Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED.

PubMed

Hayden, Geoffrey E; Tuuri, Rachel E; Scott, Rachel; Losek, Joseph D; Blackshaw, Aaron M; Schoenling, Andrew J; Nietert, Paul J; Hall, Greg A

2016-01-01

Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes. We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets. We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates. There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates. An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock. Copyright © 2015 Elsevier Inc. All rights reserved.

Emergency department patient satisfaction survey in Imam Reza Hospital, Tabriz, Iran

PubMed Central

2011-01-01

Introduction Patient satisfaction is an important indicator of the quality of care and service delivery in the emergency department (ED). The objective of this study was to evaluate patient satisfaction with the Emergency Department of Imam Reza Hospital in Tabriz, Iran. Methods This study was carried out for 1 week during all shifts. Trained researchers used the standard Press Ganey questionnaire. Patients were asked to complete the questionnaire prior to discharge. The study questionnaire included 30 questions based on a Likert scale. Descriptive and analytical statistics were used throughout data analysis in a number of ways using SPSS version 13. Results Five hundred patients who attended our ED were included in this study. The highest satisfaction rates were observed in the terms of physicians' communication with patients (82.5%), security guards' courtesy (78.3%) and nurses' communication with patients (78%). The average waiting time for the first visit to a physician was 24 min 15 s. The overall satisfaction rate was dependent on the mean waiting time. The mean waiting time for a low rate of satisfaction was 47 min 11 s with a confidence interval of (19.31, 74.51), and for very good level of satisfaction it was 14 min 57 s with a (10.58, 18.57) confidence interval. Approximately 63% of the patients rated their general satisfaction with the emergency setting as good or very good. On the whole, the patient satisfaction rate at the lowest level was 7.7 with a confidence interval of (5.1, 10.4), and at the low level it was 5.8% with a confidence interval of (3.7, 7.9). The rate of satisfaction for the mediocre level was 23.3 with a confidence interval of (19.1, 27.5); for the high level of satisfaction it was 28.3 with a confidence interval of (22.9, 32.8), and for the very high level of satisfaction, this rate was 32.9% with a confidence interval of (28.4, 37.4). Conclusion The study findings indicated the need for evidence-based interventions in emergency care services in areas such as medical care, nursing care, courtesy of staff, physical comfort and waiting time. Efforts should focus on shortening waiting intervals and improving patients' perceptions about waiting in the ED, and also improving the overall cleanliness of the emergency room. PMID:21407998

Two Hour Evaluation and Referral Model for Shorter Turnaround Times in the emergency department.

PubMed

Burke, John A; Greenslade, Jaimi; Chabrowska, Jadwiga; Greenslade, Katherine; Jones, Sally; Montana, Jacqueline; Bell, Anthony; O'Connor, Alan

2017-06-01

The objective of this study was to assess the implementation of a novel ED model of care, which combines clinical streaming, team-based assessment and early senior consultation to reduce length of stay. A pre-post-intervention study was used to compare ED performance following an extensive clinical redesign programme. Clinical teams and work sequences were reconfigured to promote the role of the staff specialist, with a focus on earlier decisions regarding disposition. Primary outcome measures were ED length of stay and National Emergency Access Target (NEAT) compliance. Secondary outcomes included referral and workup times, wait times by triage category, ambulance offload times, ward discharges and unit transfers within 24 h of admission, representation within 48 h, and Medical Emergency Response Team (MERT) calls within 24 h of admission. Two seasonally matched 26 week intervals were compared with adjustment for demographics, triage category and arrival by ambulance. Overall, there was an 18.4% rise in NEAT performance (95% confidence interval (CI): 17.7-19.1) while ED length of stay decreased by a total of 86.8 min (95% CI: 83.6-90.1). Time series analysis did not suggest any preexisting trends to explain these results. The average time to referral decreased by 74.7 min (95% CI: 69.8-79.6) and waiting times decreased across all triage categories. Rates of MERT activation and unplanned representation were unchanged. A facilitated team leader role for senior doctors can help to reduce length of stay by via early disposition, without significant risks to the patient. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

A comparison of multivariate and univariate time series approaches to modelling and forecasting emergency department demand in Western Australia.

PubMed

Aboagye-Sarfo, Patrick; Mai, Qun; Sanfilippo, Frank M; Preen, David B; Stewart, Louise M; Fatovich, Daniel M

2015-10-01

To develop multivariate vector-ARMA (VARMA) forecast models for predicting emergency department (ED) demand in Western Australia (WA) and compare them to the benchmark univariate autoregressive moving average (ARMA) and Winters' models. Seven-year monthly WA state-wide public hospital ED presentation data from 2006/07 to 2012/13 were modelled. Graphical and VARMA modelling methods were used for descriptive analysis and model fitting. The VARMA models were compared to the benchmark univariate ARMA and Winters' models to determine their accuracy to predict ED demand. The best models were evaluated by using error correction methods for accuracy. Descriptive analysis of all the dependent variables showed an increasing pattern of ED use with seasonal trends over time. The VARMA models provided a more precise and accurate forecast with smaller confidence intervals and better measures of accuracy in predicting ED demand in WA than the ARMA and Winters' method. VARMA models are a reliable forecasting method to predict ED demand for strategic planning and resource allocation. While the ARMA models are a closely competing alternative, they under-estimated future ED demand. Copyright © 2015 Elsevier Inc. All rights reserved.

The association between automatic thoughts about eating, the actual-ideal weight discrepancies, and eating disorders symptoms: a longitudinal study in late adolescence.

PubMed

Zarychta, Karolina; Luszczynska, Aleksandra; Scholz, Urte

2014-06-01

This study tested the reciprocal relationships between automatic thoughts about eating and the actual-ideal weight discrepancies, and their role in the formation and maintenance of eating disorders (ED) symptoms in a non-clinical sample of adolescents. In particular, we investigated whether thoughts about eating mediated the effects of weight discrepancies on ED formation and whether weight discrepancies mediated the effects of thoughts about eating on ED formation were investigated. Data were collected three times, with a 2-month interval between Time 1 (T1) and Time 2 (T2), and a 9-month interval between T2 and Time 3 (T3). Adolescents (N = 55) aged 15-18 filled out the SCOFF Questionnaire, assessing eating disorders symptoms, and the Eating Disorder Thoughts Questionnaire, evaluating automatic thoughts. To assess weight discrepancies questions about actual (subjectively reported) and ideal body weight were asked followed by objective measurement of height and weight. Negative thoughts about eating (T2) mediated the relation between weight discrepancies (T1) and symptoms of anorexia and bulimia (T3). In addition, the association between negative thoughts (T1) and eating disorders symptoms (T3) was mediated by weight discrepancies (T2). The negative thoughts and the actual (both subjectively reported and objectively measured)-ideal weight discrepancies constitute a vicious cycle, related to higher ED symptoms. Prevention of eating disorders should be directed to adolescents who manifest large weight discrepancies or high levels of negative thoughts about eating, as they are at risk for developing eating disorder symptoms.

