Search

Objectives: The objective was to determine the incremental benefit of a shortness-of-breath (SOB) point-of-care biomarker panel on the diagnostic accuracy of emergency department (ED) patients presenting with dyspnea. Methods: Adult ED patients at 10 U.S. EDs with SOB were included. The physician’s estimates of the pretest clinical probability of heart failure (HF), acute myocardial infarction (MI), and pulmonary embolism (PE) were recorded using deciles (0%–100%). Blood samples were analyzed using a SOB point-of-care biomarker panel (troponin I, myoglobin, creatinine kinase-myocardial band isoenzyme [CK-MB], D-dimer, and B-type natriuretic peptide [BNP]). Thirty-day follow-up for MI, HF, and PE was performed. Data were analyzed using logistic regression and receiver operating characteristics (ROC) curve analysis. Results: Of 301 patients, the mean (±standard deviation [SD]) age was 61 (±18) years; 56% were female, 58% were white, and 38% were African American. Diagnoses included MI (n = 54), HF (n = 91), and PE (n = 16) in a total of 129 (43%) of the patients. High pretest clinical certainty (≥80%) identified 60 of these 129 (46.5%) cases. The SOB point-of-care biomarker panel identified 66 additional cases of MI (n = 24), HF (n = 31), and PE (n = 11). The overall adjusted sensitivity for any diagnosis was increased from 65% to 70% with the addition of the SOB point-of-care biomarker panel (difference = 5%, 95% CI = −1.1% to 11%) while specificity was increased from 82% to 83% (difference = 1%, 95% CI = −4% to 7%). The model containing pretest probability and the results of the SOB panel had an area under the curve (AUC) of 83.4% (95% CI = 78.4% to 88.5%), which was not significantly better than the AUC of 80.4% (95% CI = 75.1% to 85.7%) for clinical probability alone. Conclusions: The addition of the SOB panel of markers did not improve the AUC for diagnosing the combined set of clinical conditions. Using the disease-specific SOB biomarkers increased the sensitivity on a disease-by-disease basis; however, specificity was reduced.

It is widely recognized that the impact of heart failure on society is enormous. The research community has responded, resulting in an ongoing period of rapid advancement across a wide range of fields. The pace of progress is perhaps most apparent in the barrage of new and revised terminology appearing in the heart failure literature. Although sometimes confusing, the complexity of nomenclature directly reflects a growing appreciation that the symptom complex previously labeled "heart failure" is actually a spectrum of complex multisystem pathologies. Accordingly, clinicians must adopt a more sophisticated and more effective approach to evaluation and treatment that is increasingly based on objective measurement of outcome-linked physiologic parameters rather than the subjectively described symptom constellations relied on previously.

Introduction: Disaster drills are a valuable means of training healthcare providers to respond to mass casualty incidents resulting from acts of terrorism or public health crises. We present here a proposed hospital-based disaster drill evaluation tool that is designed to identify strengths and weaknesses of hospital disaster drill response, provide a learning opportunity for disaster drill participants, and promote integration of lessons learned into future responses. Methods: Clinical specialists, experienced disaster drill coordinators and evaluators, and experts in questionnaire design developed the evaluation mod-ules based upon a comprehensive review of the litera-ture, including evaluations of disaster drills. The tool comprises six evaluation modules designed to capture strengths and weaknesses of different aspects of hospital disaster response. The Predrill Module is completed by the hospital during drill planning and is used to define the scope of the exercise. The Incident Command Center Module assesses command structure, communication between response areas and the command center, and communication to outside agencies. The Triage Zone Module captures the effect of a physical space on triage activities, efficiency of triage operations, and victim flow. The Treatment Zone Module assesses the relation of the zone’s physical characteristics to treatment activities, efficacy of treatment operations, adequacy of supplies, and victim flow. A Decontamination Zone Module is available for evaluating decontamination operations and the use of decontamination and/or personal protective equipment in drills that involve biological or radiological hazardous materials. The Group Debriefing Module provides sample discussion points for drill participants in all types of drills. The tool also has addenda to evaluate specifics for 1) general observation and documentation, 2) victim tracking, 3) biological incidents, and 4) radiological incidents. Conclusion: This evaluation tool will help meet the need for standardized evaluation of disaster drills. The modular approach offers flexibility and could be used by hospitals to evaluate staff training on response to natural or man-made disasters.

Background Cardiac troponin T (cTnT), high sensitivity C-reactive protein (hs-CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) have emerged as strong predictors of adverse events among patients presenting with acute coronary syndromes (ACS). We evaluated the prognostic performance of each of these markers, individually, and in combination in patients presenting to the emergency department (ED) with ACS symptoms. Methods Serum samples were obtained from 422 consenting patients presenting to the ED with symptoms of acute coronary syndrome (ACS) and subsequently tested for cTnT, NT-proBNP, myoglobin, CK-MB, and hs-CRP. Adverse events (AEs) occurring within 30 days (death, myocardial infarction, unstable angina and the need for revascularization procedures) were recorded and ROC curves were constructed. Results AEs occurred in 42 patients (10%). Relative risk, cut-off, and predictive values for each biomarker were determined statistically, with the exception of cTnT, where the concentration meeting the 99th percentile of a healthy population with a 10% coefficient of variation (0.03 ng/ml) was used. These cut-off values, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and relative risk (RR) were calculated. Sensitivity and RR for a panel of cTnT and NT-proBNP were 78.6% (66.2–91.0) and 4.7 (2.3–9.5), respectively. Conclusions If used alone, cTnT appeared to have greater prognostic value when compared to hs-CRP, NT-proBNP, myoglobin or CK-MB. The combination of cTnT and NT-proBNP performed better than the combination of cTnT and hs-CRP. When cTnT, NT-proBNP and hs-CRP were used as a panel, there was no significant improvement in prognostic performance over using cTnT and NT-proBNP together. Thus, in patients with suspected ACS, the measurement of both cTnT and NT-proBNP may have enhanced prognostic performance over using either marker in isolation.

