Spinal epidural abscess (SEA), a highly morbid and potentially lethal deep tissue infection of the central nervous system has more than tripled in incidence over the past decade. Early recognition at the point of initial clinical presentation may prevent irreversible neurologic injury or other serious, adverse outcomes. To facilitate early recognition of SEA, we developed a predictive scoring model.
On December 2, 2015, terrorism landed in Southern California when two perpetrators aligned with the Islamic State (IS), murdered and wounded 38 civilians at the Inland Regional Center of San Bernardino, California.
To date, there have been limited studies on the effect of default tablet quantities as part of emergency department (ED) electronic order entry. Our goal was to evaluate opioid prescribing patterns before and after the removal of a default quantity of 20 tablets from ED electronic order entry.
This was a retrospective, observational, cohort study of ED patients presenting for acute alcohol intoxication from 2012 to 2016. The study hospital is a county ED with an annual volume of 100,000 visits and 7,000 visits for alcohol intoxication.
A benefit of in-hospital cardiac arrest is the opportunity for rapid initiation of “high-quality” chest compressions as defined by current American Heart Association (AHA) adult guidelines as a depth 2–2.4 inches, full chest recoil, rate 100–120 per minute, and minimal interruptions with a chest compression fraction (CCF) ≥ 60%. The goal of this study was to assess the effect of audiovisual feedback on the ability to maintain high-quality chest compressions as per 2015 updated guidelines.
While U.S. emergency medicine (EM) residency graduates are required to perform 10 low-risk normal spontaneous vaginal deliveries, little is known about how residencies prepare residents to manage obstetrical emergencies. We sought to profile the current obstetrical training curricula through a survey of U.S. training programs.
Epidemiological surveillance data for emergency department (ED) visits by children are imperative to guide resource allocation and to develop health policies that advance pediatric emergency care. However, there are sparse population-based data on patient-level information (e.g., the number of children who present to the emergency department [ED]). In this context, we aimed to investigate both the patient- and visit-level rates of ED utilization by children.
Telemedicine connects emergency departments (ED) with resources necessary for patient care; its use has not been characterized nationally, or even regionally. Our primary objective was to describe the prevalence of telemedicine use in New England EDs and the clinical applications of use. Secondarily, we aimed to determine if telemedicine use was associated with consultant availability and to identify ED characteristics associated with telemedicine use.
Emergency department observation units (EDOUs) are a valuable alternative to inpatient admissions for ED patients needing extended care. However, while the use of advanced imaging is becoming more common in the ED, there are no studies characterizing the use of magnetic resonance imaging (MRI) examinations in the EDOU.
Children often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs. We hypothesized that a significant portion of children discharged from the ED would have abnormal vital signs and that those discharged with abnormal vital signs would experience very few adverse events.
Topical benzocaine is a local anesthetic commonly used to relieve pain caused by teething, periodontal irritation, burns, wounds, and insect bites. Oral preparations may contain benzocaine concentrations ranging from 7.5% to 20%. Pediatric exposure to such large concentrations may result in methemoglobinemia and secondarily cause anemia, cyanosis, and hypoxia.
Our primary objective in this study was to evaluate the feasibility of a screening survey to identify adult victims of sex trafficking in the ED. We also compared the sensitivity of emergency physician concern and a screening survey for identifying sex trafficking victims in the ED and determined the most effective question(s) for identifying adult victims of sex trafficking.
The aim of the study was to determine if a medical degree disparity exists between those who successfully receive an EM R01 grant and those who do not, and to determine the publication characteristics of those recipients.
A subpopulation of sickle-cell disease patients, termed super-utilizers, presents frequently to emergency departments (EDs) for vaso-occlusive events and may consume disproportionate resources without broader health benefit.
Survey data regarding the prevalence of risky substance use in the emergency department (ED) is not consistent. The objective of this study was to identify the prevalence of risky substance use among injured ED patients based on the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST v3.0).
