Health Outcomes

Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions

Carmel, MD, et al.

Hospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center.

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Pain Perception in Latino vs. Caucasian and Male vs. Female Patients: Is There Really a Difference?

Molly Aufiero, DO, et al.

Pain is one of the most common complaints in emergency departments (ED) nationwide. The perception of pain in others is, therefore, an important component of patient assessment and treatment. There are difficulties in studying pain since it is subjective, which raises the question of what is a clinically significant change in pain.

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Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

Jessica R. Schumacher, PhD, et al.

Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients’ care-seeking decisions.

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Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment

Amy Stuck, PhD, RN, et al.

The study objective was to explore emergency physicians’ (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization.

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Replacement of Dislodged Gastrostomy Tubes After Stoma Dilation in the Pediatric Emergency Department

Shiloni Bhambani, MD, et al.

A dislodged gastrostomy tube (GT) is a common complaint that requires evaluation in the pediatric emergency department (ED) and, on occasion, will require stoma dilation to successfully replace the GT. The objective of this study was to describe the frequency that stoma dilation is required, the success rate of replacement, complications encountered, and the techniques used to confirm placement of the GT after dilation.

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A Comparison of Urolithiasis in the Presence and Absence of Microscopic Hematuria in the Emergency Department

Jason M. Mefford, MD, et al.

The evaluation of urolithiasis is largely influenced by the results of a urinalysis (UA). While the presence of microscopic hematuria favors a diagnosis of urolithiasis in a patient presenting with symptoms suggestive of ureteral colic, it is estimated that 10–20% of patients with urolithiasis can present without microscopic hematuria on UA.

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Management of Sickle Cell Disease Super Utilizers

Author Affiliation Gary A. Johnson, MD SUNY Upstate Medical University, Department of Emergency Medicine, Syracuse, New York   Much attention has been directed toward super utilizers of emergency department (ED) and hospital services. Often these patients have a chronic illness with significant potential for acute morbidity. In many settings, adults with sickle cell disease (SCD) […]

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Treatment of Nausea and Vomiting in Pregnancy: Factors Associated with ED Revisits

Treatment of Nausea and Vomiting in Pregnancy: Factors Associated with ED Revisits
Brian Sharp, MD, et al.

Nausea and vomiting in pregnancy (NVP) is a condition that commonly affects women in the first trimester of pregnancy. Despite frequently leading to emergency department (ED) visits, little evidence exists to characterize the nature of ED visits or to guide its treatment in the ED. Our objectives were to evaluate the treatment of NVP in the ED and to identify factors that predict return visits to the ED for NVP.

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Association of Age, Systolic Blood Pressure, and Heart Rate with Adult Morbidity and Mortality after Urgent Care Visits

Association of Age, Systolic Blood Pressure, and Heart Rate with Adult Morbidity and Mortality after Urgent Care Visits
James Hart, MD et al.

Little data exists to help urgent care (UC) clinicians predict morbidity and mortality risk. Age, systolic blood pressure (SBP), and heart rate (HR) are easily obtainable and have been used in other settings to predict short-term risk of deterioration. We hypothesized that there is a relationship between advancing age, SBP, HR, and short-term health outcomes in the UC setting.

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Contrast CT Scans in the Emergency Department Do Not Increase Risk of Adverse Renal Outcomes

Volume 17, Issue 4, July 2016
Michael Heller, MD et al.

It has long been accepted that intravenous contrast used in both computed tomography (CT) and plain imaging carries a risk of nephropathy and renal failure, particularly in subpopulations thought to be at highest risk.1-3 Although early studies used high osmolality contrast media that is not typical of emergency department (ED) use today, the issue of contrast-induced nephropathy (CIN) is still an area of active interest with many studies appearing each year from many different specialties, on its pathogenesis, incidence, prevention and treatment.4-7 The plethora of data has usually focused on the incidence of CIN, usually defined as a small (such as 25% or an absolute increase of 0.5mg/dL) increase in creatinine after receiving intravenous (IV) contrast for either a particular indication (such as cardiac catheterization) or in a particular patient group (diabetics); the meaning of a creatinine rise in this setting is not at all clear, however.8-10 Many regimens have been proposed to ameliorate this creatinine rise, but there is a scarcity of data on what actual adverse clinical events occur and whether these can truly be ascribed to the IV contrast itself rather than the events that might well occur in a (usually) hospitalized population that required imaging. A few authors have even expressed doubt as to whether modern iodinated contrast (which is iso-osmolal) is a nephrotoxin.11-13

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Trends in Hospital Admission and Surgical Procedures Following ED visits for Diverticulitis

Volume 17, Issue 4, July 2016
Margaret B. Greenwood-Ericksen, MD, MPH et al.

