Volume 16 Issue 7 Archives - The Western Journal of Emergency Medicine

Endemic Infections

Intubating Ebola Patients: Technical Limitations of Extensive Personal Protective Equipment

Volume 16, Issue 7, December 2015.
Warren Wiechmann, MD

As hospitals across the nation were preparing for the
possibility of Ebola or Middle Eastern respiratory syndrome
(MERS-CoV) cases, healthcare workers underwent intricate
training in the use of personal protective equipment (PPE).
An Ebola or MERS-CoV patient requiring intubation places
a healthcare worker at risk for exposure to bodily secretions.
The procedure must be performed only after appropriate
PPE is donned.1
Intubating while wearing PPE is yet another
challenge identified in caring for these patients. Manual
dexterity and free movement decreases when wearing PPE,
and may increase length of time to successful intubation.

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Ethical and Legal Issues

Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department

Volume 16, Issue 7, December 2015.
Jessica Wall, MD, MPH, et al.

Introduction: We conducted an epidemiologic evaluation of advance directives and do-notresuscitate
(DNR) prevalence among residents of extended care facilities (ECF) presenting to the
emergency department (ED).

Methods: We performed a retrospective medical record review on ED patients originating from an
ECF. Data were collected on age, sex, race, triage acuity, ED disposition, DNR status, power-of
attorney (POA) status, and living will (LW) status. We generated descriptive statistics, and used
logistic regression to evaluate predictors of DNR status.

Results: A total of 754 patients over 20 months met inclusion criteria; 533 (70.7%) were white, 351
(46.6%) were male, and the median age was 66 years (IQR 54-78). DNR orders were found in 124
(16.4%, 95% CI [13.9-19.1%]) patients. In univariate analysis, there was a significant difference in
DNR by gender (10.5% female vs. 6.0% male with DNR, p=0.013), race (13.4% white vs. 3.1% nonwhite
with DNR, p=0.005), and age (4.0% <65 years; 2.9% 65-74 years, p=0.101; 3.3% 75-84 years,
p=0.001; 6.2% >84 years, p<0.001). Using multivariate logistic regression, we found that factors
associated with DNR status were gender (OR 1.477, p=0.358, note interaction term), POA status
(OR 6.612, p<0.001), LW (18.032, p<0.001), age (65-74 years OR 1.261, p=0.478; 75-84 years OR
1.737, p=0.091, >84 years OR 5.258, P<0.001), with interactions between POA and gender (OR
0.294, P=0.016) and between POA and LW (OR 0.227, p<0.005). Secondary analysis demonstrated
that DNR orders were not significantly associated with death during admission (p=0.084).

Conclusion: Age, gender, POA, and LW use are predictors of ECF patient DNR use. Further, DNR
presence is not a predictor of death in the hospital.

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Treatment Protocol Assessment

Abdominal CT Does Not Improve Outcome for Children with Suspected Acute Appendicitis

Volume 16, Issue 7, December 2015.
Danielle I. Miano, BS

Introduction: Acute appendicitis in children is a clinical diagnosis, which often requires preoperative
confirmation with either ultrasound (US) or computed tomography (CT) studies. CTs expose children to
radiation, which may increase the lifetime risk of developing malignancy. US in the pediatric population
with appropriate clinical follow up and serial exam may be an effective diagnostic modality for many
children without incurring the risk of radiation. The objective of the study was to compare the rate of
appendiceal rupture and negative appendectomies between children with and without abdominal CTs;
and to evaluate the same outcomes for children with and without USs to determine if there were any
associations between imaging modalities and outcomes.

Methods: We conducted a retrospective chart review including emergency department (ED) and inpatient
records from 1/1/2009–2/31/2010 and included patients with suspected acute appendicitis.

