Emergency Department Operations

Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice

Volume 16, Issue 5, September 2015.
Jeremy J. Hess, MD, MPH

Introduction: Physicians dedicate substantial time to documentation. Scribes are sometimes used
to improve efficiency by performing documentation tasks, although their impacts have not been
prospectively evaluated. Our objective was to assess a scribe program’s impact on emergency
department (ED) throughput, physician time utilization, and job satisfaction in a large academic
emergency medicine practice.
Methods: We evaluated the intervention using pre- and post-intervention surveys and administrative
data. All site physicians were included. Pre- and post-intervention data were collected in fourmonth
periods one year apart. Primary outcomes included changes in monthly average ED length
of stay (LOS), provider-specific average relative value units (RVUs) per hour (raw and normalized
to volume), self-reported estimates of time spent teaching, self-reported estimates of time spent
documenting, and job satisfaction. We analyzed data using descriptive statistics and appropriate
tests for paired pre-post differences in continuous, categorical, and ranked variables.
Results: Pre- and post-survey response rates were 76.1% and 69.0%, respectively. Most responded
positively to the intervention, although 9.5% reported negative impressions. There was a 36%
reduction (25%-50%; p<0.01) in time spent documenting and a 30% increase (11%-46%, p<0.01) in
time spent in direct patient contact. No statistically significant changes were seen in job satisfaction
or perception of time spent teaching. ED volume increased by 88 patients per day (32-146, p=0.04)
pre- to post- and LOS was unchanged; rates of patients leaving against medical advice dropped,
and rates of patients leaving without being seen increased. RVUs per hour increased 5.5% and
per patient 5.3%; both were statistically significant. No statistically significant changes were seen
in patients seen per hour. There was moderate correlation between changes in ED volume and
changes in productivity metrics.
Conclusion: Scribes were well received in our practice. Documentation time was substantially
reduced and redirected primarily to patient care. Despite an ED volume increase, LOS was maintained,
with fewer patients leaving against medical advice but more leaving without being seen. RVUs per hour
and per patient both increased.

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Emergency Department Operations

Identifying Patient Door-to-Room Goals to Minimize Left-Without-Being-Seen Rates

Volume 16, Issue 5, September 2015.
Shea Pielsticker, BS, et al.

Introduction: Emergency department (ED) patients in the leave-without-being-seen (LWBS) group
risk problems of inefficiency, medical risk, and financial loss. The goal at our hospital is to limit LWBS
to <1%. This study’s goal was to assess the influence on LWBS associated with prolonging intervals
between patient presentation and placement in an exam room (DoorRoom time). This study’s major
aim was to identify DoorRoom cutoffs that maximize likelihood of meeting the LWBS goal (i.e. <1%).
Methods: We conducted the study over one year (8/13-8/14) using operations data for an ED with
annual census ~50,000. For each study day, the LWBS endpoint (i.e. was LWBS <1%: “yes or
no”) and the mean DoorRoom time were recorded. We categorized DoorRoom means by intervals
starting with ≤10min and ending at >60min. Multivariate logistic regression was used to assess
for DoorRoom cutoffs predicting high LWBS, while adjusting for patient acuity (triage scores and
admission %) and operations parameters. We used predictive marginal probability to assess utility of
the regression-generated cutoffs. We defined statistical significance at p<0.05 and report odds ratio
(OR) and 95% confidence intervals (CI).
Results: Univariate results suggested a primary DoorRoom cutoff of 20’, to maintain a high
likelihood (>85%) of meeting the LWBS goal. A secondary DoorRoom cutoff was indicated at 35’, to
prevent a precipitous drop-off in likelihood of meeting the LWBS goal, from 61.1% at 35’ to 34.4%
at 40’. Predictive marginal analysis using multivariate techniques to control for operational and
patient-acuity factors confirmed the 20’ and 35’ cutoffs as significant (p<0.001). Days with DoorRoom
between 21-35’ were 74% less likely to meet the LWBS goal than days with DoorRoom ≤20’ (OR
0.26, 95% CI [0.13-0.53]). Days with DoorRoom >35’ were a further 75% less likely to meet the
LWBS goal than days with DoorRoom of 21-35’ (OR 0.25, 95% CI [0.15-0.41]).
Conclusion: Operationally useful DoorRoom cutoffs can be identified, which allow for rational
establishment of performance goals for the ED attempting to minimize LWBS.

