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Introduction “Delayed discharge” is defined as patients who remain hospitalised beyond the time of being fit for discharge after a decision of discharge has been made by the managing team. There is no standardised amount of time defining delayed discharge documented in the literature, and there is a lack of evidence about this topic in Egypt. This study is a quality improvement project aiming to identify the factors associated with discharge delays at a single centre in Egypt in order to address this issue. Methods A prospective observational study included all trauma patients admitted to a University Hospital in Egypt over two months. The time of the decision of discharge and actual discharge time were recorded by reviewing patients' medical records. The patients and their caregivers were asked to fill in a questionnaire about the reasons for delayed discharge. Potential reasons for the delayed discharge were classified into system-related, medical and family-related factors. Results The study included 498 patients with a median age of 41 years (9–72). The median time from discharge decision until actual discharge was 3 h. System-related factors were documented in 48.8% of cases, followed by medical factors (36.3%), and family-related factors (28.1%). When controlling for age, gender and injury severity score using a logistic regression analysis, longer time to discharge (≥3 h) showed a stronger association with medical factors [adjusted OR (95% CI) = 5.44 (2.73–10.85)] and family-related factors [adjusted OR (95% CI) = 7.94 (3.40–18.54)] compared to system-related factors [adjusted OR (95% CI) = 2.20 (1.12–4.29)]. Discussion Although system-related factors were more prevalent, medical and family-related factors appear to be associated with longer discharge delays compared to system-related factors.

Background The Kilimanjaro region has one of the highest levels of reported alcohol intake per capita in Tanzania. Age at first drink has been found to be associated with alcohol problems in adulthood, but there is less information on the age of first drink in the Kilimanjaro region and its associations with alcohol-related consequences later in life. Furthermore, local alcohol cost and availability may influence the prevalence of alcohol use and alcohol use disorders. Method Data on the age of first drink, alcohol use disorder identification tool (AUDIT), number and type of alcohol consequences (DrInC), and perceived alcohol at low cost and high availability for children and adolescents were collected from an alcohol and health behavior survey of injury patients (N = 242) in Moshi, Tanzania. Generalized linear models were used to test age at first drink, perceived alcohol cost and availability, and their association with the AUDIT and DrInC scores, and current alcohol use, respectively. Results Consuming alcohol before age 18 was significantly associated with higher AUDIT and DrInC scores, with odds ratios of 1.22 (CI: 1.004, 1.47) and 1.72 (CI: 1.11, 2.63), respectively. Female gender is strongly associated with less alcohol use and alcohol consequences, represented by an odds ratio of 3.70 (CI: 1.72, 8.33) for an AUDIT score above 8 and an odds ratio of 3.84 (CI: 2.13, 6.67) with the DrInC score. Perceived high availability of alcohol for children is significantly related to higher alcohol use quantity, with the odds ratio of 1.6 (CI: 1.17, 2.20). Conclusions The first use of alcohol before the age of 18 is associated with higher alcohol use and alcohol-related adverse consequences. In Tanzania, age at first drink is an important target for interventions aiming to prevent negative alcohol-related consequences later in life.

This clinical policy from the American College of Emergency Physicians addresses key issues in opioid management in adult patients presenting to the emergency department. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? (2) In adult patients experiencing an acute painful condition, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (3) In adult patients with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (4) In adult patients with an acute episode of pain being discharged from the emergency department, do the harms of a short concomitant course of opioids and muscle relaxants/sedative-hypnotics outweigh the benefits? Evidence was graded and recommendations were made based on the strength of the available data.

Introduction: Despite agreement in the literature that “stable” blunt trauma patients may be managed conservatively, in Egypt many such patients receive operative management. This paper presents the results of a pragmatic, prospective, observational study to evaluate outcomes of non-operative (NOP) versus operative (OP) management of blunt abdominal solid organ trauma in hemodynamically stable adults admitted to Tanta University Emergency Hospital (TUH) in Egypt. Methods: A prospective observational study enrolled adult blunt abdominal trauma patients with solid organ injury at TUH over a 3-year period (June 2014–June 2017). Inclusion criteria were age ≥18 yr, mean arterial pressure >65 mm Hg, heart rate

IntroductionTrauma centre capacity and surge volume may affect decisions on where to transport a critically injured patient and whether to bypass the closest facility. Our hypothesis was that overcrowding and high patient acuity would contribute to increase the mortality risk for incoming admissions.MethodsFor a 6-year period, we merged and cross-correlated our institutional trauma registry with a database on Trauma Resuscitation Unit (TRU) patient admissions, movement and discharges, with average capacity of 12 trauma bays. The outcomes of overall hospital and 24 hours mortality for new trauma admissions (NEW) were assessed by multivariate logistic regression.ResultsThere were 42 003 (mean=7000/year) admissions having complete data sets, with 36 354 (87%) patients who were primary trauma admissions, age ≥18 and survival ≥15 min. In the logistic regression model for the entire cohort, NEW admission hospital mortality was only associated with NEW admission age and prehospital Glasgow Coma Scale (GCS) and Shock Index (SI) (all p1 hour) with SI ≥0.9, recent admissions (TRU ≤1 hour) with age ≥65, NEW admission age and prehospital GCS and SI (all pConclusionThe mortality of incoming patients is not impacted by routine trauma centre overcapacity. In conditions of severe overcrowding, the number of admitted patients with shock physiology and a recent surge of elderly/debilitated patients may influence the mortality risk of a new trauma admission.

Background Childhood injuries are a significant and growing global public health problem, often with high morbidity and, at times, mortality. A large proportion of injuries in preschool children occur in or around the home. We aimed to identify socioeconomic and demographic factors associated with preschool children injuries in Egypt. Methods Secondary data analysis were done for the Egyptian Demographic and Health Surveys (EDHS), 2014. Potential associated factors were measured from data on child welfare and questions on the prevalence of accidents and injuries of preschool children. These data were linked to the children demographic data, maternal age at marriage, working status of the mother, and questions on childcare arrangements. Results Out of the 634 injured children, 520 (83.4%) children required medical care for their injuries. The most common reported injury was an open wound 288 (45.5%), followed by fractures 237 (35.7%), burns 124 (19.7%), electrical shock 12 (1.9%) and other unknown types of injury 15 (2.4%). There was a positive correlation between injury and child’s age, household wealth, mother’s age at marriage, and unsupervised children or children left in the care of a minor. Conclusion Leaving children unsupervised or in the presence of other young children is significantly associated with the occurrence of child injuries.