Summary Background The ability to provide medical care during sudden increases in patient volume during a disaster or other high-consequence event is a serious concern for health-care systems. Identification of inpatients for safe early discharge (ie, reverse triage) could create additional hospital surge capacity. We sought to develop a disposition classification system that categorises inpatients according to suitability for immediate discharge on the basis of risk tolerance for a subsequent consequential medical event. Methods We did a warfare analysis laboratory exercise using evidence-based techniques, combined with a consensus process of 39 expert panellists. These panellists were asked to define the categories of a disposition classification system, assign risk tolerance of a consequential medical event to each category, identify critical interventions, and rank each (using a scale of 1–10) according to the likelihood of a resultant consequential medical event if a critical intervention is withdrawn or withheld because of discharge. Findings The panellists unanimously agreed on a five-category disposition classification system. The upper limit of risk tolerance for a consequential medical event in the lowest risk group if discharged early was less than 4%. The next categories had upper limits of risk tolerance of about 12% (IQR 8–15%), 33% (25–50%), 60% (45–80%) and 100% (95–100%), respectively. The expert panellists identified 28 critical interventions with a likelihood of association with a consequential medical event if withdrawn, ranging from 3 to 10 on the 10-point scale. Interpretation The disposition classification system allows conceptual classification of patients for suitable disposition, including those deemed safe for early discharge home during surges in demand. Clinical criteria allowing real-time categorisation of patients are awaited.

Objectives The study purpose was to examine “gray zone” B-type natriuretic peptide (BNP) levels (100-500 pg/mL) in terms of associated clinical factors, perceived severity, and outcomes in patients with established congestive heart failure (CHF). Background Although gray zone BNP levels may have diagnostic ambiguity, the implications of these levels in patients with an established diagnosis of CHF have not been examined. Methods REDHOT was a national prospective study in which 464 patients seen in the emergency department with dyspnea had BNP levels drawn. Entrance criteria included a BNP >100 pg/mL; however, physicians were blinded to the actual BNP level. Patients were followed up for 90 days. Results Thirty-three percent had gray zone BNP levels. There was no difference in perceived New York Heart Association class ( P = .32) or admission rates ( P = .76) between the gray zone and non–gray zone groups; 62% of patients with a gray zone BNP were identified as class III or IV CHF. Despite this perceived severity, the 90-day event rate was lower in the gray zone group (19.2% vs 32.9%, respectively, P = .002). Although patients in the gray zone had more symptoms of concomitant pulmonary disease, multivariate analysis could not demonstrate any variable that worsened the prognosis of patients with a gray zone BNP level. Conclusions In patients with established CHF, those with gray zone BNP levels have a better prognosis than those with non–gray zone levels despite being perceived by physicians as having New York Heart Association class III or IV CHF.

Background Previous studies have shown that in patients presenting to the emergency department (ED) with heart failure, there is a disconnect between the perceived severity of congestive heart failure (CHF) by physicians and the severity as determined by B-type natriuretic peptide (BNP) levels. Whether ethnicity plays a role in this discrepancy is unknown. Methods and Results The Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) was a 10-center trial of 464 patients seen in the ED with acute dyspnea and BNP level higher than 100 pg/mL on arrival. Physicians were blinded to BNP levels. Patients were followed for 90 days after discharge. A total of 151 patients identified themselves as white (32.5%) and 294 as black (63.4%). Of these, 90% were hospitalized. African Americans were more likely to be perceived as New York Heart Association class I or II than whites ( P = .01). Blacks who were discharged from the ED had higher median BNP levels than whites who were discharged (1293 vs. 533, P = .004). The median BNP of blacks who were discharged was actually higher than the median BNP of blacks who were admitted (1293 vs. 769, P = .04); the same did not hold true for whites. BNP was predictive of 90-day outcome in both blacks and whites; however, perceived severity of CHF, race, and ED disposition did not contribute to the prediction of events. Conclusion In patients presenting to the ED with heart failure, the disconnect between perceived severity of CHF and severity as determined by BNP levels is most pronounced in African Americans.

The relationship between BNP and NT-proBNP among physiologically and clinically relevant demographic subgroups has never been clarified in the context of the emergency department (ED).A blood sample taken from patients presenting to the E.D. with suspected acute coronary syndromes (ACS) was analyzed for BNP and NT-proBNP, and correlation between them was examined as an entire group then as subgroups according to gender, ethnicity, age, and comorbidity variables.BNP and NT-proBNP correlate well (0.89, P0.0001) in a population of 420 patients and in patient subgroups with a history of various etiologies, including vascular disorders.In general, BNP and NT-proBNP correlate very well in patients with suspected ACS and may aid in the risk stratification process in emergency departments.

