Search

Objectives: The pulmonary embolism rule-out criteria (PERC rule) is a nine-component decision rule derived to exclude pulmonary embolism (PE) without the use of formal diagnostic testing (D-dimer, computed tomography pulmonary angiography, ventilation–perfusion lung scanning, or venous ultrasonography) when all nine components are negative (“PERC negative”). This study examined whether clinicians who document PERC negative also document results of all nine components of the PERC rule. Methods: This was a pilot study at a single-center, urban teaching emergency department (ED) with a residency program in emergency medicine. Patients were over 17 years of age with at least one of nine predefined chief complaints. Clinicians were asked three questions regarding suspicion for PE, intent to use the PERC rule, and the result. Charts were independently reviewed by two authors for fidelity of the nine PERC components. Patients were followed for PE outcome at 14 days. Results: The study examined 526 patients cared for by 82 clinicians, who indicated suspicion for PE in 183 of 526 (35%) and intent to use the PERC rule in 115 of 526 (22%) cases, of whom 65 of 115 were documented as PERC negative. No formal test for PE was ordered in 49 of 65 (75%), and 46 of 49 had incomplete documentation to support PERC negative. The most common deficiency was omission of two risk factors for PE in the rule (prior venous thromboembolism or recent surgery). Six patients had PE diagnosed within 14 days, but none of these had been deemed PERC negative. Conclusions: Clinicians seldom document all nine data elements of the PERC rule in patients they deem PERC negative. These data suggest the need for paper or electronic aids to support use of the PERC rule. ACADEMIC EMERGENCY MEDICINE 2010; 17:1016–1019 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Background: Emergency physicians as front-line clinical specialists can directly advance patient care by understanding how gender-specific approaches may affect evaluation and management of diseases in the acute setting. Yet, it is unclear whether the role of gender is systematically examined in research focusing on emergency care. Objectives: The objective was to determine if the effect of gender on health outcomes is examined in published studies targeting emergency medicine (EM). Methods: Using MEDLINE, the term ''emergency'' was used to identify all English-language, EM-related studies of adult human subjects published between January 2006 and April 2009 in which the first, second, or last author belonged to an EM section, division, center, or institution functioning as an emergency department (ED). The alternative chance-corrected statistic was used for intercoder reliability, and chi-square was used to calculate odds ratios (OR) with 95% confidence intervals (CIs). Articles were coded for gender composition, as well as use of gender as a control variable, independent variable, or part of the primary hypothesis. Results: The search revealed 2,487 articles using the selected ''emergency'' terms, and 750 original studies coded as EM-related publications were reviewed. The five topics contributing the most articles (44%) were administration / crowding, cardiovascular disease, emergency medical services, trauma, and sepsis. Seventy-nine percent of articles reported the gender composition of the sample, with 11% including gender as a control variable, 18% including gender as an independent variable, and 2% including gender in the primary hypothesis. The alternative chance-corrected statistic for evaluating gender composition was 0.90 (95% CI = 0.75 to 1.00). Use of gender in the analysis did not differ between federally funded studies versus non-federally funded studies (OR = 0.86; 95% CI = 0.5 to 1.4). The number of articles analyzing the effect of gender on a health outcome increased by 5% over the study period (27%-32%). Conclusions: The majority of research articles targeted EM report gender as a demographic variable; however, few studies examined the effect of gender on health outcome. As the specialty advances into the next decade, the authors recommend that EM researchers 1) include both men and women in their study designs for appropriate gender comparisons; 2) report gender composition of study subjects and gender-specific comparisons study findings; and 3) report prognoses, outcomes, and interventions using gender as an independent variable in the study model. [ABSTRACT FROM AUTHOR]

This review aims to summarize the current literature on the effects of direct, clinical observation of residents in emergency departments (EDs) on learners, patients, and departmental functioning. A systematic literature search was conducted in Medline and ERIC, covering the years 1980-2009. Keywords were used to identify postgraduate medical staff working in the ED; direct observation of these trainees by supervising staff; and reports of outcomes relating to Kirkpatrick's levels of reaction, learning, behavior, and institutional change. From an initial 11,433 abstracts and titles, 193 full-text articles were retrieved for further study. Application of inclusion and exclusion criteria yielded seven that were relevant to the topic. These studies comprised a range of methods--descriptive, qualitative evaluation, cohort studies, and a cross-sectional survey. Learner reaction was very enthusiastic. Positive changes in behavior due to feedback provided during direct observation were suggested by two studies. A single study evaluated trainee's perceptions on patient outcomes and noted that thorough assessments and improved management decisions may be at the expense of slower throughput of patients and diversion of senior staff from direct patient care. Three studies noted the resource-intensive nature of direct observation. Direct observation of clinical practice may be useful in ED education; however, further research is required to evaluate its effects. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to evaluate the effects of direct‐access physiotherapy on patients presenting with a musculoskeletal disorder (MSKD) to the emergency department (ED) on clinical outcomes and use of health care resources. Methods: We conducted a randomized controlled trial in an academic ED in Québec City, Canada. We included patients aged 18 to 80 years with minor MSKD. The intervention group had direct access to a physiotherapist (PT) in the ED immediately after triage and prior to physician assessment, and the control group received usual care by the emergency physician without PT intervention. The key variables included clinical outcomes (pain, interference of pain on function) and resources use (ED return visit, medications, diagnostic tests, additional consultations). They were analyzed using descriptive statistics and compared between groups using two‐way analyses of variance, log‐linear analysis, and chi‐square tests. Results: Seventy‐eight patients suffering from MSKDs were included (40.2 ± 17.6 years old; 44% women). For the primary clinical outcome, participants in the PT group (n = 40) had statistically lower levels of pain and pain interference at 1 and 3 months. In terms of resource use, participants in the PT group returned significantly less often to the ED. At baseline and 1 month, less prescription medication was used, including opioids, but there were no differences at 3 months. Although over‐the‐counter medication was recommended more at baseline in the PT group, there were no differences in use at 1 month, and the PT group had used them less at 3 months. There were no differences between groups at follow‐up for imaging tests, other professionals consulted, and hospitalization rates. Conclusion: Patients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge. [ABSTRACT FROM AUTHOR]

Background Over 35 million alcohol-impaired ( AI) patients are cared for in emergency departments ( EDs) annually. Emergency physicians are charged with ensuring AI patients' safety by identifying resolution of alcohol-induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients. Objective The objective was to evaluate a novel standardized ED assessment of alcohol impairment, Hack's Impairment Index ( HII score), in a busy urban ED. Methods A retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both 'usual' and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2-5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated. Results A total of 8,074 visits from 3,219 unique patients were eligible for study, including 7,973 (98.7%) with ethanol levels, 5,061 (62.7%) with complete HII scores, and 3,646 (45.2%) with health care provider assessments. Correlations between HII scores and ethanol levels were poor (Pearson's R2 = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients' visits. Conclusions The HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with health care provider evaluations. [ABSTRACT FROM AUTHOR]

Objectives The objectives were to determine if nebulized albuterol causes an increase in the serum lactate level compared to placebo and, secondarily, to confirm that albuterol decreases serum potassium levels compared to placebo in patients with normokalemia. Methods This was a randomized, double-blind, placebo-controlled trial. Twenty-eight healthy adult volunteers were assigned to receive either 10 mg of nebulized albuterol or placebo (nebulized saline) over 1 hour. Serum lactate was measured prior to treatment and at 30 and 70 minutes after the start of treatment. Serum potassium level was measured prior to treatment and at 70 minutes. The primary outcome was the degree of change in lactate level. The secondary outcome was the degree of change in potassium level. Results In the 14 subjects who received albuterol, the mean increase in lactate was 0.77 mmol/L (95% confidence interval [ CI] = 0.52 to 1.02 mmol/L), and the mean decrease in potassium level was 0.5 mEq/L (95% CI = −0.72 to −0.28 mEq/L). Among the subjects who received placebo, the lactate level decreased by 0.15 mmol/L (95% CI = −0.39 to 0.09 mmol/L) and there was no change in potassium level at (0.0 mEq/L [95% CI = −0.21 to 0.21 mEq/L]). These differences are statistically significant (p < 0.0001 and p = 0.003, respectively). Conclusion Nebulized albuterol increases lactate levels and decreases potassium levels in healthy adults. [ABSTRACT FROM AUTHOR]

Objectives The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments ( EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. Methods Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. Results Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). Conclusions Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

