Original Research Archives - Page 21 of 40 - The Western Journal of Emergency Medicine

Use of Physician Concerns and Patient Complaints as Quality Assurance Markers in Emergency Medicine

Kiersten L. Gurley, MD et al.

The value of using patient- and physician-identified quality assurance (QA) issues in emergency medicine remains poorly characterized as a marker for emergency department (ED) QA. The objective of this study was to determine whether evaluation of patient and physician concerns is useful for identifying medical errors resulting in either an adverse event or a near-miss event.

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Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs

Author Affiliation James A. Heilman, MD Oregon Health & Science University, Department of Emergency Medicine, Portland, Oregon Moira Flanigan, BS Oregon Health & Science University, Department of Emergency Medicine, Portland, Oregon Anna Nelson, MD, PhD Oregon Health & Science University, Department of Emergency Medicine, Portland, Oregon Tom Johnson, MD, PhD Oregon Health & Science University, […]

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Critical Care

Application of Circumferential Compression Device (Binder) in Pelvic Injuries: Room for Improvement

Rahul Vaidya, MD et al.

The use of a noninvasive pelvic circumferential compression device (PCCD) to achieve pelvic stabilization by both decreasing pelvic volume and limiting inter-fragmentary motion has become commonplace, and is a well-established component of Advanced Trauma Life Support (ATLS) protocol in the treatment of pelvic ring injuries. The purpose of this study was to evaluate the following: 1) how consistently a PCCD was placed on patients who arrived at our hospital with unstable pelvic ring injuries; 2) if they were placed in a timely manner; and 3) if hemodynamic instability influenced their use.

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Critical Care

Autoinjectors Preferred for Intramuscular Epinephrine in Anaphylaxis and Allergic Reactions

Ronna L. Campbell, MD, PhD et al.

Epinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) healthcare providers regarding two methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery.

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Optic Nerve Sheath Diameter Measurement During Diabetic Ketoacidosis: A Pilot Study

Optic Nerve Sheath Diameter Measurement During Diabetic Ketoacidosis: A Pilot Study
Bergmann, DO, MS, et al.

Diabetic ketoacidosis-related cerebral edema (DKA-CE) occurs in up to 1% of children with type 1 diabetes (T1D),1 with approximately 20% displaying neurologic symptoms at presentation.2,3 Similarly, up to 54% have a mild form of subclinical DKA-CE identified by extracellular fluid measurements on magnetic resonance imaging (MRI), which is associated with alterations in neuronal function and cerebral injury on MR spectroscopy.2-6 This suggests that DKA-CE occurs along a continuum, ranging from asymptomatic imaging changes, mild neurologic injury, to cerebral herniation and death.

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Critical Care

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey
Robert S. Green, MD, et al.

Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI.

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Emergency Department Operations

Does Pneumatic Tube System Transport Contribute to Hemolysis in ED Blood Samples?

Does Pneumatic Tube System Transport Contribute to Hemolysis in ED Blood Samples?
Michael P. Phelan, MD, et al.

Our goal was to determine if the hemolysis among blood samples obtained in an emergency department and then sent to the laboratory in a pneumatic tube system was different from those in samples that were hand-carried.

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Emergency Department Operations

Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality

Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality
Guberman, MD, MS, et al.

Attending physician judgment is the traditional standard of care for emergency department (ED) admission decisions. The extent to which variability in admission decisions affect cost and quality is not well understood. We sought to determine the impact of variability in admission decisions on cost and quality.

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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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ED Patients with Prolonged Complaints and Repeat ED Visits Have an Increased Risk of Depression

ED Patients with Prolonged Complaints and Repeat ED Visits Have an Increased Risk of Depression
Kristopher R. Brickman, MD et al.

The objective of this study was to explore associations between presenting chief complaints of prolonged symptomatology, patient usage of the emergency department (ED), and underlying depression so that emergency physicians may better target patients for depression screening.

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Prehospital Care

A Comparison of Chest Compression Quality Delivered During On-Scene and Ground Transport Cardiopulmonary Resuscitation

A Comparison of Chest Compression Quality Delivered During On-Scene and Ground Transport Cardiopulmonary Resuscitation
Christopher S. Russi, DO et al.