Effects of emergency department expansion on emergency department patient flow.

PubMed

Mumma, Bryn E; McCue, James Y; Li, Chin-Shang; Holmes, James F

2014-05-01

Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding. This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained either from the electronic health record (EHR) or from administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures. The mean (±SD) daily adult volume was 128 (±14) patients before expansion and 145 (±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion versus 8.3% after expansion (difference = 0.6%, 95% confidence interval [CI] = -0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference = 20 hours, 95% CI = 8 to 32 hours). After daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing were adjusted for, the percentage of patients who LWBT was not independently associated with ED expansion (p = 0.053). After ED admissions, ED intensive care unit (ICU) admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds were adjusted for, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005). An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding. © 2014 by the Society for Academic Emergency Medicine.

Marginal analysis in assessing factors contributing time to physician in the Emergency Department using operations data.

PubMed

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

2016-01-01

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 with 22 physicians. Conclusions: The analysis identified expected variables contributing to tMD with regression demonstrating significance and effect magnitude of alterations in covariates including patient census, shift time of day, and number of physicians. Marginal analysis provided operationally useful demonstration of the need to adjust physician coverage numbers, prompting changes at the study ED. The methods used in this analysis may prove useful in other EDs wishing to analyze operations information with the goal of predicting which interventions may have the most benefit.

Should we fear "flu fear" itself? Effects of H1N1 influenza fear on ED use.

PubMed

McDonnell, William M; Nelson, Douglas S; Schunk, Jeff E

2012-02-01

Surges in patient volumes compromise emergency departments' (EDs') ability to deliver care, as shown by the recent H1N1 influenza (flu) epidemic. Media reports are important in informing the public about health threats, but the effects of media-induced anxiety on ED volumes are unclear. The aim of this study is to examine the effect of widespread public concern about flu on ED use. We reviewed ED data from an integrated health system operating 18 hospital EDs. We compared ED visits during three 1-week periods: (a) a period of heightened public concern regarding flu before the disease was present ("Fear Week"), (b) a subsequent period of active disease ("Flu Week"), and (c) a week before widespread concern ("Control Week"). Fear Week was identified from an analysis of statewide Google electronic searches for "swine flu" and from media announcements about flu. Flu Week was identified from statewide epidemiological data. Data were reviewed from 22 608 visits during the study periods. Fear Week (n = 7712) and Flu Week (n = 7687) were compared to Control Week (n = 7209). Fear Week showed a 7.0% increase in visits (95% confidence interval, 6-8). Pediatric visits increased by 19.7%, whereas adult visits increased by 1%. Flu Week showed an increase over Control Week of 6.6% (95% confidence interval, 6-7). Pediatric visits increased by 10.6%, whereas adult visits increased by 4.8%. At a time of heightened public concern regarding flu but little disease prevalence, EDs experienced substantial increases in patient volumes. These increases were significant and comparable to the increases experienced during the subsequent epidemic of actual disease. Copyright © 2012 Elsevier Inc. All rights reserved.

Work-related knee injuries treated in US emergency departments.

PubMed

Chen, Zhiqiang; Chakrabarty, Sangita; Levine, Robert S; Aliyu, Muktar H; Ding, Tan; Jackson, Larry L

2013-09-01

To characterize work-related knee injuries treated in US emergency departments (EDs). We characterized work-related knee injuries treated in EDs in 2007 and examined trends from 1998 to 2007 by using the National Electronic Injury Surveillance System-occupational supplement. In 2007, 184,300 (± 54,000; 95% confidence interval) occupational knee injuries were treated in US EDs, accounting for 5% of the 3.4 (± 0.9) million ED-treated occupational injuries. The ED-treated knee injury rate was 13 (± 4) injuries per 10,000 full-time equivalent workers. Younger workers and older female workers had high rates. Strains/sprains and contusions/abrasions were common-frequently resulting from falls and bodily reaction/overexertion events. Knee injury rates declined from 1998 through 2007. Knee injury prevention should emphasize reducing falls and bodily reaction/overexertion events, particularly among all youth and older women.

Effect of emergency physician burnout on patient waiting times.

PubMed

De Stefano, Carla; Philippon, Anne-Laure; Krastinova, Evguenia; Hausfater, Pierre; Riou, Bruno; Adnet, Frederic; Freund, Yonathan

2018-04-01

Burnout is common in emergency physicians. This syndrome may negatively affect patient care and alter work productivity. We seek to assess whether burnout of emergency physicians impacts waiting times in the emergency department. Prospective study in an academic ED. All patients who visited the main ED for a 4-month period in 2016 were included. Target waiting times are assigned by triage nurse to patients on arrival depending on their severity. The primary endpoint was an exceeded target waiting time for ED patients. All emergency physicians were surveyed by a psychologist to assess their level of burnout using the Maslach Burnout Inventory. We defined the level of burnout of the day in the ED as the mean burnout level of the physicians working that day (8:30 to the 8:30 the next day). A logistic regression model was performed to assess whether burnout level of the day was independently associated with prolonged waiting times, along with previously reported predictors. Target waiting time was exceeded in 7524 patients (59%). Twenty-six emergency physicians were surveyed. Median burnout score was 35 [Interquartile (24-49)]. A burnout level of the day higher than 35 was independently associated with an exceeded target waiting time (adjusted odds ratio 1.54, 95% confidence interval 1.39-1.70), together with previously reported predictors (i.e., day of the week, time of the day, trauma, age and daily census). Burnout of emergency physicians was independently associated with a prolonged waiting time for patients visiting the ED.

Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis.

PubMed

Brown, Kathleen; Iqbal, Sabah; Sun, Su-Lin; Fritzeen, Jennifer; Chamberlain, James; Mullan, Paul C

2016-01-01

Asthma is the most common chronic paediatric disease treated in the emergency department (ED). Rapid corticosteroid administration is associated with improved outcomes, but our busy ED setting has made it challenging to achieve this goal. Our primary aim was to decrease the time to corticosteroid administration in a large, academic paediatric ED. We conducted an interrupted time series analysis for moderate to severe asthma exacerbations of one to 18 year old patients. A multidisciplinary team designed the intervention of a bedside nurse initiated administration of oral dexamethasone, to replace the prior system of a physician initiated order for oral prednisone. Our baseline and intervention periods were 12 month intervals. Our primary process measure was the time to corticosteroid administration. Other process measures included ED length of stay, admission rate, and rate of emesis. The balance measures included rate of return visits to the ED or clinic within five days, as well as the proportion of discharged patients who were admitted within five days. No special cause variation occurred in the baseline period. The mean time to corticosteroid administration decreased significantly, from 98 minutes in the baseline period to 59 minutes in the intervention period (p < 0.01), and showed special cause variation improvement within two months after the intervention using statistical process control methodology. We sustained the improvement and demonstrated a stable process. The intervention period had a significantly lower admission rate (p<0.01) and emesis rate (p<0.01), with no unforeseen harm to patients found with any of our balance measures. In summary, the introduction of a nurse initiated, standardized protocol for corticosteroid therapy for asthma exacerbations in a paediatric ED was associated with decreased time to corticosteroid administration, admission rates, and post-corticosteroid emesis.

