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The physical and emotional stress of pregnancy can precipitate new-onset seizures in a woman. In these cases, emergency department evaluations must rule out underlying pathology. Careful consideration of antiepileptic drug use must be considered in the first trimester as all antiepileptic drugs have been linked to some teratogenic effect. Eclampsia must always be considered in the pregnant woman who is more than 20 weeks gestation; 25% of eclamptic seizures occur in the postpartum period. Magnesium is the recommended treatment for eclamptic seizures when delivery is not possible. more...

Background— American College of Cardiology/American Heart Association guidelines recommend a door-to-balloon time (DTB) Methods and Results— The Mayo Clinic STEMI protocol was implemented in April 2004 and included activation of the cardiac catheterization laboratory by the emergency medicine physician; a single call system to activate the catheterization laboratory; catheterization laboratory staff arrival within 20 to 30 minutes of activation; and real-time performance feedback within 24 to 48 hours. Data were collected on nontransferred STEMI patients. The preimplementation group (June 2002 to March 2004) comprised 96 patients with a median DTB of 97 (interquartile range, 82, 130) minutes, and 40% had a DTB P P =0.41). Conclusions— The Mayo Clinic STEMI protocol implemented strategies to reduce DTB for nontransferred patients with STEMI. DTB was significantly reduced, and the results were sustained over the 4-year follow-up period. Our experience demonstrates the effectiveness and durability of process changes targeting timeliness of primary percutaneous coronary intervention. more...

Objective: To assess stroke awareness among patients presenting to the emergency department with an acute ischaemic stroke or transient ischaemic attack (TIA). Methods: A consecutive cohort of patients presenting with a cerebrovascular event was prospectively enrolled over a 15-month period and questionnaires were administered. If the patient was unable to respond to the questions or answer the questionnaire, it was administered to the primary caregiver. Comprehension of having a cerebrovascular event, reason for delay in presentation, mode of arrival and knowledge of treatment modalities were determined. Results: Only 42% of 400 patients thought they were having a stroke or TIA. The median time to presentation was 3.4 h. Delayed presentation was almost equal in men and women. When asked about onset, 19.4% thought that a stroke came on gradually and only 51.9% thought immediate presentation was crucial. 20.8% of patients had heard of thrombolysis. Conclusion: Community knowledge of ischaemic stroke needs to be enhanced so that individuals present earlier, leading to timely management. more...

Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in the Neurosciences Intensive Care Unit. In this study, we sought to validate the use of FOUR score in the emergency department (ED) using non-neurology staff. We also compared its performance to the Glasgow Coma Scale (GCS) and correlated it to functional outcome at hospital discharge and overall survival.We prospectively rated 69 patients with initial neurologic symptoms presenting to the ED. Three types of examiners performed the FOUR score: ED physician, ED resident, and ED nurse. Patients were followed through hospital discharge; functional outcome was measured using modified Rankin Score (mRS).Interrater reliability for FOUR score and GCS was excellent (respectively, kappa(w) = 0.88 and 0.86). Both FOUR score and GCS predicted functional outcome, and overall survival with and without adjustment for age, sex, and alertness group.The FOUR score can be reliably used in the ED by non-neurology staff. Both FOUR score and GCS performed equally well, but the neurologic detail incorporated in the FOUR score makes it more useful in management and triage of patients. more...

To evaluate the association of diastolic blood pressure (dBP), systolic blood pressure (sBP), and mean arterial pressure (MAP) in the emergency department (ED) with mortality within 90 days in patients with acute ischemic stroke (AIS).This observational study was conducted at an ED with an annual census of 70,000 visits, with approximately 500 for AIS. The cohort consisted of 357 patients who presented to the ED within 24 hours of stroke symptom onset. sBP and dBP were measured at triage by a nurse blinded to the study. The duration of follow-up was limited to the first 90 days following ED presentation. BP levels were categorized as low, normotensive, and high after examining scatter plots of a patient's risk of death adjusted for duration of follow-up vs dBP, sBP, and MAP. These BP categories were evaluated using indicator variables in Cox proportional hazards models, after adjusting for age, sex, and the National Institute of Health Stroke Scale (NIHSS) score.Patients with low BP (dBP70, sBP155, or MAP100 mm Hg) were significantly more likely to die within 90 days than those with BP in the normotensive range (dBP 70 to 105, sBP 155 to 220, MAP 100 to 140 mm Hg). These associations were significant even after adjusting for age, gender, and NIHSS score.There appears to be an optimal acute BP range below which early mortality is greater following AIS, suggesting avoidance of hypotension in the first 24 hours. more...

