban Academic Emergency Departments 
Objectives
Of the 1.1 million people in the United States infected with human immunodeficiency virus (HIV), more than 20% are unaware of their infection. To increase early diagnosis and treatment, New York State recently passed legislation mandating that HIV testing be offered to all patients, ages 13 to 64 years, receiving health care services. Implementation of this legislation is complex, especially in the emergency department (ED). This study explores ED providers' perceptions of the factors affecting the implementation of the law.
Methods
The authors conducted six focus group sessions and three in-depth interviews with ED health care providers from two New York City teaching hospitals. Sessions were audiotaped and transcribed. Data were coded and summarized thematically through an iterative process after each session.
Results
A total of 49 providers participated and data saturation was achieved. Six factors were identified that predispose a provider to offer an HIV test: 1) self-efficacy, 2) behavioral intention, 3) the testing process, 4) provider knowledge of the legislation, 5) type of HIV test, and 6) follow-up procedures. Five factors were identified that enable providers to offer an HIV test: 1) resources related to time, 2) space, 3) staff, 4) type of test, and 5) timing of the offer. Improving access to HIV testing, linkage to care, and public health were all key factors in reinforcing providers' desire to offer HIV tests. Concerns regarding overall cost saving and coverage for the test were indicated as barriers that needed to be resolved in order to reinforce the providers to offer an HIV test.
Conclusions
Understanding the factors influencing the practice of ED providers charged with carrying out this mandate is critical. Despite earlier research that indicated that offering HIV testing to ED patients is largely influenced by cost, this study found additional factors that are important to consider to effectively implementing HIV testing in the ED.
doi:10.1111/acem.12084
PMCID: PMC3608143  PMID: 23517260
9.  Incremental Value of Objective Cardiac Testing in Addition to Physician Impression and Serial Contemporary Troponin Measurements in Women 
Objectives
Guidelines recommend that patients presenting to the emergency department (ED) with chest pain who are at low risk for acute coronary syndrome (ACS) receive an objective cardiac evaluation with a stress test or coronary imaging. It is uncertain whether all women derive benefit from this process. The study aim was to determine the incremental value of objective cardiac testing after serial cardiac markers and physician risk assessment.
Methods
Women enrolled in the 18-site Myeloperoxidase in the Diagnosis of Acute Coronary Syndrome (MIDAS) study had serial troponin I measured at time 0 and 90 minutes, and physician risk assessment for the presence of ACS. Risk estimates obtained at the time of ED evaluation were dichotomized as high or non-high risk. The primary outcome was the composite of acute myocardial infarction (AMI) or revascularization at 30 days. Logistic regression with receiver operator characteristic (ROC) curves and net reclassification index were used to determine the diagnostic accuracy for the composite outcome of 30-day MI or revascularization for two models: 1) troponin I results and physician risk assessment alone; and 2) troponin I results, physician risk assessment, and objective cardiac testing.
Results
Four hundred sixty women with a median age 58 years (IQR 48.5 to 68 years) were included, and 32 (6.9%) experienced AMI or revascularization by 30 days. Comparison of the area under the ROC curves (AUC) showed that the addition of objective cardiac testing to the combination of troponin I results and physician risk assessment did not significantly improve prediction of 30-day AMI or revascularization (AUC 0.85 vs. 0.89; p = 0.053). Using a threshold of 1%, net reclassification index showed that the addition of objective cardiac testing to troponin I results and physician risk assessment worsened the prediction for 30-day AMI and revascularization. All of the reclassified patients were false positives, with nine (2.1%) patients incorrectly reclassified from <1% risk to ≥1% risk of 30-day AMI or revascularization.
Conclusion
In the era of contemporary troponin assays, objective cardiac testing after an ED clinician risk assessment of non-high risk and negative troponin I results at 0 and 90 minutes does not improve the prediction of 30-day AMI or revascularization in women presenting with chest pain or other symptoms of cardiac ischemia.
doi:10.1111/acem.12092
PMCID: PMC3725334  PMID: 23517258
10.  Rates of Emergency Department Visits Due to Pneumonia in the United States, July 2006–June 2009 
Objectives
Pneumonia hospitalization rates are frequently reported as a measure of pneumonia disease burden in the United States (US). However, a detailed understanding of pneumonia burden in all healthcare settings, including the emergency department (ED), is essential for measuring the full effect of this disease on the population and planning and evaluating interventions to reduce pneumonia-related morbidity. The aim of this study was to quantify pneumonia-attributable ED visits in the US among children and adults during the three year period, July 2006 through June 2009.