ACADEMIC EMERGENCY MEDICINE 2012; 19: 402-408 © 2012 by the Society for Academic Emergency Medicine Abstract Background: Physical and molecular mechanisms for the neuroprotective effect of therapeutic hypothermia are not completely understood, and new therapeutic applications incorporating hypothermia remain to be developed and tested. Clinically relevant animal models of therapeutic hypothermia are not well established or consistent. Objectives: The objective was to develop and test an inexpensive small animal therapeutic hypothermia system that models those in widespread clinical use and verify that such a system confers neuroprotection in a rat model of global brain ischemia. Methods: A water-cooled extracorporeal system and attendant anesthesia/sedation protocol were developed and tested. In Stage 1, animals were instrumented for brain, temporalis, and rectal temperature monitoring, and the system was tested for its effect on temperature and hemodynamics. In Stage 2, animals were instrumented for rectal temperature only, subjected to global brain ischemia by two-vessel occlusion and hypotension for 8 minutes, and given either sham therapy (37°C) or hypothermia (32°C) for 4 hours. Viable CA1 neurons were counted at 7 days. Results: The system was well tolerated, provided exquisite control of animal core and brain temperatures, and conferred robust neuroprotection at 7 days. The median and interquartile ranges (IQRs) of viable neurons per 300-μm field were 130 (IQR = 128 to 135) for sham control, 19 (IQR = 15 to 30) for untreated ischemic animals, and 101 (IQR = 94 to 113) for ischemic animals treated with hypothermia (p < 0.05 for comparison between all groups). Conclusions: Like human protocols, this model incorporates sedation and analgesia, results in robust neuroprotection, is well tolerated, and offers exquisite temperature control. The system is noninvasive and inexpensive and offers a model that is similar to methods used in clinical practice. This system will be of interest to investigators using small animal models to examine neuroprotective mechanisms of hypothermia and translational strategies that combine hypothermia with targeted pharmacotherapy. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19:265-273 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: This study was performed to evaluate the burn wound-healing efficacy of crocodile oil from Crocodylus siamensis by employing deep second-degree burns in a Wistar rat model. Methods: Twenty-four rats were assigned equally into four groups using a random-number table, and two burns were created on the dorsum of each animal except for the sham group. The three treatment groups received with saline solution (12 burns, served as negative control), silver sulfadiazine (12 burns, served as positive control), or crocodile oil (12 burns). Silver sulfadiazine cream was used as standard care, and the treatments were repeated twice daily for 28 days. After day 28 the animals were euthanized and the wounds were removed for quantitative real-time polymerase chain reaction, histologic, and immunohistochemical study. Results: Crocodile oil accelerated the wound-healing process as indicated by a significant decrease in wound closure time in comparison to the burn control and silver sulfadiazine treatment groups. Histologic results showed well-organized and distributed skin structure and collagen deposition in the animals treated with crocodile oil. Transforming growth factor-β1 (TGF-β1), a key cytokine promoting scarring, was also observed to play a role in the burn wound healing. Immunohistochemical staining results showed the negative expression of TGF-β1 and Smad3 in the 28-days-postburn skin of crocodile oil group versus positive in the epidermis of burn controls. Compared to the burn control group, expressions of TGF-β1 and Smad3 mRNA decreased significantly (p < 0.01) in the 28-days-postburn skin of the crocodile oil group. Conclusions: Our results showed that crocodile oil could enhance cutaneous burn wound healing and reduce scar formation in rats, which might be related to TGF-β1/Smad3 signaling. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2011; 18:1339-1348 © 2011 by the Society for Academic Emergency Medicine Abstract Background: As hospital crowding has increased, more patients have ended up boarding in the emergency department (ED) awaiting their inpatient beds. To the best of our knowledge, no study has compared the quality of care of boarded and nonboarded patients. Objectives: This study sought to examine whether being a boarded patient and boarding longer were associated with more delays, medication errors, and adverse events among ED patients admitted with chest pain, pneumonia, or cellulitis. Methods: This study was a retrospective cohort design in which data collection was accomplished via medical record review from two urban teaching hospitals. Patients admitted with chest pain, pneumonia, or cellulitis between August 2004 and January 2005 were eligible for inclusion. Our outcomes measures were: 1) delays in administration of home medications, cardiac enzyme tests, partial thromboplastin time (PTT), and antibiotics; 2) medication errors; and 3) adverse events or near misses. Primary independent variables were boarded status, boarding time, and boarded time interval. Multiple logistic regression models controlling for patient, ED, and hospital characteristics were used. Results: A total of 1,431 patient charts were included: 811 with chest pain, 387 with pneumonia, and 233 with cellulitis. Boarding time was associated with an increased odds of home medication delays (adjusted odds ratio [AOR] = 1.07, 95% confidence interval [CI] = 1.05 to 1.10), as were boarded time intervals of 12, 18, and 24 hours. Boarding time also was associated with lower odds of having a late cardiac enzyme test (AOR = 0.93, 95% CI = 0.88 to 0.97). Conclusions: Boarding was associated with home medication delays, but fewer cardiac enzyme test delays. Boarding was not associated with delayed PTT checks, antibiotic administration, medication errors, or adverse events/near misses. These findings likely reflect the inherent resources of the ED and the inpatient units. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2011; 18:1177-1185 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objective of this study was to assess the association between the performance of practicing paramedics on a validated cognitive exam and their field performance, assessed on a simulated emergency medical services (EMS) response. Methods: This was an observational study of paramedics from a single-tiered, urban, advanced life support EMS agency. A high-fidelity simulated response to a medical emergency on environmentally realistic sound stages, and the cognitive portion of the national paramedic certification exam, were each assessed as pass or fail. Participants were randomly assigned to one of six simulations designed by the agency's educational staff, medical director, and representatives from the National Registry of EMTs to be equivalently difficult. Simulations were pilot tested to assess content and face validity. Each participant was classified as failing a simulation scenario if his or her score was one standard deviation (SD) below the population mean. Results: There were 107 paramedics who participated in the study. Participants reported a median of 7.7 years of service (interquartile range [IQR] = 4.1 to 12.8 years). Simulation scores were normally distributed. Ninety-two (86.0%) participants received a passing score for the simulation and 77 (72.0%) passed the cognitive exam. There were 70 (65.4%) individuals who passed both the simulation and the cognitive exam, eight (7.5%) who failed both the simulation and the cognitive exam, 22 (20.6%) who passed the simulation but failed the cognitive exam, and seven (6.5%) who failed the simulation but passed the cognitive exam. There was a significant association between passing the cognitive exam and passing the simulation (chi-square p-value = 0.02). Conclusions: This study simultaneously assessed cognitive knowledge and simulated field performance. Utilization of these measurement techniques allowed for the assessment and comparison of field performance and cognitive knowledge. Results demonstrated an association between a practicing paramedic's performance on a cognitive examination and field performance, assessed by a simulated EMS response. [ABSTRACT FROM AUTHOR]

Academic Emergency Medicine 2011; 18:S79-S86 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Research in cognition has yielded considerable understanding of the diagnostic reasoning process and its evolution during clinical training. This study sought to determine whether or not this literature could be used to improve the assessment of trainees' diagnostic skill by manipulating testing conditions that encourage different modes of reasoning. Methods: The authors developed an online, vignette-based instrument with two sets of testing instructions. The 'first impression' condition encouraged nonanalytic responses while the 'directed search' condition prompted structured analytic responses. Subjects encountered six cases under the first impression condition and then six cases under the directed search condition. Each condition had three straightforward (simple) and three ambiguous (complex) cases. Subjects were stratified by clinical experience: novice (third- and fourth-year medical students), intermediate (postgraduate year [PGY] 1 and 2 residents), and experienced (PGY 3 residents and faculty). Two investigators scored the exams independently. Mean diagnostic accuracies were calculated for each group. Differences in diagnostic accuracy and reliability of the examination as a function of the predictor variables were assessed. Results: The examination was completed by 115 subjects. Diagnostic accuracy was significantly associated with the independent variables of case complexity, clinical experience, and testing condition. Overall, mean diagnostic accuracy and the extent to which the test consistently discriminated between subjects (i.e., yielded reliable scores) was higher when participants were given directed search instructions than when they were given first impression instructions. In addition, the pattern of reliability was found to depend on experience: simple cases offered the best reliability for discriminating between novices, complex cases offered the best reliability for discriminating between intermediate residents, and neither type of case discriminated well between experienced practitioners. Conclusions: These results yield concrete guidance regarding test construction for the purpose of diagnostic skill assessment. The instruction strategy and complexity of cases selected should depend on the experience level and breadth of experience of the subjects one is attempting to assess. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2011; 18:S65-S70 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Most multisource feedback (MSF) evaluations are performed asynchronously, with raters reflecting on the subject's behavior. Numerous studies have demonstrated poor inter-rater reliability of MSF. This may be due to cognitive biases that are inherent in such a process. We sought to determine if within- and between-rater group reliability is increased when evaluations are gathered synchronously and relate to a specific patient interaction. Methods: This was a survey at a university emergency department (ED) of 30 emergency medicine (EM) residents. ED nurses and faculty anonymously participated in asynchronous MSF assessment of resident performance from February to April 2010 using a Web-based survey, the Emergency Medicine Humanism Scale (EM-HS). In May 2010, a second round of MSF collection was conducted in the ED. At the conclusion of patient encounters, the EM-HS was synchronously obtained from ED nurses and faculty. Evaluators were instructed to assess the resident based on the patient encounter, placing aside any preconceptions of resident performance, attitude, or behavior. Evaluators rated resident performance using a 1-9 scale ('needs improvement' to 'outstanding'). The mean rating for each of the questions and the total score provided by each evaluator class was calculated for each EM resident. Differences between the asynchronous and synchronous ratings were compared with t-tests. Pearson correlations were used to measure agreement in scores within and between nurse and faculty rater groups. Correlations > 0.70 were deemed acceptable and are reported with 95% confidence intervals (CIs). Results: Twenty-one of 30 residents had assessments collected by both asynchronous and synchronous methods. A total of 699 Web-based (asynchronous) assessments were completed by nurses and 149 by faculty. Synchronous nurse and faculty assessments were obtained in 105 resident-patient encounters. There was no difference in faculty ratings between the MSF collection methods. Nurses assigned slightly (but significantly) higher ratings during synchronous collection. Correlation of the total MSF score between asynchronous and synchronous feedback collection methods within the faculty rater group was poor (0.18, 95% CI = −0.22 to 0.60). Correlation of the total MSF score between asynchronous and synchronous feedback collection methods within nurse rater groups was moderate (0.63, 95% CI = 0.27 to 0.83). Correlations between faculty-nurse rater groups for the total MSF collected asynchronously and synchronously were moderate (0.39, 95% CI = −0.05 to 0.7; and 0.44, 95% CI 0.01 to 0.73, respectively). Conclusions: Synchronous collection of MSF did not provide clinically different EM-HS scores within rater groups and did not result in improved correlations. Our small, single-center study supports asynchronous collection of MSF. [ABSTRACT FROM AUTHOR]