The Effects of Noise on Performance

DTIC Science & Technology

1989-06-01

Performance" by C. S. Harris in W. D. Ward (Ed.) Proceedings of the International Congress on Noise as a Public Health Problem (EPA 550/9-73-008), 1973, U.S...141a duration tracking for primary task. Suggestion 35 at 1-9s Intervals Secondary task-response ot addivity for secondary 55 time task decrement. 95...In G. Rossi (Ed.) Pro eedings of the Fourth International Congress on Noise as a Public Health Problem, Vol- 2. Milan: Centro Ricerche e Studi

Managing emergency department overcrowding via ambulance diversion: a discrete event simulation model.

PubMed

Lin, Chih-Hao; Kao, Chung-Yao; Huang, Chong-Ye

2015-01-01

Ambulance diversion (AD) is considered one of the possible solutions to relieve emergency department (ED) overcrowding. Study of the effectiveness of various AD strategies is prerequisite for policy-making. Our aim is to develop a tool that quantitatively evaluates the effectiveness of various AD strategies. A simulation model and a computer simulation program were developed. Three sets of simulations were executed to evaluate AD initiating criteria, patient-blocking rules, and AD intervals, respectively. The crowdedness index, the patient waiting time for service, and the percentage of adverse patients were assessed to determine the effect of various AD policies. Simulation results suggest that, in a certain setting, the best timing for implementing AD is when the crowdedness index reaches the critical value, 1.0 - an indicator that ED is operating at its maximal capacity. The strategy to divert all patients transported by ambulance is more effective than to divert either high-acuity patients only or low-acuity patients only. Given a total allowable AD duration, implementing AD multiple times with short intervals generally has better effect than having a single AD with maximal allowable duration. An input-throughput-output simulation model is proposed for simulating ED operation. Effectiveness of several AD strategies on relieving ED overcrowding was assessed via computer simulations based on this model. By appropriate parameter settings, the model can represent medical resource providers of different scales. It is also feasible to expand the simulations to evaluate the effect of AD strategies on a community basis. The results may offer insights for making effective AD policies. Copyright © 2012. Published by Elsevier B.V.

A pilot study of implantable cardiac device interrogation by emergency department personnel.

PubMed

Neuenschwander, James F; Hiestand, Brian C; Peacock, W Frank; Billings, John M; Sondrup, Cole; Hummel, John D; Abraham, William T

2014-03-01

Implanted devices (eg, pacemakers and defibrillators) provide valuable information and may be interrogated to obtain diagnostic information and to direct management. During admission to an emergency department (ED), significant time and cost are spent waiting for device manufacturer representatives or cardiologists to access the data. If ED personnel could safely interrogate implanted devices, more rapid disposition could occur, thus leading to potentially better outcomes at a reduced cost. This was a pilot study examining the feasibility of ED device interrogation. This was a prospective convenience sample study of patients presenting to the ED with any chief complaint and who had an implantable device capable of being interrogated by a Medtronic reader. After obtaining informed consent, study patients underwent device interrogation by ED research personnel. After reviewing the device data, the physician documented their opinions of the value of data in aiding care. Patients were followed up at intervals ranging from 30 days out to 1 year to determine adverse events relating to interrogation. Forty-four patients underwent device interrogation. Their mean age was 56 ± 14.7 years (range, 28-83), 75% (33/44) were male and 75% (33/44) were hospitalized from the ED. The interrogations took less than 10 minutes 89% of the time. In 60% of the cases, ED physicians reported the data-assisted patient care. No adverse events were reported relating to the ED interrogations. In this pilot study, we found that ED personnel can safely and quickly interrogate implantable devices to obtain potentially useful clinical data.

Transformation to equivalent dimensions—a new methodology to study earthquake clustering

NASA Astrophysics Data System (ADS)

Lasocki, Stanislaw

2014-05-01

A seismic event is represented by a point in a parameter space, quantified by the vector of parameter values. Studies of earthquake clustering involve considering distances between such points in multidimensional spaces. However, the metrics of earthquake parameters are different, hence the metric in a multidimensional parameter space cannot be readily defined. The present paper proposes a solution of this metric problem based on a concept of probabilistic equivalence of earthquake parameters. Under this concept the lengths of parameter intervals are equivalent if the probability for earthquakes to take values from either interval is the same. Earthquake clustering is studied in an equivalent rather than the original dimensions space, where the equivalent dimension (ED) of a parameter is its cumulative distribution function. All transformed parameters are of linear scale in [0, 1] interval and the distance between earthquakes represented by vectors in any ED space is Euclidean. The unknown, in general, cumulative distributions of earthquake parameters are estimated from earthquake catalogues by means of the model-free non-parametric kernel estimation method. Potential of the transformation to EDs is illustrated by two examples of use: to find hierarchically closest neighbours in time-space and to assess temporal variations of earthquake clustering in a specific 4-D phase space.

Impact of the diagnostic process on the accuracy of source identification and time to antibiotics in septic emergency department patients.

PubMed

Uittenbogaard, Annemieke J M; de Deckere, Ernie R J T; Sandel, Maro H; Vis, Alice; Houser, Christine M; de Groot, Bas

2014-06-01

Timely administration of effective antibiotics is important in sepsis management. Source-targeted antibiotics are believed to be most effective, but source identification could cause time delays. First, to describe the accuracy/time delays of a diagnostic work-up and the association with time to antibiotics in septic emergency department (ED) patients. Second, to assess the fraction in which source-targeted antibiotics could have been administered solely on the basis of patient history and physical examination. Secondary analysis of the prospective observational study on septic ED patients was carried out. The time to test result availability was associated with time to antibiotics. The accuracy of the suspected source of infection in the ED was assessed. For patients with pneumosepsis, urosepsis, and abdominal sepsis, combinations of signs and symptoms were assessed to achieve a maximal positive predictive value for the sepsis source, identifying a subset of patients in whom source-targeted antibiotics could be administered without waiting for diagnostic test results. The time to antibiotics increased by 18 (95% confidence interval: 12-24) min/h delay in test result availability (n=323). In 38-79% of patients, antibiotics were administered after additional tests, whereas the ED diagnosis was correct in 68-85% of patients. The maximal positive predictive value of signs and symptoms was 0.87 for patients with pneumosepsis and urosepsis and 0.75 for those with abdominal sepsis. Use of signs and symptoms would have led to correct ED diagnosis in 33% of patients. Diagnostic tests are associated with delayed administration of antibiotics to septic ED patients while increasing the diagnostic accuracy to only 68-85%. In one-third of septic ED patients, the choice of antibiotics could have been accurately determined solely on the basis of patient history and physical examination.

ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception.

PubMed

Fee, Christopher; Metlay, Joshua P; Camargo, Carlos A; Maselli, Judith H; Gonzales, Ralph

2010-01-01

The study aimed to determine if emergency department (ED)-administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival. Time series analysis. Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Randomly selected adult (age >18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering. Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department-administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100 degrees F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007. Emergency department-administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.

Reduction of admit wait times: the effect of a leadership-based program.

PubMed

Patel, Pankaj B; Combs, Mary A; Vinson, David R

2014-03-01

Prolonged admit wait times in the emergency department (ED) for patients who require hospitalization lead to increased boarding time in the ED, a significant cause of ED congestion. This is associated with decreased quality of care, higher morbidity and mortality, decreased patient satisfaction, increased costs for care, ambulance diversion, higher numbers of patients who leave without being seen (LWBS), and delayed care with longer lengths of stay (LOS) for other ED patients. The objective was to assess the effect of a leadership-based program to expedite hospital admissions from the ED. This before-and-after observational study was undertaken from 2006 through 2011 at one community hospital ED. A team of ED and hospital leaders implemented a program to reduce admit wait times, using a computerized hospital-wide tracking system to monitor inpatient and ED bed status. The team collaboratively and consistently moved ED patients to their inpatient beds within an established goal of 60 minutes after an admission decision was reached. Top leadership actively intervened in real time by contacting staff whenever delays occurred to expedite immediate solutions to achieve the 60-minute goal. The primary outcome measures were the percentage of ED patients who were admitted to inpatient beds within 60 minutes from the time the beds were requested and ED boarding time. LOS, patient satisfaction, LWBS rate, and ambulance diversion hours were also measured. After ED census, hospital admission rates, and ED bed capacity were controlled for using a multivariable linear regression analysis, the admit wait time reduction program contributed to an increase in patients being admitted to the hospital within 60 minutes by 16 percentage points (95% confidence intervals [CI] = 10 to 22 points; p < 0.0001) and a decrease in boarding time per admission of 46 minutes (95% CI = 63 to 82 minutes; p < 0.0001). LOS decreased for admitted patients by 79 minutes (95% CI = 55 to 104 minutes; p < 0.0001), for discharged patients by 17 minutes (95% CI = 12 to 23 minutes; p < 0.0001), and for all patients by 34 minutes (95% CI = 25 to 43 minutes; p < 0.0001). Patient satisfaction increased 4.9 percentage points (95% CI = 3.8 to 6.0 points; p < 0.0001). LWBS patients decreased 0.9 percentage points (95% CI = 0.6 to 1.2 points; p < 0.0001) and monthly ambulance diversion decreased 8.2 hours (95% CI = 4.6 to 11.8 hours; p < 0.0001). A leadership-based program to reduce admit wait times and boarding times was associated with a significant increase in the percentage of patients admitted to the hospital within 60 minutes and a significant decrease in boarding time. Also associated with the program were decreased ED LOS, LWBS rate, and ambulance diversion, as well as increased patient satisfaction. © 2014 by the Society for Academic Emergency Medicine.

The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study.

PubMed

Balakrishnan, Meenakshi P; Herndon, Jill Boylston; Zhang, Jingnan; Payton, Thomas; Shuster, Jonathan; Carden, Donna L

2017-09-01

Policymakers argue that emergency department (ED) visits for conditions preventable with high-quality outpatient care contribute to waste in the healthcare system. However, access to ambulatory care is uneven, especially for vulnerable populations like minorities, the poor, and those with limited health literacy. The impact of limited health literacy on ED visits that are preventable with timely, high-quality ambulatory care is unknown. The objective was to determine the association of health literacy with preventable ED visits. We conducted an observational cross-sectional study of potentially preventable ED visits (outcome) among adults (≥18 years old) in an ED serving an urban community. We assessed health literacy (predictor) through structured interviews with the Rapid Estimate of Adult Literacy in Medicine (REALM). We recorded age, sex, race, employment, payer, marital and health status, and number of comorbidities through structured interviews or electronic record review. We identified potentially preventable ED visits in the 2 years before the index ED visit by applying Agency for Healthcare Research and Quality technical specifications to identify ambulatory care sensitive conditions using ED discharge diagnoses in hospital administrative data. We used Poisson regression to evaluate the number of preventable ED visits among patients with limited (REALM < 61) versus adequate (REALM ≥ 61) health literacy after adjusting for covariates. Of 1,201 participants, 709 (59%) were female, 370 (31%) were African American, mean age was 41.6 years, and 394 (33%) had limited health literacy. Of 4,444 total ED visits, 423 (9.5%) were potentially preventable. Of these, 260 (61%) resulted in hospital admission and 163 (39%) were treat and release. After covariates were adjusted for, patients with limited literacy had 2.3 (95% confidence interval [CI] = 1.7-3.1) times the number of potentially preventable ED visits resulting in hospital admission compared to individuals with adequate health literacy, 1.4 (95% CI = 1.0-2.0) times the number of treat-and-release visits, and 1.9 (95% CI = 1.5-2.4) times the number of total preventable ED visits. Our results suggest that the ED may be an important site to deploy universal literacy-sensitive precautions and to test literacy-sensitive interventions with the goal of reducing the burden of potentially preventable ED visits on patients and the healthcare system. © 2017 by the Society for Academic Emergency Medicine.

High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents.

PubMed

Shah, Manish N; Wasserman, Erin B; Wang, Hongyue; Gillespie, Suzanne M; Noyes, Katia; Wood, Nancy E; Nelson, Dallas; Dozier, Ann; McConnochie, Kenneth M

2016-03-01

The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents. We performed a prospective cohort study over 3.5 years. Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls. Consenting patients at intervention facilities could access telemedicine for acute illness care. Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses. The primary outcome was the rate of ED use. We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group; 1,058 subjects served as controls. Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home. Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction). Primary care use and mortality were not significantly different. High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.

Prosthetic hip dislocations: is relocation in the emergency department by emergency medicine staff better?

