Children with blunt abdominal trauma (BAT) are often hospitalized despite no intervention. We identified factors associated with emergency department (ED) disposition of children with BAT and differing computed tomography (CT) findings.
We surveyed pediatric and general emergency physicians (EPs), pediatric and trauma surgeons regarding care of 2 hypothetical asymptomatic patients: a 9-year-old struck by a slow-moving car (Case 1) and an 11-month-old who fell 10 feet (Case 2). We presented various abdominal CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis, adjusting for hospital and ED characteristics, and clinician experience. Pediatric EPs served as the reference group.
Of 2,003 eligible surveyed, 636 (32%) responded. For normal CTs, 99% would discharge in Case 1 and 88% in Case 2. Prominent specialty differences included: for trace intraperitoneal fluid (TIF), 68% would discharge in Case 1 and 57% in Case 2. Patients with TIF were less likely to be discharged by pediatric surgeons (Case 1: OR 0.52, 95% CI 0.32, 0.82; Case 2: OR 0.49, 95% CI 0.30, 0.79). Patients with renal contusions were less likely to be discharged by pediatric surgeons (Case 1: OR 0.55, 95% CI 0.32, 0.95) and more likely by general EPs (Case 1: OR 1.83, 95% CI 1.25, 2.69; Case 2: OR 2.37, 95% CI 1.14, 4.89).
Substantial variation exists between specialties in reported hospitalization practices of asymptomatic children after abdominal trauma with minor CT findings. Better evidence is needed to guide disposition decisions.
Emergency department (ED) crowding has been shown to negatively impact patient outcomes. Few studies have addressed the effect of ED crowding on patient satisfaction. Our objective was to evaluate the impact of ED crowding on patient satisfaction in patients discharged from the ED.
We measured patient satisfaction using Press-Ganey surveys returned by patients that visited our ED between August 1, 2007 and March 31, 2008. We recorded all mean satisfaction scores and obtained mean ED occupancy rate, mean emergency department work index (EDWIN) score and hospital diversion status over each 8-hour shift from data archived in our electronic tracking board. Univariate and multivariate logistic regression analysis was calculated to determine the effect of ED crowding and hospital diversion status on the odds of achieving a mean satisfaction score ≥ 85, which was the patient satisfaction goal set forth by our ED administration.
A total of 1591 surveys were returned over the study period. Mean satisfaction score was 77.6 (standard deviation [SD] ±16) and mean occupancy rate was 1.23 (SD ± 0.31). The likelihood of failure to meet patient satisfaction goals was associated with an increase in average ED occupancy rate (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.17 to 0.59, P < 0.001) and an increase in EDWIN score (OR 0.05, 95% CI 0.004 to 0.55, P = 0.015). Hospital diversion resulted in lower mean satisfaction scores, but this was not statistically significant (OR 0.62, 95% CI 0.36 to 1.05). In multivariable analysis controlling for hospital diversion status and time of shift, ED occupancy rate remained a significant predictor of failure to meet patient satisfaction goals (OR 0.34, 95% CI 0.18 to 0.66, P = 0.001).
Increased crowding, as measured by ED occupancy rate and EDWIN score, was significantly associated with reduced patient satisfaction. Although causative attribution was limited, our study suggested yet another negative impact resulting from ED crowding.
Emergency physician (EP) turnover is a significant issue that can have strong economic impact on hospital systems, as well as implications on research efforts to test and improve clinical practice. This work is particularly important to researchers planning randomized trials directed toward EPs because a large degree of turnover within a physician group would attenuate the effectiveness of the desired intervention. We sought to determine the incidence and factors associated with EP workforce changes.
In an attempt to determine EP turnover and workforce change, data from the INSTINCT (INcreasing Stroke Treatment through INterventional behavior Change Tactics) trial were used. The INSTINCT trial is a prospective, cluster-randomized, controlled trial evaluating a targeted behavioral intervention to increase appropriate use of tissue plasminogen activator in acute ischemic stroke. Individual EPs staffing each of the study hospitals were identified at baseline and 18 months. Surveys were sent to EPs at both intervals. Models were constructed to investigate relationships between physician/hospital characteristics and workforce change.
A total of 278 EPs were identified at baseline. Surveys were sent to all EPs at baseline and 18 months with a response rate of 72% and 74%, respectively. At 18 months, 37 (15.8%) had left their baseline hospital and 66 (26.3%) new EPs were working. Seven EPs switched hospitals within the sample. The total number of EPs at 18 months was 307, a 10.8% overall increase. Among the 24 hospitals, 6 had no EP departures and 5 had no new arrivals. The median proportion of EP workforce departing by hospital was 16% (interquartile range [IQR] = 4%–25%; range = 0%–73%), and the median proportion added was 21% (IQR = 7%–41%; range = 0%–120%). None of the evaluated covariates investigating relationships between physician/hospital characteristics and workforce change were significant.
