Home About us Contact
|
Home About us Contact | ||
|
|
||
Emergency Department (emergency + department)
Kinds of Emergency Department Terms modified by Emergency Department Selected AbstractsThe Impact of a Brief Expectation Survey on Parental Satisfaction in the Pediatric Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 12 2006Christopher D. Spahr MD Abstract Objectives To determine the effect of physician knowledge of parental expectations on satisfaction with emergency department (ED) care. Methods This was a prospective, controlled, interventional trial involving parents of children presenting to a children's hospital ED. Parents completed an expectation survey on arrival, which was either immediately placed back in the enrollment envelope (control) or shown to the physician caring for the child (intervention). The physician was instructed to initial the expectation survey to acknowledge receipt of the survey. Parents then completed a satisfaction survey at discharge. The primary outcomes were differences in satisfaction with physician review of the expectation survey, as measured by 1) parental ratings of overall care and 2) their willingness to recommend the ED to others. A third (baseline) group completed only a satisfaction survey at discharge. Results A total of 614 (66%) of the 930 enrolled parents completed the study. Intention-to-treat analysis did not show a significant increase in parental satisfaction ratings for either overall care or recommend the ED; however, only 42% of the intervention group surveys had documented physician review. When these initialed surveys were compared with the control group in a per-protocol analysis, there was a significant improvement in parental satisfaction. There were no differences between the control and baseline groups, indicating no effect of the expectation survey completion on satisfaction. Conclusions Physician knowledge of written parental expectations may improve parental satisfaction during an ED visit. Further work is needed to overcome the barriers to physician review of the expectation survey to maximize parent satisfaction. [source] Usefulness of Serial Assessment of Natriuretic Peptides in the Emergency Department for Patients With Acute Decompensated Heart FailureCONGESTIVE HEART FAILURE, Issue 4 2008Salvatore DiSomma MD The value of natriuretic peptides, both B-type natriuretic peptide (BNP) and N-terminal prohormone brain natriuretic peptide (NTproBNP), for determining diagnosis, severity, and prognosis of emergency department (ED) patients with acute decompensated heart failure (ADHF) has been well documented. Emerging data support the hypothesis that repeated natriuretic peptide determinations in the acute phase of ADHF may assist in confirming the diagnosis, monitoring drug therapy, and evaluating the adequacy of patient stabilization. Data from the authors' group demonstrate that in patients admitted to the ED for acute dyspnea, serial NTproBNP measurement at admission and 4, 12, and 24 hours later was useful in confirming the diagnosis of ADHF compared with patients with chronic obstructive pulmonary disease. Moreover, in the same patients receiving intensive intravenous diuretic therapy, there was a progressive reduction of NTproBNP blood levels from hospitalization to discharge (P<.001), accompanied by clinical improvement and stabilization of heart failure. More recently, the authors also demonstrated that in ADHF patients improving with diuretics, a progressive reduction in BNP levels was observed, starting 24 hours after ED admission and continuing until discharge. Comparing BNP and NTproBNP, there was a significant correlation between NTproBNP and BNP levels but not between NTproBNP's and BNP's percent variation compared with baseline. In ADHF, serial ED measurements of BNP are useful for monitoring the effects of treatment. A reduction in BNP from admission to discharge is indicative of clinical improvement. [source] Combination of B-Type Natriuretic Peptide Levels and Non-Invasive Hemodynamic Parameters in Diagnosing Congestive Heart Failure in the Emergency DepartmentCONGESTIVE HEART FAILURE, Issue 4 2004Erin Barcarse BS This study aimed to assess whether the combination of a B-type natriuretic peptide (BNP) level with various noninvasive hemodynamic parameters can help physicians more quickly and accurately diagnose congestive heart failure and determine the type of left ventricular dysfunction present in patients presenting to the emergency department with dyspnea. Subjects were 98 men (aged 64.57±1.23 years) that presented to the VA San Diego Healthcare System. Hemodynamic parameters were measured using impedance cardiography, and BNP levels were quantified using a rapid immunoassay. All patients with a BNP <100 pg/mL (n=37) had no evidence of congestive heart failure 97% of the time. In those with a BNP >100 pg/mL (601 ±55 pg/mL; n=61), a cardiac index of 2.6 L/min/m2 is 65% sensitive and 88% specific in determining systolic dysfunction. In patients with a BNP >100 pg/mL, a multivariate model consisting of noninvasive hemodynamic measurements was able to predict cardiac deaths, readmissions, and emergency department visits within 90 days with 83% accuracy. The authors conclude that, in patients presenting to an emergency department with dyspnea, the addition of impedance cardiography measurements to BNP level measurements will more effectively diagnose congestive heart failure and determine both the type of heart dysfunction and the severity of illness. [source] Categorizing Urgency of Infant Emergency Department Visits: Agreement between CriteriaACADEMIC EMERGENCY MEDICINE, Issue 12 2006Rakesh D. Mistry MD Abstract Background The lack of valid classification methods for emergency department (ED) visit urgency has resulted in large variation in reported rates of nonurgent ED utilization. Objectives To compare four methods of defining ED visit urgency with the criterion standard, implicit criteria, for infant ED visits. Methods This was a secondary data analysis of a prospective birth cohort of Medicaid-enrolled infants who made at least one ED visit in the first six months of life. Complete ED visit data were reviewed to assess urgency via implicit criteria. The explicit criteria (adherence to prespecified criteria via complete ED charts), ED triage, diagnosis, and resources methods were also used to categorize visit urgency. Concordance and agreement (,) between the implicit criteria and alternative methods were measured. Results A total of 1,213 ED visits were assessed. Mean age was 2.8 (SD ± 1.78) months, and the most common diagnosis was upper respiratory infection (21.0%). Using implicit criteria, 52.3% of ED visits were deemed urgent. Urgent visits using other methods were as follows: explicit criteria, 51.8%; ED triage, 60.6%; diagnosis, 70.3%; and resources, 52.7%. Explicit criteria had the highest concordance (78.3%) and agreement (,= 0.57) with implicit criteria. Of limited data methods, resources demonstrated the best concordance (78.1%) and agreement (,= 0.56), while ED triage (67.9%) and diagnosis (71.6%) exhibited lower concordance and agreement (,= 0.35 and ,= 0.42, respectively). Explicit criteria and resources equally misclassified urgency for 11.1% of visits; ED triage and diagnosis tended to overclassify visits as urgent. Conclusions The explicit criteria and resources methods best approximate implicit criteria in classifying ED visit urgency in infants younger than six months of age. If confirmed in further studies, resources utilized has the potential to be an inexpensive, easily applicable method for urgency classification of infant ED visits when limited data are available. [source] Ethics Seminars: Withdrawal of Treatment in the Emergency Department,When and How?ACADEMIC EMERGENCY MEDICINE, Issue 12 2006Kelly Bookman MD Abstract Although increasing discussion has occurred within emergency medicine about indications for withholding cardiac life support and other resuscitative interventions, emergency physicians (EPs) may be less familiar with the ethical, legal, and practical issues surrounding withdrawal of life support that has already been initiated. Both physicians and out-of-hospital personnel must act rapidly in critical situations and must assume that the patient has the desire to be resuscitated, unless clear evidence exists to the contrary. Often, only after initial life-saving actions have stabilized the patient is there time to reflect and determine a patient's desires regarding such interventions. When the EP can clearly discern a patient's previously stated wishes during the emergency department (ED) stay, these wishes should be honored in the ED. Respecting a patient's request to avoid unwanted, invasive treatments near death may involve withdrawing interventions that could not be withheld during the first few minutes of care. In this article, the authors use a case of out-of-hospital stabilization of a patient as a springboard to review the ethical and legal framework for withdrawal of life-sustaining care, as well as the practical issues involved with withdrawal of such care in the ED. [source] Resident Portfolio: Sandstorm in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 12 2006Mateen A. Khan MD (EM-III) No abstract is available for this article. [source] System Complexity As a Measure of Safe Capacity for the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 11 2006Daniel J. France PhD Objectives System complexity is introduced as a new measure of system state for the emergency department (ED). In its original form, the measure quantifies the uncertainty of demands on system resources. For application in the ED, the measure is being modified to quantify both workload and uncertainty to produce a single integrated measure of system state. Methods Complexity is quantified using an information-theoretic or entropic approach developed in manufacturing and operations research. In its original form, complexity is calculated on the basis of four system parameters: 1) the number of resources (clinicians and processing entities such as radiology and laboratory systems), 2) the number of possible work states for each resource, 3) the probability that a resource is in a particular work state, and 4) the probability of queue changes (i.e., where a queue is defined by the number of patients or patient orders being managed by a resource) during a specified time period. Results An example is presented to demonstrate how complexity is calculated and interpreted for a simple system composed of three resources (i.e., emergency physicians) managing varying patient loads. The example shows that variation in physician work states and patient queues produces different scores of complexity for each physician. It also illustrates how complexity and workload differ. Conclusions System complexity is a viable and technically feasible measurement for monitoring and managing surge capacity in the ED. [source] End-tidal Carbon Dioxide Monitoring in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 10 2006Gerald Kierzek MD No abstract is available for this article. [source] Clinical and Economic Factors Associated with Ambulance Use to the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 8 2006Jennifer Prah Ruger PhD Background: Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods. Objectives: To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED. Methods: This was a retrospective, cross-sectional study of all patients seen during 2001 (N= 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air-medical transport, walk-in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use. Results: In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0,10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight,8 AM (OR, 2.0; 95% CI = 1.8 to 2.1), and age ,65 years (OR, 1.3; 95% CI = 1.2 to 1.5). Conclusions: Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means. [source] National Study on Emergency Department Visits for Transient Ischemic Attack, 1992,2001ACADEMIC EMERGENCY MEDICINE, Issue 6 2006Jonathan A. Edlow MD Abstract Objectives: To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic attack (TIA) and to measure rates of antiplatelet medication use, neuroimaging, and hospitalization during a ten-year time period. Methods: The authors obtained data from the 1992,2001 National Hospital Ambulatory Medical Care Survey. TIA cases were identified by having ICD-9 code 435. Results: From 1992 to 2001, there