The 2010 American Heart Association (AHA)/International Liaison Committee on Resuscitation (ILCOR) Cardiopulmonary Resuscitation (CPR) Guidelines call for a minimum chest compression rate of 100 to 120 compressions per minute and a minimum chest compression depth of 1.5 to 2 inches (3.75–5 cm).1 Two clinical studies have reported the quality of chest compressions delivered before emergency medical services (EMS) transport and the quality of those delivered during transport.2,3 Further evidence has suggested that visual, automated CPR feedback improves CPR quality.

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Prehospital Care

Determinants of Success and Failure in Prehospital Endotracheal Intubation

Determinants of Success and Failure in Prehospital Endotracheal Intubation
Lucas A. Myers, BAH et al.

Endotracheal intubation (ETI) performance by emergency medical services (EMS) personnel remains a heavily examined and debated issue for medical directors and prehospital care providers. Research on success rates in adults has demonstrated ranges from 77.2% to 98.5%.1-4 Unfortunately, opportunities for clinical intubation are infrequent.5 EMS educational programs have highlighted the need for greater frequency of ETI performance through clinical opportunities such as the operating suite.6 Given the relatively few opportunities for practicing the procedure in some EMS systems, detailed patient selection and guideline criteria aimed at limiting difficult intubation attempts may increase the relative proportion of success.

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Prehospital Care

Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria

Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria
Lori L. Boland, MPH et al.

We aimed to pilot test the delivery of sepsis education to emergency medical services (EMS) providers and the feasibility of equipping them with temporal artery thermometers (TATs) and handheld lactate meters to aid in the prehospital recognition of sepsis.

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Prehospital Care

Geospatial Analysis of Pediatric EMS Run Density and Endotracheal Intubation

Geospatial Analysis of Pediatric EMS Run Density and Endotracheal Intubation
Matthew Hansen, MD, MCR et al.

The association between geographic factors, including transport distance, and pediatric emergency medical services (EMS) run clustering on out-of-hospital pediatric endotracheal intubation is unclear. The objective of this study was to determine if endotracheal intubation procedures are more likely to occur at greater distances from the hospital and near clusters of pediatric calls.

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Prehospital Care

The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval

The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval
Megan H. Halliday, MSIII, BS et al.

A lack of coordination between emergency medical services (EMS), emergency departments (ED) and systemwide management has contributed to extended ambulance at-hospital times at local EDs. In an effort to improve communication within the local EMS system, the Baltimore City Fire Department (BCFD) placed a medical duty officer (MDO) in the fire communications bureau. It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the EMS at-hospital time.

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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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Prehospital Care

Accuracy of Perceived Estimated Travel Time by EMS to a Trauma Center in San Bernardino County, California

Volume 17, Issue 4, July 2016
Michael M. Neeki, DO, MS, et al.

Mobilization of trauma resources has the potential to cause ripple effects throughout hospital operations. One major factor affecting efficient utilization of trauma resources is a discrepancy between the prehospital estimated time of arrival (ETA) as communicated by emergency medical services (EMS) personnel and their actual time of arrival (TOA). The current study aimed to assess the accuracy of the perceived prehospital estimated arrival time by EMS personnel in comparison to their actual arrival time at a Level II trauma center in San Bernardino County, California.

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Emergency Department Operations

Emergency Department Length of Stay for Maori and European Patients in New Zealand

Volume 17, Issue 4, July 2016
David Prisk, DO et al.

Emergency department length of stay (ED LOS) is currently used in Australasia as a quality measure. In our ED, Maori, the indigenous people of New Zealand, have a shorter ED LOS than European patients. This is despite Maori having poorer health outcomes overall. This study sought to determine drivers of LOS in our provincial New Zealand ED, particularly looking at ethnicity as a determining factor.

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Emergency Department Operations

Comparison of Result Times Between Urine and Whole Blood Point-of-care Pregnancy Testing

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

Point-of-care (POC) pregnancy testing is commonly performed in the emergency department (ED). One prior study demonstrated equivalent accuracy between urine and whole blood for one common brand of POC pregnancy testing. Our study sought to determine the difference in result times when comparing whole blood versus urine for the same brand of POC pregnancy testing.