EP workforce changes over an 18-month period were common. This has implications for emergency department directors, researchers, and individual EPs. Those planning research involving interventions upon EPs should account for turnover as it may have an impact when designing clinical trials to improve performance on healthcare delivery metrics for time-sensitive medical conditions such as stroke, acute myocardial infarction, or trauma.
Cutaneous abscesses are commonly treated in the emergency department (ED). Although incision and drainage (I&D) remains the standard treatment, there is little high-quality evidence to support additional interventions such as pain control, type of incision, and use of irrigation, wound cultures, and packing. Although guidelines exist to support clinician management of abscesses, they do not clearly specify these additional interventions. This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting.
Four hundred and seventy-four surveys were distributed to 15 EDs across the United States. Participants were queried about their level of training and practice environment as well as specific questions regarding their management of cutaneous abscesses in the ED.
In total, 350 providers responded to the survey (74%). One hundred eighty-nine respondents (54%) were attending physicians, 135 (39%) were residents, and 26 (7%) were midlevel providers. Most providers (76%) used narcotics for pain management, 71% used local anesthetic over the roof of the abscess, and 60% used local anesthetic in a field block for pain control. More than 48% of responders routinely used irrigation after (I&D). Eighty-five percent of responders used a linear incision to drain the abscess and 91% used packing in the wound cavity. Thirty-two percent routinely sent wound cultures and 17% of providers routinely prescribed antibiotics. Most providers (73%) only prescribed antibiotics if certain historical factors or physical findings were present on examination. Antibiotic treatment, if used, favored a combination of 2 or more drugs to cover both Streptococcus and methicillin-resistant Staphylococcus aureus (47%). Follow-up visits were most frequently recommended at 48 hours unless wound was concerning and required closer evaluation.
Variability exists in the treatment strategies for abscess care. Most providers used narcotic analgesics in addition to local anesthetic, linear incisions, and packing. Most providers did not irrigate, order wound cultures, or routinely prescribe oral antibiotics unless specific risk factors or physical signs were present. Limited evidence is available at this time to guide these treatment strategies.
Questions surround the appropriate emergency department (ED) disposition of children who have sustained blunt head trauma (BHT). Our objective was to identify physician disposition preferences of children with blunt head trauma (BHT) and varying computed tomography (CT) findings.
We surveyed pediatric and general emergency physicians (EP), pediatric neurosurgeons (PNSurg), general neurosurgeons (GNSurg), pediatric surgeons (PSurg) and trauma surgeons regarding care of two hypothetical patients: Case 1: a 9-year-old who fell 10 feet and Case 2: an 11-month-old who fell 5 feet. We presented various CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis adjusting for hospital and ED characteristics and clinician experience. Pediatric EPs served as the reference group.
Of 2,341 eligible surveyed, 715 (31%) responded. Most would discharge children with linear skull fractures (Case 1, 71%; Case 2, 62%). Neurosurgeons were more likely to discharge children with small subarachnoid hemorrhages (Case 1 PNSurg OR 6.87, 95% CI 3.60, 13.10; GNSurg OR 6.54, 95% CI 2.38, 17.98; Case 2 PNSurg OR 5.38, 95% CI 2.64, 10.99; GNSurg OR 6.07, 95% CI 2.08, 17.76). PSurg were least likely to discharge children with any CT finding, even linear skull fractures (Case 1 OR 0.14, 95% CI 0.08, 0.23; Case 2 OR 0.18, 95% CI 0.11, 0.30). Few respondents (<6%) would discharge children with small intraventricular, subdural, or epidural bleeds.
Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with BHT and traumatic CT findings.
Much of the emergency medical research on sedation-assisted orthopedic reductions has been undertaken with two physicians––one dedicated to the sedation and one to the procedure. Clinical practice in community emergency departments (EDs), however, often involves only one physician, who both performs the procedure and simultaneously oversees the crendentialed registered nurse who administers the sedation medication and monitors the patient. Although the dual-physician model is advocated by some, evidence in support of its superiority is lacking.
In this electronic health records review we describe sedation-assisted closed reductions of major joints and forearm fractures in three suburban community EDs. The type of procedure and sedation medication, need for specialty assistance, success rates, and intervention-requiring adverse events are reported.
