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Pain is common in patients with cancer seeking emergency department (ED) care. Fifty percent of ED patients with cancer present with pain and 39% report pain at final ED pain assessment. Thus, ED practitioners seemingly remain challenged to manage pain in this population. Such findings support calls encouraging safe, effective, and timely pain management in EDs. Brown and colleagues encourage research into any racial or socioeconomic gaps in the treatment of pain in ED cancer patients.

BACKGROUND Data are lacking on how emergency medicine (EM) malpractice cases with resident involvement differs from cases that do not name a resident. OBJECTIVES The objective was to compare malpractice case characteristics in cases where a resident is involved (resident case) to cases that do not involve a resident (nonresident case) and to determine factors that contribute to malpractice cases utilizing EM as a model for malpractice claims across other medical specialties. METHODS We used data from the Controlled Risk Insurance Company (CRICO) Strategies' division Comparative Benchmarking System (CBS) to analyze open and closed EM cases asserted from 2009 to 2013. The CBS database is a national repository that contains professional liability data on > 400 hospitals and > 165,000 physicians, representing over 30% of all malpractice cases in the United States (>350,000 claims). We compared cases naming residents (either alone or in combination with an attending) to those that did not involve a resident (nonresident cohort). We reported the case statistics, allegation categories, severity scores, procedural data, final diagnoses, and contributing factors. Fisher's exact test or t-test was used for comparisons (alpha set at 0.05). RESULTS A total of 845 EM cases were identified of which 732 (87%) did not name a resident (nonresident cases), while 113 (13%) included a resident (resident cases). There were higher total incurred losses for nonresident cases. The most frequent allegation categories in both cohorts were "failure or delay in diagnosis/misdiagnosis" and "medical treatment" (nonsurgical procedures or treatment regimens, i.e., central line placement). Allegation categories of safety and security, patient monitoring, hospital policy and procedure, and breach of confidentiality were found in the nonresident cases. Resident cases incurred lower payments on average ($51,163 vs. $156,212 per case). Sixty-six percent (75) of resident versus 57% (415) of nonresident cases were high-severity claims (permanent, grave disability or death; p = 0.05). Procedures involved were identified in 32% (36) of resident and 26% (188) of nonresident cases (p = 0.17). The final diagnoses in resident cases were more often cardiac related (19% [21] vs. 10% [71], p

Objectives Anticoagulant and antiplatelet medications are known to increase the risk and severity of traumatic intracranial hemorrhage (tICH), even with minor head trauma. Most studies on bleeding propensity with head trauma are retrospective, based on trauma registries, or include heterogeneous mechanisms of injury. The goal of this study was to determine the rate of tICH from only a common low-acuity mechanism of injury, that of a ground level fall, in patients taking one or more of the following antiplatelet or anticoagulant medications: aspirin, warfarin, prasugrel, ticagrelor, dabigatran, rivaroxaban, apixaban or enoxaparin. Methods This was a prospective cohort study conducted at a level 1 tertiary care trauma center of consecutive patients meeting the inclusion criteria of: a ground level fall with head trauma as affirmed by the treating clinician, a CT head obtained, and taking and one of the above antiplatelet or anticoagulants. Patients were identified prospectively through electronic screening with confirmatory chart review. ED charts were abstracted without subsequent knowledge of the hospital course. Patients transferred with a known abnormal CT head were excluded. Primary outcome was rate of tICH on initial CT head. Rates with 95% confidence intervals were compared. Results Over 30 months, we enrolled 939 subjects. The average age was 79.2 years and 44.6% were male. There were a total of 33 patients with tICH (3.5%, 95% CI 2.5%-4.9%). Antiplatelets had a rate of tICH of 4.3% (3.0 - 6.2%) compared to anticoagulants with a rate of 1.7% (0.4 - 4.5%). Aspirin without other agents had an tICH rate of 4.6% (3.2 - 6.6%); of these, 81.5% were taking low dose 81mg. Two patients received a craniotomy (1 taking aspirin, 1 taking warfarin). There were 4 deaths (3 taking aspirin, 1 taking warfarin). Most (72.7%) subjects with tICH were discharged home or to a rehabilitation facility. There were no tICH in 31 subjects taking a DOAC. Confidence intervals were overlapping for the groups. Conclusion There is a low incidence of clinically significant tICH with a ground level fall in head trauma in patients taking an anticoagulant or antiplatelet medication. There was no statistical difference in rate of tICH between antiplatelet and anticoagulants, which is unanticipated and counter-intuitive as most literature and teaching suggests a higher rate with anticoagulants. A larger data set is needed to determine if small differences between the groups exist. This article is protected by copyright. All rights reserved.