Background Voodoo is a heterogeneous mixture of psychoactive substances that has recently grown in popularity among youth in Egypt. Patients can present with a variety of manifestations that may lead to death in some cases. This study assessed the acute toxic effects of voodoo among patients presented to the Poison Control Center of Ain Shams University Hospitals (PCC-ASUH) during a one year period. Methods This is a retrospective study of all patients presented with voodoo intoxication at the PCC-ASUH from 1 January 2017 to 31 December 2017. Clinical data, routine laboratory findings, and ECG results as well as duration of hospitalization and outcome were compiled from hospital records. Results Seventy-one voodoo intoxication cases meeting the inclusion criteria were analyzed (mean age: 25.19 ± 9.54 years, range: 15–50 years, 97.2 % male). Pulse, blood pressure, and respiratory rate were normal in more than half of all patients. Neurological abnormalities including agitation, hallucinations, disturbance of consciousness were the most frequent manifestations. Respiratory acidosis was the most common laboratory finding (54.9 %), followed by increased serum urea (43.6 %), hypokalemia (33.8 %), hyperglycemia (28.1 %), and leukocytosis (26.7 %). The most common ECG finding was sinus tachycardia (31 %), followed by QT prolongation (15.4 %). More than half of the studied patients (53.5 %) co-administered other illicit substances, most frequently cannabis and tramadol. Most patients recovered fully and were discharged, but death occurred in two cases. Conclusions Voodoo toxicity can manifest with many presentations, hampering timely diagnosis. Clinicians should consider possible voodoo poisoning in patients presenting with a history of drug use with neurological symptoms, and they should conduct follow-up arterial blood gases, electrolytes and ECG as voodoo may contain potentially fatal psychoactive substances.

Author(s): Ren, Ai; Golden, Bruce; Alt, Frank; Wasil, Edward; Bjarnadottir, Margret; Hirshon, Jon Mark; Pimentel, Laura | Abstract: Introduction: On January 1, 2014, the State of Maryland implemented the Global Budget Revenue (GBR) program. We investigate the impact of GBR on length of stay (LOS) for inpatients in emergency departments (ED) in Maryland.Methods: We used the Hospital Compare data reports from the Centers for Medicare and Medicaid Services (CMS) and CMS Cost Reports Hospital Form 2552-10 from January 1, 2012–March 31, 2016, with GBR hospitals from Maryland and hospitals from West Virginia (WV), Delaware (DE), and Rhode Island (RI). We implemented difference-in-differences analysis and investigated the impact of GBR implementation on the LOS or ED1b scores of Maryland hospitals using a mixed-effects model with a state-level fixed effect, a hospital-level random effect, and state-level heterogeneity.Results: The GBR impact estimator was 9.47 (95% confidence interval [CI], 7.06 to 11.87, p-valuel0.001) for Maryland GBR hospitals, which implies, on average, that GBR implementation added 9.47 minutes per year to the time that hospital inpatients spent in the ED in the first two years after GBR implementation. The effect of the total number of hospital beds was 0.21 (95% CI, 0.089 to 0.330, p-value = 0 .001), which suggests that the bigger the hospital, the longer the ED1b score. The state-level fixed effects for WV were -106.96 (95% CI, -175.06 to -38.86, p-value = 0.002), for DE it was 6.51 (95% CI, -8.80 to 21.82, p-value=0.405), and for RI it was -54.48 (95% CI, -82.85 to -26.10, p-valuel0.001).Conclusion: Our results indicate that GBR implementation has had a statistically significant negative impact on the efficiency measure ED1b of Maryland hospital EDs from January 2014 to April 2016. We also found that the significant state-level fixed effect implies that the same inpatient might experience different ED processing times in each of the four states that we studied. [West J Emerg Med.

Egypt has one of the highest traffic crash rates in the world. This study aims to investigate the correlates with driving behaviors and road traffic crashes (RTCs) among professional and nonprofessional drivers in South Egypt. A total of 518 drivers (203 professional and 315 nonprofessional) were interviewed and their sociodemographic characteristics, driving habits, and RTC involvement during the preceding 2 years were documented. The Arabic version of the Driver Behavior Questionnaire (DBQ) was used to assess drivers' lapses, errors, and violations. The results showed that professional drivers had more lapses (OR 3.03, 95% CI 1.54-5.96), errors (OR 2.88, 95% CI 1.44-5.76), and violations (OR 2.04, 95% CI 1.05-3.97) compared to nonprofessional drivers and female drivers were more likely to lapse than males (OR 3.18, 95% CI 1.79-5.66). RTC involvement was associated with female sex (OR 3.27, 95% CI 1.56-6.86), age30 years (OR 2.31, 95% CI 1.20-4.44), illiteracy (OR 1.51, 95% CI 1.02-2.23), eating while driving (OR 2.41, 95% CI 1.43-4.06), and not using seatbelt (OR 1.89, 95% CI 1.06-3.37). Driving lapses, errors, and violations did not significantly increase the risk of RTCs.

Background When intravenous access cannot be established using traditional methods of inspection/palpation, advanced methods are often required, leading to substantial delays in care. Knowing the likelihood of intravenous access failure can improve emergency department (ED) efficiency. Objective Our aim was to validate prior need for an advanced technique to establish intravenous access as a predictor of failure to achieve access via traditional methods and to estimate the risk difference associated with this finding. Methods We re-analyzed data collected for a clinical trial that randomized ED patients requiring intravenous access to one of two types of intravenous catheter; gauge size was selected by the inserter. The re-analysis pools data from both groups to examine predictors of failure to establish intravenous access by traditional methods, with failure defined as abandonment or use of an advanced technique (ultrasound guidance or external jugular vein catheterization). Confidence intervals for the difference between proportions were calculated using a normal binomial approximation. Results We obtained data from 600 patients, with a median age of 52 years (interquartile range 36–63 years). We noted failure of traditional methods in 28 (4.7%) patients, including 17 of 109 (16%) with prior need for advanced techniques. The risk difference for prior need for advanced techniques versus no prior difficulty was 14% (95% confidence interval 7–22). Conclusions Patients with a prior need for advanced techniques were 14% more likely to have failure of intravenous access by traditional methods than those without prior difficulty.