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Endemic Infections

Identify-Isolate-Inform: A Modified Tool for Initial Detection and Management of Middle East Respiratory Syndrome Patients in the Emergency Department

Volume 16, Issue 5, September 2015.
Kristi L. Koenig, MD.

Middle East respiratory syndrome (MERS) is a novel infectious disease caused by a coronavirus
(MERS-CoV) first reported in Saudi Arabia in September 2012. MERS later spread to other countries
in the Arabian Peninsula, followed by an outbreak in South Korea in 2015. At least 26 countries
have reported MERS cases, and these numbers may increase over time. Due to international
travel opportunities, all countries are at risk of imported cases of MERS, even if outbreaks do not
spread globally. Therefore, it is essential for emergency department (ED) personnel to be able to
rapidly assess MERS risk and take immediate actions if indicated. The Identify-Isolate-Inform (3I)
tool, originally conceived for initial detection and management of Ebola virus disease patients in the
ED and later adjusted for measles, can be adapted for real-time use for any emerging infectious
disease. This paper reports a modification of the 3I tool for use in initial detection and management
of patients under investigation for MERS. Following an assessment of epidemiologic risk factors,
including travel to countries with current MERS transmission and contact with patients with confirmed
MERS within 14 days, patients are risk stratified by type of exposure coupled with symptoms of fever
and respiratory illness. If criteria are met, patients must be immediately placed into airborne infection
isolation (or a private room until this type of isolation is available) and the emergency practitioner
must alert the hospital infection prevention and control team and the local public health department.
The 3I tool will facilitate rapid categorization and triggering of appropriate time-sensitive actions for
patients presenting to the ED at risk for MERS.

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Endemic Infections

Tuberculoma-Induced Seizures

Volume 16, Issue 5, September 2015.
R. James Salway, MD, et al.

Seizures in human immunodeficiency virus (HIV) patients can be caused by a wide variety of
opportunistic infections, and, especially in developing countries, tuberculosis (TB) should be high
on the differential. In India, TB is the most common opportunistic infection in HIV and it can have
several different central nervous system manifestations, including intracranial tuberculomas. In this
case, an HIV patient presenting with new-onset seizure and fever was diagnosed with tuberculous
meningitis and multiple intracranial tuberculomas. The patient received standard TB medications,
steroids, and anticonvulsants in the emergency department and was admitted for further care.

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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

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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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Accuracy of ‘My Gut Feeling:’ Comparing System 1 to System 2 Decision-Making for Acuity Prediction, Disposition and Diagnosis in an Academic Emergency Department

Volume 16, Issue 5, September 2015.
Daniel Cabrera, MD, et al.

Introduction: Current cognitive sciences describe decision-making using the dual-process theory,
where a System 1 is intuitive and a System 2 decision is hypothetico-deductive. We aim to compare
the performance of these systems in determining patient acuity, disposition and diagnosis.
Methods: Prospective observational study of emergency physicians assessing patients in the
emergency department of an academic center. Physicians were provided the patient’s chief
complaint and vital signs and allowed to observe the patient briefly. They were then asked to predict
acuity, final disposition (home, intensive care unit (ICU), non-ICU bed) and diagnosis. A patient was
classified as sick by the investigators using previously published objective criteria.
Results: We obtained 662 observations from 289 patients. For acuity, the observers had a sensitivity
of 73.9% (95% CI [67.7-79.5%]), specificity 83.3% (95% CI [79.5-86.7%]), positive predictive value
70.3% (95% CI [64.1-75.9%]) and negative predictive value 85.7% (95% CI [82.0-88.9%]). For final
disposition, the observers made a correct prediction in 80.8% (95% CI [76.1-85.0%]) of the cases.
For ICU admission, emergency physicians had a sensitivity of 33.9% (95% CI [22.1-47.4%]) and a
specificity of 96.9% (95% CI [94.0-98.7%]). The correct diagnosis was made 54% of the time with
the limited data available.
Conclusion: System 1 decision-making based on limited information had a sensitivity close to 80%
for acuity and disposition prediction, but the performance was lower for predicting ICU admission
and diagnosis. System 1 decision-making appears insufficient for final decisions in these domains
but likely provides a cognitive framework for System 2 decision-making.