During the 18-month study period, procedural sedation was performed 457 times on 442 patients undergoing closed reduction for shoulder dislocations (n = 111), elbow dislocations (n = 29), hip dislocations (n = 101), and forearm fractures (n = 201). In the vast majority of this cohort (98.4% [435/442]), a single emergency physician simultaneously managed both the procedural sedation and the initial orthopedic reduction without the assistance of a second physician. The reduction was successful or satisfactory in 96.6% (425/435; 95% confidence interval [CI], 95.8–98.8%) of these cases, with a low incidence of intervention-requiring adverse events (2.8% [12/435]; 95% CI, 1.5–4.8%).
Sedation-assisted closed reduction of major joint dislocations and forearm fractures can be performed effectively and safely in the ED using a one physician/one nurse model. A policy that requires a separate physician (or nurse anesthetist) to administer medications for all sedation-assisted ED procedures appears unwarranted. Further research is needed to determine which specific clinical scenarios might benefit from a dual-physician approach.
Emergency department (ED) cardioversion (EDCV) and discharge of patients with recent onset atrial fibrillation or atrial flutter (AF) has been shown to be a safe and effective management strategy. This study examines the impact of such aggressive ED management on hospital charges.
A random sample of 300 AF patients were identified from an ED electronic data base and screened for timing of onset of their symptoms. Patients were considered eligible for EDCV if either nursing or physician notes documented an onset of symptoms less than 48 hours prior to ED presentation and the patient was less than 85 years of age. An explicit chart review was then performed to determine patient management and disposition. Cardioversion attempts were defined as ED administration of procainamide, flecainide, propafenone, ibutilide, amiodarone or direct current cardioversion (DCCV). Total hospital charges for each patient were obtained from the hospital billing office. Differences across medians were analyzed utilizing through Wilcoxon rank sum tests and chi square.
A total of 51 patients were included in the study. EDCV was attempted on 24 (47%) patients, 22 (92%) were successfully cardioverted to normal sinus rhythm (NSR). An additional 12 (23%) spontaneously converted to NSR. Twenty (91%) of those successfully cardioverted were discharged from the ED along with 4 (33%) of those spontaneously converting. Pharmacologic cardioverson was attempted in six patients and was successful in three (50%), one after failed DCCV attempt. Direct current cardioversion was attempted in 21 (88%) and was successful in 19 (90%), two after failed pharmacologic attempts. Median charges for patients cardioverted and discharged from the ED were $5,460 (IQR $4,677–$6,190). Median charges for admitted patients with no attempt at cardioversion were $23,202 (IQR $19,663–$46,877). Median charges for patients whose final ED rhythm was NSR were $5,641 (IQR $4,638–$12,339) while for those remaining inAF median charges were $30,299 (IQR $20,655 – $69,759).
ED cardioversion of recent onset AF patients results in significant hospital savings.
The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to the national public health burden associated with trauma and injury. In the United States (U.S.), injury is the leading cause of death for persons aged 1–44 years. In 2008, approximately 30 million injuries resulted in an emergency department (ED) evaluation; 5.4 million (18%) of these patients were transported by Emergency Medical Services (EMS).1 EMS providers determine the severity of injury and begin initial management at the scene. The decisions to transport injured patients to the appropriate hospital are made through a process known as “field triage.” Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process though its “Field Triage Decision Scheme.” In 2005, the CDC, with financial support from the National Highway Traffic Safety Administration (NHTSA), collaborated with ASC-COT to convene the initial meeting of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme. This revised version was published in 2006 by ASC-COT, and in 2009 the CDC published a detailed description of the scientific rational for revising the field triage criteria entitled, “Guidelines for Field Triage of Injured Patients.”2–3 In 2011, the CDC reconvened the Panel to review the 2006 Guidelines and recommend any needed changes. We present the methodology, findings and updated guidelines from the Morbidity & Mortality Weekly Report (MMWR) from the 2011 Panel along with commentary on the burden of injury in the U.S., and the role emergency physicians have in impacting morbidity and mortality at the population level.
Introduction: The state of emergency department (ED) crowding in Pennsylvania has not previously been reported.
Methods: We assessed perceptions of ED crowding by surveying medical directors/chairs from Pennsylvania EDs in the spring of 2008.
Results: A total of 106 completed the questionnaire (68% response rate). A total of 83% (86/104) agreed that ED crowding was a problem; 26% (27/105) reported that at least half of admitted patients boarded for more than 4 hours. Ninety-eight percent (102/104) agreed that patient satisfaction suffers during crowding and 79% (84/106) stated that quality suffers. Sixty-five percent (68/105) reported that crowding had worsened during the past 2 years. Several hospital interventions were used to alleviate crowding: expediting discharges, 81% (86/106); prioritizing ED patients for inpatient beds, 79% (84/106); and ambulance diversion, 55% (57/105). Almost all respondents who had improved ED operations reported that it had reduced crowding.