were 769 cases, representing 2,969,000 ED visits for TIA. The population rate of 1.1 ED visits per 1,000 U.S. population (95% CI = 0.92 to 1.30) was stable over time. TIA was diagnosed in 0.3% of all ED visits. Physicians administered aspirin and other antiplatelet agents to a small percentage of patients, and 42% of TIA patients (95% CI = 29% to 55%) received no medications at all in the ED. Too few data points existed to measure a statistically valid trend over time. Physicians performed computed tomography scanning in 56% (95% CI = 45% to 66%) of cases and performed magnetic resonance imaging (MRI) in < 5% of cases, and there was a trend toward increased imaging over time. Admission rates did not increase during the ten-year period, with 54% (95% CI = 42% to 67%) admitted. Regional differences were noted, however, with the highest admission rate found in the Northeast (68%). Conclusions: Between 1992 and 2001, the population rate of ED visits for TIA was stable, as were admission rates (54%). Antiplatelet medications appear to be underutilized and to be discordant with published guidelines. Neuroimaging increased significantly. These findings may reflect the limited evidence base for the guidelines, educational deficits, or other barriers to guideline implementation. [source] Screening for Adolescent Depression in a Pediatric Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 5 2006Emily Gale Scott MD Abstract Objectives: To describe the prevalence of depressive symptoms in adolescents presenting to the emergency department (ED) and to describe their demographics and outcomes compared with adolescents endorsing low levels of depressive symptoms. Methods: The Beck Depression Inventory,2nd edition (BDI-II) was used to screen all patients 13,19 years of age who presented to the ED during the period of study. The BDI-II is a 21-item self-report instrument used to measure the presence and severity of depressive symptoms in adolescents and adults. Demographics and clinical outcomes of screening-program participants were abstracted by chart review. Patients were categorized into one of four severity categories (minimal, mild, moderate, or severe) and one of three presenting complaint categories (medical, trauma, mental health). Results: Four hundred eighty-seven patients were approached, and 351(72%) completed the screening protocol. Participants endorsed minimal (n= 192, 55%), mild (n= 52, 15%), moderate (n= 41, 11%), or severe depressive symptoms (n= 66, 19%). Those with moderate or severe depressive symptoms were more likely to be hospitalized. Of patients completing the BDI-II, 72% with psychiatric, 12% with traumatic, and 19% with medical chief complaints endorsed either moderate or severe depressive symptoms. Conclusions: Depressive symptoms are prevalent in this screening sample, regardless of presenting complaint. A substantial proportion of patients with nonpsychiatric chief complaints endorsed moderate or severe depressive symptoms. A screening program might allow earlier identification and referral of patients at risk for depression. [source] Management of Acute Undifferentiated Agitation in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 5 2006William J. Holubek MD No abstract is available for this article. [source] Pathophysiology of ketoacidosis in Type 2 diabetes mellitusDIABETIC MEDICINE, Issue 10 2005P. Linfoot Abstract Aims Despite an increasing number of reports of ketoacidosis in populations with Type 2 diabetes mellitus, the pathophysiology of the ketoacidosis in these patients is unclear. We therefore tested the roles of three possible mechanisms: elevated stress hormones, increased free fatty acids (FFA), and suppressed insulin secretion. Methods Forty-six patients who presented to the Emergency Department with decompensated diabetes (serum glucose > 22.2 mmol/l and/or ketoacid concentrations , 5 mmol/l), had blood sampled prior to insulin therapy. Three groups of subjects were studied: ketosis-prone Type 2 diabetes (KPDM2, n = 13) with ketoacidosis, non-ketosis-prone subjects with Type 2 diabetes (DM2, n = 15), and ketotic Type 1 diabetes (n = 18). Results All three groups had similar mean plasma glucose concentrations. The degree of ketoacidosis (plasma ketoacids, bicarbonate and anion gap) in Type 1 and 2 subjects was similar. Mean levels of counterregulatory hormones (glucagon, growth hormone, cortisol, epinephrine, norepinephrine), and FFA were not significantly different in DM2 and KPDM2 patients. In contrast, plasma C-peptide concentrations were approximately three-fold lower in KPDM2 vs. non-ketotic DM2 subjects (P = 0.0001). Type 1 ketotic subjects had significantly higher growth hormone (P = 0.024) and FFA (P < 0.002) and lower glucagon levels (P < 0.02) than DM2. Conclusions At the time of hospital presentation, the predominant mechanism for ketosis in KPDM2 is likely to be greater insulinopenia. [source] Electronic Medical Record Review as a Surrogate to Telephone Follow-up to Establish Outcome for Diagnostic Research Studies in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 11 2005Jeffrey A. Kline MD Abstract Background: Follow-up for diagnostic research studies might be facilitated if medical record review (MRR) could be used instead of telephone calls. Objectives: The authors hypothesized that MRR would yield similar accuracy to telephone follow-up. Methods: This was a secondary analysis of 2,178 initially disease-free patients who were followed after enrollment in a diagnostic study of either acute coronary syndrome (45 days) or pulmonary embolism (90 days) conducted in an urban teaching emergency department (ED). Disease status (positive or negative) was defined explicitly. Using structured data forms, trained researchers performed MRR using a comprehensive electronic database, and formulated an opinion about disease status. Trained researchers, blinded to the MRR, then dialed telephone numbers, asked questions from a script, and categorized disease status. The criterion standard was adjudication by consensus of two of three physicians who independently determined disease status based on explicit criteria and access to all follow-up data. Results: Adjudicators found that 13 of 2,178 patients developed disease