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The objective was to identify clinical, social, and environmental risk factors for increased emergency department (ED) use in children with sickle cell disease (SCD).This study was a secondary analysis of ED utilization data from the international multicenter Silent Cerebral Infarct Transfusion (SIT) trial. Between December 2004 and June 2010, baseline demographic, clinical, and laboratory data were collected from children with SCD participating in the trial. The primary outcome was the frequency of ED visits for pain. A secondary outcome was the frequency of ED visits for acute chest syndrome.The sample included 985 children from the United States, Canada, England, and France, for a total of 2,955 patient-years of data. There were 0.74 ED visits for pain per patient-year. A past medical history of asthma was associated with an increased risk of ED utilization for both pain (rate ratio [RR] = 1.28, 95% confidence interval [CI] = 1.04 to 1.58) and acute chest syndrome (RR = 1.60, 95% CI = 1.03 to 2.49). Exposure to environmental tobacco smoke in the home was associated with 73% more ED visits for acute chest syndrome (RR = 1.73, 95% CI = 1.09 to 2.74). Each $10,000 increase in household income was associated with 5% fewer ED visits for pain (RR = 0.95, 95% CI = 0.91 to 1.00, p = 0.05). The association between low income and ED utilization was not significantly different in the United States versus countries with universal health care (p = 0.51).Asthma and exposure to environmental tobacco smoke are potentially modifiable risk factors for greater ED use in children with SCD. Low income is associated with greater ED use for SCD pain in countries with and without universal health care.

To assess the associations between a doctor diagnosis of asthma and wheezing (independent of a diagnosis of asthma) with sickle cell disease (SCD) morbidity, we conducted a retrospective review of Emergency Department (ED) visits to the Mount Sinai Medical Center for SCD between 1 January 2007 and 1 January 2011. Outcomes were ED visits for pain and acute chest syndrome. The cohort included 262 individuals, median age 23·8 years, (range: 6 months to 67·5 years). At least one episode of wheezing recorded on a physical examination was present in 18·7% (49 of 262). Asthma and wheezing did not overlap completely, 53·1% of patients with wheezing did not carry a diagnosis of asthma. Wheezing was associated with a 118% increase in ED visits for pain (95% confidence interval [CI]: 56–205%) and a 158% increase in ED visits for acute chest syndrome (95% CI: 11–498%). A diagnosis of asthma was associated with a 44% increase in ED utilization for pain (95% CI: 2–104%) and no increase in ED utilization for acute chest syndrome (rate ratio 1·00, 95%CI 0·41–2·47). In conclusion, asthma and wheezing are independent risk factors for increased painful episodes in individuals with SCD. Only wheezing was associated with more acute chest syndrome.

Many barriers exist to the translation of research to policy, and large gaps exist between evidence-based medicine and practice (Institute of Medicine [U.S.]. Committee on Quality of Health Care in America 2001). Documented obstacles to such transfer of information include limited contact between policy makers and researchers, little incentive for researchers to make their research policy-relevant, and lack of significance to the current policy environment (Jewell and Bero 2008). Dissemination of results is often limited to academic journals, which emphasize methods and limitations, rather than more easily interpretable summaries of research findings. A survey of state policy makers revealed that they receive too much information, and that the majority is neither timely nor framed in a policy-relevant manner (Sorian and Baugh 2002). At the same time, well-documented facilitators exist to improve the policy process to incorporate up-to-date evidence. These include framing results in ways that link them to concrete impacts on costs, benefits, or specific populations, translating research results into policy-relevant products, and developing early collaborative relationships with decision makers to generate policy-relevant research (Jewell and Bero 2008). The Robert Wood Johnson Foundation's Synthesis Project was designed to strengthen the link between research and policy by having researchers synthesize evidence into readable formats that could be used by legislators and their staff (Colby et al. 2008). Some experts have promoted community-partnered participatory research as a way to improve the relevance of research to the real world (Jones and Wells 2007). Such an approach emphasizes an equitable and long-term partnership between researchers and an outside group or community, in which knowledge is integrated and disseminated for the benefit of all involved (Ditto et al. 1996; Israel 2005; Minkler and Wallerstein 2008). It is a cyclical and iterative process by design, and the approach is tailored to the needs of the partners and the project. In an effort to conduct research that would decrease unnecessary and potentially harmful cardiopulmonary resuscitation attempts, and facilitate subsequent translation into policy by our county, a health services research team formed an ongoing collaboration with leadership within the Los Angeles County Emergency Medical Services (LAC EMS) Agency, henceforth referred to as the EMS-UCLA Collaborative. Until 2007, when paramedics were called to the scene of a cardiac arrest, they would attempt resuscitation unless there were signs of obvious death, such as rigor mortis, or the family or nursing home staff could immediately produce a valid, written prehospital Do Not Attempt Resuscitate (DNAR) form. Most U.S. prehospital systems have not balanced the obvious potential benefits with the potential for harm when constructing policies regarding attempts at resuscitation after cardiac arrest. Potential harms of indiscriminate resuscitation attempts include violating patient preferences, in which we resuscitate patients who would have chosen to forgo chest compressions and/or artificial respiration (Ditto et al. 1996). Attempts at resuscitation, when there is little hope for meaningful recovery, can also harm patients who may linger in intensive care settings, harm families who are often traumatized by those memories (Jones et al. 2004; Azoulay et al. 2005; Anderson et al. 2008), and could harm paramedics, emergency medical technicians (EMTs), and other providers who may experience moral and emotional conflict over providing potentially burdensome treatment to patients when they are dying (Meltzer and Huckabay 2004; Mobley et al. 2007). In response, the EMS-UCLA Collaborative worked together to translate a set of evidence-based clinical standards, designed to allow paramedics to forgo resuscitation attempts in selected patients in whom the harm would probably exceed benefit, into a feasible policy to be implemented in the field. Elsewhere in this article, we describe the yearlong process of translating these standards into a new policy that would be appropriate and feasible to implement in the field, and that better reflected patient and family preferences. This includes a timeline and description of the members of the Collaborative and selected stakeholders, their acceptance or rejection of each standard, and the final changes to the revised policy. In addition, we explore reasons as to why stakeholders may or may not have voted to change certain types of clinical standards.