Diverticulitis is a common diagnosis in the emergency department (ED). Outpatient management of diverticulitis is safe in selected patients, yet the rates of admission and surgical procedures following ED visits for diverticulitis are unknown, as are the predictive patient characteristics. Our goal is to describe trends in admission and surgical procedures following ED visits for diverticulitis, and to determine which patient characteristics predict admission.

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Undertriage of Trauma-Related Deaths in U.S. Emergency Departments

Volume 17, Issue 3, May 2016
Jenelle Holst, MD. et al.

Introduction: Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers.
Methods: This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression.
Results: We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0–46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1–37.1]) and most rural ED visits (86.4%, 95% CI [81.5–90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70–0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1–40,999) (OR 0.54, 95% CI [0.43–0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71–1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38–0.66]).
Conclusion: We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.

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Vital Signs Predict Rapid-Response Team Activation Within Twelve Hours of Emergency Department Admission

Volume 17, Issue 3, May 2016
James Walston, MD. et al.

Introduction: Rapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration marked by decline in vital signs. Traditionally emergency department (ED) disposition is partially based on the patients’ vital signs (VS) at the time of hospital admission. We aimed to identify which patients will have RRT activation within 12 hours of admission based on their ED VS, and if their outcomes differed.
Methods: We conducted a case-control study of patients presenting from January 2009 to December 2012 to a tertiary ED who subsequently had RRT activations within 12 hours of admission (early RRT activations). The medical records of patients 18 years and older admitted to a non-intensive care unit (ICU) setting were reviewed to obtain VS at the time of ED arrival and departure, age, gender and diagnoses. Controls were matched 1:1 on age, gender, and diagnosis. We evaluated VS using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all patients. Our study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational studies.
Results: A total of 948 patients were included (474 cases and 474 controls). Patients who had RRT activations were more likely to be tachycardic (odds ratio [OR] 2.02, 95% CI [1.25–3.27]), tachypneic (OR 2.92, 95% CI [1.73–4.92]), and had lower oxygen saturations (OR 2.25, 95% CI [1.42–3.56]) upon arrival to the ED. Patients who had RRT activations were more likely to be tachycardic at the time of disposition from the ED (OR 2.76, 95% CI [1.65–4.60]), more likely to have extremes of systolic blood pressure (BP) (OR 1.72, 95% CI [1.08–2.72] for low BP and OR 1.82, 95% CI [1.19–2.80] for high BP), higher respiratory rate (OR 4.15, 95% CI [2.44–7.07]) and lower oxygen saturation (OR 2.29, 95% CI [1.43–3.67]). Early RRT activation was associated with increased healthcare utilization and worse outcomes including increased rates of ICU admission within 72 hours (OR 38.49, 95%CI [19.03–77.87]), invasive interventions (OR 5.49, 95%CI [3.82–7.89]), mortality at 72 hours (OR 4.24, 95%CI [1.60–11.24]), and mortality at one month (OR 4.02, 95%CI [2.44–6.62]).
Conclusion: After matching for age, gender and ED diagnosis, we found that patients with an abnormal heart rate, respiratory rate or oxygen saturation at the time of ED arrival or departure are more likely to trigger RRT activation within 12 hours of admission. Early RRT activation was associated with higher mortality at 72 hours and one month, increased rates of invasive intervention and ICU admission. Determining risk factors of early RRT activation is of clinical, operational, and financial importance, as improved medical decision-making regarding disposition would maximize allocation of resources while potentially limiting morbidity and mortality.

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Trauma Triage and Trauma System Performance

Volume 17, Issue 3, May 2016
Gary Johnson, MD

Trauma systems seek to provide complex medical care at the correct time and the correct place. During the past four decades numerous articles have been published that validate trauma systems from many points of view. Achievements of trauma systems include improvement in mortality and morbidity, efficiencies of care, and economic outcomes. Prehospital policy execution is intrinsic to trauma system performance. Trauma system criteria are relatively standardized. However, flexibility in emergency medical service (EMS) decision-making is commonly allowed. These decisions have major impacts on resource allocation, trauma center utilization, and patient outcome.

In this edition, Holst, et al1 reviewed adult emergency department (ED) trauma deaths as reported in the 2010 National Emergency Department Sample. They recorded the association of these deaths to trauma or non-trauma center designation, as well as geographic and patient demographics including rural vs urban site, gender, and patient income data. They found that one half of all trauma ED deaths nationally and one third of ED urban trauma patients died in non-trauma centers. Both elderly trauma deaths and deaths due to falls more frequently occurred in non-trauma centers. Like most studies describing trauma system performance, this is a retrospective review taken from a large database. Therefore, causation of outcome cannot be directly attributed to undertriage. However, the magnitude of the non-trauma center death rate merits further investigation.

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Inadequate Sensitivity of Laboratory Risk Indicator to Rule Out Necrotizing Fasciitis in the Emergency Department

Volume 17, Issue 3, May 2016
Elizabeth Burner, MD et al.