PubMed

Lawrey, Emma; Jones, Peter; Mitchell, Robin

2012-04-01

Prosthetic hip dislocation is common. This study compares prosthetic hip relocations attempted within the ED by emergency doctors and those under orthopaedic care in the ED or operating theatre (OT). Retrospective cohort study of patients presenting to Auckland City Hospital Adult Emergency Department with prosthetic hip dislocations between 1 January 2003 and 14 April 2008. Primary outcomes were proportion of successful relocation attempts and length of hospital stay. Secondary outcomes were: time to relocation, complications, post-procedural advice, representation rate and long-term outcomes for first-time dislocations. There were 410 eligible presentations during the study period. Emergency medicine (EM) was successful in 254/323 attempts (79%, 95% confidence interval [CI] 74-83). Orthopaedics were successful in 25/35 reductions in the ED (71%, 95% CI 55-84) and 49/51 OT attempts (96%, 95% CI 86-100), P = 0.004 for location OT versus ED. Median times to discharge were 8.8 h for EM, 28.3 h for orthopaedics in the ED and 81 h for orthopaedics in the OT, P < 0.001 for EM versus orthopaedics. Mechanical complications of procedures and early redislocations were infrequent. Complication of sedation were more often seen in OT compared to ED (23/47 [49%, 95% CI 35-63]vs 37/318 [12%, 95% CI 9-16]). There was no difference between EM and orthopaedics in the proportion of hips successfully relocated or complications in the ED; however, EM patients were discharged much sooner, with important resource implications. Procedures carried out in the OT were more successful than in the ED but resulted in prolonged hospital stays and were associated with more complications. © 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Emergency Department Crowding and Outcomes After Emergency Department Discharge

PubMed Central

Gabayan, Gelareh Z.; Derose, Stephen F.; Chiu, Vicki Y.; Yiu, Sau C.; Sarkisian, Catherine A.; Jones, Jason P.; Sun, Benjamin C.

2015-01-01

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

Erectile dysfunction in the community: trends over time in incidence, prevalence, GP consultation and medication use--the Krimpen study: trends in ED.

PubMed

Schouten, Boris W V; Bohnen, Arthur M; Groeneveld, Frans P M J; Dohle, Gert R; Thomas, Siep; Bosch, J L H Ruud

2010-07-01

In the general population, erectile dysfunction (ED) is surrounded by a "taboo." Epidemiologists studying this problem have to be aware of the phenomenon of the "tip-of-the-iceberg." Our aim is to describe the iceberg phenomenon for ED and their help-seeking behavior in the general population during a period when public interest in ED heightened and waned after the introduction of the drug sildenafil. The data were obtained as part of a large longitudinal community-based study, i.e., the Krimpen study. With four rounds of data collection with an approximate 2.1 years interval, the local pharmacists provided data on medication use, whereas abstracts from the medical record and history were provided by the local general practitioners (GPs). The data from the questionnaires were entered into the Krimpen study database but were not communicated to the GPs. ED: according to the ICS-questionnaire, GP consultation: search of electronic medical dossier for ED or reports from any specialist, use of ED medication as delivered by the pharmacy. The age-standardized prevalence of ED is stable, i.e., around 40%. During the period 1995 to 2000, the incidence increased from 5% to 6.5%, then it stabilizes around 5% per year. The first-time use of ED medication increases exponentially between 1995 and 2000, then it stabilizes at about 3.5% per year. The number of GP consultations by men with ED increases up to 1999, after which it stabilizes at about 1.8% per year. We suggest that the availability and awareness of a new pharmacological option induced a change of behavior among GPs and their patients.

Applying Lean: Implementation of a Rapid Triage and Treatment System

PubMed Central

Murrell, Karen L.; Offerman, Steven R.; Kauffman, Mark B.

2011-01-01

Objective: Emergency department (ED) crowding creates issues with patient satisfaction, long wait times and leaving the ED without being seen by a doctor (LWBS). Our objective was to evaluate how applying Lean principles to develop a Rapid Triage and Treatment (RTT) system affected ED metrics in our community hospital. Methods: Using Lean principles, we made ED process improvements that led to the RTT system. Using this system, patients undergo a rapid triage with low-acuity patients seen and treated by a physician in the triage area. No changes in staffing, physical space or hospital resources occurred during the study period. We then performed a retrospective, observational study comparing hospital electronic medical record data six months before and six months after implementation of the RTT system. Results: ED census was 30,981 in the six months prior to RTT and 33,926 after. Ambulance arrivals, ED patient acuity and hospital admission rates were unchanged throughout the study periods. Mean ED length of stay was longer in the period before RTT (4.2 hours, 95% confidence interval [CI] = 4.2–4.3; standard deviation [SD] = 3.9) than after (3.6 hours, 95% CI = 3.6–3.7; SD = 3.7). Mean ED arrival to physician start time was 62.2 minutes (95% CI = 61.5–63.0; SD = 58.9) prior to RTT and 41.9 minutes (95% CI = 41.5–42.4; SD = 30.9) after. The LWBS rate for the six months prior to RTT was 4.5% (95% CI = 3.1–5.5) and 1.5% (95% CI = 0.6–1.8) after RTT initiation. Conclusion: Our experience shows that changes in ED processes using Lean thinking and available resources can improve efficiency. In this community hospital ED, use of an RTT system decreased patient wait times and LWBS rates. PMID:21691524

Is adherence to weight monitoring or weight-based diuretic self-adjustment associated with fewer heart failure-related emergency department visits or hospitalizations?

PubMed

Jones, Christine D; Holmes, George M; Dewalt, Darren A; Erman, Brian; Broucksou, Kimberly; Hawk, Victoria; Cene, Crystal W; Wu, Jia-Rong; Pignone, Michael

2012-07-01

Heart failure (HF) self-care interventions can improve outcomes, but less than optimal adherence may limit their effectiveness. We evaluated if adherence to weight monitoring and diuretic self-adjustment was associated with HF-related emergency department (ED) visits or hospitalizations. We performed a case-control analysis nested in a HF self-care randomized trial. Participants received HF self-care training, including weight monitoring and diuretic self-adjustment, which they were to record in a diary. We defined case time periods as HF-related ED visits or hospitalizations in the 7 preceding days; control time periods were defined as 7-day periods free of ED visits and hospitalizations. We used logistic regression to compare weight monitoring and diuretic self-adjustment adherence in case and control time periods, adjusted for demographic and clinical covariates. Among 303 participants, we identified 81 HF-related ED visits or hospitalizations (cases) in 54 patients over 1 year of follow-up. Weight monitoring adherence (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.23-0.76) and diuretic self-adjustment adherence (OR 0.44, 95% CI 0.19-0.98) were both associated with lower adjusted odds of HF-related ED visits or hospitalizations. Adherence to weight monitoring and diuretic self-adjustment was associated with lower odds of HF-related ED visits or hospitalizations. Adherence to these activities may reduce HF-related morbidity. Copyright © 2012 Elsevier Inc. All rights reserved.

