Belanger, April; Devine, Lauren T.; Lane, Aaron; Condren, Michelle E.
This study described discharge prescription medication errors written for emergency department patients. This study used content analysis in a cross-sectional design to systematically categorize prescription errors found in a report of 1000 discharge prescriptions submitted in the electronic medical record in February 2015. Two pharmacy team members reviewed the discharge prescription list for errors. Open-ended data were coded by an additional rater for agreement on coding categories. Coding was based upon majority rule. Descriptive statistics were used to address the study objective. Categories evaluated were patient age, provider type, drug class, and type and time of error. The discharge prescription error rate out of 1000 prescriptions was 13.4%, with “incomplete or inadequate prescription” being the most commonly detected error (58.2%). The adult and pediatric error rates were 11.7% and 22.7%, respectively. The antibiotics reviewed had the highest number of errors. The highest within-class error rates were with antianginal medications, antiparasitic medications, antacids, appetite stimulants, and probiotics. Emergency medicine residents wrote the highest percentage of prescriptions (46.7%) and had an error rate of 9.2%. Residents of other specialties wrote 340 prescriptions and had an error rate of 20.9%. Errors occurred most often between 10:00 am and 6:00 pm.
Martin, Ian B.K.; Quinlivan, Evelyn B.; Gay, Cynthia L.; Leone, Peter A.
Objectives We evaluated emergency department (ED) provider adherence to guidelines for concurrent HIV-sexually transmitted disease (STD) testing within an expanded HIV testing program and assessed demographic and clinical factors associated with concurrent HIV-STD testing. Methods We examined concurrent HIV-STD testing in a suburban academic ED with a targeted, expanded HIV testing program. Patients aged 18–64 years who were tested for syphilis, gonorrhea, or chlamydia in 2009 were evaluated for concurrent HIV testing. We analyzed demographic and clinical factors associated with concurrent HIV-STD testing using multivariate logistic regression with a robust variance estimator or, where applicable, exact logistic regression. Results Only 28.3% of patients tested for syphilis, 3.8% tested for gonorrhea, and 3.8% tested for chlamydia were concurrently tested for HIV during an ED visit. Concurrent HIV-syphilis testing was more likely among younger patients aged 25–34 years (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [CI] 0.78, 2.10) and patients with STD-related chief complaints at triage (AOR=11.47, 95% CI 5.49, 25.06). Concurrent HIV-gonorrhea/chlamydia testing was more likely among men (gonorrhea: AOR=3.98, 95% CI 2.25, 7.02; chlamydia: AOR=3.25, 95% CI 1.80, 5.86) and less likely among patients with STD-related chief complaints at triage (gonorrhea: AOR=0.31, 95% CI 0.13, 0.82; chlamydia: AOR=0.21, 95% CI 0.09, 0.50). Conclusions Concurrent HIV-STD testing in an academic ED remains low. Systematic interventions that remove the decision-making burden of ordering an HIV test from providers may increase HIV testing in this high-risk population of suspected STD patients. PMID:24385644
English, Anthony M.
This chapter describes how professional and continuing higher education units can develop and sustain successful partnerships with academic departments in order to deliver educational programs effectively to students.
Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.
Carpenter, Christopher R; Bromley, Marilyn; Caterino, Jeffrey M; Chun, Audrey; Gerson, Lowell W; Greenspan, Jason; Hwang, Ula; John, David P; Lyons, William L; Platts-Mills, Timothy F; Mortensen, Betty; Ragsdale, Luna; Rosenberg, Mark; Wilber, Scott
In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and strained healthcare systems. In response, geriatric emergency medicine clinicians, educators, and researchers collaborated with the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations, equipment, policies, and protocols. These Geriatric Emergency Department Guidelines represent the first formal society-led attempt to characterize the essential attributes of the geriatric ED and received formal approval from the boards of directors of each of the four societies in 2013 and 2014. This article is intended to introduce emergency medicine and geriatric healthcare providers to the guidelines while providing recommendations for continued refinement of these proposals through educational dissemination, formal effectiveness evaluations, cost-effectiveness studies, and eventually institutional credentialing.
Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.
Carpenter, Christopher R; Bromley, Marilyn; Caterino, Jeffrey M; Chun, Audrey; Gerson, Lowell W; Greenspan, Jason; Hwang, Ula; John, David P; Lyons, William L; Platts-Mills, Timothy F; Mortensen, Betty; Ragsdale, Luna; Rosenberg, Mark; Wilber, Scott
In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and a strained health care system. In response, geriatric emergency medicine (EM) clinicians, educators, and researchers collaborated with the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations; equipment; policies; and protocols. These "Geriatric Emergency Department Guidelines" represent the first formal society-led attempt to characterize the essential attribute of the geriatric ED and received formal approval from the boards of directors for each of the four societies in 2013 and 2014. This article is intended to introduce EM and geriatric health care providers to the guidelines, while providing proposals for educational dissemination, refinement via formal effectiveness evaluations and cost-effectiveness studies, and institutional credentialing.
McGrath, Jayne; LeGare, Anne; Hermanson, Leigh; Repplinger, Michael D.
Introduction Crowding in emergency departments is a multifaceted problem. We hypothesized that implementing an on-call “Flexible Care Area” (FCA), utilizing multiple front-end throughput solutions, would reduce emergency department (ED) length of stay (LOS). Methods This retrospective study evaluates the impact of an FCA on ED throughput at one hospital over a two-year period (2011–2012). The average arrival-to-room time, arrival-to-physician time, LOS, number of inpatient admissions, and number of discharges during FCA hours were collected, comparing days with and without FCA functionality. Results The FCA was open 165 days in 2011 and 252 days in 2012. The mean daily ED census as well as number of ED visits and inpatient admissions during FCA hours were higher on days with FCA functionality than without. Total ED LOS was shorter for Emergency Severity Index (ESI) 3 patients on days with FCA than days without it in 2011, but this finding was not repeated in 2012. ESI 4 patients had shorter LOS on FCA days in both years. The arrival-to-room and arrival-to-physician times showed variable improvement for ESI 3 and 4 patients over the study period. There was no statistically significant difference for these measures when evaluating ESI levels 2 and 5. Discussion Implementing upfront throughput solutions through use of the FCA correlated with reduced ED LOS for all ESI 3–4 patients, not just those who were seen in FCA. PMID:26296717
Gunn, Martin L; Marin, Jennifer R; Mills, Angela M; Chong, Suzanne T; Froemming, Adam T; Johnson, Jamlik O; Kumaravel, Manickam; Sodickson, Aaron D
In May 2015, the Academic Emergency Medicine consensus conference "Diagnostic imaging in the emergency department: a research agenda to optimize utilization" was held. The goal of the conference was to develop a high-priority research agenda regarding emergency diagnostic imaging on which to base future research. In addition to representatives from the Society of Academic Emergency Medicine, the multidisciplinary conference included members of several radiology organizations: American Society for Emergency Radiology, Radiological Society of North America, the American College of Radiology, and the American Association of Physicists in Medicine. The specific aims of the conference were to (1) understand the current state of evidence regarding emergency department (ED) diagnostic imaging utilization and identify key opportunities, limitations, and gaps in knowledge; (2) develop a consensus-driven research agenda emphasizing priorities and opportunities for research in ED diagnostic imaging; and (3) explore specific funding mechanisms available to facilitate research in ED diagnostic imaging. Through a multistep consensus process, participants developed targeted research questions for future research in six content areas within emergency diagnostic imaging: clinical decision rules; use of administrative data; patient-centered outcomes research; training, education, and competency; knowledge translation and barriers to imaging optimization; and comparative effectiveness research in alternatives to traditional computed tomography use.
Yildirim, Cuma; Bayraktaroğlu, Ziya; Gunay, Nurullah; Bozkurt, Selim; Köse, Ataman; Yilmaz, Mehmet
The objective of this study is to describe the clinical status, procedural interventions, and outcomes of critically ill patients with poisoning and snake bite injuries presenting to a tertiary-care emergency department for treatment with therapeutic plasmapheresis. Records of 20 patients who presented to our academic emergency department over a 2-year period and who underwent plasmapheresis for poisoning or snake bite were retrospectively reviewed. Plasmapheresis was performed using centrifugation technology via an intravenous antecubital venous or subclavian vein catheter access. Human albumin or fresh frozen plasma were used as replacement fluids. Data extracted from the patient record included demographic data, clinical status, and outcome measures. Sixteen patients underwent plasmapheresis because of toxicity from snake bite. Three patients were treated for drug poisoning (phenytoin, theophylline, bipyridene HCl) and one patient for mushroom poisoning. Haematologic parameters such as platelet count, PT, and INR resolved rapidly in victims of snake bite injuries after treatment with plasmapheresis. Loss of limbs did not occur in these cases. Seven patients required admission to the intensive care unit. One patient with mushroom poisoning died. Mean length of hospital stay was 14.3 days (range 3-28 days) for all cases. Plasmapheresis was a clinically effective and safe approach in the treatment of snake bite envenomation and other drug poisoning victims especially in the management of hematologic problems and in limb preservation/salvage strategies. In addition to established conventional therapies, emergency physicians should consider plasmapheresis among the therapeutic options in treatment strategies for selected toxicologic emergencies.
Marin, Jennifer R; Mills, Angela M
The 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization" was held on May 12, 2015, with the goal of developing a high-priority research agenda on which to base future research. The specific aims of the conference were to (1) understand the current state of evidence regarding emergency department (ED) diagnostic imaging use and identify key opportunities, limitations, and gaps in knowledge; (2) develop a consensus-driven research agenda emphasizing priorities and opportunities for research in ED diagnostic imaging; and (3) explore specific funding mechanisms available to facilitate research in ED diagnostic imaging. Over a 2-year period, the executive committee and other experts in the field convened regularly to identify specific areas in need of future research. Six content areas within emergency diagnostic imaging were identified before the conference and served as the breakout groups on which consensus was achieved: clinical decision rules; use of administrative data; patient-centered outcomes research; training, education, and competency; knowledge translation and barriers to imaging optimization; and comparative effectiveness research in alternatives to traditional computed tomography use. The executive committee invited key stakeholders to assist with the planning and to participate in the consensus conference to generate a multidisciplinary agenda. There were a total of 164 individuals involved in the conference and spanned various specialties, including general emergency medicine, pediatric emergency medicine, radiology, surgery, medical physics, and the decision sciences.
Marin, Jennifer R; Mills, Angela M
The 2015 Academic Emergency Medicine (AEM) consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization," was held on May 12, 2015, with the goal of developing a high-priority research agenda on which to base future research. The specific aims of the conference were to: 1) understand the current state of evidence regarding emergency department (ED) diagnostic imaging utilization and identify key opportunities, limitations, and gaps in knowledge; 2) develop a consensus-driven research agenda emphasizing priorities and opportunities for research in ED diagnostic imaging; and 3) explore specific funding mechanisms available to facilitate research in ED diagnostic imaging. Over a 2-year period, the executive committee and other experts in the field convened regularly to identify specific areas in need of future research. Six content areas within emergency diagnostic imaging were identified prior to the conference and served as the breakout groups on which consensus was achieved: clinical decision rules; use of administrative data; patient-centered outcomes research; training, education, and competency; knowledge translation and barriers to imaging optimization; and comparative effectiveness research in alternatives to traditional computed tomography use. The executive committee invited key stakeholders to assist with planning and to participate in the consensus conference to generate a multidisciplinary agenda. There were 164 individuals involved in the conference spanning various specialties, including emergency medicine (EM), radiology, surgery, medical physics, and the decision sciences. This issue of AEM is dedicated to the proceedings of the 16th annual AEM consensus conference as well as original research related to emergency diagnostic imaging.
The 2014 Academic College of Emergency Experts in India's Education Development Committee (EDC) White Paper on establishing an academic department of Emergency Medicine in India – Guidelines for Staffing, Infrastructure, Resources, Curriculum and Training
Aggarwal, Praveen; Galwankar, Sagar; Kalra, Om Prakash; Bhalla, Ashish; Bhoi, Sanjeev; Sundarakumar, Sundarajan
Emergency medicine services and training in Emergency Medicine (EM) has developed to a large extent in developed countries but its establishment is far from optimal in developing countries. In India, Medical Council of India (MCI) has taken great steps by notifying EM as a separate specialty and so far 20 medical colleges have already initiated 3-year training program in EM. However, there has been shortage of trained faculty, and ambiguity regarding curriculum, rotation policy, infrastructure, teachers’ eligibility qualifications and scheme of examination. Academic College of Emergency Experts in India (ACEE-India) has been a powerful advocate for developing Academic EM in India. The ACEE's Education Development Committee (EDC) was created to chalk out guidelines for staffing, infrastructure, resources, curriculum, and training which may be of help to the MCI and the National Board of Examinations (NBE) to set standards for starting 3-year training program in EM and develop the departments of EM as centers of quality education, research, and treatment across India. This paper has made an attempt to give recommendations so as to provide a uniform framework to the institutions, thus guiding them towards establishing an academic Department of EM for starting the 3-year training program in the specialty of EM. PMID:25114431
Yordanov, Youri; Beltramini, Alexandra; Debuc, Erwan; Pateron, Dominique
Emergency departments use has been constantly increasing over the world. Overcrowding is defined as a situation which compromises patient safety because of delayed cares. This situation is often reached. Emergency departments have to continuously improve their organization to be able to ensure the same quality of care to a higher number of patients. Thus a good organization is essential: it doesn't always avoid overcrowding. The rest of the hospital has to be involved in this process to ensure efficiency. We examine the various interventions and procedures that can be found in medical literature for improving patients flow and management in emergency departments.
Liptzin, Benjamin; Meyer, Roger E.
Objective: The authors describe the many financial challenges facing academic departments of psychiatry and the resulting opportunities that may arise. Method: The authors review the history of financial challenges, the current economic situation, and what may lie ahead for academic departments of psychiatry. Results: The current environment has…
Ethical issues in the response to Ebola virus disease in United States emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine.
Venkat, Arvind; Asher, Shellie L; Wolf, Lisa; Geiderman, Joel M; Marco, Catherine A; McGreevy, Jolion; Derse, Arthur R; Otten, Edward J; Jesus, John E; Kreitzer, Natalie P; Escalante, Monica; Levine, Adam C
The 2014 outbreak of Ebola virus disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged U.S. emergency departments (EDs) to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to U.S. acute care facilities, ethical questions have been raised in both the press and medical literature as to how U.S. EDs, emergency physicians (EPs), emergency nurses, and other stakeholders in the health care system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to U.S. EPs, emergency nurses, and other stakeholders in the health care system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to U.S. EDs in how they approach preparation for and management of potential patients with EVD.
Blanchard, A.; Bell, K.; Kelly, J.; Hudson, J.
In 1995 the SRS Fire Department published the initial Operations Basis Document (OBD). This document was one of the first of its kind in the DOE complex and was widely distributed and reviewed. This plan described a multi-mission Fire Department which provided fire, emergency medical, hazardous material spill, and technical rescue services.
Musey, Paul I; Linnstaedt, Sarah D; Platts-Mills, Timothy F; Miner, James R; Bortsov, Andrey V; Safdar, Basmah; Bijur, Polly; Rosenau, Alex; Tsze, Daniel S; Chang, Andrew K; Dorai, Suprina; Engel, Kirsten G; Feldman, James A; Fusaro, Angela M; Lee, David C; Rosenberg, Mark; Keefe, Francis J; Peak, David A; Nam, Catherine S; Patel, Roma G; Fillingim, Roger B; McLean, Samuel A
Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas, in May 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine and the pain research field reviewed the current literature and identified eight candidate priority areas. At the conference, these eight areas were reviewed and all eight were ratified using a nominal group technique to build consensus. These priority areas were: 1) gender differences in the pharmacological and nonpharmacological interventions for pain, including differences in opioid tolerance, side effects, or misuse; 2) gender differences in pain severity perceptions, clinically meaningful differences in acute pain, and pain treatment preferences; 3) gender differences in pain outcomes of ED patients across the life span; 4) gender differences in the relationship between acute pain and acute psychological responses; 5) the influence of physician-patient gender differences and characteristics on the assessment and treatment of pain; 6) gender differences in the influence of acute stress and chronic stress on acute pain responses; 7) gender differences in biological mechanisms and molecular pathways mediating acute pain in ED populations; and 8) gender differences in biological mechanisms and molecular pathways mediating chronic pain development after trauma, stress, or acute illness exposure. These areas represent priority areas for future scientific inquiry, and gaining understanding in these will be essential to improving our understanding of sex and gender
The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emergency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India.
Chauhan, Vivek; Shah, Pavitra Kotini; Galwankar, Sagar; Sammon, Maura; Hosad, Prabhakar; Beeresha; Erickson, Timothy B; Gaieski, David F; Grover, Joydeep; Hegde, Anupama V; Hoek, Terry Vanden; Jarwani, Bhavesh; Kataria, Himanshu; LaBresh, Kenneth A; Manjunath, Cholenahally Nanjappa; Nagamani, A C; Patel, Anjali; Patel, Ketan; Ramesh, D; Rangaraj, R; Shamanur, Narendra; Sridhar, L; Srinivasa, K H; Tyagi, Shweta
There have been no published recommendations for the management of low-risk chest pain in emergency departments (EDs) across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in EDs. Risk stratification of patients utilizing an accelerated diagnostic protocol has been shown to decrease hospitalizations by approximately 40% with a low 30-day risk of major adverse cardiac events. The experts group of academic leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with academic experts in emergency medicine and cardiology from leading institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in EDs across India.
The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emergency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India
Chauhan, Vivek; Shah, Pavitra Kotini; Galwankar, Sagar; Sammon, Maura; Hosad, Prabhakar; Beeresha; Erickson, Timothy B.; Gaieski, David F.; Grover, Joydeep; Hegde, Anupama V.; Hoek, Terry Vanden; Jarwani, Bhavesh; Kataria, Himanshu; LaBresh, Kenneth A.; Manjunath, Cholenahally Nanjappa; Nagamani, A. C.; Patel, Anjali; Patel, Ketan; Ramesh, D.; Rangaraj, R.; Shamanur, Narendra; Sridhar, L.; Srinivasa, K. H.; Tyagi, Shweta
There have been no published recommendations for the management of low-risk chest pain in emergency departments (EDs) across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in EDs. Risk stratification of patients utilizing an accelerated diagnostic protocol has been shown to decrease hospitalizations by approximately 40% with a low 30-day risk of major adverse cardiac events. The experts group of academic leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with academic experts in emergency medicine and cardiology from leading institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in EDs across India. PMID:28367012
Bosso, John A; Chisholm-Burns, Marie; Nappi, Jean; Gubbins, Paul O; Ross, Leigh Ann
Benchmarking in academic pharmacy, and recommendations for the potential uses of benchmarking in academic pharmacy departments are discussed in this paper. Benchmarking is the process by which practices, procedures, and performance metrics are compared to an established standard or best practice. Many businesses and industries use benchmarking to compare processes and outcomes, and ultimately plan for improvement. Institutions of higher learning have embraced benchmarking practices to facilitate measuring the quality of their educational and research programs. Benchmarking is used internally as well to justify the allocation of institutional resources or to mediate among competing demands for additional program staff or space. Surveying all chairs of academic pharmacy departments to explore benchmarking issues such as department size and composition, as well as faculty teaching, scholarly, and service productivity, could provide valuable information. To date, attempts to gather this data have had limited success. We believe this information is potentially important, urge that efforts to gather it should be continued, and offer suggestions to achieve full participation.
Nestler, David M.; Fratzke, Alesia R.; Church, Christopher J.; Scanlan-Hanson, Lori; Sadosty, Annie T.; Halasy, Michael P.; Finley, Janet L.; Boggust, Andy; Hess, Erik P.
Objectives Overcapacity issues plague emergency departments (EDs). Studies suggest triage liaison providers (TLPs) may shorten patient length of stay (LOS) and reduce the proportion of patients who leave without being seen (LWBS), but these results are not universal. Previous studies used physicians as TLPs. We evaluated whether a physician assistant (PA), acting as a TLP, would shorten LOS and decrease LWBS rates. Methods The authors used an observational cohort controlled before-and-after study design with predefined outcome measures, comparing eight pilot days to eight control days. The TLP evaluated all Emergency Severity Index (ESI) level 3, 4, and 5 patients, excluding pediatric and behavioral health patients. Results Three hundred fifty-three patients were included on pilot days, and 371 on control days. LOS was shorter on pilot days than control days (median 229 minutes [IQR 168 to 303 minutes] vs. 270 minutes [IQR 187 to 372 minutes], p < 0.001). Waiting room times were similar between pilot and control days (median 69 minutes [IQR 20 to 119 minutes] vs. 70 minutes [IQR 19 to 137 minutes], p = 0.408), but treatment room times were shorter (median 151 minutes [IQR 92 to 223 minutes] vs. 187 minutes [IQR 110 to 254 minutes], p < 0.001). Finally, a lower proportion of patients LWBS on pilot days (1.4% vs. 9.7%, p < 0.001). Conclusions The addition of a PA as a TLP was associated with a 41 minute decrease in median total LOS, and a lower proportion of patients who LWBS. The decrease in total LOS is likely attributable to the addition of the TLP, with patients having shorter duration in treatment rooms on pilot days compared to control days. PMID:23167853
Bates, David D B; Tkacz, Jaroslaw N; LeBedis, Christina A; Holalkere, Nagaraj
Optimal CT pulmonary angiography (CTPA) is a prerequisite for accurate diagnosis and management of suspected venous thromboembolic disease (VTE) in the emergency department (ED). However, a certain proportion of CTPA studies are diagnostically limited or non-diagnostic due to various technical causes. In this study, we analyze the incidence and cause of suboptimal CTPA studies in the ED and assess the need for additional imaging. Reports of 1444 consecutive CTPAs performed in an ED on adult patients over a 25-month period beginning November 30, 2011, were reviewed. The observed suboptimal CTPA rate was 4.2 % (60/1444). The most common causes of limited or non-diagnostic CTPA in the ED were related to timing of contrast bolus or IV infiltration (26/60, 43.4 %), respiratory motion (16/60, 26.7 %), multifactorial causes (10/60, 16.7 %), and patient motion (8/60, 13.3 %). Of the 60 studies included, only 7 patients (11.7 %) underwent additional diagnostic imaging during the same hospital visit for VTE, while 3 patients (5.0 %) underwent additional imaging for suspected VTE over the next 2 months. A total of 2/60 (3.4 %) patients had documented acute PE on additional imaging performed either on the same hospital visit or within 2 months. Regardless of the factors contributing to suboptimal CTPA, only a very small proportion of patients receive additional imaging to evaluate for VTE, either on the same visit or during the next 2 months (16.7 %, 10/60 patients). A small number (3.4 %) of these patients have documented acute PE within 2 months when additional imaging tests were performed.
Elrod, Cassandra C.; Daughton, William J.; Murray, Susan L.; Fisher, Caroline M.; Flachsbart, Barry B.
The complexity of the market in higher education, and the lack of literature regarding marketing, particularly branding, at the academic department level, presented an opportunity to establish a systematic process for evaluating an academic department's brand meaning. A process for evaluating a brand's meaning for an academic department is…
Mahajan, Prashant; Batra, Prerna; Shah, Binita R; Saha, Abhijeet; Galwankar, Sagar; Aggrawal, Praveen; Hassoun, Ameer; Batra, Bipin; Bhoi, Sanjeev; Kalra, Om Prakash; Shah, Dheeraj
The concept of pediatric emergency medicine (PEM) is virtually nonexistent in India. Suboptimally organized prehospital services substantially hinder the evaluation, management, and subsequent transport of the acutely ill and/or injured child to an appropriate facility. Furthermore, the management of the ill child at the hospital level is often provided by overburdened providers who, by virtue of their training, lack experience in the skills required to effectively manage pediatric emergencies. Finally, the care of the traumatized child often requires the involvement of providers trained in different specialities, which further impedes timely access to appropriate care. The recent recognition of Doctor of Medicine in Emergency Medicine as an approved discipline of study as per the Indian Medical Council Act provides an unprecedented opportunity to introduce PEM as a formal academic program in India. PEM has to be developed as a 3 year superspeciality course after completion of MD Diplomate of National Board (DNB) Pediatrics or MD DNB in EM. The National Board of Examinations that accredits and administers postgraduate and postdoctoral programs in India also needs to develop an academic program DNB in PEM. The goals of such a program would be to impart theoretical knowledge, training in the appropriate skills and procedures, development of communication and counseling techniques, and research. In this paper, the Joint Working Group of the Academic College of Emergency Experts in India (JWG ACEE India) gives its recommendations for starting 3 year DM DNB in PEM, including the curriculum, infrastructure, staffing, and training in India. This is an attempt to provide an uniform framework and a set of guiding principles to start PEM as a structured superspeciality to enhance emergency care for Indian children.
The 2015 Academic College of Emergency Experts in India's INDO-US Joint Working Group White Paper on Establishing an Academic Department and Training Pediatric Emergency Medicine Specialists in India.
Mahajan, Prashant; Batra, Prerna; Shah, Binita R; Saha, Abhijeet; Galwankar, Sagar; Aggrawal, Praveen; Hassoun, Ameer; Batra, Bipin; Bhoi, Sanjeev; Kalra, Om Prakash; Shah, Dheeraj
The concept of pediatric emergency medicine (PEM) is virtually nonexistent in India. Suboptimally, organized prehospital services substantially hinder the evaluation, management, and subsequent transport of the acutely ill and/or injured child to an appropriate facility. Furthermore, the management of the ill child at the hospital level is often provided by overburdened providers who, by virtue of their training, lack experience in the skills required to effectively manage pediatric emergencies. Finally, the care of the traumatized child often requires the involvement of providers trained in different specialities, which further impedes timely access to appropriate care. The recent recognition of Doctor of Medicine (MD) in Emergency Medicine (EM) as an approved discipline of study as per the Indian Medical Council Act provides an unprecedented opportunity to introduce PEM as a formal academic program in India. PEM has to be developed as a 3-year superspeciality course (in PEM) after completion of MD/Diplomate of National Board (DNB) Pediatrics or MD/DNB in EM. The National Board of Examinations (NBE) that accredits and administers postgraduate and postdoctoral programs in India also needs to develop an academic program - DNB in PEM. The goals of such a program would be to impart theoretical knowledge, training in the appropriate skills and procedures, development of communication and counseling techniques, and research. In this paper, the Joint Working Group of the Academic College of Emergency Experts in India (JWG-ACEE-India) gives its recommendations for starting 3-year DM/DNB in PEM, including the curriculum, infrastructure, staffing, and training in India. This is an attempt to provide an uniform framework and a set of guiding principles to start PEM as a structured superspeciality to enhance emergency care for Indian children.
Lee, C T; Guo, H R; Chen, J B
Hyponatremia is a clinical manifestation of a wide variety of diseases, some of which have high mortality rates. To assess the prevalence, cause, and prognosis of hyponatremia encountered in the emergency department, we conducted a prospective study at a major hospital in southern Taiwan. We included all adult internal medicine patients treated in the emergency department during a 2-month period. Hyponatremia was defined as a serum sodium level below 134 mEq/L, and cases patients were followed till being discharged. Among the 3,784 patients included, 166 case patients were identified. Most (65%) case patients were hypovolemic, and the overall mortality rate was 17.9%. The mortality rate increased as the sodium level decreased, but was not related to gender, age, cause, or serum potassium level. When 21 hyperglycemic patients whose serum sodium levels went beyond 134 mEq/L after the adjustment for blood sugar levels were excluded, the prevalence of true hyponatremia was 3.83%. The most common underlying diseases were those of the gastrointestinal system. It is concluded that hyponatremia is a common condition encountered in the emergency department. The mortality is correlated with the serum sodium level, and adjustment of the level is required in hyperglycemic patients to make a correct diagnosis. Unlike the cases in some other clinical settings, almost all cases of hyponatremia encountered in the emergency department were not iatrogenic and had recognizable underlying diseases. Therefore, more effort is generally required to identify the cause of hyponatremia cases in the emergency department.
Thijssen, Wendy A M H; Giesen, Paul H J; Wensing, Michel
Emergency medicine in The Netherlands is faced with an increasing interest by politicians and stakeholders in health care. This is due to crowding, increasing costs, criticism of the quality of emergency care, restructuring of out-of-hours services in primary care and the introduction of a training programme for emergency physicians in 2000. A comprehensive search was conducted of published research, policy reports and updated Dutch websites on acute care. Publications were included in this review if these referred to emergency care, including emergency departments (ED), general practitioner (GP) cooperatives and emergency medical services in The Netherlands and were written in English or Dutch. The literature search identified 14 eligible papers. The manual search identified 11 additional papers. Seven reports and two PhD theses were also included. Given the lack of relevant empirical research the review was liberal in its inclusion, but the analysis focused on research when available. ED in The Netherlands are in different stages of development. However, it is obvious that the presence of emergency physicians is increasing and more ED will be staffed by emergency physicians. Although this seems an important step, it does not necessarily imply a good position of the emergency physician in the ED. What the characteristics of the future patient of the Dutch ED will be is dependent on the development of different ED levels of care and GP cooperatives. The lack of empirical research also points out the need for research on quality of care in Dutch ED.
Jaimes-Albornoz, Walter; Serra-Mestres, Jordi
Disturbances of the level of awareness are a frequent motive of attendance to emergency departments where the initial assessment and management will determine the direction of their outcome. The syndrome of catatonia must be taken into consideration and although it is normally associated with psychiatric diagnoses, it is also very often found in a great variety of neurological and medical conditions. Due to the clinical complexity of catatonia, there are still difficulties in its correct identification and initial management, something that leads to diagnostic delays and increased morbidity and mortality. In this article, a review of the literature on catatonia is presented with the aim of assisting emergency department doctors (and clinicians assessing patients in emergency situations) in considering this condition in the differential diagnosis of stupor due to its high frequency of association with organic pathology.
McHenry, Dean E.; And Others
Do academic departments promote scholarship, protect higher learning from stagnation and interference, and provide a sound basis for hiring and advancing faculty? Or do they stifle teaching and research, foster parochialism, and limit the development of professors and students? There exist operating alternatives to conventional departments. Those…
Weiner, Scott G
Advertising emergency department (ED) wait times has become a common practice in the United States. Proponents of this practice state that it is a powerful marketing strategy that can help steer patients to the ED. Opponents worry about the risk to the public health that arises from a patient with an emergent condition self-triaging to a further hospital, problems with inaccuracy and lack of standard definition of the reported time, and directing lower acuity patients to the higher cost ED setting instead to primary care. Three sample cases demonstrating the pitfalls of advertising ED wait times are discussed. Given the lack of rigorous evidence supporting the practice and potential adverse effects to the public health, caution about its use is advised.
Many patients present to emergency departments with anorectal problems, such as haemorrhoids, anal fissure and pruritis ani. Often, patients with such problems are embarrassed about them or fearful about their potential diagnoses, so practitioners must approach history taking and examination sensitively. They should also have a good understanding of the anatomy of the anorectal area, and be able to recognise the signs and symptoms of relevant conditions. This article provides an overview of the anatomy and physiology of the anorectal area, explains how to undertake anorectal examinations, and describes the signs and symptoms of some common conditions.
The 2016 Academic Emergency Medicine Consensus Conference, Shared Decision Making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda May 10, 2016, New Orleans, LA.
Grudzen, Corita R; Anderson, Jana R; Carpenter, Christopher R; Hess, Erik P
Shared decision making in emergency medicine has the potential to improve the quality, safety, and outcomes of emergency department (ED) patients. Given that the ED is the gateway to care for patients with a variety of illnesses and injuries and the safety net for patients otherwise unable to access care, shared decision making in the ED is relevant to numerous disciplines and the interests of the United States (U.S.) public. On May 10, 2016 the 16th annual Academic Emergency Medicine (AEM) consensus conference, "Shared Decision Making: Development of a Policy-Relevant Patient-Centered Research Agenda" was held in New Orleans, Louisiana. During this one-day conference clinicians, researchers, policy-makers, patient and caregiver representatives, funding agency representatives, trainees, and content experts across many areas of medicine interacted to define high priority areas for research in 1 of 6 domains: 1) diagnostic testing; 2) policy, 3) dissemination/implementation and education, 4) development and testing of shared decision making approaches and tools in practice, 5) palliative care and geriatrics, and 6) vulnerable populations and limited health literacy. This manuscript describes the current state of shared decision making in the ED context, provides an overview of the conference planning process, the aims of the conference, the focus of each respective breakout session, the roles of patient and caregiver representatives and an overview of the conference agenda. The results of this conference published in this issue of AEM provide an essential summary of the future research priorities for shared decision making to increase quality of care and patient-centered outcomes.
Cremonesi, P; Di Bella, E; Montefiori, M
This paper is intended to examine both clinical and economic data concerning the activity of an emergency department of an Italian primary Hospital. Real data referring to arrivals, waiting times, service times, severity (according to triage classification) of patients' condition collected along the whole 2009 are matched up with the relevant accounting and economic information concerning the costs faced. A new methodological approach is implemented in order to identify a "standard production cost" and its variability. We believe that this kind of analysis well fits the federalizing process that Italy is experiencing. In fact the federal reform is driving our Country toward a decentralized provision and funding of local public services. The health care services are "fundamental" under the provisions of the law that in turn implies that a standard cost has to be defined for its funding. The standard cost (as it is defined by the law) relies on the concepts of appropriateness and efficiency in the production of the health care service, assuming a standard quality level as target. The identification and measurement of health care costs is therefore a crucial task propaedeutic to health services economic evaluation. Various guidelines with different amount of details have been set up for costing methods which, however, are defined in simplified frameworks and using fictious data. This study is a first attempt to proceed in the direction of a precise definition of the costs inherent to the emergency department activity.
Healthcare professionals manage patients with a vast range of conditions, but often specialise and acquire expertise in specific disease processes. Emergency and pre-hospital clinicians care for patients with various conditions for short periods of time, so have less opportunity to become familiar with more unusual conditions, yet it is vital that they have some knowledge and understanding of these. Patients with rare conditions can present at emergency departments with common complaints, but the effect of their original diagnosis on the presenting complaint may be overlooked or underestimated. This article uses a case study to describe the experience of one patient who presented with vomiting, but who also had hypopituitarism and therefore required specific management she did not at first receive. The article describes hypopituitarism and the initial management of patients with this condition who become unwell, and discusses how the trust responded to the patient's complaint to improve patient safety and care. It has been written with the full participation and consent of the patient and her husband.
Kuhn, Gloria J; Abbuhl, Stephanie B; Clem, Kathleen J
The Society for Academic Emergency Medicine (SAEM) convened a taskforce to study issues pertaining to women in academic emergency medicine (EM). The charge to the Taskforce was to "Create a document for the SAEM Board of Directors that defines and describes the unique recruitment, retention, and advancement needs for women in academic emergency medicine." To this end, the Taskforce and authors reviewed the literature to highlight key data points in understanding this issue and made recommendations for individuals at four levels of leadership and accountability: leadership of national EM organizations, medical school deans, department chairs, and individual women faculty members. The broad range of individuals targeted for recommendations reflects the interdependent and shared responsibility required to address changes in the culture of academic EM. The following method was used to determine the recommendations: 1) Taskforce members discussed career barriers and potential solutions that could improve the recruitment, retention, and advancement of women in academic EM; 2) the authors reviewed recommendations in the literature by national consensus groups and experts in the field to validate the recommendations of Taskforce members and the authors; and 3) final recommendations were sent to all Taskforce members to obtain and incorporate additional comments and ensure a consensus. This article contains those recommendations and cites the relevant literature addressing this topic.
Mahmoudi, Sadrollah; Taghipour, Hamid Reza; Javadzadeh, Hamid Reza; Ghane, Mohammad Reza; Goodarzi, Hassan; Kalantar Motamedi, Mohammad Hosein
Background Hospital readmission places a high burden on both health care systems and patients. Most readmissions are thought to be related to the quality of the health care system. Objectives The aim of this study was to examine the causes and rates of early readmission in emergency department in a Tehran hospital. Patients and Methods A cross-sectional investigation was performed to study readmission of inpatients at a large academic hospital in Tehran, Iran. Patients admitted to hospital from July 1, 2014 to December 30, 2014 via the emergency department were enrolled. Descriptive statistics were used to summarize the distribution demographics in the sample. Data was analyzed by chi2 test using SPSS 20 software. Results The main cause of readmission was complications related to surgical procedures (31.0%). Discharge from hospital based on patient request at the patient's own risk was a risk factor for emergency readmission in 8.5%, a very small number were readmitted after complete treatment (0.6%). The only direct complication of treatment was infection (17%). Conclusions Postoperative complications increase the probability of patients returning to hospital. Physicians, nurses, etc., should focus on these specific patient populations to minimize the risk of postoperative complications. Future studies should assess the relative connections of various types of patient information (e.g., social and psychosocial factors) to readmission risk prediction by comparing the performance of models with and without this information in a specific population. PMID:27626018
Gabayan, Gelareh Z.; Derose, Stephen F.; Chiu, Vicki Y.; Yiu, Sau C.; Sarkisian, Catherine A.; Jones, Jason P.; Sun, Benjamin C.
Study objective We assess whether a panel of emergency department (ED) crowding measures, including 2 reported by the Centers for Medicare & Medicaid Services (CMS), is associated with inpatient admission and death within 7 days of ED discharge. Methods We conducted a retrospective cohort study of ED discharges, using data from an integrated health system for 2008 to 2010. We assessed patient transit-level (n=3) and ED system-level (n=6) measures of crowding, using multivariable logistic regression models. The outcome measures were inpatient admission or death within 7 days of ED discharge. We defined a clinically important association by assessing the relative risk ratio and 95% confidence interval (CI) difference and also compared risks at the 99th percentile and median value of each measure. Results The study cohort contained a total of 625,096 visits to 12 EDs. There were 16,957 (2.7%) admissions and 328 (0.05%) deaths within 7 days. Only 2 measures, both of which were patient transit measures, were associated with the outcome. Compared with a median evaluation time of 2.2 hours, the evaluation time of 10.8 hours (99th percentile) was associated with a relative risk of 3.9 (95% CI 3.7 to 4.1) of an admission. Compared with a median ED length of stay (a CMS measure) of 2.8 hours, the 99th percentile ED length of stay of 11.6 hours was associated with a relative risk of 3.5 (95% CI 3.3 to 3.7) of admission. No system measure of ED crowding was associated with outcomes. Conclusion Our findings suggest that ED length of stay is a proxy for unmeasured differences in case mix and challenge the validity of the CMS metric as a safety measure for discharged patients. PMID:26003004
Jarvis, Paul Richard Edwin
Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED's capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. A literature review was performed to identify evidence-based strategies to reduce the amount of time patients spend in the ED in order to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED.
Jarvis, Paul Richard Edwin
Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED’s capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. A literature review was performed to identify evidence-based strategies to reduce the amount of time patients spend in the ED in order to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED. PMID:27752619
Adebayo, Omoyemi; Rogers, Robert L
Hypertension affects approximately one-third of Americans. An additional 30% are unaware that they harbor the disease. Significantly increased blood pressure constitutes a hypertensive emergency that could lead to end-organ damage. When organs such as the brain, heart, or kidney are affected, an intervention that will lower the blood pressure in several hours is indicated. Several pharmacologic options are available for treatment, with intravenous antihypertensive therapy being the cornerstone, but there is no standard of care. Careful consideration of each patient's specific complaint, history, and physical examination guides the emergency physician through the treatment algorithm.
Lee, Joon Ki; Kang, Hyunggu; Choi, Hyuk Joong
Objective The aim of this study was to assess the success rate of the GlideScope video laryngoscope (GVL) and direct laryngoscope (DL) over ten years in two academic emergency departments. Methods We used adult intubation data using DL and GVL collected from airway management registries at two academic emergency departments. We analyzed changes in first-pass success (FPS) rate by device and operator training level. We conducted a multivariate logistic regression analysis to predict the FPS according to time period. Results Over the study period (2006 to 2010, season I; 2013-2015, season II) the DL usage rate dropped from 91.6% to 45.0% while the GVL usage rate increased from 8.4% to 55.4%. The FPS rate using DL also declined from 90.8% in 2007 to 75.5% in 2015. On the other hand, the FPS rate using GVL increased from 87.8% to 95.2%. With DL, all operators’ FPS rate declined by approximately 10% in season II compared to season I. The FPS rate with GVL was significantly higher in the providers of postgraduate year over 3 years (P=0.043). Multivariate logistic regression analysis revealed an adjusted odds ratio for GVL FPS of 0.799 during season I (P=0.274). However, the adjusted odds ratio for GVL FPS was 3.744 during season II (P<0.001). Conclusion We found that the FPS rates of GVL have slightly increased but DL’s FPS rate has significantly decreased during the last ten years. PMID:28168228
Gras-Le Guen, Christèle; Vrignaud, Bénédicte; Levieux, Karine
The number of children admitted to paediatric emergencies is increasing steadily, and is responsible for an altered quality in the patients' reception and some major perturbations in the care organization. In this context, the primary care physicians play a major role in explaining their patients "how to use" the paediatric emergency department (priority in case of vital emergency, periods with lot of admissions and increased waiting time ...). Everything must be done to find an altemative to the pediatric emergency department passage by facilitating communication between caregivers and for example by offering semi urgent consultations possibility.
Danila, Richard N.; Cieslak, Paul R.; Meek, James I.; Schaffner, William; Smith, Kirk E.; Cartter, Matthew L.; Harrison, Lee H.; Vugia, Duc J.; Lynfield, Ruth
The Emerging Infections Program (EIP) is a collaboration between the Centers for Disease Control and Prevention and 10 state health departments working with academic partners to conduct active population-based surveillance and special studies for several emerging infectious disease issues determined to need special attention. The Centers for Disease Control and Prevention funds the 10 EIP sites through cooperative agreements. Our objective was to highlight 1) what being an EIP site has meant for participating health departments and associated academic centers, including accomplishments and challenges, and 2) the synergy between the state and federal levels that has resulted from the collaborative relationship. Sharing these experiences should provide constructive insight to other public health programs and other countries contemplating a collaborative federal–local approach to collective public health challenges. PMID:26289952
Leetch, Aaron N; Woolridge, Dale
Child abuse presents commonly to emergency departments. Emergency providers are confronted with medical, social, and legal dilemmas with each case. A solid understanding of the definitions and risk factors of victims and perpetrators aids in identifying abuse cases. Forensic examination should be performed only after the child is medically stable. Emergency providers are mandatory reporters of a reasonable suspicion of abuse. The role of the emergency provider is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and to provide an ethical testimony if called to court.
Gill, Kenneth J; Barrett, Nora M
Psychiatric rehabilitation is an emerging profession and academic discipline. This paper provides an overview of the need for psychiatric rehabilitation education, the workforce challenges this field faces and an introduction to the various efforts that institutions of higher education are making to meet this need. This paper also introduces some empirical findings in this area, reviewing three previously published evaluations of academic programs, and providing preliminary results of an unpublished evaluation from an American university with a career ladder in this field. The results of these evaluations suggest positive impact on the careers of the students, who appear to be knowledgeable and competent in psychiatric rehabilitation. More detailed evaluations of this education on the service outcomes of persons with serious mental illness are warranted as are studies of the methods of instruction used to develop the needed skills and attitudes. Replication of these existing academic programs should be considered.
Universities confront many challenges in their efforts to manage staff activity with the aid of workload assessment and allocation systems. This article sets out fresh perspectives from an exploratory study designed to uncover patterns of subjective views about various aspects of workloads. Using Q methodology, academic staff in a single…
Improved management of tuberculosis is a key priority for Public Health England due to unacceptably high rates of the disease in the UK, particularly in London and other major cities. A survey of 20 staff in the acute medical unit at Queen Alexandra Hospital, Portsmouth, explored potential barriers to early TB detection and infection control in busy emergency departments. Low awareness and little familiarity with TB among many emergency admissions staff increased the likelihood of transmission from undiagnosed patients in crowded waiting areas. The study suggested regular updates on TB so staff could refresh their knowledge and awareness, and help improve TB detection and infection control.
Louis, Karen Seashore; And Others
A survey of faculty in 98 college chemistry, civil engineering, microbiology, and sociology departments explored effects of faculty behaviors and attitudes on departmental rates of observed misconduct and espoused scientific research values. Results suggest misconduct is best predicted by department climate variables. Adherence to traditional…
Ryan, Doris W.
Studies the response of 15 academic departments at Ohio State University to reorganization. Implications of the study deal with methods of introducing change, the importance of group norms, and the link between informal norms and existing formal structure. (MK)
During redevelopment of the emergency department at the Royal Sussex County Hospital, Brighton, it was deemed vital that its internal communication system should be as effective as possible. An audit of staff perceptions of the existing communication system and a relevant literature review were undertaken, therefore, to inform a proposal for the development of a new online system. This article describes the development and implementation of the system.
Newton, Edward J; Love, John
Rather than providing an encyclopedic review of extremity injuries, this article reviews selected serious injuries of the extremities that can be missed in the emergency department, either because they are relatively uncommon or because they are subtle in their clinical and radiographic presentation. They include injuries to the scapula, the shoulder, the forearm, the femur and hip, the knee, the tibia (which is the most common long bone fracture), and the ankle and foot. Their various causes include sports injuries, falls, and motor vehicle accidents. Several of these injuries can result in emergent complications or have time-dependent outcomes. Consequently, these injuries often must be managed by emergency physicians before specialist expertise becomes available.
PD-R1469659 SUMMARY OF RESEARCH ACADEMIC DEPARTMENTS 1982-1983(U) 1/3 NARIR RCRDEMY ANNAPOLIS NO Rd I HEFLIN OCT 93 USNR-AR-8 UNCLASSIFIED F/G 5/2 NI...SUMMARY OF RESEARCH 4, 1982- 1983 COMPILED AND EDITED BY PROFESSOR WILSON L. HEFLIN ENGLISH DEPARTMENT 1-4. OCTOBER 1983-M UNITED STATES NAVAL ACADEMY...WEAPONS Aerospace Engineering Department .......................................... 3 Electrical Engineering Department
Bezeau, Lawrence M.
This paper describes an approach to faculty timetabling and course scheduling that uses computerized linear programming. After reviewing the literature on linear programming, the paper discusses the process whereby a timetable was created for a department at the University of New Brunswick. Faculty were surveyed with respect to course offerings…
Tauer, Loren W.; Fried, Harold O.; Fry, William E.
Technical and allocative efficiencies of 26 academic departments in the College of Agriculture and Life Sciences at Cornell University are computed using Data Envelopment Analysis over 2004/05. Allocations of faculty time between teaching, research, and extension vary by department and are used as unique prices in calculating allocative…
Migraine can be a disabling condition for the sufferer. For the small number of patients who fail home therapy and seek treatment in an emergency department, there are a number of therapeutic options. This paper reviews the evidence regarding the effectiveness and safety of the following therapies: the phenothiazines, lignocaine (lidocaine), ketorolac, the ergot alkaloids, metoclopramide, the "triptans", haloperidol, pethidine and magnesium. Based on available evidence, the most effective agents seem to be prochlorperazine, chlorpromazine and sumatriptan, each of which have achieved greater then 70% efficacy in a number of studies. PMID:10921808
Stiell, Ian G; Artz, Jennifer D; Perry, Jeffrey; Vaillancourt, Christian; Calder, Lisa
The vision of the recently created Canadian Association of Emergency Physicians (CAEP) Academic Section is to promote high-quality emergency patient care by conducting world-leading education and research in emergency medicine. The Academic Section plans to achieve this goal by enhancing academic emergency medicine primarily at Canadian medical schools and teaching hospitals. It seeks to foster and develop education, research, and academic leadership amongst Canadian emergency physicians, residents, and students. In this light, the Academic Section began in 2013 to hold the annual Academic Symposia to highlight best practices and recommendations for the three core domains of governance and leadership, education scholarship, and research. Each year, members of three panels are asked to review the literature, survey and interview experts, achieve consensus, and present their recommendations at the Symposium (2013, Education Scholarship; 2014, Research; and 2015, Governance and Funding). Research is essential to medical advancement. As a relatively young specialty, emergency medicine is rapidly evolving to adapt to new diagnostic tools, the challenges of crowding in emergency departments, and the growing needs of emergency patients. There is significant variability in the infrastructure, support, and productivity of emergency medicine research programs across Canada. All Canadians benefit from an investigation of the means to improve research infrastructure, training programs, and funding opportunities. Such an analysis is essential to identify areas for improvement, which will support the expansion of emergency medicine research. To this end, physician-scientist leaders were gathered from across Canada to develop pragmatic recommendations on the improvement of emergency medicine research through a comprehensive analysis of current best practices, systematic literature reviews, stakeholder surveys, and expert interviews.
Henderson, Charles; Quardokus, Kathleen
Efforts to improve teaching in higher education have often focused on individual faculty. However, there is a growing consensus that the academic department is a more productive focus of change initiatives. Yet, academic departments are not all the same. Understanding the structure of relationships within a department is important for identifying who should be involved in the change effort and in what roles. It is also likely that a successful change effort will modify the structure of relationships within a department. This paper presents the preliminary results from a study of two academic departments at a research university. A social network for each department was constructed based on a web survey that asked faculty to identify colleagues with whom they had teaching-related conversations. We identify characteristics of the individuals and departments and describe how learning about this hidden structure can be beneficial to change agents.
Liang, Stephen Y.; Theodoro, Daniel L.; Schuur, Jeremiah D.; Marschall, Jonas
Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to healthcare personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, healthcare personnel vaccination, and environmental controls to strategies for preventing healthcare-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care. PMID:24721718
Emergency department (ED) overcrowding has been an international phenomenon for more than 10 years. It is important to understand that ED overcrowding is a measure of health system efficiency and is not strictly related to ED volumes or capacity. ED overcrowding is defined as a situation in which the demand for emergency services exceeds the ability of physicians and nurses to provide quality care within a reasonable time. The major factor resulting in ED overcrowding is the presence of admitted patients in the ED for prolonged periods of time, not a high volume of low-acuity patients. While limited data are available for paediatric EDs, winter respiratory illnesses set the stage for ED overcrowding, which are epidemic in adult or general EDs. Prehospital-, ED- and hospital-related factors are described in the present article, and these may help prevent or manage this important patient safety problem. PMID:19030415
Mohr, Nicholas M; Smith-Coggins, Rebecca; Larrabee, Hollynn; Dyne, Pamela L; Promes, Susan B
Strategies for approaching generational issues that affect teaching and learning, mentoring, and technology in emergency medicine (EM) have been reported. Tactics to address generational influences involving the structure and function of the academic emergency department (ED), organizational culture, and EM schedule have not been published. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic EM. Understanding generational characteristics and mitigating strategies can address some common issues encountered in academic EM. By understanding the differences and strengths of each of the cohorts in academic EM departments and considering simple mitigating strategies, faculty leaders can maximize their cooperative effectiveness and face the challenges of a new millennium.
El Sayed, Mazen J.; El-Eid, Ghada R.; Saliba, Miriam; Jabbour, Rima; Hitti, Eveline A.
Abstract The aim of this study is to determine the effectiveness of using lean management methods on improving emergency department door to doctor times at a tertiary care hospital. We performed a before and after study at an academic urban emergency department with 49,000 annual visits after implementing a series of lean driven interventions over a 20 month period. The primary outcome was mean door to doctor time and the secondary outcome was length of stay of both admitted and discharged patients. A convenience sample from the preintervention phase (February 2012) was compared to another from the postintervention phase (mid-October to mid-November 2013). Individual control charts were used to assess process stability. Postintervention there was a statistically significant decrease in the mean door to doctor time measure (40.0 minutes ± 53.44 vs 25.3 minutes ± 15.93 P < 0.001). The postintervention process was more statistically in control with a drop in the upper control limits from 148.8 to 72.9 minutes. Length of stay of both admitted and discharged patients dropped from 2.6 to 2.0 hours and 9.0 to 5.5 hours, respectively. All other variables including emergency department visit daily volumes, hospital occupancy, and left without being seen rates were comparable. Using lean change management techniques can be effective in reducing door to doctor time in the Emergency Department and improving process reliability. PMID:26496278
Bruner, David; Gustafson, Corey G; Visintainer, Catherine
According to 2007 data, gunshot wounds from homicides, suicides, and accidents caused 31,000 deaths in the United States, with even higher numbers of serious, nonfatal injuries. In recent years, new evidence on effective treatment of patients with gunshot wounds has come from military settings and is being adapted for civilian emergency departments (EDs). Effective, evidence-based management of ballistic injuries in the ED is vital. This issue reviews the physics of ballistics as it relates to the tracts and patterns of tissue injury caused by different types of firearms and missiles, and it takes a regional approach to reviewing the current evidence for managing gunshot wounds to the head, neck, thorax, abdomen, genitourinary (GU) system, extremities, and soft tissues. Current guidelines as well as new research and evidence regarding fluid resuscitation, airway management, evaluation strategies, drug therapies, and documentation are discussed.
Bellow, Aaron A; Flottemesch, Thomas J; Gillespie, Gordon L
As health care systems across the United States continue to grapple with emergency department (ED) crowding and identify mechanisms to improve ED throughput, quantification of intradepartmental efficiency and workload is required to provide much-needed objective measures to assist in the continuing development, implementation, and evaluation of these strategic initiatives. In an attempt to establish a straightforward measure of ED efficiency in relation to daily census and ED crowding, T. J. Flottemesch (2006) developed the ED Census Model. The purpose of this study was to apply the ED Census Model in a Southwestern U.S. community hospital setting. This application of the ED Census Model yielded 3 components: the ED Census Component, the ED Throughput Component, and the ED Efficiency Threshold Component. The components provide information necessary for understanding the impact of patient arrivals and departures on the underlying workflow processes that determine throughput.
Mierendorf, Susanne M; Gidvani, Vinita
The Emergency Department (ED) is the place where people most frequently seek urgent care. For patients living with chronic disease or malignancy who may be in a crisis, this visit may be pivotal in determining the patients’ trajectory. There is a large movement in education of emergency medicine physicians, hospitalists, and intensivists from acute aggressive interventions to patient-goal assessment, recognizing last stages of life and prioritizing symptom management. Although the ED is not considered an ideal place to begin palliative care, hospital-based physicians may assist in eliciting the patient’s goals of care and discussing prognosis and disease trajectory. This may help shift to noncurative treatment. This article will summarize the following: identification of patients who may need palliation, discussing prognosis, eliciting goals of care and directives, symptom management in the ED, and making plans for further care. These efforts have been shown to improve outcomes and to decrease length of stay and cost. The focus of this article is relieving “patient” symptoms and family distress, honoring the patient’s goals of care, and assisting in transition to a noncurative approach and placement where this may be accomplished. PMID:24694318
Patterson, P. Daniel; Pfeiffer, Anthony J.; Lave, Judith R.; Weaver, Matthew D.; Abebe, Kaleab; Krackhardt, David; Arnold, Robert M.; Yealy, Donald M.