Background Failure to normalize lactate is associated with poor outcomes in septic shock. It has been suggested that persistently elevated lactate may result from regional ischemia due to disturbed and/or heterogenous microcirculatory blood flow. Objectives The goal of this study was to determine if lactate clearance (LC) may serve as a surrogate marker for changes in microcirculatory blood flow in patients with septic shock. Methods This was a prospective observational study performed within a previously published clinical trial of l-carnitine for the treatment of vasopressor-dependent septic shock. Intravital video microscopy was performed at enrollment and 12 hours later, and microcirculatory flow index (MFI) was assessed. Associations between enrollment MFI, lactate, and Sequential Organ Failure Assessment (SOFA) score were determined, in addition to associations between ∆MFI, LC, and ∆SOFA. A preplanned subgroup analysis of only patients with an elevated initial lactate was performed. Results We enrolled a total of 31 patients, 23 with survival and sufficient quality videos both at enrollment and at 12 hours. ∆MFI, LC, and ∆SOFA were 0.1 (interquartile range [IQR] = 0 to 0.3), 18% (IQR = −10% to 46%), and −2 (IQR = −4 to 0). Both ∆MFI and LC were associated with ∆SOFA (β = −5.3, p = 0.01; and β = −3.5, 0.047), but not with each other, even in the subgroup of patients with an initially elevated lactate. Conclusions We observed no association between degree of LC and change in microcirculatory blood flow in patients with septic shock. These data suggest against the hypothesis that LC may be used as a surrogate marker of microcirculatory blood flow.

Objectives Quantitative pretest probability (qPTP) incorporated into a decision support tool with advice can reduce unnecessary diagnostic testing among patients with symptoms suggestive of acute coronary syndrome (ACS) and pulmonary embolism (PE), reducing 30-day costs without an increase in 90-day adverse outcomes. This study estimates long-term (beyond 90-day) costs and outcomes associated with qPTP. The authors hypothesized that qPTP reduces lifetime costs and improves outcomes in low-risk patients with symptoms suggestive of ACS and PE. Methods This was a cost-effectiveness analysis of a multicenter, randomized controlled trial of adult emergency patients with dyspnea and chest pain, in which a clinician encountering a low-risk patient with symptoms suggestive of ACS or PE conducted either the intervention (qPTP for ACS and PE with advice) or the sham (no qPTP and no advice). Effect of the intervention over a patient's lifetime was assessed using a Markov microsimulation model. Short-term costs and outcomes were from the trial; long-term outcomes and costs were from the literature. Outcomes included lifetime transition to PE, ACS, and intracranial hemorrhage (ICH); mortality from cancer, ICH, PE, ACS, renal failure, and ischemic stroke; quality-adjusted life-years (QALYs); and total medical costs compared between simulated intervention and sham groups. Results Markov microsimulation for a 40-year-old patient receiving qPTP found lifetime cost savings of $497 for women and $528 for men, associated with small gains in QALYs (2 and 6 days, respectively) and lower rates of cancer mortality in both sexes, but a reduction in ICH only in males. Sensitivity analysis for patients aged 60 years predicted that qPTP would continue to save costs and also reduce mortality from both ICH and cancer. Use of qPTP significantly reduced the lifetime probability of PE diagnosis, with lower probability of death from PE in both sexes aged 40 to 60 years. However, use of qPTP reduced the rate of ACS diagnosis and death from ACS at age 40, but increased the death rate from ACS at age 60 for both sexes. Conclusions Widespread use of a combined qPTP for both ACS and PE has the potential to decrease costs by reducing diagnostic testing, while improving most long-term outcomes in emergency patients with chest pain and dyspnea.