Applying Systems Engineering Reduces Radiology Transport Cycle Times in the Emergency Department.

PubMed

White, Benjamin A; Yun, Brian J; Lev, Michael H; Raja, Ali S

2017-04-01

Emergency department (ED) crowding is widespread, and can result in care delays, medical errors, increased costs, and decreased patient satisfaction. Simultaneously, while capacity constraints on EDs are worsening, contributing factors such as patient volume and inpatient bed capacity are often outside the influence of ED administrators. Therefore, systems engineering approaches that improve throughput and reduce waste may hold the most readily available gains. Decreasing radiology turnaround times improves ED patient throughput and decreases patient waiting time. We sought to investigate the impact of systems engineering science targeting ED radiology transport delays and determine the most effective techniques. This prospective, before-and-after analysis of radiology process flow improvements in an academic hospital ED was exempt from institutional review board review as a quality improvement initiative. We hypothesized that reorganization of radiology transport would improve radiology cycle time and reduce waste. The intervention included systems engineering science-based reorganization of ED radiology transport processes, largely using Lean methodologies, and adding no resources. The primary outcome was average transport time between study order and complete time. All patients presenting between 8/2013-3/2016 and requiring plain film imaging were included. We analyzed electronic medical record data using Microsoft Excel and SAS version 9.4, and we used a two-sample t-test to compare data from the pre- and post-intervention periods. Following the intervention, average transport time decreased significantly and sustainably. Average radiology transport time was 28.7 ± 4.2 minutes during the three months pre-intervention. It was reduced by 15% in the first three months (4.4 minutes [95% confidence interval [CI] 1.5-7.3]; to 24.3 ± 3.3 min, P=0.021), 19% in the following six months (5.4 minutes, 95% CI [2.7-8.2]; to 23.3 ± 3.5 min, P=0.003), and 26% one year following the intervention (7.4 minutes, 95% CI [4.8-9.9]; to 21.3 ± 3.1 min, P=0.0001). This result was achieved without any additional resources, and demonstrated a continual trend towards improvement. This innovation demonstrates the value of systems engineering science to increase efficiency in ED radiology processes. In this study, reorganization of the ED radiology transport process using systems engineering science significantly increased process efficiency without additional resource use.

Applying Systems Engineering Reduces Radiology Transport Cycle Times in the Emergency Department

PubMed Central

White, Benjamin A.; Yun, Brian J.; Lev, Michael H.; Raja, Ali S.

2017-01-01

Introduction Emergency department (ED) crowding is widespread, and can result in care delays, medical errors, increased costs, and decreased patient satisfaction. Simultaneously, while capacity constraints on EDs are worsening, contributing factors such as patient volume and inpatient bed capacity are often outside the influence of ED administrators. Therefore, systems engineering approaches that improve throughput and reduce waste may hold the most readily available gains. Decreasing radiology turnaround times improves ED patient throughput and decreases patient waiting time. We sought to investigate the impact of systems engineering science targeting ED radiology transport delays and determine the most effective techniques. Methods This prospective, before-and-after analysis of radiology process flow improvements in an academic hospital ED was exempt from institutional review board review as a quality improvement initiative. We hypothesized that reorganization of radiology transport would improve radiology cycle time and reduce waste. The intervention included systems engineering science-based reorganization of ED radiology transport processes, largely using Lean methodologies, and adding no resources. The primary outcome was average transport time between study order and complete time. All patients presenting between 8/2013–3/2016 and requiring plain film imaging were included. We analyzed electronic medical record data using Microsoft Excel and SAS version 9.4, and we used a two-sample t-test to compare data from the pre- and post-intervention periods. Results Following the intervention, average transport time decreased significantly and sustainably. Average radiology transport time was 28.7 ± 4.2 minutes during the three months pre-intervention. It was reduced by 15% in the first three months (4.4 minutes [95% confidence interval [CI] 1.5–7.3]; to 24.3 ± 3.3 min, P=0.021), 19% in the following six months (5.4 minutes, 95% CI [2.7–8.2]; to 23.3 ± 3.5 min, P=0.003), and 26% one year following the intervention (7.4 minutes, 95% CI [4.8–9.9]; to 21.3 ± 3.1 min, P=0.0001). This result was achieved without any additional resources, and demonstrated a continual trend towards improvement. This innovation demonstrates the value of systems engineering science to increase efficiency in ED radiology processes. Conclusion In this study, reorganization of the ED radiology transport process using systems engineering science significantly increased process efficiency without additional resource use. PMID:28435492

Time-to-subsequent head injury from sports and recreation activities.

PubMed

Harris, Andrew W; Voaklander, Donald C; Jones, C Allyson; Rowe, Brian H

2012-03-01

To provide population-based risk estimates for sustaining subsequent head injuries (HIs), which occur in sports and recreation (SR). Population-based, retrospective, cross-sectional study. Retrospective review of data from 2 tertiary care and 3 community care emergency departments (EDs) in Edmonton, Alberta, Canada. Individuals younger than 36 years presenting to an ED with an SR-related injury between April 1, 1997, and March 31, 2008. There were 9246 subsequent ED records identified for 8958 patients in the main analysis. Clinically diagnosed HI occurring in SR activities after an index presentation, and the number of days between ED presentations for diagnosed SR-HIs. Individuals with 1 and 2 previous SR-related HIs were 2.62 [95% confidence interval (CI), 2.23-3.07] and 5.94 times, respectively, more likely (95% CI, 3.43-10.29) to sustain a subsequent HI than those without a previous HI. The median time-to first HI was 758 days from an initial injury and decreased to 613 days and 303 days for those at risk of second and third SR-related HIs (P < 0.0001). Individuals aged 7 to 13 years were 4.29 times more likely (95% CI, 2.65-6.92) to sustain an HI when presenting with a subsequent SR injury, compared with those aged 30 to 35 years. The odds of sustaining a subsequent HI substantially increase with each successive HI. Time between SR-related HIs shortens as the number of HIs increases. Initial HI may be a key marker to institute high-risk injury prevention measures directed at young persons who present to EDs.

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits.