Objectives Lack of familiarity between teammates is linked to worsened safety in high-risk settings. The Emergency Department (ED) is a high-risk health care setting where unfamiliar teams are created by diversity in clinician shift schedules and flexibility in clinician movement across the department. We sought to characterize familiarity between clinician teammates in one urban teaching hospital Emergency Department (ED) over a 22-week study period. Methods We used a retrospective study design of shift-scheduling data to calculate the mean weekly hours of familiarity between teammates at the dyadic level, and the proportion of clinicians with a minimum of 2-hours, 5-hours, 10-hours, and 20-hours of familiarity at any given hour during the study period. Results Mean weekly hours of familiarity between ED clinician dyads was 2 hours (SD 1.5). At any given hour over the study period, the proportion of clinicians with a minimum of 2, 5, 10, or 20-hours of familiarity was 80%, 51%, 27%, and 0.8%, respectively. Conclusions In our study, few clinicians could be described as having a high level of familiarity with teammates. The limited familiarity between ED clinicians identified in this study may be a natural feature of ED care delivery in academic settings. We provide a template for measurement of ED team familiarity. PMID:24351519
Smith, Lillian Upton; Waddell, Lisa; Kyle, Joseph; Hand, Gregory A
Given the limited resources available to public health, it is critical that university programs complement the development needs of agencies. Unfortunately, academic and practice public health entities have long been challenged in building sustainable collaborations that support practice-based research, teaching, and service. The academic health department concept offers a promising solution. In South Carolina, the partners started their academic health department program with a small grant that expanded into a dynamic infrastructure that supports innovative professional exchange and development programs. This article provides a background and describes the key elements of the South Carolina model: joint leadership, a multicomponent memorandum of agreement, and a shared professional development mission. The combination of these elements allows the partners to leverage resources and deftly respond to challenges and opportunities, ultimately fostering the sustainability of the collaboration.
Cook, Kevin L.
Explores both the allocation of resources to documents departments in academic libraries and the wide variation in local levels of support. Ways in which documents librarians may change levels of support through sources within and beyond their libraries are suggested. (CLB)
Walvoord, Barbara E.; Carey, Anna K.; Smith, Hoke L.; Soled, Suzanne Wegener; Way, Philip K.; Zorn, Debbie
Academic departments across the nation must reinvent new forms of collegiality and become more outward-oriented, more focused on results, and more entrepreneurial. They must develop new systems to reward their members, enhance productivity, and assure the quality of their work. Change strategies in the literature fall into six categories: (1)…
Ahanhanzo, Yolaine Glèlè; Kpozehouen, Alphonse; Sopoh, Ghislain; Sossa-Jérôme, Charles; Ouedraogo, Laurent; Wilmet-Dramaix, Michèle
Introduction The management of health information is a key pillar in both emergencies reception and handling facilities, given the strategic position and the potential of these facilities within hospitals, and in the monitoring of public health and epidemiology. With the technological revolution, computerization made the information systems evolve in emergency departments, especially in developed countries, with improved performance in terms of care quality, productivity and patient satisfaction. This study analyses the situation of Benin in this field, through the case of the Academic Clinic of Emergency Department of the National University Teaching Hospital of Cotonou, the national reference hospital. Methods The study is cross-sectional and evaluative. Collection techniques are literature review and structured interviews. The components rated are resources, indicators, data sources, data management and the use-dissemination of the information through a model adapted from Health Metrics Network framework. We used quantitative and qualitative analysis. Results The absence of a regulatory framework restricts the operation of the system in all components and accounts for the lack and inadequacy of the dedicated resources. Conclusion Dedication of more resources for this system for crucial needs such as computerization requires sensitization and greater awareness of the administrative authorities about the fact that an effective health information management system is of prime importance in this type of facility. PMID:27800116
Peterson, Lars E.; Dodoo, Martey; Bennett, Kevin J.; Bazemore, Andrew; Phillips, Robert L., Jr.
Context: Rural areas have fewer physicians compared to urban areas, and rural emergency departments often rely on community or contracted providers for staffing. The emergency department workforce is composed of a variety of physician specialties and clinicians. Purpose: To determine the distribution of emergency department clinicians and the…
Bernard, Marie A; Blanchette, Patricia L; Brummel-Smith, Kenneth
The United States is establishing new medical schools and increasing class size by 30% in response to the predicted increased needs of the baby boom generation, which will retire soon and live longer than prior generations. Society in general and the medical profession in particular are ill equipped to care for the special needs of the elderly. Since the early 1980s, departments of geriatric medicine have been developed in the United States. However, the prevailing U.S. system for the training of physicians in geriatrics is through sections, divisions, or institutes. This article reviews the advantages and disadvantages of departments of geriatrics, using case examples from three (University of Oklahoma College of Medicine, Florida State University College of Medicine, and University of Hawaii at Mãnoa John A. Burns School of Medicine) of the extant 11 medical schools in the United States with departments of geriatrics. Commonalities among the three departments include a seat at the planning table in academic life, equal treatment and collaboration with other departments in academic and research program development, and direct access to key decision makers and opportunities for negotiation for funds. Each department has outreach to all undergraduate medical students through its training program. All three departments were launched through the investment of significant resources obtained both internally and externally. The challenge for the future will be to definitively demonstrate the efficacy of the department model versus the more prevalent section, division, and institute approach to training physicians to care for the elderly.
Jung, Ileok; Kim, Ji-Soo
Acute dizziness/vertigo is among the most common causes for visiting the emergency department. The traditional approach to dizziness starts with categorizing dizziness into four types: vertigo, presyncope, disequilibrium, and nonspecific dizziness. However, a recently proposed approach begins with classifying dizziness/vertigo as acute prolonged spontaneous dizziness/vertigo, recurrent spontaneous dizziness/vertigo, recurrent positional vertigo, or chronic persistent dizziness and imbalance. Vestibular neuritis and stroke are key disorders causing acute prolonged spontaneous dizziness/vertigo, but the diagnosis of isolated vascular vertigo has increased by virtue of developments in clinical neurotology and neuroimaging. However, a well-organized bedside examination appears more sensitive than brain imaging in diagnosing strokes presenting with acute dizziness/vertigo. A detailed history is vital to diagnose recurrent spontaneous dizziness/vertigo since confirmatory diagnostic tests are usually unavailable. Isolated positional vertigo is usually caused by benign paroxysmal positional vertigo, which can be treated at the bedside. In recent years, marked progress has occurred in the evaluation/management of acute dizziness/vertigo. However, even with developments in imaging technology, the diagnosis of acute dizziness/vertigo largely relies on bedside examination. PMID:27752577
Goodarzi, Hassan; Javadzadeh, Hamidreza; Hassanpour, Kasra
Background: Emergency Department (ED) is considered to be the heart of a hospital. Based on many studies, a well-organized physical environment can enhance efficacy. Objectives: In this study, we aimed to investigate the influence of physical environment in EDs on efficacy. Materials and Methods: This analytical cross-sectional study was conducted via the faculty members of the ED and residents of Shahid Beheshti University of Medical Sciences in Tehran, Iran. Data were collected using a predefined questionnaire. Descriptive statistics and ANOVA were used to analyze the data. Results: Sixty-two participants, including 21 females and 41 males, completed the questionnaires. The mean age of the participants was 37 years (SD: 8.42). The mean work experience was 8 years (SD: 4.52) and all the studied variables varied within a range of 3.3 - 4.2. Time indices had the highest mean among variables followed by capacity, work space, treatment units, critical care units and, triage indices, respectively. Conclusions: In general, time indices including length of patient stay in the ED and space capacity, emphasizing the need to address these shortcomings. PMID:26839860
Richards, J R; Bretz, S W; Johnson, E B; Turnipseed, S D; Brofeldt, B T; Derlet, R W
Methamphetamine (MAP) abuse continues to increase worldwide, based on morbidity, mortality, drug treatment, and epidemiologic studies and surveys. MAP abuse has become a significant health care, environmental, and law enforcement problem. Acute intoxication often results in agitation, violence, and death. Chronic use may lead to infection, heart failure, malnutrition, and permanent psychiatric illness. MAP users frequently use the emergency department (ED) for their medical care. Over a 6-month period we studied the demographics, type, and frequency of medical and traumatic problems in 461 MAP patients presenting to our ED, which serves an area noted for high levels of MAP production and consumption. Comparison was made to the general ED population to assess use patterns. MAP patients were most commonly Caucasian males who lacked health insurance. Compared to other ED patients during this time, MAP patients used ambulance transport more and were more likely to be admitted to the hospital. There was a significant association between trauma and MAP use in this patient population. Our data suggest MAP users utilize prehospital and hospital resources at levels higher than the average ED population. Based on current trends, we can expect more ED visits by MAP users in the future. PMID:10344172
Hategan, Ana; Tisi, Daniel; Abdurrahman, Mariam; Bourgeois, James A.
Background Homeless adults frequently use emergency departments (EDs), yet previous studies investigating ED utilization by the older segment received little attention. This study sought to characterize older homeless adults who utilized local urban EDs. Methods ED encounters at three hospitals in Hamilton (Ont.) were analyzed, and demographic and clinical characteristics of the older homeless (age > 50) vs. younger counterparts (age ≤ 50) were compared during a 24-month period. Results Of all adults, 1,330 were homeless, of whom 66% were above age 50. Older homeless adults sought less acute care within 30 days from an index visit compared with their younger counterparts. Non-acute illnesses constituted only 18% of triaged cases. Older homeless women with access to a primary care physician (PCP) were 3.3 times more likely to return to ED within 30 days, whereas older homeless men (irrespective of PCP access) were less likely to return to ED. Conclusions Despite high homeless patient acuity, a lesser number of ED visits with increasing age remains concerning because of previously reported high morbidity and mortality rates. Access to primary care may not be enough to reduce ED utilization. Further research is needed to evaluate acute care interventions and their effectiveness in ED, and to identify homeless patients requiring more targeted services. PMID:28050223
Reichard, Audrey A.; Konda, Srinivas; Jackson, Larry L.
Background Despite reported declines, occupational burn injuries remain a workplace safety concern. More severe burns may result in costly medical treatment and long-term physical and psychological consequences. Methods We used the National Electronic Injury Surveillance System—Occupational Supplement to produce national estimates of burns treated in emergency departments (EDs). We analyzed data trends from 1999 to 2008 and provided detailed descriptions of 2008 data. Results From 1999 to 2008 there were 1,132,000 (95% CI: ±192,300) nonfatal occupational burns treated in EDs. Burn numbers and rates declined approximately 40% over the 10 years. In 2008, men and younger workers 15–24 years old had the highest rates. Scalds and thermal burns accounted for more than 60% of burns. Accommodation and food service, manufacturing, and construction industries had the largest number of burns. Conclusions Despite declining burn rates, emphasis is needed on reducing burn hazards to young food service workers and using job specific hazard analyses to prevent burns. PMID:25678457
Swartz, Jordan L; Cimino, James J; Fred, Matthew R; Green, Robert A; Vawdrey, David K
Data fragmentation within electronic health records causes gaps in the information readily available to clinicians. We investigated the information needs of emergency medicine clinicians in order to design an electronic dashboard to fill information gaps in the emergency department. An online survey was distributed to all emergency medicine physicians at a large, urban academic medical center. The survey response rate was 48% (52/109). The clinical information items reported to be most helpful while caring for patients in the emergency department were vital signs, electrocardiogram (ECG) reports, previous discharge summaries, and previous lab results. Brief structured interviews were also conducted with 18 clinicians during their shifts in the emergency department. From the interviews, three themes emerged: 1) difficulty accessing vital signs, 2) difficulty accessing point-of-care tests, and 3) difficulty comparing the current ECG with the previous ECG. An emergency medicine clinical dashboard was developed to address these difficulties.
Tyagi, Preeti; Yadav, Shiv Prasad; Singh, S P
The process of liberalization and globalization of Indian economy has brought new opportunities and challenges in all areas of human endeavor including education. Educational institutions have to adopt new strategies to make best use of the opportunities and counter the challenges. One of these challenges is how to assess the performance of academic programs based on multiple criteria. Keeping this in view, this paper attempts to evaluate the performance efficiencies of 19 academic departments of IIT Roorkee (India) through data envelopment analysis (DEA) technique. The technique has been used to assess the performance of academic institutions in a number of countries like USA, UK, Australia, etc. But we are using it first time in Indian context to the best of our knowledge. Applying DEA models, we calculate technical, pure technical and scale efficiencies and identify the reference sets for inefficient departments. Input and output projections are also suggested for inefficient departments to reach the frontier. Overall performance, research performance and teaching performance are assessed separately using sensitivity analysis.
Iannuzzi, Dorothea A.; Cheng, Erika R.; Broder-Fingert, Sarabeth; Bauman, Margaret L.
To identify medical problems most commonly presenting to emergency departments among individuals with autism as compared to non-autistic persons across age groups. Data was obtained from the 2010 National Emergency Department database and was analyzed by age categories: 3-5, 6-11, 12-15, 16-18 and 19 years and older. Epilepsy emerged as the…
Taylor, Todd B
Information system planning for the ED is complex and new to emergency medicine, despite being used in other industries for many years. It has been estimated that less than 15% of EDs have comprehensive EDIS currently in place. The manner in which administration is approached in large part determines the success in obtaining appropriate institutional support for an EDIS. Active physician and nurse involvement is essential in the process if the new system is to be accepted at the user level. In the ED, large volumes of information are collected, collated,interpreted, and acted on immediately. Effective information management therefore is key to the successful operation of any ED. Although computerized information systems have tremendous potential for improving information management, such systems are often underused or implemented in such a way that they increase the workload on caregivers and staff. This is counter productive and should be avoided. In developing and implementing EDIS one should be careful not to automate poorly designed manual processes. Examples are ED tracking systems that require staff to manually relocate patients in the system. This task probably is completed only when the ED volume is low and "worked around" when the department is busy. Information from such a system is, therefore, flawed; at best useless and at worst counter productive. Alternatively, systems are available that can track patients automatically through the ED by way of infrared sensors similar to those used in baggage-tracking systems that have been in place in airports for years. In the automated (computerized) ED, we must have zero-fault-tolerant,enterprise-wide, hospital information networked systems that prevent unnecessary duplication of tasks, assist in tracking and entering data, and ultimately help analyze the information on a minute-to-minute basis. Such systems only reach their potential when they are fully integrated, including legacy systems, rather than stand
Erwin, Paul Campbell; Keck, C William
The Academic Health Department (AHD) involves an arrangement between a governmental health agency and an academic institution, which provides mutual benefits in teaching, service, research, and practice. From its initial development in the mid-1980s as the public health equivalent of the relationship between a teaching hospital and a medical school, the AHD concept has evolved to include multiple levels of governmental public health agencies (local, state, and federal) as well as multiple academic institutions (public health, medicine, and primary care medical residencies). Throughout the decade of the 2000s, multiple influences have impacted both the quality and quantity of AHDs, leading to an expansion of AHDs through the Council on Linkages' AHD Learning Community. The value of the AHD--as described from prior studies as well as the AHD case examples in this current special issue--is evident in its impact on the quality of educational experiences and workforce development, agency and academic accreditation, practice-based research, and the potential to influence health reform.
Lee, Amy F; Quade, Thomas; Dwinnells, Ronald
In 1997, the Office of Public Health Practice was chartered at Northeast Ohio Medical University (NEOMED). Through this office, public health practitioners and academics have engaged in informal collaborations, formal collaborations, and formal agreements. Projects that have helped public health practitioners included a sanitarian preparation course, educational opportunities, and shared faculty arrangements. The academic programs have benefited through support in accreditation activities, teaching and precepting of public health and medical students, and advice on community-oriented curriculum. Formal affiliation agreements have been developed between the medical school and 5 local health departments, and public health practitioners have been given faculty appointments. Factors that have resulted in the longevity of Academic Health Department relationships through the Office of Public Health Practice include individuals dedicated to these relationships, agencies willing to support collaborative efforts, mutually beneficial activities, and a culture conducive to continued engagement.
Nicks, B. A.; Manthey, D. M.
Objectives. Studies have demonstrated the adverse effects of emergency department (ED) boarding. This study examines the impact of resource utilization, throughput, and financial impact for psychiatric patients awaiting inpatient placement. Methods. The authors retrospectively studied all psychiatric and non-psychiatric adult admissions in an Academic Medical Center ED (>68,000 adult visits) from January 2007-2008. The main outcomes were ED length of stay (LOS) and associated reimbursement. Results. 1,438 patients were consulted to psychiatry with 505 (35.1%) requiring inpatient psychiatric care management. The mean psychiatric patient age was 42.5 years (SD 13.1 years), with 2.7 times more women than men. ED LOS was significantly longer for psychiatric admissions (1089 min, CI (1039–1140) versus 340 min, CI (304–375); P < 0.001) when compared to non-psychiatric admissions. The financial impact of psychiatric boarding accounted for a direct loss of ($1,198) compared to non-psychiatric admissions. Factoring the loss of bed turnover for waiting patients and opportunity cost due to loss of those patients, psychiatric patient boarding cost the department $2,264 per patient. Conclusions. Psychiatric patients awaiting inpatient placement remain in the ED 3.2 times longer than non-psychiatric patients, preventing 2.2 bed turnovers (additional patients) per psychiatric patient, and decreasing financial revenue. PMID:22888437
Brouns, Steffie H. A.; Lambooij, Suze L. E.; Dieleman, Jeanne; Vanderfeesten, Irene T. P.; Haak, Harm R.
Background Emergency department (ED) crowding leads to prolonged emergency department length of stay (ED-LOS) and adverse patient outcomes. No uniform definition of ED crowding exists. Several scores have been developed to quantify ED crowding; the best known is the Emergency Department Work Index (EDWIN). Research on the EDWIN is often applied to limited settings and conducted over a short period of time. Objectives To explore whether the EDWIN as a measure can track occupancy at a Dutch ED over the course of one year and to identify fluctuations in ED occupancy per hour, day, and month. Secondary objective is to investigate the discriminatory value of the EDWIN in detecting crowding, as compared with the occupancy rate and prolonged ED-LOS. Methods A retrospective cohort study of all ED visits during the period from September 2010 to August 2011 was performed in one hospital in the Netherlands. The EDWIN incorporates the number of patients per triage level, physicians, treatment beds and admitted patients to quantify ED crowding. The EDWIN was adjusted to emergency care in the Netherlands: modified EDWIN (mEDWIN). ED crowding was defined as the 75th percentile of mEDWIN per hour, which was ≥0.28. Results In total, 28,220 ED visits were included in the analysis. The median mEDWIN per hour was 0.15 (Interquartile range (IQR) 0.05–0.28); median mEDWIN per patient was 0.25 (IQR 0.15–0.39). The EDWIN was higher on Wednesday (0.16) than on other days (0.14–0.16, p<0.001), and a peak in both mEDWIN (0.30–0.33) and ED crowding (52.9–63.4%) was found between 13:00–18:00 h. A comparison of the mEDWIN with the occupancy rate revealed an area under the curve (AUC) of 0.86 (95%CI 0.85–0.87). The AUC of mEDWIN compared with a prolonged ED-LOS (≥4 hours) was 0.50 (95%CI 0.40–0.60). Conclusion The mEDWIN was applicable at a Dutch ED. The mEDWIN was able to identify fluctuations in ED occupancy. In addition, the mEDWIN had high discriminatory power for
Angelis, Maria Vittoria De; Giacomo, Roberta Di; Muzio, Antonio Di; Onofrj, Marco; Bonanni, Laura
Abstract Background: Movement disorder emergencies include any movement disorder which develops over hours to days, in which failure to appropriately diagnose and manage can result in patient morbidity or mortality. Movement disorder emergencies include acute dystonia: sustained or intermittent muscle contractions causing abnormal, often repetitive, movements. Acute dystonia is a serious challenge for emergency room doctors and neurologists, because of the high probability of misdiagnosis, due to the presence of several mimickers including partial seizures, meningitis, localized tetanus, serum electrolyte level abnormalities, strychnine poisoning, angioedema, malingering, catatonia, and conversion. Methods: We describe 2 examples, accompanied by videos, of acute drug-induced oro-mandibular dystonia, both subsequent to occasional haloperidol intake. Results: Management and treatment of this movement disorder are often difficult: neuroleptics withdrawal, treatment with benzodiazepines, and anticholinergics are recommended. Conclusion: Alternative treatment options are also discussed. PMID:27741141
Repplinger, Michael D.; Li, Annabel J.; Svenson, James E.; Ehlehbach, William J.; Westergaard, Ryan P.; Reeder, Scott B.; Jacobs, Elizabeth A.
Objective To evaluate emergency department patients’ knowledge of radiation exposure and subsequent risks from CT and MRI scans. Methods This is a cross-sectional survey study of adult, English-speaking patients from 6/2011-8/2011 at two emergency departments, one academic and one community-based, in the upper Midwest. The survey consisted of two sets of three questions evaluating patients’ knowledge of radiation exposure from medical imaging and subsequent radiation-induced malignancies, and was based on a previously published survey. The question sets paralleled each other, but one pertained to CT and the other to MRI. Questions in the survey ascertained patients’ understanding of: 1) the relative amount of radiation exposed from CT/MRI compared with a single chest x-ray, 2) the relative amount of radiation exposed from CT/MRI compared with a nuclear power plant accident, and 3) the possibility of radiation-induced malignancies from CT/MRI. Sociodemographic data were also gathered. The primary outcome measure was the proportion of correct answers to each question of the survey. Multiple logistic regression was then used to examine the relationship between the percentage correct for each question and sociodemographic variables, using odds ratios with 95% confidence intervals. P-values less than 0.05 were considered statistically significant. Results There were 500 participants in this study, 315 from the academic center and 185 from the community hospital. Overall, 14.1% (95% CI 11.0%-17.2%) of participants understood the relative radiation exposure of a CT scan compared with a chest x-ray while 22.8% (95% CI 18.9%-26.7%) of respondents understood the lack of ionizing radiation use with MRI. 25.6% (95% CI 21.8%-29.4%) believed that there was an increased risk of developing cancer from repeated abdominal CTs while 55.6% (95% CI 51.1%-60.1%) believed this to be true of abdominal MRI. Higher educational level and identification as a healthcare professional were
Boyle, Adrian; Beniuk, Kathleen; Higginson, Ian; Atkinson, Paul
This paper summarises the consequences of emergency department crowding. It provides a comparison of the scales used to measure emergency department crowding. We discuss the multiple causes of crowding and present an up-to-date literature review of the interventions that reduce the adverse consequences of crowding. We consider interventions at the level of an individual hospital and a policy level. PMID:22454772
Pallin, Daniel J; Camargo, Carlos A; Yokoe, Deborah S; Espinola, Janice A; Schuur, Jeremiah D
Contact precautions policies in US emergency departments have not been studied. We surveyed a structured random sample and found wide variation; for example, 45% required contact precautions for stool incontinence or diarrhea, 84% for suspected Clostridium difficile, and 79% for suspected methicillin-resistant Staphylococcus aureus infection. Emergency medicine departments and organizations should enact policies.
Mastitis is a common clinical condition and, although not exclusive to lactating mothers, most patients with the condition seen by clinical staff fall into this group. Between 3 and 33 per cent of lactating mothers experience an episode of mastitis (Academy of Breastfeeding Medicine 2008, Jahanfar et al 2009). Most of these mothers receive treatment from their midwives or GPs, but some attend EDs and require treatment for, and education about, the condition from emergency care staff, including nurse practitioners (NPs). This article describes mastitis and the various treatment measures, and aims to improve NPs' ability and confidence in recognising and treating the condition.
Carbone, Paula M.; Orellana, Marjorie Faulstich
This paper examines how writing samples produced by middle school students reveal their emerging academic identities through their rhetorical choices in writing. Analyses of two texts produced by each student revealed students' implicit understandings of the requirements of academic voice. Through comparisons of each student's texts, strategies…
As an emerging field within higher education, academic development remains fragmented, both as a field of theory and practice. In the vibrant, on-going debate about the theoretical foundations and directions of academic development as a nascent field, some relatively wide-ranging claims which have been made seem to be lacking in supporting…
The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report.
Describes the jobs, training, qualifications, and advancement potential of the following emergency department personnel: physicians, nurses, medical technicians, and registration clerks. Briefly reviews eleven other occupations with emergency medical services. Employment outlook and earnings/benefits of emergency personnel are discussed. Provides…
Endom, E E; Myers, J H; Shook, J E
Computers are becoming an increasingly important tool in the management of emergency departments across the United States. Many emergency physicians are unfamiliar with computer systems and are uncomfortable with the idea of implementing computer technology into their departments. This article summarizes the benefits of computerized patient tracking systems and outlines the process by which such a program can be selected and incorporated into an emergency center.
Baillargeon, Jacques; Paar, David; Giordano, Thomas P; Zachariah, Brian; Rudkin, Laura L; Wu, Z Helen; Raimer, Ben G
The number of uninsured Texas residents who rely on the medical emergency department as their primary health care provider continues to increase. Unfortunately, little information about the characteristics of this group of emergency department users is available. Using an administrative billing database, we conducted a descriptive study to examine the demographic and clinical features of 17,110 consecutive patients without medical insurance who presented to the emergency department of the University of Texas Medical Branch in Galveston over a 12-month period. We also analyzed the risk of multiple emergency department visits or hospitalization according to demographic characteristics. Twenty percent of the study population made two or more emergency department visits during the study period; 19% of the population was admitted to the hospital via the emergency department. The risk of multiple emergency department visits was significantly elevated among African Americans and increased in a stepwise fashion according to age. The risk of being hospitalized was significantly reduced among females, African Americans, and Hispanics. There was an age-related monotonic increase in the risk of hospitalization. Abdominal pain, cellulitis, and spinal disorders were the most common primary diagnoses in patients who made multiple emergency department visits. Hospitalization occurred most frequently in patients with a primary diagnosis of chest pain, nonischemic heart disease, or an affective disorder. Additional studies of emergency department usage by uninsured patients from other regions of Texas are warranted. Such data may prove helpful in developing effective community-based alternatives to the emergency department for this growing segment of our population. Local policymakers who are responsible for the development of safety net programs throughout the state should find this information particularly useful.
Browning, J; Atwood, B; Gray, A
Aim To describe the current use of non‐invasive ventilation in UK emergency departments. Methods A structured questionnaire was sent to all UK emergency departments assessing 25,000 new patients annually. Results 222 of 233 departments completed the questionnaire. 148 currently use non‐invasive ventilation (NIV). Most used NIV for either cardiogenic pulmonary oedema (n = 128) or chronic obstructive pulmonary disease (n = 115). Only 49 departments have protocols for NIV use and 23 audited practice. Conclusion NIV is commonly used in UK emergency departments. Practices vary significantly. One solution would be the development of guidelines on when and how to use NIV in emergency medicine practice. PMID:17130599
Magnuson, J A; Klockner, Rocke; Ladd-Wilson, Stephen; Zechnich, Andrew; Bangs, Christopher; Kohn, Melvin A
Electronic emergency department reporting provides the potential for enhancing local and state surveillance capabilities for a wide variety of syndromes and reportable conditions. The task of protecting data confidentiality and integrity while developing electronic data interchange between a hospital emergency department and a state public health department proved more complex than expected. This case study reports on the significant challenges that had to be resolved to accomplish this goal; these included application restrictions and incompatibilities, technical malfunctions, changing standards, and insufficient dedicated resources. One of the key administrative challenges was that of coordinating project security with enterprise security. The original project has evolved into an ongoing pilot, with the health department currently receiving secure data from the emergency department at four-hour intervals. Currently, planning is underway to add more emergency departments to the project.
Kadri, Farid; Harrou, Fouzi; Chaabane, Sondès; Tahon, Christian
Efficient management of patient flow (demand) in emergency departments (EDs) has become an urgent issue for many hospital administrations. Today, more and more attention is being paid to hospital management systems to optimally manage patient flow and to improve management strategies, efficiency and safety in such establishments. To this end, EDs require significant human and material resources, but unfortunately these are limited. Within such a framework, the ability to accurately forecast demand in emergency departments has considerable implications for hospitals to improve resource allocation and strategic planning. The aim of this study was to develop models for forecasting daily attendances at the hospital emergency department in Lille, France. The study demonstrates how time-series analysis can be used to forecast, at least in the short term, demand for emergency services in a hospital emergency department. The forecasts were based on daily patient attendances at the paediatric emergency department in Lille regional hospital centre, France, from January 2012 to December 2012. An autoregressive integrated moving average (ARIMA) method was applied separately to each of the two GEMSA categories and total patient attendances. Time-series analysis was shown to provide a useful, readily available tool for forecasting emergency department demand.
Johnson, Laurie H; Chambers, Patricia; Dexheimer, Judith W
Asthma is one of the most common chronic pediatric diseases. Patients with asthma often present to the emergency department for treatment for acute exacerbations. These patients may not have a primary care physician or primary care home, and thus are seeking care in the emergency department. Asthma care in the emergency department is multifaceted to treat asthma patients appropriately and provide quality care. National and international guidelines exist to help drive clinical care. Electronic and paper-based tools exist for both physicians and patients to help improve emergency, home, and preventive care. Treatment of patients with asthma should include the acute exacerbation, long-term management of controller medications, and controlling triggers in the home environment. We will address the current state of asthma research in emergency medicine in the US, and discuss some of the resources being used to help provide a medical home and improve care for patients who suffer from acute asthma exacerbations. PMID:27471415
Cork, Alison; Ferns, Terry
Violence in the emergency department (ED) is a global problem. In our first paper, we highlighted the potential psychological effects of alcohol intoxication, the literatures discussion of alcohol related violence in the emergency department and the importance of developing positive nurse/service user relationships. In this second paper, we discuss personal and organisational strategies clinical nursing staff may consider appropriate to minimise the risk of assault when caring for service users projecting alcohol related aggression.
Yersin, Corinne; Hemme, Denis; Gehri, Mario; Pittet, Anne; Rey-Bellet Gasser, Céline
In Switzerland, overcrowding in tertiary emergency departments is a frequent problem, resulting in lengthy waiting times, lower satisfaction on the part of families and a risk for patient's safety. The setting up of a nurse consultation in a university paediatric emergency centre has helped to improve the quality of care in this context.
Handel, Daniel A.; Ma, O. John; Workman, Judi; Fu, Rongwei
Objective: Our hypothesis was that an individual whose primary role was to assist with patient throughput would decrease emergency department (ED) length of stay (LOS), elopements and ambulance diversion. The objective of this study was to measure how the use of an expeditor affected these throughput metrics. Methods: This pre-and post-intervention study analyzed ED patients ≥ 21-years-old between June 2008 and June 2009, at a level one trauma center in an academic medical center with an annual ED census of 40,000 patients. We created the expeditor position as our study intervention in December 2008, by modifying the job responsibilities of an existing paramedic position. An expeditor was on duty from 1PM–1AM daily. The pre-intervention period was June to November 2008, and the post-intervention period was January to June 2009. We used multivariable to assess the impact of the expeditor on throughput metrics after adjusting for confounding variables. Results: We included a total of 13,680 visits in the analysis. There was a significant decrease in LOS after expeditor implementation by 0.4 hours, despite an increased average daily census (109 vs. 121, p<0.001). The expeditor had no impact on elopements. The probability that the ED experienced complete ambulance diversion during a 24-hour period decreased from 55.2% to 16.0% (OR:0.17, 95%CI:0.05–0.67). Conclusion: The use of an expeditor was associated with a decreased LOS and ambulance diversion. These findings suggest that EDs may be able to improve patient flow by using expeditors. This tool is under the control of the ED and does not require larger buy-in, resources, or overall hospital changes. PMID:21691526
Richman, Peter B; Loutfi, Hassan; Lester, Steven J; Cambell, Patricia; Matthews, Jessica; Friese, Jeremy; Wood, Joseph; Kasper, David; Chen, Frederick; Mandell, Mark
To assess the pre-study, null hypothesis that there is no difference in the electrocardiogram (EKG) findings for Emergency Department (ED) patients who rule in vs. rule out for suspected pulmonary embolism, a retrospective review of a cohort of patients with pulmonary embolism and their controls was conducted in an academic, suburban ED. Patients who were evaluated in the ED during a one-year study period for symptoms suggestive of pulmonary embolism were eligible for inclusion. All patients with pulmonary embolism and sex- and age-matched controls comprised the final study groups. Two board-certified cardiologists reviewed each patient's EKG. There were 350 eligible patients identified; 49 patients with pulmonary embolism and 49 controls were entered into the study. The most common rhythm observed in both groups was normal sinus rhythm (67.3% cases vs. 68.6 % controls; p = 1.0). Abnormalities believed to be associated with pulmonary embolism occurred with similar frequency in both case and control groups (sinus tachycardia [18.8 % vs. 11.8%, respectively; p = 0.40]), incomplete right bundle branch block (4.2% vs. 0.0%, respectively; p = 0.24), complete right bundle branch block (4.2% vs. 6.0, respectively; p = 1.0), S1Q3T3 pattern (2.1 vs. 0.0, respectively; p = 0.49), S1Q3 pattern (0.0 vs. 0.0), and extreme right axis (0.0 vs. 0.0). New EKG changes were identified more frequently for patients with pulmonary embolism (33.3% vs. 12.5% controls; p = 0.03), but specific findings were rarely different between cases and controls. In our cohort of ED patients, we did not identify EKG features that are likely to help distinguish patients with pulmonary embolism from those who rule out for the disease.
McNaughton, Candace; Self, Wesley H.; Jones, Ian D.; Arbogast, Patrick G.; Chen, Ning; Dittus, Robert S.; Russ, Stephan
Background and Objectives In an effort to compensate for crowding, many emergency departments (EDs) evaluate and treat patients in nontraditional settings such as gurneys in hallways and conference rooms. The impact of this practice on ED evaluation time is unknown. Research Design and Subjects An historical cohort of adult ED visits to an academic hospital between 8/1/2009 and 8/1/2010 was used to evaluate the relationship between ED bed assignment (traditional, hallway, or conference room bed) and mean ED evaluation time, defined as the time spent in an ED bed before admission or discharge. Chief complaints were categorized into the five most frequent categories: abdominal/genitourinary, joint/muscle, general (fever, malaise), head/neck, and other. Multiple linear regression and marginal prediction were used to calculate mean ED evaluation times for each bed type, overall and by chief complaint category. Results During the study period, 15,073 patient visits met inclusion criteria. After adjustment for patient and ED factors, assignments to hallway and conference room beds were associated with increases in mean ED evaluation time of 13.3 minutes (95% confidence interval 13.2, 13.3) and 10.9 minutes (95% CI 10.8, 10.9), respectively, compared to the traditional bed ED evaluation time. This varied by chief complaint category. Conclusions Use of nontraditional beds is associated with increases in mean ED evaluation time; however, these increases are small and may be further minimized by restricting use of nontraditional beds to patients with specific chief complaints. Nontraditional beds may have a role in improving ED throughput during times of crowding. PMID:22386355
Ciesielski, Gail; Clark, Nora
Emergency departments must answer the call of all patients at any time of the day. However, as the typical day progresses, bottlenecks may develop in the process of delivering care. Patient safety can be compromised. This article summarizes key current issues in emergency department safety. Factors that affect patient safety are numerous; however, the best intervention may be reducing patient length of stay. Increasing number of patients and aging populations add to the risk of injury when the patient's length of stay exceeds the accommodations and capabilities of traditional short-stay acute-care oriented emergency facilities.
Ferns, Terry; Cork, Alison
Internationally, violence in the emergency department (ED) is of a constant concern to emergency practitioners. Frequently, both original research papers and anecdotal reports emphasise the phenomenon of alcohol related aggression in the ED. In this first paper, we highlight the literatures discussion of alcohol related violence in the emergency department and the potential psychological effects of alcohol intoxication. In the second we offer personal and organisational strategies clinical nursing staff may consider appropriate to minimise the risk of assault when caring for service users projecting alcohol related aggression.
Avwiri, H. E.
Emerging Trends in Science Education in a Dynamic Academic Environment highlights the changes that have occurred in science education particularly in institutions of higher learning in southern Nigeria. Impelled by the fact that most Nigerian Universities and Colleges of Education still adhere to the practices and teaching methodologies of the…
Gilbert, Stefanie K.; Wen, Leana S.; Pines, Jesse M.
BACKGROUND: Costs of care are increasingly important in healthcare policy and, more recently, in clinical care in the emergency department (ED). We compare ED resident and patient perspectives surrounding costs in emergency care. METHODS: We conducted a mixed methods study using surveys and qualitative interviews at a single, academic ED in the United States. The two study populations were a convenience sample of adult ED patients (>17 years of age) and ED residents training at the same institution. Participants answered open- and closed-ended questions on costs, medical decision making, cost-related compliance, and communication about costs. Closed-ended data were tabulated and described using standard statistics while open-ended responses were analyzed using grounded theory. RESULTS: Thirty ED patients and 24 ED residents participated in the study. Both patients and residents generally did not have knowledge of medical costs. Patients were comfortable discussing costs while residents were less comfortable. Residents agreed that doctors should consider costs when making medical decisions whereas patients somewhat disagreed. Additionally, residents generally took costs into consideration during clinical decision-making, yet nearly all residents agreed that they had too little education on costs. CONCLUSION: There were several notable differences in ED patient and resident perspectives on costs in this U.S. sample. While patients somewhat disagree that cost should factor into decision making, generally they are comfortable discussing costs yet report having insufficient knowledge of what care costs. Conversely, ED residents view costs as important and agree that cost should factor into decision making but lack education on what emergency care costs. PMID:28123619
Decker, Summer J; Grajo, Joseph R; Hazelton, Todd R; Hoang, Kimberly N; McDonald, Jennifer S; Otero, Hansel J; Patel, Midhir J; Prober, Allen S; Retrouvey, Michele; Rosenkrantz, Andrew B; Roth, Christopher G; Ward, Robert J
Between 2004 and 2012, US funding for the biomedical sciences decreased to historic lows. Health-related research was crippled by receiving only 1/20th of overall federal scientific funding. Despite the current funding climate, there is increased pressure on academic radiology programs to establish productive research programs. Whereas larger programs have resources that can be utilized at their institutions, small to medium-sized programs often struggle with lack of infrastructure and support. To address these concerns, the Association of University Radiologists' Radiology Research Alliance developed a task force to explore any untapped research productivity potential in these smaller radiology departments. We conducted an online survey of faculty at smaller clinically funded programs and found that while they were interested in doing research and felt it was important to the success of the field, barriers such as lack of resources and time were proving difficult to overcome. One potential solution proposed by this task force is a collaborative structured research model in which multiple participants from multiple institutions come together in well-defined roles that allow for an equitable distribution of research tasks and pooling of resources and expertise. Under this model, smaller programs will have an opportunity to share their unique perspective on how to address research topics and make a measureable impact on the field of radiology as a whole. Through a health services focus, projects are more likely to succeed in the context of limited funding and infrastructure while simultaneously providing value to the field.
Novak, Ronald D; Mansoori, Bahar; Sivit, Carlos J; Ros, Pablo R
This study identifies the major sources of overhead fees/costs and subsidies in academic radiology departments (ARDs) in the US and determines the differences between them based on geographic location or the size of their affiliated hospital. ARDs in the Northeast had the highest level of financial support from their affiliated hospitals when compared to those in the South/Southwest; however, a greater number of Midwest ARDs receive high levels of funding for teaching from their medical schools when compared to the northeast. Significantly fewer ARDs affiliated with hospitals of less than 200 beds receive subsidies for their activities when compared to those affiliated with larger hospitals. Differences in levels of overhead costs/ subsidies available to ARDs are associated with either geographic location or the size of the affiliated hospital. The reasons for these differences may be related to a variety of legal, contractual, or fiscal factors. Investigation of existing geographic and affiliate size fiscal differences and their causes by ARDs may be of benefit.
Mehrotra, Abhishek; Sklar, David P; Tayal, Vivek S; Kocher, Keith E; Handel, Daniel A; Myles Riner, R
This article is drawn from a report created for the American College of Emergency Physicians (ACEP) Emergency Department (ED) Categorization Task Force and also reflects the proceedings of a breakout session, "Beyond ED Categorization-Matching Networks to Patient Needs," at the 2010 Academic Emergency Medicine consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." The authors describe a brief history of the significant national and state efforts at categorization and suggest reasons why many of these efforts failed to persevere or gain wider implementation. The history of efforts to categorize hospital (and ED) emergency services demonstrates recognition of the potential benefits of categorization, but reflects repeated failures to implement full categorization systems or limited excursions into categorization through licensing of EDs or designation of receiving and referral facilities. An understanding of the history of hospital and ED categorization could better inform current efforts to develop categorization schemes and processes.
Tamás, T László; Garai, Tibor; Tompos, Tamás; Szirmai, Ágnes
According to international statistics, the first examination of 25% of patients with vertigo is carried out in Emergency Departments. The most important task of the examining physician is to diagnose life threatening pathologic processes. One of the most difficult otoneurological diagnostic challange in Emergency Departments is to differentiate between dangerous posterior scale stroke presenting with isolated vertigo and the benign vestibular neuritis.These two disorders can be safely differentiated using fast, non-invasive, evidence based bedside tests which have been introduced in the past few years. 35% of stroke cases mimicking vestibular neuritis (pseudoneuritis) are misdiagnosed at the Emergency Department, and 40% of these cases develop complications. During the first 48 hours, sensitivity for stroke of the new test that is based on the malfunction of the oculomotor system is better than the diffusion-weighted cranial magnetic resonance imaging. Using special test glasses each component of the new test can be made objective and repeatable.
Trask, Jeffrey A
To achieve effective emergency management and business continuity, all hazards should be considered during the planning and preparedness process. In recent years, several new hazards have attracted the attention of Emergency Management and Business Continuity practitioners. Climate change presents a unique challenge. Practitioners must rely on historical data combined with scientific projections to guide their planning and preparedness efforts. This article examines how an academic institution's emergency management programme can plan successfully for this hazard by focusing on best practices in the area of building cross-departmental and cross-jurisdictional relationships. Examples of scientific data related to the hazard of climate change will be presented along with the latest guidance from the Federal Emergency Management Agency encouraging the planning for future hazards. The article presents a functional exercise in which this hazard was prominently featured, and presents testimony from subject matter experts. Recommendations for emergency management and business continuity programmes are so provided.
This study shows a case of a department heavily involved in industry-academia collaborations and patenting activities while exhibiting high levels of academic norms such as teaching, basic research, academic freedom and free dissemination of knowledge. Based on the findings, the author argues that academic capitalism is a highly contextual…
Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicine's report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems' administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Children's National Medical Center, Family Voices, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic
Mirhaghi, Amir; Heydari, Abbas; Ebrahimi, Mohsen; Noghani Dokht Bahmani, Mohsen
Background Triage in the interactive atmosphere of the emergency department (ED) has been described as complex and challenging. Nonemergent ED visits have been accompanied by ethical and legal conflicts. Objectives The aim of this study was to gain an understanding of ED nurses’ practice regarding triage of nonemergent patients. Patients and Methods Focused micro-ethnography based on Spradley’s developmental research sequence (DRS) was used. This study was conducted in an emergency department. Data was collected through complete participant observations along with formal and informal interviews, and then analyzed using DRS. Results Nine key informants were interviewed formally. Four main categories emerged from the nurses’ culture: nonemergent patient as an uninvited guest, nonemergent patient as an elephant in a dark room, nonemergent patient as an aggressive client, and being nonemergency unless at risk of death. Conclusions Providing care in the emergency department is significantly affected by nonemergent patients, as the emergency department is a place for critically ill patients thus awareness training program is recommended. PMID:28180119
Julián-Jiménez, Agustín; Candel-González, Francisco Javier; González Del Castillo, Juan
Infectious processes account for 10% of patient seen in the emergency department. To administer antibiotics early, and before any other therapeutic-diagnostic decisions (complementary tests, microbiological samples, intensity of hemodynamic support, need for admission, etc.) have direct repercussions on the survival of patients with severe bacterial infections (bacteremia, severe sepsis or septic shock). In this context, the emergency department represents a critical level where the suspicion of infection and it diagnosis is made and treatment is started, and the progression and prognosis will be determined by the speed of this action. However, the clinical manifestations of infectious diseases are often non-specific and variable which makes early recognition of these patients and situations difficult. Inflammation and infection biomarkers have been around for years as helpful tools for improving emergency medical diagnoses and management of infection in the emergency department. The aim of this review is to summarize the published scientific evidence, in order to clarify the existing controversies, comparing the usefulness of the major biomarkers of inflammation and infection. It will alas suggest recommendations for their use in order to improve diagnosis, prognostic evaluation and management of infected patients in the emergency department.
Rintoul, Yvonne; Wynaden, Dianne; McGowan, Sunita
Incidents of aggression are frequent occurrences in hospitals, particularly the emergency department. Aggression creates instability in the environment, impacts on patient care outcomes and leads to increased levels of stress in staff. Regular exposure to aggression in the workplace can have detrimental effects on health professionals' ongoing quality of life. The emergency department is a gateway to care and is heavily populated 24h a day. Therefore, it is essential that all health professionals are confident and well prepared to manage aggression. Based upon a review of the literature this paper outlines the causes of aggression and provides an interdisciplinary action plan for intervening with aggressive patients in the emergency department. The importance of interdisciplinary ownership and the well planned management of aggression are outlined. When well managed, the impact of aggression can be limited. Stability in the emergency department ensures that health professionals can be responsive to the community's needs for emergency care. This leads to the provision of effective and timely care and a stable work environment for all health professionals.
Innes, Kelli; Crawford, Kimberley; Jones, Tamsin; Blight, Renee; Trenham, Catherine; Williams, Allison; Griffiths, D; Morphet, Julia
In response to increasing demands some emergency departments have introduced transdisciplinary care coordination teams. Such teams comprise staff from multiple disciplines who are trained to perform roles outside their usual scope of practice. This study aimed to critically evaluate the patient, carer and ED staff perceptions of the transdisciplinary model of care in an emergency department in a Melbourne metropolitan hospital. The evaluation of the transdisciplinary team involved interviews with patients and carers who have received the transdisciplinary team services, and focus groups with emergency nursing and transdisciplinary team staff. Analysis of the data revealed that the transdisciplinary model provided an essential service, where staff members were capable of delivering care across all disciplines. The ability to perform comprehensive patient assessments ensured safe discharge, with follow-up services in place. The existence of this team was seen to free up time for the emergency nursing staff, enabling them to see other patients, and improving department efficiency while providing quality care and increasing staff satisfaction. This study identified several important factors which contributed to the success of the transdisciplinary team, which was well integrated into the larger emergency department team.
Boulet, Marie-Claude; Dami, Fabrice; Hugli, Olivier; Renard, Delphine; Foucault, Eliane; Carron, Pierre-Nicolas
Demographic evolution results in a growing use of emergency department by elderly patients. They require special care to avoid any further degradation of cognitive and functional abilities already compromised by the disease or injury that led them to hospital in the first place. Through a clinical case, we list the risks related to the care of these particular patients in the emergency department. Early recognition of those risks and careful management of these patients' specific needs can significantly contribute to reduce lengths of stay, an important outcome from both the individual patient's and society's perspective.
Di Sabato, Francesco; Giacovazzo, Mario
Although cluster headache (CH) is considered one of the most distinctive and painful primary headache disorders in clinical practice because of the brevity of each attack, its management is not always ergonomic or possible in the Emergency Department. In case of a previously competent diagnosis, the Emergency Department's team should send the patient to a headache centre where specialists in the management of CH can handle the pathology in the best way. In our headache centre we treat patients with CH attacks with a hyperbaric chamber, confirming the effectiveness of hyperbaric oxygen in CH patients.
Simpson, Scott A.; Pasic, Jagoda
Many emergency department (ED) psychiatric patients present after traveling. Although such travel, or peregrination, has long been associated with factitious disorder, other diagnoses are more common among travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers’ intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of local resources complicate treatment. These patients can consume disproportionate time and resources from emergency providers. We review the literature on the emergency psychiatric treatment of peregrinating patients and use case examples to illustrate common presentations and treatment strategies. Difficulties in studying this population and suggestions for future research are discussed. PMID:27625725
Jung, Hyemin; Do, Young Kyung; Kim, Yoon; Ro, Junsoo
Objectives: This study aimed to test our hypothesis that a raise in the emergency fee implemented on March 1, 2013 has increased the proportion of patients with emergent symptoms by discouraging non-urgent emergency department visits. Methods: We conducted an analysis of 728 736 patients registered in the National Emergency Department Information System who visited level 1 and level 2 emergency medical institutes in the two-month time period from February 1, 2013, one month before the raise in the emergency fee, to March 31, 2013, one month after the raise. A difference-in-difference method was used to estimate the net effects of a raise in the emergency fee on the probability that an emergency visit is for urgent conditions. Results: The percentage of emergency department visits in urgent or equivalent patients increased by 2.4% points, from 74.2% before to 76.6% after the policy implementation. In a group of patients transferred using public transport or ambulance, who were assumed to be least conscious of cost, the change in the proportion of urgent patients was not statistically significant. On the other hand, the probability that a group of patients directly presenting to the emergency department by private transport, assumed to be most conscious of cost, showed a 2.4% point increase in urgent conditions (p<0.001). This trend appeared to be consistent across the level 1 and level 2 emergency medical institutes. Conclusions: A raise in the emergency fee implemented on March 1, 2013 increased the proportion of urgent patients in the total emergency visits by reducing emergency department visits by non-urgent patients. PMID:25475198
Kilner, Emily; Sheppard, Lorraine A
The aim of this study was to develop a systematic review using international research to describe the role of teamwork and communication in the emergency department, and its relevance to physiotherapy practice in the emergency department. Searches were conducted of CINAHL, Academic Search Premier, Scopus, Cochrane, PEDro, Medline, Embase, Amed and PubMed. Selection criteria included full-text English language research papers related to teamwork and/or communication based directly in the emergency department, involvement of any profession in the emergency department, publication in peer-reviewed journals, and related to adult emergency services. Studies were appraised using a validated critical appraisal tool. Fourteen eligible studies, all of mid-range quality, were identified. They demonstrated high levels of staff satisfaction with teamwork training interventions and positive staff attitudes towards the importance of teamwork and communication. There is moderate evidence that the introduction of multidisciplinary teams to the ED may be successful in reducing access block, and physiotherapists may play a role in this. The need for teamwork and communication in the ED is paramount, and their roles are closely linked, with the common significant purposes of improving patient safety, reducing clinical errors, and reducing waiting times.
Zulu, C. B.
Research on women in leadership has received growing attention in recent years. But not enough studies have investigated the way women construct leadership and management of the academic department. This article reports on the findings of an inquiry into the experiences of women heads of academic departments (HoDs) at universities in South Africa…
Franklin, Kathy K.; Hart, Jan K.
The purpose of this study was to examine academic department chair perceptions about the future influence of web-based distance education on departmental operations and their changing role as academic leader. Using a rating, modified-policy Delphi method, the researcher worked with 22 department chairs employed at public, urban universities in the…
Fan, Lin; Shah, Manish N.; Veazie, Peter J.; Friedman, Bruce
Context: Emergency Department (ED) use among the rural elderly may present a different pattern from the urban elderly, thus requiring different policy initiatives. However, ED use among the rural elderly has seldom been studied and is little understood. Purpose: To characterize factors associated with having any versus no ED use among the rural…
Green, Adam; Bowman-Burns, Carley; Cumberbatch, Gary
Rupture of a splenic artery aneurysm is a rare but life-threatening presentation to the emergency department. This case demonstrates the importance of swift resuscitation and the benefit of bedside imaging in a highly unstable patient. The definitive management of this condition in patients who are refractory to resuscitative attempts is immediate surgery with the diagnosis often only confirmed at laparotomy. PMID:23761509
Support is often mentioned as a goal of nursing care . The purpose of this study was to identify nursing behaviors that Emergency Department patients...physical nursing care , information- giving, and attitude of the nurse important to feeling supported. Results of the open-ended questions revealed that...the attitude of the nurse, prompt treatment, and physical nursing care were important.
Nee, P; Cartlidge, D; Morton, R
This paper describes the results of a survey in 1990 which examined the practice of general anaesthesia in Accident and Emergency Departments. Data were obtained concerning the anaesthetics induced during the previous year, specifically the number of procedures undertaken, the equipment, the facilities and the personnel involved, including any complications. These findings are discussed in relation to recommendations for minimum standards in anaesthetic practice.
Klingner, Jill; Moscovice, Ira
Purpose: Communication problems are a major contributing factor to adverse events in hospitals. The contextual environment in small rural hospitals increases the importance of emergency department (ED) patient transfer communication quality. This study addresses the communication problems through the development and testing of ED quality…
Flood, Colin; Sheehan, Karen; Crandall, Marie
Preventable visits to the emergency department (ED) are estimated to represent as much as 56% of overall annual ED utilization and contribute to the high cost of health care in the United States. There are more than 25 million annual pediatric ED visits.
van Egmond, Pim W; van de Rest, Hendrik J M; Nolte, Peter A
A 31-year-old woman came to the Emergency Department with a painful ankle 2 days after a fall off a horse. On the day of the accident, she was misdiagnosed with a lateral ankle sprain. A lateral X-ray of the ankle showed a positive 'V-sign', which is pathognomonic for a fracture of the lateral process of the talus.
Bennett, Kevin J.; Moore, Charity G.; Probst, Janice C.
Context: Rural hospitals face multiple financial burdens. Due to federal law, emergency departments (ED) provide a gateway for uninsured and self-pay patients to gain access to treatment. It is unknown how much uncompensated care in rural hospitals is due to ED visits. Purpose: To develop a national estimate of uncompensated care from patients…
Dismuke, Clara, E.; Kunz, F. Michael, Jr.
Since Grossman's seminal paper in 1972, there have been a number of studies concerning the effect of education on health and health care demand. Though several studies have distinguished between preventive and curative care, no study has investigated the effects of general education on the utilization of unnecessary emergency department use. We…
DelliFraine, Jami; Langabeer, James; King, Brent
Objective To assess academic emergency medicine (EM) chairs’ perceptions of quality improvement (QI) training programs. Methods A voluntary anonymous 20 item survey was distributed to a sample of academic chairs of EM through the Association of Academic Chairs of Emergency Medicine. Data was collected to assess the percentage of academic emergency physicians who had received QI training, the type of training they received, their perception of the impact of this training on behavior, practice and outcomes, and any perceived barriers to implementing QI programs in the emergency department. Results The response rate to the survey was 69% (N = 59). 59.3% of respondents report that their hospital has a formal QI program for physicians. Chairs received training in a variety of QI programs. The type of QI program used by respondents was perceived as having no impact on goals achieved by QI (χ2 = 12.382; p = 0.260), but there was a statistically significant (χ2 = 14.383; p = 0.006) relationship between whether or not goals were achieved and academic EM chairs’ perceptions about return on investment for QI training. Only 22% of chairs responded that they have already made changes as a result of the QI training. 78.8% of EM chairs responded that quality programs could have a significant positive impact on their practice and the healthcare industry. Chairs perceived that QI programs had the most potential value in the areas of understanding and reducing medical errors and improving patient flow and throughput. Other areas of potential value of QI include improving specific clinical indicators and standardizing physician care. Conclusion Academic EM chairs perceived that QI programs were an effective way to drive needed improvements. The results suggest that there is a high level of interest in QI but a low level of adoption of training and implementation. PMID:21293770
Carpenter, Christopher R; Platts-Mills, Timothy F
Alternative management methods are essential to ensure high-quality and efficient emergency care for the growing number of geriatric adults worldwide. Protocols to support early condition-specific treatment of older adults with acute severe illness and injury are needed. Improved emergency department care for older adults will require providers to address the influence of other factors on the patient's health. This article describes recent and ongoing efforts to enhance the quality of emergency care for older adults using alternative management approaches spanning the spectrum from prehospital care, through the emergency department, and into evolving inpatient or outpatient processes of care.