Introduction:Recently, mass-casualty incident (MCI) preparedness and training has received increasing attention at the hospital level.Objectives:To review the existing evidence on the effectiveness of disaster drills, technology-based interventions and tabletop exercises in training hospital staff to respond to an MCI.Methods:A systematic, evidence-based process was conducted incorporating expert panel input and a literature review with the key terms: “mass casualty”, “disaster”, “disaster planning”, and “drill”. Paired investigators reviewed citation abstracts to identify articles that included evaluation of disaster training for hospital staff. Data were abstracted from the studies (e.g., MCI type, training intervention, staff targeted, objectives, evaluation methods, and results). Study quality was reviewed using standardized criteria.Results:Of 243 potentially relevant citations, twenty-one met the defined criteria. Studies varied in terms of targeted staff, learning objectives, outcomes, and evaluation methods. Most were characterized by significant limitations in design and evaluation methods. Seventeen addressed the effectiveness of disaster drills in training hospital staff in responding to an MCI, four addressed technology-based interventions, and none addressed tabletop exercises. The existing evidence suggests that hospital disaster drills are effective in allowing hospital employees to become familiar with disaster procedures, identify problems in different components of response (e.g., incident command, communications, triage, patient flow, materials and resources, and security) and provide the opportunity to apply lessons learned to disaster response. The strength of evidence on other training methods is insufficient to draw valid recommendations.Conclusions:Current evidence on the effectiveness of MCI training for hospital staff is limited. A number of studies suggest that disaster drills can be effective in training hospital staff. However, more attention should be directed to evaluating the effectiveness of disaster training activities in a scientifically rigorous manner.

Objectives The purpose of this study was to examine the relationships among B-type natriuretic peptide (BNP) levels within the diagnostic range, perceived congestive heart failure (CHF) severity, clinical decision making, and outcomes of the CHF patients presenting to emergency department (ED). Background Since BNP correlates with the presence of CHF, disease severity, and prognosis, we hypothesized that BNP levels in the diagnostic range offer value independent of physician decision making with regard to critical outcomes in emergency medicine. Methods The Rapid Emergency Department Heart failure Outpatient Trial (REDHOT) study was a 10-center trial in which patients seen in the ED with shortness of breath were consented to have BNP levels drawn on arrival. Entrance criteria included a BNP level >100 pg/ml. Physicians were blinded to the actual BNP level and subsequent BNP measurements. Patients were followed up for 90 days after discharge. Results Of the 464 patients, 90% were hospitalized. Two-thirds of patients were perceived to be New York Heart Association (NYHA) functional class III or IV. The BNP levels did not differ significantly between patients who were discharged home from the ED and those admitted (976 vs. 766, p = 0.6). Using logistic regression analysis, an ED doctor's intention to admit or discharge a patient had no influence on 90-day outcomes, while the BNP level was a strong predictor of 90-day outcome. Of admitted patients, 11% had BNP levels 200 pg/ml was 9% and 29%, respectively (p = 0.006). Conclusions In patients presenting to the ED with heart failure, there is a disconnect between the perceived severity of CHF by ED physicians and severity as determined by BNP levels. The BNP levels can predict future outcomes and thus may aid physicians in making triage decisions about whether to admit or discharge patients. Emerging clinical data will help further refine biomarker-guided outpatient therapeutic and monitoring strategies involving BNP.

The potential clinical utility of single sample CK-MB isoforms measurement for early risk stratification of Emergency Department (ED) patients with possible myocardial ischemia was evaluated among 405 patients presenting to two urban EDs. Clinical and serologic data were prospectively collected and the occurrence of adverse events (AEs) and myocardial infarction (MI) during the 14-day outcome period was recorded and utilized to calculate and compare relative risks (RR) and predictive values of isoforms and CK-MB alone. Among the 405 patients, 67 accrued 105 AEs. Both isoforms and CK-MB alone were predictive of AEs with RR of 3.32 (2.09, 5.27) and 6.28 (4.64, 8.52), respectively. Isoforms had higher sensitivity for AEs compared to CK-MB (65.7% [54.3, 77.0] vs. 14.9% [6.4, 23.5]; p0. 01) but lower specificity (69.2% [64.3, 74.2] vs. 99.7% [99.1,100. 0]; p0.01). Isoforms' superior sensitivity allowed identification of many high risk patients missed by CK-MB alone. Further, for the prediction of MI, isoforms had superior diagnostic sensitivity and equivalent specificity. This investigation supports the emergency department use of early, single sample CK-MB isoform testing.

Objectives: To determine and compare the prognostic abilities of early, single-sample myoglobin measurement with that of creatine kinase-MB (CK-MB), with cardiac troponin T (cTnT), and with physician judgment in the absence of marker results among emergency department (ED) patients with possible myocardial ischemia. Methods: Prospective collection of clinical and serologic data using an identity-unlinked technique from patients with possible myocardial ischemia at two urban EDs. Outcome data concerning the occurrence of adverse events (AEs) during the 14 days after enrollment were used to calculate and compare the relative risks (RRs) and predictive values (with 95% confidence intervals) of the various markers for predicting AEs. Results: Among 396 analyzed patients, 65 (16.4%) accrued 104 AEs, including 13 deaths (3.3%) and 31 (7.8%) myocardial infarctions. Myoglobin predicted AEs (RR = 3.36 [95% CI = 2.19 to 5.15]) with significantly higher sensitivity (50.8% [95% CI = 38.6 to 62.9]) than either CK-MB (15.4% [95% CI = 6.6 to 24.2]) or cTnT (24.6% [95% CI = 14.1 to 35.1]), but with lower specificity (81.9% [95% CI = 77.7 to 86.0]; CK-MB = 99.7% [95% CI = 99.1 to 100]; cTnT = 93.1% [95% CI = 90.3 to 95.8]). Myoglobin had prognostic ability among patients with chest pain (3.86 [95% CI = 2.39 to 6.22]) and atypical (non-chest pain) presentations (2.71 [95% CI = 1.09 to 6.71]), including those with a non-diagnostic electrocardiogram (3.11 [95% CI = 1.44 to 6.69]). The combination of myoglobin and physician decision making identified 63 of the 65 patients (96.9% [95% CI = 92.7 to 100]) with subsequent AEs. Conclusions: The early prognostic sensitivity of myoglobin may allow identification of some high-risk patients missed by physician judgment, CK-MB, and cTnT. Myoglobin should be considered for use in the ED based on both its diagnostic and prognostic abilities.