In June 2016, the American College of Emergency Physicians (ACEP) Emergency Quality Network began its Reduce Avoidable Imaging Initiative, designed to “reduce testing and imaging with low risk patients through the implementation of Choosing Wisely recommendations.”
Author Affiliation Eric Shappell, MD University of Chicago, Department of Medicine, Section of Emergency Medicine, Chicago, Illinois Abra Fant, MD, MS Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois Benjamin Schnapp, MD Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois Jill P. Craig, BA Northwestern University Feinberg […]
We sought to compare three hospital cost-estimation models for patients undergoing evaluation for unexplained syncope using hospital cost data. Developing such a model would allow researchers to assess the value of novel clinical algorithms for syncope management.
Our goal was to reduce ordering of coagulation studies in the emergency department (ED) that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR).
Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions
Chun Nuk Lam, MPH, et al.
Patients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.
Volume 17, Issue 4, July 2016
Lauren K. Whiteside, MD, MS et al.
Emerging infectious diseases often create concern and fear among the public. Ebola virus disease (EVD) and enterovirus (EV-68) are uncommon viral illnesses compared to influenza. The objective of this study was to determine risk for these viral diseases and then determine how public perception of influenza severity and risk of infection relate to more publicized but less common emerging infectious diseases such as EVD and EV-68 among a sample of adults seeking care at an emergency department (ED) in the United States.
Introduction: The National Emergency X-radiography Utilization Study (NEXUS) criteria are used
extensively in emergency departments to rule out C-spine injuries (CSI) in the general population.
Although the NEXUS validation set included 2,943 elderly patients, multiple case reports and the
Canadian C-Spine Rules question the validity of applying NEXUS to geriatric populations. The
objective of this study was to validate a modified NEXUS criteria in a low-risk elderly fall population
with two changes: a modified definition for distracting injury and the definition of normal mentation.
Methods: This is a prospective, observational cohort study of geriatric fall patients who presented
to a Level I trauma center and were not triaged to the trauma bay. Providers enrolled nonintoxicated
patients at baseline mental status with no lateralizing neurologic deficits. They
recorded midline neck tenderness, signs of trauma, and presence of other distracting injury.
Results: We enrolled 800 patients. One patient fall event was excluded due to duplicate
enrollment, and four were lost to follow up, leaving 795 for analysis. Average age was 83.6 (range
65-101). The numbers in parenthesis after the negative predictive value represent confidence
interval. There were 11 (1.4%) cervical spine injuries. One hundred seventeen patients had midline
tenderness and seven of these had CSI; 366 patients had signs of trauma to the face/neck, and
10 of these patients had CSI. Using signs of trauma to the head/neck as the only distracting injury
and baseline mental status as normal alertness, the modified NEXUS criteria was 100% sensitive
(CI [67.9-100]) with a negative predictive value of 100 (98.7-100).
Conclusion: Our study suggests that a modified NEXUS criteria can be safely applied to lowrisk
Volume 17, Issue 2, March 2016.
Tadahiro Goto, MD, et al.
Introduction: The objective of this study was to investigate the factors associated with first-pass
success in pediatric intubation in the emergency department (ED).
Methods: We analyzed the data from two multicenter prospective studies of ED intubation in 17
EDs between April 2010 and September 2014. The studies prospectively measured patient’s age,
sex, principal indication for intubation, methods (e.g., rapid sequence intubation [RSI]), devices, and
intubator’s level of training and specialty. To evaluate independent predictors of first-pass success,
we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we
repeated the analysis in children <10 years.