Objectives Microcirculatory dysfunction plays an important role in sepsis pathophysiology. Previous studies using sidestream dark-field (SDF) imaging have demonstrated microcirculatory flow abnormalities in patients with septic shock; however, the microcirculation is relatively unstudied in lower-acuity sepsis patients. The hypothesis was that patients with sepsis, but without hypotension, will demonstrate signs of flow abnormalities compared to noninfected control patients. Methods This was a prospective, observational study in a convenience sample of patients with sepsis and noninfected controls, conducted in three urban, tertiary care emergency departments (EDs) in the United States. Sepsis was defined as suspected infection plus two or more systemic inflammatory response syndrome (SIRS) criteria; those with hypotension were excluded. Noninfected controls were ED patients without infection and without SIRS criteria. SDF imaging was obtained in all study patients during ED evaluation. Recommended microcirculatory flow parameters were measured, and the difference in these measures between sepsis patients and noninfected controls were calculated. The authors also correlated microcirculatory flow parameters with patient variables, including serum lactate. Results A total of 106 patients were enrolled: 63 with sepsis and 43 noninfected controls. There were no differences in microcirculatory flow scores between sepsis patients and noninfected controls. Median microvascular flow index (MFI; with interquartile range [IQR] was 3.00 (IQR = 2.73 to 3.00) in sepsis patients versus 2.93 (IQR = 2.73 to 3.00) in control patients (p = 0.33), and mean proportion of perfused small vessels (PPV) was 91.5% (95% CI = 89.7% to 93.3%) versus 91.8% (95% CI = 89.7% to 93.9%), with a mean difference of 0.3% (95% CI = –2.5% to 3.1%; p = 0.84). Similarly, there were no significant differences in total vessel density, perfused vessel density, or heterogeneity index (HI). In the subset of infected patients for whom serum lactates were obtained (n % 37), MFI and PPV were negatively correlated with elevated serum lactate values: r = –0.32, p = 0.04; and r = –0.44, p

Objectives Progressive organ dysfunction is the leading cause of sepsis-associated mortality; however, its incidence and management are incompletely understood. Sepsis patients with moderately impaired perfusion (serum lactate 2.0 to 3.9 mmol/L) who are not in hemodynamic shock (“preshock” sepsis patients) may be at increased risk for progressive organ dysfunction and increased mortality. The objectives of this study were to: 1) quantify the occurrence of progressive organ dysfunction among preshock sepsis patients, 2) examine if there were baseline differences in demographic and physiologic parameters between preshock sepsis patients who experienced progressive organ dysfunction and those who did not, and 3) examine if intravenous (IV) fluid administered in the emergency department (ED) differed between these two groups of patients. Methods This was a prospective, observational study in four urban EDs targeting the preshock sepsis population, defined as adults (18 years or older) with suspected infection, serum lactate between 2.0 and 3.9 mmol/L, and without hypotension (systolic blood pressure [sBP]