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Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction

Volume 16, Issue 5, September 2015.
Carlos J. Roldan, MD

Despite the level of skill of the operator and the use of ultrasound guidance, central venous catheter
(CVC) placement can result in CVC malpositioning, an unintended placement of the catheter tip in
an inadequate vessel. CVC malpositioning is not a complication of central line insertion; however,
undiagnosed CVC malpositioning can be associated with significant morbidity and mortality. The
objectives of this review were to describe factors associated with intravascular malpositioning of
CVCs inserted via the neck and chest and to offer ways of preventing, identifying, and correcting
such malpositioning. A literature search of PubMed, Cochrane Library, and MD Consult was
performed in June 2014. By searching for “Central line malposition” and then for “Central venous
catheters intravascular malposition,” we found 178 articles written in English. Of those, we found
that 39 were relevant to our objectives and included them in our review. According to those articles,
intravascular CVC malpositioning is associated with the presence of congenital and acquired
anatomical variants, catheter insertion in left thoracic venous system, inappropriate bevel orientation
upon needle insertion, and patient’s body habitus variants. Although plain chest radiography is
the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC
malpositioning even in presence of normal or inconclusive conventional radiography findings should
prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning. With very
few exceptions, the recommendation in cases of intravascular CVC malpositioning is to remove and
relocate the catheter. Knowing the mechanisms of CVC malpositioning and how to prevent, identify,
and correct CVC malpositioning could decrease harm to patients with this condition.

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Pediatric Tape: Accuracy and Medication Delivery in the National Park Service

Volume 16, Issue 5, September 2015.
Danielle D. Campagne, MD, et al.

Introduction: The objective is to evaluate the accuracy of medication dosing and the time to
medication administration in the prehospital setting using a novel length-based pediatric emergency
resuscitation tape.
Methods: This study was a two-period, two-treatment crossover trial using simulated pediatric
patients in the prehospital setting. Each participant was presented with two emergent scenarios;
participants were randomized to which case they encountered first, and to which case used the
National Park Service (NPS) emergency medical services (EMS) length-based pediatric emergency
resuscitation tape. In the control (without tape) case, providers used standard methods to determine
medication dosing (e.g. asking parents to estimate the patient’s weight); in the intervention (with
tape) case, they used the NPS EMS length-based pediatric emergency resuscitation tape. Each
scenario required dosing two medications (Case 1 [febrile seizure] required midazolam and
acetaminophen; Case 2 [anaphylactic reaction] required epinephrine and diphenhydramine). Twenty
NPS EMS providers, trained at the Parkmedic/Advanced Emergency Medical Technician level,
served as study participants.
Results: The only medication errors that occurred were in the control (no tape) group (without tape:
5 vs. with tape: 0, p=0.024). Time to determination of medication dose was significantly shorter
in the intervention (with tape) group than the control (without tape) group, for three of the four
medications used. In case 1, time to both midazolam and acetaminophen was significantly faster in
the intervention (with tape) group (midazolam: 8.3 vs. 28.9 seconds, p=0.005; acetaminophen: 28.6
seconds vs. 50.6 seconds, p=0.036). In case 2, time to epinephrine did not differ (23.3 seconds vs.
22.9 seconds, p=0.96), while time to diphenhydramine was significantly shorter in the intervention
(with tape) group (13 seconds vs. 37.5 seconds, p<0.05).
Conclusion: Use of a length-based pediatric emergency resuscitation tape in the prehospital setting
was associated with significantly fewer dosing errors and faster time-to-medication administration in
simulated pediatric emergencies. Further research in a clinical field setting to prospectively confirm
these findings is needed.

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Sensitivity of a Clinical Decision Rule and Early Computed Tomography in Aneurysmal Subarachnoid Hemorrhage

Volume 16, Issue 5, September 2015.
Dustin G. Mark, MD, et al.