Results: 1,493 children, aged less than one year to 20 years, were identified in the ED with suspected
appendicitis. These patients presented with abdominal pain who had either a surgical consult or an
abdominal imaging study to evaluate for appendicitis, or were transferred from an outside hospital or
primary care physician office with the stated suspicion of acute appendicitis. Of these patients, 739 were
sent home following evaluation in the ED and did not return within the subsequent two weeks and were
therefore presumed not to have appendicitis. A total of 754 were admitted and form the study population,
of which 20% received a CT, 53% US, and 8% received both. Of these 57%, 95% CI [53.5,60.5] had
pathology-proven appendicitis. Appendicitis rates were similar for children with a CT (57%, 95% CI
[49.6,64.4]) compared to those without (57%, 95% CI [52.9,61.0]). Children with perforation were similar
between those with a CT (18%, 95% CI [12.3,23.7]) and those without (13%, 95% CI [10.3,15.7]).
The proportion of children with a negative appendectomy was similar in both groups: CT (7%, 95% CI
[2.1,11.9]), US (8%, 95% CI [4.7,11.3]) and neither (12%, 95% CI [5.9,18.1]).

Conclusion: In this uncontrolled study, the accuracy of preoperative diagnosis of appendicitis and
the incidence of pathology-proven perforation appendix were similar for children with suspected acute
appendicitis whether they had CT, US or neither imaging, in conjunction with surgical consult. The
imaging modality of CT was not associated with better outcomes for children presenting to the ED with
suspected appendicitis.

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Prehospital Care

Chest Pain of Suspected Cardiac Origin: Current Evidence-based Recommendations for Prehospital Care

Volume 16, Issue 7, December 2015.
P. Brian Savino, MD

Introduction: In the United States, emergency medical services (EMS) protocols vary widely across
jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation
and treatment of chest pain of suspected cardiac origin and to compare these recommendations
against the current protocols used by the 33 EMS agencies in the state of California.

Methods: We performed a literature review of the current evidence in the prehospital treatment
of chest pain and augmented this review with guidelines from various national and international
societies to create our evidence-based recommendations. We then compared the chest pain
protocols of each of the 33 EMS agencies for consistency with these recommendations. The
specific protocol components that we analyzed were use of supplemental oxygen, aspirin, nitrates,
opiates, 12-lead electrocardiogram (ECG), ST segment elevation myocardial infarction (STEMI)
regionalization systems, prehospital fibrinolysis and β-blockers.

Results: The protocols varied widely in terms of medication and dosing choices, as well as listed
contraindications to treatments. Every agency uses oxygen with 54% recommending titrated
dosing. All agencies use aspirin (64% recommending 325mg, 24% recommending 162mg and 15%
recommending either), as well as nitroglycerin and opiates (58% choosing morphine). Prehospital 12-
Lead ECGs are used in 97% of agencies, and all but one agency has some form of regionalized care
for their STEMI patients. No agency is currently employing prehospital fibrinolysis or β-blocker use.

Conclusion: Protocols for chest pain of suspected cardiac origin vary widely across California. The
evidence-based recommendations that we present for the prehospital diagnosis and treatment of this
condition may be useful for EMS medical directors tasked with creating and revising these protocols.

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Provider Workforce

Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians

Volume 16, Issue 7, December 2015.
Dave W. Lu, MD, MBE

Introduction: Burnout is a syndrome of depersonalization, emotional exhaustion and sense of low
personal accomplishment. Emergency physicians (EPs) experience the highest levels of burnout among
all physicians. Burnout is associated with greater rates of self-reported suboptimal care among surgeons
and internists. The association between burnout and suboptimal care among EPs is unknown. The
objective of the study was to evaluate burnout rates among attending and resident EPs and examine their
relationship with self-reported patient care practices.
Methods: In this cross-sectional study burnout was measured at two university-based emergency
medicine residency programs with the Maslach Burnout Inventory. We also measured depression, quality
of life (QOL) and career satisfaction using validated questionnaires. Six items assessed suboptimal care
and the frequency with which they were performed.
Results: We included 77 out of 155 (49.7%) responses. The EP burnout rate was 57.1%, with no
difference between attending and resident physicians. Residents were more likely to screen positive
for depression (47.8% vs 18.5%, p=0.012) and report lower QOL scores (6.7 vs 7.4 out of 10, p=0.036)
than attendings. Attendings and residents reported similar rates of career satisfaction (85.2% vs 87.0%,
p=0.744). Burnout was associated with a positive screen for depression (38.6% vs 12.1%, p=0.011) and
lower career satisfaction (77.3% vs 97.0%, p=0.02). EPs with high burnout were significantly more likely
to report performing all six acts of suboptimal care.
Conclusion: A majority of EPs demonstrated high burnout. EP burnout was significantly associated
with higher frequencies of self-reported suboptimal care. Future efforts to determine if provider burnout
is associated with negative changes in actual patient care are necessary