Objectives Radiocontrast nephropathy (RCN) is a known complication of procedures in which intravascular iodinated contrast material is used. The authors sought to determine the risk factors for RCN after emergency department (ED) contrast-enhanced computerized tomography (CECT). Methods This was a retrospective case–control study of patients presenting to a tertiary care ED between January 1, 2004, and December 31, 2006. Inclusion criteria were CECT performed in the ED, serum creatinine measured prior to CECT, and serum creatinine measured 48 to 96 hours after CECT. Exclusion criterion was dialysis-dependent renal failure prior to CECT. The outcome of RCN was defined as an absolute creatinine increase of greater than or equal to 0.5 mg/dL, or a 25% increase above baseline. The charts of all RCN patients and a random sample of non-RCN patients were reviewed to document the presence or absence of potential risk factors. Univariate analysis was performed using chi-square and multiple logistic regression applying a weighted technique to account for sampling of non-RCN patients. Results Among the 5,006 patients meeting inclusion criteria, 349 (7%) developed RCN. Multiple regression analysis demonstrated that serum creatinine > 2 mg/dL, liver disease, heart failure, hematocrit 75 years, vascular disease, and serum creatinine > 1.5 mg/dL were not. The area under the curve (AUC) for the model was 0.65. Although the risk of RCN increased with the number of risk factors present, we could not develop a model with sufficient diagnostic accuracy to guide clinical decision-making. Conclusions The authors report risk factors for RCN in a large case–control study, but could not develop an accurate decision tool to identify patients at increased risk for RCN after ED CECT. Resumen Factores de Riesgo de Nefropatia por Radiocontraste tras la Tomografia Computarizada con Contraste Realizada en el Servicio de Urgencias Objetivos La nefropatia por radiocontraste (NRC) es una complicacion conocida de los procedimientos que usan material de contraste yodado intravascular. El objetivo fue determinar los factores de riesgo para NRC tras la realizacion de un atomografia computarizada con contraste (TCCC) en el servicio de urgencias (SU). Metodo Estudio retrospectivo de una cohorte de 3 anos. Incluyo pacientes que acudieron a un SU de un centro terciario entre el 1 de enero del 2004 y el 31 de diciembre del 2006. Los criterios de inclusion fueron la realizacion de un TCCC en el SU y la medicion de la creatinina sirica previa y entre las 48 y las 96 horas tras la realizacion del TCCC. El criterio de exclusion fue la insuficiencia renal en dialisis previamente a la realizacion de TCCC. El resultado de NRC se definio como un incremento absoluto de la creatinina mayor o igual a 0,5 mg/dl o un incremento del 25% por encima de la basal. Se revisaron las historias clinicas de todos los pacientes con NRC asi como una muestra al azar de pacientes sin NRC para documentar la presencia o ausencia de factores de riesgo potenciales. Se realizo un analisis univariable mediante el test de la ji-cuadrado y una regresion logistica multiple aplicando una tecnica para contabilizar una muestra de los pacientes sin NRC. Resultados De los 5.006 pacientes que cumplieron los criterios de inclusion, 349 (7%) desarrollaron NRC. El analisis de regresion multiple mostro que la creatinina serica > 2 mg/dL, la hepatopatia, la insuficiencia cardiaca, el hematocrito 75 anos, la enfermedad vascular y la creatinina serica > 1.5 mg/dL. El area bajo la curva del modelo fue de 0,65. A pesar del aumento del riesgo de NRC con el numero de factores de riesgo presentes, no se pudo desarrollar un modelo con suficiente certeza diagnostica para guiar la toma de decisiones clinicas. Conclusiones Se documentaron factores de riesgo para la NRC en un estudio caso y control, pero no se pudo desarrollar una escala de decision certera para identificar a los pacientes con riesgo incrementado de NRC tras la realizacion de un TCCC en el SU.