Academic Emergency Medicine 2011; 18:S54-S58 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The purpose of this study was to determine the effect of an automated procedure logging (APL) system on the number of procedures logged by emergency medicine (EM) residents. Secondary objectives were to assess the APL's effect on completeness and accuracy of procedure logging and to measure resident compliance with the system. Methods: This was a before-and-after study conducted at a university-affiliated, urban medical center, with an annual emergency department census of >130,000. The EM residency is a 4-year, Residency Review Committee (RRC)-accredited program with 12 residents per year. We developed software to electronically search and abstract resident procedures documented in the electronic medical record (EMR) and automatically export them into a Web-based residency management system. We compared the mean daily number of procedures logged for two 6-month periods: October 1, 2009, to March 31, 2010 (pre-APL), and October 1, 2010, to March 31, 2011 (post-APL), using a two-sample t-test. We also generated a random sample of 231 logged procedures from both the pre- and post-APL time periods to assess for completeness and accuracy of data transfer. Completeness and accuracy in the pre- and post-APL periods were compared using Fisher's exact test. Aggregate resident compliance with the system was also measured. Results: The mean daily number of procedures logged increased by 168% (10.0 vs. 26.8, mean difference = 16.8, 95% confidence interval [CI] = 15.4 to 18.2, p < 0.001) after the implementation of APL. Procedures logged with the APL system were more complete (76% vs. 100%, p < 0.001) and more accurate (87% vs. 99%, p < 0.001). Most residents (42/48, 88%) used APL to log at least 90% of procedures. Only 4% of procedures eligible for automation were logged manually in the post-APL period. Conclusions: There was a significant increase in the daily mean number of procedures logged after the implementation of APL. Recorded data were more complete and more accurate during this time frame. This innovative system improved resident logging of required procedures and helped our assessment of Accreditation Council for Graduate Medical Education (ACGME) Patient Care and Practice-Based Learning Competencies for individual residents. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2011; 18:1027-1035 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Adolescents with a history of peer assault are known to report high rates of other risky behaviors. The characteristics of adolescents seeking care in the ED for acute assault-related injury are less well established. This knowledge deficit is particularly noticeable for adolescent female victims of peer assault. This study's objectives were: 1) to characterize the demographics and risk behaviors of youths presenting to the emergency department (ED) with acute assault-related injury and 2) to compare assaulted youths' demographic characteristics, past experiences with violence, and other risk behaviors by sex. Methods: A systematic sample of adolescents (ages 14 to 18 years) presenting to an urban ED with acute assault-related injury (excluding dating violence, sexual assault, and child abuse) was recruited. Consenting participants self-administered a computerized survey about demographics, history of peer and dating aggression, and theoretical correlates of violence (e.g., alcohol and other drug use, depressive symptoms, weapon carriage). Multivariate logistic regression was performed to identify factors that were differentially associated with presentation to the ED for acute assault-related injury for females versus males. Results: Of 3,338 adolescents completing a screening survey during the 36-month study period, 197 had presented to the ED with acute assault-related injuries; seven of these were excluded from this study due to being victims of dating violence. Most ( n = 179, 94.2%) of these 190 acutely assaulted participants were discharged home. The majority reported a history of past-year peer aggression ( n = 160, 84.2%) and past-year violent injury ( n = 106, 55.8%). Similar rates of past-year peer aggression, past-year violent injury, alcohol use, and weapon carriage were observed for adolescent males and females presenting with acute assault-related injury. Males and females also reported similar age, race, socioeconomic status, and education levels. Compared to males, females were less likely to report living with a parent (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.08 to 0.84) and were more likely to report depressive symptoms (OR = 2.59, 95% CI = 1.23 to 5.48) and past-year dating aggression (OR = 2.23, 95% CI = 1.04 to 4.82). Conclusions: Male and female adolescents with acute assault-related injuries were very similar. Both reported extremely high rates of past year peer violence, assault-related injury, and substance use. The greater prevalence of some risk factors among adolescent females, such as depressive symptoms, dating aggression, and independent living status, should be further investigated. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2011; 18:934-940 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to evaluate the effect of arrival to the emergency department (ED) by emergency medical services (EMS) on time to initiation of antibiotics, time to initiation of intravenous fluids (IVF), and in-hospital mortality in patients with severe sepsis and septic shock. Methods: The authors performed an evaluation of prospectively collected registry data of patients with a diagnosis of severe sepsis or septic shock who presented to an urban academic ED during a 2-year period from January 1, 2005, to December 31, 2006. Descriptive and multivariate analytic methods were used to analyze the data. Using unadjusted and adjusted models, out-of-hospital patients who presented to the ED by ambulance (EMS) were compared to control patients who arrived by alternative means (non-EMS). Primary outcomes measured were ED time to initiation of antibiotics, ED time to initiation of IVF, and in-hospital mortality. Results: A total of 963 severe sepsis patients were enrolled in the registry. Median time to antibiotics was 116 minutes for EMS (interquartile range [IQR] = 66 to 199) vs. 152 minutes for non-EMS (IQR = 92 to 252, p ≤ 0.001). Median time to initiation of IVF was 34 minutes for EMS (IQR = 10 to 88) and 68 minutes for non-EMS (IQR = 25 to 121, p ≤ 0.001). After adjustment for the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, age, and initial serum lactate level, no significant differences in hospital mortality were seen (adjusted relative risk [aRR] for EMS vs. non EMS = 1.24, 95% confidence interval [CI] = 0.92 to 1.66, p = 0.16). The Cox proportional hazard ratio (HR) comparing EMS to non-EMS care after similar adjustment was HR = 1.27 for IVF (95% CI = 1.10 to 1.47, p = 0.004) and HR = 1.25 for antibiotics (95% CI = 1.08 to 1.44, p = 0.003). Conclusions: Out-of-hospital care was associated with improved in-hospital processes for the care of critically ill patients. Despite shortened ED treatment times for septic patients who arrive by EMS, a mortality benefit could not be demonstrated. [ABSTRACT FROM AUTHOR]

Objectives: Dysphagia is a common complication for emergency department (ED) patients presenting with acute stroke (AS). Recent stroke recommendations have suggested that EDs screen patients with AS for dysphagia prior to administering anything by mouth. This study sought to develop and test a novel ED dysphagia screen to be used in this population. Methods: A multidisciplinary approach was used to create a novel dysphagia screen performed by ED nurses during the initial evaluation of patients with suspected AS. The screen consists of five questions of which any single affirmative answer signified possible dysphagia. A prospective cohort study was conducted to evaluate the performance of this screen in detecting dysphagia after AS. Patients were followed for 30 days, and true dysphagia was determined if the patient had an abnormal modified barium swallow study (MBS), had placement of a feeding tube, or was placed on a dysphagia diet after assessment by a speech pathologist. The authors performed a substudy to determine agreement using a blinded kappa (j) assessment with a convenience sample of 40 patients. Results: Over a 21-month period, 283 patients met eligibility for analysis. The rate of cerebral infarction in this cohort was 245 (87%). The rates for true dysphagia, pneumonia, and death were 91 (32%), 26 (9%), and 18 (6%), respectively. The dysphagia screen had a sensitivity of 95% (95% confidence [CI] = 88% to 98%) and a negative likelihood ratio of 0.1 (95% CI = 0.04 to 0.2). The inter-rater agreement assessed by kappa was substantial (0.69, 95% CI = 0.55 to 0.83). Conclusions: These data suggest that this dysphagia screen may be a valuable tool for detecting dysphagia in ED patients presenting with AS. The simple screen can be performed by nursing personnel and appears to perform well with good agreement. Given the overall rate of dysphagia in one-third of AS patients, the use of an ED dysphagia screen appears warranted. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study that examined the use of Second Life (SL), a virtual simulation learning environment technology, to conduct mock oral examinations to emergency medicine (EM) residents. The study showed that 92.6 percent of EM residents found SL to be easy to log into while 96.3 percent have it easy to navigate. Furthermore, most of EM residents believed that the SL encounter was real. It concludes with a suggestion on the potential use of SL in mock oral examinations.