Santillanes, Genevieve; Luc, Quyen
Seizures account for 1% of all emergency department visits for children, and the etiologies range from benign to life-threatening. The challenge for emergency clinicians is to diagnose and treat the life-threatening causes of seizures while avoiding unnecessary radiation exposure and painful procedures in patients who are unlikely to have an emergent pathology. When treating patients in status epilepticus, emergency clinicians are also faced with the challenge of choosing anticonvulsant medications that will be efficacious while minimizing harmful side effects. Unfortunately, evidence to guide the evaluation and management of children presenting with new and breakthrough seizures and status epilepticus is limited. This review summarizes available evidence and guidelines on the diagnostic evaluation of first-time, breakthrough, and simple and complex febrile seizures. Management of seizures in neonates and seizures due to toxic ingestions is also reviewed.
Yeater, Elizabeth A.; Miltenberger, Patricia; Laden, Rita M.; Ellis, Shannon; O'Donohue, William
Discusses the history of a collaboration between an academic department and student affairs on a university campus. Provides details regarding the development and evaluation of a sexual assault prevention and counseling program. Highlights the advantages to this collaboration for both the psychology department and student affairs. Discusses…
El Sayed, Mazen J; El-Eid, Ghada R; Saliba, Miriam; Jabbour, Rima; Hitti, Eveline A
The aim of this study is to determine the effectiveness of using lean management methods on improving emergency department door to doctor times at a tertiary care hospital.We performed a before and after study at an academic urban emergency department with 49,000 annual visits after implementing a series of lean driven interventions over a 20 month period. The primary outcome was mean door to doctor time and the secondary outcome was length of stay of both admitted and discharged patients. A convenience sample from the preintervention phase (February 2012) was compared to another from the postintervention phase (mid-October to mid-November 2013). Individual control charts were used to assess process stability.Postintervention there was a statistically significant decrease in the mean door to doctor time measure (40.0 minutes ± 53.44 vs 25.3 minutes ± 15.93 P < 0.001). The postintervention process was more statistically in control with a drop in the upper control limits from 148.8 to 72.9 minutes. Length of stay of both admitted and discharged patients dropped from 2.6 to 2.0 hours and 9.0 to 5.5 hours, respectively. All other variables including emergency department visit daily volumes, hospital occupancy, and left without being seen rates were comparable.Using lean change management techniques can be effective in reducing door to doctor time in the Emergency Department and improving process reliability.
Al-Harbi, Nada; El-Masri, Samir; Saddik, Basema
In this paper we propose an Emergency Department Information System that will be integrated with the ambulance system to improve the communication, enhance the quality of provided emergency services and facilitate information sharing. The proposed system utilizes new advanced technologies such as mobile web services that overcome the problems of interoperability between different systems, HL7 and GPS. The system is unique in that it allows ambulance officers to locate the nearest specialized hospital and allows access to the patient's electronic health record as well as providing the hospital with required information to prepare for the incoming patient.
Hill, Emily K.; Blake, Rachel A.; Emerson, Jenna B.; Svider, Peter; Eloy, Jean Anderson; Raker, Christina; Robison, Katina; Stuckey, Ashley
OBJECTIVE To estimate whether there is a gender difference in scholarly productivity among academic gynecologic oncologists. METHODS In this cross-sectional study, the academic rank and gender of gynecologic oncology faculty in the United States were determined from online residency and fellowship directories and departmental web sites. Each individual’s h-index and years of publication were determined from Scopus (a citation database of peer-reviewed literature). The h-index is a quantification of an author’s scholarly productivity that combines the number of publications with the number of times the publications have been cited. We generated descriptive statistics and compared rank, gender, and productivity scores. RESULTS Five hundred seven academic faculty within 137 U.S. teaching programs were identified. Of these, 215 (42%) were female and 292 (58%) were male. Men had significantly higher median h-indices than women, 16 compared with 8, respectively (P<.001). Women were more likely to be of junior academic rank with 63% of assistant professors being female compared with 20% of full professors. When stratifying h-indices by gender and academic rank, men had significantly higher h-indices at the assistant professor level (7 compared with 5, P<.001); however, this difference disappeared at the higher ranks. Stratifying by the years of active publication, there was no significant difference between genders. CONCLUSION Female gynecologic oncologists at the assistant professor level had lower scholarly productivity than men; however, at higher academic ranks, they equaled their male counterparts. Women were more junior in rank, had published for fewer years, and were underrepresented in leadership positions. PMID:26551177
Casey, Michelle M.; Wholey, Douglas; Moscovice, Ira S.
Context: The practice of emergency medicine presents many challenges in rural areas. Purpose: We describe how rural hospitals nationally are staffing their Emergency Departments (EDs) and explore the participation of rural ED physicians and other health care professionals in selected certification and training programs that teach skills needed to…
Wijesekera, Olindi; Reed, Amanda; Chastain, Parker S; Biggs, Shauna; Clark, Elizabeth G; Kole, Tamorish; Chakrapani, Anoop T; Ashish, Nandy; Rajhans, Prasad; Breaud, Alan H; Jacquet, Gabrielle A
Introduction Without a universal Emergency Medical Services (EMS) system in India, data on the epidemiology of patients who utilize EMS are limited. This retrospective chart review aimed to quantify and describe the burden of disease and patient demographics of patients who arrived by EMS to four Indian emergency departments (EDs) in order to inform a national EMS curriculum.
Mahadevan, Swaminatha V; Gisondi, Michael A; Sovndal, Shannon S; Gilbert, Gregory H
To assure a smooth transition to their new work environment, rotating students and housestaff require detailed orientations to the physical layout and operations of the emergency department. Although such orientations are useful for new staff members, they represent a significant time commitment for the faculty members charged with this task. To address this issue, the authors developed a series of short instructional videos that provide a comprehensive and consistent method of emergency department orientation. The videos are viewed through Web-based streaming technology that allows learners to complete the orientation process from any computer with Internet access before their first shift. This report describes the stepwise process used to produce these videos and discusses the potential benefits of converting to an Internet-based orientation system.
Nelson, Joan M; Robinson, Marylou V
Hyponatremia is a common disorder seen in the emergency department and is more prevalent in older adults than in other adult populations (Miller, 2009). Though often discovered by accident, through routine bloodwork, even mild hyponatremia has been shown to have potentially dangerous consequences for older adults, increasing their risks for falls, altered mental status, osteoporosis and fractures, and gastrointestinal disturbances (Soiza and Talbot, 2011). Optimal management of older adults with hyponatremia in the ED involves not only treatment of serum sodium levels and the immediate consequence of the disorder, but exploration and reversal of the causes of the hyponatremia to avoid recurrence. This case study illustrates the clinical presentation, complications and management of hyponatremia in the setting of the emergency department.
Patel, Pranjal R; Quinn, James V
Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion with spontaneous return to baseline function without intervention. It is a common chief complaint of patients presenting to the emergency department. The differential diagnosis for syncope is broad and the management varies significantly depending on the underlying etiology. In the emergency department, determining the cause of a syncopal episode can be difficult. However, a thorough history and certain physical exam findings can assist in evaluating for life-threatening diagnoses. Risk-stratifying patients into low, moderate and high-risk groups can assist in medical decision making and help determine the patient’s disposition. Advancements in ambulatory monitoring have made it possible to obtain prolonged cardiac evaluations of patients in the outpatient setting. This review will focus on the diagnosis and management of the various types of syncope. PMID:27752576
Traystman, Richard J.
Discusses in general the importance of a research division, whether basic or clinical, in an academic setting and factors to consider in establishing one. Uses John Hopkins' newly created research division for Anesthesiology and Critical Care Medicine to specifically address funding and intra- and interdepartmental clinical research programs. (DC)
Distance education has been one of the hottest and most controversial topics in higher education circles for approximately the past 10 years. It has been viewed at once as the panacea for educating the world and that which, through its inherent depersonalization of the academic process, will destroy higher education "as we know it." This article…
O'Toole, Erin; Barham, Rebecca; Monahan, Jo
Academic librarians have been engaged in embedded librarianship for nearly 15 years, yet there are few published research studies on the impact of physically embedded librarians, who work alongside departmental faculty. This study leveraged a change in reference service to analyze what happened when subject librarians moved from the library…
Su, Xuhong; Johnson, Japera; Bozeman, Barry
Full inclusion of women into the academics remains a daunting challenge in the United States. The situation is particularly acute within science, technology, engineering and mathematics (STEM) fields where the underrepresentation of women and their career disadvantages attract a great deal of attention. Based on a dataset combining a survey of…
Leaming, Deryl R.
This book is intended as a practical guide for university administrators, especially those department chairpersons who are new on the job. Chapter topics include: (1) "Advice to the New Department Chairperson"; (2) "Seven Habits of Successful Chairpersons"; (3) "Duties and Responsibilities of Department Chairpersons"; (4) "Providing Leadership";…
Dillard, James N; Knapp, Sharon
One primary reason patients go to emergency departments is for pain relief. Understanding the physiologic dynamics of pain, pharmacologic methods for treatment of pain, as well CAM therapies used in treatment of pain is important to all providers in emergency care. Asking patients about self-care and treatments used outside of the emergency department is an important part of the patient history. Complementary and alternative therapies are very popular for painful conditions despite the lack of strong research supporting some of their use. Even though evidenced-based studies that are double blinded and show a high degree of interrater observer reliability do not exist, patients will likely continue to seek out CAM therapies as a means of self-treatment and a way to maintain additional life control. Regardless of absolute validity of a therapy for some patients, it is the bottom line: "it seems to help my pain." Pain management distills down to a very simple endpoint, patient relief, and comfort. Sham or science, if the patient feels better, feels comforted, feels less stressed, and more functional in life and their practices pose no health risk, then supporting their CAM therapy creates a true wholistic partnership in their health care.CAM should be relatively inexpensive and extremely safe. Such is not always the case, as some patients have discovered with the use of botanicals. It becomes an imperative that all providers be aware of CAM therapies and informed about potential interactions and side effects when helping patients manage pain and explore adding CAM strategies for pain relief. The use of regulated breathing, meditation, guided imagery, or a massage for a pain sufferer are simple but potentially beneficial inexpensive aids to care that can be easily employed in the emergency department. Some CAM therapies covered here, while not easily practiced in the emergency department, exist as possibilities for exploration of patients after they leave, and may
Vohra, Rini; Madhavan, Suresh; Sambamoorthi, Usha
A cross-sectional analyses using Nationwide Emergency Department Sample (2006-2011) was conducted to examine the trends, type of ED visits, and mean total ED charges for adults aged 22-64 years with and without ASD (matched 1:3). Around 0.4% ED visits (n = 25,527) were associated with any ASD and rates of such visits more than doubled from 2006 to…
Amigó Tadín, Montserrat
Alcohol, tobacco, heroin, cocaine and benzodiazepines, in that order, are the most common substance addictions in Spain. The medical problems caused both by chronic medical pathologies associated with their consumption and by overdoses and withdrawal syndromes, are frequently seen in emergency departments. Knowledge of substance abuse and addiction--how it is caused, the behaviour and pathology it produces--are essential to enable nurses to determine the attitudes to adopt the skills necessary to manage patients with problems of substance.
Medical identity theft in the emergency department (ED) can harm numerous individuals, and many frontline healthcare providers are unaware of this growing concern. The two cases described began as typical ED encounters until red flags were discovered upon validating the patient's identity. Educating all healthcare personnel within and outside the ED regarding the subtle signs of medical identity theft and implementing institutional policies to identify these criminals will discourage further fraudulent behavior.
Göransson, Katarina; Ehrenberg, Anna; Ehnfors, Margareta
The aim of this study was to identify the organisation of and knowledge about triage work in Swedish emergency departments (ED) as a first step to understanding what is necessary for decision support in ED triage systems in Sweden. A national survey using telephone interviews for data collection was used. Results showed great variety in how work regarding ED triage is organised and performed. The variety occurs in several areas including education, personnel performing triage, facilities available and scales used. PMID:14728356
Pedrosa, Maria; Prieto-García, Alicia; Sala-Cunill, Anna
Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.
Waseem, Muhammad; Ryan, Mary; Foster, Carla Boutin; Peterson, Janey
Bullying is an important public health issue in the United States. Up to 30% of children report exposure to such victimization. Not only does it hurt bully victim, but it also negatively impacts the bully, other children, parents, school staff, and health care providers. Because bullying often presents with accompanying serious emotional and behavioral symptoms, there has been an increase in psychiatric referrals to emergency departments. Emergency physicians may be the first responders in the health care system for bullying episodes. Victims of bullying may present with nonspecific symptoms and be reluctant to disclose being victimized, contributing to the underdiagnosis and underreporting of bully victimization. Emergency physicians therefore need to have heightened awareness of physical and psychosocial symptoms related to bullying. They should rapidly screen for bullying, assess for injuries and acute psychiatric issues that require immediate attention, and provide appropriate referrals such as psychiatry and social services. This review defines bullying, examines its presentations and epidemiology, and provides recommendations for the assessment and evaluation of victims of bullying in the emergency department. PMID:23462401
Hess, Erik P; Grudzen, Corita R; Thomson, Richard; Raja, Ali S; Carpenter, Christopher R
Shared decision-making (SDM), a collaborative process in which patients and providers make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences, is being increasingly advocated as the optimal approach to decision-making for many health care decisions. The rapidly paced and often chaotic environment of the emergency department (ED), however, is a unique clinical setting that offers many practical and contextual challenges. Despite these challenges, in a recent survey emergency physicians reported there to be more than one reasonable management option for over 50% of their patients and that they take an SDM approach in 58% of such patients. SDM has also been selected as the topic on which to develop a future research agenda at the 2016 Academic Emergency Medicine consensus conference, "Shared Decision-making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda" (http://www.saem.org/annual-meeting/education/2016-aem-consensus-conference). In this paper the authors describe the conceptual model of SDM as originally conceived by Charles and Gafni and highlight aspects of the model relevant to the practice of emergency medicine. In addition, through the use of vignettes from the authors' clinical practices, the applicability of SDM to contemporary EM practice is illustrated and the ethical and pragmatic implications of taking an SDM approach are explored. It is hoped that this document will be read in advance of the 2016 Academic Emergency Medicine consensus conference, to facilitate group discussions at the conference.
Hoot, Nathan R.; LeBlanc, Larry J.; Jones, Ian; Levin, Scott R.; Zhou, Chuan; Gadd, Cynthia S.; Aronsky, Dominik
Objective Emergency department crowding threatens quality and access to health care, and a method of accurately forecasting near-future crowding should enable novel ways to alleviate the problem. The authors sought to implement and validate the previously developed ForecastED discrete event simulation for real-time forecasting of emergency department crowding. Design and Measurements The authors conducted a prospective observational study during a three-month period (5/1/07–8/1/07) in the adult emergency department of a tertiary care medical center. The authors connected the forecasting tool to existing information systems to obtain real-time forecasts of operational data, updated every 10 minutes. The outcome measures included the emergency department waiting count, waiting time, occupancy level, length of stay, boarding count, boarding time, and ambulance diversion; each forecast 2, 4, 6, and 8 hours into the future. Results The authors obtained crowding forecasts at 13,239 10-minute intervals, out of 13,248 possible (99.9%). The R2 values for predicting operational data 8 hours into the future, with 95% confidence intervals, were 0.27 (0.26, 0.29) for waiting count, 0.11 (0.10, 0.12) for waiting time, 0.57 (0.55, 0.58) for occupancy level, 0.69 (0.68, 0.70) for length of stay, 0.61 (0.59, 0.62) for boarding count, and 0.53 (0.51, 0.54) for boarding time. The area under the receiver operating characteristic curve for predicting ambulance diversion 8 hours into the future, with 95% confidence intervals, was 0.85 (0.84, 0.86). Conclusions The ForecastED tool provides accurate forecasts of several input, throughput, and output measures of crowding up to 8 hours into the future. The real-time deployment of the system should be feasible at other emergency departments that have six patient-level variables available through information systems. PMID:19261948
collaboration with personnel of the Coastal Studies Institute of Louisiana State University. SCOUR AROUND MULTIPLE PILE GROUPS SUBJECTED TO UNIDIRECTIONAL AND...academic excellence of an educational institution is measured by the achievements of its faculty in teaching, research, and related scholarly endeavors. It...the faculty and outstanding midshipmen may flourish. The research activities of the faculty range from very applied cooperative studies with the Navy
Edlich, Richard F; Taylor, Catherine C; Winters, Kathryne; Martin, Marcus L; Anima, Gloria; Long, William B; Werner, Charles L; Perches, Colette R
Dusting powders were first applied to gloves to facilitate donning. After 1980, manufacturers devised innovative techniques to manufacture gloves without dusting powders. It has been well documented that the powders on gloves present a health hazard to patients, as well as healthcare workers. First, these powders elicit tissue toxicity in every tissue in the body. Second, these powders serve as carriers of latex allergen and may precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powders have caused a growing number of emergency medical technicians, paramedics, firelighters, and hospitals to abandon the use of powdered emergency medical examination gloves, using only powder-free gloves. Powder-free latex as well as non-latex gloves are now available to emergency medical technicians, paramedics, firefighters, and emergency department personnel. The use of powder-free natural rubber latex-free gloves is especially important to emergency medical technicians, paramedics, firefighters, as well as emergency department personnel to avoid eliciting an allergic reaction in the latex sensitized patient. The majority of our emergency medical technicians, paramedics and firefighters are now wearing powder-free emergency medical examination gloves that comply with the stringent Codes and Standards established by the National Fire Protection Association (NFPA), while very few hospital emergency department personnel have been provided with NFPA approved gloves. It is the purpose of this report to review the stringent regulations for emergency medical examination gloves that are outlined by the NFPA. This design and performance Standard was devised by the NFPA to address protective clothing for emergency medical operations. The design and performance requirement of the emergency medical examination gloves were described in the NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 1997 Edition. In
... 34 Education 3 2012-07-01 2012-07-01 false How does an academic department select fellows? 648.40 Section 648.40 Education Regulations of the Offices of the Department of Education (Continued) OFFICE OF POSTSECONDARY EDUCATION, DEPARTMENT OF EDUCATION GRADUATE ASSISTANCE IN AREAS OF NATIONAL NEED How Are...
Sanders, Mark E.
Leaders new to academic departments that possess dysfunctional histories due to ineffective "management" face many difficulties in the transformation of department dynamics. Indeed, the challenge for transformational department leaders is fostering positive and proactive attitudes among faculty where previous management was hostile,…
Pato, Carlos; Abulseoud, Osama; Pato, Michelle
Objective: The authors demonstrate the role that research can play in the development of an academic department of psychiatry. Method: The authors explore the challenges and achievements in the transition of one department from a strong clinically- and educationally-centered department to one with an equally strong research focus. Results: The…
Watson, Paula D.; Landis, Martha
Data from 43 responses to a questionnaire distributed to the academic members of the RASD Discussion Group in Reference Services in Large Research Libraries are summarized in tables. The purpose of the survey was to reflect patterns of staff size, services, and organization in reference departments in large academic libraries. The tables present…
Munch, Richard; Baier, Christian
This paper demonstrates how the application of New Public Management (NPM) and the accompanying rise of academic capitalism in allocating research funds in the German academic field have interacted with a change from federal pluralism to a more stratified system of universities and departments. From this change, a tendency to build cartel-like…
Meyer, Roger E.
Within academic medical centers, psychiatry, pediatrics, and certain other specialties of internal medicine carry a disproportionate responsibility for teaching but are least able to support teaching and research through clinical income. This article reviews the educational, research and clinical missions of an academic psychiatry department and…
Smart, John C.; McLaughlin, Gerald W.
Findings suggest that Holland's theory of vocational choice can assist in the interpretation of goal priorities within the academic community. Suggestions indicate how this theory might be employed by university administrators and in subsequent research on the administration of academic departments and the roles of their chairmen. (Editor/PG)
Qualter, Anne; Willis, Ian
In changing times for higher education that are dominated by a neoliberal ideology, we set out to uncover how Heads of Departments (HoDs) perceive their role with respect to supporting their staff and their academic freedom. Freedom to pursue academic research is seen as key to the generation of new knowledge yet it is potentially constrained by…
Loo, Jeffery L.; Dupuis, Elizabeth A.
This article presents a qualitative evaluation methodology of academic departments for library organizational learning and library enhancement planning. This evaluation used campus units' academic program review reports as a data source and employed collaborative content analysis by library liaisons to extract departmental strengths, weaknesses,…
Kampmann, Jennifer A.
Within the scope of leadership and management, decision making greatly defines the role of university administrator, in particular, the university department head and his/her ability to be a reflective practitioner in the realm of decision making. Decision making is one characteristic of university department head work which warrants close…
Gmelch, Walter H.
Nearly 80,000 scholars currently serve as department chairs, and almost one-quarter will need to be replaced each year. Such a high turnover rate is partly due to surprises and unexpected sacrifices embedded in the department chair position. In an effort to help professors prepare for and overcome unforseen tradeoffs, the University Council for…
Merrill, Jacqueline; Hripcsak, George
In order to assess the mission and strategic direction in an academic department of biomedical informatics, we used social network analysis to identify patterns of common interest among the department's multidisciplinary faculty. Data representing faculty and their self-identified research methods and expertise were analyzed by applying a network modularity algorithm to detect community structure. Three distinct communities of practice emerged: empirical discovery and prediction; human and organizational factors; and information management. This analysis made intuitive sense and served the goal of stimulating discussion from new perspectives. The findings will guide future direction and faculty recruitment efforts. Communities of practice present a novel view of interdisciplinarity in biomedical informatics.
Sabbagh, C; Chaddad, M; El Rassy, E
Morning report in the emergency medicine departments is an emerging teaching modality in the medicine curriculum. Our institution, Hotel-Dieu de France hospital, a multidisciplinary tertiary care university hospital affiliated to the Saint Joseph University of Medical Sciences, is the only hospital in Middle East to hold morning reports in the emergency department (ED). We evaluate the usefulness of the morning report as a pedagogic tool as it assesses the content, quality of the discussions, professionalism, leadership, participation and duration of the morning report. The particularity of this paper is that it takes into consideration the interns' input often under-recognised in the studies. An anonymous questionnaire was diffused to the residents and interns that rotated in the ED during the previous year. It consisted of seven multiple-choice questions to evaluate the quality of the presentations, targeted discussions, ethics and professionalism, evidence-based medicine, clinical reasoning, relation of cases to discussions and implication of the ED physician. Overall, of the 63 patients who answered the survey, 65.1% were satisfied by the content. The majority considered the quality of the discussions acceptable and the leadership and participation satisfactory, professionalism was judged poor. Both residents and interns were satisfied of the teaching point of the morning reports. The only fail back observed was professionalism and pathophysiological discussions that require to be added to the sessions, whereas clinical management, teaching points, leadership and time management were completely satisfactory.
Background Patients with infections account for a significant proportion of Emergency Department (ED) workload, with many hospital patients admitted with severe sepsis initially investigated and resuscitated in the ED. The aim of this registry is to systematically collect quality observational clinical and microbiological data regarding emergency patients admitted with infection, in order to explore in detail the microbiological profile of these patients, and to provide the foundation for a significant programme of prospective observational studies and further clinical research. Methods/design ED patients admitted with infection will be identified through daily review of the computerised database of ED admissions, and clinical information such as site of infection, physiological status in the ED, and components of management abstracted from patients' charts. This information will be supplemented by further data regarding results of investigations, microbiological isolates, and length of stay (LOS) from hospital electronic databases. Outcome measures will be hospital and intensive care unit (ICU) LOS, and mortality endpoints derived from a national death registry. Discussion This database will provide substantial insights into the characteristics, microbiological profile, and outcomes of emergency patients admitted with infections. It will become the nidus for a programme of research into compliance with evidence-based guidelines, optimisation of empiric antimicrobial regimens, validation of clinical decision rules and identification of outcome determinants. The detailed observational data obtained will provide a solid baseline to inform the design of further controlled trials planned to optimise treatment and outcomes for emergency patients admitted with infections. PMID:21269438
Gordon, J A
In an era of social welfare reform marked by the erosion of a societal safety net, few institutions remain that can guarantee assistance to those most in need. The hospital emergency department is perhaps the only local institution where professional help is mandated by law, with guaranteed availability for all persons, all the time, regardless of the problem. Although the ED serves as a true social safety net, its potential as a social welfare institution generally goes underestimated, hampering its full development as an effective societal resource. More of the disadvantaged may pass through the ED than through any other community institution, making it a logical site not only for the treatment of acute illness, but also for the identification of basic social needs and the extension of existing community resources. By helping more fully incorporate the ED into the total care of its community, emergency physicians can become leaders in the design and implementation of integrated sociomedical systems of care.
Urso, D L
This article describes the management of acute asthma exacerbation in the Emergency Department (ED). An asthma exacerbation can be defined as clinical worsening of disease or an asymptomatic decrease in peak flows. Acute exacerbations of asthma may represent reactions to airway irritants or failures of chronic treatment. Hospitalizations and ED visits account for a large proportion of the health-care cost burden of asthma. The assessment of an asthma exacerbation constitutes a process with two different dimensions: to determine the severity of attack, and to evaluate the response to treatment. The principal goals of managing an asthma acute exacerbation may be summarized as maintenance of adequate arterial oxygen saturation with supplemental oxygen, relief of airflow obstruction with repetitive administration of short acting beta-2 agonists (SABA), and treatment of airway inflammation with systemic corticosteroids (CS) to prevent future relapses. SABA, oxygen, and CS form the basis of management of acute asthma exacerbation but a role is emerging for anthicolinergics.
Prendergast, Heather M; Close, Matthew; Jones, Brett; Furtado, Nicholas; Bunney, E Bradshaw; Mackey, Mark; Marquez, Diego; Edison, Marcia
Obesity among children is rising at an alarming rate. This study examines pediatric emergency department visits for children aged 2 to 17 years to determine the prevalence of normal, overweight, and obesity as well as to characterize discharge diagnosis and level of service among the different groups. The electronic emergency department medical record and billing service data were used in the review process. Body mass index (BMI) and percentiles were calculated using the Centers for Disease Control formulas with overweight being defined as BMI between 85th and 94th sex- and age-specific percentiles and obesity as greater than 95th sex- and age-specific percentile. The study was reviewed and approved by the institutional review board. Of the 596 patients meeting inclusion criteria, there was a predominance of African American and Hispanic patients. Approximately 53% (313) of patients were classified as normal weight, while 46% (272) of patients were either overweight or obese. The percentages of overweight and obesity were similar across racial/ethnic classifications, with a slight predominance of obesity among minority groups (30% and 35%, respectively, in minority groups vs 28% and 25%, respectively, in nonminority groups). There were no statistically significant differences between discharge diagnosis and level of service among the different weight categories. Rates of overweight and obesity in this predominately minority pediatric population were significantly greater than the published national rates. The impact of the epidemic of childhood obesity mandates the need for innovative strategies of weight control and reduction. Emergency departments routinely treat high-risk pediatric populations and can therefore serve as a resource for screening and early referral that has been previously untapped in combating childhood obesity.
Wang, Hao; Coppola, Paolo T; Coppola, Marco
Trauma is one of the leading causes of death before the age of 40 years and approximately 5% of patients with trauma who require hospital admission have pelvic fractures. This article updates the emergency department classification of pelvic fractures first described in 2000. This information is of practical value to emergency physicians in identifying the potential vascular, genitourinary, gastrointestinal, orthopedic, and neurologic complications and further assists them in the initial evaluation and treatment of patients with pelvic fractures.
Mayer, T A; Tilson, W; Hemingway, J
This article outlines the elements of successful ED marketing, as well as providing definitions for terms used within the marketing process. In today's competition and rapidly changing environment, marketing and public relations are tools that every ED Medical Director may want to consider. Because the marketing process requires a great deal of time and effort, as well as a high degree of intellectual honesty, it should never be entered into without a strong commitment. However, marketing the ED can be among the most productive, stimulating, and gratifying experiences for the ED Medical Director, the emergency department physicians, and all ED service personnel.
Ooi, S B
This 10-year (May 1986-31 December 1995) retrospective study was done to analyse the types of complaints received by the National University Hospital's Emergency Department (NUH EMD), so as to take remedial measures. It was done by reviewing three sources of complaints received by the department, namely formal written complaints, verbal feedback received by the Corporate Affairs Department, and via feedback forms. The areas of complaints looked for included the nature, number, validity, whether remediable and triage priority of the patients. One hundred and eighty-eight subcategories of complaints were received from 169 complaints. The complaint frequency was 0.26 per 1,000 visits or 1 complaint per 3,846 visits. The complaint frequency over the 10 years did not vary much (range 0 to 0.44). Most of the complaints are divided into 4 broad categories ie medical, doctor-patient/paramedical staff-patient relationship, patient flow/logistics at EMD and in-house complaints. The majority (71.3%) of the complaints were due to medical and doctor-patient relationship problems. Complaints tend to arise from Priority 2 and 3 rather than Priority 1 patients. 33.7% of the complaints were considered valid, 21.6% not valid while in the remaining 44.7%, validity could not be determined. 48.4% of complaints were likely to be remediable. Based on this study, we have since instituted a compulsory emergency department-driven "Customer Service Training Programme" and weekly teaching sessions for each incoming group of medical officers posted to the NUH EMD.
McCaughey, Deirdre; Erwin, Cathleen O; DelliFraine, Jami L
Capacity management (CM) is a critical component of maintaining and improving healthcare quality and patient safety. One particular area for concern has been the emergency department and the growing issues of patient overcrowding, boarding, and ambulance diversion, which can result in poor patient care and less efficient operations. This study provides a review of the current and most relevant academic literature on capacity management directly related to hospital emergency departments, identifies strengths and weaknesses of the approaches discussed in the literature, and provides practical recommendations for health services administrators implementing CM in their organizations. An extensive literature search was conducted using several search engines and scholarly databases. Articles were identified based on a combination of keywords and then were reviewed and selected for inclusion in the study in adherence to specified criteria. The CM literature includes a great divergence of themes, topics, and definitions. Twenty-two articles were selected for their relevance to emergency department CM with a focus on operations management concepts. A categorization scheme was used, resulting in four thematic groups of articles: problems, solutions, outcomes, and metrics. Healthcare managers wishing to implement solutions to CM problems have a wide variety of operations literature to draw on that can address scheduling and patient throughput, but there are also a number of studies that consider electronic and technological solutions to CM problems. All of these solutions have the potential to positively influence the quality of patient care, including satisfaction.
In this study, we evaluated national differences in emergency department (ED) crowding to identify factors significantly associated with crowding in institutes and communities across Korea. This was a cross-sectional nationwide observational study using data abstracted from the National Emergency Department Information System (NEDIS). We calculated mean occupancy rates to quantify ED crowding status and divided EDs into three groups according to their occupancy rates (cutoffs: 0.5 and 1.0). Factors potentially related to ED crowding were collected from the NEDIS. We performed a multivariate regression analysis to identify variables significantly associated with ED crowding. A total of 120 EDs were included in the final analysis. Of these, 73 were categorized as 'low crowded' (LC, occupancy rate < 0.50), 37 as 'middle crowded' (MC, 0.50 ≤ occupancy rate < 1.00), 10 EDs as 'high crowded' (HC, 1.00 ≤ occupancy rate). The mean ED occupancy rate varied widely, from 0.06 to 2.33. The median value was 0.39 with interquartile ranges (IQRs) from 0.20 to 0.71. Multivariate analysis revealed that after adjustment, ED crowding was significantly associated with the number of visits, percentage of patients referred, number of nurses, and ED disposition. This nationwide study observed significant variety in ED crowding. Several input, throughput, and output factors were associated with crowding. PMID:27478347
Mowery, Danielle; Wiebe, Janyce; Visweswaran, Shyam; Harkema, Henk; Chapman, Wendy W
Information extraction applications that extract structured event and entity information from unstructured text can leverage knowledge of clinical report structure to improve performance. The Subjective, Objective, Assessment, Plan (SOAP) framework, used to structure progress notes to facilitate problem-specific, clinical decision making by physicians, is one example of a well-known, canonical structure in the medical domain. Although its applicability to structuring data is understood, its contribution to information extraction tasks has not yet been determined. The first step to evaluating the SOAP framework's usefulness for clinical information extraction is to apply the model to clinical narratives and develop an automated SOAP classifier that classifies sentences from clinical reports. In this quantitative study, we applied the SOAP framework to sentences from emergency department reports, and trained and evaluated SOAP classifiers built with various linguistic features. We found the SOAP framework can be applied manually to emergency department reports with high agreement (Cohen's kappa coefficients over 0.70). Using a variety of features, we found classifiers for each SOAP class can be created with moderate to outstanding performance with F(1) scores of 93.9 (subjective), 94.5 (objective), 75.7 (assessment), and 77.0 (plan). We look forward to expanding the framework and applying the SOAP classification to clinical information extraction tasks.
He, Qiang; Chu, Henry
We present a method adapted from medical sensor data analysis, viz. independent component analysis of electroencephalography data, to health system analysis. Timely and effective care in a hospital emergency department is measured by throughput measures such as median times patients spent before they were admitted as an inpatient, before they were sent home, before they were seen by a healthcare professional. We consider a set of five such measures collected at 3,086 hospitals distributed across the U.S. One model of the performance of an emergency department is that these correlated throughput measures are linear combinations of some underlying sources. The independent component analysis decomposition of the data set can thus be viewed as transforming a set of performance measures collected at a site to a collection of outputs of spatial filters applied to the whole multi-measure data. We compare the independent component sources with the output of the conventional principal component analysis to show that the independent components are more suitable for understanding the data sets through visualizations.
Lohiya, Ghan-Shyam; Lohiya, Sapna; Lohiya, Sunita; Krishna, Vijay
Background. Scombrotoxinism is an acute toxin-induced illness caused primarily by bacterial synthesis of histamine in decomposed fish. Case Report. Immediately after taking 2-3 bites of cooked salmon, a clerical worker developed oral burning, urticaria, and asthma. In the emergency department, she was diagnosed with “allergies”; scombrotoxinism was never considered. She then developed wide-ranging symptoms (e.g., chronic fatigue, asthma, anxiety, multiple chemical sensitivity, and paresthesiae) and saw many specialists (in pulmonology, otorhinolaryngology, allergy, toxicology, neurology, psychology, and immunology). During the next 500+ days, she had extensive testing (allergy screens, brain MRI, electroencephalogram, electromyogram, nerve conduction velocity, heavy metal screen, and blood chemistry) with essentially normal results. She filed a workers' compensation claim since this injury occurred following a business meal. She was evaluated by a Qualified Medical Evaluator (GL) on day 504, who diagnosed scombrotoxinism. Comment. Scombrotoxinism should be considered in all patients presenting to the emergency department with “oral burning” or allergy symptoms following “fish consumption.” Initial attention to such history would have led to a correct diagnosis and averted this patient's extended illness. Specialist referrals and tests should be ordered only if clinically indicated and not for diagnostic fishing expedition. Meticulous history is crucial in resolving clinical dilemmas. PMID:26357577
Smith, Bryan; Burscough, Sheila
Orthopaedic and musculoskeletal injuries are commonly identified in the emergency department (ED). Whilst much orthopaedic trauma literature focuses on fractures of the proximal femur, raising key issues such as length of stay and timely discharge, the start of the patients' journey is just as important in ensuring an appropriate assessment and a smooth transition through each stage of care. In the UK targets have been set for proximal hip fractured patients to attend theatre within 48 hours of admission, if fit. Appraising such patients expediently on initial point of contact in the ED has demonstrated that a number of factors can impinge and delay the patients' progress. This said a large number of other orthopaedic and musculoskeletal self presenting patients rely on the same appropriate transition to suitable medical assistance. The emergency department triage system has been used in the UK in its latest format since 2001, yet elderly patients with painful Colles fractures find they wait for specialist attention in a linear queue, possibly over extended lengths of time. This short paper explores how 'streaming' patients in one local ED has improved waiting/treatment times, and identified the fact that in some months (December 2012), 1 in 3 attendees present with a musculoskeletal problem. Using audit data collected over the last four years the benefits of 'streaming' patients is evident.
Perry, Warren M; Lee, Christoph I; Steers, W Neil; Post, Lori A; Forman, Howard P
Our objective was to characterize the tasks of emergency radiologists and emergency physicians and quantify the proportion of time spent on these tasks to assess their roles in patient evaluation. Our study involved emergency radiologists and emergency physicians at an urban academic level I trauma medical center. Participants were observed for continuous 2-h periods during which all of their activities were timed and categorized into the following tasks: patient history, patient physical findings, assessment/plan, procedures, technical/administration, paperwork, and personal time. We performed multivariate analyses to compare the proportion of time spent on task categories between specialties. Twenty physicians (10 emergency medicine and 10 radiology) were observed for a total of 146,802 s (2,446.7 min). Radiologists spent a significantly larger combined proportion of time on determining physical findings and paperwork than emergency physicians (61.9 vs. 28.3 %, p<0.0001). Emergency physicians spent a significantly larger proportion of time than radiologists on determining patient history (17.5 vs. 2.5 %, p=0.0008) and assessment/plan (42.3 vs. 19.3 %, p<0.0001). Both specialties devoted minimal time toward personal tasks. Radiologists play a major role in the diagnostic evaluation of a subset of acute patients, spending significantly more of their time determining physical findings than their emergency physician counterparts.
An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.
Kerner, Robert L.; Gallo, Kathleen; Cassara, Michael; D'Angelo, John; Egan, Anthony; Simmons, John Galbraith
Summary Statement Simulation in multiple contexts over the course of a 10-week period served as a core learning strategy to orient experienced clinicians before opening a large new urban freestanding emergency department. To ensure technical and procedural skills of all team members, who would provide care without on-site recourse to specialty backup, we designed a comprehensive interprofessional curriculum to verify and regularize a wide range of competencies and best practices for all clinicians. Formulated under the rubric of systems integration, simulation activities aimed to instill a shared culture of patient safety among the entire cohort of 43 experienced emergency physicians, physician assistants, nurses, and patient technicians, most newly hired to the health system, who had never before worked together. Methods throughout the preoperational term included predominantly hands-on skills review, high-fidelity simulation, and simulation with standardized patients. We also used simulation during instruction in disaster preparedness, sexual assault forensics, and community outreach. Our program culminated with 2 days of in-situ simulation deployed in simultaneous and overlapping timeframes to challenge system response capabilities, resilience, and flexibility; this work revealed latent safety threats, lapses in communication, issues of intake procedure and patient flow, and the persistence of inapt or inapplicable mental models in responding to clinical emergencies. PMID:27607095
Kozin, Elliott D.; Sethi, Rosh K.V.; Remenschneider, Aaron K.; Kaplan, Alyson; del Portal, Daniel A.; Gray, Stacey T.; Shrime, Mark G.; Lee, Daniel J.
Objective Otologic complaints may place a significant burden on emergency departments (EDs) in the United States; however, few studies have comprehensively examined this discrete patient population. We aim to identify utilization of EDs by patients with primary otologic complaints. Study Design Retrospective analysis of the Nationwide Emergency Department Sample (NEDS) from 2009 through 2011. Methods The NEDS database was queried for patient encounters with a primary otologic diagnosis based on ICD9 codes (380–389). Weighted estimates for demographic, diagnostic characteristics, SES, and trends over time were extracted. Predictors of mortality and admission were determined by multivariable logistic regression. Results A weighted total of 8,611,282 visits between 2009 and 2011 were attributed to otologic diagnoses, representing 2.21% of all ED visits. Stratified by patient age, otologic diagnoses encompassed 1.01% and 6.79% of all adult and pediatric ED visits, respectively. The majority of patients were treated and released (98.17%). The average age of patients presenting with an otologic complaint was 17.9 years (Standard Error [SE] = 0.23). Overall, 62.7% of patients that presented with an otologic complaint were 0–17 years old. The most common diagnoses among all age groups included otitis media NOS (60.6%), infected otitis externa NOS (11.8%), and otalgia NOS (6.8%). Conclusions We provide a comprehensive overview of otologic complaints that are an overlooked diagnostic category in public health research. NEDS data demonstrates significant number of visits related to otologic complaints, especially in the pediatric population, that are non-emergent. PMID:25702897
Jahanshir, Amirhosein; Karimialavijeh, Ehsan; Sheikh, Hojjat; Vahedi, Motahar; Momeni, Mehdi
Introduction: Medical applications help physicians to make more rapid and evidence based decisions that may provide better patient care. This study aimed to determine the extent to which smart phones and medical applications are integrated in the emergency department daily practice. Method: In a cross sectional study, a modified standard questionnaire (Payne et al.) consisting of demographic data and information regarding quality and quantity of smartphone and medical app utilization was sent to emergency-medicine residents and interns twice (two weeks apart), in January 2015. The questionnaire was put online using open access "Web-form Module" and the address of the web page was e-mailed along with a cover letter explaining the survey. Finally, responses were analyzed using descriptive statistics and SPSS 22 software. Results: 65 cases participated (response rate 86%). The mean age of interns and residents were 25.03 ± 1.13 and 30.27 ± 4.68 years, respectively (p < 0.001). There was no significant difference between interns and residents in owning a smartphone (p = 0.5). Android was more popular than IOS (67.7% against 25.8%) and the most popular medical apps were Medscape and UpToDate, respectively. 38 (61.3%) of the respondents were using their apps more than once a day and mostly for drug information. English (83.9%), Persian (12.9%), and other languages (3.2%) were preferred languages for designing a medical software among the participants, respectively. Conclusion: The findings of present study showed that smartphones are very popular among Iranian interns and residents in emergency department and a substantial number of them own a smartphone and are using medical apps regularly in their clinical practice. PMID:28286821
Marshall, R; Rainer, T
OBJECTIVE: To assess the workload generated by police inquiries to an accident and emergency (A&E) department and the adherence of medical staff to departmental guidelines relating to these inquiries. DESIGN: Prospective analysis of the number, nature, and timing of police inquiries and the information released by medical staff. SETTING: A&E department of an inner city teaching hospital. OUTCOME MEASURES: Number of personal and telephone requests for information from police; completion of a form of inquiry; record of patient consent for release of information. RESULTS: A daily average of 8.7 police inquiries were made, but in only 10% of cases was a form of inquiry completed. The patient's consent for release of information to the police was recorded in 4% of cases. CONCLUSIONS: Police inquiries generate a significant workload for an A&E department, often at clinically busy times. Medical staff need further education to ensure that patient confidentiality is respected while assisting the police with their investigations. Images Figure 2 PMID:8947799
Yu, Denny; Blocker, Renaldo C; Sir, Mustafa Y; Hallbeck, M Susan; Hellmich, Thomas R; Cohen, Tara; Nestler, David M; Pasupathy, Kalyan S
Sociometers are wearable sensors that continuously measure body movements, interactions, and speech. The purpose of this study is to test sociometers in a smart environment in a live clinical setting, to assess their reliability in capturing and quantifying data. The long-term goal of this work is to create an intelligent emergency department that captures real-time human interactions using sociometers to sense current system dynamics, predict future state, and continuously learn to enable the highest levels of emergency care delivery. Ten actors wore the devices during five simulated scenarios in the emergency care wards at a large non-profit medical institution. For each scenario, actors recited prewritten or structured dialogue while independent variables, e.g., distance, angle, obstructions, speech behavior, were independently controlled. Data streams from the sociometers were compared to gold standard video and audio data captured by two ward and hallway cameras. Sociometers distinguished body movement differences in mean angular velocity between individuals sitting, standing, walking intermittently, and walking continuously. Face-to-face (F2F) interactions were not detected when individuals were offset by 30°, 60°, and 180° angles. Under ideal F2F conditions, interactions were detected 50 % of the time (4/8 actor pairs). Proximity between individuals was detected for 13/15 actor pairs. Devices underestimated the mean duration of speech by 30-44 s, but were effective at distinguishing the dominant speaker. The results inform engineers to refine sociometers and provide health system researchers a tool for quantifying the dynamics and behaviors in complex and unpredictable healthcare environments such as emergency care.
Bridglall, Beatrice L.; Gordon, Edmund W.
This paper describes U.S. Department of Defense Schools, an education system with significant outcomes that may be pertinent to raising academic achievement among minority students. A research group examined the high achievement of African American and Hispanic students in Department of Defense Education Activity (DoDEA) schools. Results find that…
Lecky, Fiona; Benger, Jonathan; Mason, Suzanne; Cameron, Peter; Walsh, Chris
All emergency departments (EDs) have an obligation to deliver care that is demonstrably safe and of the highest possible quality. Emergency medicine is a unique and rapidly developing specialty, which forms the hub of the emergency care system and strives to provide a consistent and effective service 24 h a day, 7 days a week. The International Federation of Emergency Medicine, representing more than 70 countries, has prepared a document to define a framework for quality and safety in the ED. Following a consensus conference and with subsequent development, a series of quality indicators have been proposed. These are tabulated in the form of measures designed to answer nine quality questions presented according to the domains of structure, process and outcome. There is an urgent need to improve the evidence base to determine which quality indicators have the potential to successfully improve clinical outcomes, staff and patient experience in a cost-efficient manner--with lessons for implementation.
Faust, Jeremy Samuel; Nemes, Andreea
Transient global amnesia is a clinically distinct syndrome characterized by the acute inability to form new memories. It can last up to 24 hours. The diagnosis is dependent on eliminating other more serious etiologies including toxic ingestions, acute strokes, complex partial seizures, and central nervous system infections. Transient global amnesia confers no known long-term risks; however, when abnormal signs or symptoms are present, they take precedence and guide the formulation of a differential diagnosis and investigation. In witnessed transient global amnesia with classic features, a minimalist approach is reasonable, avoiding overtesting, inappropriate medication, and medical interventions in favor of observation, ensuring patient safety, and reassuring patients and their families. This review provides a detailed framework for distinguishing transient global amnesia from its dangerous mimics and managing its course in the emergency department.
Wilber, Scott T.
Synopsis Altered mental status is a common chief complaint among older emergency department (ED) patients. Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. These forms of acute brain dysfunction are commonly precipitated by an underlying medical illness that can be potentially life-threatening and are associated with a multitude of adverse outcomes. Though stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute brain dysfunction, the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple etiologies may exist concurrently. PMID:23177603
Thompson, James R; Stephens, Sheila; Summers, Richard L
The objective of this study was to determine if correspondence sent by regular mail would be delivered more often than correspondence sent by certified mail. Correspondence was prospectively randomized and mailed by United States Postal Service using either regular mail service or certified mail service. Mailings were analyzed based on patient demographic information, whether or not mail was returned, and the reason for the return. Certified mail was sent to 145 patients; 58 (40%) of the mailings were returned. Wrong addresses accounted for only 23 (16%) of these, whereas the addressee never claimed 35 (24%). Regular mail was sent to 126 patients, and 19 (15%) of the letters were returned. Wrong addresses accounted for 18 (14%) of these letters, and only 1 (1%) was refused for delivery. In conclusion, when compared with certified mail, regular mail is a more effective means of reaching patients with follow-up information after an Emergency Department visit.
Strader, Cliff; Ellis, Elizabeth; Barrie, Martin D; Tankersley, William; Wallace, Phil; Nichols, Gregory
As a major user of engineered nanoparticles, the U.S. Department of Energy (DOE) uses various methods to monitor the health of emergent technologies workers (ETW) who handle or could potentially be exposed to unbound engineered nanoparticles (UNP). Using data from DOE’s Illness and Injury Surveillance Program (IISP), Oak Ridge Associated Universities (ORAU) created a registry of ETWs. IISP currently tracks 125,000 workers at 14 DOE facilities. Workers in IISP, who were classified as ETWs, were placed in a separate database using Microsoft Access. Using SAS (Version 9.2; Cary, NC), the health status of this cohort was analyzed by a variety of different variables such as age, gender, occupation, years of employment, number of years classified as an ETW, and site.
Núñez, S; Moreno, A; Green, K; Villar, J
The purposes of this study were to determine whether microorganisms can be isolated from the membranes of stethoscopes used by clinicians and nurses, and to analyse whether or not the degree of bacterial colonization could be reduced with different cleaning methods. We designed a transversal before-after study in which 122 stethoscopes were examined. Coagulase negative staphylococci (which are also potentially pathogenic microorganisms) were isolated together with 13 other potentially pathogenic microorganisms, including S. aureus, Acinetobacter sp. and Enterobacter agglomerans. The most effective antiseptic was propyl alcohol. Analysis of the cleaning habits of the Emergency Department (ED) staff, showed that 45% cleaned the stethoscope annually or never. The isolation of potentially pathogenic microorganisms suggests that the stethoscope must be considered as a potential vector of infection not only in the ED but also in other hospital wards and out-patient clinics.
Mell, Howard K
The epidemiology of oral and genital herpes has dramatically changed over the past decade. Herpes simplex virus-1, traditionally associated with oral herpes, is now implicated in an increasing percentage of genital herpes cases. The possibility of "autoinoculation" (or self-infection) of anatomic sites other than that of the primary infection has been recognized. New methods of suppression therapy are being examined. These changes have led to a revision in the recommendations by the Centers for Disease Control and Prevention (CDC). This review discusses herpes infections of the oral and genital mucosa and the suggested approach to the infected patient who presents in the emergency department. Specific attention is given to the CDC's 2006 guidelines for the treatment of sexually transmitted diseases.
Murphy, Alison R.; Reddy, Madhu C.
Patient-care teams frequently encounter information problems during their daily activities. These information problems include wrong, outdated, conflicting, incomplete, or missing information. Information problems can negatively impact the patient-care workflow, lead to misunderstandings about patient information, and potentially lead to medical errors. Existing research focuses on understanding the cause of these information problems and the impact that they can have on the hospital’s workflow. However, there is limited research on how patient-care teams currently identify and manage information problems that they encounter during their work. Through qualitative observations and interviews in an emergency department (ED), we identified the types of information problems encountered by ED staff, and examined how they identified and managed the information problems. We also discuss the impact that these information problems can have on the patient-care teams, including the cascading effects of information problems on workflow and the ambiguous accountability for fixing information problems within collaborative teams. PMID:25954457
Magu, Sarita; Agarwal, Shalini; Jain, Nitin; Dalal, Nityasha
Detection of diaphragmatic hernia in the acute setting is problematic and diagnosing diaphragmatic hernia as hydropneumothorax is not an uncommon mistake. We present a series of four such cases diagnosed over a 7-year period, from December 2004 to January 2011 and analyse them for how this mistake can be avoided. In case of all the patients reported by us the initial radiographs were technically compromised because the patient could not be positioned properly. Also they were examined by non-radiologists. We feel that treating surgeons in emergency department tend to overdiagnose pneumothorax as it is a life-threatening condition. We feel that in the appropriate setting suspicion of diaphragmatic hernia should be raised in patients having fractured ribs associated with homogenous opacity, which cannot be differentiated from the diaphragm. Evidence of loculation of hydropneumothorax in the appropriate setting should also raise the possibility of diaphragmatic hernia. PMID:23907963
Aminuddin, Wan Malissa Wan Mohd; Ismail, Wan Rosmanira
This study aims to determine the best resource allocation and to increase the efficiency service of an emergency department in a public hospital in Kuala Lumpur. We integrate Discrete Event Simulation (DES) and three models of Data Envelopment Analysis (DEA); Input-oriented CCR model, Input-oriented BCC model and Super-Efficiency model to fulfill such objective. Based on the comparison of results taken from the DEA models, the combination of DES, Input-oriented BCC model and Super-Efficiency BCC model is seen to be the best resource allocation technique to be used for enhancing the hospital efficiency. The combination has reduced patients waiting time while improving the average utilization rate of hospital resources compared to the current situation.
Price, M; Phillips, C I
After a short period of intensive training, a general practitioner successfully replaced a senior house officer (SHO) in the accident and emergency department of an eye hospital on one morning a week for a year. An unbiased observer compared the performance of the general practitioner after one year with that of a full-time SHO who had had 17 months' experience; their performances were about equal. Although a sessional general practitioner costs about 28% more than an SHO, the real cost is much less because undue length of service as an SHO or change to another specialty (because of the SHO surplus) delays achievement of a permanent grade. Continuity is a great advantage of the general practitioner. Replacement of some SHOs by general practitioners would reduce the surplus of SHOs with poor promotion prospects. The commonest diagnoses were Meibomian cysts (18%), corneal foreign bodies (20%), corneal abrasions (12%), and conjunctivitis (8%).
Ryan, J M; McQuillan, R
A prospective study was carried out on 242 patients attending an Accident & Emergency Department with injuries sustained while playing rugby football. The average age was 19.8 years. Head and neck injuries were more prevalent but less serious then in studies carried out before recent law changes. The lower limb was still the part of the body most frequently injured but again there were fewer serious injuries. There was a marked increase in upper limb injuries. Wing forward was the position most likely to give rise to injuries and prop was the least. Poor compliance is still a significant problem with rugby injuries can only lead to an improvement in the safety of the game.
O'Malley, Patricia; Barata, Isabel; Snow, Sally
The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.
Hsia, Renee Y.; Asch, Steven M.; Weiss, Robert E.; Zingmond, David; Liang, Li-Jung; Han, Weijuan; McCreath, Heather; Sun, Benjamin C.
Study objective The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates. Methods We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits. Results We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching
Yock-Corrales, Adriana; Churilov, Leonid; Monagle, Paul; Donnan, Geoffrey A.; Babl, Franz E.