As the marketplace for academic positions in emergency medicine grows more competitive, it becomes increasingly important for residents who desire academic careers to distinguish themselves during their residency. This report attempts to outline a road map for department and residency program leaders to help their houseofficers become successful candidates for an academic emergency medicine position. Specific ways a resident can enhance his or her "academic marketability" include 1) involvement in research, 2) establishment of a track record of productivity via scholarly writing, 3) awareness of the literature in the specialty, 4) involvement in specialty organizations and hospital committees, 5) competition for national awards, 6) gaining education skills, 7) developing an academic niche, and 8) fellowship training. more...

Objectives: To date, no studies in emergency medicine (EM) have addressed the educational value of the Residency Review Committee for Emergency Medicine's (RRC-EM) requirement for patient follow-up (FU). The authors examined whether performance of patient FU improved EM resident education. Methods: All EM resident FU encounters from September 25, 2001, through September 24, 2002, were documented and analyzed. All EM residents at a regional tertiary referral emergency department (ED) initiated patient FU encounters by entering information regarding patients' initial ED presentations into a Web-based follow-up system (WBFUS), subsequently entered FU information, and indicated whether they thought that the specific FU encounters improved their education (yes/no). Supervising faculty members then reviewed the residents' completed FU entries. Blinded to residents' responses regarding educational utility, faculty members evaluated whether they thought the specific FU encounters were educational for the residents (yes/no). Data entered into the WBFUS were then summarized as percentages. Results: Eight hundred forty-seven FU encounters were completed by 18 EM residents and 29 EM faculty. Ninety-three percent of the FU entries were deemed by at least one evaluator (resident or faculty) to have educational value. Residents found the act of performing FU educational in 81.3% of cases, whereas faculty thought 80.4% were educational for the resident. Although the residents and faculty agreed on the educational value in 75.4% of cases, the overall strength of the agreement was slight to fair (kappa statistic = 0.21). Conclusions: This study indicates that EM residents and faculty believe that the act of performing patient FU has educational value for EM residents; however, the interobserver agreement between residents and faculty was low. more...

Objective: To determine whether changes in graduate medical education (GME) funding have had an impact on emergency medicine (EM) residency training programs. Methods: A 34-question survey was mailed to the program directors (PDs) of all 115 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs in the United States in the fall of 1998, requesting information concerning the impact of changes in GME funding on various aspects of the EM training. The results were then compared with a similar unpublished survey conducted in the fall of 1996. Results: One hundred one completed surveys were returned (88% response rate). Seventy-one (70%) of the responding EM residency programs were PGY-I through PGY-III, compared with 55 (61%) of the responding programs in 1996. The number of PGY-II through PGY-IV programs decreased from 25 (28%) of responding programs in 1996 to 17 (16%). The number of PGY-I through PGY-IV programs increased slightly (13 vs 10); the number of EM residency positions remained relatively stable. Fifteen programs projected an increase in their number of training positions in the next two years, while only three predicted a decrease. Of the respondents, 56 programs reported reductions in non-EM residency positions and 35 programs reported elimination of fellowship positions at their institutions. Only four of these were EM fellowships. Forty-six respondents reported a reduction in the number of non-EM residents rotating through their EDs, and of these, 11 programs reported this had a moderate to significant effect on their ability to adequately staff the ED with resident physicians. Sixteen programs limited resident recruitment to only those eligible for the full three years of GME funding. Eighty-seven EM programs reported no change in faculty size due to funding issues. Sixty-two programs reported no change in the total number of hours of faculty coverage in the ED, while 34 programs reported an increase. Three EM programs reported recommendations being made to close their residency programs in the near future. Conclusions: Changes in GME funding have not caused a decrease in the number of existing EM residency and fellowship training positions, but may have had an impact in other areas, including: an increase in the number of EM programs structured in a PGY-I through PGY-III format (with a corresponding decrease in the number of PGY-II through PGY-IV programs); a decrease in the number of non-EM residents rotating through the ED; restriction of resident applicants who are ineligible for full GME funding from consideration by some EM training programs; and an increase in the total number of faculty clinical hours without an increase in faculty size. more...

