Search

Objectives: Peripheral intravenous catheter (PIV) placement is a common, painful, and frequently difficult procedure in children. The VeinViewer is a device that delineates subcutaneous veins using near-infrared light and video technology. To the best of our knowledge, the benefit of this device for PIV placement in children in the emergency department (ED) has not been studied., Methods: The authors enrolled a prospective, randomized sample of children aged 0 to 17 years who required a nonemergent PIV in a tertiary care pediatric ED. Participants were randomized to standard PIV cannulation (SC) or PIV cannulation with the VeinViewer (VV). The primary outcome measure was time to PIV placement. Secondary outcome measures included number of PIV attempts and pain scores as reported by the child, parent or guardian, and nurse using a 100-mm visual analog scale (VAS)., Results: A total of 323 patients completed the study: 174 boys and 149 girls. Age, sex, and body mass index (BMI) were not different between groups. There were no differences in time to PIV placement, number of PIV attempts, or pain scores for the overall study group. However, a planned subgroup analysis of children age 0 to 2 years (n = 107) did yield significant results for the geometric mean time to place the PIV (121 seconds [VV] vs. 167 seconds [SC], p = 0.047) and for nurses' perception of pain (median VAS 34 [VV] vs. 46 [SC], p = 0.01)., Conclusions: While no results were significant for the overall study group, subgroup analysis of children age 0 to 2 years suggests that the VeinViewer may decrease the time to PIV placement., (© 2011 by the Society for Academic Emergency Medicine.)

Abstract Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. This article is the product of a breakout session from the 2009 Academic Emergency Medicine consensus conference entitled "Public Health in the ED: Screening, Surveillance, and Intervention" and serves to describe in detail aspects of performing emergency department (ED)-based public health research, while serving as a resource for current and future researchers. In doing so, the authors describe methodologic features of study design, participant selection and retention, and measurements and analyses pertinent to public health research. In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation., ((c) 2009 by the Society for Academic Emergency Medicine.)

Objectives: Video-based delivery of human immunodeficiency virus (HIV) pretest information might assist in streamlining HIV screening and testing efforts in the emergency department (ED). The objectives of this study were to determine if the video "Do you know about rapid HIV testing?" is an acceptable alternative to an in-person information session on rapid HIV pretest information, in regard to comprehension of rapid HIV pretest fundamentals, and to identify patients who might have difficulties in comprehending pretest information., Methods: This was a noninferiority trial of 574 participants in an ED opt-in rapid HIV screening program who were randomly assigned to receive identical pretest information from either an animated and live-action 9.5-minute video or an in-person information session. Pretest information comprehension was assessed using a questionnaire. The video would be accepted as not inferior to the in-person information session if the 95% confidence interval (CI) of the difference (Delta) in mean scores on the questionnaire between the two information groups was less than a 10% decrease in the in-person information session arm's mean score. Linear regression models were constructed to identify patients with lower mean scores based upon study arm assignment, demographic characteristics, and history of prior HIV testing., Results: The questionnaire mean scores were 20.1 (95% CI = 19.7 to 20.5) for the video arm and 20.8 (95% CI = 20.4 to 21.2) for the in-person information session arm. The difference in mean scores compared to the mean score for the in-person information session met the noninferiority criterion for this investigation (Delta = 0.68; 95% CI = 0.18 to 1.26). In a multivariable linear regression model, Blacks/African Americans, Hispanics, and those with Medicare and Medicaid insurance exhibited slightly lower mean scores, regardless of the pretest information delivery format. There was a strong relationship between fewer years of formal education and lower mean scores on the questionnaire. Age, gender, type of insurance, partner/marital status, and history of prior HIV testing were not predictive of scores on the questionnaire., Conclusions: In terms of patient comprehension of rapid HIV pretest information fundamentals, the video was an acceptable substitute to pretest information delivered by an HIV test counselor. Both the video and the in-person information session were less effective in providing pretest information for patients with fewer years of formal education.

