Shock Index and Early Recognition of Sepsis in the Emergency Department: Pilot Study

Intro: Our objective was to compare the ability of SI, individual vital signs, and the systemic inflammatory response syndrome (SIRS) criteria to predict the primary outcome of hyperlactatemia (serum lactate ≥ 4.0 mmol/L) as a surrogate for disease severity, and the secondary outcome of 28-day mortality.
Conclusion: In this cohort, SI ≥ 0.7 performed as well as SIRS in NPV and was the most sensitive screening test for hyperlactatemia and 28-day mortality. SI ≥ 1.0 was the most specific predictor of both outcomes.

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Injury Outcomes

Riding the Escalator: How Dangerous is it Really?

Intro: About 10,000 escalator-related injuries per year result in emergency department treatment in the United States. Since the 1990s, a steady increase has been reported, but few statistics on escalator-related injuries have been published worldwide.
Conclusion: Escalator accidents can result in severe trauma. Significant gender differences in escalator accidents have been observed. Alcohol intoxication and age are significant risk factors in escalator-related accidents and might be possible targets for preventive measures.

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Bedside Teaching on Time to Disposition Improves Length of Stay for Critically-ill Emergency Departments Patients

Introduction: We tested the effect of a brief disposition process intervention on residents’ time to disposition and emergency department (ED) length of stay (LOS) in high acuity ED patients.
Conclusion: Prompting residents to enter administrative disposition orders in high acuity patients is associated with significant reduction in both time to disposition and ED LOS.

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Implementation of Computerized Physician Order Entry for Critical Patients in an Academic Emergency Department is Not Associated with a Change in Mortality Rate

Introduction: There is limited literature on the effect of computerized physician order entry (CPOE) on mortality. The objective of our study was to determine if there was a change in mortality among critically ill patients presenting to the emergency department (ED) after the implementation of a CPOE system.
Conclusion: The implementation of CPOE was not associated with a change in mortality of critically ill ED patients, but was associated with a decrease in proportion of patients discharged to home after hospitalization.

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Use of an Electronic Medical Record “Dotphrase” Data Template for a Prospective Head Injury Study

Introduction: The adoption of electronic medical records (EMRs) in emergency departments (EDs) has changed the way that healthcare information is collected, charted, and stored. A challenge for researchers is to determine how EMRs may be leveraged to facilitate study data collection efforts. Our objective is to describe the use of a unique data collection system leveraging EMR technology and to compare data entry error rates to traditional paper data collection.
Conclusion: DP data collection is a feasible means of data collection. DP data forms maintain all study data within the secure EMR environment, obviating the need to maintain and collect paper data forms.

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Clinician-performed Beside Ultrasound for the Diagnosis of Traumatic Pneumothorax

Intro: Prior studies have reported conflicting results regarding the utility of ultrasound in the diagnosis of traumatic pneumothorax (PTX) because they have used sonologists with extensive experience. This study evaluates the characteristics of ultrasound for PTX for a large cohort of trauma and emergency physicians.
Conclusion: In a large heterogenous group of clinicians who typically care for trauma patients, the sonographic evaluation for pneumothorax was as accurate as supine chest radiography. Thoracic ultrasound may be helpful in the initial evaluation of patients with truncal trauma.

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Prehospital Care

Education On Prehospital Pain Management: A Follow-Up Study

Introduction: In a 2001 quality improvement (QI) study, we demonstrated improvement in paramedic knowledge, perceptions, and management of pain. This follow-up study examines the impact of this QI program, repeated educational intervention (EI), and effectiveness of a new pain management standard operating procedure.
Conclusion: In this follow up study, paramedics’ baseline knowledge, perceptions, and management of pain have all improved from 6 years ago.

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Emergency Department Access

Comparison Between Emergency Department and Inpatient Nurses’ Perceptions of Boarding of Admitted Patients

Introduction: The boarding of admitted patients in the emergency department (ED) is a major cause of crowding and access block. One solution is boarding admitted patients in inpatient ward (W) hallways.
Conclusion: Inpatient nurses and those who have never worked in the ED are more opposed to inpatient boarding than ED nurses and nurses who have worked previously in the ED. Primary nursing concerns about boarding are lack of monitoring and privacy in hallway beds. Nurses admitted as patients seemed to prefer not being boarded where they work.