during follow-up; all 13 true positives occurred among the 2,054 (94.3%) of patients who acknowledged intent to return to the study hospital. Telephone follow-up was successful in 81% of patients, and found all 13 true positives (sensitivity 100%) but with three additional false-positive cases. MRR disclosed 12 of 13 cases of disease (sensitivity 92%) with no false-positive cases. Further review of the one false-negative case from MRR revealed that it occurred after the prescribed time limit for follow-up. Conclusions: Under limited circumstances, accurate clinical follow-up for diagnostic studies conducted in the ED can be obtained by medical record review. [source] Telemetry Monitoring during Transport of Low-risk Chest Pain Patients from the Emergency Department: Is It Necessary?ACADEMIC EMERGENCY MEDICINE, Issue 10 2005Adam J. Singer MD Abstract Background: Low-risk emergency department (ED) patients with chest pain (CP) are often transported by nurses to monitored beds on telemetry monitoring, diverting valuable resources from the ED and delaying transport. Objectives: To test the hypothesis that transporting low-risk CP patients off telemetry monitoring is safe. Methods: This was a secondary analysis of a prospective, observational cohort of ED patients with low-risk chest pain (no active chest pain, normal or nondiagnostic electrocardiogram, normal initial troponin I) admitted to a non,intensive care unit monitored bed who were transported off telemetry monitor by nonclinical personnel. A protocol allowing transportation of low-risk CP patients off telemetry monitoring to a monitored bed was developed, and an ongoing daily log of patients transported off telemetry was maintained for the occurrence of any adverse events en route to the floor. Adverse events requiring treatment included dysrhythmias, hypotension, syncope, and cardiac arrest. The study population included patients who presented during September,October 2004, whose data were abstracted from the medical records using standardized methodology. A subset of 10% of the medical records were reviewed by a second investigator for interrater reliability. Death, syncope, resuscitation, and dysrhythmias during transport or immediately on arrival to the floor were the outcomes measured. Descriptive statistics and confidence intervals (CIs) were used in data analysis. Results: During the study period, 425 patients had CP of potentially ischemic origin, of whom 322 (75.8%) were low risk and met the inclusion criteria and were transported off monitors. Their mean (±standard deviation) age was 58.3 (±16.0) years; 48.1% were female. During transport from the ED, there was no patient with any adverse events requiring treatment and there was no death (95% CI = 0% to 0.93%). Conclusions: Transportation of low-risk ED chest pain patients off telemetry monitoring by nonclinical personnel to the floor appears safe. This may reduce diversion of ED nurses from the ED, helping to alleviate nursing shortages. [source] Hand-Held Echocardiogram Does Not Aid in Triaging Chest Pain Patients from the Emergency DepartmentECHOCARDIOGRAPHY, Issue 6 2009Mayank Kansal M.D. Background: Accurate triage of emergency department (ED) patients presenting with chest pain is a primary goal of the ED physician. In addition to standard clinical history and examination, a hand-held echocardiogram (HHE) may aid the emergency physician in making correct decisions. We tested the hypothesis that an HHE performed and interpreted by a cardiology fellow could help risk-stratify patients presenting to the ED with chest pain. Methods: ED physicians evaluated 36 patients presenting with cardiovascular symptoms. Patients were then dispositioned to either an intensive care bed, a monitored bed, an unmonitored bed, or home. Following disposition, an HHE was performed and interpreted by a cardiology fellow to evaluate for cardiac function and pathology. The outcomes evaluated (1) a change in the level of care and (2) additional testing ordered as a result of the HHE. Results: The HHE showed wall motion abnormalities in 31% (11 out of 36) of the studies, but the level of care did not change after HHE for any patients who presented with chest pain to the ED. No additional laboratory or imaging tests were ordered for any patients based on the results of the HHE. Eighty-six percent (31 out of 36) of the studies were of adequate quality for interpretation, and 32 out of 36 (89%) interpretations correlated with an attending overread. Conclusion: Despite the high prevalence of abnormal wall motion in this population, hand-held echocardiography performed in this ED setting did not aid in the risk stratification process of chest pain patients. (ECHOCARDIOGRAPHY, Volume 26, July 2009) [source] Impact of Scribes on Performance Indicators in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 5 2010Rajiv Arya MD Abstract Objectives:, The objective was to quantify the effect of scribes on three measures of emergency physician (EP) productivity in an adult emergency department (ED). Methods:, For this retrospective study, 243 clinical shifts (of either 10 or 12 hours) worked by 13 EPs during an 18-month period were selected for evaluation. Payroll data sheets were examined to determine whether these shifts were covered, uncovered, or partially covered (for less than 4 hours) by a scribe; partially covered shifts were grouped with uncovered shifts for analysis. Covered shifts were compared to uncovered shifts in a clustered design, by physician. Hierarchical linear models were used to study the association between percentage of patients with which a scribe was used during a shift and EP productivity as measured by patients per hour, relative value units (RVUs) per hour, and turnaround time (TAT) to discharge. Results:, RVUs per hour increased by 0.24 units (95% confidence interval [CI] = 0.10 to 0.38, p = 0.0011) for every 10% increment in scribe usage during a shift. The number of patients per hour increased by 0.08 (95% CI = 0.04 to 0.12, p = 0.0024) for every 10% increment of scribe usage during a shift. TAT was not significantly associated with scribe use. These associations did not lose significance after accounting for physician assistant (PA) use. Conclusions:, In