Author(s): Aledhaim, Ali; Walker, Anne; Vesselinov, Roumen; Hirshon, Jon Mark; Pimentel, Laura | Abstract: Introduction: Advanced practice providers (APP), including physicians’ assistants and nurse practitioners, have been increasingly incorporated into emergency department (ED) staffing over the past decade. There is scant literature examining resource utilization and the cost benefit of having APPs in the ED. The objectives of this study were to compare resource utilization in EDs that use APPs in their staffing model with those that do not and to estimate costs associated with the utilized resources.Methods: In this five-year retrospective secondary data analysis of the Emergency Department Benchmarking Alliance (EDBA), we compared resource utilization rates in EDs with and without APPs in non-academic EDs. Primary outcomes were hospital admission and use of computed tomography (CT), radiography, ultrasound, and magnetic resonance imaging (MRI). Costs were estimated using the 2014 physician fee schedule and inpatient payments from the Centers for Medicare and Medicaid Services. We measured outcomes as rates per 100 visits. Data were analyzed using a mixed linear model with repeated measures, adjusted for annual volume, patient acuity, and attending hours. We used the adjusted net difference to project utilization costs between the two groups per 1000 visits.Results: Of the 1054 EDs included in this study, 79% employed APPs. Relative to EDs without APPs, EDs staffing APPs had higher resource utilization rates (use per 100 visits): 3.0 more admissions (95% confidence interval [CI], 2.0–4.1), 1.7 more CTs (95% CI, 0.2–3.1), 4.5 more radiographs (95% CI, 2.2–6.9), and 1.0 more ultrasound (95% CI, 0.3–1.7) but comparable MRI use 0.1 (95% CI, -0.2–0.3). Projected costs of these differences varied among the resource utilized. Compared to EDs without APPs, EDs with APPs were estimated to have 30.4 more admissions per 1000 visits, which could accrue $414,717 in utilization costs.Conclusion: EDs staffing APPs were associated with modest increases in resource utilization as measured by admissions and imaging studies.

BackgroundHarmful alcohol use is a leading risk factor for injury-related death and disability in low- and middle-income countries (LMICs). Brief negotiational interventions (BNIs) administered in emergency departments (EDs) to injury patients with alcohol use disorders (AUDs) are effective in reducing post-hospital alcohol intake and re-injury rates. However, most BNIs to date have been developed and implemented in high-income countries. The efficacy of BNIs in LMICs is largely unknown as few studies have undertaken the rigorous task of culturally adapting these interventions to new settings. Given the high prevalence of alcohol-related injury in the Kilimanjaro region of Tanzania, we culturally adapted a BNI to reduce post-injury alcohol use for implementation in this patient population.MethodsWe used an iterative, multiphase process to culturally adapt a high-income country standard of care BNI to the Tanzanian setting using the Intervention Mapping ADAPT framework. Our team consisted of local healthcare professionals with extensive experience in counseling patients who use alcohol, as well as an international team of academic and clinical professionals. Focus groups were used to inform culturally appropriate changes to the standard of care BNI protocol. Objective assessment of BNI delivery was performed to ensure adherence to the FRAMES model of motivational interviewing.ResultsWe developed the Punguza Pombe Kwa Afya Yako (PPKAY); a one-time, 15-minute nurse-led BNI that encourages safe alcohol use and motivates change in alcohol use behaviors among injury patients in the Kilimanjaro region of Tanzania. Adaptations to the original intervention protocol include changes regarding the interventionist, how a patient is greeted, how the topic of alcohol use is raised, how a patient is informed of their harmful alcohol use, how graphics are visualized within the intervention protocol, how behavior change is motivated, and which behavior changes are encouraged.ConclusionsThe PPKAY intervention is the first BNI to be culturally adapted for delivery to injury patients in an LMIC population. Our study demonstrates a unique approach to adapting substance use interventions for use in LMICs, and shows that cultural adaptation of alcohol use interventions is feasible even in settings where community knowledge regarding harmful alcohol use is limited. Our study prompts the need for further research and cultural adaptation of BNIs for other low-income communities at increased risk of alcohol-related harm.

IntroductionTrauma deaths account for 8% of all deaths in Egypt. Patients with multiple injuries are at high risk but may be saved with a good triage system and a well-trained trauma team in dedicated institutions. The incidence of missed injuries in the Emergency Department (ED) of Suez Canal University Hospital (SCUH) was found to be 9.0% after applying Advanced Trauma Life Support (ATLS) guidelines. However, this rate is still high compared with many trauma centers.AimImprove the quality of management of polytrauma patients by decreasing the incidence of missed injuries by implementing the Sequential Trauma Education Programs (STEPs) course in the ED at SCUH.MethodsThis interventional training study was conducted in the SCUH ED that adheres to CONSORT guidelines. The study was conducted during the 1-month precourse and for 6 months after the implementation of the STEPs course for ED physicians. Overall, 458 polytrauma patients were randomly selected, of which 45 were found to have missed injuries after applying the inclusion and exclusion criteria. We assessed the clinical relevance of these cases for missed injuries before and after the STEPs course.ResultsOverall, 45 patients were found to have missed injuries, of which 15 (12%) were pre-STEPs and 30 (9%) were post-STEPs course. The STEPs course significantly increased adherence to vital data recording, but the reduction of missed injuries (3.0%) was not statistically significant in relation to demographic and trauma findings. However, the decrease in missed injuries in the post-STEPs course group was an essential clinically significant finding.ConclusionSTEPs course implementation decreased the incidence of missed injuries in polytrauma patients. Thus, the STEPs course can be considered at the same level of other advanced trauma courses as a training skills program or possibly better in dealing with trauma patients. Repetition of this course by physicians should be mandatory to prevent more missed injuries. Therefore, the validation of STEPs course certification should be completed at least every 2 years to help decrease the number of missed injuries, especially in low-income countries and low-resource settings.Trial RegistrationProject manager for the Pan African Clinical Trial Registry (www.pactr.org) database has been accepted with the date of approval:18/11/2020. Current Controlled Trials number for the registry is PACTR202011853914203. Please note that the article state Retrospectively registered that my study adheres to CONSORT guidelines.

Background Cardiopulmonary resuscitation (CPR) is a fundamental skill that should be acquired by all medical community members. This study aims to evaluate the knowledge and attitudes of junior doctors and medical students towards CPR and CPR training at Beni-Suef University Hospital in Upper Egypt, a representative region with conditions common to LMIC settings. Participants and methods In this cross-sectional study, a total of 205 participants (60 junior doctors and 145 medical students) responded to a self-administered questionnaire assessing their knowledge regarding basic life support (BLS) and CPR techniques in neonates, children, and adults, in addition to attitudes towards the importance and necessity of CPR and CPR training. Results Of the 60 junior doctors that participated in the study, only 31.7% had adequate knowledge of CPR, but up to 95% reported positive attitudes towards CPR training. Among the 145 medical student participants, only 6.2% had adequate knowledge of CPR, while 91% reported positive attitudes towards training. Deficiencies in CPR knowledge were more apparent in questions related to CPR in children and neonates. Junior doctors and medical students with previous CPR training demonstrated significantly better CPR knowledge than their counterparts without prior training. A statistically significant positive correlation was detected between CPR knowledge and attitude towards CPR training among medical students (r = 0.41, p < 0.001). Conclusion The results of this study demonstrate suboptimal and inadequate CPR knowledge among junior doctors and medical students in a representative hospital in Upper Egypt. However, participants reported overwhelmingly positive attitudes and eagerness towards the implementation of CPR training. Further research needs to be done to establish CPR skill proficiency as well as to investigate barriers to CPR training, effectiveness of available programs, and the potential implementation of such a program in Egypt and other LMICs.