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Body Mass Index is a Poor Predictor of Bedside Appendix Ultrasound Success or Accuracy

Volume 17, Issue 4, July 2016
Samuel Lam, MD, et al.

In recent years studies have been published on the use of beside ultrasound (BUS) to diagnose appendicitis in the emergency department (ED). Its popularity is likely due to the improving ultrasound skills of emergency physicians, as well as the obvious BUS advantages of no ionizing radiation emission, and ease of performance and interpretation at the bedside. Use of ultrasound in suspected appendicitis is also supported by American College of Radiology recommendations, especially in the pediatric population.

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Societal Impact on Emergency Care

Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements

Volume 17, Issue 3, May 2016
Nadia Zuabi, BS et al.

Introduction: The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 was enacted
to prevent hospitals from “dumping” or refusing service to patients for financial reasons. The statute
prohibits discrimination of emergency department (ED) patients for any reason. The Office of the
Inspector General (OIG) of the Department of Health and Human Services enforces the statute.
The objective of this study is to determine the scope, cost, frequency and most common allegations
leading to monetary settlement against hospitals and physicians for patient dumping.
Methods: Review of OIG investigation archives in May 2015, including cases settled from
2002-2015 (https://oig.hhs.gov/fraud/enforcement/cmp/patient_dumping.asp).
Results: There were 192 settlements (14 per year average for 4000+ hospitals in the USA).
Fines against hospitals and physicians totaled $6,357,000 (averages $33,435 and $25,625
respectively); 184/192 (95.8%, $6,152,000) settlements were against hospitals and eight against
physicians ($205,000). Most common settlements were for failing to screen 144/192 (75%) and
stabilize 82/192 (42.7%) for emergency medical conditions (EMC). There were 22 (11.5%) cases
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of inappropriate transfer and 22 (11.5%) more where the hospital failed to transfer. Hospitals failed
to accept an appropriate transfer in 25 (13.0%) cases. Patients were turned away from hospitals
for insurance/financial status in 30 (15.6%) cases. There were 13 (6.8%) violations for patients in
active labor. In 12 (6.3%) cases, the on-call physician refused to see the patient, and in 28 (14.6%)
cases the patient was inappropriately discharged. Although loss of Medicare/Medicaid funding is
an additional possible penalty, there were no disclosures of exclusion of hospitals from federal
funding. There were 6,035 CMS investigations during this time period, with 2,436 found to have
merit as EMTALA violations (40.4%). However, only 192/6,035 (3.2%) actually resulted in OIG
settlements. The proportion of CMS-certified EMTALA violations that resulted in OIG settlements
was 7.9% (192/2,436).
Conclusion: Of 192 hospital and physician settlements with the OIG from 2002-15, most were
for failing to provide screening (75%) and stabilization (42%) to patients with EMCs. The reason
for patient “dumping” was due to insurance or financial status in 15.6% of settlements. The vast
majority of penalties were to hospitals (95% of cases and 97% of payments). Forty percent of
investigations found EMTALA violations, but only 3% of investigations triggered fines.

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Practice Variability

Quality Improvement Initiative to Decrease Variability of Emergency Physician Opioid Analgesic Prescribing

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

Introduction: Addressing pain is a crucial aspect of emergency medicine. Prescription opioids
are commonly prescribed for moderate to severe pain in the emergency department (ED);
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unfortunately, prescribing practices are variable. High variability of opioid prescribing decisions
suggests a lack of consensus and an opportunity to improve care. This quality improvement (QI)
initiative aimed to reduce variability in ED opioid analgesic prescribing.
Methods: We evaluated the impact of a three-part QI initiative on ED opioid prescribing by
physicians at seven sites. Stage 1: Retrospective baseline period (nine months). Stage 2:
Physicians were informed that opioid prescribing information would be prospectively collected and
feedback on their prescribing and that of the group would be shared at the end of the stage (three
months). Stage 3: After physicians received their individual opioid prescribing data with blinded
comparison to the group means (from Stage 2) they were informed that individual prescribing
data would be unblinded and shared with the group after three months. The primary outcome was
variability of the standard error of the mean and standard deviation of the opioid prescribing rate
(defined as number of patients discharged with an opioid divided by total number of discharges
for each provider). Secondary observations included mean quantity of pills per opioid prescription,
and overall frequency of opioid prescribing.
Results: The study group included 47 physicians with 149,884 ED patient encounters. The
variability in prescribing decreased through each stage of the initiative as represented by the
distributions for the opioid prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46%
reduction, p<0.01), and Stage 3 mean 8% (60% reduction, p<0.01). The mean quantity of pills
prescribed per prescription was 16 pills in Stage 1, 14 pills in Stage 2 (18% reduction, p<0.01),
and 13 pills in Stage 3 (18% reduction, p<0.01). The group mean prescribing rate also decreased
through each stage: 20% in Stage 1, 13% in Stage 2 (46% reduction, p<0.01), and 8% in Stage
3 (60% reduction, p<0.01).
Conclusion: ED physician opioid prescribing variability can be decreased through the systematic
application of sharing of peer prescribing rates and prescriber specific normative feedback.