Background and Purpose— Clinical identification of stroke in the pediatric emergency department is critical for improving access to hyperacute therapies. We identified key clinical features associated with childhood stroke or transient ischemic attack compared with mimics. Methods— Two hundred and eighty consecutive children presenting to the emergency department with mimics, prospectively recruited over 18 months from 2009 to 2010, were compared with 102 children with stroke or transient ischemic attack, prospectively/retrospectively recruited from 2003 to 2010. Results— Cerebrovascular diagnoses included arterial ischemic stroke (55), hemorrhagic stroke (37), and transient ischemic attack (10). Mimic diagnoses included migraine (84), seizures (46), Bell’s palsy (29), and conversion disorders (18). Being well in the week before presentation (odds ratio [OR] 5.76, 95% confidence interval [CI] 2.25–14.79), face weakness (OR 2.94, 95% CI 1.19–7.28), arm weakness (OR 8.66, 95% CI, 2.50–30.02), and inability to walk (OR 3.38, 95% CI 1.54–7.42) were independently associated with increased odds of stroke diagnosis. Other symptoms were independently associated with decreased odds of stroke diagnosis (OR 0.28, 95% CI 0.10–0.77). Associations were not observed between seizures or loss of consciousness. Factors associated with stroke differed by arterial and hemorrhagic subtypes. Conclusions— Being well in the week before presentation, inability to walk, face and arm weakness are associated with increased odds of stroke. The lack of positive or negative association between stroke and seizures or loss of consciousness is an important difference to adults. Pediatric stroke pathways and bedside tools need to factor in differences between children and adults and between stroke subtypes. PMID:27601378
Schwartz, L R; Overton, D T
We conducted an analysis of all complaints received in a busy suburban emergency department during 1985. All complaints were handled in a standardized fashion, and were categorized as billing, physician, nursing, or miscellaneous. Data were expressed as a "complaint frequency" (complaints per 1,000 patient visits). Complaints were analyzed for the following characteristics: reason, gender of the patient, gender of the complaining party, relationship of the complaining party to the patient, health care provider, patient age, and patient disposition. The chi-square method was used to identify characteristics associated with a high risk for complaints. There were a total of 244 complaints, arising from 64,910 patient visits, yielding an overall complaint frequency of 3.8. The largest number of complaints (135), involved billing (frequency, 2.0). The most common (60) was insurance carrier rejection of the bill as a nonemergency. The next most common billing complaint (25) was a charge mistakenly billed too high by the ED. There were 70 complaints regarding emergency physicians, for a complaint frequency of 1.1. Of these, 17 were due to a perceived lack of communication with the patient, the patient's family, or the patient's private physician. Eighteen complaints were regarding a perceived misdiagnosis. One physician had a significantly higher complaint frequency than the group as a whole (P less than .005). There were 17 complaints regarding the nursing staff, for a complaint frequency of 0.2. Twenty-two complaints were classified as miscellaneous. Expressing data as complaint frequencies allows comparison of trends in a department, staff members, and different EDs with varied patient populations.(ABSTRACT TRUNCATED AT 250 WORDS)
Nadir, Nur-Ain; Bentley, Suzanne; Papanagnou, Dimitrios; Bajaj, Komal; Rinnert, Stephan; Sinert, Richard
Introduction Benefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing; however, data on its practice in academic emergency departments (ED), is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in academic EDs;, however, limited research has been performed on this subject. The objective of this study was to characterize real-time, non-critical incident debriefing practices in emergency medicine (EM). Methods We conducted this multicenter cross-sectional study of EM attendings and residents at four large, high-volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. We sought a convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining >100 responses. The survey was sent electronically to the four residency list-serves with a total of six monthly completion reminder emails. We collected all data electronically and anonymously using SurveyMonkey.com; the data were then entered into and analyzed with Microsoft Excel. Results The data elucidate various characteristics of current real-time debriefing trends in EM, including its definition, perceived benefits and barriers, as well as the variety of formats of debriefings currently being conducted. Conclusion This survey regarding the practice of real-time, non-critical incident debriefings in four major academic EM programs within New York City sheds light on three major, pertinent points: 1) real-time, non-critical incident debriefing
Latham, Lesley P.; Ackroyd-Stolarz, Stacy
Background Emergency Departments (EDs) are playing an increasingly important role in the care of older adults. Characterizing ED usage will facilitate the planning for care delivery more suited to the complex health needs of this population. Methods In this retrospective cross-sectional study, administrative and clinical data were extracted from four study sites. Visits for patients aged 65 years or older were characterized using standard descriptive statistics. Results We analyzed 34,454 ED visits by older adults, accounting for 21.8% of the total ED visits for our study time period. Overall, 74.2% of patient visits were triaged as urgent or emergent. Almost half (49.8%) of visits involved diagnostic imaging, 62.1% involved lab work, and 30.8% involved consultation with hospital services. The most common ED diagnoses were symptom- or injury-related (25.0%, 17.1%. respectively). Length of stay increased with age group (Mann-Whitney U; p < .0001), as did the proportion of visits involving diagnostic testing and consultation (χ2; p < .0001). Approximately 20% of older adults in our study population were admitted to hospital following their ED visit. Conclusions Older adults have distinct patterns of ED use. ED resource use intensity increases with age. These patterns may be used to target future interventions involving alternative care for older adults. PMID:25452824
McGarry, Jonathon; Krall, Scott P.; McLaughlin, Thomas
Objective: Evaluate the impact of adding emergency medicine residents to a medium-size urban hospital by comparing emergency department (ED) admission rate, total census, length of stay (LOS), and proportion of patients who left without being seen (LWBS). Methods: Using the student t-test, the study compared commonly used ED metrics for a mid-sized urban hospital (annual census 43,000) for the four-month period prior to (March-June 2006) and after (March-June 2007) residents began providing 24-hour coverage at the institution. Results: There was no significant difference in the number of patients seen (NPS) in the two time periods, 14,471 and 14,699 patients respectively (p=0.507). Analysis of the NPS and LWBS was not statistically significant. The percentage of patients who LWBS decreased with the presence of residents (6.5% to 5.8%, p=0.531), and the overall ED LOS was similar (210 min vs. 219 min, p=0.56). Admission rate data demonstrated that residents had a similar admission rate (17.5% vs. 18%, p =0.332). Conclusion: ED flow depends on a number of variables with complex interactions. When comparing two similar time periods in consecutive years, the presence of resident physicians in the ED had no effect on the number of patients seen, patient LOS in the ED, or LWBS, thus supporting the conclusion that residents did not adversely affect the patient flow within the ED. PMID:21079704
Chisholm, Robin; Finnell, John T.
Objective: This study explored the Internet log files from emergency department workstations to determine search patterns, compared them to discharge diagnoses, and the emergency medicine curriculum as a way to quantify physician search behaviors. Methods: The log files from the computers from January 2006 to March 2010 were mapped to the EM curriculum and compared to discharge diagnoses to explore search terms and website usage by physicians and students. Results: Physicians in the ED averaged 1.35 searches per patient encounter using Google.com and UpToDate.com 83.9% of the time. The most common searches were for drug information (23.1%) by all provider types. The majority of the websites utilized were in the third tier evidence level for evidence-based medicine (EBM). Conclusion: We have shown a need for a readily accessible drug knowledge base within the EMR for decision support as well as easier access to first and second tier EBM evidence. PMID:23304394
White, Faber A; Zwemer, Frank L; Beach, Christopher; Westesson, Per-Lennart; Fairbanks, Rollin J; Scialdone, Gary
Emergency department (ED) patient care relies heavily on radiologic imaging. As advances in technologic innovation continue to present opportunities to streamline and simplify the delivery of care, emergency medicine (EM) practitioners face the challenge of transitioning from a system of primarily film-based radiography to one that utilizes digitized images. The move to digital radiology can result in enhanced quality of patient care, reduction of errors, and increased ED efficiency; however, making this transition will necessarily involve changes in EM practice. As the technology evolves, digital radiology will gradually become ingrained into everyday practice because of these and other notable benefits; however, EM practitioners will need to overcome several challenges to make the transition smoothly and consider the potential impacts that this change will have on ED workflow. The authors discuss the benefits, challenges, and other operational considerations involved with the ED implementation of digital radiology and close by presenting guiding principles for current and future users. Despite the unresolved issues, digital radiology will mature as a technology and improve EM practice, making it one of the great information technology advances in EM.
Moon, J M; Chun, B J
Objectives: The purpose of this study was to identify independent factors that can be used to predict whether febrile neutropenic patients who appear healthy at presentation will develop subsequent complications, using variables that are readily available in the emergency department (ED). Method: The medical records of 192 episodes in which the patients presented to the ED with neutropenic fever resulting from chemotherapy, with an alert mental state and haemodynamic stability were retrospectively reviewed. Endpoints examined were fever response to administered antibiotics, death or severe medical complications during hospitalisation. Results: Thirty-eight episodes of neutropenic fever with complicated outcomes were identified from among a total of 192 episodes. Three parameters emerged as independent factors for the prediction of neutropenic fever with complications in the multivariate regression analysis: platelet count (130−450 × 103 cells/mm3) <50 000 cells/mm3, serum C-reactive protein (CRP, 0.1–1 mg/dl) >10 mg/dl and pulmonary infiltration on chest x ray. Conclusions: Platelet count, CRP and pulmonary infiltration on chest x ray at presentation could be used to identify febrile neutropenic patients who will develop complications, and these factors may be useful in making treatment-related decisions in the ED. PMID:19850806
Nolen, Haley A.; Moore, Justin Xavier; Rodgers, Joel B.; Wang, Henry E.; Walter, Lauren A.
Despite historical gender bias against female physicians, few studies have investigated patients’ physician gender preference in the emergency department (ED) setting. We sought to determine if there is an association between ED patient demographics and physician gender preference. We surveyed patients presenting to an ED to determine association between patient demographics and patient physician gender preference for five ED situations: 1) ‘routine’ visit, 2) emergency visit, 3) ‘sensitive’ medical visit, 4) minor surgical/‘procedural’ visit, and 5) ‘bad news’ delivery. A total of 200 ED patients were surveyed. The majority of ED patients reported no physician gender preference for ‘routine’ visits (89.5 percent), ‘emergent’ visits (89 percent), ‘sensitive’ medical visits (59 percent), ‘procedural’ visits (89 percent) or when receiving ‘bad news’ (82 percent). In the setting of ‘routine’ visits and ‘sensitive’ medical visits, there was a propensity for same-sex physician preference. PMID:27354840
OBJECTIVE: To determine the extent of communication problems that arose from patients whose primary language was non-English presenting to an inner city accident and emergency (A&E) department. METHODS: A prospective survey over seven consecutive days during September 1995. All adult patients other than those directly referred by their general practitioner to an inpatient team had a questionnaire completed by the A&E doctor first seeing the patient. The doctor recorded language ability and form of interpreter used, and estimated any prolongation of the consultation and ability to improve communication by the use of additional services. RESULTS: 103 patients (17%) did not speak English as their primary language; 55 patients (9.1% of the study population) had an English language ability rated as other than good, and 16 (29%) of these consultations could have been improved by the use of additional interpreter services; 28 patients overall (4.6% of the study population) required the use of an interpreter, who was usually a relative. CONCLUSIONS: A significant number of patients presenting to A&E have difficulty in communicating in English. These consultations could often have been improved by the use of additional interpreter services. Telephone interpreter services may provide the answer for use in A&E departments because of their instant and 24 hour availability. Images p99-a PMID:9132201
Ince, Abdulkadir; Ozucelik, Dogac Niyazi; Avci, Akkan; Nizam, Ozgur; Dogan, Halil; Topal, Mehmet Ali
Background: Pneumothorax is common and life-threatening clinical condition which may require emergency treatment in Emergency Medicine Departments. Objectives: We aimed to reveal the epidemiological analysis of the patients admitted to the Emergency Department with pneumothorax. Material and Methods: This case-control and multi-center study was conducted in the patients treated with the diagnosis of pneumothorax between 01.01.2010-31.12.2010. Patient data were collected from hospital automation system. According to the etiology of the pneumothorax, study groups were arranged like spontaneous pneumothorax and traumatic pneumothorax. Results: 82.2% (n = 106) of patients were male and 17.8% (n = 23) of patients were female and mean age were 31.3 ± 20,2 (Minimum: 1, Maximum: 87). 68.2% (n = 88) of patients were spontaneous pneumothorax (61.36%, n=79 were primary spontaneous pneumothorax) and 31.8% (n = 41) of patients were traumatic pneumothorax (21.95% were iatrogenic pneumothorax). Main complaint is shortness of breath (52.3%, n=67) and 38% (n=49) of patients were smokers. Posteroanterior (PA) Chest X-Ray has been enough for 64.3% (n = 83) of the patients' diagnosis. Tube thoracostomy is applied to 84.5% (n = 109) of patients and surgery is applied to 9.3% (n = 12) of patients and 6.2% (n = 8) of patients were discharged with conservative treatment. Spontaneous pneumothorax showed statistically significant high recurrence compared with traumatic pneumothorax (P = 0.007). 4.65% of (n = 6) patients died. The average age of those who died (9.3 ± 19.9), statistically were significantly lower the mean age of living patients (32.4 ± 19.7) (t test, P = 0,006). 83.33% of the patients who died were neonatals and in the 0-1 years age group, and five of these patients were secondary spontaneous pneumothorax, and one of these patients were iatrogenic pneumothorax due to mechanical ventilation. Conclusions: Pneumothorax in adults can be treated by tube thoracostomy or
Jamjoom, Roaa S; Etoom, Yousef; Solano, Tanya; Desjardins, Marie-Pier; Fischer, Jason W
The use of point-of-care ultrasound in the pediatric emergency department is evolving beyond conventional applications as users become more expert with the technology. In this case series, we describe the potential utility of recognizing abnormal anatomy to impact care in the context of possible cancer in pediatric patients. We describe 4 patients with Langerhans histiocytosis, neuroblastoma, Wilms tumor, and rhabdomyosarcoma, in which point-of-care ultrasound was used to facilitate the diagnoses.
Trzeciak, S; Rivers, E P
Numerous reports have questioned the ability of United States emergency departments to handle the increasing demand for emergency services. Emergency department (ED) overcrowding is widespread in US cities and has reportedly reached crisis proportions. The purpose of this review is to describe how ED overcrowding threatens patient safety and public health, and to explore the complex causes and potential solutions for the overcrowding crisis. A review of the literature from 1990 to 2002 identified by a search of the Medline database was performed. Additional sources were selected from the references of the articles identified. There were four key findings. (1) The ED is a vital component of America's health care "safety net". (2) Overcrowding in ED treatment areas threatens public health by compromising patient safety and jeopardising the reliability of the entire US emergency care system. (3) Although the causes of ED overcrowding are complex, the main cause is inadequate inpatient capacity for a patient population with an increasing severity of illness. (4) Potential solutions for ED overcrowding will require multidisciplinary system-wide support.
Pierce, Mary Clyde; Magana, Julia N.; Kaczor, Kim; Lorenz, Douglas J.; Meyers, Gabriel; Bennett, Berkeley L.; Kanegaye, John T.
Objective Bruising can indicate abuse for infants. Bruise prevalence among infants in the Pediatric Emergency Department (PED) setting is unknown. Our objective was to determine prevalence of bruising, associated chief complaints (CC), and frequency of abuse evaluations in previously healthy infants presenting to PEDs. Methods We conducted a prospective, observational, multi-center study of infants ≤12 months old presenting to PEDs. Structured sampling was utilized. Pediatric Emergency Medicine (PEM) clinicians performed complete skin examinations to screen for bruising. Study investigators documented skin findings, date of visit, patient's age, CC, and abuse evaluation. The primary outcome was prevalence of bruising. Secondary outcomes were prevalence of bruising based on CC and frequency of abuse evaluation. Point estimates of bruise prevalence and differences in bruise prevalence between patient subgroups were calculated with 95% confidence intervals (CI). Results Bruising was identified in 88 of 2488 infants (3.5%, 95% CI: [2.9%, 4.4%]). Rates of bruising for infants ≤5 and >5 months old were 1.3% and 6.4%, respectively (difference 5.1%, 95% CI: [3.6%, 6.8%]). For infants ≤5 months old, 83% of bruising was associated with a trauma CC and only 0.2% of infants presenting with a medical CC had bruising. PEM clinicians obtained abuse evaluations on 23% of infants with bruising and that rate increased to 50% for infants ≤ 5 months of age. Conclusions Bruising prevalence in children ≤ 12 months of age evaluated in PEDs was low, increased within age strata, and was most often associated with a trauma CC. Most bruised infants did not undergo an abuse evaluation. PMID:26233923
Paik, Angie M; Granick, Mark S; Scott, Sandra
Plastic surgery is a field that is particularly amenable to a telehealth milieu, as visual exam and radiographs guide proper diagnosis and management. The goals of this study were to evaluate telehealth feedback executed through an iPad app for plastic surgery-related consultations. A Quality Assurance/Quality Improvement (QA/QI) study was conducted over a 1-month period during which patients with hand injuries, facial injuries, or acute wounds presenting to the Emergency Department (ED) of a level-one trauma centre and university hospital were monitored. The study utilized a commercial iPad application through which up to four images and a brief history could be sent to a remote Plastic Surgery Educator (PSE) for evaluation. The PSE would respond with best practice information, references and videos to assist ED point-of-care providers. During the 1-month period of this study, there were 42 ED consultations for plastic surgical conditions. There was a highly significant difference in overall mean response time between consultants and PSEs (48.3 minutes vs. 8.9 minutes respectively, p < 0.001). The agreement between PSEs and consultants regarding patient assessment and care was 85.7% for in-person consultations and 100% for phone consultations. In four cases of telephone consultations, the ED providers placed splints incorrectly on hand-injured patients. Our results show that telehealth consultations to a remote plastic surgeon based on digital images and a brief history were able to produce timely and accurate responses in an emergency care facility. This design may have significant impact in rural areas, underserved populations, or regions abroad.
Lee, Carol; Walters, Elizabeth; Borger, Rodney; Clem, Kathleen; Fenati, Gregory; Kiemeney, Michael; Seng, Sakona; Yuen, Ho-Wang; Neeki, Michael; Smith, Dustin
On December 2, 2015, a terror attack in the city of San Bernardino, California killed 14 Americans and injured 22 in the deadliest attack on U.S. soil since September 11, 2001. Although emergency personnel and law enforcement officials frequently deal with multi-casualty incidents (MCIs), what occurred that day required an unprecedented response. Most of the severely injured victims were transported to either Loma Linda University Medical Center (LLUMC) or Arrowhead Regional Medical Center (ARMC). These two hospitals operate two designated trauma centers in the region and played crucial roles during the massive response that followed this attack. In an effort to shed a light on our response to others, we provide an account of how these two teaching hospitals prepared for and coordinated the medical care of these victims. In general, both centers were able to quickly mobilize large number of staff and resources. Prior disaster drills proved to be invaluable. Both centers witnessed excellent teamwork and coordination involving first responders, law enforcement, administration, and medical personnel from multiple specialty services. Those of us working that day felt safe and protected. Although we did identify areas we could have improved upon, including patchy communication and crowd-control, they were minor in nature and did not affect patient care. MCIs pose major challenges to emergency departments and trauma centers across the country. Responding to such incidents requires an ever-evolving approach as no two incidents will present exactly alike. It is our hope that this article will foster discussion and lead to improvements in management of future MCIs.
Pereira, Rui; Oliveira, Sara; Almeida, André
Nursing home-acquired pneumonia (NHAP) is one of the most common infections arising amongst nursing home residents, and its incidence is expected to increase as population ages. The NHAP recommendation for empiric broad-spectrum antibiotic therapy, arising from the concept of healthcare-associated pneumonia, has been challenged by recent studies reporting low rates of multidrug-resistant (MDR) bacteria. This single center study analyzes the results of NHAP patients admitted through the Emergency Department (ED) at a tertiary center during the year 2010. There were 116 cases, male gender corresponded to 34.5 % of patients and median age was 84 years old (IQR 77-90). Comorbidities were present in 69.8 % of cases and 48.3 % of patients had used healthcare services during the previous 90 days. In-hospital mortality rate was 46.6 % and median length-of-stay was 9 days. Severity assessment at the Emergency Department provided CURB65 index score and respective mortality (%) results: zero: n = 0; one: n = 7 (0 %); two: n = 18 (38.9 %); three: n = 26 (38.5 %); four: n = 30 (53.3 %); and five; n = 22 (68.2 %); and sepsis n = 50 (34.0 %), severe sepsis n = 43 (48.8 %) and septic shock n = 22 (72.7 %). Significant risk factors for in-hospital mortality in multivariate analysis were polypnea (p = 0.001), age ≥ 75 years (p = 0.02), and severe sepsis or shock (p = 0.03) at the ED. Microbiological testing in 78.4 % of cases was positive in 15.4 % (n = 15): methicillin-resistant Staphylococcus aureus (26.7 %), Pseudomonas aeruginosa (20.0 %), S. pneumoniae (13.3 %), Escherichia coli (13.3 %), others (26.7 %); the rate of MDR bacteria was 53.3 %. This study reveals high rates of mortality and MDR bacteria among NHAP hospital admissions supporting the use of empirical broad-spectrum antibiotic therapy in these patients.
Background In The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients’ length of stay and ED nurse managers’ experiences of crowding. Methods A survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients’ LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow. Results Surveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners. Conclusions Despite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage
Case, Sarah D.; Case, Brady G.; Olfson, Mark; Linakis, James G.; Laska, Eugene M.
Objective: To compare pediatric mental health emergency department visits to other pediatric emergency department visits, focusing on length of stay. Method: We analyzed data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of US emergency department visits from 2001 to 2008, for patients aged less than…
Rust, P; Hunt, I; Wallis, D; Jowett, A; Rottenberg, G
Objective—To investigate the contribution of alcohol ingestion to the radiological workload of an inner city accident and emergency (A&E) department. Methods—A prospective survey of patients presenting to A&E who required radiographs was performed over a seven day period. The A&E clinician questioned patients about alcohol intake during the six hours before the onset of the presenting complaint or injury, and made an objective assessment of signs of alcohol ingestion or intoxication. An assessment was made also of the relative contribution of alcohol as a cause of patients' injuries. Results—A total of 419 patients who had radiography fulfilled the inclusion criteria, and a questionnaire was completed for 351 (84%). Forty (11%) of 351 were found to have ingested alcohol. Thirty five (87%) of 40 patients who had ingested alcohol were radiographed for trauma, as compared with 171 (55%) of the 311 who had not (p<0.001). Alcohol was considered to have been causative of injury in 30% and a contributory factor in an additional 58%. Radiographs of the skull, face and jaw accounted for 18 (33%) of 55 radiographs from trauma patients who had ingested alcohol compared with 20 (9%) of 212 radiographs from those who had not (p<0.001). There was no significant difference in the proportion of abnormal radiographs between these two groups (27% of radiographs from trauma patients who had ingested alcohol compared with 23% of radiographs from those who had not, p>0.2). Conclusion—Patients with alcohol related injuries requiring radiography have a significant impact on the radiological workload of an A&E department, although the prevalence of alcohol ingestion detected in this study was less than expected from previous studies. PMID:11696496
Brunetti, Lorenzo; Bambi, Stefano
Workplace violence is a widespread phenomenon in every kind of settings. Among these ones there are emergency departments (ED), that have distinctive features as like the large daily number of patients' presentations, and high emotional content or stressing situations related to the management of diagnostic-therapeutic priorities. We reviewed the medical and nursing literature to quantify the international widespread of aggressions towards nurses working in EDs, distinguish the typologies and the perpetrators, and identify the consequences on victims and healthcare organizations. Original papers were searched using Medline, CINHAL, and Medscape databases. 35 research articles met the inclusion criteria, but 6 were not retrieved. The rate of verbal abuses reported by ED nurses varies from 50% to 100% of those who were surveyed, while physical violence ranges between 16.7% and 72%. Patients and relatives are the main perpetrators, followed by doctors, and, only in lower percentages, by nurses colleagues. Alcohol, drugs abuse, and overcrowding in EDs are acknowledged as motivating factors for violent events. Under-reporting of aggressions is frequent up to the 80% of victims, and some papers report that nurses consider assaults as a normal part of their work. There is a direct relation between aggressions and symptoms of post-traumatic stress disturb syndrome. Moreover there is a sense of continuous fear in nurses, causing the likelihood of workplace leaving. Special educational courses seem to be effective in diminishing the number of aggressions and to adopt adequate adaptive behaviors.
LaMantia, Michael A; Stump, Timothy E; Messina, Frank C; Miller, Douglas K; Callahan, Christopher M
Although persons with dementia are frequently hospitalized, relatively little is known about the health profile, patterns of health care use, and mortality rates for patients with dementia who access care in the emergency department (ED). We linked data from our hospital system with Medicare and Medicaid claims, Minimum Data Set, and Outcome and Assessment Information Set data to evaluate 175,652 ED visits made by 10,354 individuals with dementia and 15,020 individuals without dementia over 11 years. Survival rates after ED visits and associated charges were examined. Patients with dementia visited the ED more frequently, were hospitalized more often than patients without dementia, and had an increased odds of returning to the ED within 30 days of an index ED visit compared with persons who never had a dementia diagnosis (odds ratio, 2.29; P<0.001). Survival rates differed significantly between patients by dementia status (P<0.001). Mean Medicare payments for ED services were significantly higher among patients with dementia. These results show that older adults with dementia are frequent ED visitors who have greater comorbidity, incur higher charges, are admitted to hospitals at higher rates, return to EDs at higher rates, and have higher mortality after an ED visit than patients without dementia.
Baibergenova, Akerke; Leeb, Kira; Jokovic, Aleksandra; Gushue, Sharon
The rate of patients who visit emergency departments (EDs) but leave before being evaluated and treated is an important indicator of ED performance. This study examines patient- and hospital-level characteristics that may increase the risk of patients leaving EDs before being seen. The data are from the National Ambulatory Care Reporting System, an administrative database, and represent 4.3 million patient visits made to 163 Ontario EDs between April 2003 and March 2004. Among these data, the proportion that left without being seen (LWBS) was 3.1% (136,805). The rate of LWBS was highest among patients aged 15 to 35 years, those with less acute conditions and facilities that handle the highest volume of patients. Facility rates were positively correlated with facility median ED length of stay, annual facility volume and percentage of inpatient admissions. Understanding patient and facility characteristics that increase rates of LWBS may inform the process of developing measures to ensure timely access to ED care for all who seek it.
Goldman, Ran D; Vohra, Sunita; Rogovik, Alexander L
Increasing use of vitamins has been documented worldwide in children and adolescents, and potential for vitamin-drug interactions exists. The aim of this study was to identify vitamin use by children visiting a pediatric emergency department (ED). A survey of parents and/or patients 0-18 years was conducted at a large pediatric ED in Canada. A total of 1804 families were interviewed. The main outcome measure was prevalence of vitamin use by children in the preceding 3 months. A third (32.3%) of the patients in our cohort had used vitamins in the preceding 3 months, and 48% of them were taking vitamins daily. Over 8% of all children used vitamins within the last 24 h. The use of vitamins was higher with older patient and parental age (P<0.001), chronic patient illness (P<0.001), completed immunization (P<0.001), concurrent patient use of prescribed medications (P=0.02), higher parental education (P<0.01), and English as a primary language spoken at home (P=0.002). Prevalence of vitamin use among children in the ED is 32% in the preceding 3 months and 8% within the last 24 h. In light of these findings, pediatricians should ask about vitamin use and discuss with parents potential interactions and possible adverse effects.
Sauter, Thomas C.; Veerakatty, Sajitha; Haider, Dominik G.; Geiser, Thomas; Ricklin, Meret E.; Exadaktylos, Aristomenis K.
Introduction Somnambulism is a state of dissociated consciousness, in which the affected person is partially asleep and partially awake. There is pervasive public opinion that sleepwalkers are protected from hurting themselves. There have been few scientific reports of trauma associated with somnambulism and no published investigations on the epidemiology or trauma patterns associated with somnambulism. Methods We included all emergency department (ED) admissions to University Hospital Inselspital, Berne, Switzerland, from January 1, 2000, until August 11, 2015, when the patient had suffered a trauma associated with somnambulism. Demographic data (age, gender, nationality) and medical data (mechanism of injury, final diagnosis, hospital admission, mortality and medication on admission) were included. Results Of 620,000 screened ED admissions, 11 were associated with trauma and sleepwalking. Two patients (18.2%) had a history of known non-rapid eye movement parasomnias. The leading cause of admission was falls. Four patients required hospital admission for orthopedic injuries needing further diagnostic testing and treatment (36.4%). These included two patients with multiple injuries (18.2%). None of the admitted patients died. Conclusion Although sleepwalking seems benign in the majority of cases and most of the few injured patients did not require hospitalization, major injuries are possible. When patients present with falls of unknown origin, the possibility should be evaluated that they were caused by somnambulism. PMID:27833677
Holden, Richard J
Emergency departments (EDs) face problems with crowding, delays, cost containment, and patient safety. To address these and other problems, EDs increasingly implement an approach called Lean thinking. This study critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. An analytic framework based on human factors engineering and occupational research generated 6 core questions about the effects of Lean on ED work structures and processes, patient care, and employees, as well as the factors on which Lean's success is contingent. The review revealed numerous ED process changes, often involving separate patient streams, accompanied by structural changes such as new technologies, communication systems, staffing changes, and the reorganization of physical space. Patient care usually improved after implementation of Lean, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative patient care effects were reported, and studies typically did not report patient quality or safety outcomes beyond patient satisfaction. The effects of Lean on employees were rarely discussed or measured systematically, but there were some indications of positive effects on employees and organizational culture. Success factors included employee involvement, management support, and preparedness for change. Despite some methodological, practical, and theoretic concerns, Lean appears to offer significant improvement opportunities. Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.
Pich, Jacqueline; Hazelton, Michael; Sundin, Deborah; Kable, Ashley
In a finding that reflects international experiences, nurses in Australia have been identified as the occupation at most risk of patient-related violence in the health-care sector. A search of the literature was undertaken to explore this concept, with a focus on the emergency department and triage nurses. Significant findings included the fact that nurses are subjected to verbal and physical abuse so frequently that, in many instances, it has become an accepted part of the job. This attitude, combined with the chronic under-reporting of violent incidents, perpetuates the normalization of violence, which then becomes embedded in the workplace culture and inhibits the development of preventative strategies and the provision of a safe working environment. Nurses are entitled to a safe workplace that is free from violence under both the occupational health and safety legislation and the zero-tolerance policies that have been adopted in many countries including Australia, the UK, Europe, and the USA. Therefore, policy-makers and administrators should recognize this issue as a priority for preventative action.
Gillespie, Gordon Lee; Bresler, Scott; Gates, Donna M; Succop, Paul
Workplace aggression has the potential to adversely affect the psychological health of emergency department (ED) workers. The purpose of this study was to compare posttraumatic stress symptomatology based on verbal and verbal plus physical aggression. A descriptive cross-sectional design was used with a convenience sample (n = 208) of ED workers who completed a three-component survey. Descriptive statistics were computed to compare traumatic stress scores based on type of aggression. Two-way analysis of variance statistics were computed to determine if scores differed on the demographic variables. Fewer than half of the ED workers reported traumatic stress symptomatology; however, workplace aggression has the potential to adversely affect the mental health of ED workers. Occupational health nurses can establish or maintain a nurturing and protective environment open to discussing the personal thoughts, feelings, and behaviors of ED workers related to their experiences of workplace aggression. This open and more positive work environment may aid in reducing the negative impact of posttraumatic stress symptoms among those ED workers who have been victimized.
Van Parys, Jessica
Despite the significant responsibility that physicians have in healthcare delivery, we know surprisingly little about why physician practice styles vary within or across institutions. Estimating variation in physician practice styles is complicated by the fact that patients are rarely randomly assigned to physicians. This paper uses the quasi-random assignment of patients to physicians in emergency departments (EDs) to show how physicians vary in their treatment of patients with minor injuries. The results reveal a considerable degree of variation in practice styles within EDs; physicians at the 75th percentile of the spending distribution spend 20% more than physicians at the 25th percentile. Observable physician characteristics do not explain much of the variation across physicians, but there is a significant degree of sorting between physicians and EDs over time, with high-cost physicians sorting into high-cost EDs as they gain experience. The results may shed light on why some EDs remain persistently higher-cost than others. PMID:27517464
White, Benjamin A.; Baron, Jason M.; Dighe, Anand S.; Camargo, Carlos A.; Brown, David F.M.
Background Increasing the value of healthcare delivery is a national priority, and providers face growing pressure to reduce cost while improving quality. Ample opportunity exists to increase efficiency and quality simultaneously through the application of systems engineering science. Objective We examined the hypothesis that Lean-based reorganization of laboratory process flow would improve laboratory turnaround times (TAT) and reduce waste in the system. Methods This study was a prospective, before-after analysis of laboratory process improvement in a teaching hospital Emergency Department (ED). The intervention included a reorganization of laboratory sample flow based in systems engineering science and Lean methodologies, with no additional resources. The primary outcome was the median TAT from sample collection to result for six tests previously performed in an ED kiosk. Results Following the intervention, median laboratory TAT decreased across most tests. The greatest decreases were found in “reflex tests” performed after an initial screening test: troponin T TAT was reduced by 33 minutes (86 to 53 min, 99%CI 30–35 min) and urine sedimentation TAT by 88 minutes (117 to 29 min, 99% CI 87–90 min). In addition, troponin I TAT was reduced by 12 minutes, urinalysis by 9 minutes, and urine HCG by 10 minutes. Microbiology rapid testing TAT, a ‘control’, did not change. Conclusions In this study, Lean-based reorganization of laboratory process flow significantly increased process efficiency. Broader application of systems engineering science might further improve healthcare quality and capacity, while reducing waste and cost. PMID:26145581
Brady, Joanne E.; DiMaggio, Charles J.; Keyes, Katherine M.; Doyle, John J.; Richardson, Lynne D.; Li, Guohua
Purpose Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality. Methods Using data from the New York Statewide Planning and Research Cooperative System for 2006–2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18–64 years and subsequent PDO death. Results The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50–5.34) for those with two ED visits, 16.61 (95% CI: 14.72–18.75) for those with three ED visits, and 48.24 (95% CI: 43.23–53.83) for those with four ED visits or more. Conclusions Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality. PMID:25935710
Schuur, Jeremiah D; Hsia, Renee Y; Burstin, Helen; Schull, Michael J; Pines, Jesse M
As the United States seeks to improve the value of health care, there is an urgent need to develop quality measurement for emergency departments (EDs). EDs provide 130 million patient visits per year and are involved in half of all hospital admissions. Efforts to measure ED quality are in their infancy, focusing on a small set of conditions and timeliness measures, such as waiting times and length-of-stay. We review the history of ED quality measurement, identify policy levers for implementing performance measures, and propose a measurement agenda. Initial priorities include measures of effective care for serious conditions that are commonly seen in EDs, such as trauma; measures of efficient use of resources, such as high-cost imaging and hospital admission; and measures of diagnostic accuracy. More research is needed to support the development of measures of care coordination and regionalization and the episode cost of ED care. Policy makers can advance quality improvement in ED care by asking ED researchers and organizations to accelerate the development of quality measures of ED care and incorporating the measures into programs that publicly report on quality of care and incentive-based payment systems.
Nielsen, Gayla; Peschel, Laura; Burgess, Ann
The use of real-time feedback about documentation may improve compliance with best practice standards, provide immediate rewards for high-quality documentation, and present an opportunity to make instantaneous improvements to the documentation. This project was conducted in a large, urban emergency department (ED) to enhance patient safety, improve documentation quality, and increase timeliness of documentation. The PDSA (Plan, Do, Study, Act) model was used to develop a valid and reliable process to enhance the clinical care process. Passive electronic visual cues with real-time feedback to the clinician were developed. Between March 2011 and 2012, a total of 89,521 ED records were reviewed for compliance with 16 documentation elements. Documentation improvements were achieved with seven elements. There was a slight decrease in compliance for four elements, and equivalent levels of compliance in five elements were noted. Staff reported that the program was helpful in providing reminders and that passive cues were more helpful than hard stops. Areas for software refinement were also identified. This process demonstrated that the data collection burden was reduced and sampling error was eliminated. Although additional study is needed, the electronic health record can provide passive visual cues to enhance nursing care, improve regulatory compliance and data collection, and provide immediate feedback to the clinician.
Émond, Marcel; Grenier, David; Morin, Jacques; Eagles, Debra; Boucher, Valérie; Le Sage, Natalie; Mercier, Éric; Voyer, Philippe; Lee, Jacques S.
Background Caring for older patients can be challenging in the Emergency Department (ED). A > 12 hr ED stay could lead to incident episodes of delirium in those patients. The aim of this study was to assess the incidence and impacts of ED-stay associated delirium. Methods A historical cohort of patients who presented to a Canadian ED in 2009 and 2011 was randomly constituted. Included patients were aged ≥ 65 years old, admitted to any hospital ward, non-delirious upon arrival and had at least a 12-hour ED stay. Delirium was detected using a modified chart-based Confusion Assessment Method (CAM) tool. Hospital length of stay (LOS) was log-transformed and linear regression assessed differences between groups. Adjustments were made for age and comorbidity profile. Results 200 records were reviewed, 55.5% were female, median age was 78.9 yrs (SD:7.3). 36(18%) patients experienced ED-stay associated delirium. Nearly 50% of episodes started in the ED and within 36 hours of arrival. Comorbidity profile was similar between the positive CAM group and the negative CAM group. Mean adjusted hospital LOS were 20.5 days and 11.9 days respectively (p<.03). Conclusions 1 older adult out of 5 became delirious after a 12 hr ED stay. Since delirium increases hospital LOS by more than a week, better screening and implementation of preventing measures for delirium could reduce LOS and overcrowding in the ED.
Caplan, Edward; Dey, Indranil; Scammell, Andrea; Burnage, Katy; Paul, Siba Prosad
Seizure is defined as 'a sudden surge of electrical activity in the brain, which usually affects how a person appears or acts for a short time'. Children who have experienced seizures commonly present to emergency departments (EDs), and detailed history taking will usually help differentiate between epileptic and non-epileptic events. ED nurses are often the first health professionals to manage children with seizures, and this is best done by following the ABCDE approach. Treatment involves termination of seizures with anticonvulsants, and children may need other symptomatic management. Seizures in children can be an extremely distressing experience for parents, who should be supported and kept informed by experienced ED nurses. Nurses also play a vital role in educating parents on correct administration of anticonvulsants and safety advice. This article discusses the aetiology, clinical presentation, diagnosis and management of children with seizures, with particular emphasis on epilepsy. It includes two reflective case studies to highlight the challenges faced by healthcare professionals managing children who present with convulsions.
White, J M; Nowak, R M; Martin, G B; Best, R; Carden, D L; Tomlanovich, M C
Approximately 25% of patients in prehospital cardiac arrest present in bradyasystolic rhythms, and their long-term prognosis is very poor. Our study was undertaken to determine the utility of immediate emergency department (ED) external cardiac pacing in this situation. Twenty patients presenting with bradyasystolic prehospital cardiac arrest were entered in the study. All received the usual advanced cardiac life support therapy, but also were externally paced immediately using an automated external defibrillator and pacemaker (AEDP). Only two of 20 patients showed evidence of electrical capture, and none developed pulses with pacing. Four of the 20 patients developed a sinus rhythm and blood pressure during resuscitation. Three survived to leave the ED, but none survived to leave the hospital. An increase in the rate of bradycardia and pulseless idioventricular rhythms that was independent of electrical capture or pharmacologic therapy was noted occasionally. Although survival was not enhanced using the AEDP, the device was reliable, easy to use, and free of complications. External cardiac pacing warrants further investigation in the prehospital setting.
Hoot, Nathan R; Aronsky, Dominik
Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, "frequent-flyer" patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.
Weiland, Tracey J.; Chong, Alvin H.; Jelinek, George A.
Background/Objectives. There is minimal data available on the types of dermatological conditions which present to tertiary emergency departments (ED). We analysed demographic and clinical features of dermatological presentations to an Australian adult ED. Methods. The St. Vincent's Hospital Melbourne (SVHM) ED database was searched for dermatological presentations between 1 January 2009 and 31 December 2011 by keywords and ICD-10 diagnosis codes. The lists were merged, and the ICD-10 codes were grouped into 55 categories for analysis. Demographic and clinical data for these presentations were then analysed. Results. 123 345 people presented to SVHM ED during the 3-year period. 4817 (3.9%) presented for a primarily dermatological complaint. The most common conditions by ICD-10 diagnosis code were cellulitis (n = 1741, 36.1%), allergy with skin involvement (n = 939, 19.5%), boils/furuncles/pilonidal sinuses (n = 526, 11.1%), eczema/dermatitis (n = 274, 5.7%), and varicella zoster infection (n = 161, 3.3%). Conclusion. The burden of dermatological disease presenting to ED is small but not insignificant. This information may assist in designing dermatological curricula for hospital clinicians and specialty training organisations as well as informing the allocation of dermatological resources to ED. PMID:24800080
Pagano, Antonio; Numis, Fabio Giuliano; Visone, Giuseppe; Pirozzi, Concetta; Masarone, Mario; Olibet, Marinella; Nasti, Rodolfo; Schiraldi, Fernando; Paladino, Fiorella
Lung ultrasound (LUS) in the emergency department (ED) has shown a significant role in the diagnostic workup of pulmonary edema, pneumothorax and pleural effusions. The aim of this study is to assess the reliability of LUS for the diagnosis of acute pneumonia compared to chest X-ray (CXR) study. The study was conducted from September 2013 to March 2015. 107 patients were admitted to the ED with a clinical appearance of pneumonia. All the patients underwent a CXR study, read by a radiologist, and an LUS, performed by a trained ED physician on duty. Among the 105 patients, 68 were given a final diagnosis of pneumonia. We found a sensitivity of 0.985 and a specificity of 0.649 for LUS, and a sensitivity of 0.735 and specificity of 0.595 for CXR. The positive predictive value for LUS was 0.838 against 0.7 for CXR. The negative predictive value of LUS was 0.960 versus 0.550 for CXR. This study has shown sensitivity, positive predictive value and negative predictive value of LUS compared to the CXR study for the diagnosis of acute pneumonia. These results suggest the use of bedside thoracic US first-line diagnostic tool in patients with suspected pneumonia.
Nordt, Sean Patrick; Vilke, Gary M; Clark, Richard F; Lee Cantrell, F; Chan, Theodore C; Galinato, Melissa; Nguyen, Vincent; Castillo, Edward M
Energy drink usage is common and contains caffeine or other stimulants. We evaluated demographics, prevalence, reasons and adverse effects with consuming energy beverages. Cross-sectional study of a convenience sample of patients recruited from two San Diego Emergency Departments from January to December 2009. One-thousand-two-hundred-ninety-eight subjects participated of which 52.6% were male. Ethnicity: Caucasian 48.3%, African American 17%, Hispanic 18%, Other 16.7%. Age ranges: 18-29 years (38.4%), 30-54 years (49.6%) and greater than 55 years (12%). Reasons for use: 57% to "increase energy", 9.5% for studying/work projects, 2.4% while prolonged driving, improve sports performance 2%, with ethanol 6.3%, "other" reasons 22.1%. Adverse reactions reported by 33.5% (429) patients. Two-hundred-eighty report feeling "shaky/jittery", insomnia 136, palpitations 150, gastrointestinal upset 82, headache 68, chest pain 39, and seizures in 6. Eighty-five patients reported co-ingestion with illicit "stimulants" including cocaine and methamphetamine. We identified one-third of patients reported at least one adverse effect. Whilst most were not severe, a small number were serious e.g., seizures. In addition, some report purposely ingesting with illicit drugs.
Olsen, Jon C; Sabin, Brad R
The study objective was to determine if Emergency Department (ED) patients experience breaches of privacy and confidentiality during their ED stay and to determine if the type of room in which the patient is placed affects privacy. We surveyed a convenience sample of ED patients at the conclusion of their ED stay regarding their privacy and confidentiality. Overall, 36% of patients overheard conversations with similar frequencies in walled and curtained rooms. The location of conversations overheard varied depending on the type of patient room, as curtained rooms allowed conversations from adjacent rooms to be overheard and walled rooms allowed more conversations from the hallway or nursing station to be overheard. Patients felt more comfortable giving their history and having physical examinations performed in walled vs. curtained rooms. Inappropriate or unprofessional comments by staff were heard by 1.6% of patients. Health care providers in the ED need to be aware of breaches in confidentiality and privacy, as our patients deserve respect of their privacy and confidentiality during their ED visit.
Hicks, Derek; Li, Chi-Ying
Macroscopic haematuria is a commonly seen condition in the emergency department (ED), which has a variety of causes. However, most importantly, macroscopic haematuria has a high diagnostic yield for urological malignancy. 30% of patients presenting with painless haematuria are found to have a malignancy. The majority of these patients can be managed in the outpatient setting. This review of current literature suggests a management pathway that can be used in the ED. A literature search was done using Medline, PubMed and Google. In men aged >60 years, the positive predictive value of macroscopic haematuria for urological malignancy is 22.1%, and in women of the same age it is 8.3%. In terms of the need for follow-up investigation, a single episode of haematuria is equally important as recurrent episodes. Baseline investigation in the ED includes full blood count, urea and electrolyte levels, midstream urine dipstick, beta human chorionic gonadotrophin, and formal microscopy, culture and sensitivities. Treatment of macroscopic haematuria aims at RESP--Resuscitation, Ensuring, Safe and Prompt. Indications for admission include clot retention, cardiovascular instability, uncontrolled pain, sepsis, acute renal failure, coagulopathy, severe comorbidity, heavy haematuria or social restrictions. Discharged patients should drink plenty of clear fluids and return for further medical attention if the following occur: clot retention, worsening haematuria despite adequate fluid intake, uncontrolled pain or fever, or inability to cope at home. Follow-up by a urological team should be promptly arranged, ideally within the 2-week cancer referral target.
Langabeer, James R.; Gonzalez, Michael; Alqusairi, Diaa; Champagne-Langabeer, Tiffany; Jackson, Adria; Mikhail, Jennifer; Persse, David
Introduction Emergency medical services (EMS) agencies transport a significant majority of patients with low acuity and non-emergent conditions to local emergency departments (ED), affecting the entire emergency care system’s capacity and performance. Opportunities exist for alternative models that integrate technology, telehealth, and more appropriately aligned patient navigation. While a limited number of programs have evolved recently, no empirical evidence exists for their efficacy. This research describes the development and comparative effectiveness of one large urban program. Methods The Houston Fire Department initiated the Emergency Telehealth and Navigation (ETHAN) program in 2014. ETHAN combines telehealth, social services, and alternative transportation to navigate primary care-related patients away from the ED where possible. Using a case-control study design, we describe the program and compare differences in effectiveness measures relative to the control group. Results During the first 12 months, 5,570 patients participated in the telehealth-enabled program, which were compared against the same size control group. We found a 56% absolute reduction in ambulance transports to the ED with the intervention compared to the control group (18% vs. 74%, P<.001). EMS productivity (median time from EMS notification to unit back in service) was 44 minutes faster for the ETHAN group (39 vs. 83 minutes, median). There were no statistically significant differences in mortality or patient satisfaction. Conclusion We found that mobile technology-driven delivery models are effective at reducing unnecessary ED ambulance transports and increasing EMS unit productivity. This provides support for broader EMS mobile integrated health programs in other regions. PMID:27833678
Alderson, Philip O; Bresolin, Linda B; Becker, Gary J; Thrall, James H; Dunnick, N Reed; Hillman, Bruce J; Lee, Joseph K T; Nagy, Edward C
Opportunities for funded radiologic research are greater than ever, and the amount of federal funding coming to academic radiology departments is increasing. Even so, many medical school-based radiology departments have little or no research funding. Accordingly, a consensus panel was convened to discuss ways to enhance research productivity and broaden the base of research strength in as many academic radiology departments as possible. The consensus panel included radiologists who have leadership roles in some of the best-funded research departments, radiologists who direct other funded research programs, and radiologists with related expertise. The goals of the consensus panel were to identify the attributes associated with successful research programs and to develop an action plan for radiology research based on these characteristics.
Stockard, Jean; Greene, Jessica; Lewis, Priscilla; Richmond, Geraldine
Although the proportion of doctoral degrees in chemistry that have gone to women has increased markedly over the past few decades, the representation of women among higher education faculty has not increased at the same rate. This paper reports the results of a systematic effort to change this pattern by increasing the commitment of department heads in leading departments to the hiring and support of women faculty. Results indicate that participants in a carefully planned intervention changed their attitudes regarding reasons underlying women's underrepresentation and barriers to their progress in the field from pre- to postworkshop. Participants also reported commitment to change immediately after the event and engaging in a number of specific change efforts in the following months. While the quality of these change efforts was not related to changes in attitudes, those with fewer women in their department were more likely to report more fully on change efforts.
Canales Opazo, Tatiana Andrea
Although quality of life (QoL) has been a highly investigated issue over the last decades, there is still little agreement on its definition, and even less information about the validity of its measurements in specific settings. Additionally, in complex institutions like a university, functional units such as academic department usually are more…
Keith, Samuel J.; Buckley, Peter F.
Objective: Effective leadership in academic medicine requires a broad constellation of skills, experiences, and core values. The authors sought to describe and define these. Method: The authors conducted a web-based survey among 132 Chairs of North American departments of psychiatry. Results: Eighty-five Chairs (64%) responded to the survey, the…
This study questions whether administrative location of an academic department influences the qualitative nature of its educational output, as measured by the distribution of field choices among graduating students. To address this question, the author recorded curriculum vitae data on 661 economics PhD candidates, all of whom were on the Spring…
The focus of this paper is on speakers' rationalisations of their everyday linguistic choices as members of a multilingual academic department in the US. Given the monolingual macro-context, the myriad of native languages spoken by participants, and the professional stake in language competence, the question of how speakers arrive at language…
Huusko, Mira; Ursin, Jani
In Europe, national quality assurance systems of higher education have begun to be established. In Finland, this development has had the consequence of forcing universities to take notice of assessment procedures. However, little is known about the procedures taking place in individual academic departments as a result of this pan-European trend.…
Mullen, Carol A.; Bettez, Silvia C.; Wilson, Camille M.
Creating desirable academic departments for individuals' well-being and quality scholarship is an important effort as well as a novel idea. The focus of this reflective article is twofold: (a) We present a social capital theory of social justice covenants as a product and process of community building, and (b) we share the multiple lived…
Quardokus, Kathleen; Henderson, Charles
Calls for improvement of undergraduate science education have resulted in numerous initiatives that seek to improve student learning outcomes by promoting changes in faculty teaching practices. Although many of these initiatives focus on individual faculty, researchers consider the academic department to be a highly productive focus for creating…
A survey of the cataloging departments of 166 OCLC-member academic libraries showed that these libraries do not rely exclusively on OCLC for card production and that a large majority do not accept non-Library of Congress OCLC records without substantial checking. Three references are noted. (Author/FM)
Ramsey, V. Jean; Dodge, L. Delf
The appropriateness of using academic departments as a level of analysis of organizational administration is examined. Factors analyzed include homogeneity of faculty responses to measures of organizational structure, environmental uncertainty, and task routineness. Results were mixed, demonstrating the importance of empirically testing rather…
Holligan, Chris; Wilson, Michael; Humes, Walter
The paper reports the findings of a small-scale qualitative investigation into academic staff perceptions of research cultures across 10 English and Scottish university education departments. The study sheds light on four interrelated issues: the nature of research cultures, perceived facilitators, perceived constraints and the emotional landscape…
Brody, Aaron; Rahman, Tahsin; Reed, Brian; Millis, Scott; Ference, Brian; Flack, John M.; Levy, Phillip D.
Background Poor blood pressure (BP) control is a primary risk factor for target organ damage in the heart, brain, and kidney. Uncontrolled hypertension is common among emergency department (ED) patients, particularly in underresourced settings, but it is unclear what role ED providers should play in the management of chronic antihypertensive therapy. Objectives The objective was to evaluate the safety and efficacy of prescribing antihypertensive therapy from the ED. Methods This was a retrospective study of data pooled from two prospective, longitudinal, randomized controlled trials, both of which enrolled ED patients with asymptomatic hypertension. Antihypertensives were prescribed at emergency physician discretion, and this was not related to randomization arm. Demographic data, BP at screening and randomization visit, and data on adverse effects potentially related to antihypertensive therapy were compiled. Means were compared using Student’s t-tests, and proportions were compared using chi-square tests. The effect of antihypertensive therapy on BP control was further analyzed using multivariable regression modeling controlling for age, race, sex, hypertension history, study cohort, and ED BP. Results Data were abstracted for 217 subjects. The median interval from ED visit to randomization was 12 days. Seventy-six subjects (35%) received one or more prescriptions for antihypertensive therapy. Age, sex, race, hypertension history, and mean duration of hypertension were equivalent between groups. Although mean ED BP was higher among those who received prescriptions, the mean systolic BP (sBP) reduction from ED to randomization was significantly greater (difference = 19 mm Hg, 95% confidence interval = 12 to 26 mm Hg). No patient in either group had an sBP less than 100 mm Hg at randomization. On multiple regression modeling, randomization sBP reduction was independently associated with antihypertensive prescription (p = 0.001). The incidence of adverse effects
Kumar, Juvva Gowtham; Abhilash, K. P. P.; Saya, Rama Prakasha; Tadipaneni, Neeha; Bose, J. Maheedhar
Background: Hypoglycemia is one among the leading causes for Emergency Department (ED) visits and is the most common and easily preventable endocrine emergency. This study is aimed at assessing the incidence and elucidating the underlying causes of hypoglycemia. Materials and Methods: A retrospective, observational study which included patients registering in ED with a finger prick blood glucose ≤60 mg/dl at the time of arrival. All patients aged above 15 years with the above inclusion criteria during the period of August 2010 to July 2013 were selected. The study group was categorized based on diabetic status into diabetic and nondiabetic groups. Results: A total of 1196 hypoglycemic episodes encountered at the ED during the study period were included, and of which 772 with complete data were analyzed. Underlying causes for hypoglycemia in the diabetic group (535) mainly included medication related 320 (59.81%), infections 108 (20.19%), and chronic kidney disease 61 (11.40%). Common underlying causes of hypoglycemia in nondiabetic group (237, 30.69%) included infections 107 (45.15%), acute/chronic liver disease 42 (17.72%), and malignancies 22 (9.28%). Among diabetic subjects on antidiabetic medications (n = 320), distribution over 24 h duration clearly reported two peaks at 8th and 21st h. The incidence of hypoglycemia and death per 1000 ED visits were 16.41 and 0.73 in 2011, 16.19 and 0.78 in 2012, 17.20 and 1.22 in 2013 with an average of 16.51 and 0.91, respectively. Conclusion: Bimodal distribution with peaks in incidences of hypoglycemic attacks at 8th and 21st h based on hourly distribution in a day can be correlated with the times just before next meal. None of the patients should leave ED without proper evaluation of the etiology of hypoglycemia and the problem should be addressed at each individual level. Increasing incidence of death over the years is alarming, and further studies are needed to conclude the root cause. PMID:28217510
Rodriguez, Robert M.; Reeves, Jabari; Houston, Sherard; McClung, Christian
Study Objective: From September through December 2001, 22 Americans were diagnosed with anthrax, prompting widespread national media attention and public concern over bioterrorism. The purpose of this study was to determine the effect of the threat of anthrax bioterrorism on patient presentation to a West Coast emergency department (ED). Methods: This survey was conducted at an urban county ED in Oakland, CA between December 15, 2001 and February 15, 2002. During random 8-hour blocks, all adult patients presenting for flu or upper respiratory infection (URI) symptoms were surveyed using a structured survey instrument that included standard visual numerical and Likert scales. Results: Eighty-nine patients were interviewed. Eleven patients (12%) reported potential exposure risk factors. Eighty percent of patients watched television, read the newspaper, or listened to the radio daily, and 83% of patients had heard about anthrax bioterrorism. Fifty-five percent received a chest x-ray, 10% received either throat or blood cultures, and 28% received antibiotics. Twenty-one percent of patients surveyed were admitted to the hospital. Most patients were minimally concerned that they may have contracted anthrax (mean=3.3±3.3 where 0=no concern and 10=extremely concerned). Patient concern about anthrax had little influence on their decision to visit the ED (mean=2.8±3.0 where 0=no influence and 10=greatly influenced). Had they experienced their same flu or URI symptoms one year prior to the anthrax outbreak, 91% of patients stated they would have sought medical attention. Conclusions: After considerable exposure to media reports about anthrax, most patients in this urban West Coast ED population were not concerned about anthrax infection. Fear of anthrax had little effect on decisions to come to the ED, and most would have sought medical help prior to the anthrax outbreak. PMID:20847852
Samuels-Kalow, Margaret; Rhodes, Karen; Uspal, Julie; Smith, A. Reyes; Hardy, Emily; Mollen, Cynthia
Objectives Emergency department (ED) discharge requires conveying critical information in a time-limited and distracting setting. Limited health literacy may put patients at risk of incomplete comprehension, but the relationship between discharge communication needs and health literacy has not been well defined. The goal of this study was to characterize the variation in needs and preferences regarding the ED discharge process by health literacy, and identify novel ideas for process improvement from parents and patients. Methods This was an in-depth qualitative interview study in two EDs using asthma as a model system for health communication. Adult patients and parents of pediatric patients with an asthma exacerbation and planned discharge were enrolled using purposive sampling to balance across literacy groups at each site. Interviews were audiotaped, transcribed, coded independently by two team members, and analyzed using a modified grounded theory approach. Interviews were conducted until thematic saturation was reached in both literacy groups at each site. Results In-depth interviews were completed with 51 participants: 20 adult patients and 31 pediatric parents. The majority of participants identified barriers related to ED providers, such as use of medical terminology; and systems of care, such as absence of protected time for discharge communication. Patients with limited health literacy, but not those with adequate literacy, identified conflicting information between health care sources as a barrier to successful ED discharge. Conclusions Participants across literacy groups and settings identified multiple actionable areas for improvement in the ED discharge process. These included the use of simplified/lay language, increased visual learning and demonstration, and the desire for complete information. Individuals with limited literacy may particularly benefit from increased attention to consistency. PMID:26683867
Hsia, Renee Y; Antwi, Yaa Akosa
Objective Previous studies have shown that charges for inpatient and clinic procedures vary substantially; however, there is scant data on variation in charges for emergency department (ED) visits. Outpatient ED visits are typically billed using CPT-coded levels to standardize the intensity of services received, providing an ideal element on which to evaluate charge variation. Thus, we sought to analyze the variation in charges for each level of ED visits, and examine whether hospital and market-level factors could help predict these charges. Methods Using 2011 charge data provided by every non-federal California hospital to the Office of Statewide Health Planning and Development, we analyzed the variability in charges for each level of ED visits and used linear regression to assess whether hospital and market characteristics could explain the variation in charges. Results Charges for each ED visit level varied widely; for example, charges for a level 4 visit ranged from $275 to $6,662. Government hospitals charged significantly less than non-profit hospitals, while hospitals that paid higher wages, served higher proportions of Medicare and Medicaid patients, and were located in areas with high costs of living charged more. Overall our models explained only 30–41% of the between-hospital variation in charges for each level of ED visits. Conclusions Our findings of extensive charge variation in ED visits add to the literature in demonstrating the lack of systematic charge setting in the U.S. healthcare system. These widely varying charges affect the hospital bills of millions of uninsured patients and insured patients seeking care out-of-network, and continue to play a role in many aspects of healthcare financing. PMID:24888673
Heilbrunn, Benjamin R.; Wittern, Rachael E.; Lee, Justin B.; Pham, Phung K.; Hamilton, Anita H.; Nager, Alan L.