Introduction: Safe and efficient intravenous access is paramount to the practice of emergency medicine. We compared the first-stick success rates and blood spillage of two peripheral intravenous catheters in a busy urban emergency department. Methods: In this randomized controlled trial, we assigned emergency department patients requiring peripheral intravenous access to use of either a flash-tip catheter (SurFlash Plus, Terumo Medical Corporation, Somerset, New Jersey) or a widely used control catheter (Insyte Autoguard; Becton, Dickinson and Company, Franklin Lakes, New Jersey). We compared frequency of first-stick success and blood contamination between catheters using chi-squared analysis. Results: We enrolled 600 patients, randomizing 309 to the flash-tip catheter and 291 to the control catheter. The first-stick success rate of each device was 79%. Blood contamination, defined as spillage of blood on the patient’s skin, bedding, or the inserter, occurred in 8 of 309 cases (2.6%) with the flash-tip catheter versus 92 of 291 cases (31.6%) for the control catheter. Conclusion: The two catheters tested in this study had comparable rates of first-stick success, but the flash-tip catheter was associated with significantly less blood contamination during insertion attempts.

From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department: Thomas W. Lukens, MD, PhD, (Chair) Stephen J. Wolf, MD Jonathan A. Edlow, MD Samina Shahabuddin, MD Michael H. Allen, MD, (American Association for Emergency Psychiatry) Glenn W. Currier, MD, MPH, (American Association for Emergency Psychiatry) Andy S. Jagoda, MD, (Chair, Clinical Policies Committee)

Introduction On January 1, 2014, the financing and delivery of healthcare in the state of Maryland (MD) profoundly changed. The insurance provisions of the Patient Protection and Affordable Care Act (ACA) began implementation and a major revision of MD’s Medicare Waiver ushered in global budget revenue (GBR) structure for hospital reimbursement. Our objective is to analyze the impact of these policy changes on Emergency Department (ED) utilization, admission practices, insurance profiles, and professional revenue. We stratified our analysis by the socioeconomic status (SES) of the ED patient population. Methods Monthly mean data including patient volume, admission and observation percentages, payer mix, and professional revenue were collected from January 2013 through December 2015 from a convenience sample of 11 EDs in Maryland. Using regression models, we compared each of the variables 18 months after the policy changes and a six-month washout period to the year prior to ACA/GBR implementation. We included the median income of each ED’s patient population as an explanatory variable and stratified our results by SES. Results Our 11 EDs saw an annualized volume of 399,310 patient visits during the study period. This ranged from a mean of 41 daily visits in the lowest volume rural ED to 171 in the highest volume suburban ED. After ACA/GBR, ED volumes were unchanged (95% Confidence Interval (CI): (-1.58, 1.24), p=.817). Admission plus observation percentages decreased significantly by 1.9% from 17.2% to 15.3% (95% CI: (-2.47%, - 1.38%), p

After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT.The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups.Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P .0001) and 6 months (8.8; P .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups.Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.

Background Egypt plays a pivotal role in North Africa and the Middle East, and has the largest population of any Arab country and serves as a regional cultural hub. Emergency medicine as a field of study was first initiated at Alexandria University in 1978, but it was only formally recognized as a medical specialty in 2002. Since then, the prehospital system and practice of emergency medicine has evolved and grown. Objectives This article will outline the development of emergency medicine in Egypt, including infrastructure, education, specialty certification, and future challenges, including those which are common to other specialties in development, and also those which are unique to Egypt. Discussion Opportunities remain with respect to the development of emergency medicine in Egypt, most notably in a continuing ‘brain drain’ of physicians who leave the country after receiving training, supervision, and oversight of residency programs, and general public and professional awareness of this new specialty. Conclusion Egypt has made great strides with respect to the delivery of emergency services, physician education and certification within the specialty of emergency medicine. Learning about these developments in Egypt will provide the reader with a compelling example of how an emergency system is developed in an advancing national setting.

Objective The primary objective of this study is to better understand the preferences of the general public regarding cardiopulmonary resuscitation (CPR) education as it relates to both format and the time and place of delivery. Methods Survey data were collected from a convenience sample at large public gatherings in Baltimore, Maryland, between May 23, 2015, and February 11, 2017. The survey was a 23-item single-page instrument administered at fairs and festivals. Results A total of 516 surveys were available for analysis. Twenty-four percent of the total population reported being very confident in performing CPR (scoring 8 to 10 on a Likert scale). Thirty-two percent of respondents who had previously taken a CPR class reported being very confident in performing CPR. A stepwise decline in reported confidence in performing CPR was observed as the time from last CPR class increased. Among all respondents the most favored instruction style was an instructor-led class. Least favorable was a local learning station at an event. The most favored location for instruction were libraries, while community festivals were least favored. Conclusion Respondent preferences regarding the location and style of the training differed little between socioeconomic groups. Instructor-led instruction at local libraries was the most preferred option. CPR education offered at local learning stations during events and at community festivals were least favored among respondents. This study’s findings can be used to more effectively structure CPR outreach and educational programs in an attempt to increase rates of bystander CPR.

Road traffic injuries are a leading killer of youth (aged 15-29) and are projected to be the 7th leading cause of death by 2030. To better understand road traffic crash locations and characteristics in the city of Baltimore, we used police and census data, to describe the epidemiology, hotspots, and modifiable risk factors involved to guide further interventions.Data on all crashes in Baltimore City from 2009 to 2013 were made available from the Maryland Automated Accident Reporting System. Socioeconomic data collected by the US CENSUS 2010 were obtained. A time series analysis was conducted using an ARIMA model. We analyzed the geographical distribution of traffic crashes and hotspots using exploratory spatial data analysis and spatial autocorrelation. Spatial regression was performed to evaluate the impact of socioeconomic indicators on hotspots.In Baltimore City, between 2009 and 2013, there were a total of 100,110 crashes reported, with 1% of crashes considered severe. Of all crashes, 7% involved vulnerable road users and 12% had elderly or youth involvement. Reasons for crashes included: distracted driving (31%), speeding (6%), and alcohol or drug use (5%). After 2010, we observed an increasing trend in all crashes especially from March to June. Distracted driving then youth and elderly drivers were consistently the highest risk factors over time. Multivariate spatial regression model including socioeconomic indicators and controlling for age, gender and population size did not show a distinct predictor of crashes explaining only 20% of the road crash variability, indicating crashes are not geographically explained by socioeconomic indicators alone.In Baltimore City, road traffic crashes occurred predominantly in the high density center of the city, involved distracted driving and extremes of age with an increase in crashes from March to June. There was no association between socioeconomic variables where crashes occurred and hotspots. In depth analysis of how modifiable risk factors are impacted by geospatial characteristics and the built environment is warranted in Baltimore to tailor interventions.