this retrospective study, EP use of a scribe was associated with improved overall productivity as measured by patients treated per hour (Pt/hr) and RVU generated per hour by EPs, but not as measured by TAT to discharge. ACADEMIC EMERGENCY MEDICINE 2010; 17:490,494 © 2010 by the Society for Academic Emergency Medicine [source] Triage Patients with Suspected Pulmonary Embolism in the Emergency Department Using a Portable Ultrasound DeviceECHOCARDIOGRAPHY, Issue 5 2008Nicolas Mansencal M.D. The diagnosis of pulmonary embolism (PE) is difficult, despite validated diagnostic models. We sought to determine the value of a portable ultrasound device for triage of patients with suspected PE referred to the emergency department, using simplified echo criteria. We prospectively studied 103 consecutive patients with suspected PE, referred to our emergency department. After D-dimer screening, 76 patients were prospectively enrolled in this ultrasound study and underwent helical chest tomography, transthoracic echocardiography, and venous ultrasonography. Among patients with PE (n = 31), a right ventricular dilation was detected in 17 patients (55%), a direct visualization of clot in the lower limbs was present in 18 patients (58%), and 8 patients (26%) had both right ventricular dilation and deep venous thrombosis. The sensitivity and specificity of a combined ultrasound strategy using echocardiography and venous ultrasonography were respectively 87% (95% confidence interval 74% to 96%), and 69% (95% confidence interval 53% to 82%). The sensitivity of this combined strategy was significantly improved as compared to venous ultrasonography alone (P = 0.01) or echocardiography alone (P = 0.005). In patients with dyspnea or with high clinical probability of PE, this combined strategy was particularly relevant with high sensitivities (respectively 94% and 100%). Echocardiography combined with venous ultrasonography using a portable ultrasound device is a reliable method for screening patients with suspected PE referred to an emergency department, especially in patients with dyspnea or with high clinical probability. [source] The Effect of Noise in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 7 2005Leslie S. Zun MD Abstract Background: It is hypothesized that high ambient noise in the emergency department (ED) adversely affects the ability of the examiner to hear heart and lung sounds. Objective: To determine the ability of various examiners to hear heart tones and lung sounds at the high end of loudness typically found in the ED setting. Methods: The study was divided into two parts. First, sound levels in the ED were measured over various times during the months of January through June 2001, using a sound level monitor. The second part of the study was the determination of the ability to hear heart and lung sounds on a young healthy volunteer using the same Littmann lightweight stethoscope at a predetermined ambient noise level of 90 dB. The results were entered into a database and analyzed using SPSS version 10 (Chicago, IL). Descriptive statistics, analysis of variance, frequencies, and correlation were calculated using this program. Results: Two hundred five sound measurements were taken in the ED during the study period in three locations at various hours. The mean noise level at the nursing station was 57.60 dB, with a minimum of 45.00 dB and a maximum of 70.00 dB. Four of the 104 test subjects (3.8%) were unable to hear the heart tones, and nine of the 104 (8.7%) were unable to hear the lung sounds. Fifty percent (27 of 54) of the test subjects reported diminished lung sounds and eight of 15 (53.3%) reported diminished heart sounds. No significant difference was found between hearing heart sounds and years of experience, age, professional position, and quality of the sound. Significant differences were found between hearing lung sounds and years of experience and professional position, but not with age, gender, and sound quality. Conclusions: This study demonstrated that most of the tested examiners have the ability to hear heart and lung sounds at the extreme of loudness found in one ED. [source] Nuclear Cardiology in the Evaluation of Acute Chest Pain in the Emergency DepartmentECHOCARDIOGRAPHY, Issue 6 2000Brian G. Abbott M.D. Only a minority of patients presenting to the emergency department (ED) with acute chest pain will eventually be diagnosed with an acute coronary syndrome. The majority will have an electrocardiogram that is normal or nondiagnostic for acute myocardial ischemia or infarction. Typically, these patients are admitted to exclude myocardial infarction despite a very low incidence of coronary artery disease. However, missed myocardial infarctions in patients who are inadvertently sent home from the ED have significant adverse outcomes and associated legal consequences. This leads to a liberal policy to admit patients with chest pain, presenting a substantial burden in terms of cost and resources. Many centers have developed chest pain centers, using a wide range of diagnostic modalities to deal with this dilemma. We discuss the methods currently available to exclude myocardial ischemia and infarction in the ED, focusing on the use of myocardial perfusion imaging as both an adjunct and an alternative to routine testing. We review the available literature centering on the ED evaluation of acute chest pain and then propose an algorithm for the practical use of nuclear cardiology in this setting. [source] Smoking Stage of Change and Interest in an Emergency Department,based InterventionACADEMIC EMERGENCY MEDICINE, Issue 3 2005Edwin D. Boudreaux PhD Abstract Objectives: To examine factors associated with motivation to quit smoking and interest in an emergency department (ED)-based intervention. Methods: Consecutive ED patients 18 years of age and older were interviewed. Severely ill and cognitively disabled patients were excluded. Smoking history, stage of change, self-efficacy, presence of a smoking-related illness, interest in an ED-based smoking intervention, and screening/counseling by the patient's ED provider were assessed. Results: A total of 1,461 of 2,314 patients (64%) were interviewed. A total of 581 (40%) currently smoked, with 21% in