Objectives: During disasters, the public expects that emergency care will be available at a moment's notice. As such, an emergency medical services (EMS) workforce that is trained and prepared for disasters is imperative. The primary objectives of this study were to quantify the amount of individual-level training EMS professionals receive in terrorism and disaster-preparedness, as well as to assess EMS professionals' participation in multiagency disaster drills across the United States. Characteristics of those most likely to have received individual-level training or participated in multiagency disaster drills were explored. The secondary objectives were to assess EMS professional's perception of preparedness and to determine whether the amount of training individuals received was correlated with their perceptions of preparedness. Methods: A structured survey was administered to nationally certified EMT-Basics and paramedics as part of their 2008 recertification paperwork. Outcome variables included individual-level preparedness training, participation in multiagency disaster drills, and perception of preparedness. Descriptive statistics and logistic regression modeling were used to quantify the amount of training received. Spearman rank correlation coefficients were used to analyze whether training was correlated with an individual's perception of preparedness. Results: There were 46,127 EMS professionals who had the opportunity to complete the recertification questionnaire; 30,570 (66.3%) responded. A complete case analysis was performed on 21,438 respondents. Overall, 19,551 respondents (91.2%) reported receiving at least 1 hour of individual-level preparedness training, and 12,828 respondents (59.8%) reported participating in multiagency disaster drills, in the prior 24 months. Spearman rank correlation coefficients revealed that hours of individual-level preparedness training were significantly correlated with the perception of preparedness. Conclusions: While areas where EMS should focus attention for improvement were identified, a majority of nationally certified EMT-Basics and paramedics reported participating in both individual and multiagency disaster-preparedness training. A large majority of respondents reported feeling adequately prepared to respond to man-made and natural disasters and the perception of preparedness correlated with hours of training. [ABSTRACT FROM AUTHOR]

Objectives: Consultation difficulty occurs in hospitals located in many countries, and it is understood that strategies to improve the emergency department (ED) consultation process are needed. The authors constructed a computerized consultation management system in the ED of a tertiary care teaching hospital to improve the consultation process and evaluate the influence of the consultation management system on ED length of stay (LOS) and the throughput process. Methods: Consultation management system software was developed and integrated into the hospital information system. The development process took place between June 2008 and May 2009. Before the development of the consultation system, ED personnel contacted on-call physicians of the specialty department, who are usually residents, by cellular phones. After the system had been developed, ED personnel selected the department and on-call physician in the specialty department using the consultation management software and activated the automatic consultation process when specialty consultation was necessary. If the treatment plan had not been registered for 3 hours, all of the residents in the specific department are notified of the delay in the treatment plan with a short message service (SMS) message. If an admission or discharge order had not been made in 6 hours, all of the residents and faculty staff in the specific department receive SMS messages stating the delay in disposition. ED patient data were collected from the hospital information system for 40 days before the system was developed (June 1, 2008, to July 10, 2008) and 40 days after the system was implemented (June 1, 2009, to July 10, 2009). Results: The median ED LOS decreased significantly, from 417.5 minutes (interquartile range [IQR] = 178.8-1,247.5 minutes) in the presystem period to 311.0 minutes (IQR = 128.0-817.3 minutes) in the postsystem period (p < 0.001). Also, the median time to disposition order decreased significantly, from 336.0 minutes (IQR = 145.0-943.0 minutes) to 235.0 minutes (IQR = 103.0-21.5; p = 0.001). No significant reduction was observed in the interval between the time of disposition decision and the time when the patients left the ED. Significant reductions of ED LOS were observed after implementing the system (p < 0.001) regardless of whether the visit occurred during the weekday daytime (09:00-17:00 hours), holiday and weekend daytime (09:00-17:00 hours), or nighttime (17:00-09:00 hours next day). Conclusions: This study found decreased ED LOS by implementation of a computerized consultation management system in a tertiary care teaching hospital. The automated consultation and monitoring process formalized communication between physicians providing ED patient care in the academic ED with high consultation and admission rates. [ABSTRACT FROM AUTHOR]

Objectives: There has been a rapid rise in prescription drug costs over the past decade. As a result, many Americans are unable to afford their medications, especially in the current economic recession. Medication nonadherence is known to have adverse effects on health outcomes. The purpose of this study was to gain a preliminary understanding of cost-related medication nonadherence (CRMN) disclosure among screened emergency department (ED) patients and to describe the extent to which CRMN is associated with other economic and psychosocial risk factors. Methods: This was a prospective, cross-sectional study of a convenience sample of adult patients presenting to an urban academic ED with 61,962 annual visits in 2009. Nonemergent patients received an optional self-administered Social Health Survey between May and October 2009. Results were assessed from the sample of anonymous surveys that were completed and collected. Standard statistical methods were used to determine the frequencies and relative risks (RRs) for CRMN with 95% confidence intervals (CIs). Results: A total of 384 (25.5%) of the 1,506 adult patients who completed the survey either screened positive for any prior CRMN (20.7%) or disclosed concerns about affording medication (4.8%). Patients were significantly more likely to report risk for CRMN if they used tobacco (RR = 1.8, 95% CI = 1.5 to 2.2) or illicit drugs (RR = 2.0, 95% CI = 1.6 to 2.4), experienced intimate partner violence (IPV; RR = 1.8, 95% CI = 1.5 to 2.2), or reported concerns about overall financial instability (RR = 3.9, 95% CI = 3.2 to 4.7), food insufficiency (RR = 3.7, 95% CI = 3.1 to 4.3), housing problems (RR = 2.5, 95% CI = 2.1 to 2.9), and inadequate health insurance coverage (RR = 7.7, 95% CI = 6.2 to 9.5). Conclusions: Risk for medication nonadherence due to cost concerns was identified in a quarter of non-emergent urban ED patients in our sample and was more likely to be reported by patients experiencing other economic and psychosocial risks. These findings indicate a need to include discussions about medication affordability and referrals to social services as part of ED discharge planning. [ABSTRACT FROM AUTHOR]

Objectives: The rate of recombinant tissue plasminogen activator (rtPA) use for stroke is low among the Chinese-Taiwanese. The study objective was to determine if less restrictive exclusion criteria for rtPA would increase eligibility and the rate of treatment. Methods: This retrospective before-and-after study was conducted from 2006 to 2009. The authors compared stroke patients treated under the old rtPA exclusion criteria (January 2006 to December 2008) with those treated with less restrictive rtPA exclusion criteria (January to December 2009). Rates of eligibility and treatment and reasons for exclusion from rtPA between the two phases were assessed. Results: Of 461 eligible patients during the study period, 333 were evaluated by the old criteria and 128 were evaluated by the less restrictive criteria. Minor or improving stroke was the primary exclusion reason in both groups (194/333, 58% vs. 70/128, 55%). Eligibility for rtPA was increased in the less restrictive criteria (35/127, 27%, 95% confidence interval [CI] = 20% to 36%) compared to the old criteria (40/333, 12%, 95% CI = 8.7% to 16%; p = 0.0001). Fewer patients were excluded due to old age in the less restrictive criteria (0/128, 0%) compared to the old criteria (37/333, 11%; p = 0.0001). The rate of consent refusal increased in the less restrictive criteria (27/128, 21%, 95% CI = 14% to 29%) compared to the old criteria (23/333, 6.9%, 95% CI = 4.4% to 10%; p < 0.0001). Rate of rtPA treatment was unchanged between the less restrictive criteria (8/128, 6.3%, 95% CI = 2.7% to 12%) and the old criteria (17/333, 5.1%, 95% CI = 3% to 8%; p = 0.63). Conclusions: Increasing eligibility for rtPA does not increase the rate of treatment, possibly due to the high symptomatic intracerebral hemorrhage rate among Chinese-Taiwanese, which is a major concern among emergency physicians (EPs), neurologists, and patients. Dealing with perceived safety issues of rtPA is crucial before the rate of treatment can be increased. [ABSTRACT FROM AUTHOR]

Objectives: In preparation for development of a clinical decision rule (CDR) to promote more efficient use of computed tomography (CT) for diagnosing orbital fractures, the authors sought to estimate the annual incidence of orbital fractures in emergency departments (EDs) and the usage of CT to make these diagnoses. The authors also sought to evaluate a mandatory electronic data collection instrument (EDCI) administered to providers to facilitate CDR data collection. Methods: National estimates were made by analyzing the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) database, while hospital billing system and coding data were used to make local estimates. An EDCI was integrated into the CT ordering system such that providers had to complete the form to perform a CT. Because the EDCI had to be filled out for every CT ordered, data collection efficiency was measured by compliance (counting the number of unrealistic data collection instrument answers) and by timing a convenience sample of providers completing the EDCI. Results: Out of 116.8 million ED visits in the United States in 2007, 4.1 million patients were treated for injuries of the eye and face. Of those, 820,252 patients underwent CT imaging, with 102,999 patients (12.5%) diagnosed with an orbital fracture. In our local hospital system with 122,500 annual ED visits, 752 CTs of orbits were performed, with 172 (23%) orbital fractures. The EDCI compliance rate was 94.9% and took less than 5 minutes to complete. Conclusions: National and local data demonstrate a low yield for CT imaging in identifying orbital fractures. Data collection using a mandatory EDCI linked to computerized provider order entry can provide prospective, consecutive patient data that are needed to develop a CDR for the selective use of CT imaging in orbital trauma. Such a decision rule could increase the efficiency in diagnosing orbital fractures, thereby improving patient care, reducing radiation exposure, and decreasing costs. [ABSTRACT FROM AUTHOR]