Zika virus is an arbovirus of the Flaviviridae family. It is primarily a minimally symptomatic mosquito-borne infection. However, with Zika's 2015 to 2016 introduction into the Western Hemisphere and its dramatic and rapid spread, it has become a public health concern, in large part due to congenital abnormalities associated with infection in pregnant women. In early 2016, the World Health Organization declared the microcephaly and other neurologic conditions associated with Zika virus infection a public health emergency of international concern. This article discusses the current epidemiologic and clinical understanding of Zika virus, focusing on critical information needed by emergency providers.

Objective The objective of the study is to examine the effect of the opening of a freestanding emergency department (FED) on the surrounding emergency medical services (EMS) system through an examination of EMS system metrics such as ambulance call volume, ambulance response times, and turnaround times. Methods This study is based on data from the county's computer-aided dispatch center, the FED, and the Maryland Health Services Cost Review Commission. The analysis involved a pre/post design, with a 6-month washout period. The preintervention period was April to October 2010, and the postintervention period was April to October 2011. Data were analyzed using standard t tests. Results The average daily number of EMS-related calls received in the computer-aided dispatch center was lower after the FED opened (16.3 [95% confidence interval {CI}, 15.7-16.9] vs 15.8 [95% CI, 14.9-16.9]). One-fourth of all patients were transported by ambulance to the FED after it opened. Use of the FED and adjacent hospitals increased by 8647 visits (15.8%) during the study period. Turnaround time for the county's ALS units decreased from 26.8 (95% CI, 26.2-27.5) to 25.1 (95% CI, 24.3-25.8) minutes. The ambulance out-of-service interval decreased from 87.3 (95% CI, 86.0-88.5) to 81.1 (95% CI, 79.7-82.4) minutes. Based on change in out-of-service this study had a small effect size (Cohen's d = 0.33). Conclusions The opening of an FED was associated with a modest improvement in time-specific EMS system metrics: a decrease in ambulance turnaround time and shorter out-of-service intervals.

ObjectiveUsing the example of surveys conducted by the American College of Emergency Physicians (ACEP) regarding the management of Ebola cases in the United States, we aimed to demonstrate how survey-based information networks can provide timely data to inform best practices in responding to public health emergencies.MethodsACEP conducted 3 surveys among its members in October to November 2014 to assess the state of Ebola preparedness in emergency departments. We analyzed the surveys to illustrate the types of information that can be gleaned from such surveys. We analyzed qualitative data through theme extraction and collected quantitative results through cross-tabulations and logistic regression examining associations between outcomes and potential contributing factors.ResultsIn the first survey, most respondents perceived their hospital as being reasonably prepared for Ebola. The second survey revealed significant associations between a hospital’s preparedness and its perceived ability to admit Ebola patients. The third survey identified 3 hospital characteristics that were significantly and independently associated with perceived ability to admit Ebola patients: large size, previous Ebola screening experience, and physician- and nurse-led hospital preparedness.ConclusionProfessional associations can use their member networks to collect timely survey data to inform best practices during and immediately after public health emergencies. (Disaster Med Public Health Preparedness. 2016;10:681–690)

The percentage of patients leaving before treatment is completed (LBTC) is an important indicator of emergency department performance. The objective of this study is to identify characteristics of hospital operations that correlate with LBTC rates.The Emergency Department Benchmarking Alliance 2012 and 2013 cross-sectional national data sets were analyzed using multiple regression and k-means clustering. Significant operational variables affecting LBTC including annual patient volume, percentage of high-acuity patients, percentage of patients admitted to the hospital, number of beds, academic status, waiting times to see a physician, length of stay (LOS), registered nurse (RN) staffing, and physician staffing were identified. LBTC was regressed onto these variables. Because of the strong correlation between waiting times measured as door to first provider (DTFP), we regressed DTFP onto the remaining predictors. Cluster analysis was applied to the data sets to further analyze the impact of individual predictors on LBTC and DTFP.LOS and the time from DTFP were both strongly associated with LBTC rate (P.001). Patient volume is not significantly associated with LBTC rate (P=.16). Cluster analysis demonstrates that physician and RN staffing ratios correlate with shorter DTFP and lower LBTC.Volume is not the main driver of LBTC. DTFP and LOS are much more strongly associated. We show that operational factors including LOS and physician and RN staffing decisions, factors under the control of hospital and physician executives, correlate with waiting time and, thus, in determining the LBTC rate.

Trauma records in Egyptian hospitals are widely suspected to be inadequate for developing a practical and useful trauma registry, which is critical for informing both primary and secondary prevention. We reviewed archived paper records of trauma patients admitted to the Beni-Suef University Hospital in Upper Egypt for completeness in four domains: demographic data including contact information, administrative data tracking patients from admission to discharge, clinical data including vital signs and Glasgow Coma Scale scores, and data describing the causal traumatic event (mechanism of injury, activity at the time of injury, and location/setting). The majority of the 539 medical records included in the study had significant deficiencies in the four reviewed domains. Overall, 74.3% of demographic fields, 66.5% of administrative fields, 55.0% of clinical fields, and just 19.9% of fields detailing the causal event were found to be completed. Critically, oxygen saturation, arrival time, and contact information were reported in only 7.6%, 25.8%, and 43.6% of the records, respectively. Less than a fourth of the records provided any details about the cause of trauma. Accordingly, the current, paper-based medical record system at Beni-Suef University Hospital is insufficient for the development of a practical trauma registry. More efforts are needed to develop efficient and comprehensive documentation of trauma data in order to inform and improve patient care.

The traditional model of emergency care no longer fits the growing needs of the over 20 million older adults annually seeking emergency department care. In 2007 a tailored “geriatric emergency department” model was introduced and rapidly replicated among hospitals, rising steeply over the past 5 years. This survey examined all U.S. emergency departments self-identifying themselves as Geriatric Emergency Departments (GEDs) and providing enhanced geriatric emergency care services. It was guided by the recently adopted Geriatric Emergency Department Guidelines and examined domains including, GED identity, staffing, and administration; education, equipment, and supplies; policies, procedures, and protocols; follow-up and transitions of care; and quality improvement. Results reveal a heterogeneous mix of GED staffing, procedures, physical environments and that GEDs’ familiarity with the GED Guidelines is low. Findings will inform emergency departments and gerontologists nationwide about key GED model elements and will help hospitals to improve ED services for their older adult patients.