This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs' content would be "observational" rather than involving direct "hands-on" clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.

Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.

It has long been known that among patients with end-stage renal disease (ESRD), cardiac disease is the single greatest cause of mortality, accounting for nearly one half of all deaths (1). Among community-based populations, renal insufficiency is an independent predictor of the risk of subsequent ischemic heart disease, conferring a risk equivalent to that of diabetes (2). Furthermore, the presence of even moderate renal impairment in a patient presenting with an acute coronary syndrome (ACS) is a strong short-term prognostic indicator, significantly increasing the 30-day risk of myocardial infarction, heart failure, and cardiac death (3). Thus, a strong and pervasive link clearly exists between kidney failure and cardiac disease. The common challenge to the nephrologist, cardiologist, and emergency physician therefore lies in successfully recognizing those patients within their scope of practice who are most at risk, thereby allowing targeted application of interventions designed to circumvent adverse outcomes. Accordingly, there is an exigent need for the clinical laboratory to identify and make available reliable assays for biomarkers that can predict adverse events across a range of clinical settings and among patients with various degrees of kidney dysfunction, as well as to elucidate the performance characteristics and limitations of each of these markers. A variety of individual biomarkers have previously been evaluated for this purpose, and several have been found to successfully predict outcome in patients with kidney disease. These include markers of myocardial necrosis, such as cardiac troponin T (cTnT) and I (cTnI) (4); markers of heart failure, such as B-type natriuretic peptide (BNP) and its associated inactive N-terminal fragment (NT-proBNP) (5); and the marker of systemic inflammation, high-sensitivity C-reactive protein (hsCRP) (6). However, fulfillment of the obvious potential of these biomarkers to have a positive impact on the care of renal failure patients has been elusive because of unresolved clinical …

Study objective: Chest pain and myocardial infarction following the use of cocaine have been well documented. We assessed the prevalence of cocaine use in patients who presented to the emergency department with chest pain of possibly ischemic origin. Design: During times of research assistant availability, consecutive adults with the chief complaint of chest pain unexplained by trauma or radiographic abnormality were questioned about cocaine use in the preceding week. Urine was tested for the presence of cocaine or cocaine metabolites with a highly accurate bedside urine test kit (specificity, 100%; sensitivity 98%). Anonymous unlinked data-collection methods were used. Therefore we could not determine whether the patients who used cocaine had sustained myocardial infarctions. Setting: One suburban and three urban EDs. Results: We enrolled 359 patients with a mean age of 51 years, 8% of whom sustained myocardial infarctions. Sixty patients (17%) had cocaine or cocaine metabolites in urine. The likelihood of testing positive for cocaine varied by age group: 18 to 30 years, 29%; 31 to 40 years, 48%; 41 to 50 years, 18%; 51 to 60 years, 3%; 61 years or older, 0% ( P Conclusion: Many ED patients with chest pain have recently used cocaine. Because the recent use of cocaine is not uncommon in patients with chest pain up to 60 years old, such patients should be questioned about cocaine use. When treatment or disposition may be altered, consideration should be given to objective assessment of cocaine use because patient self-report does not appear reliable. [Hollander JE, Todd KH, Green G, Heilpern KL, Karras DJ, Singer AJ, Brogan GX, Funk JP, Strahan JB: Chest pain associated with cocaine: An assessment of prevalence in suburban and urban emergency departments. Ann Emerg Med December 1995;26:671-676.]

Objectives:US hospitals are expected to function without external aid for up to 96 hours during a disaster; however, concern exists that there is insufficient capacity in hospitals to absorb large numbers of acute casualties. The aim of the study was to determine the potential for creation of inpatient bed surge capacity from the early discharge (reverse triage) of hospital inpatients at low risk of untoward events for up to 96 hours.Methods:In a health system with 3 capacity-constrained hospitals that are representative of US facilities (academic, teaching affiliate, community), a variety (N = 50) of inpatient units were prospectively canvassed in rotation using a blocked randomized design for 19 weeks ending in February 2006. Intensive care units (ICUs), nurseries, and pediatric units were excluded. Assuming a disaster occurred on the day of enrollment, patients who did not require any (previously defined) critical intervention for 4 days were deemed suitable for early discharge.Results:Of 3491 patients, 44% did not require any critical intervention and were suitable for early discharge. Accounting for additional routine patient discharges, full use of staffed and unstaffed licensed beds, gross surge capacity was estimated at 77%, 95%, and 103% for the 3 hospitals. Factoring likely continuance of nonvictim emergency admissions, net surge capacity available for disaster victims was estimated at 66%, 71%, and 81%, respectively. Reverse triage made up the majority (50%, 55%, 59%) of surge beds. Most realized capacity was available within 24 to 48 hours.Conclusions:Hospital surge capacity for standard inpatient beds may be greater than previously believed. Reverse triage, if appropriately harnessed, can be a major contributor to surge capacity. (Disaster Med Public Health Preparedness. 2009;3(Suppl 1):S10–S16)

In order to determine the sensitivity and specificity of two rapid human immunodeficiency virus (HIV-1) assays compared with enzyme immunoassay and Western blot and to assess their potential use for routine screening in an emergency department (ED), we analyzed sera from 492 consecutive ED patients using an identity-unlinked design. Sera were analyzed for HIV-1 by standard enzyme-linked immunosorbent assay and Western blot and two rapid assays: the Abbott Testpack HIV-1 (Abbott Labs, Inc, Abbott Park, IL) and the HIV-1 Genie, (Genetic Systems, Seattle, WA). Seroprevalence of HIV-1 among 492 samples was 5.1%. Both rapid assays were easy to perform and required approximately 10 minutes per test. Sensitivity and specificity of both rapid assays were 100% and 99.8%, with positive and negative predictive values of 96.2% and 100%, respectively. It was concluded that both rapid assays showed high concordance with standard enzyme-linked immunosorbent assay and Western blot. Since the ED is often the primary care setting for many patients at risk for HIV-1, the ED may be an optimal site for routine HIV-1 screening. Rapid assay screening may provide the opportunity for timely identification of HIV-1-infected patients, allowing earlier treatment and counseling. However, ethical and practical questions regarding appropriate application of rapid HIV-1 testing in EDs still needs resolution.