PubMed

Martsolf, Grant; Fingar, Kathryn R; Coffey, Rosanna; Kandrack, Ryan; Charland, Tom; Eibner, Christine; Elixhauser, Anne; Steiner, Claudia; Mehrotra, Ateev

2017-04-01

We assess whether the opening of retail clinics near emergency departments (ED) is associated with decreased ED utilization for low-acuity conditions. We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases for 2,053 EDs in 23 states from 2007 to 2012. We used Poisson regression models to examine the association between retail clinic penetration and the rate of ED visits for 11 low-acuity conditions. Retail clinic "penetration" was measured as the percentage of the ED catchment area that overlapped with the 10-minute drive radius of a retail clinic. Rate ratios were calculated for a 10-percentage-point increase in retail clinic penetration per quarter. During the course of a year, this represents the effect of an increase in retail clinic penetration rate from 0% to 40%, which was approximately the average penetration rate observed in 2012. Among all patients, retail clinic penetration was not associated with a reduced rate of low-acuity ED visits (rate ratio=0.999; 95% confidence interval=0.997 to 1.000). Among patients with private insurance, there was a slight decrease in low-acuity ED visits (rate ratio=0.997; 95% confidence interval=0.994 to 0.999). For the average ED in a given quarter, this would equal a 0.3% reduction (95% confidence interval 0.1% to 0.6%) in low-acuity ED visits among the privately insured if retail clinic penetration rate increased by 10 percentage points per quarter. With increased patient demand resulting from the expansion of health insurance coverage, retail clinics may emerge as an important care location, but to date, they have not been associated with a meaningful reduction in low-acuity ED visits. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

The impact on emergency department visits for respiratory illness during the southern california wildfires.

PubMed

Dohrenwend, Paul B; Le, Minh V; Bush, Jeff A; Thomas, Cyril F

2013-03-01

In 2007 wildfires ravaged Southern California resulting in the largest evacuation due to a wildfire in American history. We report how these wildfires affected emergency department (ED) visits for respiratory illness. We extracted data from a Kaiser Permanente database for a single metropolitan community ED. We compared the number of visits due to respiratory illness at time intervals of 2 weeks before and during the time when the fires were burning. We counted the total number of patients with chief complaint of dyspnea, cough, and asthma and final international classification of disease 9 coding diagnosis of asthma, bronchitis, chronic obstructive pulmonary disease and respiratory syndrome, and analyzed data for both total number and proportion of ED visits. We evaluated the data using Early Aberration Reporting System software to determine significant single-visit increases compared to expected counts. We also analyzed the average length of ED stay. Data on air quality were extracted from the http://www.airnow.gov site. There were significant differences between pre-fire and fire period average visit counts for the chief complaints of dyspnea and asthma. Dypnea complaints increased by 3.2 visits per day. During the fire the diagnoses of asthma increased significantly by 2.6 patients per day. Air quality reached air quality index values of 300, indicating very unhealthy conditions. Average ED length of stay times remained unchanged during the fire period compared to the pre-fire period. The 2007 Southern California wildfires caused significant surges in the volume of ED patients seeking treatment for respiratory illness. Disaster plans should prepare for these surges when future wildfires occur.

Influence of uvulopalatopharyngoplasty on alpha-EEG arousals in nonapnoeic snorers.

PubMed

Boudewyns, A; De Cock, W; Willemen, M; Wagemans, M; De Backer, W; Van de Heyning, P H

1997-01-01

Arousals are more numerous in heavy snorers than in nonsnorers and might be a cause of excessive daytime sleepiness (EDS) in these patients. The present study investigated whether treatment of snoring by uvulopalatopharyngoplasty (UPPP) had an influence on sleep microstructure in nonapnoeic snorers. The polysomnographic records of 10 nonapnoeic snorers were reviewed retrospectively and arousals scored according to the American Sleep Disorders Association (ASDA) 3 s definition. Scores for snoring, EDS and polysomnographic data were compared before and after UPPP (mean (+/-SD) time interval 249 +/- 183 days). UPPP resulted in a subjective improvement of snoring and a significant decrease in the arousal index (mean 14.6, 95% confidence interval (95% CI) 8.5-20.8 vs mean 9.1, 95% CI 6.6-11.5) (p = 0.01). EDS and the amount of slow-wave sleep remained unchanged. Uvulopalatopharyngoplasty resulted in an improvement of subjective snoring and a significant decrease of arousals in nonapnoeic snorers. Although these data do not provide any insight into whether the improvement observed can be maintained on a long-term basis, uvulopalatopharyngoplasty can be considered as a useful treatment modality to reduce sleep fragmentation and snoring in nonapnoeic snorers.

The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval

PubMed Central

Halliday, Megan H.; Bouland, Andrew J.; Lawner, Benjamin J.; Comer, Angela C.; Ramos, Daniel C.; Fletcher, Mark

2016-01-01

Introduction A lack of coordination between emergency medical services (EMS), emergency departments (ED) and systemwide management has contributed to extended ambulance at-hospital times at local EDs. In an effort to improve communication within the local EMS system, the Baltimore City Fire Department (BCFD) placed a medical duty officer (MDO) in the fire communications bureau. It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the EMS at-hospital time. Methods The MDO was implemented on November 11, 2013. A senior EMS paramedic was assigned to the position and was placed in the fire communication bureau from 9 a.m. to 9 p.m., seven days a week. We defined the pre-intervention period as August 2013 – October 2013 and the post-intervention period as December 2013 – February 2014. We also compared the post-intervention period to the “seasonal match control” one year earlier to adjust for seasonal variation in EMS volume. The MDO was tasked with the prospective management of city EMS resources through intensive monitoring of unit availability and hospital ED traffic. The MDO could suggest alternative transport destinations in the event of ED crowding. We collected and analyzed data from BCFD computer-aided dispatch (CAD) system for the following: ambulance response times, ambulance at-hospital interval, hospital diversion and alert status, and “suppression wait time” (defined as the total time suppression units remained on scene until ambulance arrival). The data analysis used a pre/post intervention design to examine the MDO impact on the BCFD EMS system. Results There were a total of 15,567 EMS calls during the pre-intervention period, 13,921 in the post-intervention period and 14,699 in the seasonal match control period one year earlier. The average at-hospital time decreased by 1.35 minutes from pre- to post-intervention periods and 4.53 minutes from the pre- to seasonal match control, representing a statistically significant decrease in this interval. There was also a statistically significant decrease in hospital alert time (approximately 1,700 hour decrease pre- to post-intervention periods) and suppression wait time (less than one minute decrease from pre- to post- and pre- to seasonal match control periods). The decrease in ambulance response time was not statistically significant. Conclusion Proactive deployment of a designated MDO was associated with a small, contemporaneous reduction in at-hospital time within an urban EMS jurisdiction. This project emphasized the importance of better communication between EMS systems and area hospitals as well as uniform reporting of variables for future iterations of this and similar projects. PMID:27625737

Bronchiolitis in US emergency departments 1992 to 2000: epidemiology and practice variation.