Introduction: Application of a clinical decision rule for subarachnoid hemorrhage, in combination with
cranial computed tomography (CT) performed within six hours of ictus (early cranial CT), may be able
to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). This study’s
objective was to examine the sensitivity of both early cranial CT and a previously validated clinical
decision rule among emergency department (ED) patients with aSAH and a normal mental status.
Methods: Patients were evaluated in the 21 EDs of an integrated health delivery system between
January 2007 and June 2013. We identified by chart review a retrospective cohort of patients
diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT.
Variables comprising the SAH clinical decision rule (age >40, presence of neck pain or stiffness,
headache onset with exertion, loss of consciousness at headache onset) were abstracted from the
chart and assessed for inter-rater reliability.
Results: One hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of
early cranial CT was 95.5% (95% CI [90.9-98.2]). The sensitivity of the SAH clinical decision rule
was also 95.5% (95% CI [90.9-98.2]). Since all false negative cases for each diagnostic modality
were mutually independent, the combined use of both early cranial CT and the clinical decision rule
improved sensitivity to 100% (95% CI [97.6-100.0]).
Conclusion: Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal
sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might
optimize sensitivity for this life-threatening disease.

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Treatment Protocol Assessment

Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department

Volume 16, Issue 5, September 2015.
Kelly N. Sawyer, MD, MS, et al.

Introduction: Undifferentiated chest pain in the emergency department (ED) is a diagnostic
challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary
embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a
coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study
was to describe the ED patient course and short-term safety for these evaluation methods.
Methods: This was a retrospective observational study of adult patients presenting to a large,
community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal
biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation
exposures. We evaluated 30-day return visits for major adverse cardiac events.
Results: A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing
TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs.
30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to
incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs.
16.6mSv). No patient in either group had a related 30-day revisit.
Conclusion: Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO
safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to
further assess this approach to ED chest pain evaluation.

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Treatment Protocol Assessment

Comparing an Unstructured Risk Stratification to Published Guidelines in Acute Coronary Syndromes

Volume 16, Issue 5, September 2015.
Ann-Jean CC. Beck, MD

Introduction: Guidelines are designed to encompass the needs of the majority of patients with a
particular condition. The American Heart Association (AHA) in conjunction with the American College
of Cardiology (ACC) and the American College of Emergency Physicians (ACEP) developed risk
stratification guidelines to aid physicians with accurate and efficient diagnosis and management
of patients with acute coronary syndrome (ACS). While useful in a primary care setting, in the
unique environment of an emergency department (ED), the feasibility of incorporating guidelines
into clinical workflow remains in question. We aim to compare emergency physicians’ (EP) clinical
risk stratification ability to AHA/ACC/ACEP guidelines for ACS, and assessed each for accuracy in
predicting ACS.
Methods: We conducted a prospective observational cohort study in an urban teaching hospital
ED. All patients presenting to the ED with chest pain who were evaluated for ACS had two risk
stratification scores assigned: one by the treating physician based on clinical evaluation and
the other by the AHA/ACC/ACEP guideline aforementioned. The patient’s ACS risk stratification
classified by the EP was compared to AHA/ACC/ACEP guidelines. Patients were contacted at 30
days following the index ED visit to determine all cause mortality, unscheduled hospital/ED revisits,
and objective cardiac testing performed.
Results: We enrolled 641 patients presenting for evaluation by 21 different EPs. There was a
difference between the physician’s clinical assessment used in the ED, and the AHA/ACC/ACEP
task force guidelines. EPs were more likely to assess patients as low risk (40%), while AHA/ACC/
ACEP guidelines were more likely to classify patients as intermediate (45%) or high (45%) risk. Of
the 119 (19%) patients deemed high risk by EP evaluation, 38 (32%) were diagnosed with ACS.
AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk with 56 (98%) of those patients
diagnosed with no ACS.
Conclusion: In the ED, physicians are more efficient at correctly placing patients with underlying
ACS into a high-risk category. A small percentage of patients were considered low risk when
applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to
make an efficient assessment of cardiac risk and established criteria may be overly conservative
when applied to an acute care population.

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Critical Care

Interposed Abdominal Compression CPR for an Out-of-Hospital Cardiac Arrest Victim Failing Traditional CPR

Volume 16, Issue 5, September 2015.
Christian D. McClung, MD, MPhil, et al.