The effect of emergency department (ED) crowding on equitable care is the least studied of the domains of quality as defined by the Institute of Medicine (IOM). Inequities in access and treatment throughout the health care system are well documented in all fields of medicine. While there is little evidence demonstrating that inequity is worsened by crowding, theory and evidence from social science disciplines, as well as known barriers to care for vulnerable populations, would suggest that crowding will worsen inequities. To design successful interventions, however, it is important to first understand how crowding can result in disparities and base interventions on these mechanisms. A research agenda is proposed to understand mechanisms that may threaten equity during periods of crowding and design and test potential interventions that may ensure the equitable aspect of quality of care.

International audience; OBJECTIVES: The objective of this study was to examine the associations of brain tumours with radio frequency (RF) fields from mobile phones. METHODS: Patients with brain tumour from the Australian, Canadian, French, Israeli and New Zealand components of the Interphone Study, whose tumours were localised by neuroradiologists, were analysed. Controls were matched on age, sex and region and allocated the 'tumour location' of their matched case. Analyses included 553 glioma and 676 meningioma cases and 1762 and 1911 controls, respectively. RF dose was estimated as total cumulative specific energy (TCSE; J/kg) absorbed at the tumour's estimated centre taking into account multiple RF exposure determinants. RESULTS: ORs with ever having been a regular mobile phone user were 0.93 (95% CI 0.73 to 1.18) for glioma and 0.80 (95% CI 0.66 to 0.96) for meningioma. ORs for glioma were below 1 in the first four quintiles of TCSE but above 1 in the highest quintile, 1.35 (95% CI 0.96 to 1.90). The OR increased with increasing TCSE 7+ years before diagnosis (p-trend 0.01; OR 1.91, 95% CI 1.05 to 3.47 in the highest quintile). A complementary analysis in which 44 glioma and 135 meningioma cases in the most exposed area of the brain were compared with gliomas and meningiomas located elsewhere in the brain showed increased ORs for tumours in the most exposed part of the brain in those with 10+ years of mobile phone use (OR 2.80, 95% CI 1.13 to 6.94 for glioma). Patterns for meningioma were similar, but ORs were lower, many below 1.0. CONCLUSIONS: There were suggestions of an increased risk of glioma in long-term mobile phone users with high RF exposure and of similar, but apparently much smaller, increases in meningioma risk. The uncertainty of these results requires that they be replicated before a causal interpretation can be made.

In order for DNA biobanks to be a valuable reservoir of genetic information, large numbers of participants from all racial and ethnic backgrounds need to be recruited. This study explored reasons for participating in a new biobank among primarily Hispanic and African American individuals, as well as their general attitudes towards genetic research, and their views on obtaining genetic tests. Focus groups were conducted with Mount Sinai Biobank participants recruited from predominantly lower income, minority communities. The topic guide included questions on The Mount Sinai Biobank, genetic research, and genetic testing. All focus groups were audio recorded, transcribed, and analyzed using thematic analysis. The six focus groups comprised 43 participants: 39 females and four males, aged 27–76 years, with a median household income category of $20,000–$39,999. Twenty-one participants were Hispanic, 20 African American, one Asian, and one White. Participants’ reasons for participating in the biobank included altruism, personal and family benefit, and general curiosity. Although there was evidence of conflation between genetic research and genetic testing, most participants held positive views of genetic research and expressed interest in receiving personal genetic test results. Participants wanted to learn more about genetic research and suggested various venues such as health fairs for disseminating information. Participation in biobanks by racial and ethnic minorities is apparently driven by altruism, and desire for personal or collective health benefits. Participants had generally positive attitudes, limited understanding of genetics and genetic research, and made useful suggestions regarding information dissemination mechanisms.