ACADEMIC EMERGENCY MEDICINE 2012; 19:252–258 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Lactate clearance (LC) and central venous oxygen saturation (ScvO2) have been proposed as goals of early sepsis resuscitation. The authors sought to determine the agreement and prognostic value of achieving ScvO2 or LC goals in septic shock patients undergoing emergency department (ED)-based early resuscitation. Methods: This was a preplanned analysis of a multicenter ED randomized controlled trial of early sepsis resuscitation targeting three variables: central venous pressure, mean arterial pressure, and either ScvO2 or LC. Inclusion criteria included suspected infection, two or more systemic inflammation criteria, and either systolic blood pressure of 4 mmol/L. Both ScvO2 and LC were measured simultaneously. The ScvO2 goal was defined as ≥70%. Lactate was measured at enrollment and every 2 hours until the goal was reached or up to 6 hours. LC goal was defined as a decrease of ≥10% from initial measurement. The primary outcome was in-hospital mortality. Results: A total of 203 subjects were included, with an overall mortality of 19.7%. Achievement of the ScvO2 goal only was associated with a mortality rate of 41% (9/22), while achievement of the LC goal only was associated with a mortality rate of 8% (2/25; proportion difference = 33%; 95% confidence interval [CI] = 9% to 55%). No agreement was found between goal achievement (κ = –0.02), and exact test for matched pairs demonstrated no significant difference between discordant pairs (p = 0.78). Conclusions: No agreement was found between LC and ScvO2 goal achievement in early sepsis resuscitation. Achievement of a ScvO2≥ 70% without LC ≥ 10% was more strongly associated with mortality than achievement of LC ≥ 10% with failure to achieve ScvO2≥ 70%.

ACADEMIC EMERGENCY MEDICINE 2011; 18:483–487 © 2011 by the Society for Academic Emergency Medicine Abstract Background: Implementation of rapid response systems to identify deteriorating patients in the inpatient setting has demonstrated improved patient outcomes. A “trigger” system using vital sign abnormalities to initiate evaluation by physician was recently described as an effective rapid response method. Objectives: The objective was to evaluate the effect of a triage-based trigger system on the primary outcome of time to physician evaluation and the secondary outcomes of therapeutic intervention, antibiotics, and disposition in emergency department (ED) patients. Methods: A separate-samples pre- and postintervention study was conducted using retrospective chart review of outcomes in ED patients for three arbitrarily selected 5-day periods in 2007 (pretriggers) and 2008 (posttriggers). There were 2,165 and 2,212 charts in the pre- and posttriggers chart review, with 71 and 79 patients meeting trigger criteria. Trigger criteria used to identify patients at triage were: heart rate of 130 beats/min, respiratory rate of 30 breaths/min, systolic blood pressure of

ACADEMIC EMERGENCY MEDICINE 2011; 18:551–554 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Vitamin D is increasingly recognized as an important mediator of immune function and may have a preventive role in the pathogenesis of sepsis. We sought to evaluate the association between vitamin D status and sepsis severity and hypothesized that vitamin D insufficiency would be associated with increased sepsis severity. Methods: This was a pilot study of emergency department (ED) patients age ≥18 years evaluated for suspected infection at an urban, teaching hospital. The authors measured illness severity using the following assessments at baseline and 24 hours: 1) severe sepsis, defined as suspected infection plus two or more elements of systemic inflammatory response syndrome criteria and acute dysfunction of one or more organ systems; 2) Acute Physiology Age Chronic Health Evaluation (APACHE) II scores; and 3) Sepsis-related Organ Failure Assessment (SOFA) scores. Vitamin D insufficiency was defined as baseline serum 25-hydroxyvitamin D (25OHD) levels

