Brief Research Report

Emergency Department Utilization by Children in the USA, 2010–2011

Goto, MD, et al.

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.

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Characterizing New England Emergency Departments by Telemedicine Use

Zachrison, MD, et al.

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.

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Emergency Department Operations

Magnetic Resonance Imaging Utilization in an Emergency Department Observation Unit

Sánchez, BA, et al.

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.

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Pediatric Exposures to Topical Benzocaine Preparations Reported to a Statewide Poison Control System

Vohra, MD, et al.

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.

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Screening for Victims of Sex Trafficking in the Emergency Department: A Pilot Program

Bryn E. Mumma, MD, MAS, et al.

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.

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A Novel Collaboration to Reduce the Travel-Related Cost of Residency Interviewing

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 […]

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Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions

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.

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Endemic Infections

Perception of the Risks of Ebola, Enterovirus-E68 and Influenza Among Emergency Department Patients

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.

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Treatment Protocol Assessment

Prospective Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk Elderly Fall Patients

Volume 17, Issue 3, May 2016
John Tran, MD et al.

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
elderly falls.

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Factors Associated with First-Pass Success in Pediatric Intubation in the Emergency Department

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.

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There’s an App for That? Highlighting the Difficulty in Finding Clinically Relevant Smartphone Applications

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.

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Emergency Department Access

Access to In-Network Emergency Physicians and Emergency Departments Within Federally Qualified Health Plans in 2015

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.

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Emergency Department Access

Association of Insurance Status with Severity and Management in ED Patients with Asthma Exacerbation

Volume 17, Issue 1, January 2016.
Kohei Hasegawa, MD, MPH, et al.

frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine
the relationship of insurance status – a proxy for socioeconomic status – with asthma severity and
management in adults. The objective is to investigate chronic and acute asthma management disparities
by insurance status among adults requiring emergency department (ED) treatment in the United States.
Methods: We conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients,
aged 18-54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture,
practice charts, certification) before reviewing randomly selected charts. We categorized patients
into three groups based on their primary health insurance: private, public, and no insurance.
Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period)
and management prior to the index ED visit, acute asthma management in the ED, and prescription
at ED discharge.
Results: The analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had
private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with
private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits
during the preceding year (35%, 49%, and 45%, respectively; p<0.001). Despite the higher chronic
severity, those with no insurance were less likely to have guideline-recommended chronic asthma care
– i.e., lower use of inhaled corticosteroids (ICS [41%, 41%, and 29%; p<0.001]) and asthma specialist
care (9%, 10%, and 4%; p<0.001). By contrast, there were no significant differences in acute asthma
management in the ED – e.g., use of systemic corticosteroids (75%, 79%, and 78%; p=0.08) or initiation
of ICS at ED discharge (12%, 12%, and 14%; p=0.57) – by insurance status.
Conclusion: In this multicenter observational study of ED patients with acute asthma, we found
significant discrepancies in chronic asthma severity and management by insurance status. By
contrast, there were no differences in acute asthma management among the insurance groups.

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Emergency Medicine Resident Rotations Abroad: Current Status and Next Steps

Volume 17, Issue 1, January 2016.
Stephen C. Morris, MD, MPH, et al.

Introduction: International rotations for residents are increasingly popular, but there is a dearth of
evidence to demonstrate that these rotations are safe and that residents have appropriate training
and support to conduct them.
Methods: A survey was sent to all U.S. emergency medicine (EM) residencies with publicly
available e-mail addresses. The survey documents and examines the training and support that
emergency medicine residents are offered for international rotations and the frequency of adverse
safety events.
Results: 72.5% of program director responded that their residents are participating in rotations
abroad. However, only 15.4% of programs reported offering training specific to working abroad. The
results point to an increased need for specific training and insurance coverage.
Conclusion: Oversight of international rotations should be improved to guarantee safety and
education benefit.

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Healthcare Utilization

Inpatient Readmissions and Emergency Department Visits within 30 Days of a Hospital Admission

Volume 16, Issue 7, December 2015.
Jesse J. Brennan, MA, et al.