Objectives: The authors sought to determine the diagnostic test characteristics of bedside emergency physician (EP)-performed ultrasound (US) for cholelithiasis in symptomatic emergency department (ED) patients. Methods: A search was conducted of MEDLINE, EMBASE, the Cochrane Library, bibliographies of previous systematic reviews, and abstracts from major emergency medicine conference proceedings. We included studies that prospectively assessed the diagnostic accuracy of emergency US (EUS) for cholelithiasis, compared to a criterion reference standard of radiology-performed ultrasound (RADUS), computed tomography (CT), magnetic resonance imaging (MRI), or surgical findings. Two authors independently performed relevance screening of titles and abstracts, extracted data, and performed the quality analysis. Disagreements were resolved by conference between the two reviewers. EUS performance was assessed with summary receiver operator characteristics curve (SROC) analysis, with independently pooled sensitivity and specificity values across included studies. Results: The electronic search yielded 917 titles; eight studies met the inclusion criteria, yielding a sample of 710 subjects. All included studies used appropriate selection criteria and reference standards, but only one study reported uninterpretable or indeterminate results. The pooled estimates for sensitivity and specificity were 89.8% (95% confidence interval [CI] = 86.4% to 92.5%) and 88.0% (95% CI = 83.7% to 91.4%), respectively. Conclusions: This study suggests that in patients presenting to the ED with pain consistent with biliary colic, a positive EUS scan may be used to arrange for appropriate outpatient follow-up if symptoms have resolved. In patients with a low pretest probability, a negative EUS scan should prompt the clinician to consider an alternative diagnosis. [ABSTRACT FROM AUTHOR]

Objectives: There is a growing awareness of the effects of patient death on physician well-being, and the importance of cultural and educational changes to improve coping mechanisms. The objective of this study was to explore both the effects of patient death on academic emergency physicians (EPs) and the coping mechanisms they use to deal with these events. Methods: Faculty at a convenience sample of four emergency medicine (EM) residency programs were questioned about their responses to patient death in a 15-question on-line survey. Descriptive analysis of the data was performed. Independent variables were analyzed for differences in complaints of physical symptoms or consideration of important life changes after patient death. Results: Of 207 EPs surveyed, 145 (70%) responded. Patient death was experienced frequently, with 95 (66%) witnessing a death at least every month. No training on coping with patient death had occurred for 35 (24%); 93 (64%) had less than 6 hours of training. The most common coping mechanisms included talking with colleagues (113; 78%) or friends and family (100; 69%), as well as simply continuing to work (89; 61%). Postdeath debriefing occurred rarely or never for 93 (64%) of respondents. Most EPs had experienced physical responses to patient death, the most common being insomnia (54; 37%) and fatigue (21; 14%). Common emotional responses included sadness (112; 70%) and disappointment (55; 38%). No significant differences in response rates for physical symptoms or consideration of life changes were found for any of the variables. Conclusions: Patient death was reported to lead to both physical and emotional symptoms in academic EPs. Postdeath debriefing appears to happen infrequently in teaching settings, and most respondents reported that they themselves received limited training in coping with patient death. Further study is needed to both identify coping mechanisms that are feasible and effective in emergency department settings and develop teaching strategies to incorporate this information into EM residency training. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to examine the effectiveness of triage liaison physicians (TLPs) on mitigating the effects of emergency department (ED) overcrowding. Methods: Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, HealthSTAR, Dissertation Abstracts, and ABI / INFORM Global), controlled trial registry websites, conference proceedings, study references, contact with experts in the field, and correspondence with authors were used to identify potentially relevant TLP studies. Intervention studies in which a TLP was used to influence ED overcrowding metrics (length of stay [LOS] in minutes, physician initial assessment [PIA], and left without being seen [LWBS]) were included in the review. Two reviewers independently conducted data extraction and assessed the citation relevance, inclusion, and study quality. For continuous outcomes, weighted mean differences (WMD) were calculated and reported with corresponding 95% confidence intervals (CIs). For dichotomous variables, individual and pooled statistics were calculated as relative risk (RR) with 95% CI. Results: From 14,446 potentially relevant studies, 28 were included in the systematic review. Thirteen were journal publications, 12 were abstracts, and three were Web-based articles. Most studies employed before--after designs; 23 of the 28 studies were considered of weak quality. Based on the statistical pooling of data from two randomized controlled trials (RCTs), TLP resulted in shorter ED LOS compared to nurse-led triage (WMD = )36.85 min; 95% CI = )51.11 to -22.58). One of these RCTs showed a significant reduction in the PIA associated to TLP presence (WMD = )30.00 min; 95% CI = )56.91 to -3.09); the other RCT showed no change in LWBS due to a CI that included unity (RR = 0.82; 95% CI = 0.67 to 1.00). Conclusions: While the evidence summarized here suggests that to have a TLP is an effective intervention to mitigate the effects of ED overcrowding, due to the weak research methods identified, more research is required before its widespread implementation. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to describe the emergency department (ED) resource burden of the spring 2009 H1N1 influenza pandemic at U.S. children's hospitals by quantifying observed-to-expected utilization. Methods: The authors performed an ecologic analysis for April through July 2009 using data from 23 EDs in the Pediatric Health Information System (PHIS), an administrative database of widely distributed U.S. children's hospitals. All ED visits during the study period were included, and data from the 5 prior years were used for establishing expected values. Primary outcome measures included observed-to-expected ratios for ED visits for all reasons and for influenza-related illness (IRI). [ABSTRACT FROM AUTHOR]

Objectives: The objectives were to characterize physician beliefs and practice of analgesia and anesthesia use for infant lumbar puncture (LP) in the emergency department (ED) and to determine if provider training type, experience, and beliefs are associated with reported pain intervention use. Methods: An anonymous survey was distributed to ED faculty and pediatric emergency medicine (PEM) fellows at five Midwestern hospitals. Questions consisted of categorical, yes / no, descriptive, and incremental responses. Data were analyzed using descriptive statistics with confidence intervals (CIs) and odds ratios (ORs). Results: A total of 156 of 164 surveys (95%) distributed were completed and analyzed. Training background of respondents was 52% emergency medicine (EM), 30% PEM, and 18% pediatrics. Across training types, there was no difference in the belief that pain treatment was worthwhile (overall 78%) or in the likelihood of using at least one pain intervention. Pharmacologic pain interventions (sucrose, injectable lidocaine, and topical anesthetic) were used in the majority of LPs by 20, 29, and 27% of respondents, respectively. Nonpharmacologic pain intervention (pacifier / nonnutritive sucking) was used in the majority of LPs by 67% of respondents. Many respondents indicated that they never used sucrose (53%), lidocaine (41%), or anesthetic cream (49%). Physicians who thought pain treatment was worthwhile were more likely to use both pharmacologic and nonpharmacologic pain interventions than those who did not (93% vs. 53%, OR = 10.98, 95% CI = 4.16 to 29.00). The number of LPs performed or supervised per year was not associated with pain intervention use. Other than pacifiers, injectable lidocaine was the most frequently reported pain intervention. Conclusions: Provider beliefs regarding infant pain are associated with variation in anesthesia and analgesia use during infant LP in the ED. Although the majority of physicians hold the belief that pain intervention is worthwhile in this patient group, self-reported pharmacologic interventions to reduce pain associated with infant LP are used regularly by less than one-third. Strategies targeting physician beliefs on infant pain should be developed to improve pain intervention use in the ED for infant LPs. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to determine the effect of paralytic type and dose on first-attempt rapid sequence intubation (RSI) success in the emergency department (ED). Methods: This was a retrospective evaluation of information collected prospectively in a quality improvement database between July 1, 2007, and October 31, 2008. Information regarding all intubations performed in a tertiary care ED was recorded in this database. All RSI performed using succinylcholine or rocuronium were included. Logistic regression was used to analyze the effect of paralytic type and dosing, as well as age, sex, body mass index, physician experience, device type, and presence of difficult airway predictors on first attempt RSI success. Results: A total of 327 RSI were included in the final analyses. All patients received etomidate as the induction sedative and were successfully intubated. Of these, 113 and 214 intubations were performed using succinylcholine and rocuronium, respectively. The rate of first-attempt intubation success was similar between the succinylcholine and rocuronium groups (72.6% vs. 72.9%, p = 0.95). Median doses used for succinylcholine and rocuronium were 1.65 mg/ kg (interquartile range [IQR] = 1.26-1.95 mg/ kg) and 1.19 mg/ kg (IQR = 1-1.45 mg/ kg), respectively. In the univariate logistic regression analyses, variables predictive of first-attempt intubation success were laryngeal view (more success if Grade 1 or 2 compared to Grade 3 or 4 of the Cormack-Lehane classification, odds ratio [OR] = 55.18, 95% confidence interval [CI] = 18.87 to 161.39), intubation device (less success if direct laryngoscopy, OR = 0.57, 95% CI = 0.34 to 0.96), and presence of a difficult airway predictor (OR = 0.55, 95% CI = 0.31 to 0.99). In the multivariate analysis, the only variable predictive of first-attempt intubation success was laryngeal view. Conclusions: Succinylcholine and rocuronium are equivalent with regard to first-attempt intubation success in the ED when dosed according to the ranges used in this study. [ABSTRACT FROM AUTHOR]