Background Anxiety among patients in a Pediatric Emergency Department (PED) can be significant but often goes unaddressed. Objective To determine whether exposure to Child Life (CL) or Hospital Clowning (HC) can reduce anxiety in children presenting to a PED. Methods Patients were randomized to CL, HC or control and assessed upon: entry to examination room (T1), prior to physician arrival (T2) and during physician examination (T3), using the modified Yale Preoperative Anxiety Scale (m-YPAS). CL and HC interventions occurred for 5–10 minutes prior to physician entry. Effects were analyzed using mixed ANOVA. Results m-YPAS scores ranged from 23 to 59, with a higher score indicating increased anxiety. Mixed ANOVA on the study sample (n=113) showed a significant interaction between groups (CL, HC, control) and time, p = .02. Further analyses indicated effect of group only at T2 (MCL = 23.8, 95% CI 23.2–24.5; MHC = 25.2, 95% CI 24.2–26.2; Mcontrol = 26.1, 95% CI 24.2–27.9), p = .02. Sub-analysis of patients with T1 m-YPAS score ≥ 28 (n=56) showed a significant interaction between group and time, p = .01. Further analysis showed effect of group only at T2 (MCL = 24.4, 95% CI 23.3–25.6; MHC = 27.0, 95% CI 25.2–28.7; Mcontrol = 29.2, 95% CI 25.6–32.7), p = .003. Conclusion CL services can reduce SA for patients presenting to a PED with heightened anxiety at baseline. This reduction occurred immediately following CL intervention, but was not observed in patients exposed to HC or during physician examination. PMID:25271180
Lash, Rebecca S.; Bell, Janice F.; Reed, Sarah C.; Poghosyan, Hermine; Rodgers, James; Kim, Katherine K.; Bold, Richard J.; Joseph, Jill G.
Background Recent reports call for reductions in costly and potentially avoidable services such as emergency department (ED) visits. Providing high-quality and safe care for oncology patients remains challenging for ED providers given the diversity of patients seeking care and the unpredictable clinical environment. While ED use by oncology patients is appropriate for acute health concerns, some ED visits may be preventable with well-coordinated care and adequate symptom management. Objective The aim of this study was to summarize available evidence regarding the incidence, predictors of, and reasons for ED visits among oncology patients. Methods Keyword/MeSH term searches were conducted using 4 online databases. Inclusion criteria were publication date between April 1, 2003, and December 5, 2014; sample size of 50 or more; and report of the incidence or predictors of ED use among oncology patients. Results The 15 studies that met criteria varied in study aim, design, and time frames for calculating ED utilization rates. The incidence of ED visits among oncology patients ranged from 1% to 83%. The 30-day standardized visit rate incidence ranged from 1% to 12%. Collectively, the studies lack population-based estimates for all cancers combined. Conclusions The studies included in this review suggest that rates of ED use among cancer patients exceed those of the general population. However, the extent of ED use by oncology patients and the reasons for ED visits remain understudied. Implications for Practice Nurses are involved in the treatment of cancer, patient education, and symptom management. Nurses are well positioned to develop patient-centered treatment and care coordination plans to improve quality of care and reduce ED visits. PMID:26925998
Imperato, Jason; Morris, Darren Scott; Binder, David; Fischer, Christopher; Patrick, John; Sanchez, Leon Dahomey; Setnik, Gary
To determine if a physician in triage (PIT) improves Emergency Department (ED) patient flow in a community teaching hospital. This is an interventional study comparing patient flow parameters for the 3-month periods before and after implementation of a PIT model. During the interventional time an additional attending physician was assigned to triage from 1 p.m. to 9 p.m. daily. Outcome measures were median time to attending physician evaluation, median length of stay (LOS), number of patients who left without being seen (LWBS), and total time and number of days on ambulance diversion. Non-normally distributed values were compared with the Wilcoxon rank sum test. Proportions were compared with Chi-square test. Outcome measures were available for 17,631 patients, of whom 8,620 were seen before the initiation of PIT, and 9,011 were seen after PIT was implemented. For all patients, the median time from registration to attending physician evaluation was reduced by 36 min (1:41 to 1:05, p < 0.01) while the median LOS for all patients was reduced by 12 min (3:51 to 3:39, p < 0.01) after the intervention. Both the number of days on diversion (24 vs. 9 days) and total time on diversion (68 h 25 min vs. 26 h 7 min) were decreased, p < 0.01. Finally, there was a slight reduction in the number of patients who LWBS from 1.5 to 1.3 %, but this was not statistically significant (p = 0.36). Patient flow parameters in a community teaching hospital were modestly improved as a result of PIT implementation.
McElroy, Lisa M.; Schmidt, Kathryn A.; Richards, Christopher T.; Lapin, Brittany; Abecassis, Michael M.; Holl, Jane L.; Adams, James; Ladner, Daniela P.
Background Research on post-transplant care has predominantly focused on predictors of readmission with little attention to emergency department (ED) visits. The goal of this study was to describe early postoperative ED care of transplant recipients. Methods A secondary database analysis of adult patients who underwent abdominal organ transplantation between January 1, 2008 and December 31, 2013 and sought ED care within one year post-transplantation was conducted. Survival was compared using the Kaplan-Meier method with log-rank test. Cox proportional hazards regression analysis was performed to adjust for pertinent covariates. Results A total of 1,900 abdominal organ transplants were performed during the study period. Of these, 37% (N=711) transplant recipients sought care in the ED (1,343 total visits) with 1.89 mean ED visits per recipient. Of recipients seen in the ED, 58% received a kidney transplant and 28% received a liver transplant, with 45% of recipients presenting within the first 60 postoperative days. The most common chief complaints were gastroenterological (17%) and abnormal laboratory values or vital signs (17%). In total, 74% of recipients were readmitted and 50% of admitted patients were discharged in less than 24 hours. Transplant recipients with ED visits had lower 3-year graft (81% vs. 87%; p<0.001) and patient (89% vs. 93%; p=0.002) survival. Conclusion Transplant recipients have a high frequency of ED visits in the first post-transplantation year and high rates of subsequent hospital admission. Further investigation is needed to understand what drives recipient presentation to the ED and create care models that achieve the best outcomes. PMID:26050012
Mistry, Rakesh D; Newland, Jason G; Gerber, Jeffrey S; Hersh, Adam L; May, Larissa; Perman, Sarah M; Kuppermann, Nathan; Dayan, Peter S
BACKGROUND Antimicrobial stewardship programs (ASPs) effectively optimize antibiotic use for inpatients; however, the extent of emergency department (ED) involvement in ASPs has not been described. OBJECTIVE To determine current ED involvement in children's hospital ASPs and to assess beliefs and preferred methods of implementation for ED-based ASPs. METHODS A cross-sectional survey of 37 children's hospitals participating in the Sharing Antimicrobial Resistance Practices collaboration was conducted. Surveys were distributed to ASP leaders and ED medical directors at each institution. Items assessed included beliefs regarding ED antibiotic prescribing, ED prescribing resources, ASP methods used in the ED such as clinical decision support and clinical care guidelines, ED participation in ASP activities, and preferred methods for ED-based ASP implementation. RESULTS A total of 36 ASP leaders (97.3%) and 32 ED directors (86.5%) responded; the overall response rate was 91.9%. Most ASP leaders (97.8%) and ED directors (93.7%) agreed that creation of ED-based ASPs was necessary. ED resources for antibiotic prescribing were obtained via the Internet or electronic health records (EHRs) for 29 hospitals (81.3%). The main ASP activities for the ED included production of antibiograms (77.8%) and creation of clinical care guidelines for pneumonia (83.3%). The ED was represented on 3 hospital ASP committees (8.3%). No hospital ASPs actively monitored outpatient ED prescribing. Most ASP leaders (77.8%) and ED directors (81.3%) preferred implementation of ED-based ASPs using clinical decision support integrated into the EHR. CONCLUSIONS Although ED involvement in ASPs is limited, both ASP and ED leaders believe that ED-based ASPs are necessary. Many children's hospitals have the capability to implement ED-based ASPs via the preferred method: EHR clinical decision support. Infect Control Hosp Epidemiol 2017;38:469-475.
Takase, Miyuki; Carlin, John
Overcrowding is a phenomenon commonly observed at emergency departments (EDs) in many hospitals, and negatively impacts patients, healthcare professionals and organisations. Health care organisations are expected to act proactively to cope with a high patient volume by understanding and predicting the patterns of ED presentations. The aim of this study was, therefore, to identify the patterns of patient flow at a paediatric ED in order to assist the management of EDs. Data for ED presentations were collected from the Royal Children's Hospital in Melbourne, Australia, with the time-frame of July 2003 to June 2008. A linear regression analysis with trigonometric functions was used to identify the pattern of patient flow at the ED. The results showed that a logarithm of the daily average ED presentations was increasing exponentially (as explained by 0.004t + 0.00005t2 with t representing time, p<0.001). The model also indicated that there was a yearly oscillation in the frequency of ED presentations, in which lower frequencies were observed in summer and higher frequencies during winter (as explained by -0.046 sin(2(pi)t/12)-0.083 cos(2(pi)t/12), p<0.001). In addition, the variation of the oscillations was increasing over time (as explained by -0.002t*sin(2(pi)t/12)-0.001t*cos(2(pi)t/12), p<0.05). The identified regression model explained a total of 96% of the variance in the pattern of ED presentations. This model can be used to understand the trend of the current patient flow as well as to predict the future flow at the ED. Such an understanding will assist health care managers to prepare resources and environment more effectively to cope with overcrowding.
Eggman, Ashley A.; Leff, Jared A.; Braunlin, Megan; Felsen, Uriel R.; Fitzpatrick, Lisa; Telzak, Edward E.; El-Sadr, Wafaa; Branson, Bernard M.
Objective The HIV Prevention Trials Network (HPTN) 065 trial sought to expand HIV screening of emergency department (ED) patients in Bronx, New York, and Washington, D.C. This study assessed the testing costs associated with different expansion processes and compared them with costs of a hypothetical optimized process. Methods Micro-costing studies were conducted in two participating EDs in each city that switched from point-of-care (POC) to rapid-result laboratory testing. In three EDs, laboratory HIV testing was only conducted for patients having blood drawn for clinical reasons; in the other ED, all HIV testing was conducted with laboratory testing. Costs were estimated through direct observation and interviews to document process flows, time estimates, and labor and materials costs. A hypothetical optimized process flow used minimum time estimates for each process step. National wage and fringe rates and local reagent costs were used to determine the average cost (excluding overhead) per completed nonreactive and reactive test in 2013 U.S. dollars. Results Laboratory HIV testing costs in the EDs ranged from $17.00 to $23.83 per completed nonreactive test, and POC testing costs ranged from $17.64 to $37.60; cost per completed reactive test ranged from $89.29 to $123.17. Costs of hypothetical optimized HIV testing with automated process steps were approximately 45% lower for nonreactive tests and 20% lower for reactive tests. The cost per ED visit to conduct expanded HIV testing in each hospital ranged from $1.21 to $3.96. Conclusion An optimized process could achieve additional cost savings but would require an investment in electronic system interfaces to further automate testing processes. PMID:26862232
White, Douglas A. E.; Anderson, Erik S.; Pfeil, Sarah K.; Deering, Laura J.; Todorovic, Tamara; Trivedi, Tarak K.
Background Recent studies demonstrate high rates of previously undiagnosed hepatitis C virus (HCV) infection among patients screened in urban emergency departments (ED). Experts caution, however, that public health interventions, such as screening for infectious diseases, must not interfere with the primary mission of EDs to provide timely acute care. Increases in ED length of stay (LOS) have been associated with decreased quality of ED care. Objective In this study, we assess the influence of an integrated HCV screening protocol on ED LOS. Methods This was a retrospective cohort study analyzing timestamp data for all discharged patients over a 1-year period. The primary outcome compared the median LOS in minutes between patients who completed HCV screening and those who did not. Further analysis compared LOS for HCV screening by whether or not complete blood count (CBC) testing was conducted. Results Of 69,639 visits, 2,864 (4%) had HCV screening tests completed and 272 (9.5%) were antibody positive. The median LOS for visits that included HCV screening was greater than visits that did not include screening (151 versus 119 minutes, P < 0.001). Among the subset of visits in which CBC testing was conducted, there was no significant difference in median LOS between visits that also included HCV screening and those that did not (240 versus 242 minutes, P = 0.68). Conclusion Integrated HCV screening modestly prolongs ED LOS. However, among patients undergoing other blood tests, screening had no effect on LOS. Programs may consider routinely offering HCV screening to patients who are undergoing laboratory testing. PMID:27760176
Neuenschwander, James F.; Peacock, W. Frank; Migeed, Madgy; Hunter, Sara A.; Daughtery, John C.; McCleese, Ian C.; Hiestand, Brian C.
Objective Patients with implanted cardiac devices may wait extended periods for interrogation in emergency departments (EDs). Our purpose was to determine if device interrogation could be done safely and faster by ED staff. Methods Prospective randomized, standard therapy controlled, trial of ED staff device interrogation vs. standard process (SP), with 30-day follow-up. Eligibility criteria: ED presentation with a self-report of a potential device related complaint, with signed informed consent. SP interrogation was by company representative or hospital employee. Results Of 60 patients, 42 (70%) were male, all were white, with a median (interquartile range) age of 71 (64 to 82) years. No patient was lost to follow up. Of all patients, 32 (53%) were enrolled during business hours. The overall median (interquartile range) ED vs. SP time to interrogation was 98.5 (40 to 260) vs. 166.5 (64 to 412) minutes (P=0.013). While ED and SP interrogation times were similar during business hours, 102 (59 to 138) vs. 105 (64 to 172) minutes (P=0.62), ED interrogation times were shorter vs. SP during non-business hours; 97 (60 to 126) vs. 225 (144 to 412) minutes, P=0.002, respectively. There was no difference in ED length of stay between the ED and SP interrogation, 249 (153 to 390) vs. 246 (143 to 333) minutes (P=0.71), regardless of time of presentation. No patient in any cohort suffered an unplanned medical contact or post-discharge adverse device related event. Conclusion ED staff cardiac device interrogations are faster, and with similar 30-day outcomes, as compared to SP. PMID:28168230
Capote, Allan; Michael, Andrew; Almodovar, Jorge; Chan, Patricia; Skinner, Ruby; Martin, Maureen
Emergency department thoracotomy (EDT) is a dramatic lifesaving procedure demanding timely surgical intervention, technical expertise, and coordinated resuscitation efforts. Inappropriate use is costly and futile. All patients admitted to a Level II trauma center who underwent EDT from January 2003 to July 2012 were studied. The primary end point was appropriateness of EDT. Secondary end points were staff exposure, survival, and return to normal function. Eighty-seven patients including 59 patients with penetrating wounds had a mean loss of vital signs (LOV) 11.6 ±10.6 minutes and Injury Severity Score (ISS) of 45.8 ± 16.1, whereas 28 blunt injury patients had a mean LOV of 10.4 ± 11.5 minutes and ISS of 50.4 ± 19.4. Mortality was 81 per cent (48 of 59) in penetrating injury and 93 per cent (26 of 28) in blunt injury patients, respectively (odds ratio [OR] 2.99; P 0.21). Fifty-five EDTs were indicated with 10 survivors (18.2%) and 32 not indicated with three survivors (9.4%). Surgeons adhered to guidelines more compared with ED physicians (OR, 4.9; P = 0.03) whose patients were more likely to die (OR, 3.52; P = 0.124). Survivors (11 of 13 [84.6%]) were discharged home without significant long-term neurologic disability. EDT is lifesaving when performed for penetrating injury by experienced surgeons following established guidelines but futile in blunt injury or when performed by nonsurgeons regardless of mechanism.
Shahrami, Ali; Norouzi, Mehdi; Kariman, Hamid; Hatamabadi, Hamid Reza; Arhami Dolatabadi, Ali
Introduction: Vertigo prevalence is estimated to be 1.8% among young adults and more than 30% in the elderly. 13-38% of the referrals of patients over 65 years old in America are due to vertigo. Vertigo does not increase the risk of mortality but it can affect the patient’s quality of life. Therefore, this study was designed to evaluate the epidemiologic characteristics of vertigo patients referred to the emergency department (ED). Methods: In this 6-month retrospective cross-sectional study, the profiles of all vertigo patients referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2013 to March 2014 were evaluated. Demographic data and baseline characteristics of the patients were recorded and then patients were divided into central and peripheral vertigo. The correlation of history and clinical examination with vertigo type was evaluated and screening performance characteristics of history and clinical examination in differentiating central and peripheral vertigo were determined. Results: 379 patients with the mean age of 50.69 ± 11.94 years (minimum 18 and maximum 86) were enrolled (58.13% female). There was no sex difference in vertigo incidence (p = 0.756). A significant correlation existed between older age and increase in frequency of central cases (p < 0.001). No significant difference was detected between the treatment protocols regarding ED length of stay (p = 0.72). There was a significant overlap between the initial diagnosis and the final decision based on imaging and neurologist’s final opinion (p < 0.001). In the end, 361 (95.3%) patients were discharged from ED, while 18 were disposed to the neurology ward. No case of mortality was reported. Conclusion: Sensitivity and specificity of history and clinical examination in differentiating central and peripheral vertigo were 99 (95% CI: 57-99) and 99 (95% CI: 97-99), respectively PMID:26862546
Goldberg, Morris; Robertson, John G.; Belanger, Garry; Georganas, Nicolas D.; Mastronardi, Jim; Cohn-Sfetcu, Sorin; Dillon, Richard F.; Tombaugh, Jo W.
The most critical aspect of a radiologist's work is the communication of his findings to the attending physician responsible for the patient's care. This is also the part of the process that is least well organized and the most subject to failure. At the University of Ottawa Medical Communications Research Centre we are investigating technical means to improve communications between radiologists and attending physicians. We first introduce the radiology communication service problem and show why it is essentially a multimedia communication problem. We then briefly describe a multimedia communication system designed and implemented by our research team. The multimedia system consists of several workstations linked by the Hospital's LAN. Each physician workstation comprises a Compaq 386/20 Mhertz microcomputer with 16 Mbytes of RAM, a 500 Mbyte image disk, an image memory which drives a 1000 line monochrome monitor. The images are digitized using a Konica laser-based film digitizer (2430 by 2000 10-bit pixels for a standard chest radiograph). The multimedia file server manager station is built around a PC-AT compatible with a Northern Telecom MERIDIAN SL-1ST digital PBX and a Meridian Mail digital voice messaging system. This last device is used to store voice data and is linked via the PBX to the workstations' digital telephones. A SYTEK 6000 local area network (LAN) links all workstations to the file server. All data, image and graphic information is transmitted via this network, while the twisted pair connections linking the digital PBX to the telephone sets are used for transmitting voice data. Finally, we provide details of an in-hospital trial linking the Department of Radiological Sciences and the Emergency Department at the Ottawa Civic Hospital, a 950 bed tertiary care teaching hospital.
Nakikj, Drashko; Weng, Chunhua
The increasing need for interdisciplinary team sciences makes it vital for academic research departments to publicize their research and educational resources as part of "linked data" on the semantic web to facilitate research networking and recruitment. We extended an open-source ontology, VIVO, to represent the research and educational resources in an academic biomedical informatics department to enable ontology-based information storage and retrieval. Using participatory design methods, we surveyed representative types of visitors to the department web site to understand their information needs, and incorporated these needs into the ontology design. We added 114 classes and 186 properties to VIVO. Generalizability and scalability are the measures used in our theoretical evaluation.
Peruta, Maria Rosaria Della
Why do inventors and top scientists from leading universities exploit their research results differently from others? Why do apparently similar laboratory experiences make "academic entrepreneurs" achieve different entrepreneurial goals? Does the academic experience have an influence on the willingness to spin off? Or is that willingness simply…
Kulstad, Christine E.; Holt, Shannon C.; Abrahamsen, Aaron A.; Lovell, Elise O.
Objectives: Therapeutic hypothermia (TH) has been shown to improve survival and neurological outcome in patients resuscitated after out of hospital cardiac arrest (OHCA) from ventricular fibrillation/ventricular tachycardia (VF/VT). We evaluated the effects of using a TH protocol in a large community hospital emergency department (ED) for all patients with neurological impairment after resuscitated OHCA regardless of presenting rhythm. We hypothesized improved mortality and neurological outcomes without increased complication rates. Methods: Our TH protocol entails cooling to 33°C for 24 hours with an endovascular catheter. We studied patients treated with this protocol from November 2006 to November 2008. All non-pregnant, unresponsive adult patients resuscitated from any initial rhythm were included. Exclusion criteria were initial hypotension or temperature less than 30°C, trauma, primary intracranial event, and coagulopathy. Control patients treated during the 12 months before the institution of our TH protocol met the same inclusion and exclusion criteria. We recorded survival to hospital discharge, neurological status at discharge, and rates of bleeding, sepsis, pneumonia, renal failure, and dysrhythmias in the first 72 hours of treatment. Results: Mortality rates were 71.1% (95% CI, 56–86%) for 38 patients treated with TH and 72.3% (95% CI 59–86%) for 47 controls. In the TH group, 8% of patients (95% CI, 0–17%) had a good neurological outcome on discharge, compared to 0 (95% CI 0–8%) in the control group. In 17 patients with VF/VT treated with TH, mortality was 47% (95% CI 21–74%) and 18% (95% CI 0–38%) had good neurological outcome; in 9 control patients with VF/VT, mortality was 67% (95% CI 28–100%), and 0% (95% CI 0–30%) had good neurological outcome. The groups were well-matched with respect to sex and age. Complication rates were similar or favored the TH group. Conclusion: Instituting a TH protocol for OHCA patients with any
Background Patients with high emergency department (ED) utilization account for a disproportionate number of ED visits. The existing research on high ED utilization has raised doubts about the homogeneity of the frequent ED user. Attention to differences among the subgroups of frequent visitors (FV) and highly frequent visitors (HFV) is necessary in order to plan more effective interventions. In the Netherlands, the incidence of high ED utilization is unknown. The purpose of this study was to investigate if the well-documented international high ED utilization also exists in the Netherlands and if so, to characterize these patients. Therefore, we assessed the proportion of FV and HFV; compared age, sex, and visit outcomes between patients with high ED utilization and patients with single ED visits; and explored the factors associated with high ED utilization. Methods A 1-year retrospective descriptive correlational study was performed in two Dutch EDs, using thresholds of 7 to 17 visits for frequent ED use, and greater than or equal to 18 visits for highly frequent ED use. Results FV and HFV (together accounting for 0.5% of total ED patients) attended the ED 2,338 times (3.3% of the total number of ED visits). FV and HFV were equally likely to be male or female, were less likely to be self-referred, and they suffered from urgent complaints more often compared to patients with single visits. FV were significantly older than patients with single visits and more often admitted than patients with single visits. Several chief complaints were indicative for frequent and highly frequent ED use, such as shortness of breath and a psychiatric disorder. Conclusions Based on this study, high ED utilization in the Netherlands seems to be less a problem than outlined in international literature. No major differences were found between FV and HFV, they presented with the same, often serious, problems. Our study supports the notion that most patients with high ED utilization visit
Felder, Sarah; Curtis, R Mason; Ball, Ian; Borici-Mazi, Rozita
Angioedema is a transient, localized swelling caused by two distinct mechanisms, mediated by histamine and bradykinin, respectively, although a proportion of cases remain idiopathic. Studies that characterize undifferentiated angioedema presenting in emergency departments (EDs) are limited. This study investigates the presentation patterns of undifferentiated angioedema in the ED based on the presumed mechanism of swelling. Medical records from all ED visits to two tertiary care hospitals from July 2007 to March 2012 were electronically reviewed. Records with documented visible swelling on general inspection and/or fiberoptic laryngoscopy and a diagnostic code for anaphylactic shock, angioneurotic edema, allergy unspecified, defects in the complement system, or unspecified drug adverse effects were included. Demographic, clinical, and outcome data were collected via a standardized form. Data were analyzed descriptively, including frequencies and percentages for categorical data and means and SDs for continuous data. Predictors for admission were identified using multivariate logistic regression models. ED records from 527 visits for angioedema by 455 patients were included in the study. Annual rate of angioedema was 1 per 1000 ED visits. Urticaria was associated with peripheral (p = 0.008) and lip angioedema (p = 0.001), and the absence of urticaria correlated with tongue angioedema (p = 0.001) and trended toward correlation with pharyngeal angioedema (p = 0.056). Significant predictors of admission included nonsteroidal anti-inflammatory drug-induced angioedema (odds ratio [OR], 15.3), epinephrine treatment (OR, 8.34), hypotension (OR, 15.7), multiple-site angioedema (OR, 4.25), and pharyngeal (OR, 1.23) and tongue angioedema (OR, 4.62). Concomitant urticaria was associated with a significant longer stay in the ED (p < 0.001). The presence of urticaria correlated with the location of angioedema, need for airway management, length of ED visit, and recurrence. A
Johnson, Tara; Gaus, David; Herrera, Diego
Introduction There is a paucity of data studying patients and complaints presenting to emergency departments (EDs) in low- and middle-income countries. The town of Pedro Vicente Maldonado (PVM) is located in the northwestern highlands of Ecuador. Hospital PVM (HPVM) is a rural teaching hospital providing family medicine residency training. These physicians provide around-the-clock acute medical care in HPVM’s ED. This study provides a first look at a functioning ED in rural Latin America by reviewing one year of ED visits to HPVM. Methods All ED visits between April 14, 2013, and April 13, 2014, were included and analyzed, totaling 1,239 patient visits. Data were collected from their electronic medical record and exported into a de-identified Excel® database where it was sorted and categorized. Variables included age, gender, mode of arrival, insurance type, month and day of the week of the service, chief complaint, laboratory and imaging requests, and disposition. We performed descriptive statistics, and where possible, comparisons using Student’s T or chi-square, as appropriate. Results Of the 1239 total ED visits, 48% were males and 52% females; 93% of the visits were ambulatory, and 7% came by ambulance. Sixty-three percent of the patients had social security insurance. The top three chief complaints were abdominal pain (25.5%), fever (15.1%) and trauma (10.8%). Healthcare providers requested labs on 71.3% of patients and imaging on 43.2%. The most frequently requested imaging studies were chest radiograph (14.9%), upper extremity radiograph (9.4%), and electrocardiogram (9.0%). There was no seasonal or day-of-week variability to number of ED patients. The chief complaint of human or animal bite made it more likely the patient would be admitted, and the chief complaint of traumatic injury made it more likely the patient would be transferred. Conclusion Analysis of patients presenting to a rural ED in Ecuador contributes to the global study of acute care in
Makam, Anil N.; Nguyen, Oanh K.
Importance Cardiac biomarker testing is not routinely indicated in the emergency department (ED) because of low utility and potential downstream harms from false-positive results. However, current rates of testing are unknown. Objective To determine the use of cardiac biomarker testing overall, as well as stratified by disposition status and selected characteristics. Design, Setting, and Participants Retrospective study of ED visits by adults (≥18 years old) selected from the 2009 and 2010 National Hospital Ambulatory Medical Care Survey, a probability sample of ED visits in the United States. Exposures Selected patient, visit, and ED characteristics. Main Outcomes and Measures Receipt of cardiac biomarker testing during the ED visit. Results Of 44 448 ED visits, cardiac biomarkers were tested in 16.9% of visits, representing 28.6 million visits. Biomarker testing occurred in 8.2% of visits in the absence of acute coronary syndrome (ACS)-related symptoms, representing 8.5 million visits, almost one-third of all visits with biomarker testing. Among individuals subsequently hospitalized, cardiac biomarkers were tested in 47.0% of all visits. In this group, biomarkers were tested in 35.4% of visits despite the absence of ACS-related symptoms. Among all ED visits, the number of other tests or services performed was the strongest predictor of biomarker testing independent of symptoms of ACS. Compared with 0 to 5 other tests or services performed, more than 10 other tests or services performed was associated with 59.55 (95% CI, 39.23-90.40) times the odds of biomarker testing. The adjusted probabilities of biomarker testing if 0 to 5, 6 to 10, or more than 10 other tests or services performed were 6.3%, 34.3%, and 62.3%, respectively. Conclusions and Relevance Cardiac biomarker testing in the ED is common even among those without symptoms suggestive of ACS. Cardiac biomarker testing is also frequently used during visits with a high volume of other tests or services
Lee, V M; Wong, T W; Lau, C C
A prospective study was carried out in an Accident and Emergency department (A&E) to (1) examine the pattern of home accidents in elderly patients presenting to the A&E; (2) determine the nature and mechanisms of the accidents; and (3) investigate the associated factors in these accidents. All patients aged 65 or above with a history of injury at home within one week were included. Patients who needed immediate resuscitation and patients with mental illness or violent behaviour were excluded. A convenient sample was chosen during an 8-week period. A standardized questionnaire was used to collect data on (1) demographics; (2) nature of the accident and injury; and (3) health status. Health status assessment involved three components: physical status, drug history and past health. A total of 100 subjects were included giving an average occurrence of 3.3 cases per shift. The mean age of the group was 75 with female patients (66) outnumbering the males by about two to one. The toilet was the most common site (29%) of home accident, followed by the sitting room (18%), the kitchen (14%), the bedroom (11%) and the dining room (10%). In 79 cases the patient was alone at home during the accident. Falls were the most common (75%) type of accident. The remaining 25% of injuries were categorized as sharps injury (8%), foreign body ingestion (6%), crush injury (4%), burns/scald (3%), hit by/onto fallen objects (3%) and finally, electric shock (1%). Eighteen fractures were recorded. Thirty-two patients were admitted, 16 to the surgical ward and 16 to the orthopedic ward. In the functional assessment only 34 patients could perform the get-up-and-go test satisfactorily and only 61 patients had good hand grasp. Visual and hearing impairment were common. Over 45% of the patients had more than one disease and the majority of patients (80) were taking some medication. The roles of A&E staff in the prevention of home accidents in the elderly are discussed.
Aguilera, Pablo; Garrido, Marcela; Lessard, Eli; Swanson, Julian; Mallon, William K.; Saldias, Fernando; Basaure, Carlos; Lara, Barbara; Swadron, Stuart P.
Introduction While a nationwide poison control registry exists in Chile, reporting to the center is sporadic and happens at the discretion of the treating physician or by patients’ self-report. Moreover, individual hospitals do not monitor accidental or intentional poisoning in a systematic manner. The goal of this study was to identify all cases of intentional medication overdose (MO) that occurred over two years at a large public hospital in Santiago, Chile, and examine its epidemiologic profile. Methods This study is a retrospective, explicit chart review conducted at Hospital Sótero del Rio from July 2008 until June 2010. We included all cases of identified intentional MO. Alcohol and recreational drugs were included only when they were ingested with other medications. Results We identified 1,557 cases of intentional MO and analyzed a total of 1,197 cases, corresponding to 0.51% of all emergency department (ED) presentations between July 2008 and June 2010. The median patient age was 25 years. The majority was female (67.6%). Two peaks were identified, corresponding to the spring of each year sampled. The rate of hospital admission was 22.2%. Benzodiazepines, selective serotonin reuptake inhibitors, and tricyclic antidepressants (TCA) were the causative agents most commonly found, comprising 1,044 (87.2%) of all analyzed cases. Acetaminophen was involved in 81 (6.8%) cases. More than one active substance was involved in 35% of cases. In 7.3% there was ethanol co-ingestion and in 1.0% co-ingestion of some other recreational drug (primarily cocaine). Of 1,557 cases, six (0.39%) patients died. TCA were involved in two of these deaths. Conclusion Similar to other developed and developing nations, intentional MO accounts for a significant number of ED presentations in Chile. Chile is unique in the region, however, in that its spectrum of intentional overdoses includes an excess burden of tricyclic antidepressant and benzodiazepine overdoses, a relatively low rate
Hertz, Judith E.; Douglass, Carolinda; Johnson, Angela; Richmond, Shirley S.
Little is known about the organization, characteristics or services offered by academic interdisciplinary gerontology centers located in higher education institutions. This article presents a description and an emerging typology of academic interdisciplinary gerontology centers based on information collected from the Websites of 47 centers. The…
Shaikh, Sanober B.; Jerrard, David A.; Witting, Michael D.; Winters, Michael E.; Brodeur, Michael N.
Introduction: Our goal was to evaluate patients’ threshold for waiting in an emergency department (ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness to wait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status. Methods: We conducted this survey-based study from March to July 2010 at an urban academic medical center. After triage, patients were given a multiple-choice questionnaire, designed to ascertain how long they would wait for medical care. We collected data including age, gender, race, insurance status, and triage acuity level. We looked at the association between willingness to wait and these variables, using stratified analysis and logistic regression. Results: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventy-one (51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and 110 (32%) would wait indefinitely. No association was found between willingness to wait and race, gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended to be older than 25, have higher acuity, and prefer the study site ED. Conclusion: Many patients have a defined, limited period that they are willing to wait for emergency care. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED without being seen. This result suggests that efforts to reduce the percentage of patients who LWBS must factor in time limits. PMID:23359833
Vogel, Jody A.; Ginde, Adit A.; Lowenstein, Steven R.; Betz, Marian E.
Introduction: To describe the epidemiology and characteristics of emergency department (ED) visits by older adults for motor vehicle collisions (MVC) in the United States (U.S.). Methods: We analyzed ED visits for MVCs using data from the 2003–2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Using U.S. Census data, we calculated annual incidence rates of driver or passenger MVC-related ED visits and examined visit characteristics, including triage acuity, tests performed and hospital admission or discharge. We compared older (65+ years) and younger (18–64 years) MVC patients and calculated odds ratios (OR) and 95% confidence intervals (CIs) to measure the strength of associations between age group and various visit characteristics. Multivariable logistic regression was used to identify independent predictors of admissions for MVC-related injuries among older adults. Results: From 2003–2007, there were an average of 237,000 annual ED visits by older adults for MVCs. The annual ED visit rate for MVCs was 6.4 (95% CI 4.6–8.3) visits per 1,000 for older adults and 16.4 (95% CI 14.0–18.8) visits per 1,000 for younger adults. Compared to younger MVC patients, after adjustment for gender, race and ethnicity, older MVC patients were more likely to have at least one imaging study performed (OR 3.69, 95% CI 1.46–9.36). Older MVC patients were not significantly more likely to arrive by ambulance (OR 1.47; 95% CI 0.76–2.86), have a high triage acuity (OR 1.56; 95% CI 0.77–3.14), or to have a diagnosis of a head, spinal cord or torso injury (OR 0.97; 95% CI 0.42–2.23) as compared to younger MVC patients after adjustment for gender, race and ethnicity. Overall, 14.5% (95% CI 9.8–19.2) of older MVC patients and 6.1% (95% CI 4.8–7.5) of younger MVC patients were admitted to the hospital. There was also a non-statistically significant trend toward hospital admission for older versus younger MVC patients (OR 1.78; 95% CI 0.71–4.43), and
Ross, Judith W; Roberts, Diane; Campbell, James; Solomon, Karen Sofranko; Brouhard, Ben H
The purpose of this study was to determine whether social work intervention would reduce nonemergent visits to the emergency department and increase scheduled pediatric visits. A high-risk repeater group of 104 pediatric patients with three or more emergency department visits was randomly selected to receive social work intervention. Control and intervention groups were compared for inappropriate emergency department utilization and scheduled primary care visits. Pre- and postintervention emergency department visits were significantly reduced in the intervention group compared with the group that received no intervention and with prior utilization. Scheduled visits declined in the control group but increased by 26 percent in the intervention group.
Schoenenberger, Lukas K; Bayer, Steffen; Ansah, John P; Matchar, David B; Mohanavalli, Rajagopal L; Lam, Sean SW; Ong, Marcus EH
Objectives: Emergency Department crowding is a serious and international health care problem that seems to be resistant to most well intended but often reductionist policy approaches. In this study, we examine Emergency Department crowding in Singapore from a systems thinking perspective using causal loop diagramming to visualize the systemic structure underlying this complex phenomenon. Furthermore, we evaluate the relative impact of three different policies in reducing Emergency Department crowding in Singapore: introduction of geriatric emergency medicine, expansion of emergency medicine training, and implementation of enhanced primary care. Methods: The construction of the qualitative causal loop diagram is based on consultations with Emergency Department experts, direct observation, and a thorough literature review. For the purpose of policy analysis, a novel approach, the path analysis, is applied. Results: The path analysis revealed that both the introduction of geriatric emergency medicine and the expansion of emergency medicine training may be associated with undesirable consequences contributing to Emergency Department crowding. In contrast, enhancing primary care was found to be germane in reducing Emergency Department crowding; in addition, it has apparently no negative side effects, considering the boundary of the model created. Conclusion: Causal loop diagramming was a powerful tool for eliciting the systemic structure of Emergency Department crowding in Singapore. Additionally, the developed model was valuable in testing different policy options. PMID:27757231
Lewin, Matthew R
The Emergency Department (ED) may be an ideal place to screen and refer patients for blood pressure monitoring in the outpatient setting. Yet, little is known about the public health significance of asymptomatically elevated blood pressure measurements in the ED and what to tell patients when these abnormal vital signs are recorded. Since the prevalence of hypertension and inadequately treated hypertension is so high, the incidental finding of elevated blood pressure in a previously undiagnosed patient may be a pivotal moment in that patient's life. For those patients carrying the diagnosis of hypertension, it is the author's opinion that the observation of elevated blood pressures should trigger advice to see their physicians to consider medication adjustments or changes. Emergency Physicians and their staff are in a unique position to screen and refer large populations of patients to their community physicians and help abort the long-term sequelae of unidentified or inadequately managed hypertension. How best to advise physicians and their patients requires research and innovative methods for transmitting important information to patients that may be unrelated to their primary complaint in the ED.
Layani, Géraldine; Fleet, Richard; Dallaire, Renée; Tounkara, Fatoumata K.; Poitras, Julien; Archambault, Patrick; Chauny, Jean-Marc; Ouimet, Mathieu; Gauthier, Josée; Dupuis, Gilles; Tanguay, Alain; Lévesque, Jean-Frédéric; Simard-Racine, Geneviève; Haggerty, Jeannie; Légaré, France
Background: Evidence-based indicators of quality of care have been developed to improve care and performance in Canadian emergency departments. The feasibility of measuring these indicators has been assessed mainly in urban and academic emergency departments. We sought to assess the feasibility of measuring quality-of-care indicators in rural emergency departments in Quebec. Methods: We previously identified rural emergency departments in Quebec that offered medical coverage with hospital beds 24 hours a day, 7 days a week and were located in rural areas or small towns as defined by Statistics Canada. A standardized protocol was sent to each emergency department to collect data on 27 validated quality-of-care indicators in 8 categories: duration of stay, patient safety, pain management, pediatrics, cardiology, respiratory care, stroke and sepsis/infection. Data were collected by local professional medical archivists between June and December 2013. Results: Fifteen (58%) of the 26 emergency departments invited to participate completed data collection. The ability to measure the 27 quality-of-care indicators with the use of databases varied across departments. Centres 2, 5, 6 and 13 used databases for at least 21 of the indicators (78%-92%), whereas centres 3, 8, 9, 11, 12 and 15 used databases for 5 (18%) or fewer of the indicators. On average, the centres were able to measure only 41% of the indicators using heterogeneous databases and manual extraction. The 15 centres collected data from 15 different databases or combinations of databases. The average data collection time for each quality-of-care indicator varied from 5 to 88.5 minutes. The median data collection time was 15 minutes or less for most indicators. Interpretation: Quality-of-care indicators were not easily captured with the use of existing databases in rural emergency departments in Quebec. Further work is warranted to improve standardized measurement of these indicators in rural emergency departments
Grigsby, R Kevin; Aber, Robert C; Quillen, David A
Medical schools and teaching hospitals are experiencing more frequent turnover of department chairs. Loss of a department chair creates instability in the department and may have a negative effect on the organization at large. Interim leadership of academic departments is common, and interim chairs are expected to immediately demonstrate skills and leadership abilities. However, little is known about how persons are prepared to assume the interim chair role. Newer competencies for effective leadership include an understanding of the business of medicine, interpersonal and communication skills, the ability to deal with conflict and solve adaptive challenges, and the ability to build and work on teams. Medical schools and teaching hospitals need assistance to meet the unique training and support needs of persons serving as interim leaders. For example, the Association of American Medical Colleges and individual chair societies can develop programs to allow current chairs to reflect on their present positions and plan for the future. Formal leadership training, mentorship opportunities, and conscientious succession planning are good first steps in preparing to meet the needs of academic departments during transitions in leadership. Also, interim leadership experience may be useful as a means for "opening the door" to underrepresented persons, including women, and increasing the diversity of the leadership team.
Kanwar, Rajdeep; Delasobera, Bronson E; Hudson, Korin; Frohna, William
Most spinal cord injuries involve the cervical spine, highlighting the importance of recognition and proper management by emergency physicians. Initial cervical spine injury management should follow the ABCDE (airway, breathing, circulation, disability, exposure) procedure detailed by Advanced Trauma Life Support. NEXUS (National Emergency X-Radiography Utilization Study) criteria and Canadian C-spine Rule are clinical decision-making tools providing guidelines of when to obtain imaging. Computed tomography scans are the preferred initial imaging modality. Consider administering intravenous methylprednisolone after discussion with the neurosurgical consultant in patients who present with spinal cord injuries within 8 hours.
Gavalas, M; Sadana, A; Metcalf, S
An algorithm for the emergency treatment of anaphylaxis is presented. The need for early hands-on involvement of senior personnel is stressed. Continuous assessment, monitoring of response to treatment, and a low threshold for hospital admission for observation and further treatment if necessary are required. PMID:9570048
Fernández, Iván Sánchez; Loddenkemper, Tobias; Datta, Anita; Kothare, Sanjeev; Riviello, James J; Rotenberg, Alexander
This study aimed to identify the indications in which electroencephalography in the pediatric emergency department is most useful. We retrospectively reviewed the influence that the results of the emergent electroencephalogram had on the eventual disposition of patients at our pediatric emergency department. Sixty-eight children (mean age, 7.3 years; 32 males) underwent 70 emergent electroencephalograms. Fifty-seven emergent electroencephalograms were performed for the suspicion of ongoing seizures or status epilepticus. Thirteen of the 22 children (59.1%) discharged from the emergency department were sent home mainly based on the results of the emergent electroencephalogram, which prevented an admission. In particular, 11 of 38 children with frequent and recurrent paroxysmal events concerning for seizures and 2 of 19 children with suspected ongoing status epilepticus were discharged after excluding an epileptic disturbance. The emergent electroencephalogram provided meaningful clinical information that influenced disposition, especially in patients with ongoing events in which the clinical picture was clarified by a rapidly acquired electroencephalogram.
Bitterman, Joan E.
Academic advisors have increasingly been referred to as "resource people" and "change agents." Advisors are now in the business of helping their students reach their full potential. This shift in emphasis is discussed and the future role of advisors is described. (MLW)
Kim, Deborah H; Proctor, Pamela W; Amos, Linda K
Recent changes in the Joint Commission Accrediting Hospital Organization (JCAHO) Environment of Care standards are forcing hospitals to revisit their disaster planning process. Emergency Management, a process that is familiar to municipal and industry planners is now part of hospital disaster planning. A framework for making the necessary changes to the hospital disaster plan is presented. Examples of tools that might be useful in the planning process are also included.
large amount of RBCs and FFP. The length of stay in the ICU was highly variable among the survivors. AKA, above knee amputation; ED, emergency...aortic occlusion be- fore laparotomy can be beneficial in abdominal exsangui- nation. Branney and colleagues15 showed that gunshot wounds to the abdomen...multiple injuries and multiple sources for exsanguination is relatively un- studied in its relation to EDT. EDT followed by aortic occlusion may allow
Cabell, Sonia Q.; Justice, Laura M.; Konold, Timothy R.; McGinty, Anita S.
The purpose of this study was to explore patterns of within-group variability in the emergent literacy skills of preschoolers who are at risk for academic difficulties. We used the person-centered approach of cluster analysis to identify profiles of emergent literacy skills, taking into account both oral language and code-related skills.…
Background Hospital-based Emergency Departments are struggling to provide timely care to a steadily increasing number of unscheduled ED visits. Dwindling compensation and rising ED closures dictate that meeting this challenge demands greater operational efficiency. Methods Using techniques from operations research theory, as well as a novel event-driven algorithm for processing priority queues, we developed a flexible simulation platform for hospital-based EDs. We tuned the parameters of the system to mimic U.S. nationally average and average academic hospital-based ED performance metrics and are able to assess a variety of patient flow outcomes including patient door-to-event times, propensity to leave without being seen, ED occupancy level, and dynamic staffing and resource use. Results The causes of ED crowding are variable and require site-specific solutions. For example, in a nationally average ED environment, provider availability is a surprising, but persistent bottleneck in patient flow. As a result, resources expended in reducing boarding times may not have the expected impact on patient throughput. On the other hand, reallocating resources into alternate care pathways can dramatically expedite care for lower acuity patients without delaying care for higher acuity patients. In an average academic ED environment, bed availability is the primary bottleneck in patient flow. Consequently, adjustments to provider scheduling have a limited effect on the timeliness of care delivery, while shorter boarding times significantly reduce crowding. An online version of the simulation platform is available at http://spark.rstudio.com/klopiano/EDsimulation/. Conclusion In building this robust simulation framework, we have created a novel decision-support tool that ED and hospital managers can use to quantify the impact of proposed changes to patient flow prior to implementation. PMID:24912662
Natali, Jean-Philippe; Schwald, Nathalie; Bach, Frédérique; Bourgouin, Gaëlle; Chiffray, Dominique; Bloch, Frédéric
A geriatric mobile team was created in the emergency department of Cochin Hospital in Paris, in 2005. This key player in the multi-disciplinary management of elderly patients in the emergency department and in the geriatric care pathway, showed, during its 10-year of existence, its utility.
Ilgen, Mark A.; Walton, Maureen A.; Cunningham, Rebecca M.; Barry, Kristen L.; Chermack, Steve T.; De Chavez, Peter; Blow, Frederic C.
The rates and associated features of suicidal ideation among 5,641 patients seeking routine, nonsuicide related care in an inner-city emergency department were examined. Approximately 8% of patients seeking routine care in the emergency department reported some form of suicidal ideation within the past 2 weeks. Suicidal ideation was common in…
... the application of a prudent-layperson standard for payment or coverage of emergency medical services... emergency department. 447.54 Section 447.54 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS PAYMENTS FOR...
methodologies to be used will confirm the accuracy of the solution, displaying the asset on an electronic map that consistently corresponds to a real...patient’s current location to Valley and Meditech for processing and display within the modified Meditech UI. Meditech edit to the RFID # field to...outbound interface to disassociate the RFID tag from the discharged patient. This has been corrected by connecting all the depart patient
Kane, Marlena; Chui, Kristen; Rimicci, Janet; Callagy, Patrice; Hereford, James; Shen, Sam; Norris, Robert; Pickham, David
A multidisciplinary team led by nursing leadership and physicians developed a plan to meet increasing demand and improve the patient experience in the ED without expanding the department's current resources. The approach included Lean tools and engaged frontline staff and physicians. Applying Lean management principles resulted in quicker service, improved patient satisfaction, increased capacity, and reduced resource utilization. Incorporating continuous daily management is necessary for sustainment of continuous improvement activities.
Edlich, Richard F; Winters, Kathryne L; Martin, Marcus L; Long Iii, William B; Werner, Charles L; Gubler, K Dean
The use of powder-free natural rubber or latex-free emergency medical examination gloves is especially important to emergency medical technicians, paramedics, firefighters, and emergency department personnel to avoid eliciting an allergic reaction in the latex sensitized patient. The majority of our emergency medical technicians, paramedics, and firefighters are now wearing powder-free emergency medical examination gloves that comply with the stringent codes and standards established by the National Fire Protection Association (NFPA), while very few hospital emergency department personnel have been provided with NFPA-approved gloves. There are four well-defined goals of this report that will assist emergency medical services, fire departments, and hospitals in the selection and purchase of emergency medical examination gloves. First, we will review again the stringent regulations for emergency medical examination gloves that are outlined by the NFPA. This design and performance standard was devised by the NFPA to address protective clothing for emergency medical operations. The design and performance requirement of the emergency medical examination gloves were described in the NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 1997 Edition. As of September 2003, the emergency medical examination glove must meet the new design and performance requirements of emergency medical examination gloves discussed in NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 2003 Edition.
Tan, Mei Fen; Lopez, Violeta; Cleary, Michelle
In Singapore, anecdotal evidence suggests that nurses are concerned about managing aggressive incidents in the emergency department. In this study, registered nurses' perceptions of managing aggressive patients in an emergency department were explored. Ten registered nurses from the emergency department of an acute public hospital in Singapore were interviewed. Four overarching themes emerged from the thematic analysis: (i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing management of aggressive behaviors; and (iv) organizational support and responsiveness. Further research is required to better support nurses to deliver optimal care for aggressive patients and achieve positive and effective outcomes.
Kazzi, Ziad; Buzzell, Jennifer; Bertelli, Luiz; Christensen, Doran
After a radiation emergency that involves the dispersal of radioactive material, patients can become externally and internally contaminated with one or more radionuclides. Internal contamination can lead to the delivery of harmful ionizing radiation doses to various organs and tissues or the whole body. The clinical consequences can range from acute radiation syndrome (ARS) to the long term development of cancer. Estimating the amount of radioactive material absorbed into the body can guide the management of patients. Treatment includes, in addition to supportive care and long term monitoring, certain medical countermeasures like Prussian blue, Calcium DTPA and Zinc DTPA.
Ling, Catherine; Johnson, Heather
The life of a military child has several challenges that can provide opportunities for resilience or risk for vulnerability. Nurses in emergent/urgent care may encounter military children when they are in a stressful transition such as during a move or deployment. Understanding the unique lifestyle of military children and implementing some key suggestions for practice can improve outcomes for this population. This article highlights the exceptional context of military children, military transitions, and opportunities to recognize families who are at risk and strategies to reach out using the I CARE (identify, correlate, ask, ready resources, and encourage) framework.
Rosen, Joshua B.; Olson, Mark H.; Kelly, Marianne
Objective: The authors examined the impact of a collegiate-based emergency medical service (CBEMS) on the frequency of emergency department (ED) transports. Participants: Students transported to the ED for acute alcohol intoxication during the Fall 2008 and the Fall 2009 semesters (N = 50). Methods: The frequency of students receiving…
Ñamendys-Silva, Silvio A; Arredondo-Armenta, Juan M; Plata-Menchaca, Erika P; Guevara-García, Humberto; García-Guillén, Francisco J; Rivero-Sigarroa, Eduardo; Herrera-Gómez, Angel
Tumor lysis syndrome (TLS) is the most common oncologic emergency. It is caused by rapid tumor cell destruction and the resulting nucleic acid degradation during or days after initiation of cytotoxic therapy. Also, a spontaneous form exists. The metabolic abnormalities associated with this syndrome include hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and acute kidney injury. These abnormalities can lead to life-threatening complications, such as heart rhythm abnormalities and neurologic manifestations. The emergency management of overt TLS involves proper fluid resuscitation with crystalloids in order to improve the intravascular volume and the urinary output and to increase the renal excretion of potassium, phosphorus, and uric acid. With this therapeutic strategy, prevention of calcium phosphate and uric acid crystal deposition within renal tubules is achieved. Other measures in the management of overt TLS are prescription of hypouricemic agents, renal replacement therapy, and correction of electrolyte imbalances. Hyperkalemia should be treated quickly and aggressively as its presence is the most hazardous acute complication that can cause sudden death from cardiac arrhythmias. Treatment of hypocalcemia is reserved for patients with electrocardiographic changes or symptoms of neuromuscular irritability. In patients who are refractory to medical management of electrolyte abnormalities or with severe cardiac and neurologic manifestations, early dialysis is recommended. PMID:27147889
Westafer, Lauren; Hensley, Justin; Shaikh, Sameed; Lin, Michelle
Annals of Emergency Medicine collaborated with an educational Web site, Academic Life in Emergency Medicine (ALiEM), to host a public discussion featuring the 2014 Annals article on the association between Press Ganey scores and emergency department (ED) analgesia by Schwartz et al. The objective was to curate a 14-day (December 1 through 14, 2014) worldwide academic dialogue among clinicians in regard to preselected questions about the article. Five online facilitators hosted the multimodal discussion on the ALiEM Web site, Twitter, and Google Hangout. Comments across the social media platforms were curated for this report, as framed by the 4 preselected questions. Engagement was tracked through Web analytic tools and analysis of tweets. Blog comments, tweets, and video expert commentary involving the featured article are summarized and reported. The dialogue resulted in 978 page views from 342 cities in 33 countries on the ALiEM Web site, 464,345 Twitter impressions, and 83 views of the video interview with experts. Of the unique 169 identified tweets, discussion (53.3%) and learning points (32.5%) were the most common category of tweets identified. Common themes that arose in the open-access multimedia discussions included Press Ganey data validity and the utility of patient satisfaction in determining pain treatment efficacy. This educational approach using social media technologies demonstrates a free, asynchronous means to engage a worldwide scholarly discourse.