Palliative care focuses on the relief of pain and suffering and achieving the best possible quality of life for patients. Although traditionally delivered in the inpatient setting, emergency departments (EDs) are a new focus for palliative care consultation teams.To explore attitudes and beliefs among emergency care providers regarding the provision of palliative care services in the ED.Three semistructured focus groups were conducted with attending emergency physicians from an academic medical center, a public hospital center, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews.Twenty emergency physicians participated (mean age 41 years, range 31-61 years, median practice time nine years, 40% female). Providers acknowledged many benefits of palliative care presence in the ED, including provision of a specialized skill set, time to discuss goals of care, and an opportunity to intervene for seriously ill or injured patients. Providers believed that concerns about medicolegal issues impaired their ability to forgo treatments where risks outweigh benefits. Additionally, the culture of emergency medicine-to provide stabilization of acute medical emergencies-was sometimes at odds with the culture of palliative care, which balances quality of life with the burdens of invasive treatments. Some providers also felt it was the primary physician's responsibility, and not their own, to address goals of care. Finally, some providers expressed concern that palliative care consultation was only available on weekdays during daytime hours. Automatic consultation based on predetermined criteria was suggested as a way to avoid conflicts with patients and family.Emergency providers identified many benefits to palliative care consultation. Solving logistical problems and developing clear indications for consultation might help increase the use of such services.

The objectives were to measure the financial impact of implementing a fully integrated emergency department information system (EDIS) and determine the length of time to "break even" on the initial investment.A before-and-after study design was performed using a framework of analysis consisting of four 15-month phases: 1) preimplementation, 2) peri-implementation, 3) postimplementation, and 4) sustained effects. Registration and financial data were reviewed. Costs and rates of professional and facility charges and receipts were calculated for the phases in question and compared against monthly averages for covariates such as volume, collections rates, acuity, age, admission rate, and insurance status with an autoregressive time series analysis using a segmented model. The break-even point was calculated by measuring cumulative monthly receipts for the last three study phases in excess of the average monthly receipts from the preimplementation phase, corrected for change in volume, and then plotting this against cumulative overall cost.Time to break even on the initial EDIS investment was less than 8 months. Total revenue enhancement at the end of the 5-year study period was $16,138,953 with an increase of 69.40% in charges and 70.06% in receipts. This corresponds to an increase in receipts per patient from $50 to $90 for professional services and $131 to $183 for facilities charges. Other than volume, there were no significant changes in trends for covariates between the preimplementation and sustained-effects periods.A comprehensive EDIS implementation with process redesign resulted in sustained increases in professional and facility revenues and a rapid initial break-even point. .

Racial and ethnic disparities in health are multifactorial; they reflect differences in biological vulnerability to disease as well as differences in social resources, environmental factors, and health care interventions. Understanding and intervening in health inequity require an understanding of the disparate access to all of the personal resources and environmental conditions that are needed to generate and sustain health, a set of circumstances that constitute access to health. These include access to health information, participation in health promotion and disease prevention activities, safe housing, nutritious foods, convenient exercise spaces, freedom from ambient violence, adequate social support, communities with social capital, and access to quality health care. Access to health care is facilitated by health insurance, a regular source of care, and a usual primary care provider. Various mechanisms through which access to health and access to health care are mediated by race and ethnicity are discussed; these include the built environment, social environment, residential segregation, stress, racism, and discrimination. Empirical evidence supporting the association between these factors and health inequities is also reviewed.

Study objective In 2003, the Institute of Medicine Committee on the Future of Emergency Care in the United States Health System convened and identified a crisis in emergency care in the United States, including a need to enhance the research base for emergency care. As a result, the National Institutes of Health (NIH) formed an NIH Task Force on Research in Emergency Medicine to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. The objectives of these discussions were to identify key research questions essential to advancing the scientific underpinnings of emergency care and to discuss the barriers and best means to advance research by exploring the role of research networks and collaboration between the NIH and the emergency care community. Methods The Medical-Surgical Research Roundtable was convened on April 30 to May 1, 2009. Before the roundtable, the emergency care domains to be discussed were selected and experts in each of the fields were invited to participate in the roundtable. Domain experts were asked to identify research priorities and challenges and separate them into mechanistic, translational, and clinical categories. After the conference, the lists were circulated among the participants and revised to reach a consensus. Results Emergency care research is characterized by focus on the timing, sequence, and time sensitivity of disease processes and treatment effects. Rapidly identifying the phenotype and genotype of patients manifesting a specific disease process and the mechanistic reasons for heterogeneity in outcome are important challenges in emergency care research. Other research priorities include the need to elucidate the timing, sequence, and duration of causal molecular and cellular events involved in time-critical illnesses and injuries, and the development of treatments capable of halting or reversing them; the need for novel animal models; and the need to understand why there are regional differences in outcome for the same disease processes. Important barriers to emergency care research include a limited number of trained investigators and experienced mentors, limited research infrastructure and support, and regulatory hurdles. The science of emergency care may be advanced by facilitating the following: (1) training emergency care investigators with research training programs; (2) developing emergency care clinical research networks; (3) integrating emergency care research into Clinical and Translational Science Awards; (4) developing emergency care–specific initiatives within the existing structure of NIH institutes and centers; (5) involving emergency specialists in grant review and research advisory processes; (6) supporting learn-phase or small, clinical trials; and (7) performing research to address ethical and regulatory issues. Conclusion Enhancing the research base supporting the care of medical and surgical emergencies will require progress in specific mechanistic, translational, and clinical domains; effective collaboration of academic investigators across traditional clinical and scientific boundaries; federal support of research in high-priority areas; and overcoming limitations in available infrastructure, research training, and access to patient populations.