Objectives: Observational studies of patients with cocaine-associated myocardial infarction have suggested more coronary disease than expected on the basis of patient age. The study objective was to determine whether cocaine use is associated with coronary disease in low- to intermediate-risk emergency department (ED) patients with potential acute coronary syndrome (ACS). Methods: The authors conducted a cross-sectional study of low- to intermediate-risk patients < 60 years of age who received coronary computerized tomographic angiography (CTA) for evaluation of coronary artery disease (CAD) in the ED. Patients were classified into three groups with respect to CAD: maximal stenosis <25%, 25% to 49%, and ≥50%. Prespecified multivariate modeling (generalized estimating equations) was used to assess relationship between cocaine and CAD. Results: Of 912 enrolled patients, 157 (17%) used cocaine. A total of 231 patients had CAD ≥25%; 111 had CAD ≥50%. In univariate analysis, cocaine use was not associated with a lesion 25% or greater (12% vs. 14%; relative risk [RR] = 0.89, 95% confidence interval [CI] = 0.5 to 1.4) or 50% or greater (12% vs. 11%; RR = 1.15, 95% CI = 0.6 to 2.3). In multivariate modeling adjusting for age, race, sex, cardiac risk factors, and Thrombosis in Myocardial Infarction (TIMI) score, cocaine use was not associated with the presence of any coronary lesion (adjusted RR = 0.95, 95% CI = 0.69 to 1.31) or coronary lesions 50% or greater (adjusted RR = 0.78, 95% CI = 0.45 to 1.38). There was also no relationship between repetitive cocaine use and coronary calcifications or between recent cocaine use and CAD. Conclusions: In symptomatic ED patients at low to intermediate risk of an ACS, cocaine use was not associated with an increased likelihood of coronary disease after adjustment for age, race, sex, and other risk factors for coronary disease. [ABSTRACT FROM AUTHOR]

As the specialty of emergency medicine evolves in countries around the world, and as interest in international emergency medicine (IEM) grows within the United States, the IEM Literature Review Group recognizes an ongoing need for a high-quality, consolidated, and easily accessible evidence base of literature. The IEM Literature Review Group produces an annual publication that strives to provide readers with access to the highest quality and most relevant IEM research from the previous year. This publication represents our fifth annual review, covering the top 24 IEM research articles published in 2009. Articles were selected for the review according to explicit, predetermined criteria that emphasize both methodologic quality and impact of the research. It is our hope that this annual review acts as a forum for disseminating best practices, while also stimulating further research in the field of IEM. [ABSTRACT FROM AUTHOR]

Objectives: Acute gastroenteritis is a very common emergency department (ED) diagnosis accounting for greater than 1.5 million outpatient visits and 200,000 hospitalizations annually among children in the United States. Although guidelines exist to assist clinicians, they do not clearly address topics for which evidence is new or limited, including the use of antiemetic agents, probiotics, and intravenous (IV) fluid rehydration regimens. This study sought to describe the ED treatments administered to children with acute gastroenteritis and to compare management between Canadian and U.S. physicians practicing pediatric emergency medicine (PEM). Methods: Members of PEM research networks located in Canada and the United States were invited to participate in a cross-sectional, Internet-based survey. Participants were included if they are attending physicians and provide care to patients < 18 years of age in an ED. Results: In total, 235 of 339 (73%) eligible individuals responded. A total of 103 of 136 Canadian physicians (76%) report initiating oral rehydration therapy (ORT) in children with moderate dehydration, compared with 44 of 94 (47%) of their U.S. colleagues (p < 0.001). The latter more often administer antiemetic agents to children with vomiting (67% vs. 45%; p = 0.001). American physicians administer larger IV fluid bolus volumes (p < 0.001) and over shorter time periods (p = 0.001) and repeat the fluid boluses more frequently (p < 0.001). Probiotics are routinely recommended by only 35 of 230 respondents (15%). Conclusions: The treatment of pediatric gastroenteritis varies by geographic location and differs significantly between Canadian and American PEM physicians. Oral rehydration continues to be underused, particularly in the United States. Probiotic use remains uncommon, while ondansetron administration has become routine. Children frequently receive IV rehydration, with the rate and volume administered being greater in the United States. [ABSTRACT FROM AUTHOR]

Problems with on-call specialist physician coverage have been identified as a significant issue for our nation's health care system. Despite this, little is known about the full extent of these coverage deficiencies in emergency departments (EDs), their effect on emergency care provision, or the subsequent effect on patient flow should specialist-requiring patients need to be transferred to centers of higher-level care. The objective was to report the experiences of a national sample of ED directors regarding the degree of difficulty in providing specialist coverage and the effect of on-call coverage problems on emergency patient care. The authors conducted a cross-sectional self-administered survey of a national sample of ED directors. How frequently ED directors reported on-call coverage problems, whether they recently lost on-call coverage, whether their current on-call coverage was reliable, and the potential effect on emergency care provision were all assessed. The overall response rate was 62% (442 of 715). Seventy-four percent of respondents reported on-call coverage problems with specialist physicians. Sixty percent reported having lost 24/7 coverage for at least one specialty in the past 4 years. Twenty-six percent reported unreliability in their current on-call coverage. Twenty-three percent noted that their trauma center designation level had been affected by on-call coverage, and 22% noted an increase in patients leaving before being seen by a medically needed specialist. Difficulties in obtaining specialty on-call coverage are a pervasive issue for EDs at the national level. Emergency care provision appears to have been affected, and this issue is further impacted by a perceived unreliability in current on-call coverage provision as well as the attrition of coverage for individual specialties. ACADEMIC EMERGENCY MEDICINE 2010; 17:1374-1382 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

The objective was to assess the predictive value of clinical signs and symptoms of herpes zoster ophthalmicus (HZO) for development of moderate to severe eye disease. This was a prospective cohort multicenter study of 54 patients referred to the ophthalmology service after presenting to the emergency department (ED) or primary care clinic with a zosteriform rash of less than 10 days' duration. Upon referral to ophthalmology, easily assessable clinical signs and symptoms were documented. A complete ocular exam was then performed. Patients were followed for 2 months. Twenty-three patients (43%) developed moderate to severe disease as defined by corneal or intraocular involvement. Eye redness and rash in the supratrochlear nerve distribution had a statistically significant association with clinically relevant eye disease. All 23 patients who developed moderate to severe eye disease presented with a red eye. Hutchinson's sign (nasociliary nerve involvement) was not predictive of clinically relevant eye disease. Eye redness was 100% sensitive for predicting moderate to severe eye disease in this sample of patients and should necessitate immediate referral for ophthalmologic assessment. Patients lacking eye redness, even with a positive Hutchinson's sign, may not require immediate specialist consultation. All patients not being referred require careful instructions to seek further care should they develop any concerning eye symptoms such as redness, pain, photophobia, or visual disturbance. ACADEMIC EMERGENCY MEDICINE 2010; 17:1183-1188 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Methamphetamine is a drug of abuse that has been manufactured locally by chemical conversion from the decongestant pseudoephedrine. In July 2006, an Oregon state law was enacted to establish pseudoephedrine as a schedule III drug and make it available by prescription only. This study sought to determine if this legislation altered the number of emergency department (ED) visits that are related to methamphetamine use. This was a retrospective analysis of a database created during a prospective study aimed at determining the effect of methamphetamine on ED visits. That prospective study was 1 year in duration and required ED clinicians to determine whether a patient's visit was related to methamphetamine and if the patient had confirmed use of methamphetamine. The clinicians received initial and continued education and training on methamphetamine during the study period. The questions were asked at every ED visit during the study period and were electronically linked to the patient's disposition and could not be circumvented. The study period was divided into prelegislation (February 5, 2006, to June 30, 2006) and postlegislation periods (July 1, 2006, to February 5, 2007). Over the 1-year study period, 37,625 patients were enrolled, 1.90% ( n = 714) of patients had methamphetamine-related ED visits (MREDVs), and 1.65% ( n = 620) had confirmed methamphetamine use. Patients with MREDVs were more likely than patients with non-MREDVs to be white and uninsured. The number and proportion of weekly MREDVs significantly decreased from the prelegislation period to the postlegislation period (mean number of weekly visits, 18.0 vs. 11.3, p = 0.001; mean proportion of weekly visits, 2.3% vs. 1.6%, p = 0.003). The number and proportion of weekly confirmed users of methamphetamine also significantly decreased during the study period (mean number of weekly users, 14.6 vs. 10.3, p = 0.004; mean proportion of weekly users, 1.9% vs. 1.4%, p = 0.017). There were no significant differences in the diagnoses of MREDVS between the pre- and postlegislation periods. This study found an association between the enactment of legislation that limits pseudoephedrine availability and a decrease in MREDVs and confirmed users of methamphetamine in the study ED. ACADEMIC EMERGENCY MEDICINE 2010; 17:1216-1222 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

