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Objectives: Patients with an alcohol use disorder experiencing acute intoxication or withdrawal may be at risk for electrocardiograph (ECG) abnormalities, including prolongation of repolarization (long QTc [corrected QT]) that may contribute to arrhythmias and may be associated with a threefold increase in the likelihood of sudden cardiac events. Patients with acute coronary syndrome may have prolonged QTc as well. To our knowledge, no previous studies have compared the QTc of ACS with acute ethanol (EtOH) withdrawal syndromes in the emergency department (ED). The purpose of our study was to compare the QTc of those with EtOH withdrawal emergencies with patients with ACS in our ED. Our hypothesis was that the QTc would be similarly prolonged in the two cohorts.Methods: The study compared two cohort groups, those with ACS and those with EtOH withdrawal-related ED visits over a 1-year period. We compared ECG QTc, cardiac medication use, and electrolyte differences. We considered a QTc of >450 ms elevated for men and >470 ms elevated for women based on the literature. Fifty subjects in whom an ECG, serum osmolality, and EtOH level were recorded within 2 hours of one another and who were administered a Clinical Institute Withdrawal Assessment protocol were compared with 203 patients with ACS during the same period. We excluded patients with incomplete data. Medications compared included clopidogrel, acetylsalicylic acid, β-blockers, angiotensin-converting enzyme inhibitors, and statins. ECG QT and QTc, as well as electrolytes, were recorded and compared. Data were extracted by two investigators with a 20% sample re-evaluated by the other extractor as a reliability measure. Descriptive statistics including medians and interquartile ranges were measured for continuous variables. Comparisons were made using two-tailed t tests for parametric data and the Mann-Whitney U test for nonparametric data.Results: Agreement in the 20% sampling between investigators was high (96%). The mean QTc in the ACS group was 457 ms and the mean QTc in the EtOH withdrawal-related group was 468 ms (diff 11, not significant). Significantly more patients had a prolonged QTc in the EtOH withdrawal group than in the ACS group 62% vs 46%; diff 16; 95% CI (0.1, 30). There was significantly more use of clopidogrel, acetylsalicylic acid, angiotensin-converting enzyme inhibitors, and statins (P < 0.05 for all) in the ACS group compared with the EtOH withdrawal group; however, there was no difference in β-blocker usage. There was a significantly higher admission rate: 100% of ACS compared with 76% of the EtOH withdrawal group (P < 0.01, diff 24, 95% confidence interval 18-29). Electrolytes were not significantly different in the two groups.Conclusions: More patients with EtOH withdrawal-related ED visits had a long QTc than patients presenting with ACS. ED physicians should carefully monitor patients experiencing EtOH withdrawal for cardiac arrhythmias and obtain an ECG. If any medications that prolong the QTc are considered, then an ECG should be obtained before administering medications that may affect the myocardium to make medication safer for the patient. [ABSTRACT FROM AUTHOR]

Introduction: Ambulance diversion is a problem in many communities. When patients are diverted prompt and appropriate medical care may be delayed., Objective: Compare diversion hours and drop-off times before and after a dramatic change in diversion policy restricting each hospital to 1 hour out of every 8., Methods: This study was a retrospective study in a county of 600,000 people and 10 hospitals from September 2004 to February 2006. A countywide diversion protocol was implemented in March 2005 that limited diversion hours to 1 hour out of every 8 (maximum of 90 h/mo). No other changes were implemented during the study period. Pretrial (9/04-2/05), interim (3/05-8/05), and posttrial (9/05-2/06) periods were compared. The main outcome measures were ambulance diversion hours and emergency medical service (EMS) drop-off times. Results were compared using analysis of variance and a Tukey post hoc analysis. P < .05 was considered significant., Results: There was no significant difference in the number of monthly transports comparing the posttrial vs pretrial periods; however, a significant decrease in monthly ambulance diversion hours (difference, 251 hours; 95% CI, 136-368) and significant increase in additional time that EMS crews required to transport patients (drop-off times) (difference, 178 hours; 95% CI, 74-283) were observed. Posttrial diversion hours decreased to 18% of the pretrial values (from 305 to 54)., Conclusion: This novel ambulance diversion protocol dramatically reduced diversion hours at the cost of increasing EMS drop-off times in a large community.