precontemplation (no intention to quit), 43% in contemplation (intention to quit but not within the next 30 days), and 36% in preparation (intention to quit within the next 30 days). Approximately 50% indicated a willingness to remain 15 extra minutes in the ED to receive counseling. Only 8% received counseling by their ED provider. A regression analysis showed that greater readiness to change was associated with multiple lifetime quit attempts, presence of a quit attempt in the past 30 days, and higher self-efficacy. Interest in an ED-based intervention was more likely among patients who reported higher self-efficacy. Conclusions: Approximately 50% of smokers reported at least moderate interest in an ED-based intervention and a willingness to stay 15 extra minutes, but only 8% reported receiving counseling during their ED visit. Considering time and resource constraints, counseling/referral may be best suited for patients characterized by a strong desire to quit, multiple previous quit attempts, high self-efficacy, a smoking-related ED visit, and strong interest in ED-based counseling. [source] Pain Scores Improve Analgesic Administration Patterns for Trauma Patients in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 3 2004Paul A. Silka MD Abstract Objective: To determine the efficacy of pain scores in improving pain management practices for trauma patients in the emergency department (ED). Methods: A prospective, observational study of analgesic administration to trauma patients was conducted over a nine-week period following educational intervention and introduction of verbal pain scores (VPSs). All ED nursing and physician staff in an urban Level I trauma center were trained to use the 0,10 VPS. Patients younger than 12 years old, having a Glasgow Coma Scale score (GCS) <8, or requiring intubation were excluded from analysis. Demographics, mechanism of injury, vital signs, pain scores, and analgesic data were extracted from a computerized ED database and patients' records. The staff was blinded to the ongoing study. Results: There were 150 patients studied (183 consecutive trauma patients seen; 33 patients excluded per criteria). Pain scores were documented for 73% of the patients. Overall, 53% (95% confidence interval [CI] = 45% to 61%) of the patients received analgesics in the ED. Of the patients who had pain scores documented, 60% (95% CI = 51% to 69%) received analgesics, whereas 33% (95% CI = 18% to 47%) of the patients without pain scores received analgesics. No patient with a VPS < 4 received analgesics, whereas 72% of patients with a VPS > 4 and 82% with a VPS > 7 received analgesics. Mean time to analgesic administration was 68 minutes (95% CI = 49 to 87). Conclusions: Pain assessment using VPS increased the likelihood of analgesic administration to trauma patients with higher pain scores in the ED. [source] Profiles in Patient Safety: Medication Errors in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 3 2004Pat Croskerry MD Abstract Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here. [source] Knowledge and attitude towards paediatric cardiopulmonary resuscitation among the carers of patients attending the Emergency Department of the Children's Hospital at WestmeadEMERGENCY MEDICINE AUSTRALASIA, Issue 5 2009Jonathan Cu Abstract The present study aimed to describe the knowledge and attitudes of parents and carers in performing cardiopulmonary resuscitation on infants and children. A self-administered questionnaire distributed to a convenience sample of parents and carers attending the Emergency Department of The Children's Hospital at Westmead, Australia from February to March 2008. Main outcome measures were the prevalence of previous cardiopulmonary resuscitation training, willingness and confidence to perform cardiopulmonary resuscitation on infants and children compared with adults, and an objective assessment of knowledge of current resuscitation guidelines. A total of 348 parents and carers were surveyed; 53% had received previous cardiopulmonary resuscitation training, 75% prior to the previous year. There was no significant difference on their willingness to perform cardiopulmonary resuscitation on an adult versus a child (75.6% and 75.8% respectively, P= 0.870). However, 81% were willing to perform cardiopulmonary resuscitation on a relative whereas only 64% were willing to perform cardiopulmonary resuscitation on a stranger (P < 0.001). Respondents were moderately confident in delivering cardiopulmonary resuscitation to a collapsed child; mean score of 2.9 on 5-point Likert scale. Only 11% of respondents knew the correct rate for chest compressions and the ratio of compressions to ventilations; 8% had performed cardiopulmonary resuscitation in a real situation. Parents and carers are willing to perform cardiopulmonary resuscitation, especially on family members. However, their knowledge of the current guidelines was poor. More public education is required to update those with previous training and to encourage those who haven't to be trained. [source] Trauma Team Activation Criteria as Predictors of Patient Disposition from the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 1 2004Michael A. Kohn MD Many trauma centers use mainly physiologic, first-tier criteria and mechanism-related, second-tier criteria to determine whether and at what level to activate a multidisciplinary trauma team in response to an out-of-hospital call. Some of these criteria result in a large number of unnecessary team activations while identifying only a few additional patients who require immediate operative intervention. Objectives: To separately evaluate the incremental predictive value of individual first-tier and second-tier trauma team activation criteria for severe injury as reflected by patient disposition from the emergency department (ED). Methods: This was a prospective cohort study in which activation criteria were collected prospectively on all adult patients for whom the trauma team was activated during a five-month period at an urban, Level 1 trauma center. Severe injury disposition ("appropriate" team activation) was defined as immediate operative intervention, admission to the intensive care unit (ICU), or death in the ED. Data