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Emergency Department Access

Established and Novel Initiatives to Reduce Crowding in Emergency Departments

Introduction: We sought to determine the degree that ACEP-identified high-impact initiatives for ED crowding and vertical patient flow have been implemented in academic EDs in the United States (U.S.).
Conclusion: We found great variability in the extent academic EDs have implemented ACEP’s established high-impact ED crowding initiatives, yet most (70%) have adopted to some extent the novel initiative vertical patient flow.

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Emergency Department Access

The Impact on Emergency Department Visits for Respiratory Illness During the Southern California Wildfires

Introduction: In 2007 wildfires ravaged Southern California resulting in the largest evacuation due to a wildfire in American history. We report how these wildfires affected emergency department (ED) visits for respiratory illness.
Conclusion: The 2007 Southern California wildfires caused significant surges in the volume of ED patients seeking treatment for respiratory illness. Disaster plans should prepare for these surges when future wildfires occur.

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Healthcare Utilization

Sedation-assisted Orthopedic Reduction in Emergency Medicine: The Safety and Success of a One Physician/One Nurse Model

Introduction: Much of the emergency medical research on sedation-assisted orthopedic reductions has been undertaken with two physicians––one dedicated to the sedation and one to the procedure. Although the dual-physician model is advocated by some, evidence in support of its superiority is lacking.

Conclusion: Sedation-assisted closed reduction of major joint dislocations and forearm fractures can be performed effectively and safely in the ED using a one physician/one nurse model. A policy that requires a separate physician (or nurse anesthetist) to administer medications for all sedation-assisted ED procedures appears unwarranted.

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Practice Variability

Variation in Specialists’ Reported Hospitalization Practices of Children Sustaining Blunt Abdominal Trauma

Introduction: Children with blunt abdominal trauma (BAT) are often hospitalized despite no intervention. We identified factors associated with emergency department (ED) disposition of children with BAT and differing computed tomography (CT) findings.

Conclusion: Substantial variation exists between specialties in reported hospitalization practices of asymptomatic children after abdominal trauma with minor CT findings. Better evidence is needed to guide disposition decisions.

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Practice Variability

Variation in Specialists’ Reported Hospitalization Practices of Children Sustaining Blunt Head Trauma

Introduction: Questions surround the appropriate emergency department (ED) disposition of children who have sustained blunt head trauma (BHT). Our objective was to identify physician disposition preferences of children with blunt head trauma (BHT) and varying computed tomography (CT) findings.

Conclusion: Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with BHT and traumatic CT findings.

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Practice Variability

The Treatment of Cutaneous Abscesses: Comparison of Emergency Medicine Providers’ Practice Patterns

Introduction: Cutaneous abscesses are commonly treated in the emergency department (ED). This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting.

Conclusion:Variability exists in the treatment strategies for abscess care. Most providers used narcotic analgesics in addition to local anesthetic, linear incisions, and packing. Most providers did not irrigate, order wound cultures, or routinely prescribe oral antibiotics unless specific risk factors or physical signs were present.

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Population Health Research Design

The Impact of Emergency Physician Turnover on Planning for Prospective Clinical Trials

Introduction: Emergency physician (EP) turnover is a significant issue that can have strong economic impact on hospital systems, as well as implications on research efforts to test and improve clinical practice.

Conclusion: EP workforce changes over an 18-month period were common. This has implications for emergency department directors, researchers, and individual EPs. Those planning research involving interventions upon EPs should account for turnover as it may have an impact when designing clinical trials to improve performance on healthcare delivery metrics for time-sensitive medical conditions such as stroke, acute myocardial infarction, or trauma.

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Emergency Department Crowding is Associated with Reduced Satisfaction Scores in Patients Discharged from the Emergency Department

Introduction: Emergency department (ED) crowding has been shown to negatively impact patient outcomes. Few studies have addressed the effect of ED crowding on patient satisfaction. Our objective was to evaluate the impact of ED crowding on patient satisfaction in patients discharged from the ED.

Conclusion: Increased crowding, as measured by ED occupancy rate and EDWIN score, was significantly associated with reduced patient satisfaction. Although causative attribution was limited, our study suggested yet another negative impact resulting from ED crowding.

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Perceptions of Emergency Department Crowding in the Commonwealth of Pennsylvania

Introduction: The state of emergency department (ED) crowding in Pennsylvania has not previously been reported.

Conclusion: ED crowding is a common problem in Pennsylvania and is worsening in the majority of hospitals, despite the implementation of a variety of interventions.