Bosmia, Anand N.; Quinn, James F.; Peterson, Todd B.; Griessenauer, Christoph J.; Tubbs, R. Shane
Outlaw motorcycle gangs (OMGs) are an iconic element of the criminal landscape in the United States, the country of their origin. Members of OMGs may present to the emergency department (ED) as a result of motor vehicle accidents or interpersonal violence. When one member of an OMG is injured, other members and associates are likely to arrive in the ED to support the injured member. The extant literature for ED personnel lacks an overview of the culture of OMGs, a culture that promotes the display of unique symbols and that holds certain paraphernalia as integral to an outlaw biker’s identity and pride. The objective of this manuscript is to discuss various aspects of the culture of OMGs so that ED personnel may better understand the mentality of the outlaw biker. Knowledge of their symbols, values, and hierarchy can be crucial to maintaining order in the ED when an injured outlaw biker presents to the ED. We used standard search engines to obtain reports from law enforcement agencies and studies in academic journals on OMGs. We present the observations of 1 author who has conducted ethnographic research on outlaw bikers since the 1980s. PMID:25035762
Bosmia, Anand N; Quinn, James F; Peterson, Todd B; Griessenauer, Christoph J; Tubbs, R Shane
Outlaw motorcycle gangs (OMGs) are an iconic element of the criminal landscape in the United States, the country of their origin. Members of OMGs may present to the emergency department (ED) as a result of motor vehicle accidents or interpersonal violence. When one member of an OMG is injured, other members and associates are likely to arrive in the ED to support the injured member. The extant literature for ED personnel lacks an overview of the culture of OMGs, a culture that promotes the display of unique symbols and that holds certain paraphernalia as integral to an outlaw biker's identity and pride. The objective of this manuscript is to discuss various aspects of the culture of OMGs so that ED personnel may better understand the mentality of the outlaw biker. Knowledge of their symbols, values, and hierarchy can be crucial to maintaining order in the ED when an injured outlaw biker presents to the ED. We used standard search engines to obtain reports from law enforcement agencies and studies in academic journals on OMGs. We present the observations of 1 author who has conducted ethnographic research on outlaw bikers since the 1980s.
Okafor, Nnaemeka G.; Doshi, Pratik B.; Miller, Sara K.; McCarthy, James J.; Hoot, Nathan R.; Darger, Bryan F.; Benitez, Roberto C.; Chathampally, Yashwant G.
Introduction Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remediation, is essential for continuous quality improvement. The emergency department (ED) is recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design and implementation of a web-based ED-specific incident reporting system using an iterative process. Methods A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. Results The utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers reported 24% and 16% respectively. The most commonly reported incidents were delays in care and management concerns. Conclusion Error reporting frequency can be dramatically improved by using a web-based, user-friendly, voluntary, and non-punitive reporting system. PMID:26759657
The Jehovah's Witnesses Society is best known to outsiders for its refusal of blood products, even when such a refusal may result in death. Since the introduction of the blood ban in 1945, Jehovah's Witness (JW) parents have fought for their rights to refuse blood on behalf of their children, based on religious beliefs and their right to raise children as they see fit. Adolescent JWs have also sought to refuse blood products based on their beliefs, regardless of the views of their parents. Adult JWs have fought to protect their autonomy when making both contemporaneous and advance treatment refusal. The refusal of blood products by JWs raises ethical and legal dilemmas that are not easily answered. Do an individual's rights (namely bodily control, right to privacy, right to decide about life/death issues, right to religious freedom) outweigh society's rights (namely the preservation of life, the prevention of suicide, the protection of innocent third parties, and the maintenance of the ethical integrity of the medical profession)? Does the right to choose outweigh the value of human life? For doctors, conflict occurs between the desire to respect patient autonomy and the need to provide good medical care. The Watchtower Society (the JW governing body) imposes a strict code of moral standards among its members, and it is unlikely that individual JWs are making truly autonomous decisions about blood transfusions. While young children and adolescents are protected by the courts and conscious adults are afforded autonomy, dilemmas still arise in the emergency situation. This article examines the rights of young children, adolescents, and adults, focusing in the latter half on adults in the emergency situation.
Swanson, Joan Ann; Walker, Erica
Emerging adult college students have developmental and educational needs which are unique to their phase of life. Emerging adults are also increasingly identified by their technology use and practices. Collegiate instructors will be better equipped for educating these individuals when armed with insights concerning emerging adults' technology…
Woolard, Robert; Degutis, Linda C; Mello, Michael; Rothman, Richard; Cherpitel, Cheryl J; Post, Lori A; Hirshon, Jon Mark; Haukoos, Jason S; Hungerford, Daniel W
This article summarizes the work and discussions of the funding and sustainability work group at the 2009 Academic Emergency Medicine consensus conference "Public Health in the ED: Surveillance, Screening, and Intervention." The funding and sustainability session participants were asked to address the following overarching question: "What are the opportunities and what is needed to encourage academic emergency medicine (EM) to take advantage of the opportunities for funding available for public health research initiatives and build stronger academic programs focusing on public health within EM?" Prior to the session, members of the group reviewed research funding for EM in public health, as well as the priorities of federal agencies and foundations. Recommendations for actions by EM summarize the findings of workshop.
... academic department makes a commitment to a fellow at any point in his or her graduate study for the length of time necessary for the fellow to complete the course of graduate study, but in no case longer...
Shah, Kaushal H; Slovis, Benjamin H; Runde, Dan; Godbout, Brandon; Newman, David H; Lee, Jarone
The risk of cancer from computed tomography (CT) scan radiation is a rising concern in the medical field. Our objectives were to determine how many patients received more than ten CT scans in an academic emergency department (ED) over the course of 7 years and to quantify their radiation exposure and lifetime attributable risk of cancer. An electronic chart review was performed at our urban academic institution with an annual census of 110,000 patients. All patients who underwent a CT scan performed during ED management between the dates of January 2001 and December 2007 were identified. Specific predetermined data elements (e.g., subject demographics, type of CT scan) were extracted by two researchers blinded to hypothesis, using a preformatted data form. After identifying patients with more than ten CTs performed during the study period, radiation exposure was calculated based on accepted and reported radiation doses for the respective anatomic CTs, and lifetime attributable cancer risk was calculated based on the seventh report of the Biological Effects of Ionizing Radiation (BEIR VII) projections. Over the 7-year study period, 24,393 patients received 34,671 CT scans. The vast majority of patients (17,909) received a single CT. Twenty-six (0.1 %) patients received more than ten CTs totaling 374 scans with an average radiation exposure of 83.4 mSv. The maximum lifetime attributable risk for any individual in this cohort was 1.7 % above the baseline cancer risk. Among those undergoing CT imaging in our ED, high-exposure patients (greater than ten scans) constituted a significant minority, while more than one in four patients underwent more than one CT scan during the study period. While the presumed overall risk of radiation-induced cancer continues to be low, it is important for the emergency physician to use clinical knowledge as well as concern for the patient when utilizing radiographic imaging. Increasing attributable cancer risk may have important
FitzGerald, Michael; Mallory, Mia; Mittiga, Matthew; Schubert, Charles; Schwartz, Hamilton; Gonzalez, Javier; Duma, Elena; McAneney, Constance
Background The importance and benefits of direct observation in residency training have been underscored by a number of studies. Yet, implementing direct observation in an effective and sustainable way is hampered by demands on physicians' time and shrinking resources for educational innovation. Objective To describe the development and pilot implementation of a direct observation tool to assess the history and physical examination skills of interns in a pediatric emergency department rotation. Methods A task force developed specific history and physical examination checklists for a range of common conditions. For the pilot implementation, 10 pediatric emergency medicine faculty attendings conducted the initial observations of 34 interns during the course of 1 academic year. At the conclusion of the pilot, the faculty observers and interns were interviewed to assess the feasibility and benefits of the process. Results A total of 33 of the 34 interns were observed during their rotation, with 26 of the observations conducted when the faculty observer was off shift, and it took approximately 20 minutes to complete each observation. In terms of learning benefits, interns and faculty observers reported that it facilitated clear and useful feedback and revealed gaps that would not have otherwise been identified. Faculty observers also mentioned that it helped them focus their teaching effort, built empathy with learners, and gave them a way to demonstrate a true concern for their learning. Conclusion Our results offer evidence for the feasibility and benefits of the direct observation checklists. The description of the implementation, challenges, and response to those challenges may help others avoid some of the common problems faced when implementing direct observation methods. PMID:24294433
Heinert, Sara; Carter, Julius; Mauntel-Medici, Cammeo; Lin, Janet
Routine opt-out HIV screening is recommended for everyone between 13 and 64 years of age. An urban, academic emergency department implemented a nurse-driven routine opt-out HIV screening program. The aim of our study was to assess program uptake and opportunities to improve the program from the perspectives of emergency nurses. Emergency nurses completed a brief prediscussion questionnaire and then participated in a focus group or semi-structured one-on-one interview to elicit feedback on the routine opt-out HIV screening program. All 16 participants felt adequately prepared for the screening program. Several themes emerged from the discussions, including challenges of specific patient characteristics and overall nurse and patient support for the program. One thread across themes was the importance of good language and communication skills in such programs. While there are opportunities to improve nurse-driven routine opt-out HIV testing programs in emergency settings, this program was found to be accepted by emergency nurses.
Kiang, Lisa; Supple, Andrew J; Stein, Gabriela L; Gonzalez, Laura M
Research on the academic adjustment of immigrant adolescents has been predominately conducted in large cities among established migration areas. To broaden the field's restricted focus, data from 172 (58% female) Asian American adolescents who reside within a non-traditional or emerging immigrant community in the Southeastern US were used to examine gender differences in academic adjustment as well as school, family, and cultural variables as potential mediators of gender differences found. Results suggest that girls report significantly higher educational goals, intrinsic academic motivation, and utility value of school compared to boys. These gender differences are statistically mediated by ethnic exploration and family processes, most prominently, family respect. School connectedness and perceived discrimination are also associated with academic adjustment at the bivariate level, suggesting that academic success may be best promoted if multiple domains of influence can be targeted.
The United States Department of Energy (DOE) Region 6 Transportation Emergency Preparedness Program Plan (TEPP Plan) operates within the framework of the DOE emergency management system for developing, coordinating, and directing emergency planning, preparedness, and readiness assurance activities for radiological transportation incidents. The DOE Region 6 TEPP Plan is a narrative description of the DOE Transportation Emergency Preparedness Program activities, training and technical assistance provided to states and tribes along DOE's transportation corridors in DOE Region 6.
Janz, Timothy G; Johnson, Roy L; Rubenstein, Scott D
Anemia is a common worldwide problem that is associated with nonspecific complaints. The initial focus for the emergency evaluation of anemia is to determine whether the problem is acute or chronic. Acute anemia is most commonly associated with blood loss, and the patient is usually symptomatic. Chronic anemia is usually well tolerated and is often discovered coincidentally. Once diagnosed, the etiology of anemia can often be determined by applying a systematic approach to its evaluation. The severity of the anemia impacts clinical outcomes, particularly in critically ill patients; however, the specific threshold to transfuse is uncertain. Evaluation of the current literature and clinical guidelines does not settle this controversy, but it does help clarify that a restrictive transfusion strategy (ie, for patients with a hemoglobin < 6-8 g/dL) is associated with better outcomes than a more liberal transfusion strategy. Certain anemias may have well-defined treatment options (eg, sickle cell disease), but empiric use of nutritional supplements to treat anemia of uncertain etiology is discouraged.
Hausfater, Pierre; Juillien, Gaëlle; Madonna-Py, Beatrice; Haroche, Julien; Bernard, Maguy; Riou, Bruno
Introduction Identification of bacterial infections is crucial if treatment is to be initiated early and antibiotics used rationally. The primary objective of this study was to test the efficiency of procalcitonin (PCT) in identifying bacterial/parasitic episodes among febrile adult patients presenting to an emergency department. Secondary objectives were to identify clinical or biological variables associated with either bacterial/parasitic infection or critical illness. Methods This was a prospective, single centre, non-interventional study, conducted in the adult emergency department of an academic tertiary care hospital. We included patients with body temperature of 38.5°C or greater. A serum sample for measurement of PCT was collected in the emergency room. Patients were followed up until day 30. After reviewing the medical files, two independent experts, who were blind to the PCT results, classified each of the patients as having a bacterial/parasitic infection, viral infection, or another diagnosis. Results Among 243 patients included in the study, 167 had bacterial/parasitic infections, 35 had viral infections and 41 had other diagnoses. The PCT assay, with a 0.2 μg/l cutoff value, had a sensitivity of 0.77 and a specificity of 0.59 in diagnosing bacterial/parasitic infection. Of the patients with PCT 5 μg/l or greater, 51% had critical illness (death or intensive care unit admission) as compared with 13% of patients with lower PCT values. Conclusion Bearing in mind the limitations of an observational study design, the judgements of the emergency department physicians were reasonably accurate in determining the pretest probability of bacterial/parasitic infection. PCT may provide additional, valuable information on the aetiology and prognosis of infection in the emergency department. PMID:17521430
Weinick, Robin M; Burns, Rachel M; Mehrotra, Ateev
Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7-27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually. The primary conditions that could be treated at these sites include minor acute illnesses, strains, and fractures. There is some evidence that patients can safely direct themselves to these alternative sites. However, more research is needed to ensure that care of equivalent quality is provided at urgent care centers and retail clinics compared to emergency departments.
Mahmoodian, Farzad; Eqtesadi, Razie; Ghareghani, Atefe
Background: Hospital emergency departments (EDs) are as barometers of the health care system. Crowded EDs threaten delivery of timely care. Prolonged ED wait times reduce the quality of care and increase adverse and sometimes irreversible events. Objectives: The purpose of this study was to determine the patients' waiting time at Namazi and Shahid Faghihi hospitals in Shiraz, Iran. Patients and Methods: This analytical cross-sectional study was conducted in two phases from December 2012 to May 2013. First, the researcher attended the EDs of the two hospitals and recorded the information of 900 patients who entered the ED, including arrival time, level of triage, and time of first visit by physician. Then, among patients admitted to the ED units, 273 were followed and waiting times for the first physician order in the referral unit and the commencement of clinical interventions (defined as check time by the nurse) were recorded. Results: The median waiting time from arrival to first visit by physician for the 900 patients included in the study was 8 (5-14) minutes [median (interquartile range)]. For the patients admitted to referral units, waiting time was 84 (43-145) minutes for the physician order and 85 (45-147) minutes for the commencement of first clinical intervention; 75% of the patients in triage level I, 84.6% in triage level II, and 95.6% in triage level III were visited within the target time limit. Conclusions: Waiting time for commencement of clinical action in patients admitted to the EDs was considerably high for patients with higher priorities; so, rapid care of critically ill patients, identified during the triage process, should be emphasized. PMID:25738132
Croft, Damien J
Maternity care in Philadelphia is in an unprecedented and precarious situation, as all the community hospitals that once provided maternity care services have either closed completely or stopped providing maternity services. Six academic medical centers (AMCs) in the city of Philadelphia now provide care to a population of 1.5 million requiring increasingly complex and expensive maternity care, at the same time as insurance premiums and the malpractice crisis in Pennsylvania peaked. The AMCs are able to continue providing maternity care to this population that includes a large proportion of poor, minority, and un- or underinsured patients thanks to government subsidization of resident education, the services provided by resident physicians, and the influx of government and industry research funds, but the financial outlook of academic obstetrics-gynecology departments in this city is dire. Obstetric academic medicine in Philadelphia has come to more closely resemble a "big wheel" tricycle than Flexner's "three-legged stool." Clinical medicine is the driver (the large front wheel and pedal) pulling along education and research, the two smaller wheels in the back. A maternity care alliance is needed in Philadelphia allowing area AMCs to pool and trade resources, reduce costs, improve quality and innovation, and share risks. Philadelphia may serve as an early warning for other cities and AMCs around the country and has the opportunity to serve as a model for how to overcome these serious challenges.
Waugh, Jeff L
The objective of residency training is to produce physicians who can function independently within their chosen subspecialty and practice environment. Skills in the business of medicine, such as clinical billing, are widely applicable in academic and private practices but are not commonly addressed during formal medical education. Residency and fellowship training include limited exposure to medical billing, but our academic department's performance of these skills was inadequate: in 56% of trainee-generated outpatient notes, documentation was insufficient to sustain the chosen billing level. We developed a curriculum to improve the accuracy of documentation and coding and introduced practice changes to address our largest sources of error. In parallel, we developed tools that increased the speed and efficiency of documentation. Over 15 months, we progressively eliminated note devaluation, increased the mean level billed by trainees to nearly match that of attending physicians, and increased outpatient revenue by $34,313/trainee/year. Our experience suggests that inclusion of billing education topics into the formal medical curriculum benefits both academic medical centers and trainees.
Ham, Nathan J.; Blankenship, Dennis E.; Payton, Mark E.; Murray, Kelly A.
Longitudinal time-based emergency department (ED) performance measures were quantified 12 months before and 12 months after (March 2012–February 2014) implementation of a Meditech 6.0® electronic health record (EHR) at a single urban academic ED. Data assessed were length of stay from door to door, door to admission, door to bed, bed to provider, provider to disposition, and disposition to admission, as well as number of patients leaving against medical advice and number of patients leaving without being seen. Analysis of variance was used to compare levels before and after EHR implementation for each variable, with adjustments made for the number of admissions, transfers, and month. No difference was seen in monthly volume, admissions, or transfers. Implementation of an EHR resulted in a sustained increase in ED time metrics for mean length of stay and times from door to door, door to admission, door to bed, and provider to disposition. Decreased ED time metrics were seen in bed-to-provider and disposition-to-admit times. The number of patients who left against medical advice increased after implementation, but the number of patients who left without being seen was not significantly different. Thus, EHR implementation was associated with an increase in time with most performance metrics. Although general times trended back to near preimplementation baselines, most ED time metrics remained elevated beyond the study length of 12 months. Understanding the impact of EHR system implementation on the overall performance of an ED can help departments prepare for potential adverse effects of such systems on overall efficiency.
Rosenblatt, R A; Wright, G E; Baldwin, L M; Chan, L; Clitherow, P; Chen, F M; Hart, L G
OBJECTIVES: This study sought to determine the rate of emergency department use among the elderly and examined whether that use is reduced if the patient has a principal-care physician. METHODS: The Health Care Financing Administration's National Claims History File was used to study emergency department use by Medicare patients older than 65 years in Washington State during 1994. RESULTS: A total of 18.1% of patients had 1 or more emergency department visits during the study year; the rate increased with age and illness severity. Patients with principal-care physicians were much less likely to use the emergency department for every category of disease severity. After case mix, Medicaid eligibility, and rural/urban residence were controlled for, the odds ratio for having any emergency department visit was 0.47 for patients with a generalist principal-care physician and 0.58 for patients with a specialist principal-care physician. CONCLUSIONS: The rate of emergency department use among the elderly is substantial, and most visits are for serious medical problems. The presence of a continuous relationship with a physician--regardless of specialty--may reduce emergency department use. PMID:10630144
Lyons, Rachel; Reinisch, Courtney
Social media is a growing and popular means of communication. It is understandable that health care providers may not share identifying information on patients through these sources. Challenges arise when patients and family members wish to record the care provided in the emergency department. The health care provider may be faced with an ethical and possibly legal dilemma when social media is present in the emergency department. This article seeks to discuss the legal and ethical principles surrounding social media in the emergency department.
Källberg, Ann-Sofie; Ehrenberg, Anna; Florin, Jan; Östergren, Jan; Göransson, Katarina E
The emergency department has been described as a high-risk area for errors. It is also known that working conditions such as a high workload and shortage off staff in the healthcare field are common factors that negatively affect patient safety. A limited amount of research has been conducted with regard to patient safety in Swedish emergency departments. Additionally, there is a lack of knowledge about clinicians' perceptions of patient safety risks. Therefore, the purpose of this study was to describe emergency department clinicians' experiences with regard to patient safety risks.
Lim, Magdalen; Weiland, Tracey; Gerdtz, Marie; Dent, Andrew
Objective. We explored perspectives of emergency department users (patients and visitors) regarding the management of acute behavioural disturbances in the emergency department and whether these disturbances influenced their levels of anxiety. Methods. Emergency department patients and visitors were surveyed using the State-Trait Anxiety Inventory, and a purpose-designed questionnaire and semistructured interview. The main outcome measures were themes that emerged from the questionnaires, the interviews, and scores from the state component of the State-Trait Anxiety Inventory. Results. 70 participants were recruited. Users of the emergency department preferred behaviourally disturbed people be managed in a separate area from the general emergency department population so that the disturbance was inaudible (n = 32) and out of view (n = 40). The state anxiety levels of those that witnessed an acute behavioural disturbance were within the normal range and did not differ to that of ED patients that were not present during such a disturbance (median, control = 37, Code Grey = 33). Conclusions. Behavioural disturbances in the emergency department do not provoke anxiety in other users. However, there is a preference that such disturbances be managed out of visual and audible range. Innovative design features may be required to achieve this. PMID:22046537
Cox, Mougnyan; Hansberry, David; Balasubramanya, Rashmi; Li, Zhengteng; Gandhe, Ashish; Selvarajan, Santosh; Sharma, Pranshu
Interest in emergency radiology as a distinct subspecialty within radiology continues to rise in the USA and globally. While acute care imaging has been performed since the earliest days of the specialty, fellowship training in emergency radiology is a relatively new phenomenon. The purpose of this study was to examine the current status of emergency radiology training in the USA, using data derived from the official websites of US residency training programs. The most current list of radiology residency programs participating in the 2017 match was obtained from the official Electronic Residency Application Service (ERAS) website. The total number of emergency radiology fellowships was recorded after visiting available websites of each academic radiology program. The total number of subspecialty fellowships offered by each academic radiology program was also recorded. There were 12 confirmed emergency radiology fellowships offered in the USA for a combined total of 22 fellowship positions. Eleven programs were 1 year in duration, with one program offering a one- or two-year option. One hundred eight of the 174 (approximately 62 %) surveyed academic radiology programs offered at least one subspecialty fellowship. Emergency radiology fellowships are on the rise, paralleling the growth of emergency radiology as a distinct subspecialty within radiology.
Johnson, Diana; Snedeker, Kristie; Swoboda, Michael; Zalieckas, Cheryl; Dorsey, Rachel; Nohe, Cassandra; Smith, Paige; Roche, Renuka
The Department of Rehabilitation Services, within the University of Maryland Medical Center's 650-bed academic medical center, was experiencing difficulty in meeting productivity standards. Therapists in the outpatient division believed they were not spending enough time performing billable patient care activities. Therapists in the inpatient division had difficulty keeping pace with the volume of incoming referrals. Collectively, these issues caused dissatisfaction among referral sources and frustration among the staff within the rehabilitation department. The department undertook a phased approach to address these issues that included examining the evidence, using Lean process improvement principles, and employing transformational leadership strategies to drive improvements in productivity and efficiency. The lessons learned support the importance of having meaningful metrics appropriate for the patient population served, the use of Lean as an effective tool for improving productivity in rehabilitation departments, the impact of engaging staff at the grassroots level, and the importance of having commitment from leaders. The study findings have implications for not only rehabilitation and hospital leadership, but CEOs and managers of any business who need to eliminate waste or increase staff productivity.
Peek, Monica E.; Kim, Karen E.; Johnson, Julie K.; Vela, Monica B.
Purpose There is little evidence regarding which factors and strategies are associated with high proportions of underrepresented minority (URM) faculty in academic medicine. The authors conducted a national study of U.S. academic medicine departments to better understand the challenges, successful strategies, and predictive factors for enhancing racial and ethnic diversity among faculty (i.e., physicians with an academic position or rank). Method This was a mixed-methods study using quantitative and qualitative methods. The authors conducted a cross-sectional study of eligible departments of medicine in 125 accredited U.S. medical schools, dichotomized into low-URM (bottom 50%) versus high-URM rank (top 50%). They used t tests and chi-squared tests to compare departments by geographic region, academic school rank, city type, and composite measures of “diversity best practices.” The authors also conducted semistructured in-depth interviews with a subsample from the highest-and lowest-quartile medical schools in terms of URM rank. Results Eighty-two medical schools responded (66%). Geographic region and academic rank were statistically associated with URM rank, but not city type or composite measures of diversity best practices. Key themes emerged from interviews regarding successful strategies for URM faculty recruitment and retention including institutional leadership, the use of human capital and social relationships and strategic deployment of institutional resources. Conclusions Departments of medicine with high proportions of URM faculty employ a number of successful strategies and programs for recruitment and retention. More research is warranted to identify new successful strategies and to determine the impact of specific strategies on establishing and maintaining workforce diversity. PMID:23348090
Vandenberg, Ann E; Stevens, Melissa; Echt, Katharina V; Hastings, S Nicole; Powers, James; Markland, Alayne; Hwang, Ula; Hung, William; Belbis, Stephanie; Vaughan, Camille P
The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUiPPED) program aimed to reduce potentially inappropriate medication prescribing to older adults at 5 VAMCs.
Gillespie, Gordon Lee; Pekar, Bunnany; Byczkowski, Terri L; Fisher, Bonnie S
Workplace violence committed by patients and visitors has high propensity to occur against emergency department employees. This article reports the association of worker, workplace, and community/environmental factors with violence risks. A cross-sectional research design was used with 280 employees from six emergency departments in the Midwest United States. Respondents completed the Survey of Violence Experienced by Staff and a 10-item demographic questionnaire. Data were analyzed using frequencies, percentages, Chi-square tests, and adjusted relative risks with 95% confidence intervals. Over 80% of respondents experienced at least one type of workplace violence with their current employer and approximately 40% experienced all three types. Risks for workplace violence were significantly higher for registered nurses and hospital-based emergency departments. Workplace violence can impact all employees in the emergency department regardless of worker, workplace, and community/environmental factors.
O'Malley, Ann S; Gerland, Anneliese M; Pham, Hoangmai H; Berenson, Robert A
Pressures--ranging from persuading specialists to provide on-call coverage to dealing with growing numbers of patients with serious mental illness--are building in already-crowded hospital emergency departments (EDs) across the country, according to findings from the Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. As the number of ED visits rises significantly faster than population growth, many hospitals are expanding emergency department capacity. At the same time, hospitals face an ongoing nursing shortage, contributing to tight inpatient capacity that in turn hinders admitting ED patients. In their role as hospitals' "front door" for attracting insured inpatient admissions, emergency departments also increasingly are expected to help hospitals compete for insured patients while still meeting obligations to provide emergency care to all-comers under federal law. Failure to address these growing pressures may compromise access to emergency care for patients and spur already rapidly rising health care costs.
Hecht, Irene W. D.; Higgerson, Mary Lou; Gmelch, Walter H.; Tucker, Allan
This book provides a comprehensive guide to the role of the academic department chair in a time when the chair's role is rapidly becoming more important and more complex. Part 1 describes the new roles chairs face, followed by a general discussion of their responsibilities. Part 2 is concerned with the department chair's work with people,…
Keegan, Joshua; Wira, Charles R
Severe sepsis and septic shock have great relevance to Emergency Medicine physicians because of their high prevalence, morbidity, and mortality. Treatment is time-sensitive, depends on early identification risk stratification, and has the potential to significantly improve patient outcomes. In this article, we review the pathophysiology of, and evidence basis for, the emergency department management of severe sepsis and septic shock.
Kunisch, Joseph Martin
Background: The Emergency Severity Index (ESI) is an emergency department (ED) triage classification system based on estimated patient-specific resource utilization. Rules for a computerized clinical decision support (CDS) system based on a patient's chief complaint were developed and tested using a stochastic model for predicting ESI scores.…
... Management Agency--011 Training and Exercise Program Records System of Records AGENCY: Privacy Office, DHS... titled, ``Department of Homeland Security Federal Emergency Management Agency--011 Training and Exercise.../Federal Emergency Management Agency to collect and maintain records on its training and exercise...
Jones, Courtney M C; Wasserman, Erin B; Li, Timmy; Amidon, Ashley; Abbott, Marissa; Shah, Manish N
Introduction Previous studies have found that older adults are more likely to use Emergency Medical Services (EMS) than younger adults, but the reasons for this remain understudied. Hypothesis/Problem This study aimed to determine if older age is associated with using EMS for transportation to an emergency department (ED) after controlling for confounding variables.
Mohr, Nicholas M.; Moreno-Walton, Lisa; Mills, Angela M.; Brunett, Patrick H.; Promes, Susan B.
For the first time in history, four generations are working together – Traditionalists, Baby Boomers, Generation Xers, and Millennials. Members of each generation carry with them a unique perspective of the world and interact differently with those around them. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine (SAEM) Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic emergency medicine (EM). Understanding generational characteristics and mitigating strategies can help address some common issues encountered in academic EM. Through recognition of the unique characteristics of each of the generations with respect to teaching and learning, mentoring, and technology, academicians have the opportunity to strategically optimize interactions with one another. PMID:21314779
Mohr, Nicholas M; Moreno-Walton, Lisa; Mills, Angela M; Brunett, Patrick H; Promes, Susan B
For the first time in history, four generations are working together-traditionalists, baby boomers, generation Xers (Gen Xers), and millennials. Members of each generation carry with them a unique perspective of the world and interact differently with those around them. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic emergency medicine (EM). Understanding generational characteristics and mitigating strategies can help address some common issues encountered in academic EM. Through recognition of the unique characteristics of each of the generations with respect to teaching and learning, mentoring, and technology, academicians have the opportunity to strategically optimize interactions with one another.
Boughey, Chrissie; Niven, Penny
This paper uses an analytical framework developed from the work of philosopher Roy Bhaskar and sociologist Margaret Archer to explore the emergence of a body of research on teaching and learning in South African higher education. This research, generated in a field known as "Academic Development" in South Africa and as "Educational…
Kiang, Lisa; Supple, Andrew J.; Stein, Gabriela L.; Gonzalez, Laura M.
Research on the academic adjustment of immigrant adolescents has been predominately conducted in large cities among established migration areas. To broaden the field's restricted focus, data from 172 (58% female) Asian American adolescents who reside within a non-traditional or emerging immigrant community in the Southeastern US were used to…
This paper contributes to the discussion about the marketisation of universities by providing a historical perspective. Going back to the time when the market for academic knowledge emerged, I argue that it was created through incorporating a number of inherent tensions that have been, and still are, shaping its development. I show how these…
This commentary explores the role that academic developers (ADs) play in universities. Three case studies illustrate the roles that ADs may enact as agents of change. They reflect an emergent shift from acting as the institutional teaching and learning "'expert" (i.e. agent of change) to a more adaptive, collaborative partnership model…
Hytönen, Kaisa; Palonen, Tuire; Lehtinen, Erno; Hakkarainen, Kai
This article examines a new training design for continuing professional development that aims to support the learning of the novel knowledge and skills needed in emerging professional fields by interconnecting academic and workplace settings. The training design is based on using two advisors, one from working life and the other from an academic…
Rezende, Ederlon; Junior, João Manoel Silva; Isola, Alexandre Marine; Campos, Edvaldo Vieira; Amendola, Cristina Prata; Almeida, Samantha Longhi
BACKGROUND The aim of this study was to determine the occurrence rate, demographics, clinical characteristics, and outcomes of patients with severe sepsis admitted to the emergency department. METHODS A prospective study evaluating all patients admitted to the emergency department unit in a public hospital of tertiary complexity in a six-month period was conducted. During this period, the emergency team was trained to diagnose sepsis. Patients who met the diagnostic criteria for severe sepsis were followed until their discharge from the hospital. RESULTS A total of 5,332 patients were admitted to the emergency department, and 342 met the criteria for severe sepsis/septic shock. The median (interquartile range) age of patients was 74 (65–84) years, and 52.1% were male. The median APACHE II and SOFA scores at diagnosis were 19 (15–25) and 5 (3–7), respectively. The median number of dysfunctional organ systems per patient was 2 (1–3). The median hospital length of stay was 10 (4.7–17) days, and the hospital mortality rate was 64%. Only 31% of the patients were diagnosed by the emergency department team as septic. About 33.5% of the 342 severe sepsis patients admitted to the emergency department were referred to an ICU, with a median time delay of 24 (12–48) hours. Training improved diagnosis and decreased the time delay for septic patients in arriving at the ICU. CONCLUSIONS The occurrence rate of severe sepsis in the emergency department was 6.4%, and the rate of sepsis diagnosed by the emergency department team as well as the number of patients transferred to the ICU was very low. Educational campaigns are important to improve diagnosis and, hence, treatment of severe sepsis. PMID:18719755
Harvey, Richard P
Based on anecdotal evidence and networking with colleagues at other facilities, it has become evident that some radiation safety departments are not adequately staffed and radiation safety professionals need to increase their staffing levels. Discussions with management regarding radiation safety department staffing often lead to similar conclusions. Management acknowledges the Radiation Safety Officer (RSO) or Director of Radiation Safety's concern but asks the RSO to provide benchmarking and justification for additional full-time equivalents (FTEs). The RSO must determine a method to benchmark and justify additional staffing needs while struggling to maintain a safe and compliant radiation safety program. Benchmarking and justification are extremely important tools that are commonly used to demonstrate the need for increased staffing in other disciplines and are tools that can be used by radiation safety professionals. Parameters that most RSOs would expect to be positive predictors of radiation safety staff size generally are and can be emphasized in benchmarking and justification report summaries. Facilities with large radiation safety departments tend to have large numbers of authorized users, be broad-scope programs, be subject to increased controls regulations, have large clinical operations, have significant numbers of academic radiation-producing machines, and have laser safety responsibilities.
Navi, Babak B.; Kamel, Hooman; Shah, Maulik P.; Grossman, Aaron W.; Wong, Christine; Poisson, Sharon N.; Whetstone, William D.; Josephson, S. Andrew; Johnston, S. Claiborne; Kim, Anthony S.
Objective To describe the rate and predictors of central nervous system (CNS) disease in emergency department (ED) patients with dizziness in the modern era of neuroimaging. Patients and Methods We retrospectively reviewed the medical records of all adults presenting between January 1, 2007, and December 31, 2009, to an academic ED for a primary triage complaint of dizziness, vertigo, or imbalance. The final diagnosis for the cause of dizziness was independently assigned by 2 neurologists, with a third neurologist resolving any disagreements. The primary outcome was a composite of ischemic stroke, intracranial hemorrhage, transient ischemic attack, seizure, brain tumor, demyelinating disease, and CNS infection. Univariate and multivariate logistic regression were used to assess the association between clinical variables and serious CNS causes of dizziness. Results Of 907 patients experiencing dizziness (mean age, 59 years; 58% women [n=529]), 49 (5%) had a serious neurologic diagnosis, including 37 cerebrovascular events. Dizziness was often caused by benign conditions, such as peripheral vertigo (294 patients [32%]) or orthostatic hypotension (121 patients [13%]). Age 60 years or older (odds ratio [OR], 5.7; 95% confidence interval [CI], 2.5-11.2), a chief complaint of imbalance (OR, 5.9; 95% CI, 2.3-15.2), and any focal examination abnormality (OR, 5.9; 95% CI, 3.1-11.2) were independently associated with serious neurologic diagnoses, whereas isolated dizziness symptoms were inversely associated (OR, 0.2; 95% CI, 0.0-0.7). Conclusion Dizziness in the ED is generally benign, although a substantial fraction of patients harbor serious neurologic disease. Clinical suspicion should be heightened for patients with advanced age, imbalance, or focal deficits. PMID:23063099
Weiner, Scott G.; Horton, Laura C.; Green, Traci C.; Butler, Stephen F.
Introduction Tablet computer-based screening may have the potential for detecting patients at risk for opioid abuse in the emergency department (ED). Study objectives were a) to determine if the revised Screener and Opioid Assessment for Patients with Pain (SOAPP®-R), a 24-question previously paper-based screening tool for opioid abuse potential, could be administered on a tablet computer to an ED patient population; b) to demonstrate that >90% of patients can complete the electronic screener without assistance in <5 minutes and; c) to determine patient ease of use with screening on a tablet computer. Methods This was a cross-sectional convenience sample study of patients seen in an urban academic ED. SOAPP®-R was programmed on a tablet computer by study investigators. Inclusion criteria were patients ages ≥18 years who were being considered for discharge with a prescription for an opioid analgesic. Exclusion criteria included inability to understand English or physical disability preventing use of the tablet. Results 93 patients were approached for inclusion and 82 (88%) provided consent. Fifty-two percent (n=43) of subjects were male; 46% (n=38) of subjects were between 18–35 years, and 54% (n=44) were >35 years. One hundred percent of subjects completed the screener. Median time to completion was 148 (interquartile range 117.5–184.3) seconds, and 95% (n=78) completed in <5 minutes. 93% (n=76) rated ease of completion as very easy. Conclusions It is feasible to administer a screening tool to a cohort of ED patients on a tablet computer. The screener administration time is minimal and patient ease of use with this modality is high. PMID:25671003
Vazin, Afsaneh; Zamani, Zahra; Hatam, Nahid
This study was conducted with the purpose of determining the frequency of medication errors (MEs) occurring in tertiary care emergency department (ED) of a large academic hospital in Iran. The incidence of MEs was determined through the disguised direct observation method conducted by a trained observer. A total of 1,031 medication doses administered to 202 patients admitted to the tertiary care ED were observed over a course of 54 6-hour shifts. Following collection of the data and analysis of the errors with the assistance of a clinical pharmacist, frequency of errors in the different stages was reported and analyzed in SPSS-21 software. For the 202 patients and the 1,031 medication doses evaluated in the present study, 707 (68.5%) MEs were recorded in total. In other words, 3.5 errors per patient and almost 0.69 errors per medication are reported to have occurred, with the highest frequency of errors pertaining to cardiovascular (27.2%) and antimicrobial (23.6%) medications. The highest rate of errors occurred during the administration phase of the medication use process with a share of 37.6%, followed by errors of prescription and transcription with a share of 21.1% and 10% of errors, respectively. Omission (7.6%) and wrong time error (4.4%) were the most frequent administration errors. The less-experienced nurses (P=0.04), higher patient-to-nurse ratio (P=0.017), and the morning shifts (P=0.035) were positively related to administration errors. Administration errors marked the highest share of MEs occurring in the different medication use processes. Increasing the number of nurses and employing the more experienced of them in EDs can help reduce nursing errors. Addressing the shortcomings with further research should result in reduction of MEs in EDs. PMID:25525391
Bekmezian, Arpi; Fee, Christopher; Weber, Ellen
Objective Poor adherence to NIH Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. Methods Prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations. A multidisciplinary team designed a one-page clinical pathway based on NIH guidelines. Nurses, respiratory therapists, and physicians attended educational sessions prior to pathway implementation. Adjusting for demographics, acuity, and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006–2011. Subsequent hospital admission rates were also compared. Results 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95%CI 3.17–12.73). Post-intervention, median time to corticosteroid administration was 45 minutes faster (RR 0.74; 95%CI 0.67–0.81) and more patients received corticosteroids within 1 hour of arrival (45% vs 18%, OR 3.5; 95%CI 2.50–4.90). More patients received >1 bronchodilator dose within 1 hour (36% vs 24%, OR 1.65; 95%CI 1.23–2.21) and fewer received CXRs (27% vs 42%, OR 0.7; 95%CI 0.52–0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95%CI 0.37–0.76). Conclusion A clinical pathway is associated with improved adherence to NIH guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations. PMID:25985707
Erwin, Paul Campbell; Barlow, Patrick; Brownson, Ross C; Amos, Kathleen; Keck, C William
Academic Health Departments (AHDs) represent collaborative relationships between public health academia and practice. The purpose of this study was to gain a better understanding of AHD characteristics, to document the extent of collaboration between organizations in an AHD, and to explore the benefits of AHDs. An electronic survey on the AHD was sent to members of the AHD Learning Community--a virtual learning community with 338 members. There were 110 valid responses to the survey, with 65 indicating they were currently in an AHD partnership. Thirty-two percent of AHDs had been established for more than 10 years; 64% were engaged in joint research activities; and, while 92% of respondents placed a high value on improving the competencies of students, almost half placed a high value on improving the competencies of faculty. This study can be a springboard for further research on the impact of AHDs on practice, academia, and ultimately community health.
Billington, Michael; Kandalaft, Osama R.; Aisiku, Imoigele P.
Seizures are a common presentation in the prehospital and emergency department setting and status epilepticus represents an emergency neurologic condition. The classification and various types of seizures are numerous. The objectives of this narrative literature review focuses on adult patients with a presentation of status epilepticus in the prehospital and emergency department setting. In summary, benzodiazepines remain the primary first line therapeutic agent in the management of status epilepticus, however, there are new agents that may be appropriate for the management of status epilepticus as second- and third-line pharmacological agents. PMID:27563928
Woolard, Robert; Cherpitel, Cheryl; Kathleen, Thompson
This article reviews studies and current practices of brief motivational intervention in the emergency department and identifies factors related to the effectiveness of brief intervention. Studies of brief intervention in the emergency department have had mixed results with most studies showing improvements in both intervention and control groups. Most report brief intervention reducing alcohol’s negative consequences without reducing consumption. Clinical practice is incorporating brief intervention as part of emergency treatment and further research is needed to determine the factors most responsible for the improvements noted in most studies. PMID:21886943
Allen, Michael H.; Abar, Beau W.; McCormick, Mark; Barnes, Donna H.; Haukoos, Jason; Garmel, Gus M.; Boudreaux, Edwin D.
Joint Commission National Patient Safety Goal 15 calls for organizations "to identify patients at risk for suicide." Overt suicidal behavior accounts for 0.6% of emergency department (ED) visits, but incidental suicidal ideation is found in 3%-11.6%. This is the first multicenter study of suicide screening in EDs. Of 2,243 patients in…
Mathieson, Sarah; Whalen, Desmond
In a trauma situation, it is essential that emergency room physicians are able to think clearly, make decisions quickly and manage patients in a way consistent with their injuries. In order for emergency medicine residents to adequately develop the skills to deal with trauma situations, it is imperative that they have the opportunity to experience such scenarios in a controlled environment with aptly timed feedback. In the case of infant trauma, sensitivities have to be taken that are specific to pediatric medicine. The following describes a simulation session in which trainees were tasked with managing an infantile patient who had experienced a major trauma as a result of a single vehicle accident. The described simulation session utilized human patient simulators and was tailored to junior (year 1 and 2) emergency medicine residents. PMID:26487992
Pangka, Kyle R; Chandrasena, Ranjith; Wijeratne, Nishardi; Mann, Miriam
Patients presenting to a rural emergency department (ED) with mental health symptoms have difficulty accessing services of mental health professionals [1,2]. Videoconferencing (VC) has been found to improve patient access to health services that require specialist care in rural EDs [3,4,5]. Although previous studies highlight the benefit of using VC for patients presenting with mental health emergencies, no study has investigated the current views and use of VC for mental health emergencies in EDs in Southwestern Ontario [3,5,6]. To explore the views of ED staff regarding the use of VC in mental health emergencies, structured telephone interviews were conducted with representatives from EDs in the Erie St. Clair and Southwest Local Health Integration Networks (LHIN). Participants noted that using VC for mental health emergencies may improve patient experience and benefit crisis response teams. VC was perceived by some participants as a means to expedite the direct assessment of a patient presenting with a mental health emergency by a mental health specialist. However several participants stated that using VC for mental health emergencies strains ED resources. Lack of use and difficulty accessing a psychiatrist were identified as potential barriers to implementing the use of VC for mental health emergencies.
Ng, Ryan; Kendall, Claire E.; Burchell, Ann N.; Bayoumi, Ahmed M.; Loutfy, Mona R.; Raboud, Janet; Glazier, Richard H.; Rourke, Sean; Antoniou, Tony
Background: Emergency department use may reflect poor access to primary care. Our objective was to compare rates and causes of emergency department use between adults living with and without HIV. Methods: We conducted a population-based study involving Ontario residents living with and without HIV between Apr. 1, 2011, and Mar. 31, 2012. We frequency matched adults with HIV to 4 HIV-negative people by age, sex and census division, and used random-effects negative binomial regression to compare rates of emergency department use. We classified visits as low urgency or high urgency, and also examined visits for ambulatory care sensitive conditions. Hospital admission following an emergency department visit was a secondary outcome. Results: We identified 14 534 people with HIV and 58 136 HIV-negative individuals. Rates of emergency department use were higher among people with HIV (67.3 v. 31.2 visits per 100 person-years; adjusted rate ratio 1.58, 95% confidence interval [CI] 1.51-1.65). Similar results were observed for low-urgency visits. With the exception of hypertension, visit rates for ambulatory care sensitive conditions were higher among people with HIV. People with HIV were also more likely than HIV-negative individuals to be admitted to hospital following an emergency department visit (adjusted odds ratio 1.55, 95% CI 1.43-1.69). Interpretation: Compared with HIV-negative individuals, people with HIV had high rates of emergency department use, including potentially avoidable visits. These findings strongly support the need for comprehensive care for people with HIV. PMID:27398370
Lang, Eddy; Afilalo, Marc; Vandal, Alain C.; Boivin, Jean-François; Xue, Xiaoqing; Colacone, Antoinette; Léger, Ruth; Shrier, Ian; Rosenthal, Stephen
Background Electronic information exchange is believed to improve efficiency and reduce resource utilization. We developed a Web-based standardized communication system (SCS) that enables family physicians to receive detailed reports of their patients' care in the emergency department. We sought to determine the impact of the SCS on measures of resource utilization in the emergency department and family physician offices. Methods We used an open 4-period crossover cluster-randomized controlled design. During 2 separate 10-week intervention phases, family physicians received detailed reports of their patients' emergency department visits over the Internet, and in the alternating control phases they received a 1-page copy of the emergency department notes by mail. The primary outcome was the number of repeat visits to the emergency department within 14 days of the initial visit. Secondary outcomes included duplication of test and specialty consultation requests by the emergency and family physician. Outcomes were measured using the hospital database and questionnaires sent to the family physicians. Results A total of 2022 patient visits to the emergency department from 23 practices were used in the study. Use of the SCS failed to reduce the number of repeat visits to the emergency department within 14 days (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.8–1.51) and 28 days (OR 1.01, 95% CI 0.8–1.27). There was no significant duplication of requests for diagnostic tests between the emergency and family physician during the intervention and control phases (24 v. 22, p = 0.93), but there was significantly greater duplication in specialty consultation requests in the intervention phase than in the control phase (20 v. 8, p = 0.049). Interpretation An electronic link between emergency and family physicians did not result in a significant reduction in resource utilization at either service point. Investments in improved electronic information exchange between
Viswanathan, Kartik; Rosen, Tony; Mulcare, Mary R.; Clark, Sunday; Hayes, Jaime; Lachs, Mark S.; Flomenbaum, Neal
BACKGROUND Indwelling Urinary Catheters (IUCs) are placed frequently in older adults in the emergency department (ED). While often a critical intervention, IUCs carry significant risks, particularly for geriatric patients, including infection, delirium, and falls. In addition, once placed, IUCs are rarely removed in the ED and may remain for an extended period after transfer of care, leading to poor outcomes. The purpose of this research was to examine the current knowledge, attitudes, and practice of ED nurses and other providers regarding IUC placement and management in older adults. METHODS We surveyed ED providers including nurses, attending physicians, Emergency Medicine (EM) residents, nurse practitioners (NPs), and physician assistants (PAs) at a large, urban, academic medical center. We developed comprehensive written questionnaires designed using items from previously validated instruments and questions created specifically for this study. In addition, we assessed providers' management of 25 unique clinical scenarios, each representing an established appropriate or inappropriate indication for IUC placement. RESULTS 127 ED providers participated: 43 nurses, 21 attending physicians, 47 residents, and 17 NP/PAs. 91% of nurses and 88% of other providers reported comfort with appropriate indications for IUC placement. Despite this, in the clinical vignettes nurses correctly identified the appropriate approach for IUC placement in only 40% of cases and other providers in only 37%. Reported practices were most divergent from accepted standards in delirium, with 3% of nurses and 1% of other providers appropriately avoiding IUC placement. Practice varied widely between individual providers, with the nurse participants reporting appropriate practice in 16%–64% of clinical scenarios and other providers in 8%–68%. Few nurses or other providers reported reassessing their patients for IUC removal at transfer to the hospital upstairs (28% of nurses and 7% of other
Lauks, Juliane; Mramor, Blaz; Baumgartl, Klaus; Maier, Heinrich; Nickel, Christian H.; Bingisser, Roland
Emergency Departments (ED) are trying to alleviate crowding using various interventions. We assessed the effect of an alternative model of care, the Medical Team Evaluation (MTE) concept, encompassing team triage, quick registration, redesign of triage rooms and electronic medical records (EMR) on door-to-doctor (waiting) time and ED length of stay (LOS). We conducted an observational, before-and-after study at an urban academic tertiary care centre. On July 17th 2014, MTE was initiated from 9:00 a.m. to 10 p.m., 7 days a week. A registered triage nurse was teamed with an additional senior ED physician. Data of the 5-month pre-MTE and the 5-month MTE period were analysed. A matched comparison of waiting times and ED LOS of discharged and admitted patients pertaining to various Emergency Severity Index (ESI) triage categories was performed based on propensity scores. With MTE, the median waiting times improved from 41.2 (24.8–66.6) to 10.2 (5.7–18.1) minutes (min; P < 0.01). Though being beneficial for all strata, the improvement was somewhat greater for discharged, than for admitted patients. With a reduction from 54.3 (34.2–84.7) to 10.5 (5.9–18.4) min (P < 0.01), in terms of waiting times, MTE was most advantageous for ESI4 patients. The overall median ED LOS increased for about 15 min (P < 0.01), increasing from 3.4 (2.1–5.3) to 3.7 (2.3–5.6) hours. A significant increase was observed for all the strata, except for ESI5 patients. Their median ED LOS dropped by 73% from 1.2 (0.8–1.8) to 0.3 (0.2–0.5) hours (P < 0.01). In the same period the total orders for diagnostic radiology increased by 1,178 (11%) from 10,924 to 12,102 orders, with more imaging tests being ordered for ESI 2, 3 and 4 patients. Despite improved waiting times a decrease of ED LOS was only seen in ESI level 5 patients, whereas in all the other strata ED LOS increased. We speculate that this was brought about by the tendency of triage physicians to order more diagnostic radiology
Shonkoff, J P
Expertise in child development and behavior has been acknowledged as a critical prerequisite for the practice of general pediatrics since the early part of the 20th century. Recently, as the knowledge base has expanded, the concept of developmental and behavioral pediatrics as a specialized academic discipline has generated growing interest. The extent to which this emerging field achieves full recognition as a respected pediatric subspecialty will be determined by its response to three critical challenges: the process of academic acculturation, the imperative of creative collaboration and intellectual cross-fertilization, and the requirements of scientific credibility.
Grassino, Erica Clara; Guidi, Carla; Monzani, Alice; Di Pietro, Pasquale; Bona, Gianni
Objective The aim of the study was to investigate whether access to paediatric emergency departments differed between foreign and Italian patients. Methods We performed a cross-sectional study between January-December 2007 to analyse attendance's characteristics in the paediatric emergency departments of ten Italian public hospitals. The study population included each foreign patient and the following Italian patient admitted to the same emergency department. All causes of admission of these subjects were evaluated, together with the child's age, gender, country of birth, parents' nationality, time of admission, severity code and discharge-related circumstances. Results We enrolled 4874 patients, 2437 foreign (M:F = 1409:1028) and 2437 Italian ones (M:F = 1368:1069). Most of foreign and Italian patients' admissions were sorted as green (72.5% and 87.8%, respectively) or white codes (25.2% and 9.8%, respectively). The most frequent causes for attendance concerned respiratory tract diseases, followed by gastroenteric ones and injuries in both groups. Conclusion In our survey immigrants didn't access to emergency departments more than Italian children. Both of them referred to emergency departments mainly for semi-urgent or non-urgent problems. Foreign and Italian patients suffered from the same pathologies. Infectious diseases traditionally thought to be a potential problem in immigrant populations actually seem to be quite infrequent. PMID:19490660
Hefner, Jennifer L; Wexler, Randy; McAlearney, Ann Scheck
The objective was to explore variation by insurance status in patient-reported barriers to accessing primary care. The authors fielded a brief, anonymous, voluntary survey of nonurgent emergency department (ED) visits at a large academic medical center and conducted descriptive analysis and thematic coding of 349 open-ended survey responses. The privately insured predominantly reported primary care infrastructure barriers-wait time in clinic and for an appointment, constraints related to conventional business hours, and difficulty finding a primary care provider (because of geography or lack of new patient openings). Half of those insured by Medicaid and/or Medicare also reported these infrastructure barriers. In contrast, the uninsured predominantly reported insurance, income, and transportation barriers. Given that insured nonurgent ED users frequently report infrastructure barriers, these should be the focus of patient-level interventions to reduce nonurgent ED use and of health system-level policies to enhance the capacity of the US primary care infrastructure.
Burkhardt, John Christian; Smith-Coggins, Rebecca; Santen, Sally
Academic physicians train the next generation of doctors. It is important to understand the factors that lead residents to choose an academic career to continue to effectively recruit residents who will join the national medical faculty. A decision-making theory-driven, large scale assessment of this process has not been previously undertaken. To examine the factors that predict an Emergency resident's interest in pursuing an academic career at the conclusion of training. This study employs the ABEM Longitudinal Survey (n = 365). A logistic regression model was estimated using an interest in an academic career in residency as the dependent variable. Independent variables include gender, under-represented minority status, survey cohort, number of dependent children, possession of an advanced degree, ongoing research, publications, and the appeal of science, independence, and clinical work in choosing EM. Logistic regression resulted in a statistically significant model (p < 0.001). Residents who chose EM due to the appeal of science, had peer-reviewed publications and ongoing research were more likely to be interested in an academic career at the end of residency (p < 0.05). An increased number of children (p < 0.05) was negatively associated with an interest in academics. Individual resident career interests, research productivity, and lifestyle can help predict an interest in pursuing an academic career. Recruitment and enrichment of residents who have similar values and behaviors should be considered in programs interested in generating more graduates who enter an academic career.