Background: More than 10% of the population visit emergency departments (ED) every year. Many of these patients are not up-to-date on routine vaccinations that could prevent future illnesses. The ED could significantly impact these vaccination trends., Objectives: This study was a feasibility study to determine whether patients would be amenable to an ED-based program that provided appropriate immunizations when they were at high risk for these diseases. In addition, the authors sought to identify barriers that predict high-risk patients who did not receive immunizations before ED presentation and to identify barriers that predict those high-risk unvaccinated patients who are unwilling to receive vaccinations when offered in the ED., Methods: This study was a prospective cross-sectional study of all patients arriving in the ED at one inner-city trauma center between 10 am and 10 pm over the course of a three-week intervention period. The subjects completed a survey that included information about their risk of influenza (flu) and pneumococcal disease, their immunization history, and their perceptions of their need for immunization. Demographic information collected included insurance status, age, gender, and primary language. All high-risk patients who were not current with their immunizations were offered vaccination. The primary outcome was improvement in vaccination coverage based on an ED surveillance and treatment system for vaccinations. The secondary outcomes were barriers to successful vaccination before ED presentation and barriers to acceptance of vaccination in the ED. Results were compared using chi-square test and confidence interval analysis. Characteristics of barriers to immunization were determined using a logistic regression model. A p-value < 0.05 was considered significant., Results: A total of 674 subjects were entered into the study. Vaccination of subjects at high risk for flu increased significantly from 16% before to 83% after ED evaluation and treatment, and vaccination of subjects at high risk for pneumococcal disease increased significantly from 18% before to 84% after ED evaluation and treatment. Significant barriers to vaccination before ED presentation were lack of insurance (odds ratio [OR] = 0.31 for flu, 0.22 for pneumococcal disease), age younger than 50 years (OR = 0.18 for flu, 0.24 for pneumococcal disease), and no perceived need for vaccination (OR = 0.07 for flu). The sole significant barrier to vaccine administration in the ED was perceived need for vaccination (OR = 0.32 for flu)., Conclusions: An ED-based vaccination program is both feasible and successful. Other than a shortage of vaccine, the only ED barrier to vaccination (perceived need) might be overcome with patient education.

Objectives: To determine demographics of children in homes to which police are called for intimate-partner violence (IPV) and to compare the relative risk of perpetrator versus victim for those who, as children, witnessed or were victims of IPV and sexual assault., Methods: Data from Resources, Inc. Victim Assistance Unit yearly intake statistics for 2004 were accessed. In this city with a population of approximately 500,000 people, police will call for an on-site advocate intervention (a trained social worker) at their own discretion for the adult or child victims of IPV and for children witnessing IPV. The social worker collects data on victims, perpetrators of IPV, and child witnesses or victims at all police calls for IPV. Comparisons were made by using chi-square, relative risks (RRs), and 95% confidence intervals (95% CI)., Results: Police and advocates visited 2,038 homes for IPV calls; 2,617 children were in these homes. Of these children, 1,904 (76%) witnessed IPV, and 698 (27%) were victims themselves. Adult victims (31%) and perpetrators (41%) had high rates of having witnessed IPV when they were children. Perpetrators were more likely than victims to have witnessed IPV as a child (RR, 1.56; 95% CI = 1.37 to 1.78) and to have been a victim of IPV as a child (RR, 1.71; 95% CI = 1.49 to 1.96)., Conclusions: In this study population, 76% of IPV households include children, and one third of these children also are victims of IPV. Perpetrators often were victims and witnesses of IPV when they were children. This suggests that a history of childhood IPV is common for perpetrators of IPV. Development of and research on interventions for child witnesses or victims of IPV is needed.