Background: Depression is the most common psychiatric disorder among adolescents and is more prevalent among those seeking care in the emergency department (ED). However, adolescents are rarely screened for depressive symptoms in the pediatric emergency department (PED)., Objectives: To evaluate the sensitivity and specificity of one- and two-item screens for depressive symptoms compared to the 20-question Center for Epidemiologic Studies Depression Scale (CESD) among adolescents seeking care in a PED., Methods: This was a cross-sectional study of a convenience sample of adolescents 12-17 years old presenting to an urban PED with subcritical illness or injury. Participants completed three screening instruments: the two-question screen, the single-question screen, and the CESD., Results: A total of 321 patients were approached to enter the study, of whom 212 (66%) agreed to participate. Seventy-eight (37%) of the study participants screened positive for depression on the CESD using a cutoff score of >or=16. The two-question screen had a sensitivity of 78% (95% confidence interval [CI] = 73% to 84%) and specificity of 82% (95% CI = 77% to 87%) for depressive symptoms compared with the CESD. The single-question screen had a sensitivity of 56% (95% CI = 50% to 63%) and specificity of 93% (95% CI = 90% to 96%) compared with the CESD., Conclusions: The two-question screen is a sensitive and specific initial screen for depressive symptoms in adolescents being seen in the PED. This quick, simple instrument would be ideal for use in the busy PED setting and would allow clinicians to identify adolescents who require more extensive psychiatric evaluation.

Effective preventive and screening interventions have not been widely adopted in emergency departments (EDs). Barriers to knowledge translation of these initiatives include lack of knowledge of current evidence, perceived lack of efficacy, and resource availability. To address this challenge, the Academic Emergency Medicine 2007 Consensus Conference, "Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake," convened a public health focus group. The question this group addressed was "What are the unique contextual elements that need to be addressed to bring proven preventive and other public health initiatives into the ED setting?" Public health experts communicated via the Internet beforehand and at a breakout session during the conference to reach consensus on this topic, using published evidence and expert opinion. Recommendations include 1) to integrate proven public health interventions into the emergency medicine core curriculum, 2) to configure clinical information systems to facilitate public health interventions, and 3) to use ancillary ED personnel to enhance delivery of public health interventions and to obtain successful funding for these initiatives. Because additional research in this area is needed, a research agenda for this important topic was also developed. The ED provides medical care to a unique population, many with increased needs for preventive care. Because these individuals may have limited access to screening and preventive interventions, wider adoption of these initiatives may improve the health of this vulnerable population.

Objectives: To determine if respondents differed by their demography (age group, race or ethnicity, and insurance status) in their tendency to correctly answer knowledge-based questions when they were in an agree-disagree instead of a multiple-choice format., Methods: Women aged 18-55 years seeking treatment in the emergency department completed surveys of preventive health knowledge on three cancer screening tests (Pap smears, breast self-examinations, and mammograms) and two contraceptive measures (birth control pills and emergency contraception) that contained paired versions of questions in two different formats (agree-disagree format and multiple-choice format). Linear and ordinal regressions were used to determine demographic correlates of correctly answering the agree-disagree questions more often than the corresponding multiple-choice questions., Results: Of the 570 women included in this analysis, 64.6% were younger than 35 years, 62.1% were white, and 54.8% had private health care insurance. Older, white, and privately insured women demonstrated greater comprehension of all topics. Younger women, nonwhite women, and women without private health care insurance were more likely to respond to items correctly when they were in an agree-disagree format compared with a multiple-choice format., Conclusions: This study demonstrated that survey responses are influenced by the format of the questions, particularly in certain demographic groups. Policy makers and researchers might draw false conclusions about the baseline knowledge and need for education of patients, especially in these populations. The use of agree-disagree format questions in preventive health knowledge surveys should be avoided whenever possible.

Objectives: Emergency Medicine Patients' Access To Healthcare (EMPATH) was a cross-sectional, observational study conducted to identify the principal reasons why patients seek care in hospital emergency departments (EDs) in the United States., Methods: Twenty-eight U.S. hospitals, stratified by geographic region and hospital characteristics, participated in this study. Demographic, clinical, and insurance data were collected for a 24-hour period at each site, using chart reviews and a structured interview administered to all consenting adult patients seeking treatment during that period. Patients' reasons for presenting to the ED were assessed by their level of agreement (on a three-point Likert scale) with 21 carefully worded statements designed to capture a range of possible reasons for seeking care in the ED. Factor analysis was used to consolidate highly correlated responses and to identify the principal factors explaining patients' reasons for coming to the ED., Results: A total of 1,579 patient interviews and 2,004 chart reviews were obtained from a diverse sample that was 55.4% female, 58.3% white, 28.3% African American, 7.0% Hispanic, and 6.0% other ethnic groups. This exploratory analysis yielded five factors characterizing patients' principal reasons for seeking ED care, with medical necessity the most frequent, followed by ED preference, convenience, affordability, and limitations of insurance., Conclusions: Use of the ED is, for most people, an affirmative choice over other providers rather than a last resort; it is often a choice driven by lack of access to or dissatisfaction with other sources of care.