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

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

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

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Healthcare Utilization

Written Informed Consent for Computed Tomography of the Abdomen/Pelvis is Associated with Decreased CT Utilization in Low-Risk Emergency Department Patients

Volume 16, Issue 7, December 2015.
Lisa H. Merck, MD, MPH, et al.

Introduction: The increasing rate of patient exposure to radiation from computerized tomography
(CT) raises questions about appropriateness of utilization. There is no current standard to employ
informed consent for CT (ICCT). Our study assessed the relationship between informed consent and
CT utilization in emergency department (ED) patients.
Methods: An observational multiphase before-after cohort study was completed from 4/2010-5/2011.
We assessed CT utilization before and after (Time I/ Time II) the implementation of an informed
consent protocol. Adult patients were included if they presented with symptoms of abdominal/pelvic
pathology or completed ED CT. We excluded patients with pregnancy, trauma, or altered mental
status. Data on history, exam, diagnostics, and disposition were collected via standard abstraction
tool. We generated a multivariate logistic model via stepwise regression, to assess CT utilization
across risk groups. Logistic models, stratified by risk, were generated to include study phase and a
propensity score that controlled for potential confounders of CT utilization.
Results: 7,684 patients met inclusion criteria. In PHASE 2, there was a 24% (95% CI [10-36%])
reduction in CT utilization in the low-risk patient group (p<0.002). ICCT did not affect CT utilization in the
high-risk group (p=0.16). In low-risk patients, the propensity score was significant (p<0.001). There were
no adverse events reported during the study period.
Conclusion: The implementation of ICCT was associated with reduced CT utilization in low-risk ED
patients. ICCT has the potential to increase informed, shared decision making with patients, as well
as to reduce the risks and cost associated with CT.

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Healthcare Utilization

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

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

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

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Healthcare Utilization

Achieving the Triple Aim Through Informed Consent for Computed Tomography

Volume 16, Issue 7, December 2015.
Dylan Carney, MD, et al.

At the end of a particularly busy shift, you meet Mary,
a 24 year-old female with no past medical history, who
presents with six hours of crampy, intermittent, periumbilical
abdominal pain but no associated fever, nausea, vomiting,
diarrhea or anorexia. Her vital signs are normal and her
abdominal and gynecological exams are notable only for mild,
diffuse abdominal tenderness without rebound or guarding.
Her lab results and urinalysis are unremarkable, and her pain
improves somewhat with intravenous pain medications. You
explain to the patient that you have a low suspicion for an
intraabdominal emergency, but cannot be certain without
a computed tomography (CT) scan. “I’ll do whatever you
recommend,” she replies. The patient ultimately gets a CT,
which is normal, and she is discharged 30 minutes later with a
diagnosis of nonspecific abdominal pain.

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Distracted Driving, A Major Preventable Cause of Motor Vehicle Collisions: “Just Hang Up and Drive”

Volume 16, Issue 7, December 2015.
Christopher A. Kahn, MD, MPH, et al.