A nationwide brewing industry study provided an opportunity to empirically test, for the first time, the construct “supplier's desire to influence.” The relationships between desire to influence and perceived use of both coercive and noncoercive power sources as well as performance were examined.

The methods of power that are used in a channel relationship have various impacts on indiviudals and institutions within the channel. This paper constrasts the perceptions of the relative source and use of those methods by presidents and sales managers within in the brewing industry.

Novel H1N1 influenza spread rapidly around the world in spring 2009. Few places were as widely affected as the New York metropolitan area. Emergency departments (EDs) in the region experienced daily visit increases in 2 distinct temporal peaks, with means of 36.8% and 60.7% over baseline in April and May, respectively, and became, in a sense, the "canary in the coal mine" for the rest of the country as we braced ourselves for resurgent spread in the fall. Biosurveillance efforts by public health agencies can lead to earlier detection, potentially forestalling spread of outbreaks and leading to better situational awareness by frontline medical staff and public health workers as they respond to a crisis, but biosurveillance has traditionally relied on manual reporting by hospital administrators when they are least able: in the midst of a public health crisis. This article explores the use of health information exchange networks, which enable the secure flow of clinical data among otherwise unaffiliated providers across entire regions for the purposes of clinical care, as a tool for automated biosurveillance reporting. Additionally, this article uses a health information exchange to assess H1N1's effect on ED visit rates and discusses preparedness recommendations and lessons learned from the spring 2009 H1N1 experience across 11 geographically distinct EDs in New York City that participate in the health information exchange.

The National Institutes of Health (NIH) Clinical and Translational Science Awards (CTSA) program and the 2006 Institute of Medicine (IOM) Report on the future of emergency care highlight the need for coordinated emergency care research (ECR) to improve the outcomes of acutely ill or injured patients. In response, the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP) sponsored the Emergency Care Research Network (ECRN) Conference in Washington, DC, on May 28, 2008. The conference objectives were to identify the unique nature of ECR and the infrastructure needed to support ECR networks and to understand the optimal role of emergency medicine (EM) and other acute care specialties in research networks. Prior to the conference, participants responded to questions addressing the relevant issues that would form the basis of breakout session discussions; two of these breakout questions are summarized in this report: 1) what makes EM research unique? and 2) what are the critical components needed to establish and maintain networked ECR? Emergency care research was defined as "the systematic examination of patient care that is expected to be continuously available to diverse populations presenting with undifferentiated symptoms of acute illness, or acutely decompensated chronic illness, and whose outcomes depend on timely diagnosis and treatment." The chain of ECR may extend beyond the physical emergency department (ED) in both place and time and integrate prehospital care, as well as short- and long-term outcome determination. ECR may extend beyond individual patients and have as the focus of investigation the actual system of emergency care delivery itself and its effects on the community with respect to access to care, use of resources, and cost. Infrastructure determinants of research network success identified by conference participants included multidisciplinary collaboration, accurate long-term outcome determination, novel information technology, intellectual infrastructure, and wider network relationships that extend beyond the ED.

Clinical practice guidelines are developed to reduce variations in clinical practice, with the goal of improving health care quality and cost. However, evidence-based practice guidelines face barriers to dissemination, implementation, usability, integration into practice, and use. The American College of Emergency Physicians (ACEP) clinical policies have been shown to be safe and effective and are even cited by other specialties. In spite of the benefits of the ACEP clinical policies, implementation of these clinical practice guidelines into physician practice continues to be a challenge. Translation of the ACEP clinical policies into real-time computerized clinical decision support systems could help address these barriers and improve clinician decision making at the point of care. The investigators convened an emergency medicine informatics expert panel and used a Delphi consensus process to assess the feasibility of translating the current ACEP clinical policies into clinical decision support content. This resulting consensus document will serve to identify limitations to implementation of the existing ACEP Clinical Policies so that future clinical practice guideline development will consider implementation into clinical decision support at all stages of guideline development.