Mass-casualty triage has developed from a wartime necessity to a civilian tool to ensure that constrained medical resources are directed at achieving the greatest good for the most number of people. Several primary and secondary triage tools have been developed, including Simple Treatment and Rapid Transport (START), JumpSTART, Care Flight Triage, Triage Sieve, Sacco Triage Method, Secondary Assessment of Victim Endpoint (SAVE), and Pediatric Triage Tape. Evidence to support the use of one triage algorithm over another is limited, and the development of effective triage protocols is an important research priority. The most widely recognized mass-casualty triage algorithms in use today are not evidence-based, and no studies directly address these issues in the mass-casualty setting. Furthermore, no studies have evaluated existing mass-casualty triage algorithms regarding ease of use, reliability, and validity when biological, chemical, or radiological agents are introduced. Currently, the lack of a standardized mass-casualty triage system that is well validated, reliable, and uniformly accepted, remains an important gap. Future research directed at triage is recognized as a necessity, and the development of a practical, universal, triage algorithm that incorporates requirements for decontamination or special precautions for infectious agents would facilitate a more organized mass-casualty medical response.

Disaster drills are a valuable means of training healthcare providers to respond to mass casualty incidents resulting from acts of terrorism or public health crises. We present here a proposed hospital-based disaster drill evaluation tool that is designed to identify strengths and weaknesses of hospital disaster drill response, provide a learning opportunity for disaster drill participants, and promote integration of lessons learned into future responses.Clinical specialists, experienced disaster drill coordinators and evaluators, and experts in questionnaire design developed the evaluation modules based upon a comprehensive review of the literature, including evaluations of disaster drills. The tool comprises six evaluation modules designed to capture strengths and weaknesses of different aspects of hospital disaster response. The Predrill Module is completed by the hospital during drill planning and is used to define the scope of the exercise. The Incident Command Center Module assesses command structure, communication between response areas and the command center, and communication to outside agencies. The Triage Zone Module captures the effect of a physical space on triage activities, efficiency of triage operations, and victim flow. The Treatment Zone Module assesses the relation of the zone's physical characteristics to treatment activities, efficacy of treatment operations, adequacy of supplies, and victim flow. A Decontamination Zone Module is available for evaluating decontamination operations and the use of decontamination and/or personal protective equipment in drills that involve biological or radiological hazardous materials. The Group Debriefing Module provides sample discussion points for drill participants in all types of drills. The tool also has addenda to evaluate specifics for 1) general observation and documentation, 2) victim tracking, 3) biological incidents, and 4) radiological incidents.This evaluation tool will help meet the need for standardized evaluation of disaster drills. The modular approach offers flexibility and could be used by hospitals to evaluate staff training on response to natural or man-made disasters.

Background The impact of primary care physicians on health care utilization remains controversial. Some have hypothesized that primary care physicians decrease health care utilization through enhanced coordination of care and a preventive care focus. Methods Using data from the Area Resource File (a Health Resources and Services Administration US county-level database) for the years 1990, 1995, and 1999, we performed a retrospective cross-sectional analysis with generalized estimating equations to determine if measures of health care utilization (inpatient admissions, outpatient visits, emergency department visits, and surgeries) were associated with the proportion of primary care physicians to total physicians within metropolitan statistical areas. Results The average proportion of primary care physicians in each metropolitan statistical area was 0.34 (SD 0.46, range 0.20-0.54). Higher proportions of primary care physicians were associated with significantly decreased utilization, with each 1% increase in proportion of primary care physicians associated with decreased yearly utilization for an average-sized metropolitan statistical area of 503 admissions, 2968 emergency department visits, and 512 surgeries (all P Conclusions Increased proportions of primary care physicians appear to be associated with significant decreases in measures of health care utilization across the 1990s. National efforts aimed at limiting health care utilization may benefit from focusing on the proportion of primary care physicians relative to specialists in this country.

Background: The existence of race and gender differences in the provision of cardiovascular health care has been increasingly recognized. However, few studies have examined whether these differences exist in the emergency department (ED) setting. Objectives: To evaluate race, gender, and insurance differences in the receipt of early, noninvasive diagnostic tests among persons presenting to an ED with a complaint of chest pain. Methods: Data were drawn from the U.S. National Hospital Ambulatory Health Care Survey of EDs. Visits made during 1995–2000 by persons aged 30 years or older with chest pain as a reason for the visit were included. Factors affecting the likelihood of ordering electrocardiography, cardiac monitoring, oxygen saturation measurement using pulse oximetry, and chest radiography were analyzed using multivariate probit analysis. Results: A total of 7,068 persons aged 30 years or older presented to an ED with a primary complaint of chest pain during the six-year period, corresponding to more than 32 million such visits nationally. The adjusted probability of ordering a test was highest for non–African American patients for all tests considered. African American men had the lowest probabilities (74.3% and 62% for electrocardiography and chest radiography, respectively), compared with 81.1% and 70.3%, respectively, among non African American men. Only 37.5% of African American women received cardiac monitoring, compared with 54.5% of non–African American men. Similarly, African American women were significantly less likely than non–African American men to have their oxygen saturation measured. Patients who were uninsured or self-pay, as well as patients with ‘‘other’’ insurance, also had a lower probability than insured persons of having these tests ordered. Conclusions: This study documents race, gender, and insurance differences in the provision of electrocardiography and chest radiography testing as well as cardiac rhythm and oxygen saturation monitoring in patients presenting with chest pain. These observed differences should catalyze further study into the underlying causes of disparities in cardiac care at an earlier point of patient contact with the health care system.