This is a systematic review abstract, a regular feature of the Annals’ Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: Ciccone A, Abraha I, Santilli I. Glycoprotein IIb-IIIa inhibitors for acute ischaemic stroke. Cochrane Review 2006; Issue 4. Chichester, UK: John Wiley and Sons. DOI:10.1002/14651858.CD005208.pub2. The Annals’ EBEM editors helped prepare the abstract of this Cochrane systematic review, as well as the Evidence-Based Medicine Teaching Points. more...

This is a systematic review abstract, a regular feature of the Annals’ Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: Gubitz G, Counsell C, Sandercock P, Signorini D. Anticoagulants for acute ischaemic stroke (Cochrane Review). In: The Cochrane Library. Issue 3. Oxford, United Kingdom: Update Software; 2004. The Annals’ EBEM editors helped prepare the abstract of this Cochrane systematic review as well as the EvidenceBased Medicine Teaching Points. more...

E B E M / S Y S T E M A T I C R E V I E W A B S T R A C T J U L Y 2 0 0 3 4 2 : 1 A N N A L S O F E M E R G E N C Y M E D I C I N E 1 5 1 authors meant that the researchers made some sort of effort to exclude hemorrhagic stroke, although only 1 of the 7 trials included actually used computed tomography (CT) to make the distinction. D A T A E X T R A C T I O N Two authors independently selected trials, extracted data, and assessed the quality of the trials. Odds of death, functional outcome, and adverse effects were assessed with 95% confidence intervals (CIs). M A I N R E S U L T S A total of 22 trials were identified, of which 7 fulfilled the inclusion criteria (n=453 patients) and were included in this updated review. Two of the 7 studies used betamethasone, whereas the remainder used dexamethasone. Corticosteroid treatment was associated with very variable change in odds of death (95% CI 0.68 to 1.72). No meaningful analysis could be derived for functional outcome, because the studies did not use common neurologic impairment scales or common time intervals for assessment, making it impossible to pool data for analysis. Similarly, only 1 of the 7 studies reported adverse effects in a systematic manner, thereby precluding meta-analysis. Overall, adverse effects were infrequent and consisted of gastrointestinal bleeding, infection, and hyperglycemia. more...

Posterior reversible encephalopathy syndrome (PRES) can present with focal neurologic deficits, mimicking a stroke and can often represent a diagnostic challenge when presenting atypically. A high degree of suspicion is required in the clinical setting in order to yield the diagnosis. Cerebral CT perfusion (CTP) is utilized in many institutions as the first line in acute stroke imaging. CTP has proved to be a very sensitive measure of cerebral blood flow dynamics, most commonly employed to delineate the infarcted tissue from penumbra (at-risk tissue) in ischemic strokes. But abnormal CTP is also seen in stroke mimics such as seizures, hypoglycemia, tumors, migraines and PRES. In this article we describe a case of PRES in an elderly bone marrow transplant recipient who presented with focal neurological deficits concerning for a cerebrovascular accident. CTP played a pivotal role in the diagnosis and initiation of appropriate management. We also briefly discuss the pathophysiology of PRES. more...