BACKGROUND: This project directly and empirically measured the level of gastrointestinal (GI) illness related to the consumption of tapwater prepared from sewage-contaminated surface waters and meeting current water quality criteria. METHODS: A randomized intervention trial was carried out; 299 eligible households were supplied with domestic water filters (reverse-osmosis) that eliminate microbial and chemical contaminants from their water, and 307 households were left with their usual tapwater without a filter. The GI symptomatology was evaluated by means of a family health diary maintained prospectively by all study families over a 15-month period. RESULTS: The estimated annual incidence of GI illness was 0.76 among tapwater drinkers compared with 0.50 among filtered water drinkers (p less than 0.01). These findings were consistently observed in all population subgroups. CONCLUSION: It is estimated that 35% of the reported GI illnesses among the tapwater drinkers were water-related and preventable. Our results raise questions about the adequacy of current standards of drinking water quality to prevent water-borne endemic gastrointestinal illness.

Objective The purpose of this study was to evaluate the effectiveness of stroke education provided to patients and their significant others in the emergency department (ED) waiting area. Our focus was on the 4 main aspects of stroke: signs and symptoms, risk factors, behavior modification, and the urgency to seek medical attention. We hypothesized that showing educational videos, providing one-on-one counseling, and distributing literature would result in greater stroke knowledge and positive behavioral modification. Methods In this pilot, randomized controlled trial, our research team enrolled patients and visitors in the fast-track waiting area of the ED. After obtaining informed written consent, participants were randomly assigned to the control group or to the intervention group. The intervention group received an educational video program, one-on-one counseling, and stroke education materials, and completed a 13-question test after receiving the education. The control group completed the same test without receiving any education. Both groups completed the same test again at 1 and 3 months to assess stroke knowledge retention. Results There were a total of 329 participants: 151 in the control group and 178 in the intervention group. Gender, age, and educational level of participants did not differ between groups. At all time points of the study, participants receiving stroke education demonstrated better test scores than those in the control group. However, knowledge retention in the intervention group gradually declined during the follow-up. Individuals enrolled in the intervention group appeared to be more motivated to reduce their smoking habits, compared with control subjects; however, the number of cigarettes they smoked per day did not dramatically decrease in comparison with their own baseline. Receiving the education session did not result in positive diet or physical activity changes. Conclusions ED stroke education, which includes video program, one-on-one counseling, and written educational materials, is able to significantly increase stroke knowledge. Modification and reinforcement of education is needed to achieve better knowledge retention and favorable lifestyle modifications.

To assess emergency department utilization by a population whose health care encounters can be tracked and quantified for behavioral and mental health conditions in the aftermath of the terrorist attacks of September 11, 2001. We assessed presentations to emergency departments using Medicaid analytic extract files for adult New York State residents for 2000 and 2001. We created four mutually exclusive geographic areas that were progressively more distant from the World Trade Center and divided data into 4 time periods. All persons in the files were categorized by their zip code of residence. We coded primary emergency department diagnoses for post traumatic stress disorder, substance abuse, psychogenic illness, severe psychiatric illness, depression, sleep disorders, eating disorders, stress-related disorders, and adjustment disorders. There was a 10.1% relative temporal increase in the rate of emergency department behavioral and mental health diagnoses following the September 11, 2001 terrorist attacks for adult Medicaid enrollees residing within a 3-mile radius of the World Trade Center site. Other geographic areas experienced relative declines. In population-based comparisons, Medicaid recipients, who lived within 3 miles of the World Trade Center following the September 11, 2001 terrorist attacks had a 20% increased risk of an emergency department mental health diagnosis (Prevalence Density Ratio 1.2, 95% CI 1.1, 1.3) compared to those who were non-New York City residents. The complex role that emergency departments may play in responding to terrorism and disasters is becoming increasingly apparent. To the best of our knowledge this is the first report of a quantifiable increase in emergency department utilization for mental health services by persons exposed to a terrorist attack in the United States.

Out-of-hospital cardiac arrest (OOH-CA) is a leading cause of mortality and the focus of significant research. Recent studies provide new evidence that may change our management of OOH-CA and improve outcomes. The findings of two recently published studies of OOH-CA are reviewed in this article. The first, the Public Access Defibrillation Trial, was a randomized, controlled trial of public access defibrillation in 993 community facilities in the U.S. and Canada . It demonstrated that a community strategy to train laypersons to respond to cardiac arrests significantly increased survival to hospital discharge following OOH-CA in nonresidential community units with community members trained and equipped to provide public access defibrillation, compared to community units with community members trained to provide cardiopulmonary resuscitation (CPR) without any capacity for defibrillation. The second, the European Resuscitation Council Vasopressor during Cardiopulmonary Resuscitation Study, was a randomized, controlled, double-blinded trial that compared vasopressin to epinephrine as the initial pharmacological therapy for 1,219 patients who sustained OOH-CA. The study demonstrated that vasopressin is similar to epinephrine for OOH-CA due to ventricular fibrillation or pulseless electrical activity, and superior to epinephrine for the initial treatment of asystolic arrest; it also demonstrated that the combination of vasopressin and epinephrine is superior to epinephrine alone in the treatment of refractory, out-of-hospital cardiac arrest. Studies on alternative CPR techniques and adjunctive devices for CPR were also reviewed. We conclude that pre-hospital access to defibrillators and the use of vasopressin in the management of asystole hold promise for improving survival for patients with out-of-hospital cardiac arrest.

