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GOALS We created an observation pathway with close outpatient follow-up for patients with mild acute pancreatitis (AP) to determine its effect on admission rates, length of stay (LOS), and costs. BACKGROUND AP is a common reason for hospitalization costing $2.6 billion annually. Majority have mild disease and improve quickly but have unnecessarily long hospital stays. STUDY We performed a pilot prospective cohort study in patients with AP at a tertiary-care center. In total, 90 patients with AP were divided into 2 groups: observation cohort and admitted cohort. Exclusion criteria from observation included end-organ damage, pancreatic complications, and/or severe cardiac, liver, and renal disease. Patients in observation received protocolized hydration and periodic reassessment in the emergency department and were discharged with outpatient follow-up. Using similar exclusion criteria, we compared outcomes with a preintervention cohort composed of 184 patients admitted for mild AP in 2015. Our primary outcome was admission rate, and secondary outcomes were LOS, patient charges, and 30-day readmission. RESULTS Admitted and preintervention cohorts had longer LOS compared with the observation cohort (89.7 vs. 22.6 h, P

Background We recently demonstrated that near-syncope patients are as likely as syncope patients to experience adverse outcomes. The Boston Syncope Criteria (BSC) identify patients with syncope unlikely to have adverse outcomes and reduce hospitalizations. It is unclear whether these guidelines could reduce hospitalization in near syncope as well. Objective To determine if BSC accurately predict which near-syncope patients require hospitalization. Methods A prospective observational study enrolled from August 2007 to October 2008 consecutive emergency department (ED) patients (aged > 18 years) with near syncope. BSC were first employed assuming that any patient with risk factors for adverse outcomes should be admitted, and then utilized using a modified rule: if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, patients may be discharged even with risk factors. Outcomes were identified by chart review and 30-day follow-up calls. Results Of 244 patients with near syncope, 111 were admitted, with 49 adverse outcomes. No adverse outcomes occurred among discharged patients. If BSC had been followed strictly, another 41 patients with risk factors would have been admitted and 34 discharged, a 3% increase in admission rate. However, using the modified criteria, only 68 patients would have required admission, a 38% reduction in admission, with no missed adverse outcomes on follow-up. Conclusion Although near-syncope patients may have risk factors for adverse outcomes similar to those with syncope, if the etiology of near syncope is dehydration or vasovagal, and ED work-up is normal, these patients may be discharged even with risk factors.

Introduction: The number of publications and how often these have been cited play a role in academic promotion. Bibliometrics that attempt to quantify the relative impact of scholarly work have been proposed. The h-index is defined as the number (h) of publications for an individual that have been cited at least h times. We calculated the h-index and number of publications for academic emergency physicians at the rank of professor. Methods: We accessed the Society for Academic Emergency Medicine professor list in January of 2012. We calculated the number of publications through Web of Science and PubMed and the h-index using Google scholar and Web of Science. Results: We identified 299 professors of emergency medicine. The number of professors per institution ranged from 1 to 13. Median h-index in Web of Science was 11 (interquartile range [IQR] 6–17, range 0–51), in Google Scholar median h-index was 14 (IQR 9–22, range 0–63) The median number of publications reported in Web of Science was 36 (IQR 18–73, range 0–359. Total number of publications had a high correlation with the h-index (r=0.884). Conclusion: The h-index is only a partial measure of academic productivity. As a measure of the impact of an individual's publications it can provide a simple way to compare and measure academic progress and provide a metric that can be used when evaluating a person for academic promotion. Calculation of the h-index can provide a way to track academic progress and impact. [West J Emerg Med. 2014;15(3):290–292.]

Ophthalmologic emergencies account for up to 3% of visits to emergency departments in the United States. Although isolated ocular complaints are rarely life-threatening, they can lead to significant short- and long-term morbidity, including permanent visual loss. The role of the emergency physician in management of ocular emergencies is similar to that for other chief complaints: to recognize and diagnose emergency conditions, to provide appropriate initial therapy, and to ensure correct disposition. This article reviews several of the essential ophthalmologic procedures that are within the scope of emergency medical practice. Slit lamp examination, foreign body removal, use of ultrasound, tonometry, and other emergency ophthalmologic procedures are discussed.