Objectives:No universally accepted methods for objective evaluation of the function of the Incident Command System (ICS) in disaster exercises currently exist. An ICS evaluation method for disaster simulations was derived and piloted.Methods:A comprehensive variable list for ICS function was created and four distinct ICS evaluation methods (quantitative and qualitative) were derived and piloted prospectively during an exercise. Delay times for key provider-victim interactions were recorded through a system of data collection using participant and observer-based instruments. Two different post exercise surveys (commanders, other participants) were used to assess knowledge and perceptions of assigned roles, organization, and communications. Direct observation by trained observers and a structured debriefing session also were employed.Results:A total of 45 volunteers participated in the exercise that included 20 mock victims. First, mean, and last victim delay times (from exercise initiation) were 2.1, 4.0, and 9.3 minutes (min) until triage, and 5.2, 11.9, and 22.0 min for scene evacuation, respectively. First, mean, and last victim delay times to definitive treatment were 6.0, 14.5, and 25.0 min. Mean time to triage (and range) for scene Zones I (nearest entrance), II (intermediate) and III (ground zero) were 2.9 (2.0–4.0), 4.1 (3.0–5.0) and 5.2 (3.0–9.0) min, respectively. The lowest acuity level (Green) victims had the shortest mean times for triage (3.5 min), evacuation (4.0 min), and treatment (10.0 min) while the highest acuity level (Red) victims had the longest mean times for all measures; patterns consistent with independent rather than ICS-directed rescuer activities. Specific ICS problem areas were identified.Conclusions:A structured, objective, quantitative evaluation of ICS function can identify deficiencies that can become the focus for subsequent improvement efforts.

Guatemala has recently undergone many advances in emergency medical services (EMS) training and disaster management. Industrialization and demographic changes have led to a continuing decline in the prevalence of infectious disease, while trauma and cardiovascular-related deaths have become increasingly important. Trauma now accounts for the nation's single greatest cause of productive years of life lost, a major indicator of a disease's impact on society. This "demographic transition" has dramatically increased the number of incidents where early prehospital intervention can have a positive impact on morbidity and mortality. However, until recently, prehospital medical care was provided by firefighters, who lacked formal medical training. Responding to a perceived need, increased collaborative efforts between prehospital care providers and governmental and nongovernmental agencies have rapidly improved provider training, initiated care standardization, and improved disaster preparedness. These efforts may serve as a model to other developing nations seeking to improve their EMS systems.

Background: Higher circulating concentrations of pregnancy-associated plasma protein A (PAPP-A), a potential proatherosclerotic metalloproteinase, have been associated with increased risk for acute coronary syndrome (ACS). Our goal was to determine the ability of circulating concentrations of PAPP-A to predict adverse events in patients presenting to the Emergency Department (ED) with symptoms of ACS. Methods: A total of 346 patients with symptoms of ACS were included in the study. Serum samples obtained immediately after enrollment were analyzed for PAPP-A and cardiac troponin T (cTnT). The occurrence of adverse events during a 30-day follow-up period was recorded, and receiver-operating characteristic (ROC) curve analysis was performed to evaluate the prognostic characteristics of PAPP-A and cTnT. Results: A total of 33 (9.5 %) patients developed adverse events during the follow up period. At a cut-off concentration of 0.22 mIU/l, PAPP-A was a predictor of adverse events with a sensitivity and specificity (95% C.I.) of 66.7% (48.2–82.0) and 51.1% (45.4–56.8), respectively. The sensitivity and specificity of cTnT were 51.5% (33.6–69.2) and 82.1% (77.4–86.2), respectively, using a 0.01-ng/ml cut-off value, which was obtained using ROC analysis. Conclusions: PAPP-A appears to be a modest predictor of adverse events in patients presenting to the ED with ACS symptoms, being inferior to cTnT in predicting adverse events in an ED setting. PAPP-A appears to be as sensitive as cTnT, but it is less specific.

Disaster simulations (drills) are widely used throughout the world and are considered a fundamental tool for evaluation and improvement of local disaster response capacity. Despite this, no generally accepted methodology exists for quantitative evaluation of the medical response to a disaster drill. We therefore set out to develop and prospectively test a comprehensive method to assess both medical provider and organizational performance during a disaster simulation. Because disasters disproportionately affect the populations of developing countries, we designed these methods to be sufficiently flexible to be applicable in both the developed and the developing world. Objective outcome measures were identified for each component of disaster medical response and were incorporated into 3 data collection instruments. The derived methods were applied to a multiagency disaster simulation in Guatemala City, Guatemala. On the basis of this pilot study, suggested modifications and recommendations were made. The ability to objectively identify the specific strengths and weaknesses of an emergency medical services systems' medical response to a disaster is an important step toward optimizing system performance. On the basis of our experience, we recommend the incorporation of objective evaluation methods such as these into every disaster simulation.