To evaluate the effect of emergency department (ED) crowding on assessment and treatment of pain in older adults.Retrospective review of ED records from a prospective cohort study.Urban, academically affiliated, tertiary medical center.One hundred fifty-eight patients, aged 50 and older, evaluated and hospitalized from the ED with hip fracture.Patient-related risk factors: age, sex, nursing home residence, ED triage status, dementia, Acute Physiology in Age and Chronic Health Evaluation II physiological score, and RAND comorbidity score. ED crowding risk factors: ED census and mean length of stay.documentation of pain assessment, time to pain assessment, time to pain treatment, patients reporting pain receiving analgesia, and meperidine use.Mean age was 83 (range 52-101), 81.0% of patients complained of pain, mean time to pain assessment was 40 minutes (range 0-600), time to treatment was 141 minutes (range 10-525), and mean delay to treatment was 122 minutes (range 0-526). Of those with pain, 35.9% received no analgesia, 7.0% received nonopioids, and 57.0% received opioids. Of those receiving opioids, 32.8% received meperidine. ED crowding at census levels greater than 120% bed capacity was significantly associated with a lower likelihood of documentation of pain assessment (P = .05) and longer times to pain assessment (P = .01).Older adults with hip fracture are at risk for underassessment of pain, considerable delays in analgesic administration after pain is identified, and treatment with inappropriate analgesics (e.g., meperidine) in the ED. Higher levels of ED census are significantly associated with poorer pain management.

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

In order to set the stage for the later discussion of future directions, this Consensus Conference began by reviewing some of the existing research on conducting resuscitation studies using an exception from informed consent. That research is described in this article. The authors conclude that, based on the experiences reported by researchers and institutional review boards, resuscitation research may be ethically and legally conducted under the current regulations, but such research requires substantial effort, financial resources, and personnel. Federal regulations have set the bar appropriately high, and this may pose significant difficulties for small sponsors and individual investigators. However, further study of the experiences of subjects, researchers, and the regulatory process is warranted.

Background The Public Access Defibrillation (PAD) Trial was a randomized, controlled trial designed to measure survival to hospital discharge following out-of-hospital cardiac arrest (OOH-CA) in community facilities trained and equipped to provide PAD, compared with community facilities trained to provide cardiopulmonary resuscitation (CPR) without any capacity for defibrillation. Objectives To report the implementation of community-based lay responder emergency response programs in 1,260 participating facilities recruited for the PAD Trial in the United States and Canada. Methods This was a descriptive study of the characteristics of participating facilities, volunteers, and automated external defibrillator (AED) placements compiled by the PAD Trial, and a qualitative study of factors that facilitated or impeded implementation of emergency lay responder programs using focus groups of PAD Trial site coordinators. Results The PAD Trial enrolled 1,260 community facilities (14.8% residential), with 20,400 lay volunteers (mean +/- standard deviation = 13.4 +/- 10.7 per facility) trained to respond to OOH-CA. The 598 locations randomized to receive AEDs required 2.7 +/- 1.8 AEDs per facility. Volunteer attrition was high, 36% after two years. Barriers to recruitment and implementation included identification of appropriate "at-risk" facilities, lack of interest or fear of litigation by a facility key decision maker, lack of motivated potential volunteer responders, training and retraining resource requirements, and lack of an existing communication/response infrastructure. Conclusions These data indicate that implementation of community-based lay responder programs is feasible in many types of facilities, although these programs require substantial resources and commitment, and many barriers to implementation of effective PAD programs exist.

Social marketing techniques have enhanced the success of programs designed to improve the health outcomes of individuals or communities when adopting new health behaviors. Current research suggests, however, that behavior change models, when added to social marketing techniques, could result in even greater success in changing health behaviors and health outcomes. This retrospective analysis of the results of a Public Access Defibrillation (PAD) Trial, designed to improve a community's response to cardiac arrest, tests this proposition. Data from one of the 24 participating PAD Trial sites were analyzed and interpreted from a social marketing and behavior change model perspective, to assess the success in changing a community's response to cardiac arrest victims in 61 residential buildings that participated in the PAD Trial in New York City (NYC). The findings suggest that to improve the success of community-based, emergency response systems to cardiac arrest victims, health programs must first assess the community's awareness of the health problem and their willingness to change behaviors before designing and implementing social marketing programs for health behavior change.