Background Postintubation chest X-rays (CXR) are standard practice in emergency department (ED) intubations. In the operating room, it is not usually a standard practice to confirm endotracheal tube placement with a CXR. Aims We seek to study the utility of postintubation CXR in ED patients. Methods This was a retrospective case series of 157 adult patients intubated in the ED of an urban academic hospital with an emergency medicine training program. Standardized chart review was performed by two emergency physicians (EP) using a structured data abstraction tool and final radiology attending reads of postintubation CXR to assess placement. Endotracheal tube placement was graded as satisfactory, too high, too low, or malpositioned in the esophagus. Descriptive statistics were used, and 95% confidence intervals (CI) were reported. Hospital Institutional Review Board approval was obtained. Results A total of 157 patients were intubated in the ED during the study period: 127 (81%, 95% CI: 74–86) had adequate tube placement by CXR confirmation, 9 (6%, 95% CI: 3–11) endotracheal tubes were judged to be too high, and 20 (13%, 95% CI: 8–19) were judged to be too low with 10 (6.5%, 95% CI: 3–11) of these being right mainstem bronchus intubations. One patient (

Study objective Opioid pain reliever prescribing at emergency department (ED) discharge has increased in the past decade but specific prescription details are lacking. Previous ED opioid pain reliever prescribing estimates relied on national survey extrapolation or prescription databases. The main goal of this study is to use a research consortium to analyze the characteristics of patients and opioid prescriptions, using a national sample of ED patients. We also aim to examine the indications for opioid pain reliever prescribing, characteristics of opioids prescribed both in the ED and at discharge, and characteristics of patients who received opioid pain relievers compared with those who did not. Methods This observational, multicenter, retrospective, cohort study assessed opioid pain reliever prescribing to consecutive patients presenting to the consortium EDs during 1 week in October 2012. The consortium study sites consisted of 19 EDs representing 1.4 million annual visits, varied geographically, and were predominantly academic centers. Medical records of all patients aged 18 to 90 years and discharged with an opioid pain reliever (excluding tramadol) were individually abstracted by standardized chart review by investigators for detailed analysis. Descriptive statistics were generated. Results During the study week, 27,516 patient visits were evaluated in the consortium EDs; 19,321 patients (70.2%) were discharged and 3,284 (11.9% of all patients and 17.0% of discharged patients) received an opioid pain reliever prescription. For patients prescribed an opioid pain reliever, mean age was 41 years (SD 14 years) and 1,694 (51.6%) were women. Mean initial pain score was 7.7 (SD 2.4). The most common diagnoses associated with opioid pain reliever prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity fracture (7.1%) or sprain (6.5%). The most common opioid pain relievers prescribed were oxycodone (52.3%), hydrocodone (40.9%), and codeine (4.8%). Greater than 99% of pain relievers were immediate release and 90.0% were combination preparations, and the mean and median number of pills was 16.6 (SD 7.6) and 15 (interquartile range 12 to 20), respectively. Conclusion In a study of ED patients treated during a single week across the country, 17% of discharged patients were prescribed opioid pain relievers. The majority of the prescriptions had small pill counts and almost exclusively immediate-release formulations.

Introduction Intubation is one of the most important life-saving procedures performed by emergency physicians (EPs). There is variation in practice when different countries are compared. Methods A written questionnaire on intubation practices was administered to a group of Italian doctors practicing in Tuscany during the examination period of a year-long course in emergency medicine. Results The survey was administered to 153 participants. Of these, 143 (93.4%) returned a complete survey. In the sub-group of physicians who work in the emergency department (ED), 73.6% report intubating patients. Of those that intubate patients, 92.3% use some sort of sedation, and 49.3% use paralytics. While direct visualization of the cords for intubation and auscultation of breath sounds after intubation are almost universal (97% and 100%, respectively), only 11.9% use colorimetric CO2 detectors for confirmation of intubation. After intubation 58.2% commonly place a nasogastric tube and 50.7% obtain a post intubation chest radiograph. Conclusions Practice patterns in the USA and Tuscany are different. RSI and post-intubation radiographs are the standard of care in EDs in the USA. This is not the case in Tuscany.