Interposed abdominal compression cardiopulmonary resuscitation (IAC-CPR) is an alternative
technique to traditional cardiopulmonary resuscitation (CPR) that can improve perfusion and lead to
restoration of circulation in patients with chest wall deformity either acquired through vigorous CPR
or co-morbidity such as chronic obstructive pulmonary disease. We report a case of out-of-hospital
cardiac arrest where IAC-CPR allowed for restoration of spontaneous circulation and eventual
full neurologic recovery when traditional CPR was failing to generate adequate pulses with chest
compression alone.

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Injury Prevention

Injuries Following Segway Personal Transporter Accidents: Case Report and Review of the Literature

Volume 16, Issue 5, September 2015.
John Ashurst DO, MSc, et al.

The Segway® self-balancing personal transporter has been used as a means of transport for
sightseeing tourists, military, police and emergency medical personnel. Only recently have reports
been published about serious injuries that have been sustained while operating this device. This
case describes a 67-year-old male who sustained an oblique fracture of the shaft of the femur
while using the Segway® for transportation around his community. We also present a review of the

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Healthcare Utilization

Invasive Mechanical Ventilation in California Over 2000–2009: Implications for Emergency Medicine

Volume 16, Issue 5, September 2015.
Seshadri C. Mudumbai, MD, MS, et al.

Introduction: Patients who require invasive mechanical ventilation (IMV) often represent a sequence
of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most
populous state, little information exists to define patterns of IMV use within the state of California.
Methods: We examined data from the masked Patient Discharge Database of California’s Office
of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV
during their stay were identified using the International Classification of Diseases 9th Revision
and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age
strata (18-34yr, 35-64yr, and >65yr). Using descriptive statistics and regression analyses, for IMV
discharges during the study period, we quantified the number of ED vs. non-ED based admissions;
changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV;
determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96hr); and
projected the number of IMV discharges and ED-based admissions by year 2020.
Results: There were 696,634 IMV discharges available for analysis. From 2000–2009, IMV
discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868
(328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based
admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35–64
year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients
requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by
29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of
patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for
younger patients (ages 18-34yr), non-whites, and publicly insured patients. Some of the strongest
predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites;
and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to
n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED.
Conclusion: Based on sustained growth over the past decade, by the year 2020, we project a further
increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed
capacities, ongoing increases in the number and type of IMV patients have the potential to adversely
affect California EDs that often admit patients to ICUs.

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Patient Communication

Patient Admission Preferences and Perceptions

Volume 16, Issue 5, September 2015.
Clayton Wu, MD, et al.

Introduction: Understanding patient perceptions and preferences of hospital care is important to
improve patients’ hospitalization experiences and satisfaction. The objective of this study was to
investigate patient preferences and perceptions of hospital care, specifically differences between
intensive care unit (ICU) and hospital floor admissions.
Methods: This was a cross-sectional survey of emergency department (ED) patients who were
presented with a hypothetical scenario of a patient with mild traumatic brain injury (TBI). We
surveyed their preferences and perceptions of hospital care related to this scenario. A closed-ended
questionnaire provided quantitative data on patient preferences and perceptions of hospital care and
an open-ended questionnaire evaluated factors that may not have been captured with the closedended
Results: Out of 302 study patients, the ability for family and friends to visit (83%), nurse availability
(80%), and physician availability (79%) were the factors most commonly rated “very important,” while
the cost of hospitalization (62%) and length of hospitalization (59%) were the factors least commonly
rated “very important.” When asked to choose between the ICU and the floor if they were the patient
in the scenario, 33 patients (10.9%) choose the ICU, 133 chose the floor (44.0%), and 136 (45.0%)
had no preference.
Conclusion: Based on a hypothetical scenario of mild TBI, the majority of patients preferred
admission to the floor or had no preference compared to admission to the ICU. Humanistic factors
such as the availability of doctors and nurses and the ability to interact with family appear to have a
greater priority than systematic factors of hospitalization, such as length and cost of hospitalization
or length of time in the ED waiting for an in-patient bed.

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Evaluation of Social Media Use by Emergency Medicine Residents and Faculty

Volume 16, Issue 5, September 2015.
David Pearson, MD, MS, et al.