This article reviews the capabilities, advantages, and disadvantages of three forms of automated data collection-scannable data forms, Web-based forms, and handheld computers-compared with the current standard of data entry by hand on paper forms. Each of these methods is reviewed with respect to ease of use, experience required of designer, end-user training requirements, costs, flexibility, speed, accuracy/error rate, potential for data loss, need for technical support, and equipment and/or software requirements. A discussion of their appropriate application to various kinds of studies is included, followed by examples of research studies using each of these methods.

To determine whether emergency physicians' (EPs) attitudes affect their support and practice of brief intervention in the Emergency Department (ED), EPs completed an anonymous survey. EPs were asked about their attitudes toward patients with alcohol problems, current ED screening, use of brief intervention, and barriers to use of brief intervention. Chi-square analysis was used and a step-wise regression model was constructed. Respondents reported a high prevalence of patients with alcohol-related problems: 18% in a typical shift. Eighty-one percent said it is important to advise patients to change behavior; half said using a brief intervention is important. Attending physicians had significantly less alcohol education than residents, but were significantly more likely to support the use of brief intervention. Support was not associated with gender, race, census, hours of education, or personal experience. EPs who felt that brief intervention was an integral part of their job were more likely to use it in their daily practice.

The Institute of Medicine's landmark report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," documents the pervasiveness of racial and ethnic disparities in the U.S. health care delivery system, and provides several recommendations to address them. It is clear from research data, such as those demonstrating racial and ethnic disparities in emergency department (ED) pain management, that emergency medicine (EM) is not immune to this problem. The IOM authors describe two strategies that can reduce disparities in EM. First, workforce diversity is likely to result in a community of emergency physicians who are better prepared to understand, learn from, and collaborate with persons from other racial, ethnic, and cultural backgrounds, whether these be patients, fellow clinicians, or the larger medical and scientific community. Given the ethical and practical advantages of a more diverse EM workforce, continued and expanded initiatives to increase diversity within EM should be undertaken. Second, the specialty's educational programs should produce emergency physicians with the skills and knowledge needed to serve an increasingly diverse population. This cultural competence should include an awareness of existing racial and ethnic health disparities, recognition of the risks of stereotyping and biased treatment, and knowledge of the incidence and prevalence of health conditions among diverse populations. Culturally competent emergency care providers also possess the skills to identify and manage racial and ethnic differences in health values, beliefs, and behaviors with the ultimate goal of delivering quality health services to all patients cared for in EDs.

This article investigates the effects of appealing hospital rooms on patient evaluations of hospital services. A field study contrasting appealing and typical rooms finds that appealing rooms result in more positive patient evaluations of physicians and nurses, as well as more favorable patient judgments of the service.

We sought to understand how emergency physicians perceive the adequacy of their training in pediatrics. A survey was distributed to emergency physicians regarding residency training, clinical experience, importance of Core Content curricular areas, and the adequacy of their training. The results demonstrated that 84.0% of respondents felt well, completely, or adequately prepared with pediatric cardiopulmonary arrests compared to 96.4% who felt prepared for adult arrests. Trauma resuscitations and care of acutely ill patients revealed differences in preparedness for children versus adults [81.5% vs. 90.1%, respectively (p < 0.001) and 92.2% vs. 97.1%, respectively (p < 0.001)]. Pediatric arrest was the most often cited clinical situation giving trouble to first year attendings (24%) and infants were second (22%). Pediatric disorders were cited as the fourth most important area in training. Certain residency characteristics were associated with an increased sense of preparedness. These results may interest Emergency Medicine educators in planning pediatric curricula and experiences for residents.

Study objectives To assess the roles of poor access to care, psychological risk factors, and asthma severity in frequent emergency department (ED) use. Design A cross-sectional survey. Setting Harlem Hospital Center ED and outpatient chest clinic. Participants Three hundred seventy-five adult residents of Harlem, a predominantly African-American community in New York City. Measurements Asthma severity was assessed by self-reported symptoms using National Asthma Education and Prevention Program guidelines, health-care utilization, and psychometric scales. Results Respondents with more severe asthma were more likely to have a primary asthma care provider, and to have had more scheduled office visits for asthma in the year prior to the interview (mean number of visits for patients with severe asthma, 3.6 visits; moderate asthma, 2.4 visits; and mild asthma, 1.7 visits). Despite having a regular source of care, 69% of respondents identified the ED as their preferred source of care; 82% visited the ED more than once in the year prior to interview (median, four visits). Persons with moderate or severe asthma were 3.8 times more likely to be frequent ED users compared to those with mild asthma (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2 to 6.6). This was the strongest predictor of frequent ED use. Other predictors of ED use were number of comorbid disorders (OR, 1.5; 95% CI, 1.1 to 2.1) and self-reported global health in the year prior to the ED visit (OR, 1.8; 95% CI, 1.2 to 2.7). Psychological characteristics were not predictive of frequent ED use when controlling for disease severity. Conclusions Frequent ED users present with serious medical conditions. They do not substitute physician care with ED care; they augment it to address serious health needs.