Introduction: Inpatient hospital readmissions have become a focus for healthcare reform and costcontainment
efforts. Initiatives targeting unanticipated readmissions have included care coordination
for specific high readmission diseases and patients and health coaching during the post-discharge
transition period. However, little research has focused on emergency department (ED) visits
following an inpatient admission. The objective of this study was to assess 30-day ED utilization and
all-cause readmissions following a hospital admission.
Methods: This was a retrospective study using inpatient and ED utilization data from two hospitals
with a shared patient population in 2011. We assessed the 30-day ED visit rate and 30-day
readmission rate and compared patient characteristics among individuals with 30-day inpatient
readmissions, 30-day ED discharges, and no 30-day visits.
Results: There were 13,449 patients who met the criteria of an index visit. Overall, 2,453 (18.2%)
patients had an ED visit within 30 days of an inpatient stay. However, only 55.6% (n=1,363) of these
patients were admitted at one of these 30-day visits, resulting in a 30-day all-cause readmission rate
of 10.1%.
Conclusion: Approximately one in five patients presented to the ED within 30 days of an inpatient
hospitalization and over half of these patients were readmitted. Readmission measures that
incorporate ED visits following an inpatient stay might better inform interventions to reduce avoidable

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Impact of Health Information Exchange on Emergency Medicine Clinical Decision Making

Volume 16, Issue 7, December 2015.
Bradley D. Gordon, MD, MS, et al.

Introduction: The objective of the study was to understand the immediate utility of health
information exchange (HIE) on emergency department (ED) providers by interviewing them shortly
after the information was retrieved. Prior studies of physician perceptions regarding HIE have only
been performed outside of the care environment.
Methods: Trained research assistants interviewed resident physicians, physician assistants and
attending physicians using a semi-structured questionnaire within two hours of making a HIE
request. The responses were recorded, then transcribed for qualitative analysis. The transcribed
interviews were analyzed for emerging qualitative themes.
Results: We analyzed 40 interviews obtained from 29 providers. Primary qualitative themes
discovered included the following: drivers for requests for outside information; the importance
of unexpected information; historical lab values as reference points; providing context when
determining whether to admit or discharge a patient; the importance of information in refining
disposition; improved confidence of provider; and changes in decisions for diagnostic imaging.
Conclusion: ED providers are driven to use HIE when they’re missing a known piece of information.
This study finds two additional impacts not previously reported. First, providers sometimes find
additional unanticipated useful information, supporting a workflow that lowers the threshold to
request external information. Second, providers sometimes report utility when no changes to their
existing plan are made as their confidence is increased based on external records. Our findings are
concordant with previous studies in finding exchanged information is useful to provide context for
interpreting lab results, making admission decisions, and prevents repeat diagnostic imaging.

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Patient Communication

A Delphi Method Analysis to Create an Emergency Medicine Educational Patient Satisfaction Survey

Volume 16, Issue 7, December 2015.
Kory S. London, MD, et al.

Introduction: Feedback on patient satisfaction (PS) as a means to monitor and improve
performance in patient communication is lacking in residency training. A physician’s promotion,
compensation and job satisfaction may be impacted by his individual PS scores, once he is in
practice. Many communication and satisfaction surveys exist but none focus on the emergency
department setting for educational purposes. The goal of this project was to create an emergency
medicine-based educational PS survey with strong evidence for content validity.
Methods: We used the Delphi Method (DM) to obtain expert opinion via an iterative process of
surveying. Questions were mined from four PS surveys as well as from group suggestion. The DM
analysis determined the structure, content and appropriate use of the tool. The group used four-point
Likert-type scales and Lynn’s criteria for content validity to determine relevant questions from the
stated goals.
Results: Twelve recruited experts participated in a series of seven surveys to achieve consensus. A
10-question, single-page survey with an additional page of qualitative questions and demographic
questions was selected. Thirty one questions were judged to be relevant from an original 48-question list.
Of these, the final 10 questions were chosen. Response rates for individual survey items was 99.5%.
Conclusion: The DM produced a consensus survey with content validity evidence. Future work will
be needed to obtain evidence for response process, internal structure and construct validity.

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Emergency Department Visits by Older Adults with Mental Illness in North Carolina

Volume 16, Issue 7, December 2015.
Anne M. Hakenewerth, PhD, et al.

Introduction: We analyzed emergency department (ED) visits by patients with mental health disorders
(MHDs) in North Carolina from 2008-2010 to determine frequencies and characteristics of ED visits by
older adults with MHDs.
Methods: We extracted ED visit data from the North Carolina Disease Event Tracking and Epidemiologic
Collection Tool (NC DETECT). We defined mental health visits as visits with a mental health ICD-9-CM
diagnostic code, and organized MHDs into clinically similar groups for analysis.
Results: Those ≥65 with MHDs accounted for 27.3% of all MHD ED visits, and 51.2% were admitted. The
most common MHD diagnoses for this age group were psychosis, and stress/anxiety/depression.
Conclusion: Older adults with MHDs account for over one-quarter of ED patients with MHDs, and their
numbers will continue to increase as the “boomer” population ages. We must anticipate and prepare for
the MHD-related needs of the elderly.

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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389


ISSN: 1936-900X
e-ISSN: 1936-9018

ISSN: 2474-252X

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.