Methods
Rates of pneumonia ED visits were calculated using the Nationwide Emergency Department Sample (NEDS), the largest source of US ED data. Pneumonia ED visits were identified using International Classification of Diseases codes within NEDS. A pneumonia ED visit was defined by a primary (first-listed) pneumonia discharge diagnosis or a secondary pneumonia diagnosis with an accompanying primary diagnosis of respiratory failure, shock, septicemia, a sign or symptom consistent with pneumonia, another acute respiratory infection, or an acute exacerbation of a chronic pulmonary disease. Population-based annual rates of pneumonia ED visits stratified by age group and geographic region from July 2006 through June 2009 were calculated. The percentages of pneumonia ED visits resulting in treat-and-release outpatient ED visits were also calculated within each age stratum.
Results
During the study period, 6,917,025 ED visits for pneumonia were identified, representing 2.2% of all US ED visits. During the three study years, defined as July through June of 2006–2007, 2007–2008, and 2008–2009, pneumonia ED visit rates per 1,000 person-years were 7.4 (95% confidence interval [CI]: 7.0–7.8), 7.8 (95% CI: 7.3–8.2), and 7.6 (95% CI: 7.1–8.0), respectively. Annual rates were stable over the three years within each age group and geographic region. Overall, 39.3% of pneumonia ED visits, including 74.5% of pediatric and 28.1% of adult visits, were managed as treat-and-release outpatient visits.
Conclusions
Pneumonia accounts for 2.2% of ED visits in the US and results in approximately 7 to 8 ED visits per 1000 persons per year. A substantial proportion of pneumonia cases diagnosed in the ED are managed in treat-and-release ED outpatient visits, highlighting that enumeration of ED visit rates provides important complementary information to hospitalization rates for the assessment of pneumonia burden.
doi:10.1111/acem.12203
PMCID: PMC3907184  PMID: 24033659
12.  Risk of Traumatic Intracranial Hemorrhage in Patients with Head Injury and Preinjury Warfarin or Clopidogrel Use 
Objectives
Appropriate use of cranial computed tomography (CT) scanning in patients with mild blunt head trauma and pre-injury anticoagulant or antiplatelet use is unknown. The objectives of this study were: 1) to identify risk factors for immediate traumatic intracranial hemorrhage (tICH) in patients with mild head trauma and preinjury warfarin or clopidogrel use, and 2) to derive a clinical prediction rule to identify patients at low risk for immediate tICH.
Methods
This was a prospective, observational study at two trauma centers and four community hospitals that enrolled adult emergency department (ED) patients with mild blunt head trauma (initial ED Glasgow Coma Scale score 13 to 15) and pre-injury warfarin or clopidogrel use. The primary outcome measure was immediate tICH, defined as the presence of ICH or contusion on the initial cranial CT. Risk for immediate tICH was analyzed in eleven independent predictor variables. Clinical prediction rules were derived with both binary recursive partitioning and multivariable logistic regression.
Results
A total of 982 patients with a mean age of 75.4 years (SD ±12.6 years) were included in the analysis. Sixty patients (6.1%; 95% CI = 4.7% to 7.8%) had immediate tICH. History of vomiting (relative risk [RR] 3.53; 95% CI = 1.80 to 6.94), abnormal mental status (RR 2.85; 95% CI = 1.65 to 4.92), clopidogrel use (RR 2.52; 95% CI = 1.55 to 4.10), and headache (RR 1.81; 95% CI = 1.11 to 2.96) were associated with an increased risk for immediate tICH. Both binary recursive partitioning and multivariable logistic regression were unable to derive a clinical prediction model that identified a subset of patients at low risk for immediate tICH.