Introduction: Clinicians and residency programs are increasing their use of social media (SM) websites
for educational and promotional uses, yet little is known about the use of these sites by residents and
faculty. The objective of the study is to assess patterns of SM use for personal and professional purposes
among emergency medicine (EM) residents and faculty.
Methods: In this multi-site study, an 18-question survey was sent by e-mail to the residents and faculty in 14
EM programs and to the Council of Emergency Medicine Residency Directors (CORD) listserv via the online
tool SurveyMonkey™. We compiled descriptive statistics, including assessment with the chi-square test or
Fisher’s exact test. StatsDirect software (v 2.8.0, StatsDirect, Cheshire, UK) was used for all analyses.
Results: We received 1,314 responses: 63% of respondents were male, 40% were <30 years of age,
39% were between the ages 31 and 40, and 21% were older than 40. The study group consisted of
772 residents and 542 faculty members (15% were program directors, 21% were assistant or associate
PDs, 45% were core faculty, and 19% held other faculty positions. Forty-four percent of respondents
completed residency more than 10 years ago. Residents used SM markedly more than faculty for social
interactions with family and friends (83% vs 65% [p<0.0001]), entertainment (61% vs 47% [p<0.0001]),
and videos (42% vs 23% [p=0.0006]). Residents used Facebook™ and YouTube™ more often than
faculty (86% vs 67% [p<0.001]; 53% vs 46% [p=0.01]), whereas residents used Twitter™ (19% vs
26% [p=0.005]) and LinkedIn™ (15% vs 32% [p<0.0001]) less than faculty. Overall, residents used SM
sites more than faculty, notably in daily use (30% vs 24% [p<0.001]). For professional use, residents
were most interested in its use for open positions/hiring (30% vs 18% [p<0.0001]) and videos (33%
vs 26% [p=0.005]) and less interested than faculty with award postings (22% vs 33% [p<0.0001]) or
publications (30% vs 38% [p=0.0007]).
Conclusion: EM residents and faculty have different patterns and interests in the personal and professional
uses of social media. Awareness of these utilization patterns could benefit future educational endeavors.

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Effectiveness of a 40-minute Ophthalmologic Examination Teaching Session on Medical Student Learning

Volume 16, Issue 5, September 2015.
Wirachin Hoonpongsimanont, MD, MS, et al.

Introduction: Emergency physicians are among the few specialists besides ophthalmologists
who commonly perform ophthalmologic examinations using the slit lamp and other instruments.
However, most medical schools in the United States do not require an ophthalmology rotation
upon completion. Teaching procedural skills to medical students can be challenging due to limited
resources and instructor availability. Our study assesses the effectiveness of a 40-minute hands-on
teaching session on ophthalmologic examination for medical students using only two instructors and
low-cost equipment.
Methods: We performed an interventional study using a convenience sample of subjects. Pre- and
post-workshop questionnaires on students’ confidence in performing ophthalmologic examination
were administered. We used a paired t-test and Wilcoxon rank test to analyze the data.
Results: Of the 30 participants in the study, the mean age was 25 and the majority were first-year
medical students. The students’ confidence in performing every portion of the ophthalmologic exam
increased significantly after the teaching session. We found that the average confidence level before
the teaching session were below 2 on a 1-5 Likert scale (1 being the least confident). Confidence
levels in using the slit lamp had the highest improvement among the skills taught (2.17 95% CI
[1.84-2.49]). Students reported the least improvement in their confidence in assessing extraocular
movements (0.73, 95% CI [0.30-1.71]) and examining pupillary function (0.73, 95% CI [0.42-1.04]).
We observed the biggest difference in median confidence level in the use of the tonometer (4 with a
p-value of <0.05).
Conclusion: A 40-minute structured hands-on training session can significantly improve students’
confidence levels in ophthalmologic skills.

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Prehospital Care

Hand Washing Practices Among Emergency Medical Services Providers

Volume 16, Issue 5, September 2015.
Bucher, MD, et al.

Introduction: Hand hygiene is an important component of infection control efforts. Our primary and
secondary goals were to determine the reported rates of hand washing and stethoscope cleaning in
emergency medical services (EMS) workers, respectively.
Methods: We designed a survey about hand hygiene practices. The survey was distributed to
various national EMS organizations through e-mail. Descriptive statistics were calculated for
survey items (responses on a Likert scale) and subpopulations of survey respondents to identify
relationships between variables. We used analysis of variance to test differences in means between
the subgroups.
Results: There were 1,494 responses. Overall, reported hand hygiene practices were poor among
pre-hospital providers in all clinical situations. Women reported that they washed their hands more
frequently than men overall, although the differences were unlikely to be clinically significant.
Hygiene after invasive procedures was reported to be poor. The presence of available hand sanitizer
in the ambulance did not improve reported hygiene rates but improved reported rates of cleaning
the stethoscope (absolute difference 0.4, p=0.0003). Providers who brought their own sanitizer were
more likely to clean their hands.
Conclusion: Reported hand hygiene is poor amongst pre-hospital providers. There is a need for
future intervention to improve reported performance in pre-hospital provider hand washing.