Eyono Obono, S. D.; Basak, Sujit Kumar
The general formulation of the assignment problem consists in the optimal allocation of a given set of tasks to a workforce. This problem is covered by existing literature for different domains such as distributed databases, distributed systems, transportation, packets radio networks, IT outsourcing, and teaching allocation. This paper presents a new version of the assignment problem for the allocation of academic tasks to staff members in departments with long leave opportunities. It presents the description of a workload allocation scheme and its algorithm, for the allocation of an equitable number of tasks in academic departments where long leaves are necessary.
Buron, Andrea; Cots, Francesc; Garcia, Oscar; Vall, Oriol; Castells, Xavier
Background The recent increase in the number of immigrants of Barcelona represents a challenge for the public healthcare system, the emergency department being the most used healthcare service by this group. However, utilisation rates in our environment have not yet been studied. We aimed to compare emergency department utilisation rates between Spanish-born and foreign-born residents in a public hospital of Barcelona. Methods The study population included all adults residing in the area of study and visiting the emergency department of Hospital del Mar in 2004. The emergency care episodes were selected from the Emergency Department register, and the population figures from the Statistics Department of Barcelona. Emergency care episodes were classified into five large clinical categories. Adjusted rate ratios (RR) of utilisation among foreign-born vs. Spanish-born residents were assessed through negative binomial regression. Results The overall utilisation rate was 382 emergency contacts per 1,000 persons-years. The RR for foreign-born versus Spanish-born residents was 0.62 (95% CI: 0.52; 0.74%). The RR was also significantly below one in surgery (0.51, 95% CI: 0.42; 0.63), traumatology (0.47, 95% CI: 0.38; 0.59), medicine (0.48, 95% CI: 0.38; 0.59) and psychiatry (0.42, 95% CI: 0.18; 0.97). No differences were found in utilisation of gynaecology and minor emergency services. Conclusion The overall lower utilisation rates obtained for foreign-born residents is consistent with previous studies and is probably due to the "healthy immigrant effect". Thus, the population increase due to immigration does not translate directly into a corresponding increase in the number of emergency contacts. The lack of differences in minor and gynaecological emergency care supports the hypothesis that immigrants overcome certain barriers by using the emergency department to access to health services. The issue of healthcare barriers should therefore be addressed, especially among
Spasoff, R. A.; Lane, P.; Steele, R.
Indicator conditions were used to evaluate the quality of 686 episodes of care provided in two emergency departments and in five family physicians' offices. Overall, the care was considered adequate in 53% of the emergency department cases and in 40% of the cases dealt with in family physicians' offices, the difference being significant (P less than 0.01). Referrals were very common in both settings, and when quality was assessed solely on the basis of the care actually given by the primary-care providers the difference between the two settings disappeared. Half the observed deficiencies in care related to failure to document the findings from history-taking and physical examination. From these and earlier findings we conclude that the emergency department can be an appropriate setting for the care of nontraumatic illness. PMID:880525
deForest, Erin Kate; Thompson, Graham Cameron
In an effort to improve the quality and flow of care provided to children presenting to the emergency department the implementation of nurse-initiated protocols is on the rise. We review the current literature on nurse-initiated protocols, validated emergency department clinical scoring systems, and the merging of the two to create Advanced Nursing Directives (ANDs). The process of developing a clinical pathway for children presenting to our pediatric emergency department (PED) with suspected appendicitis will be used to demonstrate the successful integration of validated clinical scoring systems into practice through the use of Advanced Nursing Directives. Finally, examples of 2 other Advanced Nursing Directives for common clinical PED presentations will be provided. PMID:22778944
Mitchell, Rebecca; Finch, Caroline; Boufous, Soufiane; Browne, Gary
Narrative text can be a useful means of identifying injury in routine data collections. An analysis of data from a near real-time emergency department surveillance system (NREDSS) in New South Wales (NSW, Australia) was conducted to determine if sports injuries can be identified from routine narrative text recorded in emergency departments. Around one-third of all emergency department (ED) presentations during 1 September 2003 to 15 February 2007 were identified as injury-related. Narrative text searching of triage nursing assessments using keywords identified between 282 (i.e. football) and 26,944 (i.e. play) potential sports injury presentations depending on the selected sports-related keyword used. Routine narrative text descriptions from triage nurse assessments show promise for the identification of sports injury presentations to EDs. Further work is required regarding in-depth assessment of case detection capabilities and the likelihood of improving the quality of narrative text recorded.
Chest pain is a common complaint of patients seen in the emergency department. The causes are legion, and range from the non-life threatening to the potentially catastrophic. Thallium heart scanning was done prospectively in 20 patients with a ''classic'' history for myocardial infarction (eight patients) or atypical chest pain and/or associated symptoms plus an abnormal ECG (12 patients) to discern a subset of patients from whom thallium scintography may be indicated in the emergency department. Although further investigation is needed, our preliminary study suggests that myocardial scanning with thallium can be a safe, fairly rapid, and useful objective parameter in the emergency department detection of suspected myocardial infarction, and in differential diagnosis of chest pain when other data such as the history, physical examination, ECG, or enzymes are inconclusive.
Mendoza, Kenia; Benkouiten, Samir; Brouqui, Philippe; Gautret, Philippe
A total of 304 patients with mammal-related injuries were included over the 2-year survey period (1.5% of total admissions) at the emergency departments of a large city in southern France. Admissions peaked during the summer months. Dogs accounted for 75.3% and cats for 16.8% of cases. Dog injuries were significantly more common in younger individuals. Overall, signs of infection were observed in 17.9% of cases and were more likely to occur in patients injured by cats and in patients injured more than 1 day before consulting. The majority of patients received an antibiotic prophylaxis, independent to the delay between injury and consultation. Only 1 out of 10 injured patients who consulted an emergency department were seen at the rabies treatment center. Emergency department surveillance data offers an effective and efficient method for conducting animal bite surveillance to monitor trends and characterize animal bite victims.
Rehmani, R.; Amanullah, S.
There is ample evidence that many investigations sent from the accident and emergency department are inappropriate, thus affecting the quality of patient care. A study was designed to address this issue in the emergency department of a tertiary care hospital of a large city. A prospective cross-sectional study was carried out during the 3-month period 1 December 1996 to 28 February 1997. A set of guidelines was used to assess the appropriateness of different blood tests for the initial assessment of the patients presenting with common clinical conditions, although any investigation could be done if considered important for patient management. All other blood tests were considered inappropriate. A total of 6401 patients were seen in the emergency department and 14 300 blood tests were done on 3529 patients with diagnoses covered by the guidelines. Of these 62.2% were found to be inappropriate. Of the total 22 655 investigations done on all the 6401 patients seen, only 3.8% influenced the diagnosis, 3.0% influenced patient care in the emergency department, and 4.0% influenced the decision to admit or not. Amylase and arterial blood gases were found to be the most appropriate investigations. Analysis of reasons for unnecessary use of emergency tests suggested that improving supervision, decreasing the utilization of the emergency department as a phlebotomy service for the hospital, and abolition of routine blood tests would help to improve patient care. Keywords: blood tests; accident and emergency medicine PMID:10621876
Boz, Bora; Acar, Kemalettin; Ergin, Ahmet; Erdur, Bulent; Kurtulus, Ayse; Turkcuer, Ibrahim; Ergin, Nesrin
This study sought to determine the frequency and types of violence that occurred during the previous year against health care workers in emergency departments in Denizli, Turkey, and to discern the views of workers on the prevention of such aggressive behavior. This study was conducted from March 1 to April 15, 2003, and included a group of 79 health care workers from the emergency departments of 3 hospitals in Denizli, namely, the Hospital of Pamukkale University Medical Faculty, the City Hospital of Denizli, and the Hospital of the Social Insurance Foundation. Data were collected from a self-administered questionnaire. In all, 88.6% of participants had been subjected to or had witnessed verbal violence, and 49.4% of them had been subjected to or had witnessed physical violence during the previous year. The most frequent reason (31.4%) for violence was abuse of alcohol and drugs by perpetrators. The second most frequent reason (24.7%) was the long waiting times typical of emergency departments. The most common type of violence was loud shouting; swearing, threatening, and hitting were the next most frequent violent behaviors. In all, 36.1% of subjects who had experienced violence reported that they developed psychological problems after the incident. Most participants commented on the insufficiency of currently available security systems within emergency departments and on the need for further training about violence. All health care personnel within emergency departments should be aware of the risk of violence and should be prepared for unpredictable conditions and events; in addition, security systems should be updated so that violence within emergency departments can be prevented.
Neighbour, Ryan; Oppenheimer, Luis; Mukhi, Shamir N; Friesen, Marcia R; McLeod, Robert D
This work extends ongoing development of a framework for modeling the spread of contact-transmission infectious diseases. The framework is built upon Agent Based Modeling (ABM), with emphasis on urban scale modelling integrated with institutional models of hospital emergency departments. The method presented here includes ABM modeling an outbreak of influenza-like illness (ILI) with concomitant surges at hospital emergency departments, and illustrates the preliminary modeling of 'crowdinforming' as an intervention. 'Crowdinforming', a component of 'crowdsourcing', is characterized as the dissemination of collected and processed information back to the 'crowd' via public access. The objective of the simulation is to allow for effective policy evaluation to better inform the public of expected wait times as part of their decision making process in attending an emergency department or clinic. In effect, this is a means of providing additional decision support garnered from a simulation, prior to real world implementation. The conjecture is that more optimal service delivery can be achieved under balanced patient loads, compared to situations where some emergency departments are overextended while others are underutilized. Load balancing optimization is a common notion in many operations, and the simulation illustrates that 'crowdinforming' is a potential tool when used as a process control parameter to balance the load at emergency departments as well as serving as an effective means to direct patients during an ILI outbreak with temporary clinics deployed. The information provided in the 'crowdinforming' model is readily available in a local context, although it requires thoughtful consideration in its interpretation. The extension to a wider dissemination of information via a web service is readily achievable and presents no technical obstacles, although political obstacles may be present. The 'crowdinforming' simulation is not limited to arrivals of patients at
Narasimhan, Meera; Druss, Benjamin G.; Hockenberry, Jason M.; Royer, Julie; Weiss, Paul; Glick, Gretl; Marcus, Steven C.; Magill, John
Objective This study estimates the impact of a statewide centralized emergency department telepsychiatry service provided in non-psychiatric emergency departments on use of mental health services. Methods Individuals treated via telepsychiatry were compared to a matched sample of individuals with mental health diagnoses who were treated in non-participating hospitals. Bivariate and two part and generalized linear regression models were used to assess differences in outpatient follow up, admission following the emergency department visit, length of stay, inpatient and total costs between the two groups. Results Between March 2009 and June 2013 there were 9,066 patients with at least one telepsychiatry visit. Of these, 7,261 had index telepsychiatry visits which we were able to successfully match. The telepsychiatry group was more likely to receive 30 day outpatient follow up than the matched controls (46% versus 16%, p,.001) and more likely to receive 90 day outpatient follow up (54% versus 20%, p<.001). Those receiving telepsychiatry were less likely to be admitted to the hospital at the index emergency department visit than the control group (11% versus 22%). The combined effect of having a telepsychiatry consult during the index emergency department visit was a 0.86 day reduction in inpatient length of stay associated with receiving telepsychiatry care. 30-day inpatient costs were $2,336 (p=0.04) lower for the telepsychiatry group. 30-day total health care costs were not statistically different. Conclusions Telepsychiatry delivered in the emergency department through a centralized coordinated program has great promise for improving linkage with outpatient mental health services while reducing inpatient utilization and hospital costs. PMID:26129992
Background Overcrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments. Methods A systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group. Results The interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient. Conclusions Introducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to
Reilly, Philip M.
During one year all initial attendance from one Belfast general practice to local accident and emergency departments was studied. Of the 784 attenders, 616 (78.4 per cent) referred themselves; the remaining 168 (21.6 per cent) were referred by the general practitioners. The clinical and social characteristics of both groups are compared. The discussion focuses on the appropriate use of primary care and accident and emergency services. PMID:7277300
Spencer, Sandra P; Brock, Timothy D; Matthews, Rebecca R; Stevens, Wendy K
Nontraumatic spinal cord infarction is especially rare in children. Although diagnosis is easily made with magnetic resonance imaging, the typical presenting signs and symptoms and etiology remain elusive. Evidence-based treatment courses are not available. We assess a series of 3 unique patients with nontraumatic spinal cord infarction who presented to our emergency department over the course of 2 years. We consider their presentation, etiology, and treatment course to provide other emergency department physicians with the ability to better identify and evaluate these patients. We also note the need for further research on nontraumatic spinal cord infarction because these patients' outcomes can be quite devastating.
Huang, Shu-Hsin; Chen, Ping-Ling; Yang, Ming-Chin; Chang, Wen-Yin; Lee, Haw-Jenn
The performance of the emergency department significantly improved after implementing the balanced scorecard including hours of continuing education attended by the staff, staff job satisfaction, the rate of incomplete laboratory tests within 30 minutes, the average monthly inappropriate return rate, and hospital profit. The results can assist administrators plan for the future. Although this was a pilot program for implementing a balanced scorecard in an emergency department, the indicators used in this study may also be reasonable for a hospital that has limited resources.
Quigg, Zara; Hughes, Karen; Bellis, Mark A
We explore the impact of the 2010 World Cup, held in South Africa, on levels of assault attendances to 15 emergency departments in England. The majority (70.1%) of assault attendees during the 2010 World Cup was male and aged 18-34 years (52.5%). Assault attendances increased by 37.5% on the days that England played (P 001). Preparation for major sporting events in non-host countries should include violence prevention activity. Emergency department data can be used to identify violence associated with such events and thus inform both the targeting of prevention efforts and assessments of their effectiveness.
McLaughlin, Nancy; Garrett, Matthew C; Emami, Leila; Foss, Sarah K; Klohn, Johanna L; Martin, Neil A
OBJECT While malpractice litigation has had many negative impacts on health care delivery systems, information extracted from lawsuits could potentially guide toward venues to improve care. The authors present a comprehensive review of lawsuits within a tertiary academic neurosurgical department and report institutional and departmental strategies to mitigate liability by integrating risk management data with quality improvement initiatives. METHODS The Comprehensive Risk Intelligence Tool database was interrogated to extract claims/suits abstracts concerning neurosurgical cases that were closed from January 2008 to December 2012. Variables included demographics of the claimant, type of procedure performed (if any), claim description, insured information, case outcome, clinical summary, contributing factors and subfactors, amount incurred for indemnity and expenses, and independent expert opinion in regard to whether the standard of care was met. RESULTS During the study period, the Department of Neurosurgery received the most lawsuits of all surgical specialties (30 of 172), leading to a total incurred payment of $4,949,867. Of these lawsuits, 21 involved spinal pathologies and 9 cranial pathologies. The largest group of suits was from patients with challenging medical conditions who underwent uneventful surgeries and postoperative courses but filed lawsuits when they did not see the benefits for which they were hoping; 85% of these claims were withdrawn by the plaintiffs. The most commonly cited contributing factors included clinical judgment (20 of 30), technical skill (19 of 30), and communication (6 of 30). CONCLUSIONS While all medical and surgical subspecialties must deal with the issue of malpractice and liability, neurosurgery is most affected both in terms of the number of suits filed as well as monetary amounts awarded. To use the suits as learning tools for the faculty and residents and minimize the associated costs, quality initiatives addressing the
Khorsandi, Maziar; Skouras, Christos; Shah, Rajesh
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether there is any role for resuscitative emergency department thoracotomy in severe blunt trauma. Emergency thoracotomy is an accepted intervention for patients with penetrating cardiothoracic trauma. However, its role in blunt trauma has been challenged and has been a subject of considerable debate. Altogether, 186 relevant papers were identified, of which 14 represented the best evidence to answer the question. The author, journal, date, country of publication and relevant outcomes are tabulated. The 14 studies comprised 2 systematic reviews and 12 retrospective studies. The systematic review performed by the Trauma Committee of the American College of Surgeons included 42 studies and a cumulative total of 2193 blunt trauma patients who underwent an emergency department thoracotomy, reporting a survival rate of 1.6%. According to this review, 15% of the survivors suffered from neurological sequelae, but survivors from both penetrating and blunt trauma were included. A systematic review comprising 24 studies reported a survival rate of 1.4% among 1047 blunt trauma patients. Of the retrospective studies, 11 report poor survival rates, ranging from 0 to 6%. Only one study reports a higher survival rate (12.2%). Five of the studies reported on the neurological outcome of survivors. The majority of the studies suffered from limitations due to the small number of included cases. The reported survival after an emergency department thoracotomy for blunt trauma is very low in the vast majority of available studies. Furthermore, the neurological sequelae in the few survivors are frequent and severe. Interestingly, some author groups recommend that emergency department thoracotomy should be contraindicated in cases of blunt trauma with no signs of life at the scene of trauma or on arrival at the emergency department. Larger, well-designed series will
Lovett, Paris B.; Kahn, J. Akiva; Greene, Stuart E.; Bloch, Matthew A.; Brandt, Daniel R.; Minckler, Michael R.
Introduction Many prior studies have compared the acuity of Emergency Department (ED) patients who have Left Without Being Seen (LWBS) against non-LWBS patients. A weakness in these studies is that patients may walk out prior to the assignment of a triage score, biasing comparisons. We report an operational change whereby acuity was assessed immediately upon patient arrival. We hypothesized more patients would receive acuity scores with EQAS. We also sought to compare LWBS and non-LWBS patient characteristics with reduced bias. Methods Setting: urban, academic medical center. Retrospective cohort study, electronic chart review, collecting data on all ED patients presenting between 4/1/2010 and 10/31/2011 (“Traditional Acuity Score” period, TAS) and from 11/1/2011 to 3/31/2012 (“Early Quick Acuity Score” period, EQAS). We recorded disposition (LWBS versus non-LWBS), acuity and demographics. For each subject during the EQAS period, we calculated how many prior ED visits and how many prior walkouts the subject had had during the TAS period. Results Acuity was recorded in 92,275 of 94,526 patients (97.6%) for TAS period, and 25,577 of 25,760 patients (99.3%) for EQAS period, a difference of 1.7% (1.5%, 1.8%). LWBS patients had acuity scores recorded in 5,180 of 7,040 cases (73.6%) during TAS period, compared with 897 of 1,010 cases (88.8%) during the EQAS period, a difference of 15.2% (14.8%, 15.7%). LWBS were more likely than non-LWBS to be male, were younger and had lower acuity scores. LWBS averaged 5.3 prior ED visits compared with 2.8 by non-LWBS, a difference of 2.5 (1.5, 3.5). LWBS averaged 1.3 prior ED walkouts compared with 0.2 among non-LWBS, a difference of 1.1 (0.8, 1.3). Conclusions EQAS resulted in a higher proportion of patients receiving acuity scores, particularly among LWBS. This offers more complete data when comparing LWBS and non-LWBS patient characteristics. The comparison reinforced findings from prior studies. PMID:24465699
Pulliam, Bryce C.; Liao, Mark Y.; Geissler, Theodore M.; Richards, John R.
Introduction: The boarding of admitted patients in the emergency department (ED) is a major cause of crowding and access block. One solution is boarding admitted patients in inpatient ward (W) hallways. This study queried and compared ED and W nurses’ opinions toward ED and W boarding. It also assessed their preferred boarding location if they were patients. Methods: A survey administered to a convenience sample of ED and W nurses was performed in a 631-bed academic medical center (30,000 admissions/year) with a 68-bed ED (70,000 visits/ year). We identified nurses as ED or W, and if W, whether they had previously worked in the ED. The nurses were asked if there were any circumstances where admitted patients should be boarded in ED or W hallways. They were also asked their preferred location if they were admitted as a patient. Six clinical scenarios were then presented, and the nurses’ opinions on boarding based on each scenario were queried. Results: Ninety nurses completed the survey, with a response rate of 60%; 35 (39%) were current ED nurses (cED), 40 (44%) had previously worked in the ED (pED). For all nurses surveyed 46 (52%) believed admitted patients should board in the ED. Overall, 52 (58%) were opposed to W boarding, with 20% of cED versus 83% of current W (cW) nurses (P < 0.0001), and 28% of pED versus 85% of nurses never having worked in the ED (nED) were opposed (P < 0.001). If admitted as patients themselves, 43 (54%) of all nurses preferred W boarding, with 82% of cED versus 33% of cW nurses (P < 0.0001) and 74% of pED versus 34% nED nurses (P = 0.0007). The most commonly cited reasons for opposition to hallway boarding were lack of monitoring and patient privacy. For the 6 clinical scenarios, significant differences in opinion regarding W boarding existed in all but 2 cases: a patient with stable chronic obstructive pulmonary disease but requiring oxygen, and an intubated, unstable sepsis patient. Conclusion: Inpatient nurses and those who have
Herrick, D. B.; Nakhasi, A.; Nelson, B.; Rice, S.; Abbott, P. A.; Saber Tehrani, A. S.; Rothman, R. E.; Lehmann, H. P.; Newman-Toker, D. E.
Objective Self-administered computer-assisted interviewing (SACAI) gathers accurate information from patients and could facilitate Emergency Department (ED) diagnosis. As part of an ongoing research effort whose long-range goal is to develop automated medical interviewing for diagnostic decision support, we explored usability attributes of SACAI in the ED. Methods Cross-sectional study at two urban, academic EDs. Convenience sample recruited daily over six weeks. Adult, non-level I trauma patients were eligible. We collected data on ease of use (self-reported difficulty, researcher documented need for help), efficiency (mean time-per-click on a standardized interview segment), and error (self-report age mismatched with age derived from electronic health records) when using SACAI on three different instruments: Elo TouchSystems ESY15A2 (finger touch), Toshiba M200 (with digitizer pen), and Motion C5 (with digitizer pen). We calculated descriptive statistics and used regression analysis to evaluate the impact of patient and computer factors on time-per-click. Results 841 participants completed all SACAI questions. Few (<1%) thought using the touch computer to ascertain medical information was difficult. Most (86%) required no assistance. Participants needing help were older (54 ± 19 vs. 40 ± 15 years, p<0.001) and more often lacked internet at home (13.4% vs. 7.3%, p = 0.004). On multivariate analysis, female sex (p<0.001), White (p<0.001) and other (p = 0.05) race (vs. Black race), younger age (p<0.001), internet access at home (p<0.001), high school graduation (p = 0.04), and touch screen entry (vs. digitizer pen) (p = 0.01) were independent predictors of decreased time-per-click. Participant misclick errors were infrequent, but, in our sample, occurred only during interviews using a digitizer pen rather than a finger touch-screen interface (1.9% vs. 0%, p = 0.09). Discussion Our results support the facility of interactions between ED patients and SACAI
Pathan, Sameer A.; Bhutta, Zain A.; Moinudheen, Jibin; Jenkins, Dominic; Silva, Ashwin D.; Sharma, Yogdutt; Saleh, Warda A.; Khudabakhsh, Zeenat; Irfan, Furqan B.; Thomas, Stephen H.
Background: Standard Emergency Department (ED) operations goals include minimization of the time interval (tMD) between patients' initial ED presentation and initial physician evaluation. This study assessed factors known (or suspected) to influence tMD with a two-step goal. The first step was generation of a multivariate model identifying parameters associated with prolongation of tMD at a single study center. The second step was the use of a study center-specific multivariate tMD model as a basis for predictive marginal probability analysis; the marginal model allowed for prediction of the degree of ED operations benefit that would be affected with specific ED operations improvements. Methods: The study was conducted using one month (May 2015) of data obtained from an ED administrative database (EDAD) in an urban academic tertiary ED with an annual census of approximately 500,000; during the study month, the ED saw 39,593 cases. The EDAD data were used to generate a multivariate linear regression model assessing the various demographic and operational covariates' effects on the dependent variable tMD. Predictive marginal probability analysis was used to calculate the relative contributions of key covariates as well as demonstrate the likely tMD impact on modifying those covariates with operational improvements. Analyses were conducted with Stata 14MP, with significance defined at p < 0.05 and confidence intervals (CIs) reported at the 95% level. Results: In an acceptable linear regression model that accounted for just over half of the overall variance in tMD (adjusted r 2 0.51), important contributors to tMD included shift census (p = 0.008), shift time of day (p = 0.002), and physician coverage n (p = 0.004). These strong associations remained even after adjusting for each other and other covariates. Marginal predictive probability analysis was used to predict the overall tMD impact (improvement from 50 to 43 minutes, p < 0.001) of consistent staffing
Wong, Matthew L.; Chiu, David; Shapiro, Nathan I; Grossman, Shamai A
Introduction Syncope has myriad etiologies, ranging from benign to immediately life threatening. This frequently leads to over testing. Chest radiographs (CXR) are among these commonly performed tests despite their uncertain diagnostic yield. The objective is to study the distribution of normal and abnormal chest radiographs in patients presenting with syncope, stratified by those who did or did not have an adverse event at 30 days. Methods We performed a post-hoc analysis of a prospective cohort of consecutive patients presenting to an urban tertiary care academic medical center with a chief complaint of syncope from 2003–2006. The frequency and findings for each CXR were reviewed, as well as emergency department and hospital discharge diagnoses, and 30-day outcome. Results There were 575 total subjects, 39.7% were male, and the mean age was 57.2 (SD 24.6). Of the 575 subjects, 403 (70.1%) had CXRs performed, and 116 (20.2%) had an adverse event after their syncope. Of the 116 people who had an adverse event, 15 (12.9%) had a positive CXR, 81 (69.8%) had a normal CXR, and 20 (17.2%) did not have a CXR as part of the initial evaluation. Among the 459 people who did not have an adverse event, 3 (0.7%) had a positive CXR, 304 (66.2%) had a normal CXR, and 152 (33.1%) did not have a CXR performed. Fifteen of the 18 patients (83.4%) with an abnormal CXR had an adverse event. Eighty-one of the 385 patients (21.0%) with a normal CXR had an adverse event. Among those who had a CXR performed, an abnormal CXR was associated with increased odds of adverse event (OR: 18.77 (95% CI= [5.3–66.4])). Conclusion Syncope patients with abnormal CXRs are likely to experience an adverse event, though the majority of CXRs performed in the work up of syncope are normal. PMID:27833675
White, Benjamin A.; Chang, Yuchiao; Grabowski, Beth G.; Brown, David F.M.
Introduction While emergency department (ED) crowding has myriad causes and negative downstream effects, applying systems engineering science and targeting throughput remains a potential solution to increase functional capacity. However, the most effective techniques for broad application in the ED remain unclear. We examined the hypothesis that Lean-based reorganization of Fast Track process flow would improve length of stay (LOS), percent of patients discharged within one hour, and room use, without added expense. Methods This study was a prospective, controlled, before-and-after analysis of Fast Track process improvements in a Level 1 tertiary care academic medical center with >95,000 annual patient visits. We included all adult patients seen during the study periods of 6/2010–10/2010 and 6/2011–10/2011, and data were collected from an electronic tracking system. We used concurrent patients seen in another care area used as a control group. The intervention consisted of a simple reorganization of patient flow through existing rooms, based in systems engineering science and modeling, including queuing theory, demand-capacity matching, and Lean methodologies. No modifications to staffing or physical space were made. Primary outcomes included LOS of discharged patients, percent of patients discharged within one hour, and time in exam room. We compared LOS and exam room time using Wilcoxon rank sum tests, and chi-square tests for percent of patients discharged within one hour. Results Following the intervention, median LOS among discharged patients was reduced by 15 minutes (158 to 143 min, 95%CI 12 to 19 min, p<0.0001). The number of patients discharged in <1 hr increased by 2.8% (from 6.9% to 9.7%, 95%CI 2.1% to 3.5%, p<0.0001), and median exam room time decreased by 34 minutes (90 to 56 min, 95%CI 31 to 38 min, p<0.0001). In comparison, the control group had no change in LOS (265 to 267 min) or proportion of patients discharged in <1 hr (2.9% to 2.9%), and an
Rakofsky, Jeffrey J; Ferguson, Britnay A
Physician assistants (PAs) are medical professionals who practice medicine with the supervision of a physician through delegated autonomy. PA school accreditation standards provide limited guidance for training PAs in psychiatry. As a result, PA students may receive inconsistent and possibly inadequate exposure to psychiatry. Providing broad and in-depth exposure to the field of psychiatry is important to attract PA students to pursue careers in psychiatry and provide a possible solution to the shortage of psychiatrists nationwide. Additionally, this level of exposure will prepare PA students who pursue careers in other fields of medicine to recognize and address their patient's psychiatric symptoms in an appropriate manner. This training can be provided by an academic department of psychiatry invested in the education of PA students. We describe a training model implemented at our university that emphasizes psychiatrist involvement in the preclinical year of PA school and full integration of PA students into the medical student psychiatry clerkship during the clinical years. The benefits and challenges to implementing this model are discussed as well.
Tsang, Teresa S M; Jones, Meaghan; Meneilly, Graydon S
As part of an ongoing effort to better understand barriers to academic research, we reviewed and analyzed the process of research ethics applications, focusing on ethics approval time, within the Department of Medicine from 2006 to 2011. A total of 1,268 applications for approval to use human subjects in research were included in our analysis. Three variables, risk category (minimal vs. non-minimal risk), type of funding, and year of submission, were statistically significant for prediction of ethics approval time, with risk status being the most important of these. The covariate-adjusted mean time for approval for minimal risk studies (35.7 days) was less than half that of non-minimal risk protocols (76.5 days). Studies funded through a for-profit sponsor had significantly longer approval times than those funded through other means but were also predominantly (87%) non-minimal risk protocols. Further investigations of the reasons underlying the observed differences are needed to determine whether improved training for research ethics board (REB) members and/or greater dialogue with investigators may reduce the lengthy approval times associated with non-minimal risk protocols.
Ashcroft, Judy Copeland
In American universities, early distance education needed both continuing education and academic departments for establishing institutional cooperation, developing quality standards, adapting to change, and finding a funding model. Today, the Internet and the need for additional revenue are driving new distance education models.
Nguyen, Thi Lan Huong
Middle-level academic managers play a central role in university management; however, their roles are not always clear and straightforward. Although this research subject has been comprehensively investigated in the last 40 years, most studies are western-biased. This study examines the roles of Heads of Department in a newly established…
St. Marthe, Tamara Jaslene Marcelle
The advancement of women into academic leadership remains a problem facing public, high-research activity universities. While there are more women who are qualified to assume the position of department chair in research institutions today than there were 30 years ago, women still lag behind their male counterparts in holding these academic…
The academic department chairperson continues to face significant challenges in the administration of the contemporary university. Due to retrenchment resultant from the 2008 Global Financial Crisis (GFC), higher education has already faced significant financial cutbacks, and more reductions seem inevitable. Particularly susceptible are…
Fairchild, Julie E.
The problem of low job satisfaction (JS) among academic department chairs (ADC) may result from the selection process. ADC searches seldom comply with best practices for hiring or are predictive of a good fit. Formal searches are seldom used. Some incumbents did not want the job. Research into the history, nature, and problems of the position…
Dexheimer, Judith W; Borycki, Elizabeth M
Electronic health records are increasingly used in regional health authorities, healthcare systems, hospitals, and clinics throughout North America. The emergency department provides care for urgent and critically ill patients. Over the past several years, emergency departments have become more computerized. Tablet computers and Smartphones are increasingly common in daily use. As part of the computerization trend, we have seen the introduction of handheld computers, tablets, and Smartphones into practice as a way of providing health professionals (e.g. physicians, nurses) with access to patient information and decision support in the emergency department. In this article, we present a scoping review and outline the current state of the research using mobile devices in the emergency departments. Our findings suggest that there is very little research evidence that supports the use of these mobile devices, and more research is needed to better understand and optimize the use of mobile devices. Given the prevalence of handheld devices, it is inevitable that more decision support, charting, and other activities will be performed on these devices. These developments have the potential to improve the quality and timeliness of care but should be thoroughly evaluated.
Liu, Guodong; Pearl, Amanda M.; Kong, Lan; Leslie, Douglas L.; Murray, Michael J.
There has been an increase in utilization of the Emergency Department (ED) in individuals with autism spectrum disorder (ASD) which may reflect a deficit of services (Green et al., "Journal of the American Academy of Child and Adolescent Psychiatry" 40(3):325-332, 2001; Gurney et al., "Archives of Pediatric and Adolescent…
Pasqualone, Georgia A
This article describes the need for a collaborative relationship between the advanced practice forensic nurse in the emergency department and critical care settings with law enforcement officials. The relationship is necessary when working with victims and/or perpetrators in the context of the 27 categories of forensic patients.
Choo, Esther K.; Spiro, David M.; Lowe, Robert A.; Newgard, Craig D.; Hall, Michael Kennedy; McConnell, Kenneth John
Purpose: To characterize differences in child abuse management resources between urban and rural emergency departments (EDs). Methods: We surveyed ED directors and nurse managers at hospitals in Oregon to gain information about available abuse-related resources. Chi-square analysis was used to test differences between urban and rural EDs.…
Boltz, Marie; Parke, Belinda; Shuluk, Joseph; Capezuti, Elizabeth; Galvin, James E.
Purpose: The purpose of the study was to describe nurses' views of the issues to be addressed to improve care of the older adult in the emergency department (ED). Design and Methods: An exploratory content analysis examined the qualitative responses of 527 registered nurses from 49U.S. hospitals who completed the Geriatric Institutional Profile.…
Shook, Janice; Hiestand, Brian C.
Objective: In 2003, after several post-college football game riots, multiple strategies including strict enforcement of open container laws were instituted by the authors' city and university. The authors compared alcohol-related visits to the on-campus emergency department (ED) associated with home football games in 2002 and 2006, hypothesizing…
Montano, Zorash; Mahrer, Nicole E.; Nager, Alan L.; Claudius, Ilene; Gold, Jeffrey I.
The objective of this study was to examine the level of agreement between child- and caregiver-reports of the child's psychosocial problems presenting to a Pediatric Emergency Department (PED) using a validated screening tool. This was an anonymous, prospective, cross-sectional, multi-informant (child and caregiver) study assessing cognitive,…
Boufous, Soufiane; Finch, Caroline; Close, Jacqueline; Day, Lesley; Lord, Stephen
The aim of this paper is to estimate the proportion of older people who are hospitalised following a presentation to an emergency department for hip, pelvic and wrist fractures. The findings indicate that hospitalisation data do not accurately reflect the incidence of low-trauma fractures, particularly wrist and pelvic fractures, in older people.
Boufous, Soufiane; Finch, Caroline; Close, Jacqueline; Day, Lesley
The aim of this paper is to estimate the proportion of older people who are hospitalised following a presentation to an emergency department for hip, pelvic and wrist fractures. The findings indicate that hospitalisation data do not accurately reflect the incidence of low‐trauma fractures, particularly wrist and pelvic fractures, in older people. PMID:17567981
Gustavsson, Maria; Ekberg, Kerstin
This article reports on the findings of a planned workplace health promotion intervention, and the aim is to identify conditions that facilitated or restricted the learning to promote health at an emergency care department in a Swedish hospital. The study had a longitudinal design, with interviews before and after the intervention and follow-up…
McCusker, Jane; Verdon, Josee; Veillette, Nathalie; Berg, Katherine; Emond, Tina; Belzile, Eric
Cost-effective methods have been developed to help busy emergency department (ED) staff cope with the growing number of older patients, including quick screening and assessment tools to identify those at high risk and note their specific needs. This survey, from a sample of key informants from all EDs (n=111) in the province of Quebec…
Donnelly, John P; Franco, Ricardo A; Wang, Henry E; Galbraith, James W
Hepatitis C virus (HCV) infection is a growing problem, disproportionately affecting those born between 1945 and 1965. Here, we demonstrate the wide geographic reach and surveillance potential of emergency department-based screening and identify areas of elevated HCV infection in central Alabama that were socioeconomically disadvantaged compared with surrounding communities.
Schwartz, Katherine E.; Monie, Daphne; Scribani, Melissa B.; Krupa, Nicole L.; Jenkins, Paul; Leinhart, August; Kjolhede, Chris L.
Background: Previous studies of urban school-based health centers (SBHCs) have shown that SBHCs decrease emergency department (ED) utilization. This study seeks to evaluate the effect of SBHCs on ED utilization in a rural setting. Methods: This retrospective, controlled, quasi-experimental study used an ED patient data set from the Bassett…
Emergency department information systems (EDISs) have been available for many years, but they are recently attracting wider interest. In this article, we discuss the forces shaping the EDIS market and how they should play a role in your purchasing decisions. We also offer implementation guidance and provide an overview that describes the key modules that purchasers will select among when configuring their systems.
Somji, Zeeshanefatema; Plint, Amy; McGahern, Candice; Al-Saleh, Ahmed; Boutis, Kathy
Objectives: Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International…
Rhodes, Anne E.; Boyle, Michael H.; Bethell, Jennifer; Wekerle, Christine; Tonmyr, Lil; Goodman, Deborah; Leslie, Bruce; Lam, Kelvin; Manion, Ian
Objectives: To identify factors associated with repeat emergency department (ED) presentations for suicide-related behaviors (SRB)--hereafter referred to as repetition--among children/youth to aid secondary prevention initiatives. To compare rates of repetition in children/youth with substantiated maltreatment requiring removal from their parental…
Bentley, James A; Thakore, Shobhan; Morrison, William; Wang, Weijie
Background and aim Non-urgent Emergency Department presentations contribute to overcrowding, which can adversely affect patient care. Redirecting patients to a more appropriate service is an option to help address this. We conducted a prospective evaluation of a major Scottish hospital's Emergency Department redirection policy to assess its safety. Methods and results Over two months, 620 patients triggered senior assessment for redirection with 444 (72%) redirected to primary care. Information on presentation was collected with subsequent management and outcome of redirection provided by the patient's general practitioner. Those who required admission within seven days of redirection triggered review. This was carried out independently by an Emergency Department Consultant and a GP Principal to assess the incidence of sub-optimal care or harm as a consequence of redirection. Most patients presented during daytime hours with no significant variation between days. 'Patient factors' accounted for 74% of presentations with 'convenience' (20%) cited as the most common reason. Twenty-two patients were subsequently admitted, with one case of sub-optimal care (incidence 0.23%) and no cases of harm. Conclusions Our redirection policy provides a safe and effective means of directing patients to more appropriate care. The authors believe this to be in the patient s best interest as Emergency Department clinicians are not specifically trained to manage primary care issues.
Rhodes, Anne E.; Boyle, Michael H.; Bethell, Jennifer; Wekerle, Christine; Goodman, Deborah; Tonmyr, Lil; Leslie, Bruce; Lam, Kelvin; Manion, Ian
Objectives: To determine whether the rates of a first presentation to the emergency department (ED) for suicide-related behavior (SRB) are higher among children/youth permanently removed from their parental home because of substantiated maltreatment than their peers. To describe the health care settings accessed by these children/youth before a…
Witting, Michael D.; Furuno, Jon P.; Hirshon, Jon Mark; Krugman, Scott D.; Perisse, Andre R. S.; Limcangco, Rhona
Emergency department (ED) screening for intimate partner violence (IPV) faces logistic difficulties and has uncertain efficacy. We surveyed 146 ED visitors and 108 ED care providers to compare their support for ED IPV screening in three hypothetical scenarios of varying IPV risk. Visitor support for screening was 5 times higher for the high-risk…
Rust, George; Baltrus, Peter; Ye, Jiali; Daniels, Elvan; Quarshie, Alexander; Boumbulian, Paul; Strothers, Harry
Context: Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. Purpose: We compared uninsured ED visit rates between rural…
Uva, Jane L.; Wagner, Victoria L.; Gesten, Foster C.
Purpose: This study examines variation in emergency department reliance (EDR) between rural and metro pediatric Medicaid patients in New York State for noninjury, nonpoisoning primary diagnoses and seeks to determine the relationship between receipt of preventive care and the likelihood of EDR. Methods: Rural/urban designations were based on Urban…
Stephens, Caroline E.; Newcomer, Robert; Blegen, Mary; Miller, Bruce; Harrington, Charlene
Purpose: To examine the 1-year prevalence and risk of emergency department (ED) use and ambulatory care-sensitive (ACS) ED use by nursing home (NH) residents with different levels of severity of cognitive impairment (CI). Design and Methods: We used multinomial logistic regression to estimate the effect of CI severity on the odds of any ED visit…
Nugus, Peter; Forero, Roberto; McCarthy, Sally; McDonnell, Geoff; Travaglia, Joanne; Hilman, Ken; Braithwaite, Jeffrey
Emergency department (ED) overcrowding reduces efficiency and increases the risk of medical error leading to adverse events. Technical solutions and models have done little to redress this. A full year's worth of ethnographic observations of patient flow were undertaken, which involved making hand-written field-notes of the communication and activities of emergency clinicians (doctors and nurses), in two EDs in Sydney, Australia. Observations were complemented by semi-structured interviews. We applied thematic analysis to account for the verbal communication and activity of emergency clinicians in moving patients through the ED. The theoretical model that emerged from the data analysis is the ED "carousel". Emergency clinicians co-construct a moving carousel which we conceptualise visually, and which accounts for the collective agency of ED staff, identified in the findings. The carousel model uniquely integrates diagnosis, treatment and transfer of individual patients with the intellectual labour of leading and coordinating the department. The latter involves managing staff skill mix and the allocation of patients to particular ED sub-departments. The model extends traditional patient flow representations and underlines the importance of valuing ethnographic methods in health services research, in order to foster organisational learning, and generate creative practical and policy alternatives that may, for example, reduce or ameliorate access block and ED overcrowding.
De Paor, D. G.
As every academic administrator stresses in interviews with new faculty, the role of a professor today involves balancing three areas - teaching, research, and service. Few institutions can afford the old policy of promoting and tenuring faculty based solely on research output and grantsmanship, whilst ignoring poor teaching outcomes. Outreach activities involving parents and the extramural community are increasingly important as expensive universities and four-year colleges seek to demonstrate their relevance in the age of much less expensive community colleges and distance education. Nevertheless, many faculty complain that teaching and outreach duties compete for their valuable research time. Some fields of research have such broad impacts that they merit the dedicated time of our best scientists. However, other research projects constitute little more than publicly funded professorial hobbies. The challenge is to reliably identify and prioritize the research questions that merit investigation. IN ODU's geospatial visualization group, we instituted a policy requiring Ph.D. theses to include a component (at least one chapter) dedicated to the development and testing of learning resources. TAs test visualizations in their lab sections in tandem with their research studies. They must incorporate original geophysical mapping, modeling, and/or analysis in order to justify a degree in the Physics Department (the traditional home of Geophysics at our institution) rather than, say, the College of Education. Geospatial graduate students also train to offer planetarium presentations to the public using digital full-dome projection technology that can be used with a wide range of geoscience and planetary science topics. Thus they tackle the three aspects of academic work from the outset. In contrast, students in other programs frequently serve as TAs in their first and then switch to grant-supported RA work, resulting in a steady stream of new TAs with little or no
Smith, Andrew A; Carusone, Soo B Chan; Willison, Kathleen; Babineau, Tamara J; Smith, Stephanie D; Abernathy, Tom; Marrie, Tom; Loeb, Mark
Background Despite the recent growth in home health services, data on clinical outcomes and acute health care utilization among older adults receiving homecare services are sparse. Obtaining such data is particularly relevant in Ontario where an increasing number of frail seniors receiving homecare are awaiting placement in long-term care facilities. In order to determine the feasibility of a large-scale study, we conducted a pilot study to assess utilization of acute health care services among seniors receiving homecare to determine associated clinical outcomes. Methods This prospective cohort study followed forty-seven seniors admitted to homecare by two homecare agencies in Hamilton, Ontario over a 12-month period. Demographic information and medical history were collected at baseline, and patients were followed until either termination of homecare services, death, or end of study. The primary outcome was hospitalization. Secondary outcomes included emergency department visits that did not result in hospitalization and death. Rates of hospitalization and emergency department visits without admission were calculated, and univariate analyses were performed to test for potential risk factors. Survival curves for accumulative rates of hospitalization and emergency department visits were created. Results 312 seniors were eligible for the study, of which 123 (39%) agreed to participate initially. After communicating with the research nurse, of the 123 who agreed to participate initially, 47 (38%) were enrolled in the study. Eleven seniors were hospitalized during 3,660 days of follow-up for a rate of 3.0 incident hospitalizations per 1,000 homecare-days. Eleven seniors had emergency department visits that did not result in hospitalization, for a rate of 3.3 incident emergency department visits per 1,000 homecare-days. There were no factors significantly associated with hospitalization or emergency department visits when adjustment was made for multiple comparisons
Pediatric information seeking behaviour, information needs, and information preferences of health care professionals in general emergency departments: Results from the Translating Emergency Knowledge for Kids (TREKK) Needs Assessment.
Scott, Shannon D; Albrecht, Lauren; Given, Lisa M; Hartling, Lisa; Johnson, David W; Jabbour, Mona; Klassen, Terry P
The majority of children requiring emergency care are treated in general emergency departments (EDs) with variable levels of pediatric care expertise. The goal of the Translating Emergency Knowledge for Kids (TREKK) initiative is to implement the latest research in pediatric emergency medicine in general EDs to reduce clinical variation.
Brandenburg, M A; Brown, S J; Arneson, W L; Arneson, D L
On June 15, 2004, Oklahoma became the first state to reclassify pseudoephedrine as a Schedule V drug. Arrests in Oklahoma for the manufacture of methamphetamines in clandestine laboratories precipitously declined. It was hypothesized that a decrease in methamphetamine use could be shown in the patient population in Oklahoma's largest emergency department. To test this hypothesis, all urine drug screen results in the Saint Francis Hospital Trauma Emergency Center from January 2003 through May 2005 were reviewed. There was a significant increase in the total tests performed and the percentage of positive test results for the amphetamine drug class (p = 0.0004, R2 = 0.3785) over time. These results suggest that methamphetamine usage has not decreased in the emergency department patient population. Possibly, methamphetamine usage in Oklahoma has not been impacted by the passage of HB 2176 due to an increase in drug trafficking of methamphetamine into the state.
Messina, Gabriele; Vencia, Francesco; Mecheroni, Silvana; Dionisi, Susanna; Baragatti, Lorenzo; Nante, Nicola
Background: In the emergency department satisfaction is strictly linked to the role of the nurses, namely the first interface between patients and hospital services. Objectives: The purpose of the study was to identify areas of emergency nursing activity associated with minor or major patient satisfaction. Methods: A descriptive cross-sectional study was conducted from December 2010 - May 2011, in the rural hospital of Orbetello, Tuscany (Italy). Convenience sampling was used to select patients, namely patients presenting at the emergency unit in the study period. The Consumer Emergency Care Satisfaction Scale was used to collect information on two structured subscale (Caring and Teaching). Results: 259 questionnaire were collected. Analysis indicated that only two characteristics significantly influenced overall satisfaction: “receiving continuous information from personnel about delay” positively effect (OR=7.98; p=0.022) while “waiting time for examination” had a negative effect (OR 0.42; p=0.026) Conclusions: The study was the first conduced in Italy using this instrument that enabled to obtain much important information about patient satisfaction with nursing care received in the emergency department. The results showing improvements must be related to educational aspects, such as explaining patients the colour waiting list, and communication towards patients, such as informing about emergences that cause queue. PMID:25946915
Rafiq, Muhammad Salman; Rafiq, Maria; Rafiq, Muhammad Imran; Salman, Seema Gul; Hafeez, Sania
Introduction Pre-operative investigations for emergency surgical patients differ between centers. Following established guidelines can reduce unnecessary investigation, cost of treatment and hospital stay. The present audit was carried out to evaluate the condition of doing pre-operative investigations for three common surgical emergencies compared to National Institute for Health and Care Excellence (NICE) guidelines and local criteria. Methods A retrospective clinical audit of acute-appendicitis, abscess and hernia patients admitted to the emergency department was carried out over a one-year period from July 2014 to July 2015. Data of laboratory investigations, their indication, cost and duration of hospital stay was collected and compared with NICE-guidelines. Results A total of 201 patients were admitted to the emergency department during the audit period. These included 77(38.3%) cases of acute-appendicitis, 112 (55.7%) cases of abscesses, and 12 (6%) cases of hernia. Investigations not indicated by NICE-guidelines included 42 (20.9%) full blood counts, 29 (14.4%) random blood sugars, 26 (12.9%) urea tests, 4 (2%) chest x-rays, 13 (6.5%) electrocardiographs, and 58 (28.9%) urine analyses. These cost 25,675 Rupees (245.46 Dollars) in unnecessary investigation costs and 65.7 days of additional hospital stay. Conclusions Unnecessary investigations for emergency surgical patients can be reduced by following NICE-guidelines. This will reduce workload on emergency services, treatment costs and the length of hospital stay. PMID:28286827
Krimm, John; Heinzer, Marjorie M
Victims of domestic violence appeal to the health care system through emergency room visits for injuries related to violent episodes or for proxy care for other complaints. Screening for persons who are at high risk for violence or who are victims of violence has not been performed in emergency rooms when patients present for care, nor have all health care professionals been educated in the ways to ask the questions and assess the patients. The questions for identifying domestic violence victims have not been routinely asked on admission to the emergency department, and documentation of this information is not consistent. The purpose of this survey study was to identify the numbers and characteristics of adult victims of domestic violence who present to the emergency department of an urban community medical center during a 1 0-day period to estimate the extent of the domestic violence in the community served by the acute care facility. Findings demonstrated that emergency department staff had difficulty asking the questions, and the responsibility for the screening was relegated to the triage nurse. Questions were not asked of each adult presenting to the emergency department, and health care staff identified various reasons for their resistance. Although only 12% of persons were screened and only during the hours of 0700 through 1900, positive screens for physical abuse were found in 24.6% (n = 20) of the 81 women screened. Routine screening of all patients and sensitivity to the needs of those who have experienced domestic violence are integral to prevention and safety of those who are victimized. Injury prevention programs can then be instituted in the community with the collaborative efforts of local citizen groups and the health care facility.
Background Acute poisoning is one of the most common reasons for emergency department visits around the world. In Pakistan, the epidemiological data on poisoning is limited due to an under developed poison information surveillance system. We aim to describe the characteristics associated with intentional and unintentional poisoning in Pakistan presenting to emergency departments. Methods The data was extracted from the Pakistan National Emergency Department Surveillance (Pak-NEDS) which was an active surveillance conducted between November 2010 and March 2011. All patients, regardless of age, who presented with poisoning to any of Pakistan's seven major tertiary care centers' emergency departments, were included. Information about patient demographics, type of poisoning agent, reason for poisoning and outcomes were collected using a standard questionnaire. Results Acute poisoning contributed to 1.2% (n = 233) of patients with intentional and unintentional injuries presenting to EDs of participating centers. Of these, 68% were male, 54% were aged 19 to 44 and 19% were children and adolescents (<18 years). Types of poisoning included chemical/gas (43.8%), drug/medicine (27%), alcohol (16.7%) and food/plant (6%). In half of all patients the poisoning was intentional. A total of 11.6% of the patients were admitted and 6.6% died. Conclusion Poisoning causes more morbidity and mortality in young adults in Pakistan compared to other age groups, half of which is intentional. Improving mental health, regulatory control for hazardous chemicals and better access to care through poison information centers and emergency departments will potentially help control the problem. PMID:26691609
Heffner, Alan C.; Horton, James M.; Marchick, Michael R.; Jones, Alan E.
Background Patients identified with sepsis in the emergency department often are treated on the basis of the presumption of infection; however, various noninfectious conditions that require specific treatments have clinical presentations very similar to that of sepsis. Our aim was to describe the etiology of illness in patients identified and treated for severe sepsis in the emergency department. Methods We conducted a prospective observational study of patients treated with goal-directed resuscitation for severe sepsis in the emergency department. Inclusion criteria were suspected infection, 2 or more criteria for systemic inflammation, and evidence of hypoperfusion. Exclusion criteria were age of <18 years and the need for immediate surgery. Clinical data on eligible patients were prospectively collected for 2 years. Blinded observers used a priori definitions to determine the final cause of hospitalization. Results In total, 211 patients were enrolled; 95 (45%) had positive culture results, and 116 (55%) had negative culture results. The overall mortality rate was 19%. Patients with positive culture results were more likely to have indwelling vascular lines (P = .03) be residents of nursing homes (P = .04), and have a shorter time to administration of antibiotics in the emergency department (83 vs 97 min; P = .03). Of patients with negative culture results, 44% had clinical infections, 8% had atypical infections, 32% had noninfectious mimics, and 16% had an illness of indeterminate etiology. Conclusion In this study, we found that >50% of patients identified and treated for severe sepsis in the emergency department had negative culture results. Of patients identified with a sepsis syndrome at presentation, 18% had a noninfectious diagnosis that mimicked sepsis, and the clinical characteristics of these patients were similar to those of patients with culture-positive sepsis. PMID:20144044
Tinker, Sarah C; Moe, Christine L; Klein, Mitchel; Flanders, W Dana; Uber, Jim; Amirtharajah, Appiah; Singer, Philip; Tolbert, Paige E
The extent to which drinking water turbidity measurements indicate the risk of gastrointestinal illness is not well understood. Despite major advances in drinking water treatment and delivery, infectious disease can still be transmitted through drinking water in the United States, and it is important to have reliable indicators of microbial water quality to inform public health decisions. The objective of our study was to assess the relationship between gastrointestinal illness, quantified through emergency department visits, and drinking water quality, quantified as raw water and filtered water turbidity measured at the treatment plant. We examined the relationship between turbidity levels of raw and filtered surface water measured at eight major drinking water treatment plants in the metropolitan area of Atlanta, Georgia, and over 240,000 emergency department visits for gastrointestinal illness during 1993-2004 among the population served by these plants. We fit Poisson time-series statistical regression models that included turbidity in a 21-day distributed lag and that controlled for meteorological factors and long-term time trends. For filtered water turbidity, the results were consistent with no association with emergency department visits for gastrointestinal illness. We observed a modest association between raw water turbidity and emergency department visits for gastrointestinal illness. Our results suggest that source water quality may contribute modestly to endemic gastrointestinal illness in the study area. The association between turbidity and emergency department visits for gastrointestinal illness was only observed when raw water turbidity was considered; filtered water turbidity may not serve as a reliable indicator of modest pathogen risk at all treatment plants.