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

OBJECTIVES Pediatric care is increasingly regionalized, increasing rates of interfacility transport (IFT). However, it is unknown what conditions most frequently require IFT. This study's objective was to identify high-frequency pediatric conditions requiring IFT. METHODS This is a statewide retrospective observational study from 2010 to 2012 of pediatric patients (

Prehospital triage of the seriously injured patient is fraught with challenges, and trauma scoring systems in current triage guidelines warrant further investigation. The primary objective of this study was to assess the correlation of the physiologically based Revised Trauma Score (RTS) and MGAP score (mechanism of injury, Glasgow Coma Scale, age, blood pressure) with the anatomically based Injury Severity Score (ISS). The secondary objectives for this study were to compare the accuracy of the MGAP score and the RTS for the prediction of in-hospital mortality for trauma patients.This study was a retrospective cohort including 10 years of patient data in a large single-center trauma registry at a primary adult resource center (Level I) for trauma patients. Participants included adults (age ≥18 years). The primary outcome measure was injury severity (measured by ISS) and a secondary analysis compared the RTS and MGAP for the prediction of patient mortality. Descriptive statistics were used to describe the cohort and correlation methods were employed. Each score's accuracy for the prediction of mortality was calculated using the area under receiver operating characteristic (AUROC) curves.In total, 43,082 trauma patient records were reviewed; 32,798 patients had complete RTS data available and 32,371 patients had complete data available for MGAP analyses. The correlation between scene RTS and ISS was poor (-.29), as was the correlation between MGAP and ISS (-.28). For the prediction of mortality, admission MGAP demonstrated the highest sensitivity and specificity for mortality (AUROC 0.96; 95% CI, 0.95-0.96).While elements of the RTS remain the first criterion recommended to quantify the totality of physiological injury severity, the composite RTS score derived from this system correlates poorly with actual anatomical injury severity. The MGAP scoring system demonstrated higher sensitivity and specificity for mortality but was not superior to the RTS for predicting anatomical injury severity. In the future development of national and international field triage guidelines for trauma patients, the findings from this study may be considered in order to improve the accuracy of prehospital triage. The findings in this analysis complement a growing body of evidence that suggests that MGAP may be a superior and more easily calculable prehospital scoring system for the prediction of mortality in trauma patients.

BACKGROUND: Lactate clearance has been developed into a marker of resuscitation in trauma, but no study has compared the predictive power of the various clearance calculations. Our objective was to determine which method of calculating lactate clearance best predicted 24-hour and in-hospital mortality after injury. STUDY DESIGN: Retrospective chart review of patients admitted to a Level-1 trauma center directly from the scene of injury from 2010 to 2013 who survived >E15 min, had an elevated lactate at admission (≥3 mmol/L), followed by another measurement within 24 h of admission. Lactate clearance was calculated using five models: actual value of the repeat level, absolute clearance, relative clearance, absolute rate, and relative rate. Models were compared using the areas under the respective receiver operating curves (AUCs), with an endpoint of death at 24 h and in-hospital mortality. RESULTS: 3910 patients had an elevated admission lactate concentration on admission (mean = 5.6 ± 3.0 mmol/L) followed by a second measurement (2.7 ± 1.8 mmol/L). Repeat absolute measurement best predicted 24-hour (AUC = 0.85, 95% CI: 0.84–0.86) and in-hospital death (AUC = 0.77; 95% CI, 0.76–0.78). Relative clearance was the best model of lactate clearance (AUC = 0.77, 95% CI: 0.75–0.78 and AUC = 0.705, 95% CI: 0.69–72, respectively) (p < 0.0001 for each). A sensitivity analysis using a range of initial lactate measures yielded similar results. CONCLUSIONS: The absolute value of the repeat lactate measurement had the greatest ability to predict mortality in injured patients undergoing resuscitation.

Purpose Sirolimus has purported advantages in lung transplant maintenance therapy, such as anti-fibrotic, anti-proliferative, and anti-aging effects, which may help improve survival. Methods Among U.S. lung transplant recipients from 2003-2016 in the United Network for Organ Sharing (UNOS) dataset, we compared sirolimus [SIR] (n=219) to mycophenolate mofetil [MMF] (n=5482), within a tacrolimus-based regimen. The SIR group consisted of patients on SIR within 1 year post-transplant, since prophylactic SIR initiation is usually delayed by up to 1 year to avoid the risk of bronchial anastomotic dehiscence and other complications. Due to the delayed initiation of SIR, this study was restricted to patients alive at 1 year in both groups, to prevent immortal time bias. All patients in both groups were free of bronchiolitis obliterans syndrome and malignancy at 1 year, to exclude these common rescue uses of SIR. We also assessed survival for SIR and MMF after subdividing by whether or not patients received induction therapy (with basiliximab, daclizumab, antithymocyte globulin, or alemtuzumab). Survival comparisons were based on Kaplan-Meier estimates and Cox multivariable regression utilizing multiple imputation to handle missing data. Results SIR had better survival than MMF: median (MS) 8.9 vs 7.1 yr.; adjusted Hazard Ratio (HR)=0.71, p=0.003. When subdividing by whether patients received induction, SIR with no induction had the best survival (MS=10.7 yr.; HR=0.48, p=0.002), followed by SIR with induction (MS=7.9 yr.; HR=0.90, p=0.45), MMF with induction (MS=7.4 yr.; reference group), and MMF with no induction (MS=6.8 yr.; HR=1.15, p=0.01). Conclusion Sirolimus, initiated within 1 year after lung transplantation in a tacrolimus-based regimen, may improve survival compared to MMF. National data representing the U.S. lung transplant population suggest that sirolimus + tacrolimus maintenance with no induction therapy is associated with a median survival of approximately 10 years.

INTRODUCTION: We describe how geographic information systems (GIS) can be used to assess and compare estimated transport time for helicopter and ground emergency medical services. Recent research shows that while the odds of a trauma patient's survival increase with helicopter emergency medical services (HEMS), they may not increase to the extent necessary to make HEMS cost effective. This study offers an analytic tool to objectively quantify the patient travel time advantage that HEMS offers compared to ground emergency medical services (GEMS). METHODS: Using helicopter dispatch data from the Maryland State Police from 2000-2011, we computed transport time estimates for HEMS and GEMS, compare these results to a reference transport time of 60 min, and use geospatial interpolation to extrapolate the total response times for each mode across the study region. RESULTS: Mapping the region's trauma incidents and modeling response times, our findings indicate the GIS framework for calculating transportation time tradeoffs is useful in identifying which areas can be better served by HEMS or GEMS. DISCUSSION: The use of GIS and the analytical methodology described in this study present a method to compare transportation by air and ground in the prehospital setting that accounts for how mode, distance, and road infrastructure impact total transport time. Whether used to generate regional maps in advance or applied real-time, the presented framework provides a tool to identify earlier incident locations that favor HEMS over GEMS transport modes. Widener MJ, Ginsberg Z, Schleith D, Floccare DJ, Hirshon JM, Galvagno S. Ground and helicopter emergency medical services time tradeoffs assessed with geographic information. Aerosp Med Hum Perform. 2015; 86(7):620-627. Language: en