analysis consisted of recursive partitioning and multiple logistic regression. Results: Of the 305 activations for the mainly physiologic first-tier criteria, 157 (51.5%) resulted in severe injury disposition. The first-tier criterion that caused the greatest increase in "inappropriate" activations for the lowest increase in "appropriate" activations was "age > 65." Of the 34 additional activations due to this criterion, seven (20.6%) resulted in severe injury disposition. Of the 700 activations for second-tier, mechanism-related criteria, 54 (7.7%) resulted in ICU or operating room admissions, and none resulted in ED death. The four least predictive second-tier criteria were "motorcycle crash with separation of rider,""pedestrian hit by motor vehicle,""motor vehicle crash with rollover," and "motor vehicle crash with death of occupant." Of the 452 activations for these four criteria, only 18 (4.0%) resulted in ICU or operating room admission. Conclusions: The four least predictive second-tier, mechanism-related criteria added little sensitivity to the trauma team activation rule at the cost of substantially decreased specificity, and they should be modified or eliminated. The first-tier, mainly physiologic criteria were all useful in predicting the need for an immediate multidisciplinary response. If increased specificity of the first-tier criteria is desired, the first criterion to eliminate is "age > 65." [source] Association between Insurance Status and Admission Rate for Patients Evaluated in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 11 2003Jennifer Prah Ruger PhD Abstract Objectives: To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. Methods: This was a retrospective, cross-sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis-related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for underinsured (self-pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. Results: Compared with the other insured group, underinsured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed underinsured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Underinsured patients with DRG of "menstrual and other female reproductive system disorders" (OR, 0.17; 95% CI = 0.06 to 0.51) or "esophagitis, gastroenteritis, and miscellaneous digestive disorders" (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. Conclusions: Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single-center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference. [source] Surveillance of Infectious Disease Occurrences in the Community: An Analysis of Symptom Presentation in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 7 2003Joe Suyama MD Objectives: To determine the effectiveness of a simulated emergency department (ED)-based surveillance system to detect infectious disease (ID) occurrences in the community. Methods: Medical records of patients presenting to an urban ED between January 1, 1999, and December 31, 2000, were retrospectively reviewed for ICD-9 codes related to ID symptomatology. ICD-9 codes, categorized into viral, gastrointestinal, skin, fever, central nervous system (CNS), or pulmonary symptom clusters, were correlated with reportable infectious diseases identified by the local health department (HD). These reportable infectious diseases are designated class A diseases (CADs) by the Ohio Department of Health. Cross-correlation functions (CCFs) tested the temporal relationship between ED symptom presentation and HD identification of CADs. The 95% confidence interval for lack of trend correlation was 0.0 ± 0.074; thus CCFs > 0.074 were considered significant for trend correlation. Further cross-correlation analysis was performed after chronic and non-community-acquirable infectious diseases were removed from the HD database as a model for bioterrorism surveillance. Results: Fifteen thousand five hundred sixty-nine ED patients and 6,489 HD patients were identified. Six thousand two hundred eight occurrences of true CADs were identified. Only 87 (1.33%) HD cases were processed on weekends. During the study period, increased ED symptom presentation preceded increased HD identification of respective CADs by 24 hours for all symptom clusters combined (CCF = 0.112), gastrointestinal symptoms (CCF = 0.084), pulmonary symptoms (CCF = 0.110), and CNS symptoms (CCF = 0.125). The bioterrorism surveillance model revealed increased ED symptom presentation continued to precede increased HD identification of the respective CADs by 24 hours for all symptom clusters combined (CCF = 0.080), pulmonary symptoms (CCF = 0.100), and CNS symptoms (CCF = 0.120). Conclusions: Surveillance of ED symptom presentation has the potential to identify clinically important ID occurrences in the community 24 hours prior to HD identification. Lack of weekend HD data collection suggests that the ED is a more appropriate setting for real-time ID surveillance. [source] Bispectral Electroencephalographic Analysis of Patients Undergoing Procedural Sedation in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 6 2003James R. Miner MD Abstract Objective: To determine whether there is a correlation between the level of sedation achieved during procedural sedation (PS) in the emergency department as determined by bispectral electroencephalographic (EEG) analysis (BIS) and the rate of respiratory depression (RD), the patient's perception of pain, recall of the procedure, and satisfaction. Methods: This was a prospective observational study conducted in an urban county hospital of adult patients undergoing PS using propofol, methohexital, etomidate, and the combination of fentanyl and midazolam. Consenting patients were monitored by vital signs, pulse oximetry, nasal-sample end-tidal carbon dioxide (ETCO2), and BIS monitors during PS. Respiratory depression (RD) was defined as an oxygen saturation <90%, a change from baseline ETCO2 of >10 mm Hg, or an absent ETCO2 waveform at any time during the procedure. After the procedure, patients were asked to complete three 100-mm visual analog scales (VASs) concerning their perception of pain, recall of the procedure, and satisfaction with the procedure. Patients were divided into four groups based on the lowest BIS score recorded during the procedure, group 