A 63-year-old white woman with a history of hypertension, hyperlipidemia, hypothyroidism, and transient ischemic attack, on Premarin, presented with a 2-week history of worsening edema and pain on the left side of the lower extremity associated with purplish discoloration and decreased temperature after a prolonged car travel. Physical examination revealed 2+ edema from the midthigh to the toes associated with purpuric discoloration. All arterial pulses were 4+. Ultrasound examination demonstrated an acute deep vein thrombus extending from the external iliac veins down throughout the visualized veins of the left calf. The patient was started on intravenous heparin and underwent venogram with subsequent thrombolysis. After 48 hours of alteplase infusion, balloon angioplasty was performed and 2 stents were placed in the left common and external iliac veins. Premarin was discontinued and she remains on oral anticoagulation with Coumadin. The patient did well clinically and a second ultrasound showed interval improvement. There is significant family history but no personal history of thrombotic events; however, thrombophilia evaluation is unremarkable. more...

Study objective We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack. Methods This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days. Results The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days. Conclusion The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification. more...

Objective To evaluate the feasibility of a protocol for evaluation of transient ischemic attack (TIA) in an Emergency Department Observation Unit (EDOU), and assess the risk of early stroke after such an evaluation. Methods All adult patients presenting to the Emergency Department (ED) with signs and symptoms consistent with TIA were prospectively enrolled in this observational study over a period of 3 years. Patients underwent a standardized TIA evaluation per protocol. Risk of subsequent stroke at 48 h, 1 week, 1 month, and 3 months was prospectively assessed. Results In total, 418 patients were seen during the study period, and all were evaluated per the EDOU TIA protocol. The mean age was 73.1 (±13.3) years and 53.8% were males. Comorbidities included hypertension in 71.5%, diabetes mellitus in 20.1%, prior TIA in 19.6%, and prior ischemic stroke in 19.6% of the cohort. Brain CT, neurology consult, electrocardiogram, carotid ultrasound, and additional tests were performed, and education was given. A total of 30.4% of the patients were dismissed directly from the EDOU. The risk of stroke at 2 days was 0.96%, at 7 days 1.2%, at 30 days 1.9%, and 2.4% at 90 days. Conclusion An Emergency Department Observation Unit Protocol for TIA is a feasible option for expedited evaluation of these patients. more...

In this issue’s Clinical Research Capsule, we ask the fundamental question: “Why care about research?” Clinicians sometimes have a distanced attitude towards research. The reasons for this are many: conducting research is difficult; it is only for those who are statistically minded; it means having NIH or equivalent funding; finally, it does not pertain to them as research is separate from patient care. The notion that research is separate and without impact on patient care could not be more erroneous. Why care about clinical research?  Our practice is our laboratory  Some nuances of human disease not translatable from animal models (social admit reasons, “look sicker”, )  Clinical research allows us to continually refine patient care Let’s look at a few examples: You are evaluating a patient with an acute ankle injury. Do you recognize the following questions? more...

An emergency department (ED) observation unit protocol for the management of acute onset atrial fibrillation is compared with routine hospital admission and management.Adult patients presenting to the ED with atrial fibrillation of less than 48 hours' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled. Participants were randomized to either ED observation unit care or routine inpatient care. The ED observation unit protocol included pulse rate control, cardiac monitoring, reassessment, and electrical cardioversion if atrial fibrillation persisted. Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days, whereas those still in atrial fibrillation were admitted. All cases were followed up for 6 months and adverse events recorded.Of the 153 patients, 75 were randomized to the ED observation unit and 78 to routine inhospital care. Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73% in the routine care group (difference 12%; 95% confidence interval [CI] -1% to 25%]; P=.06). The median length of stay was 10.1 versus 25.2 hours (difference 15.1 hours; 95% CI 11.2 to 19.6; P.001) for ED observation unit and inhospital care respectively. Nine ED observation unit patients required inpatient admission. Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10% of the routine inpatient care group (difference 1%; 95% CI -9% to 11%; P=.93). There was no significant difference between the groups in the frequency of hospitalization or the number of tests, and the number of adverse events during follow-up was similar in the 2 groups.An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay. more...

Severely elevated blood pressure is a common clinical problem en-countered in the Emergency Department. It is often difficult for physicians to differentiate between patients who need emergent blood pressure reduction, requiring the use of intravenous agents and in-tensive monitoring, and those for whom careful, slow reduction in BP is more appropriate. The optimal assessment and management of these patients is reviewed here, with an emphasis on clinical strategies that will most efficiently identify those at greatest risk. more...