Objectives: Physicians and nurses in the emergency department rarely use topical anesthesia when starting intravenous (IV) lines because of time constraints and lack of data on patients' perception of the pain associated with this procedure. Ultrasound pretreatment of skin increases permeation rates of hydrophobic topical medications, including topical lidocaine. The objective of this study was to demonstrate that ultrasound treatment followed by brief application of topical anesthetic decreases the patients' perception of the pain of IV cannulation., Methods: This was a randomized, controlled, prospective trial performed in a university hospital emergency department. Eighty-seven consecutive English-speaking, subcritically injured or ill adult patients able to give consent who were receiving an IV line as part of their care were enrolled. The intervention was a brief ultrasound treatment using the SonoPrep (Sontra Medical Corp., Franklin, MA) therapeutic ultrasound device (frequency, 53-56 kHz) followed by 5 minutes of 4% liposomal lidocaine cream and standard-care IV cannulation, or standard care alone. Participants rated their pain on a visual analog scale. Researchers assessed the site after IV insertion and 20-36 hours later. The primary outcome was participants' subjective pain score, and the secondary outcome was site skin irritation., Results: The ultrasound group reported significantly less pain (p<0.001), with 80% of treated participants reporting pain scores

Many published clinical trials have less than adequate follow-up. When conducting a clinical trial, researchers attempt to minimize data loss; however, some data may not be collected, particularly when subjects are lost to follow-up. Careful planning of research protocols, including comprehensive initial data collection, identification of locators, flexible scheduling, systematic subject tracking, monitoring subject loss, and systematically approaching problem cases can ensure high follow-up rates. This article presents a compendium of techniques and procedures that researchers can use to enhance follow-up and address attrition in their studies. Finally, this article outlines statistical techniques that can be used to address the effects of missing data, particularly when patients are lost to follow-up.

Objectives: To determine rates of alcohol and tobacco use among independent elder emergency department (ED) patients and assess the extent of health care use of this population., Methods: A convenience sample of independent elders (age > or =65 years) in an urban academic ED was enrolled. Patients were excluded if they were medically unstable or had a change in mental status. The Fagerstrom Test for Nicotine Dependence, and the Alcohol Use Disorders Identification Test (AUDIT) scales were used to measure tobacco and alcohol use. Subjects completed questionnaires about their health and use of the health care system. Data were analyzed by using t-tests to compare independent variables., Results: A total of 565 subjects completed the study. Of these, 296 (52.4%) were male and 269 (47.6%) were female; mean age was 77.1 years. Fifty-four (9.5%) were smokers, and 22 (3.9%) were nicotine-dependent by the Fagerstrom test (Fagerstrom+). Alcohol use was reported at least once monthly by 176 (31.2%) and twice monthly by 76 (13.5%) patients; 12 (2.1%) were alcohol-dependent by the AUDIT scale (AUDIT+). Two (0.35%) were both Fagerstrom+ and AUDIT+. Fagerstrom+ subjects visited a physician less often than Fagerstrom- subjects (3.9 vs. 4.6 annual visits, p < 0.0009). AUDIT+ subjects visited a primary care physician less (3.3 vs. 4.2 annual visits, p < 0.007) or "any" physician less (3.9 vs. 4.6 annual visits, p < 0.01) than AUDIT- subjects. AUDIT+ and Fagerstrom+ subjects did not differ from AUDIT- and Fagerstrom- subjects in number of annual ED visits, self-reported general health, physical symptoms (except nervousness, p < 0.004), comorbid illnesses, hospital admissions, and injuries requiring treatment., Conclusions: Elder ED patients have low rates of nicotine and alcohol dependence. Nicotine- or alcohol-dependent elders use outpatient providers less often than nondependent elders but use EDs at the same rate and report similar health patterns.