Results: A total of 293 children aged ≤18 years who underwent ED intubation were eligible for the
analysis. The overall first-pass success rate was 60% (95%CI [54%-66%]). In the multivariable
model, age ≥10 years (adjusted odds ratio [aOR], 2.45; 95% CI [1.23-4.87]), use of RSI (aOR, 2.17;
95% CI [1.31-3.57]), and intubation attempt by an emergency physician (aOR, 3.21; 95% CI [1.78-
5.83]) were significantly associated with a higher chance of first-pass success. Likewise, in the
sensitivity analysis, the use of RSI (aOR, 3.05; 95% CI [1.63-5.70]), and intubation attempt by an
emergency physician (aOR, 4.08; 95% CI [1.92-8.63]) were significantly associated with a higher
chance of first-pass success.
Conclusion: Based on two large multicenter prospective studies of ED airway management, we
found that older age, use of RSI, and intubation by emergency physicians were the independent
predictors of a higher chance of first-pass success in children. Our findings should facilitate
investigations to develop optimal airway management strategies in critically-ill children in the ED.
Volume 17, Issue 2, March 2016.
Warren Wiechmann, MD, MBA, et al.
Introduction: The use of personal mobile devices in the medical field has grown quickly, and a large
proportion of physicians use their mobile devices as an immediate resource for clinical decisionmaking,
prescription information and other medical information. The iTunes App Store (Apple,
Inc.) contains approximately 20,000 apps in its “Medical” category, providing a robust repository
of resources for clinicians; however, this represents only 2% of the entire App Store. The App
Store does not have strict criteria for identifying content specific to practicing physicians, making
the identification of clinically relevant content difficult. The objective of this study is to quantify
the characteristics of existing medical applications in the iTunes App Store that could be used by
emergency physicians, residents, or medical students.
Methods: We found applications related to emergency medicine (EM) by searching the iTunes App
Store for 21 terms representing core content areas of EM, such as “emergency medicine,” “critical
care,” “orthopedics,” and “procedures.” Two physicians independently reviewed descriptions of
these applications in the App Store and categorized each as the following: Clinically Relevant, Book/
Published Source, Non-English, Study Tools, or Not Relevant. A third physician reviewer resolved
disagreements about categorization. Descriptive statistics were calculated.
Results: We found a total of 7,699 apps from the 21 search terms, of which 17.8% were clinical,
9.6% were based on a book or published source, 1.6% were non-English, 0.7% were clinically
relevant patient education resources, and 4.8% were study tools. Most significantly, 64.9% were
considered not relevant to medical professionals. Clinically relevant apps make up approximately
6.9% of the App Store’s “Medical” Category and 0.1% of the overall App Store.
Conclusion: Clinically relevant apps represent only a small percentage (6.9%) of the total App
volume within the Medical section of the App Store. Without a structured search-and-evaluation
strategy, it may be difficult for the casual user to identify this potentially useful content. Given the
increasing adoption of devices in healthcare, national EM associations should consider curating
these resources for their members.
Volume 17, Issue 1, January 2016.
Stephen C. Dorner, MSc, et al.
Introduction: Under regulations established by the Affordable Care Act, insurance plans must meet
minimum standards in order to be sold through the federal Marketplace. These standards to become
a qualified health plan (QHP) include maintaining a provider network sufficient to assure access to
services. However, the complexity of emergency physician (EP) employment practices – in which
the EPs frequently serve as independent contractors of emergency departments, independently
establish insurance contracts, etc… – and regulations governing insurance repayment may hinder
the application of network adequacy standards to emergency medicine. As such, we hypothesized
the existence of QHPs without in-network access to EPs. The objective is to identify whether
there are QHPs without in-network access to EPs using information available through the federal
Marketplace and publicly available provider directories.
Results: In a national sample of Marketplace plans, we found that one in five provider networks
lacks identifiable in-network EPs. QHPs lacking EPs spanned nearly half (44%) of the 34 states
using the federal Marketplace.
Conclusion: Our data suggest that the present regulatory framework governing network adequacy
is not generalizable to emergency care, representing a missed opportunity to protect patient access
to in-network physicians. These findings and the current regulations governing insurance payment to
EPs dis-incentivize the creation of adequate physician networks, incentivize the practice of balance
billing, and shift the cost burden to patients.