Conclusion: ED crowding is a common problem in Pennsylvania and is worsening in the majority of hospitals, despite the implementation of a variety of interventions.
Introduction: Early recognition of elevated lactate levels in sepsis may hasten the detection of those patients eligible for aggressive resuscitation. Point-of-care (POC) testing is now increasingly available for use in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC device for the measurement of fingertip and whole blood lactate as compared with reference laboratory testing in critically ill ED patients.
Methods: A convenience sample of adult ED patients receiving serum lactate testing was prospectively enrolled at an urban, tertiary care US hospital. Consenting patients underwent fingertip POC lactate measurement with a portable device and simultaneous whole blood sampling for analysis by both the POC device and standard laboratory analyzer (“reference method”). Lactate measurements were compared by intraclass correlation (ICC) and Bland and Altman plots. Differences in time to test result were compared by paired t test.
Results: Twenty-four patients, 19 (79%) with sepsis and 21 (88%) with lactate levels below 4 mmol/L, were included from April 2005 to May 2005. Fingertip POC and whole blood POC lactate measurements each correlated tightly with the reference method (ICC = 0.90 and ICC = 0.92, respectively). Mean time between obtaining fingertip lactate samples and whole blood reference lactate samples was 8 ± 13 minutes. Mean time between obtaining POC and reference laboratory lactate results was 65 minutes (95% confidence interval, 30–103).
Conclusion: Fingertip POC lactate measurement is an accurate method to determine lactate levels in infected ED patients with normal or modestly elevated lactate values and significantly decreases time to test results. These findings should be verified in a larger, more critically ill, ED population.
Introduction: Injuries and fatalities in adult drivers 18–65 years of age have decreased in recent years due to safer vehicles, enhanced medical policies, and implementation of injury prevention policies. However, adult drivers over 65 years of age are continuing to suffer from motor vehicle collision-related injuries and fatalities at a more constant rate. A number of physiological factors contribute to the deterioration in visual acuity, slower reaction speeds, and decreased awareness in older drivers. The objective of this study was to examine injury severity and fatality rates in older drivers compared to their younger counterparts in Orange County, California.
Methods: This study used the Statewide Integrated Traffic Record System data for Orange County for the years 1998–2007. Drivers were categorized into 4 age groups: 25–64, 65–74, 75–84, and older than 85 years of age. Injury severity was assessed by the investigating officer.
Results: Of the 197,814 drivers involved in motor vehicle collisions, 178,481 (90.2%) were in the 25–64 age group; 11,397 (5.8%) were 65–74; 6,592 (3.3%) were 75–84; and 1,344 drivers (0.7%) were over 85. Those aged 25–64 had the lowest fatality rate per 100,000 people, 2.5, whereas those 75–84 had the highest fatality rate, 4.9. The percent of crashes involving a left turn increased with age, and the percent that were stopped in the road decreases with age. Change in injury collision involvement ratio in the 3 younger age groups decreased by 26% to 32%, but decreased by 18% among drivers aged 85 years and older.
Conclusion: The decrease in collision fatalities was greater in the 25–64-year-old group compared to the older adult population. This disparity highlights the need for further injury prevention efforts for older drivers.
On March 18, 2009, actress Natasha Richardson died after a head injury. It is possible that the rate of patients presenting with mild head injury and receiving computed tomographies (CTs) may have been influenced by the Richardson event. We hypothesized that there was a statistically significant increase in the rate of census-adjusted head CTs performed for mild trauma after March 16, 2009, compared to prior to this date.
We included all with a non-contrast head CT performed from the emergency department (ED) between March 1 and April 15, 2009, for minor trauma. The primary outcome was the census-adjusted rate of head CTs per time (# of head CTs/census). We compared the census adjusted rate for the 2 weeks prior to 2 weeks after the accident. To document media dissemination we searched Lexis-Nexis for news stories mentioning “Richardson.”
In the 2 weeks prior to March 16, 2009, the census-adjusted rate was 0.81% (95% CI 0.54–1.16) and there were no stories. The first media reports appeared on March 16, 2009, (n = 19) and quickly doubled (n = 40, n = 43) over the subsequent 2 days. The rate of CTs nearly doubled during the 2 weeks post accident 1.46% (1.10–1.91%). This absolute increase in rate percentage was statistically significant. (0.65%; 0.17 to 1.14%).