The treatment of acute ischemic stroke has evolved from observation and the passage of time dictating outcome to an approach that emphasizes time from ictus, rapid response, and a dedicated treatment team. We review the treatment of acute ischemic stroke from the prehospital setting, to the emergency department, to the inpatient hospital setting. We discuss the importance of prehospital assessment and treatment, including the use of elements of the neurologic examination, recognition of symptoms that can mimic those of acute ischemic stroke, and rapid transport of patients who are potential candidates for thrombolytic therapy to hospitals with that capability. Coordinated management of acute ischemic stroke in the emergency department is critical as well, beginning with non-contrast-enhanced computed tomography of the brain. The advantages of a multidisciplinary dedicated stroke team are discussed, as are thrombolytic therapy and other inpatient treatment options. Finally, we cover evolving management strategies, treatments, and tools that could improve patient outcomes. more...

Study objectives: Neuron-specific enolase (NSE) is a glycolytic enzyme that is found mainly in the cytoplasm of neurons and cells of neuroendocrine origin. To date, the majority of the work delineating the usefulness of NSE as a marker for acute ischemic stroke has been inconclusive and on a limited number of patients. We determine whether serum NSE correlates with time of onset of stroke symptoms, volume of infarct, stroke severity, functional outcome, or hospital length of stay. We determine whether serial NSE levels are useful as a marker for ongoing brain ischemia. We determine if NSE levels are significantly higher for patients with stroke compared with controls at various intervals. Methods: All abstracts and published full reports identified as potentially relevant by the literature search were independently assessed for inclusion in the review by each of the reviewers. This was a qualitative analysis. Results: Twelve studies satisfying the entry criteria were identified. Four studies examined time of onset of stroke symptoms versus earliest time NSE levels were detectable. NSE levels were found to be higher ranging from 4 to 8 hours postinfarct. Seven studies found increased NSE levels to be associated with increased size of stroke. Two studies found no correlation. Two studies examined stroke severity versus NSE levels. Higher NSE levels generally indicated worse outcome, but with low NSE levels, the results were equivocal. Seven of the 12 included studies examined functional outcome at discharge and follow-up versus NSE levels. Four of these 7 studies found no correlation between serum NSE and functional outcome. No correlation was found when using the Scandinavian Stroke Scale, Activities of Daily Living Scale, or the Glasgow Outcome Score. There was a correlation with Barthel index, modified Rankin Score at 90 days, admission and day 7 National Institutes of Health Stroke Scale, and a trend with the Lindley score. No trial correlated hospital length of stay with NSE levels without the confounding influence of increased volume of infarct leading to increased length of stay. Three studies found a relationship between NSE levels and time; however, 3 studies did not. Seven studies reported statistically significant differences between NSE levels in patients with stroke compared with control groups. One study reported that patients with total anterior cerebral strokes had statistically elevated levels of NSE compared with controls. However, patients with partial anterior cerebral stroke did not reach statistical significance with regard to NSE levels. Conclusion: Overall, according to the data for these 597 patients, it is possible to state that serum NSE level does in fact seem to be higher in stroke patients compared with controls and does appear to correlate with volume of infarct. However, it does not appear to correlate with functional outcome, and its relationship to stroke severity is unclear. more...