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Critical Care

Academic Emergency Medicine Physicians’ Knowledge of Mechanical Ventilation

Volume 13, Issue 3, May 2016
Susan R. Wilcox, MD et al.

Introduction: Although emergency physicians frequently intubate patients, management of
mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical
practice. The objective of this study was to quantify EM attendings’ education, experience, and
knowledge regarding mechanical ventilation in the emergency department.
Methods: We developed a survey of academic EM attendings’ educational experiences with
ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key
teaching hospitals for seven EM residency training programs in the northeastern United States
were invited to participate in this survey study. We performed correlation and regression analyses
to evaluate the relationship between attendings’ scores on the assessment instrument and their
training, education, and comfort with ventilation.
Results: Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5%
reported receiving three or fewer hours of ventilation-related education from EM sources over the
past year and 98 (46%) reported receiving between 0-1 hour of education. The overall correct
response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors
associated with a higher score were completion of an EM residency, prior emphasis on mechanical
ventilation during one’s own residency, working in a setting where an emergency physician bears
primary responsibility for ventilator management, and level of comfort with managing ventilated
patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM
management of ventilation, as well as hours of education.
Conclusion: EM attendings report caring for mechanically ventilated patients frequently, but most
receive fewer than three educational hours a year on mechanical ventilation, and nearly half
receive 0-1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is
most strongly correlated with their self-reported comfort with mechanical ventilation.

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ACE-I Angioedema: Accurate Clinical Diagnosis May Prevent Epinephrine-Induced Harm

Volume 17, Issue 3, May 2016
R. Mason Curtis, MD et al.

Introduction: Upper airway angioedema is a life-threatening emergency department (ED)
presentation with increasing incidence. Angiotensin-converting enzyme inhibitor induced
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angioedema (AAE) is a non-mast cell mediated etiology of angioedema. Accurate diagnosis by
clinical examination can optimize patient management and reduce morbidity from inappropriate
treatment with epinephrine. The aim of this study is to describe the incidence of angioedema
subtypes and the management of AAE. We evaluate the appropriateness of treatments and
highlight preventable iatrogenic morbidity.
Methods: We conducted a retrospective chart review of consecutive angioedema patients
presenting to two tertiary care EDs between July 2007 and March 2012.
Results: Of 1,702 medical records screened, 527 were included. The cause of angioedema
was identified in 48.8% (n=257) of cases. The most common identifiable etiology was AAE
(33.1%, n=85), with a 60.0% male predominance. The most common AAE management strategies
included diphenhydramine (63.5%, n=54), corticosteroids (50.6%, n=43) and ranitidine (31.8%,
n=27). Epinephrine was administered in 21.2% (n=18) of AAE patients, five of whom received
repeated doses. Four AAE patients required admission (4.7%) and one required endotracheal
intubation. Epinephrine induced morbidity in two patients, causing myocardial ischemia or
dysrhythmia shortly after administration.
Conclusion: AAE is the most common identifiable etiology of angioedema and can be accurately
diagnosed by physical examination. It is easily confused with anaphylaxis and mismanaged with
antihistamines, corticosteroids and epinephrine. There is little physiologic rationale for epinephrine
use in AAE and much risk. Improved clinical differentiation of mast cell and non-mast cell mediated
angioedema can optimize patient management.

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