Objectives: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already fa- miliar with EM. Methods: The techniques and pro- grams used by the authors and others in assisting in EM development in other countries to date are de- scribed. Conclusions: Some aspects of EM system de- velopment have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the effi- cacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts. Key words: emergency med- icine development; international emergency medi- cine; system development; EMS systems. ACA- DEMIC EMERGENCY MEDICINE 2000; 7:911-917

OBJECTIVES: To determine and compare the prognostic abilities of early, single-sample measurements of cardiac troponin I (cTn-I), cardiac troponin T (cTn-T), and creatine kinase-MB (CK-MB) among ED patients with possible myocardial ischemia. METHODS: Prospective collection of clinical and serologic data using an identity-unlinked technique from patients with possible myocardial ischemia at 2 urban EDs. Outcome data concerning the occurrence of adverse events (AEs) during the 14 days after enrollment were used to calculate and compare the relative risks (RRs) and predictive values (with 95% confidence intervals) of the 3 markers for predicting AEs. RESULTS: Among the 401 study patients, 105 AEs occurred in 67 patients. cTn-I, cTn-T, and CK-MB were all significantly predictive of AEs, with RRs of 3.87 (2.39, 6.26), 3.03 (1.92, 4.79), and 6.45 (4.74, 8.77), respectively. For prediction of AEs, sensitivity for each of the 3 markers was low (cTn-I = 15.38, cTn-T = 24.62, CK-MB = 15.38), while specificity was high (cTn-I = 97.62, cTn-T = 93.15, CK-MB = 99.70). No significant difference in predictive ability was found between cTn-I and cTn-T. However, a positive CK-MB result was a stronger predictor of AEs than either cTn-I (p = 0.01) or cTn-T (p = 0.001). CONCLUSIONS: No significant difference in predictive abilities was found between cTn-I and cTn-T. However, routine testing for both CK-MB and either of the troponins may optimize early identification of high-risk patients so they may be targeted for a higher level of care and consideration of more aggressive therapies.

Nicaragua is one of the poorest nations in the Western Hemisphere. The health of the population suffers as a result of poor nutrition, epidemic diseases, natural and manmade disasters, sporadic violence, urban industrial growth, and inadequate government funding for even basic medical equipment and supplies. Within this environment, emergency services development has been recognized as an important and cost-effective public health intervention. In recent years, government and nongovernmental agencies working together have had a dramatic positive impact on the quality of emergency care provided.

Study Objectives: To evaluate and compare the utility of measurement of troponin T and the creatine kinase MB subunit (CK-MB) for risk stratification of ED patients with possible myocardial ischemia. Methods: Prospective observational study of ED patients with symptoms of possible myocardial ischemia with early, single sample serologic testing for cardiac troponin T and CK-MB using an identity-unlinked process. Chart review (ED, inpatient, outpatient), and telephone and mail surveys identified adverse events (AEs) during the 14 days following enrollment. AEs recorded included death, respiratory or cardiac arrest, myocardial infarction (MI), atrial and ventricular arrhythmias, pulmonary edema, conduction disturbances, and recurrent angina. Measures of the predictive ability for AEs were calculated for troponin T, CK-MB, and a combined troponin T/CK-MB index (defined as positive if either troponin T or CK-MB levels exceeded threshold values). Results: Among 292 study patients, 45 (15.4%) experienced at least one AE, including seven deaths and 12 MIs. The troponin T result was positive in 34 patients, and the CK-MB result was positive in 15 patients; 6 patients had positive results for both markers and 43 patients had a positive combined troponin T/CK-MB index. Odds ratios (ORs) for occurrence of AEs among all patients were 4.4 (1.8 to 10.2), 10.0 (3.0 to 36.0), and 4.5 (2.0 to 9.8) for troponin T, CK-MB, and the troponin T/CK-MB index, respectively. Both markers were individually predictive of AEs (troponin T=4.3; CK-MB=7.5) among all those with chest pain. Only the CK-MB level was significantly predictive of AEs among those presenting with symptoms other than chest pain (OR=24.3 [1.1, 1448]), whereas only the troponin T level was significantly predictive among patients representing a disposition dilemma for the emergency physician (OR=5.7 [1.4, 20.7]). When compared, the ORs for troponin T and CK-MB were not significantly different for any patient subgroup. The troponin T/CK-MB index did not have a higher prognostic value than either troponin T or CK-MB alone in any subgroup studied. Conclusion: A positive test result for either troponin T or CK-MB in the ED successfully identified patients at significantly higher risk of adverse events during the 2 weeks following their ED visit. The two markers may complement each other in that each appears to have prognostic ability among a unique patient subgroup. ED marker measurement can provide useful prognostic information for patients with a broad spectrum of presentations consistent with possible myocardial ischemia. [Green GB, Beaudreau RW, Chan DW, DeLong D, Kelley CA, Kelen GD: Use of troponin T and creatine kinase-MB subunit levels for risk stratification of emergency department patients with possible myocardial ischemia. Ann Emerg Med January 1998;31:19-29.]

In recent years, the approach used in the evaluation of the emergency department (ED)* patient with suspected myocardial ischemia has undergone dramatic changes. Data-gathering, treatment, and disposition patterns that had been accepted for decades are now being intensely scrutinized and often abandoned in favor of assessment protocols based on new diagnostic technologies (1). Foremost among these new technologies are the many new methods for the laboratory measurement of markers of myocardial injury.

Atherosclerotic vascular disease has been present in humans for thousands of years. Atherosclerotic lesions were identified in Egyptian mummies dating as early as the 15th century B.c. In the 19th century, researchers speculated that arterial wall injury may cause an inflammatory response, resulting in atherosclerotic lesions (1). By the early 1900s investigators had proposed a correlation among the degree of atheroscle-rotic lesions, acute myocardial infarction (AMI)*, and stroke (2). The prevention and treatment of coronary artery atherogenesis is a major public health concern today (3).