Emergency physicians must stay cognizant of the rapid and dramatic changes underway in the management of patients with acute stroke syndrome. The future clearly points towards a time when emergency physicians will be called upon to treat "brain attacks" in a manner similar to heart attacks, with early recognition and treatment. As effective interventions are developed, we will be able to alter the course, increase the survival, and decrease the morbidity and long-term disability of stroke patients.

Summary One hundred insulin-dependent diabetic patients (age < 45 years, 53 smokers) were followed for six years. The age, duration of diabetes and mean glycated haemoglobin levels, were comparable between the smokers and non-smokers. Microvascular complications (retinopathy and increased urine albumin excretion) were commoner and more severe in the smoking group at six years, particularly in heavy smokers. Of the 45 original smokers reviewed at six years, 12 (27%) had stopped, six of whom had developed microvascular complications. Only two of the ‘heavy’ initial smokers, likely to be at most risk, had stopped smoking, and three original non-smokers had started smoking.

Observational findings by Solomon et al1 of safety events associated with opioid and nonsteroidal anti-inflammatory drugs (NSAIDs) have made headline news and are now at risk of misinterpretation and potentially worsening overall pain care for older adults. The studies have significant limitations that may preclude the implications investigators and journal editors hope to convey. While propensity scores were used to methodologically adjust for the limitations of Medicare and pharmacy claims data, sizeable confounders, including the severity of pain experienced by subjects, the type of medications used (including over-the-counter analgesics), and more importantly, the dose and duration of medication use could not be accounted for.1 Despite these shortcomings, the results have received considerable attention. The general public and medical communities have been quick to caution against the use of opioids and analgesics in older adults. Alarmist headlines with phrases such as “Narcotic Painkillers” and “Hazards in Elderly” were found in national headlines2–4 and medical Web sites5–7 immediately after results were released. With the continued prevalence of inadequate pain care in many health care settings, despite over a decade of heightened awareness and initiatives by regulatory bodies,8–10 study limitations must be emphasized. Clinicians who are overly concerned that analgesic risks might outweigh benefits may now withhold medications and inadvertently setback any advances made to improve pain management. An example of this is in the emergency department (ED), where Web site headlines for the largest emergency medicine specialty organization, the American College of Emergency Physicians, have warned against the use of opioids in elderly patients.7 Older adults with acute pain have poorer reduction of their pain when compared with younger counterparts and concurrently receive less opioids and more NSAIDs when in the ED.9 While such findings may be misconstrued as beneficial by Solomon et al,1 older adults with acute pain in the ED nonetheless have decreased reduction of their pain. This scenario will only worsen if clinicians incorrectly conclude that opioids are not safe and that NSAIDs are safer—a causal association not demonstrated by the article by Solomon et al,1 as investigators themselves point out. Although the article by Solomon et al1 was well intentioned and could have better advocated a balanced approach in understanding the risks and benefits of all analgesic treatments, the findings are now obscured by misinterpretations by the general public and medical community. Pain care in older adults must continue to be aggressively addressed. Any excuses to not treat pain in elderly patients cannot be tolerated.

Fueled by a decade-long increase in emergency department (ED) visits with a concomitant decrease in hospital bed capacity and the number of hospital EDs, ED crowding has reached crisis proportions. Robust information systems and process redesign are two strategies to improve the safety and quality of emergency care. At the ED at the Mount Sinai Medical Center, an urban, tertiary care academic medical center in New York City, elements of departmental work flow were redesigned to streamline patient throughput before implementation of a fully integrated emergency department information system (EDIS) with patient tracking, computerized charting and order entry, and direct access to patient historical data from the hospital data repository. Pre- and postintervention data were analyzed to examine the impact on (ED) efficiency.The length of stay for all patients (arrival to time patient left ED) decreased by 1.94 hours, from 6.69 (n = 508) pre-intervention to 4.75 (n = 691) postintervention (p.001); doctor-to-disposition time (first doctor-patient contact to disposition decision) decreased by 1.90 hours, from 3.64 (n = 508) to 1.74 (n = 691; p.001); door-to-doctor time (triage to first doctor-patient contact) decreased by 0.54 hours, from 1.22 (n = 508) to 0.68 (n = 691; p.001). X-ray turnaround time (TAT) decreased by 0.18 hours from 0.92 (n = 60) to 0.74 (n = 108; p = .179); computerized tomography (CT) scan TAT decreased by 1.56 hours, from 3.89 (n = 40) to 2.33 (n = 29; p.001), lab TAT decreased by 0.59 hours, from 2.03 (n = 121) to 1.44 (n = 271; p = .006).Increasing the clinical information available at the bedside and improving departmental work flow through EDIS implementation and process redesign led to decreased patient throughput times and improved ED efficiency.