To date, no studies in emergency medicine (EM) have addressed the educational value of the Residency Review Committee for Emergency Medicine's (RRC-EM) requirement for patient follow-up (FU). The authors examined whether performance of patient FU improved EM resident education.All EM resident FU encounters from September 25, 2001, through September 24, 2002, were documented and analyzed. All EM residents at a regional tertiary referral emergency department (ED) initiated patient FU encounters by entering information regarding patients' initial ED presentations into a Web-based follow-up system (WBFUS), subsequently entered FU information, and indicated whether they thought that the specific FU encounters improved their education (yes/no). Supervising faculty members then reviewed the residents' completed FU entries. Blinded to residents' responses regarding educational utility, faculty members evaluated whether they thought the specific FU encounters were educational for the residents (yes/no). Data entered into the WBFUS were then summarized as percentages.Eight hundred forty-seven FU encounters were completed by 18 EM residents and 29 EM faculty. Ninety-three percent of the FU entries were deemed by at least one evaluator (resident or faculty) to have educational value. Residents found the act of performing FU educational in 81.3% of cases, whereas faculty thought 80.4% were educational for the resident. Although the residents and faculty agreed on the educational value in 75.4% of cases, the overall strength of the agreement was slight to fair (kappa statistic = 0.21).This study indicates that EM residents and faculty believe that the act of performing patient FU has educational value for EM residents; however, the interobserver agreement between residents and faculty was low. more...

PE is one of the great challenges in medicine. It is a disease that carries with it a high mortality rate, yet no historical piece of information, physical examination finding, or diagnostic modality is perfect at excluding its possibility. Emergency physicians must be vigilant about considering PE in the differential diagnosis of a variety of presenting complaints and must use a variety of diagnostic and therapeutic options as they manage patients with suspected or confirmed PE. The diagnostic options range from bedside diagnostic tests to highly specialized imaging available at only specialized institutions. Knowing the advantages and disadvantages of each of the diagnostic modalities assists the physician in employing the best test. Therapeutic options also vary widely and include anticoagulation, vena caval interruption, systemic thrombolysis, embolectomy, and other therapeutic adjuncts, such as ECMO and inhaled nitric oxide. Similarly, awareness of the indications and contraindications to the varied therapeutic agents ensures appropriate therapy when the diagnosis is made. more...

Objectives: To survey academic departments of emergency medicine (ADEMs) concerning their operation and clinical practice. Methods: A survey was mailed to the chairs of the 53 ADEMs in the United States established prior to 1999 (as listed on the Society for Academic Emergency Medicine website) requesting information on operations and clinical activity in budget year 1999–2000 compared with 1997–1998. These results were then compared with results of similar surveys conducted in the autumns of 1996 and 1998. Results: Forty-eight ADEMs (91%) responded. For 1999–2000, compared with 1997–1998, 38 ADEMs (79%) reported an increase in emergency department (ED) patient volume; five (10%) reported a decrease. Thirty-one (65%) ADEMs reported an increase in ED patient severity of illness, whereas only one (2%) reported a decrease. Thirty-two ADEMs (67%) reported an increase in net clinical revenue, and eight (17%) reported a decrease. Only five ADEMs (10%) said that other academic departments within their university/medical center aggressively directed patients away from the ED, compared with nine (22%) in the 1998 study. The percentage of ADEMs using mid-level providers remained essentially unchanged over the three studies—31 (66%) in 1996 versus 28 (68%) in 1998 and 31 (65%) in the present study. For all the studies, mid-level providers were most commonly used in a fast-track setting. The number of ADEMs with an observation unit has also remained relatively stable—18 (38%) in the current study versus 15 (31%) in the 1998 study. In the current study, only two (4%) ADEMs experienced a merger with another university system, compared with 12 (29%) in 1998. Eight (17%) ADEMs reported that their institution had merged with a private entity in the current study, compared with nine (22%) in 1998. Conclusions: ADEMs continue to experience some very positive trends, namely, increases in ED patient volume, in severity of patient illness, and in net clinical revenue. more...