Introduction As one of the leading causes of death and disability in the world, human trauma and injury disproportionately affects individuals in developing countries. To meet the need for improved trauma care in Egypt, the Sequential Trauma Emergency/Education ProgramS (STEPS) course was created through the collaborative effort of U.S. and Egyptian physicians. The objective of course development was to create a high-quality, modular, adaptable, and sustainable trauma care course that could be readily adopted by a lower- or middle-income country. Methods We describe the development, transition, and host nation sustainability of a trauma care training course between a high-income Western nation and a lower-middle-income Middle Eastern/Northern African country, including the number of physicians trained and the challenges to program development and sustainability. Results STEPS was developed at the University of Maryland, based in part on World Health Organization’s Emergency and Trauma Care materials, and introduced to the Egyptian Ministry of Health and Population and Ain Shams University in May 2006. To date, 639 physicians from multiple specialties have taken the 4-day course through the Ministry of Health and Population or public/governmental universities. In 2008, the course transitioned completely to the leadership of Egyptian academic physicians. Multiple Egyptian medical schools and the Egyptian Emergency Medicine Board now require STEPS or its equivalent for physicians in training. Conclusions Success of this collaborative educational program is demonstrated by the numbers of physicians trained, the adoption of STEPS by the Egyptian Emergency Medicine Board, and program continuance after transitioning to in-country leadership and trainers.

Objective This study’s primary objective was to investigate the prevalence of physical and chemical restraint use in selected elderly hospitalized patients. Results This study was conducted in April 2014 in four major acute care hospitals. Trained data collectors assessed the use of physical and chemical restraint among all admitted elderly patients. There were 287 elderly patients (median age 64 years, 46% women). 32 patients were restrained. The overall prevalence of restraints was 11.1%, with physical restraint use alone at 3.2% and chemical restraints use alone at 7.3%. Restraint use varied by hospital type, with the highest at the private hospital (22.9%) and the lowest at the two university hospitals (

Annually, alcohol causes 3.3 million deaths; countless more alcohol-related injury patients are treated in emergency departments (EDs) worldwide. Studies show that alcohol-related injury patients reduce their at-risk alcohol-use behavior with a brief negotiational interview (BNI) in the ED. This project aims to identify potential perceived barriers to implementing a BNI in Tanzania. A knowledge, attitude, and practice questionnaire was piloted and administered to all emergency department health care practitioners, including physicians, advanced medical officers, and nurses. The questionnaire included the Perceived Alcohol Stigma (PAS) Scale. The survey was self-administered in English, the language of health care instruction, with a Swahili translation available if preferred. Data were analyzed with relative and absolute frequencies and Spearman's correlation. Thirty-four (100%) health care practitioners completed the survey. Our results found positive attitudes toward addressing alcohol misuse (88%), but very poor knowledge of recommended alcohol-use limits (24%). Participants were willing to discuss alcohol use (88%) and to screen (71%) for alcohol-use disorders. Most health care practitioners report significant stigma against those with alcohol-use disorders (39% discrimination, 53% devaluation, 71% either). Counseling patients about high-risk alcohol use was directly and positively associated with at-risk alcohol and counseling education and believing it was common to ask patients about tobacco and alcohol use; it was negatively associated with believing it was 'not my role' or that knowing about alcohol use 'won't make a difference'. Stigma was negatively and indirectly associated with counseling patients. In conclusion, in an ED in Tanzania, health care practitioners have positive attitudes toward addressing at-risk alcohol use, and endorsed having training in alcohol misuse in school. Unfortunately, participants did not demonstrate knowledge of recommended alcohol limit guidelines. Similarly, among practitioners, there is a significant discrimination and devaluation stigma against those who misuse alcohol. These factors must be addressed prior to a successful implementation of an alcohol harm reduction intervention.

Older adults have sought treatment in emergency departments (EDs) since their inception, however, increasing numbers of older adult ED patients present unique challenges to EDs. This research examines the emergence of dedicated U.S. geriatric emergency departments (GEDs) and related models of ED care between 2007–2015. Survey data was collected from N=53 U.S. hospitals out of a total of N=82 hospitals identified as promoting their geriatric emergency medical services. Analysis reveals substantial heterogeneity in the organization and provision of care. Annual openings of new GEDs reached N=15 in 2013 with fewer than half that number opening in any other year. Over 85% of setting used the term “senior” in their title in contrast to “geriatric”. Most GEDs did not allocate dedicated GED space (56%), however, the majority (>80%) made modifications to bedding, flooring, lighting, and clinical procedures in a portion of the ED. Respondents noted challenges in GED staffing, training & education, availability of validated screening tools, and sustained support of the hospital administration. Overall, the care of acutely ill older patients remains in flux. Current ED settings make specific modifications based on local needs and resources in the absence of strong incentives to adopt recently released national geriatric emergency department guidelines and principles (2014).

BACKGROUND: Injury is an escalating public health problem, representing about 9% of global mortality, which disproportionately impacts lower- and middle-income countries. There are approximately 12,000 annual fatalities from road traffic injuries in Egypt, but little information about delays in seeking emergent care is available. OBJECTIVES: To measure the time interval between sustaining an injury and presentation to the emergency department of Ain Shams University Surgery Hospital and to identify possible causes of these delays. METHODS: We conducted a cross sectional, facilitated survey of a convenience sample of trauma patients presenting to the emergency department of Ain Shams University Surgery Hospital from 1 February to 31 May 2014. Data obtained included: demographic information, trauma incident details and injury assessment. RESULTS: The average reported transport time for patients from injury to hospital arrival was 3.8 hours, while the mean ambulance response time was 45 minutes. Referral from other hospitals was revealed to be a significant cause of delay (P=0.004), while ignorance of the local ambulance phone number couldn’t be confirmed as a cause (P=0.2). CONCLUSION: This study demonstrated that trauma patients at our hospital experience more than three hours of delay until they reach the ED. It also identified the possible causes accounting for that delay. However, additional nationwide research is needed to establish the clear causation or association of these causes with the delay intervals.

Background.Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.Objective.To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.Design and Setting.Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.Methods.Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.Results.We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant (P = .32).Conclusions.Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

Background: In emergency departments (EDs), the implementation of electronic health records (EHRs) has the potential to impact the rapid assessment and management of life threatening conditions. In order to quantify this impact, we studied the implementation of EHRs in the EDs of a two hospital system. Methods: using a prospective pre–post study design, patient processing metrics were collected for each ED physician at two hospitals for 7 months prior and 10 months post-EHR implementation. Metrics included median patient workup time, median length of stay, and the composite outcome indicator "processing time." Results: median processing time increased immediately post-implementation and then returned to, and surpassed, the baseline level over 10 months. Overall, we see significant decreases in processing time as the number of patients treated increases. Conclusions: implementation of new EHRs into the ED setting can be expected to cause an initial decrease in efficiency. With adaptation, efficiency should return to baseline levels and may eventually surpass them. Implications: while EDs can expect long term gains from the implementation of EHRs, they should be prepared for initial decreases in efficiency and take preparatory measures to avert adverse effects on the quality of patient care.