Necrotizing fasciitis (NF) is a life-threatening infection with high mortality. Because NF can be misdiagnosed as a less lethal mimic, such as cellulitis and abscess, efforts have been made to identify clinical features that could help clinicians accurately diagnose NF and avoid delays to surgical debridement.1 Prior retrospective studies have shown certain laboratory values, particularly an extremely elevated leukocyte count and a low sodium concentration, are associated with NF.2 These abnormal values might help clinicians distinguish NF from less severe soft-tissue infections. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed in a large cohort of admitted patients to identify patients at higher risk for NF.3 Patients are assigned a LRINEC score based on serum sodium, glucose, creatinine, c-reactive protein (CRP), leukocyte count and hemoglobin. Scores range from 0 to 13; a score 6 or greater was associated with a high risk of NF, and a score of 8 or greater with a very high risk.

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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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Outcomes of Patients Requiring Blood Pressure Control Before Thrombolysis with tPA for Acute Ischemic Stroke

Volume 16, Issue 7, December 2015.
Bryan Darger, BA, et al.

Introduction: The purpose of this study was to assess safety and efficacy of thrombolysis in the
setting of aggressive blood pressure (BP) control as it compares to standard BP control or no BP
control prior to thrombolysis.
Methods: We performed a retrospective review of patients treated with tissue plasminogen activator
(tPA) for acute ischemic stroke (AIS) between 2004-2011. We compared the outcomes of patients
treated with tPA for AIS who required aggressive BP control prior to thrombolysis to those requiring
standard or no BP control prior to thrombolysis. The primary outcome of interest was safety, defined
by all grades of hemorrhagic transformation and neurologic deterioration. The secondary outcome
was efficacy, determined by functional status at discharge, and in-hospital deaths.
Results: Of 427 patients included in the analysis, 89 received aggressive BP control prior to
thrombolysis, 65 received standard BP control, and 273 required no BP control prior to thrombolysis.
Patients requiring BP control had more severe strokes, with median arrival National Institutes of
Health Stroke Scale of 10 (IQR [6-17]) in patients not requiring BP control versus 11 (IQR [5-16]) and
13 (IQR [7-20]) in patients requiring standard and aggressive BP lowering therapies, respectively
(p=0.048). In a multiple logistic regression model adjusting for baseline differences, there were no
statistically significant differences in adverse events between the three groups (P>0.10).
Conclusion: We observed no association between BP control and adverse outcomes in ischemic
stroke patients undergoing thrombolysis. However, additional study is necessary to confirm or refute
the safety of aggressive BP control prior to thrombolysis.

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Troponin Marker for Acute Coronary Occlusion and Patient Outcome Following Cardiac Arrest

Volume 16, Issue 7, December 2015.
David A. Pearson, MD, et al.

Introduction: The utility of troponin as a marker for acute coronary occlusion and patient outcome after
out-of-hospital cardiac arrest (OHCA) is unclear. We sought to determine whether initial or peak troponin
was associated with percutaneous coronary intervention (PCI), OHCA survival or neurological outcome.
Methods: Single-center retrospective-cohort study of OHCA patients treated in a comprehensive
clinical pathway from November 2007 to October 2012. Troponin I levels were acquired at
presentation, four and eight hours after arrest, and then per physician discretion. Cardiac
catheterization was at the cardiologist’s discretion. Survival and outcome were determined at hospital
discharge, with cerebral performance category score 1-2 defined as a good neurological outcome.
Results: We enrolled 277 patients; 58% had a shockable rhythm, 44% survived, 41% good
neurological outcome. Of the 107 (38%) patients who underwent cardiac catheterization, 30 (28%)
had PCI. Initial ED troponin (median, ng/mL) was not different in patients requiring PCI vs no PCI
(0.32 vs 0.09, p=0.06), although peak troponin was higher (4.19 versus 1.57, p=0.02). Of the 85
patients who underwent cardiac catheterization without STEMI (n=85), there was no difference in
those who received PCI vs no PCI in initial troponin (0.22 vs 0.06, p=0.40) or peak troponin (2.58 vs
1.43, p=0.27). Regarding outcomes, there was no difference in initial troponin in survivors versus nonsurvivors
(0.09 vs 0.22, p=0.11), or those with a good versus poor neurological outcome (0.09 vs 0.20,
p=0.11). Likewise, there was no difference in peak troponin in survivors versus non-survivors (1.64 vs
1.23, p=0.07), or in those with a good versus poor neurological outcome (1.57 vs 1.26, p=0.14).
Conclusion: In our single-center patient cohort, peak troponin, but not initial troponin, was
associated with higher likelihood of PCI, while neither initial nor peak troponin were associated with
survival or neurological outcome in OHCA patients.

