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Background: Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians.Methods: Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa.Results: A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified.Conclusion: Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters. [ABSTRACT FROM AUTHOR]

Emergency nurses experience multiple traumatizing events during clinical work. Early identification of work-related tension could lead to a timely intervention supporting well-being. We sought to discover whether there is an immediately measurable effect on emotional stress, as determined by changes between pre- and postshift survey scores, associated with exposure to traumatizing events during a single emergency nursing shift. The Emotional Stress Reaction Questionnaire (ESRQ) is a real-time self-assessment tool based on positively, negatively, or neutrally loaded emotions. Participants voluntarily completed pre- and postshift ESRQs over a 6-month period at a quaternary academic emergency department and recorded the number of associated traumatizing events. Associations between number of traumatizing events and ESRQ scores were evaluated using Spearman rank correlation coefficients. Changes in positive-negative balance scores were compared between shifts using a 2-sample t -test. There were 203 responses by 94 nurses. The mean preshift ESRQ score was 11.3 (SD = 5.2), mean postshift score 6.8 (SD = 7.4), and mean change −4.4 (SD = 8.2; t = −7.26; P < 0.001). The total number of traumatizing events was correlated with change in ESRQ scores (correlation coefficient of −0.31; P < 0.001). The mean change in positive-negative scores for shifts without traumatizing events was −1.4 (SD = 6.0) compared with −5.0 (SD = 8.5) for shifts with at least 1 event (t = 2.27; P = 0.03). Our results suggest that repeated exposure to traumatizing events during a single clinical shift was associated with a measurable effect on negative emotional stress in emergency nurses as determined by ESRQ positive-negative balance scores. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The study aimed to determine the diagnostic usefulness of the genital Gram stain in an emergency department (ED) population. Methods: A linked-query of an urban, tertiary-care, university- affiliated hospital laboratory database was conducted for all completed Chlamydia trachomatis and Neisseria gonorrhoeae DNA probes, Trichomonas vaginalis wet preps, and genital Gram stains performed on ED patient visits between January and December 2004. Positive criteria for a Gram stain included greater than 10 white blood cells per high-power field, gram-negative intracellular/extracellular diplococci (suggesting N gonorrhoeae), clue cells (suggesting T vaginalis), or direct visualization of T vaginalis organisms. DNA probes were used as the gold standard definition for N gonorrhoeae and C trachomatis infection. Results: Of 1511 initially eligible ED visits, 941 were analyzed (genital Gram stain and DNA probe results both present), with a prevalence of either C trachomatis or N gonorrhoeae of 11.4%. A positive genital Gram stain was 75.7% sensitive and 43.3% specific in diagnosing either C trachomatis and/or N gonorrhoeae infection, and 80.4% sensitive and 32.2% specific when the positive cutoff was lowered to more than 5 white blood cells/high-power field. No Gram stains were positive for T vaginalis (with 47 positive wet mounts), and clue cells were noted on 117 Gram stains (11.6%). Conclusion: Gram stains in isolation lack sufficient diagnostic ability to detect either C trachomatis or N gonorrhoeae infection in the ED. [Copyright &y& Elsevier]

Abstract: Background: Spontaneous retroperitoneal hematoma (SRH) can be fatal, requiring immediate recognition and intervention. Current literature is limited, providing little direction in patient care. Objective: To describe clinical characteristics of patients with SRH during an 8-year period. Methods: Observational cohort study of all consecutive patients 18 years and older with SRH from January 2000 to December 2007. SRH was defined as unrelated to invasive procedures, surgery, trauma, or abdominal aortic aneurysm. Results: Of 346 patients screened, 89 were eligible. Median age was 72 years; 56.2% were male. Overall, 66.3% were anticoagulated: 41.6% on warfarin, 30.3% heparin, and 11.2% low-molecular-weight heparin; 30.3% were on antiplatelet therapy; 16.5% were taking both anticoagulant and antiplatelet medications; 15.3% were taking neither. Primary presentation to the Emergency Department was seen in 36%; 64% developed SRH during inpatient anticoagulation therapy. The most common symptom was pain: abdominal (67.5%), leg (23.8%), hip (22.5%), and back (21.3%); 10.1% were misdiagnosed upon their initial encounter. Computed tomography (CT) was performed in 98.8%, ultrasound in 22.1%, and magnetic resonance imaging in 3.5%. Of all subjects, 40.4% were managed in an intensive care unit; 24.7% underwent interventional radiology (IR) procedures and 6.7% surgical evacuation; 75.3% received blood transfusion. Mortality was 5.6% within 7 days, 10.1% within 30 days, and 19.1% within 6 months. Conclusions: SRH is uncommon but potentially lethal, with a non-specific presentation that can lead to misdiagnosis. One-third of the cohort was not taking anticoagulants. CT was effective at identification. Most patients received aggressive management with transfusion or IR procedures. [Copyright &y& Elsevier]

Background: Drug-related problems (DRPs) are common among patients seen in the emergency department (ED), but the true incidence is not clear.Objectives: The primary objective of this study was to determine the prevalence of DRPs among patients seen in a U.S. ED. The secondary objective was to categorize these DRPs by problem type and by medication class.Methods: This was a prospective observational cohort study of a random sample of ED patients between December 2011 and March 2013. ED pharmacists screened randomly selected patients for the presence of a DRP contributing to the ED visit. Four independent auditors evaluated the results to achieve consensus for the presence or absence of DRPs and categorization of the DRPs.Results: Among 1039 patients screened for DRPs, 308 (29.6%) were found to have at least 1 DRP contributing to the ED visit. Among a total of 443 DRPs, the most commonly identified categories were adverse drug reaction (n = 193 [43.6%]), ineffective medication (n = 69 [15.6%]), and subtherapeutic dosage (n = 68 [15.3%]). The most commonly implicated drug classes were cardiovascular medications (n = 113 [26.5%]), anti-infective medications (n = 52 [12.2%]), and analgesic medications (n = 58 [13.6%]).Conclusions: A substantial proportion of ED visits are associated in part or in total with DRPs. Adverse drug reactions and cardiovascular medications are the most common category and medication class implicated, respectively. [ABSTRACT FROM AUTHOR]