Conclusions
While several risk factors for immediate tICH were identified, the authors were unable to identify a subset of patients with mild head trauma and pre-injury warfarin or clopidogrel use who are at low risk for immediate tICH. Thus, the recommendation is for urgent and liberal cranial CT imaging in this patient population, even in the absence of clinical findings.
doi:10.1111/acem.12074
PMCID: PMC3576045  PMID: 23406072
13.  Does Pre-existing Antiplatelet Treatment Influence Post-thrombolysis Intracranial Hemorrhage in Community-treated Ischemic Stroke Patients? An Observational Study 
Objectives
Intracranial hemorrhage (ICH) after acute stroke thrombolysis is associated with poor outcomes. Previous investigations of the relationship between pre-existing antiplatelet use and the safety of intravenous (IV) thrombolysis have been limited by low event rates. The objective of this study was to determine whether pre-existing antiplatelet therapy increased the risk of ICH following acute stroke thrombolysis. The primary hypothesis was that antiplatelet use would not be associated with radiographic evidence of ICH after controlling for relevant confounders.
Methods
Consecutive cases of thrombolysis patients treated in the emergency department (ED) were identified using multiple methods. Retrospective data were collected from four hospitals from 1996 to 2004, and 24 distinct hospitals from 2007 to 2010 as part of a cluster randomized trial. The same chart abstraction tool was used during both time periods, and data were subjected to numerous quality control checks. Hemorrhages were classified using a pre-specified methodology: ICH was defined as presence of hemorrhage in radiographic interpretations of follow-up imaging (primary outcome). Symptomatic ICH (sICH) was defined as radiographic ICH with associated clinical worsening. A multivariable logistic regression model was constructed to adjust for clinical factors previously identified to be related to post-thrombolysis ICH. Sensitivity analyses were conducted where the unadjusted and adjusted results from this study were combined with those of previously published external studies on this topic via meta-analytic techniques.
Results
There were 830 patients included, with 47% having documented pre-existing antiplatelet treatment. The mean age was 69 years (SD ± 15 years), and the cohort was 53% male. The unadjusted proportion of patients with any ICH was 15.1% without antiplatelet use, and 19.3% with antiplatelet use (absolute risk difference 4.2%, 95% CI = −1.2% to 9.6%); for sICH this was 6.1% without antiplatelet use and 9% with antiplatelet use (absolute risk difference 3.1%, 95% CI = −1% to 6.7%). After adjusting for confounders, antiplatelet use was not significantly associated with radiographic ICH (odds ratio 1.1, 95% CI = 0.8 to 1.7), or sICH (odds ratio 1.3, 95% CI = 0.7 to 2.2). In patients 81 years and older, there was a higher risk of radiographic ICH (absolute risk difference 11.9%, 95% CI = 0.1% to 23.6%). The meta-analyses combined the findings of this investigation with previous similar work and found increased unadjusted risks of radiographic ICH (absolute risk difference 4.9%, 95% CI = 0.7% to 9%) and sICH (absolute risk difference 4%, 95% CI = 2.3% to 5.6%). The meta-analytic adjusted odds ratio of sICH for antiplatelet use was 1.6 (95% CI = 1.1 to 2.4).
Conclusions
The authors did not find that pre-existing antiplatelet use was associated with post-thrombolysis ICH or sICH in this cohort of community treated patients. Pre-existing tobacco use, younger age, and lower severity were associated with lower odds of sICH. The meta-analyses demonstrated small, but statistically significant increases in the absolute risk of radiographic ICH and sICH, along with increased odds of sICH in patients with pre-existing antiplatelet use.
doi:10.1111/acem.12077
PMCID: PMC3576048  PMID: 23406073
14.  Short, Subjective Measures of Numeracy and General Health Literacy in an Adult Emergency Department Setting 
Objectives
To evaluate the reliability and validity of brief subjective measures of numeracy and general health literacy in the adult emergency department setting.
Methods
A convenience sample of adult emergency department patients completed subjective measures of general health literacy (Short Literacy Screening questions, SLS) and numeracy (Subjective Numeracy Scale, SNS). These patients also completed two objective tests of literacy (the Short Test of Functional Health Literacy in Adults, S-TOFHLA; and the Rapid Estimate of Adult Literacy in Medicine, REALM) and an objective test of numeracy (WRAT4).
Internal reliability of the subjective measures was assessed using Cronbach’s alpha. Construct validity of the subjective measures was assessed by correlating them against the S-TOFHLA, REALM, and WRAT4, using Spearman’s rank correlation coefficients, receiver operating characteristics (ROC) curves, and hierarchical, multiple linear regression with adjustment for patient age, gender, race, and education.