For years, public health experts have been concerned about the effect of cell phone use on motor
vehicle collisions, part of a phenomenon known as “distracted driving.” The Morbidity and Mortality
Weekly Report (MMWR) article “Mobile Device Use While Driving – United States and Seven European
Countries 2011” highlights the international nature of these concerns. Recent (2011) estimates from
the National Highway Traffic Safety Administration are that 10% of fatal crashes and 17% of injury
crashes were reported as distraction-affected. Of 3,331 people killed in 2011 on roadways in the U.S.
as a result of driver distraction, 385 died in a crash where at least one driver was using a cell phone.
For drivers 15-19 years old involved in a fatal crash, 21% of the distracted drivers were distracted by
the use of cell phones. Efforts to reduce cell phone use while driving could reduce the prevalence of
automobile crashes related to distracted driving. The MMWR report shows that there is much ground to
cover with distracted driving. Emergency physicians frequently see the devastating effects of distracted
driving on a daily basis and should take a more active role on sharing the information with patients,
administrators, legislators, friends and family.

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Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program

Volume 16, Issue 7, December 2015.
Jill M. Huded, MD, et al.

Introduction: Seniors represent the fasting growing population in the U.S., accounting for 20.3
million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for
identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT),
a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and
prompt interventions through a geriatric nurse liaison (GNL) model.
Methods: Patients aged 65 and older presenting to an urban ED were evaluated by a team of
ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk
screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical
therapy (PT), social work or home health as determined by the GNL.
Results: Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13
and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those
screened with the TUGT, 368 patients experienced a positive result. Interventions for positive
results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work
consultation (n=162, 44%).
Conclusion: The ED visit may provide an opportunity for older adults to be screened for fall risk.
Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and
place appropriate referrals based on assessment results. Identifying and intervening on high fall
risk patients who visit the ED has the potential to improve the trajectory of functional decline in our
elderly population.

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Impact of Health Information Exchange on Emergency Medicine Clinical Decision Making

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

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

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Direct Versus Video Laryngoscopy for Intubating Adult Patients with Gastrointestinal Bleeding

Volume 16, Issue 7, December 2015.
Jestin N. Carlson, MD, MSc, et al.

Introduction: Video laryngoscopy (VL) has been advocated for several aspects of emergency
airway management; however, there are still concerns over its use in select patient populations
such as those with large volume hematemesis secondary to gastrointestinal (GI) bleeds. Given the
relatively infrequent nature of this disease process, we sought to compare intubation outcomes
between VL and traditional direct laryngoscopy (DL) in patients intubated with GI bleeding, using the
third iteration of the National Emergency Airway Registry (NEARIII).
Methods: We performed a retrospective analysis of a prospectively collected national database
(NEARIII) of intubations performed in United States emergency departments (EDs) from July 1, 2002,
through December 31, 2012. All cases where the indication for intubation was “GI bleed” were analyzed.
We included patient, provider and intubation characteristics. We compared data between intubation
attempts initiated as DL and VL using parametric and non-parametric tests when appropriate.
Results: We identified 325 intubations, 295 DL and 30 VL. DL and VL cases were similar in terms
of age, sex, weight, difficult airway predictors, operator specialty (emergency medicine, anesthesia
or other) and level of operator training (post-graduate year 1, 2, etc). Proportion of successful first
attempts (DL 261/295 (88.5%) vs. VL 28/30 (93.3%) p=0.58) and Cormack-Lehane grade views
(p=0.89) were similar between devices. The need for device change was similar between DL [2/295
(0.7%) and VL 1/30 (3.3%); p=0.15].
Conclusion: In this national registry of intubations performed in the ED for patients with GI bleeds,
both DL and VL had similar rates of success, glottic views and need to change devices.

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Ultrasound of Sternal Fracture

Volume 16, Issue 7, December 2015.
Shadi Lahham, MD, MS, et al.

A 61-year-old female was brought in by ambulance after
being the restrained driver of a head-on motor vehicle collision
at 40MPH. There was positive airbag deployment and intrusion
from the other vehicle. During workup, the patient complained
of midline chest pain, and left chest wall pain. The patient
was not in acute respiratory distress, and had the following
vital signs: temperature 37°C, heart rate 84, blood pressure
of 150/64, respiratory rate 18, and oxygen saturation of 97%
on two liters of oxygen. On physical exam, breath sounds
were heard bilaterally, with no acute cardiopulmonary issues
identified. A bruise was identified on the lower abdomen,
which was thought to be a potential seatbelt sign. A focused
assessment with sonography for trauma was negative, and an
ultrasound of additional chest and mediastinal structures was
performed for the chest tenderness.