Objectives: To determine the frequency and type of patient visits for blood or body fluid exposures to a large, urban emergency department (ED); to ascertain the frequency that human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP) was prescribed for these exposures; and to compare HIV PEP usage by patient group, occupation, and exposure type., Methods: Retrospective medical record review of ED patient visits (January 1, 1995, through June 30, 2001) extracted from two separate billing record computerized databases using 14 ICD-9 codes that defined blood or body fluid exposures., Results: Of the 1,436 visits, 22% were by health care workers (HCWs) and 78% by non-HCW adults, adolescents, or children. Sixty percent of the HCWs sustained needlestick or sharp injuries, 73% of non-HCW adults had human bites, and 81% of adolescents and children had sexual exposures. Nurses were the largest group of HCWs, whereas police, correction officers, and security guards were the largest group of non-HCWs exposed at work. HCWs and non-HCW adults who sustained nonsexual exposures were much more likely to present for an evaluation within 24 hours than adolescents or children who suffered sexual assault (p<0.001). HIV PEP was prescribed 143 times: 92 to HCWs and 51 to all other patients. HIV PEP was most often prescribed to HCWs sustaining needlestick injuries., Conclusions: The majority of patients were not HCWs, which attests to the need for national, nonoccupational blood or body fluid management guidelines. There may be particular groups who would benefit from educational campaigns informing them of the need for early-intervention, postexposure measures to prevent an HIV infection.

Objectives: The purpose of this paper is to better understand marijuana use among injured problem drinkers in the emergency department (ED). The specific objectives are: 1) to assess the prevalence of marijuana use; 2) to identify factors associated with marijuana use; 3) to determine whether prior injury is associated with marijuana use; and 4) to determine whether marijuana-using problem drinkers want to change behaviors., Methods: The authors conducted a post-hoc analysis on data obtained prospectively. Subjects had injury and problem drinking: either measurable alcohol level (blood alcohol concentration, BAC), report of drinking, or an Alcohol Use Disorders Identification Test (AUDIT) score of > or =8. The study was conducted on weekend nights; 3,776 injured ED patients were screened, 383 refused, 578 were enrolled, and 433 had complete data., Results: Of the 433 subjects, 48.3% reported using marijuana in the three months prior. Marijuana-using problem drinkers had more hazardous drinking, higher AUDIT scores (14.0 vs. 11.4, p < 0.001), and higher risk-taking scores (12.4 vs. 10.1, p < 0.001). More used other drugs (69.7% vs. 30.3%, p < 0.001). In regression analyses, marijuana use remained an independent predictor of prior injury (OR = 2.16, 95% CI = 1.25 to 3.75), particularly prior alcohol-related (OR = 2.26, 95% CI = 1.45 to 3.53) and motor-vehicle-related (OR = 1.69, 95% CI = 1.03 to 2.79) injury. Readiness-to-change scores were similar (4.14 vs. 4.22, p = 0.21) between users and nonusers., Conclusions: Marijuana use among injured problem drinkers is prevalent. Their risk of prior injury is increased. Counseling for alcohol and injury should address marijuana use.

Unlabelled: Smoking remains the leading preventable cause of morbidity and mortality in the United States. The efficacy of emergency department (ED)-based patient screening and counseling for smoking cessation is not currently known., Objectives: To perform a structured, systematic review of the medical literature to assess the efficacy of limited screening and counseling for tobacco use cessation among adults in the primary care and ED settings, and develop recommendations for emergency physicians based on these data., Methods: A two-person template-driven review of all English-language articles from Medline, the Cochrane Database, and two recent smoking cessation guidelines, with evidence graded according to the scheme of the U.S. Preventive Services Task Force (USPSTF), was performed. Recommendations were developed, and strength graded, based on this evidence., Results: Of 2,078 citations reviewed, 16 were selected for inclusion, based on their methodologic strength and relevance to emergency medicine. Routine physician screening and counseling may increase quit rates at 6-12 months from 3% (usual care) to 8-11%. Interventions include brief counseling (<3 minutes), possibly supplemented with self-help literature, nicotine replacement therapy (NRT), and follow-up telephone calls., Conclusions: Strong evidence exists, in the primary care setting, that smoking cessation screening and counseling are effective. Limited data exist for ED-based practice, but, based on the burden of disease, relative ease of intervention, and likely efficacy, routine screening of all patients for tobacco use and referral of smokers to primary care and cessation programs are recommended.