Results
The median age of the 207 patients surveyed was 46 (interquartile range 32, 59); twenty-seven percent were African American. Sixty-one percent of patients reported their highest level of education was high school or below. As measured by the S-TOFHLA and REALM, most patients had adequate literacy levels (89% and 80%, respectively), while 44% of patients had below average numeracy skills on the WRAT4. Median SLS was 14 (IQR 12, 15) on a scale of 3 to 15; median SNS was 36 (IQR 30, 42) on a scale of 6 to 48.
The SLS and SNS had good internal reliability, with Cronbach’s alphas of 0.74 and 0.82, respectively. The SLS Spearman’s rank order correlation coefficient was 0.33 (95% confidence interval 0.20, 0.45) for the S-TOFHLA, with a standardized beta coefficient of 0.36 (p<0.05) after adjustment for patient demographics. The SLS correlation coefficient was 0.26 (95% CI 0.13, 0.38) for the REALM, with a standardized beta coefficient of 0.38 (p<0.05) after adjustment for patient demographics. The area under the curve (AUC) for the SLS ROC curves was 0.74 (95% CI 0.68, 0.80) when compared to the S-TOFHLA and 0.72 (95% CI 0.65, 0.78) when compared to the REALM. The SNS predicted numeracy well, with a correlation coefficient of 0.57 (95% CI 0.47,0.65) for the WRAT4, a standardized beta coefficient of 0.30(p<0.05) after adjustment for patient demographics, and an ROC AUC of 0.77 (95% CI of 0.70, 0.82).
Conclusions
The SNS and SLS are reliable, valid tests that can be used to rapidly estimate general health literacy and numeracy skill levels in adult emergency department patients. Continuing work is needed to establish their ability to predict clinical outcomes.
doi:10.1111/j.1553-2712.2011.01210.x
PMCID: PMC3886121  PMID: 22092896
Numeracy; Health Literacy; Subjective Measures; Emergency Department; Adult
15.  Frequent Emergency Department Use among Released Prisoners with HIV: Characterization Including a Novel Multimorbidity Index 
Objectives
To characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV).
Methods
Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits post-release, were described using univariate and multivariate models, and generated medical, psychiatric, and social multi-morbidity indices.
Results
Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or non-users to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life. In multivariate Poisson regression models, frequent ED use was associated with lower physical health-related quality of life (odds ratio [OR] 0.95, p = 0.02), and having not had pre-release discharge planning (OR 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multi-morbidity index values.
Conclusions
Among released prisoners with HIV, frequent ED use is driven primarily by extensive co-morbid medical and psychiatric illness. Frequent ED users were also less likely to have received pre-release discharge planning, suggesting missed opportunities for seamless linkages to care.
doi:10.1111/acem.12054
PMCID: PMC3623800  PMID: 23570481
16.  Reducing Blood Culture Contamination in the Emergency Department: An Interrupted Time Series Quality Improvement Study 
Objectives
Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED.
Methods
The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure, to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique), and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%.
Results
During the baseline period, 321 out of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p < 0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% CI = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period.
Conclusions
A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate.
doi:10.1111/acem.12057
PMCID: PMC3623801  PMID: 23570482
17.  Creating Educational Leaders: Experiences with Two Education Fellowships in Emergency Medicine 
Academic physicians aiming to build careers on the scholarship of teaching require specific career development opportunities designed to provide the skills necessary for successful advancement and promotion as clinician-educators and scholars. Completing this training prior to embarking on an academic career may facilitate a smooth transition to a faculty position, and establish mentoring networks and research collaboratives. This article describes two pilot medical education fellowships that have been successfully implemented in separate and unique departments of emergency medicine (EM). By comparing and contrasting the curricula and incorporating the experiences of graduating 10 EM education fellows over the past decade, the authors propose a fellowship structure that may be adapted to meet the needs of medical educators in a broad variety of fields and disciplines.
doi:10.1111/acem.12042
PMCID: PMC3537510  PMID: 23240922
18.  Hyperlactatemia Affects the Association of Hyperglycemia with Mortality in Nondiabetic Adults With Sepsis 
Background
Admission hyperglycemia has been reported as a mortality risk factor for septic nondiabetic patients; however, hyperglycemia’s known association with hyperlactatemia was not addressed in these analyses.
Objectives
The objective was to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia.