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Patient Communication

Derivation and Validation of Predictive Factors for Clinical Deterioration after Admission in Emergency Department Patients Presenting with Abnormal Vital Signs Without Shock

Volume 16, Issue 7, December 2015.
Daniel J. Henning, MD, MPH, et al.

Introduction: Strategies to identify high-risk emergency department (ED) patients often use markedly
abnormal vital signs and serum lactate levels. Risk stratifying such patients without using the presence of
shock is challenging. The objective of the study is to identify independent predictors of in-hospital adverse
outcomes in ED patients with abnormal vital signs or lactate levels, but who are not in shock.
Methods: We performed a prospective observational study of patients with abnormal vital signs or lactate
level defined as heart rate ≥130 beats/min, respiratory rate ≥24 breaths/min, shock index ≥1, systolic
blood pressure <90mm/Hg, or lactate ≥4mmole/L. We excluded patients with isolated atrial tachycardia,
seizure, intoxication, psychiatric agitation, or tachycardia due to pain (ie: extremity fracture). The primary
outcome was deterioration, defined as development of acute renal failure (creatinine 2x baseline), nonelective
intubation, vasopressor requirement, or mortality. Independent predictors of deterioration after
hospitalization were determined using logistic regression.
Results: Of 1,152 consecutive patients identified with abnormal vital signs or lactate level, 620 were
excluded, leaving 532 for analysis. Of these, 53/532 (9.9±2.5%) deteriorated after hospital admission.
Independent predictors of in-hospital deterioration were: lactate >4.0mmol/L (OR 5.1, 95% CI [2.1–12.2]),
age ≥80 yrs (OR 1.9, CI [1.0–3.7]), bicarbonate <21mEq/L (OR 2.5, CI [1.3–4.9]), and initial HR≥130 (OR
3.1, CI [1.5–6.1]).
Conclusion: Patients exhibiting abnormal vital signs or elevated lactate levels without shock had
significant rates of deterioration after hospitalization. ED clinical data predicted patients who suffered
adverse outcomes with reasonable reliability.

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Association of Emergency Department Length of Stay and Crowding for Patients with ST-Elevation Myocardial Infarction

Volume 16, Issue 7, December 2015.
Michael J. Ward, MD, MBA, et al.

Introduction: With the majority of U.S. hospitals not having primary percutaneous coronary intervention
(pPCI) capabilities, the time spent at transferring emergency departments (EDs) is predictive of clinical
outcomes for patients with ST-elevation myocardial infarction (STEMI). Compounding the challenges
of delivering timely emergency care are the known delays caused by ED crowding. However, the
association of ED crowding with timeliness for patients with STEMI is unknown. We sought to examine
the relationship between ED crowding and time spent at transferring EDs for patients with STEMI.
Methods: We analyzed the Centers for Medicare and Medicaid Services (CMS) quality data. The
outcome was time spent at a transferring ED (i.e., door-in-door-out [DIDO]), was CMS measure OP-3b for
hospitals with ≥10 acute myocardial infarction (AMI) cases requiring transfer (i.e., STEMI) annually: Time
to Transfer an AMI Patient for Acute Coronary Intervention. We used four CMS ED timeliness measures
as surrogate measures of ED crowding: admitted length of stay (LOS), discharged LOS, boarding time,
and waiting time. We analyzed bivariate associations between DIDO and ED timeliness measures. We
used a linear multivariable regression to evaluate the contribution of hospital characteristics (academic,
trauma, rural, ED volume) to DIDO.
Results: Data were available for 405 out of 4,129 hospitals for the CMS DIDO measure. These facilities
were primarily non-academic (99.0%), non-trauma centers (65.4%), and in urban locations (68.5%). Median
DIDO was 54.0 minutes (IQR 42.0,68.0). Increased DIDO time was associated with longer admitted
LOS and boarding times. After adjusting for hospital characteristics, a one-minute increase in ED LOS at
transferring facilities was associated with DIDO (coefficient, 0.084 [95% CI [0.049,0.119]]; p<0.001). This
translates into a five-minute increase in DIDO for every one-hour increase in ED LOS for admitted patients.
Conclusion: Among patients with STEMI presenting to U.S. EDs, we found that ED crowding has a
small but operationally insignificant effect on time spent at the transferring ED.