Interest in the development of the specialty of emergency medicine and of emergency health care systems has greatly increased worldwide in the last few years. The guidelines in this article were developed in an effort to assist others in design and evaluation of all types of emergency medicine projects.

Infections with hepatitis B virus (HBV), hepatitis C virus (HCV), and the human immunodeficiency virus type 1 (HIV-1) are common in inner-city populations, but their frequency and interrelations are not well established.During a six-week period, excess serum samples were collected, along with information on risk factors, from all adult patients presenting to an inner-city emergency department. The samples were assayed for hepatitis B surface antigen (HBsAg) and antibodies to HCV and HIV-1.Of the 2523 patients tested, 612 (24 percent) were infected with at least one of the three viruses. Five percent were seropositive for HBV, 18 percent for HCV, and 6 percent for HIV-1. HCV was found in 145 of the 175 intravenous drug users (83 percent), 36 of the 171 transfusion recipients (21 percent), and 5 of the 24 homosexual men (21 percent). Among black men 35 to 44 years of age, the seroprevalence of HCV was 51 percent. HBsAg was present in 9 percent of those whose only identifiable risk was possible heterosexual exposure. At least one viral marker was found in about 30 percent of the patients who were actively bleeding or in whom procedures were performed. Testing for HIV-1 alone would have failed to identify 87 percent of the patients infected with HBV and 80 percent of those infected with HCV.In a population of patients in an inner-city emergency room, HBV, HCV, and HIV-1 are all highly prevalent. However, routine screening for HIV-1 alone would identify only a small fraction of the patients who pose risks of severe viral infections, including HBV and HCV, to providers.

Study objectives: To determine the sensitivity, specificity, and predictive values of a new rapid creatine kinase-MB (R-CK-MB) assay compared with a standard CK-MB (S-CK-MB) assay and to determine its potential use in the evaluation of emergency department patients with possible myocardial infarction. Design: Retrospective patient identification with subsequent testing of excess sera for CK-MB and total CK using an identity-unlinked procedure. Setting: Large, urban, teaching hospital ED. Participants: All adult patients with excess sera and one of several defined presentations chosen to identify those with possible myocardial ischemia or infarction. Patients with clearly documented noncardiac etiologies of their symptoms or signs were excluded. Main results: The sensitivity, specificity, and positive and negative predictive values of 271 patient specimens for the R-CK-MB assay compared with the S-CK-MB assay were 100%, 96.8%, 75.0%, and 100%, respectively. The R-CK-MB assay was positive for 32 patients (11.8%). Of these, eight (25.0%) were admitted to unmonitored beds, and five (15.6%) were discharged home. All of these 13 patients had initial ECGs without evidence of ischemia or infarction. On follow-up, at least eight of the 13 had evidence of infarction. Conclusion: The R-CK-MB assay demonstrated high sensitivity and specificity compared with the S-CK-MB assay. When used for patients in whom a cardiac care unit admission is not considered, the rapid assay may identify some patients with unsuspected myocardial infarction and prevent inadvertent discharge or admission to unmonitored beds.

1describes the planning and implementation of a public health surveillance and response system. The article by Wetterhall et al 2 examines the 10 715 physicianpatient encounters recorded during the 17 days of the Olympic Games. These articles provide valuable information for planning future Olympic Games, and present useful lessons that can be applied to medical care for other mass gatherings and special events.

Seven months following the introduction of an institutional policy mandating compliance with universal precautions (UPs), we observed 127 health care workers performing 1421 interventions on 155 critically ill and injured patients in an emergency department setting in July 1989. Results were compared with a similar study undertaken exactly 1 year previously when UPs were considered as guidelines only. Overall adherence to UPs improved from 44.0% to 72.7% from 1 year to the next. Adherence to UPs improved from 19.5% to 55.7% during interventions on patients with profuse bleeding and from 16.7% to 54.5% during performance of major procedures. Compliance improved from 47.9% to 81.0% for emergency departmentbased health care workers (residents, attending physicians, nurses, x-ray film technicians). Prehospital care providers, a group not accountable to the institution, remained particularly noncompliant with only 13% adherence. We conclude that mandating UPs as policy with a monitoring component is effective in ensuring a reasonable level of adherence. However, given current barrier technology, achieving appropriate levels of compliance during unscheduled visits by patients requiring immediate attention and rapid intervention remains a challenge. ( Arch Intern Med. 1991;151:2051-2056)

The article extends results previously known for boundary value problems involving only a finite number of boundary points to those which involve an infinite number of (possibly dense) boundary points. Specifically, the system $$Ly = y' + Py,\sum\limits_1^\infty {A_i } y(t_i ) = 0,0 \leqslant t_i \leqslant {\text{1,}}i = 1,...,\infty $$ , is discussed in the Hilbert space L2(0, 1). Suitable conditions for inverting the operator L are found, and the Green's function is exhibited. It is shown to have the standard properties as well as some which are new, when considered as a function of its second variable It is further shown to be the limit a.e. of Green's function for problems involving only a finite number of boundary points, as those points increase in number. Finally it is shown that L−1 is compact. By using the Green's function the domain of L is shown to be dense in L2(0, 1). and the adjoint L* and its domain are found. L is also shown to be closed. Lastly, by using some theorems concerning entire functions, the eigenvalues of L are shown to lie in a vertical strip with infinity as their only limit point. This in turn implies that if L−1 fails to exist, a slight perturbation in P will result in an invertible L, and the assumption made earlier concerning the existence of the Green's function is reasonable.