The objectives were to explore the tolerance of pediatric emergency medicine (PEM) physicians for risk in choosing when to perform procedural sedation and analgesia (PSA) and to describe adherence to preprocedural fasting guidelines and factors affecting the physicians' decisions. A survey of Canadian PEM physicians who perform PSA was conducted. Respondents were asked about their PSA practices. Risk tolerance was assessed using an economics-based stated preference elicitation method called a discrete choice experiment (DCE). Using a hypothetical clinical situation of a healthy child needing PSA, three fasting scenarios (ingestion of full meal < 2 hours ago, full meal between 2 and 4 hours ago, liquids less than 1 hour ago) were created. For each fasting scenario, 16-choice questions with varying numeric risks of major and minor adverse events were presented and respondents were asked whether they would administer PSA now or wait for guidelines to be met. In this exploratory study, choice data were analyzed using multivariate regression analysis, and preliminary inferential statistics are presented. A total of 114 (63.6%) completed surveys were returned. Respondents were 54% male, were in practice for a median of 6-10 years, and reported following fasting guidelines 53% of the time. Most had institutional fasting policies (70%), used ketamine (in 78% of PSA by 95% of users), and identified patient variables (prolonged pain, parental concern) as more important than environmental variables (patient flow, use of resources) in deciding when to administer PSA. Both major and minor risks of adverse events affected the choice of whether to do immediate PSA or wait until fasting guidelines were met. A 0.1-percentage-point increase in the probability of a major adverse event reduced physician likelihood of performing immediate PSA before meeting fasting guidelines by 17.6 percentage points. In comparison, a 10-percentage-point increase in the probability of a minor adverse event reduced physician likelihood of performing immediate PSA by 17.2%. Respondents were less likely to perform PSA immediately if a child had a full meal < 2 hours ago versus 2-4 hours ago or liquids < 1 hour ago. Sex, highest level of postgraduate training, frequency of performing PSA, and experience with a prior adverse event did not affect the choice to do immediate PSA. Years in practice affected the decision, with those in practice for 6-10 years more likely to perform immediate PSA than those in practice for shorter or longer. Those who reported having an institutional fasting policy were less likely to perform immediate PSA. These results suggest that fasting guidelines are not strictly adhered to in Canadian pediatric emergency departments (EDs) currently, and there is some willingness of physicians to change their sedation practice in light of evidence from hypothetical surveillance data about risks. On the other hand, some physicians suggest that they will follow guidelines regardless of how low the estimated risk is from surveillance data. An understanding of how physicians respond to evidence about small risks and how the information is best understood by this population is interesting for knowledge translation if evidence-based practice guidelines for procedural sedation in the ED are developed in the future. ACADEMIC EMERGENCY MEDICINE 2010; 17:1207-1215 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Approximately 2% to 5% of children presenting to pediatric emergency departments (PEDs) leave prior to a complete evaluation. This study assessed risk factors for premature departure (PD) from a PED to identify key metrics and cutoffs for reducing the PD rate. A 3-year cohort (June 2004-May 2007) of children presenting to a PED was evaluated. Children were excluded if they presented for psychiatric issues, were held awaiting hospital admission in the PED due to a lack of inpatient beds, were more than 21 years old, or died before disposition. Univariate analyses, multivariable logistic regression, and recursive partitioning were used to identify factors associated with PD. A fourth year of data (June 2007-May 2008) was used for validation and sensitivity analysis. There were 132,324 patient visits in the 3-year derivation data set with a 3.8% PD rate, and 45,001 visits in the fourth-year validation data set with a 4.3% PD rate. PDs were minimized when average wait time was below 110 minutes, concurrent PDs were fewer than two, and average length of stay (LOS) was less than 224 minutes in the derivation set, with similar results in the validation set. When these metrics were exceeded, PD rates were over 10% among low-acuity patients. These findings were robust across a broad range of assumptions during sensitivity analysis. The authors identified five key metrics associated with PD in the PED: average wait time, average LOS, acuity, concurrent PDs, and arrival rate. Operational cutoffs for these metrics, determined by recursive partitioning, may be useful to physicians and administrators when selecting specific interventions to address PDs from the PED. ACADEMIC EMERGENCY MEDICINE 2010; 17:1197-1206 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Background: Principles of evidence-based medicine (EBM) may be inconsistently applied to clinical decision-making due to lack of practice-based training, experience, and time. Objectives: The authors sought to design, implement, and test the feasibility of an experiential learning model for senior emergency medicine (EM) residents to apply EBM principles during real-time clinical practice. Methods: Targeted program evaluation of this learning model was conducted through a prospective observational cohort study involving EM residents at a large, urban, 4-year EM residency program. The curriculum development of a case-based knowledge translation shift followed Kern's six-step design process. Subjects asynchronously completed a 1-hour EBM tutorial and were then assigned to clinical shifts in which they contributed to the care of emergency department (ED) patients by completing formal literature searches related to active management questions. Pre- and post-intervention self-assessments of practice norms and attitudes were used to evaluate the effect of this experiential learning model for individual residents. Self-assessments of the likelihood that the experience would result in future practice change were reported on a five-point Likert scale (1 = greatly impeded, 2 = somewhat impeded, 3 = no change, 4 = somewhat improved, 5 = greatly improved). Subjects presented available evidence to the primary ED team, formally disseminated their findings as a brief 'EBM rounds' at sign-out and completed an 'EBM consult note' and case log to document shift performance. Changes in patient management and/or disposition were recorded. EBM search questions and resultant findings were entered in a local database. Results: Of the 45 eligible senior EM resident shifts, 91% resulted in complete sets of performance data and self-assessments. A total of 80 patient encounters were documented during 45 scheduled shifts over a 3-month study period. Literature review took a mean (±SD) of 36.2 (±26.4) minutes per case. During the 3-hour interval before or after shift sign-out, residents completed a mean (±SD) of 2.11 (±1.4) literature searches and recorded a mean (±SD) of 3.0 (±1.5) articles for each case. Alterations in ED management for 13 of 80 patient encounters (16.3%) were documented to be the direct result of on-shift literature searches. Conclusions: Case-based knowledge translation shifts for senior EM residents can provide opportunities to practice EBM skills in the ED. This experiential learning model may result in future practice change by resident learners, as well as affect the management of active patients in the ED. ACADEMIC EMERGENCY MEDICINE 2010; 17:S42-S48 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Objectives: Rotating (non-emergency medicine [EM]) residents perform clinical rotations in many academic emergency departments (EDs). The primary objective of this work was to quantify characteristics of rotating residents and the didactic curricula offered to them during their EM rotations. Secondary objectives were to identify barriers to instituting such didactics and to establish ideal curricular contents. Methods: A Web-based survey was administered by e-mail to residency directors of all U.S. allopathic EM residency programs. Consent was obtained in the first part of the survey, and the study was deemed exempt from full review by the institutional review board. Questions solicited information regarding type and quantity of rotating residents in their main EDs, the 'didactic educational format' available to rotating residents, and ideal and actual didactic curricular contents. Statistics were reported as proportions and means with 95% confidence intervals (CIs) and medians with interquartile ranges (IQRs). Results: Surveys were sent to 143 programs, and the response rate was 71%. Ninety-nine percent of respondents had rotating residents in their EDs, and the median number per month was 4 (IQR = 3-6). Five percent of respondents had established didactic curricula specifically for rotating residents, and 64% sent them to either EM resident or medical student lectures. Thirty-one percent of programs reported no didactics, and 65% of these felt there was no need for such education. Resuscitation, trauma, and toxicology were cited as the most important subjects for actual and ideal curricula. Conclusions: Most academic EDs have rotating residents, but very few provide didactic education specific to their learning needs and almost a third provide no didactics. ACADEMIC EMERGENCY MEDICINE 2010; 17:S49-S53 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Background: The Accreditation Council for Graduate Medical Education (ACGME) invokes evidence-based medicine (EBM) principles through the practice-based learning core competency. The authors hypothesized that among a representative sample of emergency medicine (EM) residency programs, a wide variability in EBM resident training priorities, faculty expertise expectations, and curricula exists. Objectives: The primary objective was to obtain descriptive data regarding EBM practices and expectations from EM physician educators. Our secondary objective was to assess differences in EBM educational priorities among journal club directors compared with non-journal club directors. Methods: A 19-question survey was developed by a group of recognized EBM curriculum innovators and then disseminated to Council of Emergency Medicine Residency Directors (CORD) conference participants, assessing their opinions regarding essential EBM skill sets and EBM curricular expectations for residents and faculty at their home institutions. The survey instrument also identified the degree of interest respondents had in receiving a free monthly EBM journal club curriculum. Results: A total of 157 individuals registered for the conference, and 98 completed the survey. Seventy-seven (77% of respondents) were either residency program directors or assistant/associate program directors. The majority of participants were from university-based programs and in practice at least 5 years. Respondents reported the ability to identify flawed research (45%), apply research findings to patient care (43%), and comprehend research methodology (33%) as the most important resident skill sets. The majority of respondents reported no formal journal club or EBM curricula (75%) and do not utilize structured critical appraisal instruments (71%) when reviewing the literature. While journal club directors believed that resident learners' most important EBM skill is to identify secondary peer-reviewed resources, non-journal club directors identified residents' ability to distinguish significantly flawed research as the key skill to develop. Interest in receiving a free monthly EBM journal club curriculum was widely accepted (89%). Conclusions: Attaining EBM proficiency is an expected outcome of graduate medical education (GME) training, although the specific domains of anticipated expertise differ between faculty and residents. Few respondents currently use a formalized curriculum to guide the development of EBM skill sets. There appears to be a high level of interest in obtaining EBM journal club educational content in a structured format. Measuring the effects of providing journal club curriculum content in conjunction with other EBM interventions may warrant further investigation. ACADEMIC EMERGENCY MEDICINE 2010; 17:S54-S61 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Objectives: The objective was to critically appraise and highlight methodologically superior medical education research specific to emergency medicine (EM) published in 2009. Methods: A search of the English language literature in 2009 querying Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE 1950 to Present, Web of Science, Education Resources Information Center (ERIC), and PsychInfo identified 36 EM studies that used hypothesis-testing or observational investigations of educational interventions. Six reviewers independently ranked all publications based on 10 criteria, including four related to methodology, that were chosen a priori to standardize evaluation by reviewers. This was a refinement of the methods used to appraise medical education published in 2008. Results: Seven studies met the standards as determined by the averaged rankings and are highlighted and summarized here. This year, 16 of 36 (44%) identified studies had funding, compared to 11 of 30 (36%) identified last year; five of seven (71%) highlighted publications were funded in 2009 compared to three of five (60%) highlighted in 2008. Use of technology in medical education was reported in 14 identified and four highlighted publications, with simulation being the most common technology studied. Five of the seven (71%) featured publications used a quasi-experimental or experimental design, one was observational, and one was qualitative. Practice management topics, including patient safety, efficiency, and revenue generation, were examined in seven reviewed studies. Conclusions: Thirty-six medical education publications published in 2009 focusing on EM were identified. This critical appraisal reviews and highlights seven studies that met a priori quality indicators. Current trends are noted. ACADEMIC EMERGENCY MEDICINE 2010; 17:S16-S25 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Objectives: The objective was to evaluate safety of intravenous (IV) tissue plasminogen activator (tPA) delivered without dedicated thrombolytic stroke teams. Methods: This was a retrospective, observational study of patients treated between 1996 and 2005 at four southeastern Michigan hospital emergency departments (EDs) with a prospectively defined comparison to the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke study cohort. Main outcome measures were mortality, intracerebral hemorrhage (ICH), systemic hemorrhage, neurologic recovery, and guideline violations. Results: A total of 273 consecutive stroke patients were treated by 95 emergency physicians (EPs) using guidelines and local neurology resources. One-year mortality was 27.8%. Unadjusted Cox model relative risk (RR) of mortality compared to the NINDS tPA treatment and placebo groups was 1.20 (95% confidence interval [CI] = 0.87 to 1.64) and 1.04 (95% CI = 0.76 to 1.41), respectively. The rate of significant ICH by computed tomography (CT) criteria was 6.6% (odds ratio [OR] = 1.03, 95% CI = 0.56 to 1.90 compared to the NINDS tPA treatment group). The proportions of symptomatic ICH by two other prespecified sets of clinical criteria were 4.8 and 7.0%. The rate of any ICH within 36 hours of treatment was 9.9% (RR = 0.94, 95% CI = 0.58 to 1.51 compared to the NINDS tPA group). The occurrence of major systemic hemorrhage (requiring transfusion) was 1.1%. Functional recovery by the modified Rankin Scale score (mRS = 0 to 2) at discharge occurred in 38% of patients with a premorbid disability mRS < 2. Guideline deviations occurred in the ED in 26% of patients and in 25% of patients following admission. Conclusions: In these EDs there was no evidence of increased risk with respect to mortality, ICH, systemic hemorrhage, or worsened functional outcome when tPA was administered without dedicated thrombolytic stroke teams. Additional effort is needed to improve guideline compliance. ACADEMIC EMERGENCY MEDICINE 2010; 17:1062-1071 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Background: Trauma registry data are usually incomplete. Various methods for dealing with missing data have been used, some of which lead to biased results. One method that reduces bias, multiple imputation (MI), has not been widely adopted. There is no standardization of the approach to missing data across trauma registries. Objectives: This study examined the effect of using selected methods for handling missing data on a recognized trauma outcome measure. Methods: Data from the Victorian State Trauma Registry (VSTR) were used for the period July 2003 to June 2008. Three methods for handling missing data were investigated: complete case analysis, single imputation, and MI. The latter was applied using five distinct models, each with a different combination of variables (Trauma and Injury Severity score [TRISS] variables; prehospital Glasgow Coma Scale [GCS], respiratory rate, and systolic blood pressure; arrival by ambulance; transfer to a second hospital; and whether the GCS was 'legitimate' according to the TRISS definition). For each method, TRISS analysis (comparing actual and expected deaths) was performed; the W-score and Z-statistic were derived. A Z-statistic greater than 1.96 in absolute value was considered statistically significant. Results: Of 10,180 cases, 2,398 (24%) were missing at least one of the component variables necessary for TRISS analysis. With the use of complete case analysis, the W-score was 0.54 unexpected survivors for every 100 cases, with a Z-statistic of −1.96. Using two approaches to single imputation, the W-scores were −1.41, with Z-statistics of −5.19 and −5.30. Applying four of the five combinations of variables used for MI, there was a statistically significant number of unexpected survivors (W = −0.60, Z = −2.23; W = −0.52, Z = −1.97; W = −0.53, Z = −1.97; W = −0.63, Z = −2.24). However, using MI confined to TRISS variables only, there was a statistically significant number of unexpected deaths (W = +0.52, Z = +1.98). Conclusions: Missing data methods can influence the assessment of trauma care performance and need to be reported in all analyses. It is important that validated standardized approaches to dealing with missing data are universally adopted and reported. ACADEMIC EMERGENCY MEDICINE 2010; 17:1122-1129 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2010; 17:940–950 © 2010 by the Society for Academic Emergency Medicine Objectives: The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance. Methods: The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 410.XX), a random sample of ED visits for AMI in 58 urban EDs across 20 U.S. states between 2003 and 2006 were identified. Concordance with American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations was evaluated using five individual quality measures and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients who received guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance. Results: The cohort consisted of 3,819 subjects; their median age was 65 years, and 62% were men. The mean (± standard deviation [SD]) ED composite concordance score was 61 ± 8), with a broad range of values (42 to 84). Except for aspirin use (mean concordance, 82), ED concordance scores were low (beta-blocker use, 56; timely electrocardiogram [ECG], 41; timely fibrinolytic therapy, 26; timely ED disposition for primary percutaneous coronary intervention [PCI] candidates, 43). In multivariable analyses, older age (beta-coefficient per 10-year increase, −1.5; 95% confidence interval [CI] = −2.4 to −0.5) and southern EDs (beta-coefficient, −5.2; 95% CI = −9.6 to −0.9) were associated with lower guideline concordance, whereas ST-segment elevation on initial ED ECG was associated with higher guideline concordance (beta-coefficient, 3.6; 95% CI = 1.5 to 5.7). Conclusions: Overall ED concordance with guideline-recommended processes of care was low to moderate. Emergency physicians should continue to work with other stakeholders in AMI care, such as emergency medical services (EMS) and cardiologists, to develop strategies to improve care processes. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2010; 17:970–978 © 2010 by the Society for Academic Emergency Medicine Objectives: This study investigated whether mathematical models using calendar variables could identify the determinants of emergency department (ED) census over time in geographically close EDs and assessed the performance of long-term forecasts. Methods: Daily visits in four EDs at academic hospitals in the Paris area were collected from 2004 to 2007. First, a general linear model (GLM) based on calendar variables was used to assess two consecutive periods of 2 years each to create and test the mathematical models. Second, 2007 ED attendance was forecasted, based on a training set of data from 2004 to 2006. These analyses were performed on data sets from each individual ED and in a virtual mega ED, grouping all of the visits. Models and forecast accuracy were evaluated by mean absolute percentage error (MAPE). Results: The authors recorded 299,743 and 322,510 ED visits for the two periods, 2004–2005 and 2006–2007, respectively. The models accounted for up to 50% of the variations with a MAPE less than 10%. Visit patterns according to weekdays and holidays were different from one hospital to another, without seasonality. Influential factors changed over time within one ED, reducing the accuracy of forecasts. Forecasts led to a MAPE of 5.3% for the four EDs together and from 8.1% to 17.0% for each hospital. Conclusions: Unexpectedly, in geographically close EDs over short periods of time, calendar determinants of attendance were different. In our setting, models and forecasts are more valuable to predict the combined ED attendance of several hospitals. In similar settings where resources are shared between facilities, these mathematical models could be a valuable tool to anticipate staff needs and site allocation. [ABSTRACT FROM AUTHOR]