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Diagnosis of Aortic Dissection in Emergency Department Patients is Rare

Volume 16, Issue 5, September 2015.
Scott M. Alter, MD, et al.

Introduction: Aortic dissection is a rare event. While the most frequent symptom is chest pain,
that is a common emergency department (ED) chief complaint and other diseases causing chest
pain occur much more often. Furthermore, 20% of dissections are without chest pain and 6%
are painless. For these reasons, diagnosing dissections may be challenging. Our goal was to
determine the number of total ED and atraumatic chest pain patients for every aortic dissection
diagnosed by emergency physicians.
Methods: Design: Retrospective cohort. Setting: 33 suburban and urban New York and New
Jersey EDs with annual visits between 8,000 and 80,000. Participants: Consecutive patients seen
by emergency physicians from 1-1-1996 through 12-31-2010. Observations: We identified aortic
dissection and atraumatic chest pain patients using the International Classification of Diseases 9th
Revision and Clinical Modification codes. We then calculated the number of total ED and atraumatic
chest pain patients for every aortic dissection, along with 95% confidence intervals (CIs).
Results: From a database of 9.5 million ED visits, we identified 782 aortic dissections or one for
every 12,200 (95% CI [11,400-13,100]) visits. The mean age of dissection patients was 66±16 years
and 38% were female. There were 763,000 (8%) with atraumatic chest pain diagnoses. Thus, there is
one dissection for every 980 (95% CI [910-1,050]) atraumatic chest pain patients.
Conclusion: The diagnosis of aortic dissections by emergency physicians is rare and challenging.
An emergency physician seeing 3,000 to 4,000 patients a year would diagnose an aortic dissection
approximately every three to four years.

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Not Just an Urban Phenomenon: Uninsured Rural Trauma Patients at Increased Risk for Mortality

Volume 16, Issue 5, September 2015.
Azeemuddin Ahmed, MD, MBA, et al.

Introduction: National studies of largely urban populations showed increased risk of traumatic death
among uninsured patients, as compared to those insured. No similar studies have been done for
major trauma centers serving rural states.
Methods: We performed retrospective analyses using trauma registry records from adult, non-burn
patients admitted to a single American College of Surgeons-certified Level 1 trauma center in a rural
state (2003-2010, n=13,680) and National Trauma Data Bank (NTDB) registry records (2002-2008,
n=380,182). Risk of traumatic death was estimated using multivariable logistic regression analysis.
Results: We found that 9% of trauma center patients and 27% of NTDB patients were uninsured.
Overall mortality was similar for both (~4.5%). After controlling for covariates, uninsured trauma
center patients were almost five times more likely to die and uninsured NTDB patients were 75%
more likely to die than commercially insured patients. The risk of death among Medicaid patients
was not significantly different from the commercially insured for either dataset.
Conclusion: Our results suggest that even with an inclusive statewide trauma system and an
emergency department that does not triage by payer status, uninsured patients presenting to
the trauma center were at increased risk of traumatic death relative to patients with commercial
insurance.

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Treatment Failure Outcomes for Emergency Department Patients with Skin and Soft Tissue Infections

Volume 16, Issue 5, September 2015.
Larissa S. May, MD, et al.

Introduction: Skin and soft tissue infections (SSTIs) are commonly evaluated in the emergency
department (ED). Our objectives were to identify predictors of SSTI treatment failure within one week
post-discharge in patients with cutaneous abscesses, as well as to identify predictors of recurrence
within three months in that proportion of participants.
Methods: This was a sub-analysis of a parent study, conducted at two EDs, evaluating a new,
nucleic acid amplification test (NAAT) for Staphylococcus aureus in ED patients. Patients ≥18 years
receiving incision and drainage (I&D) were eligible. Patient-reported outcome data on improvement
of fever, swelling, erythema, drainage, and pain were collected using a structured abstraction form at
one week, one month, and three months post ED visit.
Results: We enrolled 272 participants (20 from a feasibility study and 252 in this trial), of which 198
(72.8%) completed one-week follow up. Twenty-seven additional one-week outcomes were obtained
through medical record review rather than by the one-week follow-up phone call. One hundred
ninety-three (73%) patients completed either the one- or three-month follow up. Most patients
recovered from their initial infection within one week, with 10.2% of patients reporting one-week
treatment failure. The odds of treatment failure were 66% lower for patients who received antibiotics
following I&D at their initial visit. Overall SSTI recurrence rate was 28.0% (95% CI [21.6%-34.4%])
and associated with contact with someone infected with methicillin resistant S. aureus (MRSA),
previous SSTI history, or clinician use of wound packing.
Conclusion: Treatment failure was reduced by antibiotic use, whereas SSTI recurrence was
associated with prior contact, SSTI, or use of packing.

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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
Email: editor@westjem.org

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.