The percentage of all ED patients seen with mild trauma tested with head CT almost doubled when comparing the pre-Richardson accident vs. post time periods. There was an increase in media reports of the accident that occurred rapidly after the event and peaked on day 3.
Several factors influence the final placement of a medical student candidate on an emergency medicine (EM) residency program’s rank order list, including EM grade, standardized letter of recommendation, medical school class rank, and US Medical License Examination (USMLE) scores. We sought to determine the correlation of these parameters with a candidate’s final rank on a residency program’s rank order list.
We used a retrospective cohort design to examine 129 candidate packets from an EM residency program. Class ranks were assessed according to the instructions provided by the students’ medical schools. EM grades were scored from 1 (honors) to 5 (fail). Global assessments noted on the standardized letter of recommendation (SLOR) were scored from 1 (outstanding) to 4 (good). USMLE scores were reported as the candidate’s 3-digit scores. Spearman’s rank correlation coefficient was used to analyze data.
Electronic Residency Application Service packets for 127/129 (98.4%) candidates were examined. The following parameters correlated positively with a candidate’s final placement on the rank order list: EM grade, ρ = 0.379, P < 0.001; global assessment, ρ = 0.332, P < 0.001; and class rank, ρ = 0.234, P = 0.035. We found a negative correlation between final placement on the rank order list with both USMLE step 1 scores, ρ = −0.253, P=0.006; and USMLE step 2 scores, ρ = −0.348, P = 0.004.
Higher scores on EM rotations, medical school class ranks, and SLOR global assessments correlated with higher placements on a rank order list, whereas candidates with higher USMLE scores had lower placements on a rank order list. However, none of the parameters examined correlated strongly with ultimate position of a candidate on the rank list, which underscores that other factors may influence a candidate’s final ranking.
Asterixis is not yet considered a common neurological sign of cerebellum infarction, and the pathogenic mechanism for asterixis remains elusive. We report a 58-year-old male with moderate hypertension who presented to our emergency department for acute headache in both cervical and occipital regions of the left side. About 2 hours later the patient developed ipsilateral asterixis in the upper left limb; 3 days later the asterixis disappeared. Magnetic resonance imaging of the brain disclosed cerebellar infarctions at the left superior cerebellar artery. In conclusion, we observed that a transitory asterixis associated with ipsilateral headache can be an initial clinical manifestation of ipsilateral cerebellar infarctions in the superior cerebellar artery area.
We present a case of acute appendicitis from mobile cecum presenting with left upper quadrant abdominal pain.
Hypertensive retinopathy describes a spectrum of retinal changes in patients with elevated blood pressure (BP). It is unknown why some patients are more likely to develop acute ocular end-organ damage than others with similar BP. We examined risk factors for grade III/IV hypertensive retinopathy among patients with hypertensive urgency in the emergency department (ED) and compared healthcare utilization and mortality between patients with and without grade III/IV hypertensive retinopathy.
A preplanned subanalysis of patients who presented to a university hospital ED with diastolic BP ≥ 120 mmHg and who enrolled in the Fundus Photography versus Ophthalmoscopy Trial Outcomes in the ED study was performed. Bilateral nonmydriatic ocular fundus photographs, vital signs, and demographics were obtained at presentation. Past medical history, laboratory values, healthcare utilization, and mortality were ascertained from medical record review at least 8 months after initial ED visit.
Twenty-one patients with diastolic BP ≥ 120 mmHg, 7 of whom (33%) had grade III/IV hypertensive retinopathy, were included. Patients with retinopathy were significantly younger than those without (median 33 vs 50 years, P= 0.02). Mean arterial pressure (165 vs 163 mmHg) was essentially equal in the 2 groups. Patients with retinopathy had substantially increased but nonsignificant rates of ED revisit (57% vs 29%, P = 0.35) and hospital admission after ED discharge (43% vs 14%, P = 0.28). One of the patients with retinopathy died, but none without.
Younger patients may be at higher risk for grade III/IV hypertensive retinopathy among patients with hypertensive urgency. Chronic compensatory mechanisms may have not yet developed in these younger patients. Alternatively, older patients with retinopathy may be underrepresented secondary to increased mortality among these patients at a younger age (survivorship bias). Further research is needed to validate these preliminary findings.
Thyrotoxic periodic paralysis (TPP) attacks are characterized as recurrent, transient episodes of muscle weakness that range from mild weakness to complete flaccid paralysis. Episodes of weakness are accompanied by hypokalemia, which left untreated can lead to life-threatening arrhythmias (6). In this case study, we followed a patient’s potassium levels analyzing how they correlate with electrocardiogram changes seen while treating his hypokalemia and ultimately his paralysis.