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Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department

Volume 16, Issue 7, December 2015.
Nnaemeka G. Okafor, MD, MS, et al.

Introduction: Medical errors are frequently under-reported, yet their appropriate analysis, coupled
with remediation, is essential for continuous quality improvement. The emergency department (ED) is
recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design
and implementation of a web-based ED-specific incident reporting system using an iterative process.
Methods: A web-based, password-protected tool was developed by members of a quality assurance
committee for ED providers to report incidents that they believe could impact patient safety.
Results: The utilization of this system in one residency program with two academic sites resulted
in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents
in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all
ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers
reported 24% and 16% respectively. The most commonly reported incidents were delays in care and
management concerns.
Conclusion: Error reporting frequency can be dramatically improved by using a web-based, user friendly,
voluntary, and non-punitive reporting system.

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Societal Impact on Emergency Care

The Changing Use of Intravenous Opioids in an Emergency Department

Volume 16, Issue 7, December 2015.
Mark E. Sutter, MD, et al.

Introduction: Government agencies are increasingly emphasizing opioid safety in hospitals. In
2012, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) started a
sentinel event program, the “Safe Use of Opioids in Hospitals.” We sought to determine if opioid use
patterns in our emergency department (ED) changed from 2011, before the program began, to 2013,
after start of the program.
Methods: This was a retrospective study of all adult ED patients who received an intravenous opioid
and had a serum creatinine measured. We recorded opioids used, dose prescribed, and serum
creatinine. As an index of the safety of opioids, uses of naloxone after administration of an opioid
was recorded.
Results: Morphine is still the most commonly used opioid by doses given, but its percentage of
opioids used decreased from 68.9% in 2011 to 52.8% in 2013. During the same period, use of
hydromorphone increased from 27.5% to 42.9%, while the use of fentanyl changed little (3.6% to
4.3%). Naloxone administration was rare after an opioid had been given. Opioids were not dosed in
an equipotent manner.
Conclusion: The use of hydromorphone in our ED increased by 56% (absolute increase of 15.4%),
while the use of morphine decreased by 30.5% (absolute decrease 16.1%) of total opioid use from
2011 to 2013. The JCAHO program likely was at least indirectly responsible for this change in
relative dosing of the opioids. Based on frequency of naloxone administered after administration of
an opioid, the use of opioids was safe.

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Societal Impact on Emergency Care

Opioid Considerations for Emergency Practice

Volume 16, Issue 7, December 2015.
Thomas Terndrup, MD

On a backdrop of increasingly distressing opioid misuse
in our communities, and safety concerns expressed by The
Joint Commission and others, emergency physicians are
further increasing their utilization of these important agents
in our patients. Are we selecting the best opioid for our
patients? Are we providing the relief they need? And are we
doing this safely? We all hope these questions can effectively
be answered yes, now and into our futures.

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Societal Impact on Emergency Care

Transformative Leadership: Emergency Physicians Lead AOA and AMA

Volume 16, Issue 5, December 2015.
Kory S. London, MD, et al.

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

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Patient Communication

Inability of Physicians and Nurses to Predict Patient Satisfaction in the Emergency Department

Volume 16, Issue 7, December 2015.
Matthew C. DeLaney, MD, et al.