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Prehospital Care

Telephone CPR Instructions in Emergency Dispatch Systems: Qualitative Survey of 911 Call Centers

Volume 16, Issue 5, September 2015.
John Sutter, BS, et al.

Introduction: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death. The 2010
American Heart Association Emergency Cardiovascular Care (ECC) Guidelines recognize
emergency dispatch as an integral component of emergency medical service response to OHCA
and call for all dispatchers to be trained to provide telephone cardiopulmonary resuscitation
(T-CPR) pre-arrival instructions. To begin to measure and improve this critical intervention, this
study describes a nationwide survey of public safety answering points (PSAPs) focusing on the
current practices and resources available to provide T-CPR to callers with the overall goal of
improving survival from OHCA.
Methods: We conducted this survey in 2010, identifying 5,686 PSAPs; 3,555 had valid e-mail
addresses and were contacted. Each received a preliminary e-mail announcing the survey, an e-mail
with a link to the survey, and up to three follow-up e-mails for non-responders. The survey contained
23 primary questions with sub-questions depending on the response selected.
Results: Of the 5,686 identified PSAPs in the United States, 3,555 (63%) received the survey, with
1,924/3,555 (54%) responding. Nearly all were public agencies (n=1,888, 98%). Eight hundred
seventy-eight (46%) responding agencies reported that they provide no instructions for medical
emergencies, and 273 (14%) reported that they are unable to transfer callers to another facility
to provide T-CPR. Of the 1,924 respondents, 975 (51%) reported that they provide pre-arrival
instructions for OHCA: 67 (3%) provide compression-only CPR instructions, 699 (36%) reported
traditional CPR instructions (chest compressions with rescue breathing), 166 (9%) reported some
other instructions incorporating ventilations and compressions, and 92 (5%) did not specify the type
of instructions provided. A validation follow up showed no substantial difference in the provision of
instructions for OHCA by non-responders to the survey.
Conclusion: This is the first large-scale, nationwide assessment of the practices of PSAPs in
the United States regarding T-CPR for OHCA. These data showing that nearly half of the nation’s
PSAPs do not provide T-CPR for OHCA, and very few PSAPs provide compression-only instructions,
suggest that there is significant potential to improve the implementation of this critical link in the
chain of survival for OHCA.

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Prehospital Care

Variability in Criteria for Emergency Medical Services Routing of Acute Stroke Patients to Designated Stroke Center Hospitals

Volume 16, Issue 5, September 2015.
Nikolay Dimitrov, MS, et al.

Introduction: Comprehensive stroke systems of care include routing to the nearest designated
stroke center hospital, bypassing non-designated hospitals. Routing protocols are implemented
at the state or county level and vary in qualification criteria and determination of destination
hospital. We surveyed all counties in the state of California for presence and characteristics of their
prehospital stroke routing protocols.
Methods: Each county’s local emergency medical services agency (LEMSA) was queried for the
presence of a stroke routing protocol. We reviewed these protocols for method of stroke identification
and criteria for patient transport to a stroke center.
Results: Thirty-three LEMSAs serve 58 counties in California with populations ranging from 1,175
to nearly 10 million. Fifteen LEMSAs (45%) had stroke routing protocols, covering 23 counties (40%)
and 68% of the state population. Counties with protocols had higher population density (1,500
vs. 140 persons per square mile). In the six counties without designated stroke centers, patients
meeting criteria were transported out of county. Stroke identification in the field was achieved using
the Cincinnati Prehospital Stroke Screen in 72%, Los Angeles Prehospital Stroke Screen in 7% and
a county-specific protocol in 22%.
Conclusion: California EMS prehospital acute stroke routing protocols cover 68% of the state
population and vary in characteristics including activation by symptom onset time and destination
facility features, reflecting matching of system design to local geographic resources.