Objectives: An important challenge faced by emergency physicians (EPs) is determining which patients should be admitted to an intensive care unit (ICU) and which can be safely admitted to a regular ward. Understanding risk factors leading to undertriage would be useful, but these factors are not well characterized. Methods: The authors performed a secondary analysis of two prospective, observational studies of patients admitted to the hospital with clinically suspected infection from an urban university emergency department (ED). Inclusion criteria were as follows: adult ED patient (age 18 years or older), ward admission, and suspected infection. The primary outcome was transfer to an ICU within 48 hours of admission. Using multiple logistic regression, independent predictors of early ICU transfer were identified, and the area under the curve for the model was calculated. Results: Of 5,365 subjects, 93 (1.7%) were transferred to an ICU within 48 hours. Independent predictors of ICU transfer included respiratory compromise (odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.4 to 4.3), congestive heart failure (CHF; OR = 2.2, 95% CI = 1.4 to 3.6), peripheral vascular disease (OR = 2.0, 95% CI = 1.1 to 3.7), systolic blood pressure (sBP) 90 beats/min (OR = 1.8, 95% CI = 1.1 to 2.8), and creatinine > 2.0 (OR = 1.8, 95% CI = 1.1 to 2.8). Cellulitis was associated with a lower likelihood of ICU transfer (OR = 0.33, 95% CI = 0.15 to 0.72). The area under the curve for the model was 0.73, showing moderate discriminatory ability. Conclusions: In this preliminary study, independent predictors of ICU transfer within 48 hours of admission were identified. While somewhat intuitive, physicians should consider these factors when determining patient disposition. ACADEMIC EMERGENCY MEDICINE 2010; 17:1080–1085 © 2010 by the Society for Academic Emergency Medicine

Objectives: The objective was to determine the incremental benefit of a shortness-of-breath (SOB) point-of-care biomarker panel on the diagnostic accuracy of emergency department (ED) patients presenting with dyspnea. Methods: Adult ED patients at 10 U.S. EDs with SOB were included. The physician’s estimates of the pretest clinical probability of heart failure (HF), acute myocardial infarction (MI), and pulmonary embolism (PE) were recorded using deciles (0%–100%). Blood samples were analyzed using a SOB point-of-care biomarker panel (troponin I, myoglobin, creatinine kinase-myocardial band isoenzyme [CK-MB], D-dimer, and B-type natriuretic peptide [BNP]). Thirty-day follow-up for MI, HF, and PE was performed. Data were analyzed using logistic regression and receiver operating characteristics (ROC) curve analysis. Results: Of 301 patients, the mean (±standard deviation [SD]) age was 61 (±18) years; 56% were female, 58% were white, and 38% were African American. Diagnoses included MI (n = 54), HF (n = 91), and PE (n = 16) in a total of 129 (43%) of the patients. High pretest clinical certainty (≥80%) identified 60 of these 129 (46.5%) cases. The SOB point-of-care biomarker panel identified 66 additional cases of MI (n = 24), HF (n = 31), and PE (n = 11). The overall adjusted sensitivity for any diagnosis was increased from 65% to 70% with the addition of the SOB point-of-care biomarker panel (difference = 5%, 95% CI = −1.1% to 11%) while specificity was increased from 82% to 83% (difference = 1%, 95% CI = −4% to 7%). The model containing pretest probability and the results of the SOB panel had an area under the curve (AUC) of 83.4% (95% CI = 78.4% to 88.5%), which was not significantly better than the AUC of 80.4% (95% CI = 75.1% to 85.7%) for clinical probability alone. Conclusions: The addition of the SOB panel of markers did not improve the AUC for diagnosing the combined set of clinical conditions. Using the disease-specific SOB biomarkers increased the sensitivity on a disease-by-disease basis; however, specificity was reduced.

Microcirculatory dysfunction is a critical element of the pathogenesis of severe sepsis and septic shock. In this Bench-to-Bedside review, we present: (1) the central role of the microcirculation in the pathophysiology of sepsis; (2) new translational research techniques of in vivo videomicroscopy for assessment of microcirculatory flow in human subjects; (3) clinical investigations that reported associations between microcirculatory dysfunction and outcome in septic patients; (4) the potential role of novel agents to "rescue" the microcirculation in sepsis; (5) current challenges facing this emerging field of clinical investigation; and (6) a framework for the design of future clinical trials aimed to determine the impact of novel agents on microcirculatory flow and organ failure in patients with sepsis. We specifically focus this review on the central role and vital importance of the nitric oxide molecule in maintaining microcirculatory homeostasis and patency, especially when the microcirculation sustains an insult (as with sepsis), and we present the scientific rationale for clinical trials of exogenous nitric oxide administration to treat microcirculatory dysfunction and augment microcirculatory blood flow in early sepsis therapy.