Introduction: Patient satisfaction is a commonly assessed dimension of emergency department (ED)
care quality. The ability of ED clinicians to estimate patient satisfaction is unknown. We sought to
evaluate the ability of emergency medicine resident physicians and nurses to predict patient-reported
satisfaction with physician and nursing care, pain levels, and understanding of discharge instructions.
Methods: We studied a convenience sample of 100 patients treated at an urban academic ED.
Patients rated satisfaction with nursing care, physician care, pain level at time of disposition and
understanding of discharge instructions. Resident physicians and nurses estimated responses
for each patient. We compared patient, physician and nursing responses using Cohen’s kappa,
weighting the estimates to account for the ordinal responses.
Results: Overall, patients had a high degree of satisfaction with care provided by the nurses and
physicians, although this was underestimated by providers. There was poor agreement between
physician estimation of patient satisfaction (weighted κ=0.23, standard error: 0.078) and nursing
estimates of patient satisfaction (weighted κ=0.11, standard error: 0.043); physician estimation
of patient pain (weighted κ=0.43, standard error: 0.082) and nursing estimates (weighted κ=0.39,
standard error: 0.081); physician estimates of patient comprehension of discharge instruction
(weighted κ=0.19, standard error: 0.082) and nursing estimates (weighted κ=0.13, standard error:
0.078). Providers underestimated pain and patient comprehension of discharge instructions.
Conclusion: ED providers were not able to predict patient satisfaction with nurse or physician
care, pain level, or understanding of discharge instructions.

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Patient Communication

The Need for More Prehospital Research on Language Barriers: A Narrative Review

Volume 16, Issue 7, December 2015.
Ramsey C. Tate, MD, MS

Introduction: Despite evidence from other healthcare settings that language barriers negatively
impact patient outcomes, the literature on language barriers in emergency medical services (EMS)
has not been previously summarized. The objective of this study is to systematically review existing
studies of the impact of language barriers on prehospital emergency care and identify opportunities
for future research.
Methods: A systematic review with narrative synthesis of publications with populations specific to
the prehospital setting and outcome measures specific to language barriers was conducted. A fourprong
search strategy of academic databases (PubMed, Academic Search Complete, and Clinical
Key) through March 2015, web-based search for gray literature, search of citation lists, and review
of key conference proceedings using pre-defined eligibility criteria was used. Language-related
outcomes were categorized and reported as community-specific outcomes, EMS provider-specific
outcomes, patient-specific outcomes, or health system-specific outcomes.
Results: Twenty-two studies met eligibility criteria for review. Ten publications (45%) focused on
community-specific outcomes. Language barriers are perceived as a barrier by minority language
speaking communities to activating EMS. Eleven publications (50%) reported outcomes specific
to EMS providers, with six of these studies focused on EMS dispatch. EMS dispatchers describe
less accurate and delayed dispatch of resources when confronted with language discordant callers,
as well as limitations in the ability to provide medical direction to callers. There is a paucity of
research on EMS treatment and transport decisions, and no studies provided patient-specific or
health system-specific outcomes. Key research gaps include identifying the mechanisms by which
language barriers impact care, the effect of language barriers on EMS utilization and clinically
significant outcomes, and the cost implications of addressing language barriers.
Conclusion: The existing research on prehospital language barriers is largely exploratory, and
substantial gaps in understanding the interaction between language barriers and prehospital care
have yet to be addressed. Future research should be focused on clarifying the clinical and cost
implications of prehospital language barriers.

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Patient Communication

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

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

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

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Critical Care

The Physiologically Difficult Airway

Volume 16, Issue 7, December 2015.
Jarrod M. Mosier, MD, et al.

Airway management in critically ill patients involves the identification and management of the
potentially difficult airway in order to avoid untoward complications. This focus on difficult airway
management has traditionally referred to identifying anatomic characteristics of the patient that
make either visualizing the glottic opening or placement of the tracheal tube through the vocal
cords difficult. This paper will describe the physiologically difficult airway, in which physiologic
derangements of the patient increase the risk of cardiovascular collapse from airway management.
The four physiologically difficult airways described include hypoxemia, hypotension, severe
metabolic acidosis, and right ventricular failure. The emergency physician should account for
these physiologic derangements with airway management in critically ill patients regardless of the
predicted anatomic difficulty of the intubation.