Methods
This was a post hoc, nested analysis of a retrospective cohort study performed at a single center. Providers had identified study subjects during their ED encounters; all data were collected from the electronic medical record (EMR). Nondiabetic adult ED patients hospitalized for suspected infection, two or more systemic inflammatory response syndrome (SIRS) criteria, and simultaneous lactate and glucose testing in the ED were enrolled. The setting was the ED of an urban teaching hospital from 2007 to 2009. To evaluate the association of hyperglycemia (glucose > 200 mg/dL) with hyperlactatemia (lactate ≥ 4.0 mmol/L), a logistic regression model was created. The outcome was a diagnosis of hyperlactatemia, and the primary variable of interest was hyperglycemia. A second model was created to determine if coexisting hyperlactatemia affects hyperglycemia’s association with mortality; the main outcome was 28-day mortality, and the primary risk variable was hyperglycemia with an interaction term for simultaneous hyperlactatemia. Both models were adjusted for demographics; comorbidities; presenting infectious source; and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction.
Results
A total of 1,236 ED patients were included, and the median age was 77 years (interquartile range [IQR] = 60 to 87 years). A total of 115 (9.3%) subjects were hyperglycemic, 162 (13%) were hyperlactatemic, and 214 (17%) died within 28 days of their initial ED visits. After adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (odds ratio [OR] = 4.14, 95% confidence interval [CI] = 2.65 to 6.45). Hyperglycemia and concurrent hyperlactatemia were associated with increased mortality risk (OR = 3.96, 95% CI = 2.01 to 7.79), but hyperglycemia in the absence of simultaneous hyperlactatemia was not (OR = 0.78, 95% CI = 0.39 to 1.57).
Conclusions
In this cohort of septic adult nondiabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. The previously reported association of hyperglycemia with mortality in nondiabetic sepsis may be due to the association of hyperglycemia with hyperlactatemia.
doi:10.1111/acem.12015
PMCID: PMC3506124  PMID: 23167858
19.  Effect of a Physician Assistant as Triage Liaison Provider on Patient Throughput in an Academic Emergency Department 
Objectives
Overcapacity issues plague emergency departments (EDs). Studies suggest triage liaison providers (TLPs) may shorten patient length of stay (LOS) and reduce the proportion of patients who leave without being seen (LWBS), but these results are not universal. Previous studies used physicians as TLPs. We evaluated whether a physician assistant (PA), acting as a TLP, would shorten LOS and decrease LWBS rates.
Methods
The authors used an observational cohort controlled before-and-after study design with predefined outcome measures, comparing eight pilot days to eight control days. The TLP evaluated all Emergency Severity Index (ESI) level 3, 4, and 5 patients, excluding pediatric and behavioral health patients.
Results
Three hundred fifty-three patients were included on pilot days, and 371 on control days. LOS was shorter on pilot days than control days (median 229 minutes [IQR 168 to 303 minutes] vs. 270 minutes [IQR 187 to 372 minutes], p < 0.001). Waiting room times were similar between pilot and control days (median 69 minutes [IQR 20 to 119 minutes] vs. 70 minutes [IQR 19 to 137 minutes], p = 0.408), but treatment room times were shorter (median 151 minutes [IQR 92 to 223 minutes] vs. 187 minutes [IQR 110 to 254 minutes], p < 0.001). Finally, a lower proportion of patients LWBS on pilot days (1.4% vs. 9.7%, p < 0.001).
Conclusions
The addition of a PA as a TLP was associated with a 41 minute decrease in median total LOS, and a lower proportion of patients who LWBS. The decrease in total LOS is likely attributable to the addition of the TLP, with patients having shorter duration in treatment rooms on pilot days compared to control days.
doi:10.1111/acem.12010
PMCID: PMC3506172  PMID: 23167853
20.  Overuse of Computed Tomography Pulmonary Angiography in the Evaluation of Patients with Suspected Pulmonary Embolism in the Emergency Department 
Background
Clinical decision rules have been developed and validated for the evaluation of patients presenting with suspected pulmonary embolism (PE) to the emergency department (ED).
Objectives
To assess the percentage of computed tomographic pulmonary angiography (CT-PA) which could have been avoided by use of the Wells score coupled with D-dimer testing (Wells/D-dimer) or Pulmonary Embolism Rule-Out Criteria (PERC) in ED patients with suspected PE.