Research knowledge translation into clinical practice pathways is a complex process that is often time-consuming and resource-intensive. Recent evidence suggests that the use of early goal-directed therapy (EGDT) in the emergency department care of patients with severe sepsis and septic shock results in a substantial mortality benefit; however, EGDT is a time- and resource-intensive intervention. The feasibility with which institutions may translate EGDT from a research protocol into routine clinical care, among settings with varying resources, staff, and training, is largely unknown. The authors report the individual experiences of EGDT protocol development, as well as preimplementation and postimplementation experiences, at three institutions with different emergency department, intensive care unit, and hospital organization schemes.

Objectives: A patient's baseline health status may affect the ability to survive an acute illness. Emergency medicine research requires tools to adjust for confounders such as comorbid illnesses. The Charlson Comorbidity Index has been validated in many settings but not extensively in the emergency department (ED). The purpose of this study was to examine the utility of the Charlson Index as a predictor of one-year mortality in a population of ED patients with suspected infection. Methods: The comorbid illness components of the Charlson Index were prospectively abstracted from the medical records of adult (age older than 18 years) ED patients at risk for infection (indicated by the clinical decision to obtain a blood culture) and weighted. Charlson scores were grouped into four previously established indices: 0 points (none), 1–2 points (low), 3–4 points (moderate), and ≥5 points (high). The primary outcome was one-year mortality assessed using the National Death Index and medical records. Cox proportional-hazards ratios were calculated, adjusting for age, gender, and markers of 28-day in-hospital mortality. Results: Between February 1, 2000, and February 1, 2001, 3,102 unique patients (96% of eligible patients) were enrolled at an urban teaching hospital. Overall one-year mortality was 22% (667/3,102). Mortality rates increased with increasing Charlson scores: none, 7% (95% confidence interval [CI] = 5.4% to 8.5%); low, 22% (95% CI = 19% to 24%); moderate, 31% (95% CI = 27% to 35%); and high, 40% (95% CI = 36% to 44%). Controlling for age, gender, and factors associated with 28-day mortality, and using the “none” group as a reference group, the Charlson Index predicted mortality as follows: low, odds ratio of 2.0; moderate, odds ratio of 2.5; and high, odds ratio of 4.7. Conclusions: This study suggests that the Charlson Index predicts one-year mortality among ED patients with suspected infection.

Emergency medicine (EM) presents many cognitive, social, and systems challenges to practitioners. Coordination and communication under stress between and among individuals and teams representing a number of disciplines are critical for optimal care of the patient. The specialty is characterized by uncertainty, complexity, rapidly shifting priorities, a dependence on teamwork, and elements common to other risky domains such as perioperative medicine and aviation. High-fidelity simulators have had a long tradition in aviation, and in the past few years have begun to have a significant impact in anesthesiology. A national, multicenter research program to document the costs of teamwork failures in EM and provide a remedy in the form of an Emergency Team Coordination Course has developed to the point that high-fidelity medical simulators will be added to the hands-on training portion of the course. This paper describes an evolving collaborative effort by members of the Center for Medical Simulation, the Harvard Emergency Medicine Division, and the MedTeams program to design, demonstrate, and refine a high-fidelity EM simulation course to improve EM clinician performance, increase patient safety, and decrease liability. The main objectives of the paper are: 1) to present detailed specifications of tools and techniques for high-fidelity medical simulation; 2) to share the results of a proof-of-concept EM simulation workshop introducing multiple mannequin/ three-patient scenarios; and 3) to focus on teamwork applications. The authors hope to engage the EM community in a wide-ranging discussion and handson exploration of these methods.