George, G; Ramsay, K; Rochester, M; Seah, R; Spencer, H; Vijayasankar, D; Vasicuro, L
Objective: To audit the facilities for chemical decontamination, with special reference to cyanide poisoning, in all major accident and emergency departments in the UK. Method: A simple postal questionnaire was used to audit planning, premises, equipment, protection for staff, and stocks of specific antidotes to cyanide poisoning. Results: 227 questionnaires from 261 departments (87%) were returned and used in the survey. Of the 227 departments who responded, 151 (66%) had a written plan; 168 (74%) departments had premises for decontamination; 55 (24%) were judged to have satisfactory premises; 146 (64%) departments had a shower or hose for decontamination; 60 (26%) departments had a decontamination trolley suitable for "stretcher" patients; 203 (89%) had some protective equipment for staff but only 77 (34%) had complete protection—that is, goggles, chemical resistant clothing, and breathing apparatus. In the authors' opinion only seven (3%) departments had satisfactory premises and equipment to treat "stretcher" patients and full protection for staff. A further 11 (5%) departments were equipped to manage ambulant patients at a similar level. Some 205 (90%) departments stocked one or more antidotes to cyanide and 77 (34%) stocked all four antidotes. Thirty four (15%) departments held all four antidotes to cyanide and had full protection for staff. Only five (2%) departments had satisfactory premises and equipment to treat "stretcher" patients, full protection for staff, and at least three of four antidotes. Conclusions: Most departments had some equipment for chemical decontamination. However, there were major inconsistencies in the range of equipment held and these limited its usefulness. Only a small minority of departments was satisfactorily equipped to deal with a serious chemical incident. PMID:12205006
Kline, Jeffrey A.; Walthall, Jennifer D.H.
The Patient Protection and Affordable Care Bill, commonly referred to as the “Health Care Bill” or the “Health Care Reform Bill,” became enacted in March, 2010. This article is a review and analysis of the sections of this Act that are relevant to researchers and teachers of emergency care. The purpose of this document is to serve as a citable reference for interested parties and a reference to quickly locate the sections of the Bill relevant to academic emergency physicians. When appropriate, text was copied verbatim from the bill. The source of the downloaded Act, and the page numbers of the text sections, are provided to help the reader to find the sections described. This review is presented in two parts. Part 1 presents 11 sections extirpated from the Act, with short interpretations of the significance of each section. Part II presents an analysis of the sections that the authors believe represent opportunities for emergency care researchers and teachers to make the most impact, through active involvement with the various departments and agencies of the federal government that will be charged with interpreting and implementing this Act. The Act contains sections that could lead to new funding opportunities for research in emergency care, especially for comparative clinical trials and clinical studies that focus on integration and efficiency of health care delivery. The Act will establish several new institutes, centers, and committees that will create policies highly relevant to emergency care. The authors conclude that this Act can be expected to have a profound influence on research and training in emergency care. PMID:20653573
This research examines the emerging academic subculture of international students from East Asia in U.S. academics from the cultural hybridization perspective. In a knowledge-based economy, international education plays a pivotal role in the global educational environment. Advocacy of international student mobility is essential; international…
Horne, Andre Leonard; du Plessis, Yvonne; Nkomo, Stella
This article examines the role of leadership in the development of academic talent in higher education from a social exchange and organizational support perspective. Drawing from a sample of academic staff at a large South African university, the study investigates the extent to which a quality leader-member exchange relationship versus a formal…
Takayesu, James Kimo; Hutson, H Range
Disclosing a new, life-threatening diagnosis to a patient is difficult for the physician, the patient, and the family. The disclosure provokes a wide range of reactions from both the patient and family, to which the emergency physician must respond. This interaction is further complicated by the limited time the emergency physician can spend with the patient, the strained resources of a busy emergency department (ED), and, oftentimes, the inability to make a definitive diagnosis based on the ED workup and evaluation. We present a case seen recently in the ED in which a new, life-threatening illness requires disclosure. We offer guidelines for the emergency physician that emphasize patient- and family-centered disclosure of the worrisome diagnostic findings. Additionally, we discuss the essential roles of other allied health professionals in addressing the patient's nonmedical concerns (eg, health insurance, social issues) and in creating a smooth transition for the patient from the ED to further inpatient or outpatient care.
Syed, Shahbaz; Gatien, Mathieu; Perry, Jeffrey J.; Chaudry, Hina; Kim, Soo-Min; Kwong, Kenneth; Mukarram, Muhammad; Thiruganasambandamoorthy, Venkatesh
BACKGROUND: Most patients with chest pain in the emergency department are assigned to cardiac monitoring for several hours, blocking access for patients in greater need. We sought to validate a previously derived decision rule for safe removal of patients from cardiac monitoring after initial evaluation in the emergency department. METHODS: We prospectively enrolled adults (age ≥ 18 yr) who presented with chest pain and were assigned to cardiac monitoring at 2 academic emergency departments over 18 months. We collected standardized baseline characteristics, findings from clinical evaluations and predictors for the Ottawa Chest Pain Cardiac Monitoring Rule: whether the patient is currently free of chest pain, and whether the electrocardiogram is normal or shows only nonspecific changes. The outcome was an arrhythmia requiring intervention in the emergency department or within 8 hours of presentation to the emergency department. We calculated diagnostic characteristics for the clinical prediction rule. RESULTS: We included 796 patients (mean age 63.8 yr, 55.8% male, 8.9% admitted to hospital). Fifteen patients (1.9%) had an arrhythmia, and the rule performed with the following characteristics: sensitivity 100% (95% confidence interval [CI] 78.2%–100%) and specificity 36.4% (95% CI 33.0%–39.6%). Application of the Ottawa Chest Pain Cardiac Monitoring Rule would have allowed 284 out of 796 patients (35.7%) to be safely removed from cardiac monitoring. INTERPRETATION: We successfully validated the decision rule for safe removal of a large subset of patients with chest pain from cardiac monitoring after initial evaluation in the emergency department. Implementation of this simple yet highly sensitive rule will allow for improved use of health care resources. PMID:28246315
McGeorge, Nicolette; Hegde, Sudeep; Berg, Rebecca L.; Guarrera-Schick, Theresa K.; LaVergne, David T.; Casucci, Sabrina N.; Hettinger, A. Zachary; Clark, Lindsey N.; Lin, Li; Fairbanks, Rollin J.; Benda, Natalie C.; Sun, Longsheng; Wears, Robert L.; Perry, Shawna; Bisantz, Ann
The objective of this work was to assess the functional utility of new display concepts for an emergency department information system created using cognitive systems engineering methods, by comparing them to similar displays currently in use. The display concepts were compared to standard displays in a clinical simulation study during which nurse-physician teams performed simulated emergency department tasks. Questionnaires were used to assess the cognitive support provided by the displays, participants’ level of situation awareness, and participants’ workload during the simulated tasks. Participants rated the new displays significantly higher than the control displays in terms of cognitive support. There was no significant difference in workload scores between the display conditions. There was no main effect of display type on situation awareness, but there was a significant interaction; participants using the new displays showed improved situation awareness from the middle to the end of the session. This study demonstrates that cognitive systems engineering methods can be used to create innovative displays that better support emergency medicine tasks, without increasing workload, compared to more standard displays. These methods provide a means to develop emergency department information systems—and more broadly, health information technology—that better support the cognitive needs of healthcare providers. PMID:27974881
Goodarzi, Hassan; Khatami, Seyed-Masoud; Javadzadeh, Hammidreza; Mahmoudi, Sadrollah; Khajehpour, Hojjatollah; Heidari, Soleiman; Khodaparast, Morteza; Ebrahimi, Ali; Rasouli, Hamidreza; Ghane, Mohammadreza; Faraji, Mehrdad; Hassanpour, Kasra
Background Picture archiving and communication system (PACS) has allowed the medical images to be transmitted, stored, retrieved, and displayed in different locations of a hospital or health system. Using PACS in the emergency department will eventually result in improved efficiency and patient care. In spite of the abundant benefits of employing PACS, there are some challenges in implementing this technology like users’ resistance to accept the technology, which has a critical role in PACS success. Objectives In this study, we will assess and compare user acceptance of PACS in the emergency departments of three different hospitals and investigate the effect of socio-demographic factors on this acceptance. Materials and Methods A variant of technology acceptance model (TAM) has been used in order to measure the acceptance level of PACS in the emergency department of three educational hospitals in Iran. A previously used questionnaire was validated and utilized to collect the study data. A stepwise multiple regression model was used to predict factors influencing acceptance score as the dependent variable. Results Mean age of participants was 32.9 years (standard deviation [SD] = 6.08). Participants with the specialty degree got a higher acceptance score than the three other groups (Mean ± SD = 4.17 ± 0.20). Age, gender, degree of PACS usage and participant’s occupation (profession) did not influence the acceptance score. In our multiple regression model, all three variables of perceived usefulness (PU), perceived ease of use (PEU) and the effect of PACS (change) had a significant effect in the prediction of acceptance. The most influencing factor was change with the beta of 0.22 (P value < 0.001). Conclusion PACS is highly accepted in all three emergency departments especially among specialists. PU, PEU and change are factors influencing PACS acceptance. Our study can be used as an evidence of PACS acceptance in emergency wards. PMID:27679692
Introduction In low- and middle-income countries, injuries are a leading cause of mortality in children. Much work has been done in the context of unintentional injuries but there is limited knowledge about intentional injuries among children. The objective of this paper was to understand the characteristics of children with intentional injuries presenting to emergency departments in Pakistan. Methods The data was from the Pakistan National Emergency Departments Surveillance (Pak-NEDS), conducted from November 2010 to March 2011 in seven major emergency departments of Pakistan. Data on 30,937 children under 18 years of age was collected. This paper reports frequency of intentional injuries and compares patient demographics, nature of injury, and discharge outcome for two categories of intentional injuries: assault and self-inflicted injuries. Results Intentional injuries presenting to the emergency departments (EDs) accounted for 8.2% (2551/30,937) amongst all other causes for under 18 years. The boy to girl ratio was 1:0.35. Intentional injuries included assault (n = 1679, 65.8%) and self-inflicted injuries (n = 872, 34.2%). Soft tissue injuries were most commonly seen in assault injuries in boys and girls but fractures were more common in self-inflicted injuries in both genders. Conclusion Intentional injury is one of the reasons for seeking emergency treatment amongst children and a contributor to morbidity in EDs of Pakistan. Moreover, such injuries may be underestimated due to lack of reporting and investigative resources. Early identification may be the first step leading to prevention. PMID:26692292
Choo, Esther K.; Ranney, Megan L.; Wong, Zerlina; Mello, Michael J.
Technology-based screening and interventions are emerging solutions to the challenge of addressing substance use in the emergency department (ED). A standardized questionnaire of adult patients at a large-volume, urban, academic ED assessed interest in, and potential barriers to, technology-based substance use information. Questionnaire topics included substance use, access to technology, preferences for health information, and perceived barriers to technology interventions. Among the 430 participants, mean age was 39 years and 55% were female; 37% reported alcohol misuse and 52% drug misuse. Access to technology was high. Technology was preferred by 46% of alcohol misusers (vs. 43% non-misusers, p=0.65) but only 41.9% of drug misusers (vs. 56% non-drug misusers, p=0.005). In multivariate analyses, drug misuse was associated with decreased interest in receiving technology-based information. Cited barriers included confidentiality, complexity, and time. Our findings suggest that drug misusers in particular may wish to have reassurances about the confidentiality of technology-based interactions. PMID:23107105
Ever since the terrorist attacks of 9/11, the federal government has increased funding for emergency preparedness. However, the literature continues to document several areas of weaknesses in public health emergency management by local health departments (LHD). This lack of preparedness affects the entire public. The purpose of this study was to determine whether or not Maryland LHDs have effectively put in place the information technology (IT) that is relevant for emergency preparedness. Base Firm-wide IT Infrastructure Services and the Feeny/Willcocks Framework for Core IS Capabilities are the two conceptual frameworks used in this study. This qualitative study used the survey method and the data were analyzed through content analysis. The results revealed that utilization, practice, and performance of IT by Maryland LHDs are not efficient or effective. Recommendations included the development of "best practices," increased funding for IT infrastructure and the establishment of strategic management framework for IT initiatives. Implications for positive social change include the development of recommendations to enhance emergency preparedness practice, and advancement of knowledge so as to facilitate the functions, and duties of health departments in emergency preparedness operations.
Mathes, Robert W.; Ito, Kazuhiko; Matte, Thomas
Background Prospective syndromic surveillance of emergency department visits has been used for near-real time tracking of communicable diseases to detect outbreaks or other unexpected disease clusters. The utility of syndromic surveillance for tracking cardiovascular events, which may be influenced by environmental factors and influenza, has not been evaluated. We developed and evaluated a method for tracking cardiovascular events using emergency department free-text chief complaints. Methodology/Principal Findings There were three phases to our analysis. First we applied text processing algorithms based on sensitivity, specificity, and positive predictive value to chief complaint data reported by 11 New York City emergency departments for which ICD-9 discharge diagnosis codes were available. Second, the same algorithms were applied to data reported by a larger sample of 50 New York City emergency departments for which discharge diagnosis was unavailable. From this more complete data, we evaluated the consistency of temporal variation of cardiovascular syndromic events and hospitalizations from 76 New York City hospitals. Finally, we examined associations between particulate matter ≤2.5 µm (PM2.5), syndromic events, and hospitalizations. Sensitivity and positive predictive value were low for syndromic events, while specificity was high. Utilizing the larger sample of emergency departments, a strong day of week pattern and weak seasonal trend were observed for syndromic events and hospitalizations. These time-series were highly correlated after removing the day-of-week, holiday, and seasonal trends. The estimated percent excess risks in the cold season (October to March) were 1.9% (95% confidence interval (CI): 0.6, 3.2), 2.1% (95% CI: 0.9, 3.3), and 1.8% (95%CI: 0.5, 3.0) per same-day 10 µg/m3 increase in PM2.5 for cardiac-only syndromic data, cardiovascular syndromic data, and hospitalizations, respectively. Conclusions/Significance Near real-time emergency
Neighbour, Ryan; Oppenheimer, Luis; Mukhi, Shamir N.; Friesen, Marcia R.; McLeod, Robert D.
This work extends ongoing development of a framework for modeling the spread of contact-transmission infectious diseases. The framework is built upon Agent Based Modeling (ABM), with emphasis on urban scale modelling integrated with institutional models of hospital emergency departments. The method presented here includes ABM modeling an outbreak of influenza-like illness (ILI) with concomitant surges at hospital emergency departments, and illustrates the preliminary modeling of ‘crowdinforming’ as an intervention. ‘Crowdinforming’, a component of ‘crowdsourcing’, is characterized as the dissemination of collected and processed information back to the ‘crowd’ via public access. The objective of the simulation is to allow for effective policy evaluation to better inform the public of expected wait times as part of their decision making process in attending an emergency department or clinic. In effect, this is a means of providing additional decision support garnered from a simulation, prior to real world implementation. The conjecture is that more optimal service delivery can be achieved under balanced patient loads, compared to situations where some emergency departments are overextended while others are underutilized. Load balancing optimization is a common notion in many operations, and the simulation illustrates that ‘crowdinforming’ is a potential tool when used as a process control parameter to balance the load at emergency departments as well as serving as an effective means to direct patients during an ILI outbreak with temporary clinics deployed. The information provided in the ‘crowdinforming’ model is readily available in a local context, although it requires thoughtful consideration in its interpretation. The extension to a wider dissemination of information via a web service is readily achievable and presents no technical obstacles, although political obstacles may be present. The ‘crowdinforming’ simulation is not limited to
Wiener, Charles M; Thompson, Steven J; Wu, Sandford; Chellappa, Mohan; Hasham, Salim
Governments in emerging markets face mounting challenges in managing health spending, building capability and capacity, modernizing ageing infrastructure, and investing in skills and resources. One path to overcoming these challenges is to establish new public-private models of health care development and delivery based on United States academic medical centers, whose missions are to advance medical education and clinical delivery. Johns Hopkins Medicine is a participant in the collaboration developing between the Perdana University Hospital and the Perdana University Graduate School of Medicine in Malaysia. These two organizations comprise an academic health science center based on the United States model. The Perdana project provides constructive insights into the opportunities and challenges that governments, universities, and the private sector face when introducing new models of patient care that are integrated with medical education, clinical training, and biomedical research.
Lasoff, Daniel R.; Corbett-Detig, Jimmy; Sell, Rebecca; Nolan, Matthew; Wardi, Gabriel
Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis is a novel disease discovered within the past 10 years. Antibodies directed at the NMDAR cause the patient to develop a characteristic syndrome of neuropsychiatric symptoms. Patients go on to develop autonomic dysregulation and often have prolonged hospitalizations and intensive care unit stays. There is little literature in the emergency medicine community regarding this disease process, so we report on a case we encountered in our emergency department to help raise awareness of this disease process. PMID:27330659
Nishijima, Daniel K.; Dinh, Tu; May, Larissa; Yadav, Kabir; Gaddis, Gary M.; Cone, David C.
Purpose Since 2000, Academic Emergency Medicine (AEM), the journal of the Society for Academic Emergency Medicine, has presented a one-day consensus conference to generate a research agenda for advancement of a scientific topic. One of the 12 annual issues of AEM is reserved for the proceedings of these conferences. The purpose of this study was to measure academic productivity of these conferences by evaluating subsequent federal research funding received by authors of conference manuscripts and calculating citation counts of conference papers. Method This was a cross-sectional study conducted during August and September 2012. NIH RePORTER was searched to identify subsequent federal funding obtained by authors of the consensus conference issues from 2000 to 2010. Funded projects were coded as related or unrelated to conference topic. Citation counts for all conference manuscripts were quantified using Scopus and Google Scholar. Simple descriptive statistics were reported. Results 852 individual authors contributed to 280 papers published in the 11 consensus conference issues. 137 authors (16%) obtained funding for 318 projects. A median of 22 topic-related projects per conference (range 10–97 projects) accounted for a median of $20,488,331 per conference (range $7,779,512–122,918,205). The average (±SD) number of citations per paper was 15.7 ±20.5 in Scopus and 23.7 ±32.6 in Google Scholar. Conclusions The authors of consensus conference manuscripts obtained significant federal grant support for follow-up research related to conference themes. In addition, the manuscripts generated by these conferences were frequently cited. Conferences devoted to research agenda development appear to be an academically worthwhile endeavor. PMID:24280853
Lavis, M; Vaghela, A; Tozer, C
Obective—A postal survey was conducted to gain an overview of current opinion and practice relating to intraosseous infusion in adult resuscitation in accident and emergency (A&E) departments in the UK and to use the results to generate debate in light of published and personal experience. Methods—Questionnaires were sent to 559 departments listed in the 1996 British Association for Accident and Emergency Medicine directory. Three hundred and thirty two (59%) were returned and the 157 (28%) consultant led departments with more than 30 000 new patient attendances per year were examined. Results—Seventy four per cent of respondents were aware that intraosseous infusion could be used in adult resuscitation, while only seven per cent used the technique. All (100%) were involved with training their medical staff and 11% said they taught the technique for use in adults. The majority of respondents were accredited in at least one of the adult resuscitation training courses. Conclusions—Numerous references appear in the literature relating to intraosseous infusion in adult resuscitation and represent a wealth of experience. The technique is taught and used in our department in contrast with the results of this survey, which demonstrate that it is infrequently taught and used in UK A&E departments. The more widespread teaching of this technique for adult use is recommended. PMID:10658988
Lyons, Michael S.; Lindsell, Christopher J.; Haukoos, Jason S.; Almond, Gregory; Brown, Jeremy; Calderon, Yvette; Couture, Eileen; Merchant, Roland C.; White, Douglas A.E.; Rothman, Richard E.
Early diagnosis of persons infected with human immunodeficiency virus (HIV) through diagnostic testing and screening is a critical priority for individual and public health. Emergency departments (EDs) have an important role in this effort. As EDs gain experience in HIV testing, it is increasingly apparent that implementing testing is conceptually and operationally complex. A wide variety of HIV testing practice and research models have emerged, each reflecting adaptations to site-specific factors and the needs of local populations. The diversity and complexity inherent in nascent ED HIV testing practice and research are associated with the risk that findings will not be described according to a common lexicon. This article presents a comprehensive set of terms and definitions that can be used to describe ED-based HIV testing programs, developed by consensus opinion from the inaugural meeting of the National ED HIV Testing Consortium. These definitions are designed to facilitate discussion, increase comparability of future reports, and potentially accelerate wider implementation of ED HIV testing. PMID:19076107
Neeki, Michael M.; Dong, Fanglong; Avera, Leigh; Than, Tan; Borger, Rodney; Powell, Joe; Vaezazizi, Reza; Pitts, Richard
Introduction Alternative destination transportation by emergency medical services (EMS) is a subject of hot debate between those favoring all patients being evaluated by an emergency physician (EP) and those recognizing the need to reduce emergency department (ED) crowding. This study aimed to determine whether paramedics could accurately assess a patient’s acuity level to determine the need to transport to an ED. Methods We performed a prospective double-blinded analysis of responses recorded by paramedics and EPs of arriving patients’ acuity level in a large Level II trauma center between April 2015 and November 2015. Under-triage was defined as lower acuity assessed by paramedics but higher acuity by EPs. Over-triage was defined as higher acuity assessed by paramedics but lower acuity by EPs. The degree of agreement between the paramedics and EPs’ evaluations of patient’s acuity level was compared using Chi-square test. Results We included a total of 503 patients in the final analysis. For paramedics, 2 51 (49.9%) patients were assessed to be emergent, 178 (35.4%) assessed as urgent, and 74 (14.7%) assessed as non-emergent/non-urgent. In comparison, the EPs assessed 296 (58.9%) patients as emergent, 148 (29.4%) assessed as urgent, and 59 (11.7%) assessed as non-emergent/non-urgent. Paramedics agreed with EPs regarding the acuity level assessment on 71.8% of the cases. The overall under- and over-triage were 19.3% and 8.9%, respectively. A moderate Kappa=0.5174 indicated moderate inter-rater agreement between paramedics’ and EPs’ assessment on the same cohort of patients. Conclusion There is a significant difference in paramedic and physician assessment of patients into emergent, urgent, or non-emergent/non-urgent categories. The field triage of a patient to an alternative destination by paramedics under their current scope of practice and training cannot be supported. PMID:27833674
Ryan, J; Rushdy, A; Perez-Avila, C A; Allison, R
OBJECTIVE--To determine the risk of suicide in patients attending an accident and emergency (A&E) department with deliberate self harm. METHODS--Information was obtained on suicides and open verdicts from the coroner's office and cross checked with computerised records in the A&E department. RESULTS--There was a trend to suicide among younger socially isolated males and older females. CONCLUSIONS--There is a significant association between suicide and a previous attendance at A&E with deliberate self harm. Appropriate assessment of these patients is an efficient way of managing self harm. PMID:8653229
Cali, Salvatore; Scheff, Peter; Mucha, Amy; Nickels, Leslie; Oliynyk, Irene; Hryhorczuk, Daniel
The Great Lakes Center of Excellence in Environmental Health (GLCEEH), an innovative capacity-building component of the University of Illinois, performs health hazard evaluations in collaboration with the Illinois Department of Public Health and local health departments. GLCEEH has provided state and local health departments with faculty, industrial-hygiene expertise, and research expertise to help them investigate a variety of environmental health issues. This article describes health hazard evaluations performed with support from the National Center for Environmental Health, lessons learned, and recommendations for successful collaboration between academic and public health departments. From the academic perspective, health hazard evaluations are beneficial because they provide faculty and students with the opportunity to engage in public health practice and encounter new issues that advance the science of environmental health through research. From the perspective of a public health department, health hazard evaluations are beneficial because they address priority environmental health concerns and build the capacity of department personnel to conduct health hazard evaluations with internal resources. A collaborative health hazard evaluation program increases public health capacity by developing new approaches to environmental health problems and by sharing limited resources.
Aronson, Ian David; Bania, Theodore C
Computer-based video provides a valuable tool for HIV prevention in hospital emergency departments. However, the type of video content and protocol that will be most effective remain underexplored and the subject of debate. This study employs a new and highly replicable methodology that enables comparisons of multiple video segments, each based on conflicting theories of multimedia learning. Patients in the main treatment areas of a large urban hospital's emergency department used handheld computers running custom-designed software to view video segments and respond to pre-intervention and postintervention data collection items. The videos examine whether participants learn more depending on the race of the person who appears onscreen and whether positive or negative emotional content better facilitates learning. The results indicate important differences by participant race. African American participants responded better to video segments depicting White people. White participants responded better to positive emotional content.
Ajmi, Ines; Zgaya, Hayfa; Hammadi, Slim; Gammoudi, Lotfi; Martinot, Alain; Beuscart, Régis; Renard, Jean-Marie
Patient journey in the Pediatric Emergency Department is a highly complex process. Current approaches for modeling are insufficient because they either focus only on the single ancillary units, or therefore do not consider the entire treatment process of the patients, or they do not account for the dynamics of the patient journey modeling. Therefore, we propose an agent based approach in which patients and emergency department human resources are represented as autonomous agents who are able to react flexible to changes and disturbances through pro-activeness and reactiveness. The main aim of this paper is to present the overall design of the proposed multi-agent system, emphasizing its architecture and the behavior of each agent of the model. Besides, we describe inter-agent communication based on the agent interaction protocol to ensure cooperation between agents when they perform the coordination of tasks for the users. This work is integrated into the ANR HOST project (ANR-11-TecSan-010).
Hughes, H E; Morbey, R; Hughes, T C; Locker, T E; Pebody, R; Green, H K; Ellis, J; Smith, G E; Elliot, A J
Seasonal respiratory infections place an increased burden on health services annually. We used a sentinel emergency department syndromic surveillance system to understand the factors driving respiratory attendances at emergency departments (EDs) in England. Trends in different respiratory indicators were observed to peak at different points during winter, with further variation observed in the distribution of attendances by age. Multiple linear regression analysis revealed acute respiratory infection and bronchitis/bronchiolitis ED attendances in patients aged 1-4 years were particularly sensitive indicators for increasing respiratory syncytial virus activity. Using near real-time surveillance of respiratory ED attendances may provide early warning of increased winter pressures in EDs, particularly driven by seasonal pathogens. This surveillance may provide additional intelligence about different categories of attendance, highlighting pressures in particular age groups, thereby aiding planning and preparation to respond to acute changes in EDs, and thus the health service in general.
Hanson, Aaron; Drendel, Amy L; Ashwal, Gary; Thomas, Alex
The objective of this study was to determine the feasibility of a comic education module in the Emergency Department setting. A convenience sample of 50 injured children and their caregivers were enrolled. The comic was found to be likeable, easy to read, and provided important information to both children and their caregivers. Total time to read the comic was three minutes (SD 1.4, range 1.4-7.1). Most children (60%) read the comic independently, including all children over age 14 years. At 72-hour phone follow-up, 86% of caregivers had accurate recall of all three comic teaching points. This innovative comic educational module is feasible for use for children ages 4-18 years in the Emergency Department. Though this comic was intended to educate children, caregivers recalled all three teaching points 72 hours after discharge.
White, Debra; Kaplan, Louise; Eddy, Linda
This study identifies characteristics of patients who return to the emergency department (ED) within 72 hr after an initial visit. An exploratory quantitative descriptive study was conducted to identify characteristics of patients with unscheduled 72 hr ED returns. The sample consisted of all patients with 72 hr ED return visits for the month of January 2009 at the study facility. Data were collected from electronic patient records utilizing the National Hospital Ambulatory Medical Care Survey instrument modified to eliminate patient identifiers. There were 169 individuals who had at least one 72 hr return visit to the ED for a total of 393 initial and return ED visits. The most common diagnoses were for gastrointestinal complaints. Over a third of the patients who returned had chronic health conditions. There were more emergency department return visits in individuals who lacked access to primary care.
Silva, Marta Maria Alves da; Mascarenhas, Márcio Dênis Medeiros; Lima, Cheila Marina; Malta, Deborah Carvalho; Monteiro, Rosane Aparecida; Freitas, Mariana Gonçalves de; Melo, Alice Cristina Medeiros; Bahia, Camila Alves; Bernal, Regina Tomie Ivata
The Violence and Accidents Survey Conducted in Sentinel Emergency Departments (VIVA Survey) is the sentinel surveillance component of the Violence and Accidents Surveillance System (VIVA). It was conducted for the first time in 2006 and again in 2007, 2009, 2011 and 2014. The sample is comprised of victims of accidents and violence treated in Emergency Departments linked to the Brazilian National Health System (SUS). The services are selected intentionally. This isfollowed by probability sampling of 12-hour shifts by conglomerates in single-stage selection. Data is collected by trained interviewers using a standard form. The variables include data about the service site, the victim, the event, injury and case development. The VIVA Survey provides key information for the implementation of policies for addressing violence and accidents as well as for health and peace promotion policies.
This article draws on concepts of morality and demoralisation to understand the problematic nature of relationships between staff and patients in public health services. The article uses data from a case study of a UK hospital Emergency Department to show how staff are tasked with the responsibility of treating and caring for patients, while at the same time their actions are shaped by the institutional concerns of accountability and resource management. The data extracts illustrate how such competing agendas create a tension for staff to manage and suggests that, as a consequence of this tension, staff participate in processes of ‘effacement' that limit the presence of patients and families as a moral demand. The analysis from the Emergency Department case study suggests that demoralisation is an increasingly important lens through which to understand health-care institutions, where contemporary organisational cultures challenge the ethical quality of human interaction. PMID:26823656
Asfora, Wilson T; Klapper, Hendrik B
Patients with acute or chronic subdural hematomas may present with rapidly deteriorating neurological function and are at risk for irreversible brainstem injury. In such cases, rapid surgical intervention is required to evacuate the hematoma and reverse critically elevated intracranial pressure. A variety of surgical drainage methods are in existence, none of which are clearly superior to the others. This report presents the case of a 74-year-old woman who suffered an acute-on-chronic subdural hematoma which was evacuated in the emergency department utilizing the subdural evacuating port system (SEPS). The SEPS provides for a minimally invasive technique to drain subdural hematomas and is advantageous in that it can be performed at the bedside. The SEPS is relatively simple to use and may be especially useful to emergency department staff in outlying areas where there is a shortage of neurosurgical coverage.
Merchant, Roland C; Gee, Erin M; Bock, Beth C; Becker, Bruce M; Clark, Melissa A
Background Lack of knowledge regarding preventive health services for women might impede campaigns to expand these services in the emergency department setting. For 18–55-year-old English-speaking women visiting an urban emergency department, we aimed to: (1) Ascertain their knowledge regarding the applicability, purpose, and recommended intervals of three women's cancer screening and three contraceptive methods; and (2) Determine if patient age, race/ethnicity, medical insurance status, and current or recent usage of these methods are associated with greater or lesser knowledge about them. Methods Emergency department-based survey on recent or current usage and knowledge about Pap smears, breast self-examinations, mammograms, condoms, birth control, and emergency contraception. Analyses included calculation of summary statistics and creation of multivariable logistic regression models. Results Of 1,100 patients eligible for the study, 69.9% agreed to participate. Most of the participants were < age 35, white, single (never married and no partner), Catholic, and had private medical insurance. Participant's recent or current usage of a particular cancer screening or contraceptive method varied by type of method: Pap smear within the past year (69.1%), breast self-exam within the past month (45.5%), mammogram within the past year (65.7% for women age 45–55), condom usage during every episode of sexual intercourse (15.4%), current usage of birth control pills (17.8%), and ever use of emergency contraception (9.3%). The participants correctly answered 87.9% of all survey questions about condoms, 82.5% about birth control pills, 78.5% about breast self-exams, 52.9% about Pap smears, 35.4% about mammograms, and 25.0% about emergency contraception. In multivariable logistic regression models, survey participants who had private medical insurance and those who recently or currently used a given screening or contraceptive method had a greater odds of correctly answering
Noe, R; Rocha, J; Clavel-Arcas, C; Aleman, C; Gonzales, M; Mock, C
Objectives: To identify and describe the work related injuries in both the formal and informal work sectors captured in an emergency department based injury surveillance system in Managua, Nicaragua. Setting: Urban emergency department in Managua, Nicaragua serving 200–300 patients per day. Methods: Secondary analysis from the surveillance system data. All cases indicating an injury while working and seen for treatment at the emergency department between 1 August 2001 and 31 July 2002 were included. There was no exclusion based on place of occurrence (home, work, school), age, or gender. Results: There were 3801 work related injuries identified which accounted for 18.6% of the total 20 425 injures captured by the surveillance system. Twenty seven work related fatalities were recorded, compared with the 1998 International Labor Organization statistic of 25 occupational fatalities for all of Nicaragua. Injuries occurring outside of a formal work location accounted for more than 60% of the work related injuries. Almost half of these occurred at home, while 19% occurred on the street. The leading mechanisms for work related injuries were falls (30%), blunt objects (28%), and stabs/cuts (23%). Falls were by far the most severe mechanism in the study, causing 37% of the work related deaths and more than half of the fractures. Conclusions: Occupational injuries are grossly underreported in Nicaragua. This study demonstrated that an emergency department can be a data source for work related injuries in developing countries because it captures both the formal and informal workforce injuries. Fall prevention initiatives could significantly reduce the magnitude and severity of occupational injuries in Managua, Nicaragua. PMID:15314050
Choo, Esther K.; Benz, Madeline; Rybarczyk, Megan; Broderick, Kerry; Linden, Judith; Boudreaux, Edwin L.; Ranney, Megan L.
The relationship between gender, violence, and substance use in the emergency department (ED) is complex. This paper examines the role of gender in the intersection of substance use and three types of violence: peer violence, intimate partner violence, and firearm violence. Current approaches to treatment of substance abuse and violence are similar across both genders; however, as patterns of violence and substance abuse differ by gender, interventions may be more effective if they are designed with a specific gender focus. PMID:25421993
Buckler, David L.
The Emergency Department (ED) simulation project was established to demonstrate how requirements-driven analysis and process simulation can help improve the quality of patient care for the Veterans Health Administration's (VHA) Veterans Affairs Medical Centers (VAMC). This project developed a web-based simulation prototype of patient flow in EDs, validated the performance of the simulation against operational data, and documented IT requirements for the ED simulation.
Sulyman, Naseem; Kim, Min Kyeong; Rampa, Sankeerth; Allareddy, Veerasathpurush; Nalliah, Romesh P.; Allareddy, Veerajalandhar
Objective The objectives of the current study are to provide nationally representative estimates of hospital based emergency department visits (ED) attributed to self inflicted injuries and attempted suicides among children in United States; and to identify potential methods of such intentional self inflicted injuries and attempted suicides. Methods The Nationwide Emergency Department Sample (year 2007) was used. All ED visits occurring among children (aged ≤18 years) with an External Cause of Injury for any of self inflicted injuries were selected. Outcomes examined include hospital ED charges and hospitalization charges. All estimates were projected to national levels. Results 77,420 visits to hospital based emergency departments were attributed to self inflicted injuries among children (26,045 males and 51,370 females). The average age of the ED visits was 15.7 years. 134 patients died in ED’s (106 males and 28 females) and 93 died in hospitals following in-patient admission (75 males and 18 females). A greater proportion of male ED visits were discharged routinely as opposed to female ED visits (51.1% versus 44%). A greater proportion of male ED visits also died in the emergency departments compared to female visits (0.4% versus 0.05%). 17,965 ED visits necessitated admission into same hospital. The mean charge for each ED visit was $1,874. Self inflicted injuries by poisoning were the most frequently reported sources accounting for close to 70% of all ED visits. Conclusions Females comprise a greater proportion of ED visits attributed to self inflicted injuries. 227 children died either in the ED’s or in hospitals. The current study results highlight the burden associated with such injuries among children. PMID:23875006
Sarver, Joshua; Baker, David W
OBJECTIVE To determine whether patients who encountered language barriers during an emergency department visit were less likely to be referred for a follow-up appointment and less likely to complete a recommended appointment. DESIGN Cohort study. SETTING Public hospital emergency department. PARTICIPANTS English- and Spanish-speaking patients (N =714) presenting with nonemergent medical problems. MEASUREMENTS AND MAIN RESULTS Patients were interviewed to determine sociodemographic information, health status, whether an interpreter was used, and whether an interpreter should have been used. The dependent variables were referral for a follow-up appointment after the emergency department visit and appointment compliance, as determined by chart review and the hospital information system. The proportion of patients who received a follow-up appointment was 83% for those without language barriers, 75% for those who communicated through an interpreter, and 76% for those who said an interpreter should have been used but was not (P =.05). In multivariate analysis, the adjusted odds ratio for not receiving a follow-up appointment was 1.92 (95% confidence interval [CI], 1.11 to 3.33) for patients who had an interpreter and 1.79 (95% CI, 1.00 to 3.23) for patients who said an interpreter should have been used (compared with patients without language barriers). Appointment compliance rates were similar for patients who communicated through an interpreter, those who said an interpreter should have been used but was not, and those without language barriers (60%, 54%, and 64%, respectively; P =.78). CONCLUSIONS Language barriers may decrease the likelihood that a patient is given a follow-up appointment after an emergency department visit. However, patients who experienced language barriers were equally likely to comply with follow-up appointments. PMID:10760001
Read, Jen'nan Ghazal; Varughese, Shinu; Cameron, Peter A.
Background: The use of emergency department (ED) services for non-urgent conditions is well-studied in many Western countries but much less so in the Middle East and Gulf region. While the consequences are universal—a drain on ED resources and poor patient outcomes—the causes and solutions are likely to be region and country specific. Unique social and economic circumstances also create gender-specific motivations for patient attendance. Alleviating demand on ED services requires understanding these circumstances, as past studies have shown. We undertook this study to understand why female patients with low-acuity conditions choose the emergency department in Qatar over other healthcare options. Setting and design: Prospective study at Hamad General Hospital's (HGH) emergency department female “see-and-treat” unit that treats low-acuity cases. One hundred female patients were purposively recruited to participate in the study. Three trained physicians conducted semi-structured interviews with patients over a three-month period after they had been treated and given informed consent. Results: The study found that motivations for ED attendance were systematically influenced by employment status as an expatriate worker. Forty percent of the sample had been directed to the ED by their employers, and the vast majority (89%) of this group cited employer preference as the primary reason for choosing the ED. The interviews revealed that a major obstacle to workers using alternative facilities was the lack of a government-issued health card, which is available to all citizens and residents at a nominal rate. Conclusion: Reducing the number of low-acuity cases in the emergency department at HGH will require interventions aimed at encouraging patients with non-urgent conditions to use alternative healthcare facilities. Potential interventions include policy changes that require employers to either provide workers with a health card or compel employees to acquire one for
Richards, David B; Wang, George S; Buchanan, Jennie A
Tea tree oil is an essential oil containing a mixture of aromatic hydrocarbons. We describe an 18-month-old male patient who ingested tea tree oil, developed central nervous system depression, respiratory distress, and received early emergency department treatment with surfactant. Early treatment of hydrocarbon pneumonitis with surfactant has not been previously described. Early administration of surfactant should be further evaluated for treatment of hydrocarbon aspiration.
Gras-Le Guen, Christéle; Levieux, Karine; Lucas, Valérie; Vrignaud, Bénédicte
The regular exceeding of the capacities of paediatric emergency departments in periods of epidemics disrupts the organisation of the management of seriously ill children and compromises the quality of the reception given to these children and their families. This recurring phenomenon raises the need for an analysis of the determining factors in order to find ways to improve the system and anticipate this period of the year which constitutes a real challenge for nursing teams.
Freeman, M; Zack, E
The "geriatric triage" approach for management of the most complex frail older adult population by geriatric nurses in the emergency department setting was a benefit to the patient/family and the health care system. The patients, through assessment and individualized plans of care, received the right care in the right setting. Seniors were assessed and their care planned by health care professionals who had geriatric knowledge, understood the complexity of their problems, and acted as their advocate. Geriatric triaging resulted in benefits across the health care system. Resources were used effectively. Patients received care in the most appropriate and cost-efficient setting. This new and creative approach served as a catalyst for improvement in services and care for the senior population. Health care workers in the hospitals as well as the community increased their knowledge of geriatrics through consultation with this service. The community and hospitals had a formal linkage, which provided an opportunity for collaboration and continuity of care. The hospital system experienced decreased competition for scarce acute care beds due to diverted admissions. The emergency department had consultants to assist with the decision-making for this high-risk population and decreased the number of patients held in emergency department awaiting an inpatient bed. The community system received patients with a comprehensive plan of care that provided creative and innovative care management strategies. Home care adapted its service to respond with immediate services to assist with health crises in addition to what had been traditionally available. The finding of this study supports a new approach to care of the elderly and chronically ill population who present to the emergency department in health crisis. Creative strategies are required to meet the needs of the aging population in these times of fiscal restraint. The nursing geriatric triage service is one strategy that holds
Anderson, Robert S; Hallen, Sarah A M
Generalized weakness in the geriatric patient is a vexing chief compliant to address in any setting, especially in the hectic emergency department. Studies suggest that it is associated with poor outcomes, although the ideal workup is elusive. A minimum of laboratory and imaging testing is recommended with the addition of neuroimaging if focal weakness is discovered. Considering a wide differential with attention to geriatric-specific concerns is labor intensive but necessary for this presentation.
Hotch, D; Grunfeld, A F; Mackay, K; Cowan, L
This article reports findings from the first year of operation of an emergency department-based domestic violence intervention program in one of Canada's major metropolitan areas. The program has established methods for identifying, treating, and following up battered women. Information on several key variables is now available for the group of 279 individuals who were the program's first patients. Two out of three (68%) of the patients seen were assaulted by their current spouse. Nine percent (9%) were abused by former spouses from whom they were separated or divorced. Twelve percent (12%) were assaulted by someone they were dating. Women in the program who were abused by a former or current spouse experienced severe violence, with 81% being kicked, bitten, or hit; 60% being pushed, grabbed, or shoved; 55% being threatened; and 30% being choked. Follow-up connection could only be made with 140 women (50%), highlighting the need for focused interventions during the emergency department visit. The findings confirm that women are being injured, often seriously, by those with whom they have close relationships. We present a program for addressing the needs of battered women seen in emergency departments.
Lopes, Maria Carolina Barbosa Teixeira; Lage, Julieth Santana Silva; Vancini-Campanharo, Cássia Regina; Okuno, Meiry Fernanda Pinto; Batista, Ruth Ester Assayag
ABSTRACT Objective: To assess the functional capacity of elderly patients in the emergency department as to Basic and Instrumental Activities of Daily Living. Methods: A cross-sectional study of 200 elderly patients admitted to the emergency department of a teaching hospital in São Paulo (SP), Brazil. The functional capacity of the elderly was assessed by the Katz index and Lawton & Brody scale. Statistical analyses were performed using analysis of variance, Bonferroni correction, χ2 test, or the likelihood ratio test. Results: Most seniors were independent (65%), and the degree of dependence was related to age, female gender, being single and widowed, and presence of cerebrovascular disease and dementia. The more dependent elderly for Instrumental Activities of Daily Living had increased dependence for Basic Activities. Conclusion: We emphasize the importance of assessing the functional capacity of the elderly in the emergency department as it provides data for the nursing care in order to minimize or to avoid their functional impairment. PMID:26154541
Maddineshat, Maryam; Rosenstein, Alan H; Akaberi, Arash; Tabatabaeichehr, Mahbubeh
Introduction: Disruptive behaviors cause many problems in the workplace, especially in the emergency department (ED).This study was conducted to assess the physician’s and nurse’s perspective toward disruptive behaviors in the emergency department. Methods: In this cross-sectional study a total of 45 physicians and 110 nurses working in the emergency department of five general hospitals in Bojnurd participated. Data were collected using a translated, changed, and validated questionnaire (25 item). The collected data were analyzed by SPSS ver.13 software. Results: Findings showed that physicians gave more importance to nurse-physician relationships in the ED when compared to nurses’ perspective (90% vs. 70%). In this study, 81% of physicians and 52% of nurses exhibited disruptive behaviors. According to the participants these behaviors could result in adverse outcomes, such as stress (97%), job dissatisfaction and can compromise patient safety (53%), quality of care (72%), and errors (70%). Conclusion: Disruptive behaviors could have a negative effects on relationships and collaboration among medical staffs, and on patients’ quality of care as well. It is essential to provide some practical strategies for prevention of these behaviors. PMID:27752490
Considine, Julie; Lucas, Elspeth; Martin, Roslyn; Stergiou, Helen E; Kropman, Matthew; Chiu, Herman
The impact of emergency nursing roles in demand management systems is poorly understood. The aim of this study was to evaluate emergency nurses' role in a specific emergency department (ED) demand management system: rapid intervention and treatment zone (RITZ). A descriptive exploratory approach was used. Data were collected from audit of 193 randomly selected patient records and 12 h of clinical practice observation. The median age of participants was 31 years, 51.8% were males and 99.5% were discharged home. Nurse qualifications or seniority had no significant effect on waiting time or length of stay (LOS). There were disparities between documented and observed nursing practice. The designation and qualifications of RITZ nurses made little difference to waiting times and ED LOS. Specific documentation and communication systems for areas of the ED that manage large numbers of low complexity patients warrant further research.
Yamamoto, Loren G; Manzi, Shannon; Shaw, Kathy N; Ackerman, Alice D; Chun, Thomas H; Conners, Gregory P; Dudley, Nanette C; Fein, Joel A; Fuchs, Susan M; Moore, Brian R; Selbst, Steven M; Wright, Joseph L
Although most health care services can and should be provided by their medical home, children will be referred or require visits to the emergency department (ED) for emergent clinical conditions or injuries. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of and compliance with follow-up instructions and on adherence to medication recommendations. ED visits often occur at times when the majority of pharmacies are not open and caregivers are concerned with getting their ill or injured child directly home. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing ED discharge medications from the ED's outpatient pharmacy within the facility is a major convenience that overcomes this obstacle, improving the likelihood of medication adherence. Emergency care encounters should be routinely followed up with primary care provider medical homes to ensure complete and comprehensive care.
Bui, Quan M; Simpson, Scott; Nordstrom, Kimberly
We use a case report to describe the acute psychiatric and medical management of marijuana intoxication in the emergency setting. A 34-year-old woman presented with erratic, disruptive behavior and psychotic symptoms after recreational ingestion of edible cannabis. She was also found to have mild hypokalemia and QT interval prolongation. Psychiatric management of cannabis psychosis involves symptomatic treatment and maintenance of safety during detoxification. Acute medical complications of marijuana use are primarily cardiovascular and respiratory in nature; electrolyte and electrocardiogram monitoring is indicated. This patient's psychosis, hypokalemia and prolonged QTc interval resolved over two days with supportive treatment and minimal intervention in the emergency department. Patients with cannabis psychosis are at risk for further psychotic sequelae. Emergency providers may reduce this risk through appropriate diagnosis, acute treatment, and referral for outpatient care.
Bui, Quan M.; Simpson, Scott; Nordstrom, Kimberly
We use a case report to describe the acute psychiatric and medical management of marijuana intoxication in the emergency setting. A 34-year-old woman presented with erratic, disruptive behavior and psychotic symptoms after recreational ingestion of edible cannabis. She was also found to have mild hypokalemia and QT interval prolongation. Psychiatric management of cannabis psychosis involves symptomatic treatment and maintenance of safety during detoxification. Acute medical complications of marijuana use are primarily cardiovascular and respiratory in nature; electrolyte and electrocardiogram monitoring is indicated. This patient’s psychosis, hypokalemia and prolonged QTc interval resolved over two days with supportive treatment and minimal intervention in the emergency department. Patients with cannabis psychosis are at risk for further psychotic sequelae. Emergency providers may reduce this risk through appropriate diagnosis, acute treatment, and referral for outpatient care. PMID:25987916
Clark, Lindsey N; Benda, Natalie C; Hegde, Sudeep; McGeorge, Nicolette M; Guarrera-Schick, Theresa K; Hettinger, A Zachary; LaVergne, David T; Perry, Shawna J; Wears, Robert L; Fairbanks, Rollin J; Bisantz, Ann M
This article presents an evaluation of novel display concepts for an emergency department information system (EDIS) designed using cognitive systems engineering methods. EDISs assist emergency medicine staff with tracking patient care and ED resource allocation. Participants performed patient planning and orientation tasks using the EDIS displays and rated the display's ability to support various cognitive performance objectives along with the usability, usefulness, and predicted frequency of use for 18 system components. Mean ratings were positive for cognitive performance support objectives, usability, usefulness, and frequency of use, demonstrating the successful application of design methods to create useful and usable EDIS concepts that provide cognitive support for emergency medicine staff. Nurse and provider roles had significantly different perceptions of the usability and usefulness of certain EDIS components, suggesting that they have different information needs while working.
Giuse, Nunzia B; Storrow, Alan B
Objective: This pilot study explored whether learning style–tailored education materials, “information prescriptions,” are effective in increasing hypertension knowledge in emergency room patients. Methods: In a randomized trial, hypertensive emergency medicine patients received either standard care discharge instructions or discharge instructions in combination with an information prescription individualized to each patient's learning-style preference. Two weeks post-visit, the study team assessed changes in hypertension knowledge via a survey. Results: No significant difference was observed for changes in quiz scores on the hypertension knowledge assessment, though patients receiving the tailored information prescriptions reported higher levels of satisfaction with intervention materials. Conclusion: The study demonstrated the workflow feasibility of implementing a learning-style approach to patient education in the emergency department setting. Further research is needed to develop more robust measures of high blood pressure knowledge among the emergency department patient population. This work will contribute to establishing a framework for developing customized information prescriptions that can be broadly adapted for use in varied settings and with varied health care conditions. PMID:22022222
Chinnis, A; White, K R
Chaos is order without predictability (1 ). Any unfortunate patient who has recently made a trek to an Emergency Department (ED) or even better, has watched the immensely popular TV show, ER, knows that the visit can be a frustrating and a time consuming experience. The waits are so protracted that one can observe all cycles of birth, death, love, and romance in the waiting room. The process is tedious for the patient who must tell one's tale to a triage nurse, a registration clerk, the primary nurse, the nursing care partner, and finally the emergency physician. Then, the patient must face more delays while being pushed, ineffectively, in a horizontal fashion, through vertical functional silos of care, such as laboratory and radiology. The mind-set or dominant logic of this system of ED patient flow assumes that waits are acceptable and unavoidable, and that the function of the ED is to care for only the truly emergent patient. This dominant logic, coupled with the market constraints of population-based versus case-based payment mechanisms, has led to a declining trend in ED visits for the first time in 20 years (2). In order to improve the quality of ED care as well as to increase acceptability for patient and payer, the dominant logic must be challenged. An understanding of chaos theory and perception of the Emergency Department as a complex adaptive system foster methods for challenging the dominant logic.
Thompson, L.; Bertram, M. A.
Education on climate change occurs in many departments at large research universities, but providing a coordinated educational experience for students in this topic is challenging. Departmental boundaries, accounting for student credit hours, and curricula inertia create roadblocks to the creation of interdisciplinary curriculum for both graduate and undergraduate students. We describe a hierarchy of interdisciplinary programs that reach students from seniors in high school to graduate students, targeting students from a variety of disciplines. The UWHS (University of Washington in the High School) program allows high school teachers to be trained to teach UW courses to their own high school students at their own school. The students who enroll receive a UW grade and credit for the course (as well as high school credit). A UWHS course on Climate and Climate Change (Atmospheric Sciences 211) was created in 2011 supported by training to high school science teachers on the fundamentals of climate science. For the 2012-13 academic year we anticipate at least 5 schools in Washington State will be offering this course. Once students matriculate at UW, 211 serves as a prerequisite for the Climate Minor that began in 2011. The minor is hosted by the departments of Atmospheric Sciences, Earth and Space Sciences and Oceanography, offering instruction in three focus areas: climate chemistry and biology, the physical climate, and past climate and ice. Students also take an integrative seminar where they are required to communicate to both scientific and non-scientific audiences some topic in climate science. Students enrolled in graduate programs at UW can participate in the Graduate Certificate in Climate Science that began 2008. The certificate gives students instruction in climate science covering the same topic areas as the minor and with a capstone project where student communicate some aspect of climate science to a non-physical science audience. Projects have included
Welch, Shari J; Asplin, Brent R; Stone-Griffith, Suzanne; Davidson, Steven J; Augustine, James; Schuur, Jeremiah
There is a growing mandate from the public, payers, hospitals, and Centers for Medicare & Medicaid Services (CMS) to measure and improve emergency department (ED) performance. This creates a compelling need for a standard set of definitions about the measurement of ED operational performance. This Concepts article reports the consensus of a summit of emergency medicine experts tasked with the review, expansion, and update of key definitions and metrics for ED operations. Thirty-two emergency medicine leaders convened for the Second Performance Measures and Benchmarking Summit on February 24, 2010. Before arrival, attendees were provided with the original definitions published in 2006 and were surveyed about gaps and limitations in the original work. According to survey responses, a work plan to revise and update the definitions was developed. Published definitions from key stakeholders in emergency medicine and health care were reviewed and circulated. At the summit, attendees discussed and debated key terminology and metrics and work groups were created to draft the revised document. Workgroups communicated online and by teleconference to reach consensus. When possible, definitions were aligned with performance measures and definitions put forth by the CMS, the Emergency Nurses Association Consistent Metrics Document, and the National Quality Forum. The results of this work are presented as a reference document.
Ballard, Dustin W.; Price, Mary; Fung, Vicki; Brand, Richard; Reed, Mary E.; Fireman, Bruce; Newhouse, Joseph P.; Selby, Joseph V.; Hsu, John
Background Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED) visit severity algorithm attempts to classify visits to the ED based on diagnosis, but it has not been formally validated. Objective To assess the validity of the NYU algorithm. Research Design: A longitudinal study in a single integrated delivery system (IDS) from January 1999 to December 2001. Subjects 2,257,445 commercial and 261,091 Medicare members of an IDS. Measures ED visits were classified as emergent, non-emergent, or intermediate severity, using the NYU ED algorithm. We examined the relationship between visit-severity and the probability of future hospitalizations and death using a logistic model with a general estimating equation (GEE) approach. Results Among commercially insured subjects, ED visits categorized as emergent were significantly more likely to result in a hospitalization within one-day (OR=3.37, 95% CI: 3.31–3.44) or death within 30-days (OR=2.81, 95% CI: 2.62–3.00) than visits categorized as non-emergent. We found similar results in Medicare patients and in sensitivity analyses using different probability thresholds. ED overuse for non-emergent conditions was not related to socio-economic status or insurance type. Conclusions The evidence presented supports the validity of the NYU ED visit severity algorithm for differentiating ED visits based on need for hospitalization and/or mortality risk; therefore, it can contribute to evidence-based policies aimed at reducing the use of the ED for non-emergencies. PMID:19952803
Chi, Donald L.; Masterson, Erin E.; Wong, Jacqueline J.
The authors hypothesized that individuals with intellectual and developmental disabilities (IDDs) are more likely to have an emergency department (ED) admission for nontraumatic dental conditions (NTDCs). The authors analyzed 2009 U.S. National Emergency Department Sample data and ran logistic regression models for children ages 3-17 years and…
... Outpatient medical services for Department of Veterans Affairs employees and others in emergencies. Outpatient medical services for which charges shall be made as required by § 17.101 may be authorized for... services for Department of Veterans Affairs employees and others in emergencies. 17.95 Section...
... Outpatient medical services for Department of Veterans Affairs employees and others in emergencies. Outpatient medical services for which charges shall be made as required by § 17.101 may be authorized for... services for Department of Veterans Affairs employees and others in emergencies. 17.95 Section...