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Fatality and Injury Severity of Older Adult Motor Vehicle Collisions in Orange County, California, 1998–2007

Introduction:Injuries and fatalities in adult drivers 18–65 years of age have decreased in recent years due to safer vehicles, enhanced medical policies, and implementation of injury prevention policies. The objective of this study was to examine injury severity and fatality rates in older drivers compared to their younger counterparts in Orange County, California.

Conclusion: The decrease in collision fatalities was greater in the 25–64-year-old group compared to the older adult population. This disparity highlights the need for further injury prevention efforts for older drivers.

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Accuracy of Handheld Point-of-Care Fingertip Lactate Measurement in the Emergency Department

Introduction: We examined the accuracy and time-saving effect of a handheld Point-of-care (POC) device for the measurement of fingertip and whole blood lactate as compared with reference laboratory testing in critically ill ED patients.

Conclusion: Fingertip POC lactate measurement is an accurate method to determine lactate levels in infected ED patients with normal or modestly elevated lactate values and significantly decreases time to test results.

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Healthcare Utilization

Impact of Emergency Department Management of Atrial Fibrillation on Hospital Charges

Introduction: Emergency department (ED) cardioversion (EDCV) and discharge of patients with recent onset atrial fibrillation or atrial flutter (AF) has been shown to be a safe and effective management strategy. This study examines the impact of such aggressive ED management on hospital charges.

Conclusion: ED cardioversion of recent onset AF patients results in significant hospital savings.

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Family History Is a Predictor for Appendicitis in Adults in the Emergency Department

Introduction: A family history of appendicitis has been reported to increase the likelihood of the diagnosis in children and in a retrospective study of adults. We compare positive family history with the diagnosis of acute appendicitis in a prospective sample of adults.

Conclusion: Adults presenting to the emergency department with a known family history of appendicitis are more likely to have this disease than those without.

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Emergency Department Access

How Long Are Patients Willing to Wait in the Emergency Department Before Leaving Without Being Seen?

Introduction: Our goal was to evaluate patients’ threshold for waiting in an emergency department (ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness to wait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status.

Conclusion: Many patients have a defined, limited period that they are willing to wait for emergency care. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED without being seen. This result suggests that efforts to reduce the percentage of patients who LWBS must factor in time limits.

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Factors Affecting Candidate Placement on an Emergency Medicine Residency Program’s Rank Order List

Introduction: Several factors influence the final placement of a medical student candidate on an emergency medicine (EM) residency program’s rank order list, including EM grade, standardized letter of recommendation, medical school class rank, and US Medical License Examination (USMLE) scores. We sought to determine the correlation of these parameters with a candidate’s final rank on a residency program’s rank order list.

Conclusion:Higher scores on EM rotations, medical school class ranks, and SLOR global assessments correlated with higher placements on a rank order list, whereas candidates with higher USMLE scores had lower placements on a rank order list. However, none of the parameters examined correlated strongly with ultimate position of a candidate on the rank list, which underscores that other factors may influence a candidate’s final ranking.

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Does Targeted Education of Emergency Physicians Improve Their Comfort Level in Treating Psychiatric Patients?

Introduction: We determined if targeted education of emergency physicians (EPs) regarding the treatment of mental illness will improve their comfort level in treating psychiatric patients boarding in the emergency department (ED) awaiting admission.

Conclusion: This pilot study suggests that the comfort level of EPs, when asked to treat PBPs, may be improved with education. We believe our data support further study of this idea and of whether an improved comfort level will translate to a willingness to treat.

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Hospital-Based Coalition to Improve Regional Surge Capacity

Introduction: Surge capacity for optimization of access to hospital beds is a limiting factor in response to catastrophic events. However, these factors may not be optimally functioning to generate an effective and efficient surge response. The objective was to improve the function of these factors.

Conclusion: The HCFP-SCPA successfully increased preparedness and surge capacity through a partnership of regional healthcare facilities and emergency response agencies.

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Injury Outcomes

Occult Pneumothoraces in Acute Trauma Patients

Introduction: Many traumatic pneumothoraces (PTX) are not seen on initial chest radiograph (CR) (occult PTX) but are detected only on computed tomography (CT). The primary objective of this study was to retrospectively determine the effectiveness of CR for detecting PTX in trauma patients.

Conclusion: Factors associated with PTX on CR included air in the soft tissue on CR and size of the PTX. Even when PTX is not apparent on CR, 44% of these PTXs received placement of a chest tube.

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