Emergency department (ED) over-crowding has been a topic of intense interest over the past few years, with the Institute of Medicine report “Emergency Care at a Crossroads” published in 2006 [1], followed by the American College of Emergency Physicians task force report on boarding (2008) and, most recently, the United States Government Accountability Office (GAO) Report to the Chairman [2], Committee on Finance, U.S. Senate published in April 2009. Similarly, the Canadian Association of Emergency Physicians and the Australasian College for Emergency Medicine have also recognized the primary problem of over-crowding in the ED [3, 4]. The adverse effects of the global problem of ED over-crowding are well known. Crowding negatively impacts all stakeholders: patients, physicians, and the hospital. Most important is patient safety, with decreased quality of care and an increase in medical errors in overcrowded EDs. Further, patients have a poor experience, which leads them to leave without being seen, and they are less likely to return to the ED in the future. Physicians and other providers experience decreased job satisfaction, resulting in decreased productivity and increased staff turnover. For the hospital, ED over-crowding results in lost revenue from multiple sources. Revenue is lost from patients who leave without being seen, from emergency medical service (EMS) diversion secondary to dissatisfaction among both patients and EMS crews, and from shifting of the market share to competitors. Consider the real mortality risk associated with ED over-crowding. A study of over 55,000 ED patients demonstrated a higher mortality rate among patients boarded in the ED than in those moved to an inpatient hallway bed (p 155,000 patient visits per year) tertiary referral facility with 1,400 beds which serves as the primary teaching hospital of the Chinese University of Hong Kong. The authors note that while the SARS epidemic and the introduction of co-pay in the ED resulted in an overall net decrease of ED volumes, the concurrent increase in patients brought in via ambulance plus reduction of medical and nursing staff resulted in increased waiting times. The over-crowding problem is compounded by the marked increase in the medical admission rate, which correlates with the 12% increase in the geriatric population visits. The second study, by Kulstad and Kelley [7], entitled “Over-crowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction” uses the EDWIN score as a marker of ED over-crowding and its association with ultimate delays in patients receiving percutaneous intervention for acute myocardial infarction. The EDWIN score is the sum of the number of patients in the ED multiplied by their acuity, divided by the number of attending physicians working in the ED, multiplied by the number of inpatient boarders. The authors report a decreased likelihood of timely treatment for acute MI during times of over-crowding in their emergency department. These studies underscore the very real and detrimental effects of ED over-crowding. The most important root cause of ED over-crowding is the inability to transfer emergency patients to inpatient beds and the resultant boarding of admitted patients in the ED. Solutions to decrease boarding in the ED include moving boarders into inpatient hallways at the front end, and increasing the rate of discharges by noon at the back end. Movement of patients to inpatient hallways, while known to be safer for patients, still often results in push-back from the inpatient services. One commonly cited reason is patient dissatisfaction. As the science of ED over-crowding evolves, studies addressing this very issue have also been performed. A study of 445 patients reports an overall preference of 87% for inpatient hallway beds. Reasons cited for this preference included better privacy, staff availability, safety, rest, quiet, and treatment [8]. Movement of patients to hallway beds and boosting discharges before noon are sometimes thought of as the “external factor,” as they involve practice outside of the ED, namely inpatient floors. There are of course a number of measures that can be undertaken to increase throughput in the ED that can be considered “internal factors.” These include streamlined and simplified triage, point-of-care laboratory testing for diagnostics that are a bottleneck to the next step, and care pathways, to name a few. The first step of solving any problem, acknowledging it, is well past. We know that patient volumes of EDs are going to increase at an exponential rate, as suggested by the CDC in 2005 [9], Our objectives should be to enable efficient care to everyone at all times. We have potential allies in technology, streamlined business management strategies, including Lean for process evolution and Six Sigma, and collaborative alliances between hospitals to develop creative solutions to the problem of ED over-crowding. In today’s evolving healthcare scenario, EDs are not only a point of care for the acutely ill, but also have a role as a safety net to provide healthcare to people regardless of their insurance status or ability to pay, as dictated by laws like the Emergency Medical Treatment and Labor Act (EMTALA) in the US. It is of paramount importance that a serious and unified approach to ED over-crowding be taken, at all levels. This would represent a major step towards establishing a culture of patient safety and satisfaction in the ED. more...