Objectives: The authors investigated whether models using time series methods can generate accurate short-term forecasts of emergency department (ED) bed occupancy, using traditional historical averages models as comparison. Methods: From July 2005 through June 2006, retrospective hourly ED bed occupancy values were collected from three tertiary care hospitals. Three models of ED bed occupancy were developed for each site: 1) hourly historical average, 2) seasonal autoregressive integrated moving average (ARIMA), and 3) sinusoidal with an autoregression (AR)-structured error term. Goodness of fits were compared using log likelihood and Akaike’s Information Criterion (AIC). The accuracies of 4- and 12-hour forecasts were evaluated by comparing model forecasts to actual observed bed occupancy with root mean square (RMS) error. Sensitivity of prediction errors to model training time was evaluated, as well. Results: The seasonal ARIMA outperformed the historical average in complexity adjusted goodness of fit (AIC). Both AR-based models had significantly better forecast accuracy for the 4- and the 12-hour forecasts of ED bed occupancy (analysis of variance [ANOVA] p < 0.01), compared to the historical average. The AR-based models did not differ significantly from each other in their performance. Model prediction errors did not show appreciable sensitivity to model training times greater than 7 days. Conclusions: Both a sinusoidal model with AR-structured error term and a seasonal ARIMA model were found to robustly forecast ED bed occupancy 4 and 12 hours in advance at three different EDs, without needing data input beyond bed occupancy in the preceding hours. [ABSTRACT FROM AUTHOR]