BACKGROUND Little is known regarding the prevalence or risk factors for non-comprehension and non-compliance with discharge instructions among older adults.

Objectives: To quantify the risk of 30-day unplanned hospital readmission in adults aged 65 and older with depressive symptoms. Design: Prospective cohort study. Setting: University of Maryland Medical Center. Participants: Individuals aged 65 and older admitted between July 1, 2011, and August 9, 2012, to the general medical and surgical units and followed for 31 days after hospital discharge (N = 750). Measurements: Primary exposure was depressive symptoms at admission, defined as a score of 6 or more on the 15-item Geriatric Depression Scale. Primary outcome was unplanned 30-day hospital readmission, defined as an unscheduled overnight stay at any inpatient facility not occurring in the emergency department. Results: Prevalence of depressive symptoms was 19% and incidence of 30-day unplanned hospital readmission was 19%. Depressive symptoms were not significantly associated with hospital readmission (relative risk (RR) = 1.20, 95% confidence interval (CI) = 0.83�1.72). Age, Charlson Comorbidity Index score, and number of hospitalizations within the past 6 months were significant predictors of unplanned 30-day hospital readmission. Conclusion: Although not associated with hospital readmission, depressive symptoms were associated with other poor outcomes and may be underdiagnosed in hospitalized older adults. Hospitals interested in reducing readmission should focus on older adults with more comorbid illness and recent hospitalizations.

Key Points Question Which immunosuppressive strategy is associated with the highest survival in lung transplantation? Findings In this cohort study of US recipients of lung transplants, sirolimus plus tacrolimus was associated with significantly better conditional survival from 1 year after transplant compared with mycophenolate mofetil plus tacrolimus (median survival, 8.9 vs 7.1 years after transplant). The highest conditional survival was observed in patients receiving sirolimus plus tacrolimus with no induction therapy (median survival, 10.7 years), which was significantly better than survival for those receiving mycophenolate mofetil plus tacrolimus with induction therapy (median survival, 7.4 years). Meaning Sirolimus plus tacrolimus was associated with improved patient survival compared with mycophenolate mofetil plus tacrolimus, and using no induction therapy with sirolimus plus tacrolimus was associated with the highest survival., This cohort study compares survival of US recipients of lung transplants receiving sirolimus plus tacrolimus vs standard maintenance therapy and evaluates which combination of induction and maintenance therapy is associated with the highest survival., Importance Median survival after lung transplant is less than 6 years. Standard maintenance therapy typically includes tacrolimus and an antimetabolite (mycophenolate mofetil or azathioprine). Replacing the antimetabolite with sirolimus after postoperative wound healing may improve long-term survival due to antifibrotic, antiproliferative, and antiaging effects of sirolimus. Objectives To compare survival between patients receiving sirolimus plus tacrolimus vs mycophenolate mofetil plus tacrolimus (the most common maintenance therapy) and to identify the combination of induction and maintenance therapy associated with the highest survival. Design, Setting, and Participants This cohort study of US recipients of lung transplants from January 1, 2003, through August 31, 2016, analyzed United Network for Organ Sharing (UNOS) data from January 1 through September 13, 2018. Because initiation of sirolimus therapy is usually delayed 3 to 12 months after lung transplant, primary analyses were based on patients alive and free of chronic rejection and malignant disease at 1 year in all groups, whereas sensitivity analyses used appropriate methods to include all patients from transplant time. Regression models adjusted for available potential confounders, including transplant center performance. Exposures Cell cycle inhibitor maintenance therapies, including sirolimus (n = 219), mycophenolate mofetil (n = 5782), mycophenolate sodium (n = 408), azathioprine (n = 2556), and concurrent sirolimus plus mycophenolate mofetil (n = 54), were compared within a tacrolimus-based regimen. Combinations of each induction (basiliximab, daclizumab, antithymocyte globulin, alemtuzumab, or none) and maintenance (tacrolimus plus sirolimus, mycophenolate mofetil, or azathioprine) therapy were also compared. Main Outcomes and Measures Survival was the primary outcome; chronic rejection incidence and subsequent mortality were secondary outcomes. Results Among this population of 9019 patients (median age, 57 years [interquartile range {IQR}, 46-63 years]; 5194 men [57.6%]), sirolimus plus tacrolimus was associated with better survival than mycophenolate mofetil plus tacrolimus (median, 8.9 years [IQR, 4.4-12.7 years] vs 7.1 years [IQR, 3.6-12.1 years]; adjusted hazard ratio [aHR], 0.71; 95% CI, 0.56-0.89; P = .003). Chronic rejection incidence (aHR, 0.75; 95% CI, 0.61-0.92) and mortality after chronic rejection (aHR, 0.52; 95% CI, 0.31-0.81) were lower with sirolimus plus tacrolimus. Compared with mycophenolate mofetil plus tacrolimus, survival differences for sirolimus plus mycophenolate mofetil plus tacrolimus (aHR, 1.14; 95% CI, 0.79-1.65), mycophenolate sodium plus tacrolimus (aHR, 0.95; 95% CI, 0.77-1.17), and azathioprine plus tacrolimus (aHR, 0.93; 95% CI, 0.84-1.02) were not significant. The induction-maintenance combination with the highest survival was sirolimus plus tacrolimus without induction therapy (median survival, 10.7 years [IQR, 7.3-12.7 years]; aHR, 0.48; 95% CI, 0.31-0.76; P = .002) compared with mycophenolate mofetil plus tacrolimus with induction therapy (median survival, 7.4 years [IQR, 3.9-12.6 years]). Conclusions and Relevance Sirolimus plus tacrolimus was associated with improved patient survival after lung transplant compared with mycophenolate mofetil plus tacrolimus; no antibody induction therapy with sirolimus plus tacrolimus was associated with maximal survival.

The residency teaching model is often cited as a source of inefficiency in the healthcare system. We build a simulation model of an Emergency Department (ED) at a large urban academic hospital. Using historical data and a natural experiment involving residents in the ED, we show that residents in fact increase throughput and lower service and waiting times compared to not being there at all.

The residency teaching model is often cited as a possible source of inefficiency in hospitals. In this paper, we examine data from patients in the emergency department at the University of Maryland Medical Center. We compare treatment times from when residents were present to when they were absent, due to weekly research seminars. We show that residents lower treatment times and help increase emergency department efficiency.