Methods
The authors conducted a prospective cohort study of adult ED patients undergoing CT-PA for suspected PE. Wells score and PERC were calculated. A research blood sample was obtained for D-dimer testing for subjects who did not undergo testing as part of their ED evaluation. The primary outcome was PE by CT-PA or 90-day follow-up. Secondary outcomes were ED length of stay (LOS) and CT-PA time as defined by time from order to initial radiologist interpretation.
Results
Of 152 suspected PE subjects available for analysis (mean age 46.3±15.6 years, 74% female, 59% black or African American, 11.8% diagnosed with PE), 14 (9.2%) met PERC, none of whom were diagnosed with PE. A low-risk Wells score (≤4) was assigned to 110 (72%) subjects, of whom only 38 (35%) underwent clinical D-dimer testing (elevated in 33/38). Of the 72 subjects with low-risk Wells scores who did not have D-dimers performed in the ED, archived research samples were negative in 16 (22%). All 21 subjects with low-risk Wells scores and negative D-dimers were PE-negative. CT-PA time (median 160 minutes) accounted for more than half of total ED LOS (median 295 minutes).
Conclusions
In total, 9.2% and 13.8% of CT-PA could have been avoided by use of PERC and Wells/D-dimer, respectively.
doi:10.1111/acem.12012
PMCID: PMC3506180  PMID: 23167851
21.  Unconsented HIV Testing in Cases of Occupational Exposure: Ethics, Law, and Policy 
Post-exposure prophylaxis (PEP) has substantially reduced the risk of acquiring human immunodeficiency virus (HIV) after an occupational exposure; nevertheless, exposure to HIV remains a concern for emergency department providers. According to published guidelines, PEP should be taken only when source patients are HIV positive or have risk factors for HIV. Initiating PEP when source patients are uninfected puts exposed persons at risk from taking toxic drugs with no compensating benefit. Forgoing PEP if the source is infected results in increased risk of acquiring HIV. What should be done if source patients refuse HIV testing? Is it justifiable to test the blood of these patients over their autonomous objection? The authors review current law and policy and perform an ethical analysis to determine if laws permitting unconsented testing in cases of occupational exposure can be ethically justified.
doi:10.1111/j.1553-2712.2012.01453.x
PMCID: PMC3473147  PMID: 22994417
22.  A Randomized Controlled Trial of a Comprehensive Migraine Intervention Prior to Discharge From an Emergency Department 
Objectives
Patients who use an emergency department (ED) for acute migraine headaches have higher migraine disability scores and lower socioeconomic status and are unlikely to have used a migraine-specific medication prior to presentation to the ED. The objective was to determine if a comprehensive migraine intervention, delivered just prior to ED discharge, could improve migraine impact scores 1 month after the ED visit.
Methods
This was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ED for management of acute migraine. At the time of discharge, for patients randomized to comprehensive care, the authors’ protocol reinforced their diagnosis, shared a migraine education presentation from the National Library of Medicine, provided them with six tablets of sumatriptan 100 mg and 14 tablets of naproxen 500 mg, and if they wished, provided them with an expedited free appointment to our institution's headache clinic. Patients randomized to typical care received the care their attending emergency physicians (EPs) felt was appropriate. The primary outcome was a between-group comparison of the Headache Impact Test (HIT-6) score, a validated headache assessment instrument, 1 month after ED discharge. Secondary outcomes included an assessment of satisfaction with headache care and frequency of use of migraine-specific medication within that 1-month period.
Results
Over a 19-month period, 50 migraine patients were enrolled. One-month follow-up was successfully obtained in 92% of patients. Baseline characteristics were comparable. One-month HIT-6 scores in the two groups were nearly identical (59 vs. 56, 95% confidence interval [CI] for difference of 3 = –5 to 11), as was dissatisfaction with overall headache care (17% vs. 18%, 95% CI for difference of 1% = –22% to 24%). Patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-specific therapy (43% vs. 0%, 95% CI for difference of 43% = 20 to 63%) 1 month later.
Conclusions
A comprehensive migraine intervention, when compared to typical care, did not improve HIT-6 scores (a validated measure of the effect of migraine on one's daily life) 1 month after ED discharge. Future work is needed to define a migraine intervention that is practical and useful in an ED, where many underserved patients, of necessity, present for care.
doi:10.1111/j.1553-2712.2012.01458.x
PMCID: PMC3473153  PMID: 22994458
23.  Qualitative Factors in Patients who Die Shortly After Emergency Department Discharge 
Objective
Early death after ED discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. Our goal in this hypothesis-generating study was to identify patient and process of care-level themes that may provide possible explanations for early post-discharge mortality.