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Access to and Use of Point-of-Care Ultrasound in the Emergency Department

Volume 16, Issue 5, September 2015.
Jason L. Sanders, MD, PhD, et al.

Introduction: Growing evidence supports emergency physician (EP)-performed point-of-care
ultrasound (PoC US). However, there is a utilization gap between academic emergency departments
(ED) and other emergency settings. We elucidated barriers to PoC US use in a multistate sample
of predominantly non-academic EDs to inform future strategies to increase PoC US utilization,
particularly in non-academic centers.
Methods: In 2010, we surveyed ED directors in five states (Arkansas, Hawaii, Minnesota,
Vermont, and Wyoming; n=242 EDs) about general ED characteristics. In four states we
determined barriers to PoC US use, proportion of EPs using PoC US, use privileges, and
whether EPs can bill for PoC US.
Results: Response rates were >80% in each state. Overall, 47% of EDs reported PoC US
availability. Availability varied by state, from 34% of EDs in Arkansas to 85% in Vermont. Availability
was associated with higher ED visit volume, and percent of EPs who were board certified/board
eligible in emergency medicine. The greatest barriers to use were limited training (70%), expense
(39%), and limited need (perceived or real) (32%). When PoC US was used by EPs, 50% used it
daily, 44% had privileges not requiring radiology confirmation, and 34% could bill separately for PoC
US. Only 12% of EPs used it ≥80% of the time when placing central venous lines.
Conclusion: Only 47% of EDs in our five-state sample of predominantly non-academic EDs had
PoC US immediately available. When available, the greatest barriers to use were limited training,
expense, and limited need. Recent educational and technical advancements may help overcome
these barriers.

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Focused Cardiac Ultrasound Diagnosis of Cor Triatriatum Sinistrum in Pediatric Cardiac Arrest

Volume 16, Issue 5, September 2015.
Thompson Kehri, MD, et al.

Cardiac arrest in the adolescent population secondary to congenital heart disease (CHD) is rare.
Focused cardiac ultrasound (FoCUS) in the emergency department (ED) can yield important clinical
information, aid in resuscitative efforts during cardiac arrest and is commonly integrated into the
evaluation of patients with pulseless electrical activity (PEA). We report a case of pediatric cardiac
arrest in which FoCUS was used to diagnose a critical CHD known as cor triatriatum sinistrum
as the likely cause for PEA cardiac arrest and help direct ED resuscitation.

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Bedside Ultrasound Evaluation Uncovering a Rare Urological Emergency Secondary to Neurofibromatosis

Volume 16, Issue 5, September 2015.
Thomas M. Nappe, Do, et al.

A 56-year-old female presented to the emergency
department (ED) with a chief complaint of urinary retention
and overflow incontinence for 24 hours, preceded by
progressive difficulty with voiding, worsening lower
abdominal discomfort and bloating. Her past medical
history was significant for small bowel obstruction and
neurofibromatosis with an associated benign pelvic tumor that
caused similar symptoms as a child, but had been known to
be stable since that time. She had also recently been treated
for a urinary tract infection. Her physical exam revealed
tachycardia and a diffusely tender abdomen with a palpable,
tender suprapubic mass extending just above her umbilicus.

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Splenic Rupture Diagnosed with Bedside Ultrasound in a Patient with Shock in the Emergency Department Following Colonoscopy

Volume 16, Issue 5, September 2015.
William Mulkerin, MD, et al.

A 64-year-old male presented to the emergency
department (ED) with near syncope and worsening left flank
and shoulder pain. He had undergone a difficult colonoscopy
two days prior due to a tortuous colon. Initial vital signs
were normal. He looked uncomfortable and had significant
left upper quadrant abdominal tenderness with guarding.
Thirty minutes after ED arrival, his blood pressure dropped
to 73/59 mmHg, requiring aggressive fluid resuscitation.
Bedside focused assessment with sonography in trauma
(FAST) exam demonstrated free fluid in the abdomen with
mixed echogenicity of the spleen, suggestive of splenic injury.
Computed tomography (CT) demonstrated a large subcapsular
splenic hematoma with active extravasation and surrounding
intraperitoneal free fluid.

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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

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.