In July 1996, the New York City (NYC) regional EMS implemented a new protocol whereby EMS personnel in the prehospital setting could administer 125 mg of intravenous methyl prednisolone to asthma patients as one of their medical options following telephone consultation with a medical control physician.To determine whether this protocol had any effect on hospital admission rates or the emergency department (ED) length of stay.This retrospective chart review focused on the 219 (of 603 total) patients who arrived to the ED by ambulance over a two-year period whose ED diagnosis was asthma. There were 81 patient encounters in year 1, and 138 in year 2. Eleven of the year 2 group received prehospital steroids. The study took place at an urban 911 receiving, Level 2 ED.Of the group who received prehospital steroids, none resulted in hospital admission. Due to the small sample size in the steroid-receiving group, the differences in these admission rates are not yet significant. No differences were detected in the ED length of stay between the two patient groups (157 vs. 160 minutes in year 2, p = 0.9).The differences in admission rates suggested by this study suggest a simple yet potentially powerful tool for improving patient outcome in the treatment of asthma. more...

From the experiment using an underwater bell to determine the speed of sound by J. D. Colladon in 1826, the generation of ultrasound waves by Francis Galton in 1876, the discovery of the piezoelectric effect by Pierre Curie in 1880, the development of sonar systems within a month of the sinking of the Titanic in 1912, to its early conception as the “hydrophone” by Paul Langevin and Constantin Chilowsky in 1915 and the development of medical ultrasonic systems since 1940, ultrasound is a technology that has now reached the “tipping point” and is being rapidly assimilated into multiple medical specialties beyond radiology. Emergency medicine (EM) has witnessed the addition of ultrasonography to the arsenal of emergency care. The history of ultrasound in EM, spanning 15 years, can be traced back to the publication of the first emergency ultrasound curriculum by Mateer et al. in 1994. Increasing portability and the ease of training has fueled its rapid ascent to the front lines of EM practice to improve patient care. Since the publication of the first formal policy statement for the use of ultrasound in EM by the American College of Emergency Physicians in 2001 [1], the concept of emergency screening ultrasound has gained favor with most of the residency training programs in the USA and is now an element of the core curriculum required by the Residency Review Committee for Emergency Medicine [2]. It was also recently incorporated in the guidelines of the College of Emergency Medicine, UK in 2006 [3]. A large body of research studies has provided strong evidence that with appropriate training emergency ultrasound done by emergency physicians can safely aid time-critical decisions and procedures in the emergency department (ED). The gamut of emergency ultrasound has gone from FAST (focused sonography for trauma) to comprehensive advanced scans and procedural guidance such as scans for shortness of breath, increased intracranial pressure (ICP), and central line placement. The ability of ultrasound to be incorporated in emergency medical services (EMS), telemedicine, and medical student education has mushroomed interest in the field. We are pleased to feature ultrasound in this issue of the International Journal of Emergency Medicine. The first of the ultrasound articles in this issue is a review on its use in EMS [4]. Not only does it highlight the current status of its use in Europe and the USA, but it also provides insight into the training programs, point of care use in resuscitation and trauma by EMS, and the potential application in mass casualty incident triage. There is still a long way to go as far as credentialing EMS personnel is concerned, because of the known learning curve in ultrasound applications. The growth of ultrasound in EM is twofold—first is the development and validation of new point of care applications aptly demonstrated in the brief research report on “Ultrasound as an aid to reduction of pediatric forearm fractures” [5]. This application of ultrasound helps visually demonstrate successful reductions. Although the study did not demonstrate a decrease in the treatment time or radiological exposure, further validation will likely do so. The novelty of ultrasound applications has only multiplied with time, but the result remains the same: success. The second prong of growth is the promulgation of basic training in developing systems of care as is exemplified in the study on “Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania” [6]. The study demonstrates the feasibility and the ease with which ultrasound can be adapted to use in complex, underdeveloped care systems to enhance patient care and satisfaction. This article goes a step further to demonstrate that the initial expenditure for procuring the equipment is greatly offset by the time gain and the decreased stress on ancillary medical departments in developing systems. The socioeconomic pressures of health care in all economies ranging from developed, developing and the underdeveloped will benefit from this boom of ultrasound in EM. But at the same time we must be wary that ultrasound in EM does not become a victim of its own success. Appropriate training and credentialing is the need of the hour. The spiraling growth of ultrasound in EM has only one foreseen outcome, a future made colorful by black and white. more...