Methods
We conducted a qualitative analysis of medical records of adult patients who visited any of six hospitals in an integrated health system (Kaiser Permanente Southern California – KPSC) ED and died within 7 days of discharge in 2007 and 2008. We excluded non-members, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patient with Do Not Resuscitate or Do Not Intubate orders. Under the guidance of two qualitative research scientists, a team of three emergency physicians utilized grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge.
Results
The source population consisted of a total of 290,092 members with 446,120 discharges from 6 Kaiser Permanente Southern California EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process of care factors included a discrepancy in history of present illness, incomplete physical exam, and change of discharge plan by a third party, such as a consulting or admitting physician.
Conclusions
In this hypothesis-generating study, we used qualitative research techniques to identify clinical and process of care factors in patients who die within 7-days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.
doi:10.1111/acem.12181
PMCID: PMC3785011  PMID: 24033620
24.  The Effect of Removing Cost as a Barrier to Treatment Initiation With Outpatient Tobacco Dependence Clinics Among Emergency Department Patients 
Objectives
The campaign against tobacco addiction and smoking continues to play an important role in public health. However, referrals to outpatient tobacco cessation programs by emergency physicians are rarely pursued by patients following discharge. This study explored cost as a barrier to follow-up.
Methods
The study was performed at a large urban hospital emergency department (ED) in Camden, New Jersey. Enrollment included adults who reported tobacco use in the past 30 days. Study participants were informed about a “Stop Smoking Clinic” affiliated with the hospital and, depending on enrollment date, cost of treatment was advertised as $150 (standard fee), $20 (reduced fee), or $0 (no fee). Monitoring of patient inquiries and visits to the clinic was performed for 6 months following enrollment of the last study subject.
Results
The analyzed sample consisted of 577 tobacco users. There were no statistically significant demographic differences between treatment groups (p > 0.05). Two-hundred forty-seven (43%) participants reported “very much” interest in smoking cessation. However, there was no significant difference in initiating treatment with the Stop Smoking Clinic across experimental condition. Only a single subject, enrolled in the no-fee phase, initiated treatment with the clinic.
Conclusions
Cost is unlikely to be the only barrier to pursing outpatient tobacco treatment after an ED visit. Further research is needed to determine the critical components of counseling and referral that maximize postdischarge treatment initiation.
doi:10.1111/j.1553-2712.2011.01048.x
PMCID: PMC3777236  PMID: 21518096
25.  Frequency of Pregnancy Testing among Adolescent Emergency Department Visits 
Objective
To estimate the frequency of pregnancy testing among adolescent emergency department (ED) patients and to determine factors associated with testing.
Methods
This was a retrospective cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2005-2009 of ED visits by females ages 14 to 21 years. We estimated the frequency of pregnancy testing among all visits, those for potential reproductive health complaints, and those associated with exposure to potentially teratogenic radiation. Multivariable logistic regression modeling was performed to calculate adjusted probabilities and odds ratios with 95% confidence intervals to evaluate factors associated with pregnancy testing by patient characteristics.
Results
We identified 11,531 visits, representing an estimated 41.0 million female adolescent ED visits. Of these, 20.9% (95% CI 19.3%, 22.5%) included pregnancy testing. Among visits for potential reproductive health complaints and those associated with exposure to potentially teratogenic radiation, 44.5% (95% CI 41.3%, 47.8%) and 36.7% (95% CI 32.5%, 40.9%), respectively, included pregnancy testing. Among the entire study population, we found statistically significant differences in pregnancy by testing (p<0.001 for all) by age, race/ethnicity, hospital admission, and geographic region.
Conclusions
A minority of female adolescent ED visits included pregnancy testing even if patients presented with potential reproductive health complaints or received exposure to ionizing radiation. Small but statistically significant differences in pregnancy testing rates were noted based on age, race/ethnicity, ED disposition, and geographic region. Future studies should focus on designing quality improvement interventions to increase pregnancy testing in adolescent ED patients, especially among those in whom pregnancy complications or the risk of potentially teratogenic radiation exposure is higher.
doi:10.1111/acem.12186
PMCID: PMC3775011  PMID: 24033625

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