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Critical Care

Lactate Clearance Predicts Survival Among Patients in the Emergency Department with Severe Sepsis

Volume 16, Issue 7, December 2015.
Sundeep R. Bhat, MD

Introduction: Lactate clearance has been implicated as a predictor of mortality among emergency
department (ED) patients with severe sepsis or septic shock. We aimed to validate prior studies
showing that lactate clearance during the ED stay is associated with decreased mortality.
Methods: Retrospective dual-centered cross-sectional study using patients identified in the YaleNew
Haven Hospital Emergency Medicine sepsis registry with severe sepsis or septic shock who
had initial lactate levels measured in the ED and upon arrival (<24 hours) to the hospital floor.
Lactate clearance was calculated as percent of serum lactate change from ED to floor measurement.
We compared mortality and hospital interventions between patients who cleared lactate and those
who did not.
Results: 207 patients (110 male; 63.17±17.9 years) were included. Two reviewers extracted data
with 95% agreement. One hundred thirty-six patients (65.7%) had severe sepsis and 71 patients
(34.3%) had septic shock. There were 171 patients in the clearance group and 36 patients in the
non-clearance group. The 28-day mortality rates were 15.2% in the lactate clearance group and
36.1% in the non-clearance group (p<0.01). Vasopressor support was initiated more often in the nonclearance
group (61.1%) than in the clearance group (36.8%, p<0.01) and mechanical ventilation
was used in 66.7% of the non-clearance group and 36.3% of the clearance group (p=0.001).
Conclusion: Patients who do not clear their lactate in the ED have significantly higher mortality than
those with decreasing lactate levels. Our results are confirmatory of other literature supporting that
lactate clearance may be used to stratify mortality-risk among patients with severe sepsis or septic
shock.

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Critical Care

Evidence-based Comprehensive Approach to Forearm Arterial Laceration

Volume 16, Issue 7, December 2015.
Janice N. Thai, MD, et al.

Introduction: Penetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or
a complex injury involving other structures including veins, tendons and nerves. The management of
forearm laceration with arterial injury involves both operative and nonoperative strategies. An evolution
in management has emerged especially at urban trauma centers, where the multidisciplinary resource
of trauma and hand subspecialties may invoke controversy pertaining to the optimal management of
such injuries. The objective of this review was to provide an evidence-based, systematic, operative
and nonoperative approach to the management of isolated and complex forearm lacerations. A
comprehensive search of MedLine, Cochrane Library, Embase and the National Guideline Clearinghouse
did not yield evidence-based management guidelines for forearm arterial laceration injury. No professional
or societal consensus guidelines or best practice guidelines exist to our knowledge.
Discussion: The optimal methods for achieving hemostasis are by a combination approach utilizing
direct digital pressure, temporary tourniquet pressure, compressive dressings followed by wound closure.
While surgical hemostasis may provide an expedited route for control of hemorrhage, this aggressive
approach is often not needed (with a few exceptions) to achieve hemostasis for most forearm lacerations.
Conservative methods mentioned above will attain the same result. Further, routine emergent or urgent
operative exploration of forearm laceration injuries are not warranted and not cost-beneficial. It has
been widely accepted with ample evidence in the literature that neither injury to forearm artery, nerve or
tendon requires immediate surgical repair. Attention should be directed instead to control of bleeding,
and perform a complete physical examination of the hand to document the presence or absence of other
associated injuries. Critical ischemia will require expeditious surgical restoration of arterial perfusion. In
a well-perfused hand, however, the presence of one intact artery is adequate to sustain viability without
long-term functional disability, provided the palmar arch circulation is intact. Early consultation with a hand
specialist should be pursued, and follow-up arrangement made for delayed primary repair in cases of
complex injury.
Conclusion: Management in accordance with well-established clinical principles will maximize treatment
efficacy and functional outcome while minimizing the cost of medical care.

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