1, >85; group 2, 70,85; group 3, 60,69; group 4, <60. Rates of RD and VAS outcomes were compared between groups using chi-square statistics. Results: One hundred eight patients were enrolled in the study. No serious adverse events were noted. RD was seen in three of 14 (21.4%) of the patients in group 1, seven of 34 (20.6%) in group 2, 16 of 26 (61.5%) in group 3, and 18 of 34 (52.9%) in group 4. The rate of RD in patients in group 2 was not significantly different from that in group 1 (p = 0.46). The rate of RD in group 2 was significantly lower than that in groups 3 (p = 0.0003) and 4 (p = 0.006). For the VAS data, when group 1 was compared with the combined groups 2, 3, and 4, it had significantly higher rates of pain (p = 0.003) and recall (p = 0.001), and a dissatisfaction rate (p = 0.085) that approached significance. When groups 2, 3, and 4 were compared with chi-square test, there was not a significant difference in pain (p = 0.151), recall (p = 0.27), or satisfaction (p = 0.25). Conclusions: Patients with a lowest recorded BIS score between 70 and 85 had the same VAS outcomes as more deeply sedated patients and the same rate of RD as less deeply sedated patients. This range of scores represented the optimally sedated patients in this study. [source] Preventive Care in the Emergency Department: Should Emergency Departments Conduct Routine HIV Screening?ACADEMIC EMERGENCY MEDICINE, Issue 3 2003A Systematic Review Abstract Objective: To perform a systematic review of the emergency medicine literature to assess the appropriateness of offering routine HIV screening to patients in the emergency department (ED). Methods: The systematic review was conducted with the aid of a structured template, a companion explanatory guide, and a grading and methodological scoring system based on published criteria for critical appraisal. Two reviewers conducted independent searches using OvidR, PubMed, MD Consult, and Grateful Med. Relevant abstracts were reviewed; those most pertinent to the stated objective were selected for complete evaluation using the structured template. Results: Fifty-two relevant abstracts were reviewed; of these, nine were selected for detailed evaluation. Seven ED-based prospective cross-sectional seroprevalence studies found HIV rates of 2,17%. Highest rates of infection were seen among patients with behavioral risks such as male homosexual activity and intravenous drug use. Two studies demonstrated feasibility of both standard and rapid HIV testing in the ED, with more than half of the patients approached consenting to testing by either method, consistent with voluntary testing acceptance rates described in other settings. Several cost,benefit analyses lend indirect support for HIV screening in the ED. Conclusions: Multiple ED-based studies meeting the Centers for Disease Control and Prevention Guideline threshold to recommend routine screening, in conjunction with limited feasibility trials and extrapolation from cost,benefit studies, provide evidence to recommend that EDs offer HIV screening to high-risk patients (i.e., those with identifiable risk factors) or high-risk populations (i.e., those where HIV seroprevelance is at least 1%). [source] Effect of Mandated Nurse,Patient Ratios on Patient Wait Time and Care Time in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 5 2010Theodore C. Chan MD Abstract Objectives:, The objective was to evaluate the effect of mandated nurse,patient ratios (NPRs) on emergency department (ED) patient flow. Methods:, Two institutions implemented an electronic tracking system embedded within the electronic medical record (EMR) of two EDs (an academic urban, teaching medical center,Hospital A; and a suburban community hospital,Hospital B), with a combined census of 60,000/year, to monitor real-time NPRs and patient acuity, such that compliance with state-mandated ratios could be prospectively monitored. Data were queried for a 1-year period after implementation and included patient wait times (WTs), ED care time (EDCT), patient acuity, ED census, and NPR status for each nurse, patient, and the ED overall. Median WT and EDCT with interquartile ranges (IQRs) were analyzed to determine the effect of NPR status of each patient, nurse, and the ED overall. To control for factors that could affect the "within the mandated ratio" and the "outside of the mandated ratio" status, including patient volume and acuity, log-linear regression models were used controlling for specified factors for each hospital facility and combined. Results:, There were a total of 30,404 (50.9%) patients who waited in the waiting room prior to being placed in an ED bed (53.8% at Hospital A and 46.4% at Hospital B). Patients who waited at Hospital A waited a median duration of 55 minutes (IQR = 15,128 minutes), compared with 32 minutes (IQR = 12,67 minutes) at Hospital B with a combined median WT of 44 minutes (IQR = 13,101 minutes). In the log-linear regression analysis, WTs were 17% (95% confidence interval [CI] = 10% to 25%, p < 0.001) longer at Hospital A and 13% (95% CI = 3% to 24%, p = 0.008) longer at Hospital B (combined 16% [95% CI = 10% to 22%, p < 0.001] longer at both sites) when the ED overall was out-of-ratio compared to in-ratio. There were a total of 45,660 patients discharged from both EDs during the study period, from which EDCT data were collected (26,894 in Hospital A and 18,766 in Hospital B). Median EDCT was 184 minutes (IQR = 97,311 minutes) at Hospital A, compared to 120 minutes (IQR = 63,208 minutes) at Hospital B, for a combined median EDCT of 153 minutes (IQR = 81,269 minutes). In the log-linear regression analysis, the EDCT for patients whose nurse was out-of-ratio were 34% (95% CI = 30% to 38%, p < 0.001) longer at Hospital A and 42% (95% CI = 37% to 48%, p < 0.001) longer at Hospital B (combined 37% [95% CI = 34% to 41%, p < 0.001] longer at both sites) when compared to patients whose nurse was in-ratio. Conclusions:, In these two EDs, throughput measures of WT and EDCT were shorter when the ED nurse staffing were within state-mandated levels, after controlling for ED census and patient acuity. ACADEMIC EMERGENCY MEDICINE 2010; 17:545,552 © 2010 by the Society for Academic Emergency Medicine [source] | |||||||||||||