PubMed

Mansbach, Jonathan M; Emond, Jennifer A; Camargo, Carlos A

2005-04-01

To describe the epidemiology of US emergency department (ED) visits for bronchiolitis, including the characteristics of children presenting to the ED and the variability in bronchiolitis care in the ED. Data were obtained from the 1992 to 2000 National Hospital Ambulatory Medical Care Survey. Cases had International Classification of Diseases, Ninth Revision, Clinical Modification code 466 and were younger than 2 years. National estimates were obtained using assigned patient visit weights; 95% confidence intervals were calculated using the relative standard error of the estimate; analysis used chi2 and logistic regression. From 1992 to 2000, bronchiolitis accounted for approximately 1,868,000 ED visits for children younger than 2 years. Among this same age group, the overall rate was 26 (95% confidence interval 22-31) per 1000 US population and 31 (95% confidence interval 26-36) per 1000 ED visits. These rates were stable over the 9-year period. Comparing children with bronchiolitis to those presenting with other problems, children with bronchiolitis were more likely boys (61% vs. 53%; P = 0.01) and Hispanic (27% vs. 20%; P = 0.008). Therapeutic interventions varied and 19% were admitted to the hospital. The multivariate predictor for receiving systemic steroids was urgent/emergent status at triage (odds ratio 4.0, 1.9-8.4). Multivariate predictors for admission were Hispanic ethnicity (odds ratio 2.3, 1.1-5.0) and urgent/emergent status at triage (odds ratio 3.7, 2.0-6.9). ED visit rates for bronchiolitis among children younger than 2 years were stable between 1992 and 2000. The observed ED practice variation demonstrates that children are receiving medications for which there is little supporting evidence. Boys and Hispanics are at-risk groups for presentation to the ED, and Hispanics are more likely to be hospitalized.

Effect of Emergency Medical Services Use on Hospital Outcomes of Acute Hemorrhagic Stroke.

PubMed

Kim, Sola; Shin, Sang Do; Ro, Young Sun; Song, Kyoung Jun; Lee, Yu Jin; Lee, Eui Jung; Ahn, Ki Ok; Kim, Taeyun; Hong, Ki Jeong; Kim, Yu Jin

2016-01-01

It is unclear whether the use of emergency medical services (EMS) is associated with enhanced survival and decreased disability after hemorrhagic stroke and whether the effect size of EMS use differs according to the length of stay (LOS) in emergency department (ED). Adult patients (19 years and older) with acute hemorrhagic stroke who survived to admission at 29 hospitals between 2008 and 2011 were analyzed, excluding those who had symptom-to-ED arrival time of 3 h or greater, received thrombolysis or craniotomy before inter-hospital transfer, or had experienced cardiac arrest, had unknown information about ambulance use and outcomes. Exposure variable was EMS use. Endpoints were survival at discharge and worsened modified Rankin Scale (W-MRS) defined as 3 or greater points difference between pre- and post-event MRS. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs) for the outcomes were calculated, including potential confounders (demographic, socioeconomic status, clinical parameter, comorbidity, behavior, and time of event) in the final model and stratifying patients by inter-hospital transfer and by time interval from symptom to ED arrival (S2D). ED LOS, classified into short (<120 min) and long (≥120 min), was added to the final model for testing of the interaction model. A total of 2,095 hemorrhagic strokes were analyzed in which 75.6% were transported by EMS. For outcome measures, 17.4% and 41.4% were dead and had worsened MRS, respectively. AORs (95% CIs) of EMS were 0.67 (0.51-0.89) for death and 0.74 (0.59-0.92) for W-MRS in all patients. The effect size of EMS, however, was different according to LOS in ED. AORs (95% CIs) for death were 0.74 (0.54-1.01) in short LOS and 0.60 (0.44-0.83) in long LOS group. AORs (95% CIs) for W-MRS were 0.76 (0.60-0.97) in short LOS and 0.68 (0.52-0.88) in long LOS group. EMS transport was associated with lower hospital mortality and disability after acute hemorrhagic stroke. Effect size of EMS use for mortality was significant in patients with long ED LOS. Key  words: emergency medical service; hemorrhagic stroke; mortality; disability.

Trends in diabetes-related visits to US EDs from 1997 to 2007.

PubMed

Menchine, Michael D; Wiechmann, Warren; Peters, Anne L; Arora, Sanjay

2012-06-01

The aims of the study were to describe temporal trends in the number, proportion, and per capita use of diabetes-related emergency department (ED) visits and to examine any racial/ethnic disparity in ED use for diabetes-related reasons. We analyzed the ED portion of the National Hospital Ambulatory Medical Care Survey from 1997 through 2007. Diabetes-related ED visits were identified by International Classification of Diseases, Ninth Revision codes. Descriptive statistics were developed. Weighted linear and logistic regression models were used to determine significance of temporal trends, and multivariate logistic regression was used to examine racial/ethnic disparities. A total of 20.2 million (1.69%; 95% confidence interval [CI], 1.59%-1.78%) ED visits were diabetes-related during the study period. We observed significant increases in the number and proportion of diabetes-related ED visits. Overall, there was a 5.6% relative annual increase in the proportion of ED visits that were diabetes-related during the study period. However, the per capita ED use among the population with diabetes did not change over time (P>.05 for trend). On multivariate analysis, black race (odds ratio, 1.8; 95% CI, 1.7-2.0), Hispanic ethnicity (odds ratio, 1.6; 95% CI, 1.4-1.8), and advancing age were associated with significantly higher odds of having a diabetes-related visit. Despite a marked increase in number and proportion of diabetes-related ED visits during the study period, the per capita use of ED services for diabetes-related visits among the diabetic population remained stable. Copyright © 2012 Elsevier Inc. All rights reserved.

Impact of a bronchiolitis guideline on ED resource use and cost: a segmented time-series analysis.

PubMed

Akenroye, Ayobami T; Baskin, Marc N; Samnaliev, Mihail; Stack, Anne M

2014-01-01

Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED). We conducted an interrupted time series that examined ED visits of 2929 patients with bronchiolitis, aged 1 to 12 months old, seen between November 2007 and April 2013. Outcomes were proportion having a chest radiograph (CXR), respiratory syncytial virus (RSV) testing, albuterol or antibiotic administration, and the total cost of care. Balancing measures included admission rate, returns to the ED resulting in admission within 72 hours of discharge, and ED length of stay (LOS). There were no significant preexisting trends in the outcomes. After guideline implementation, there was an absolute reduction of 23% in CXR (95% confidence interval [CI]: 11% to 34%), 11% in RSV testing (95% CI: 6% to 17%), 7% in albuterol use (95% CI: 0.2% to 13%), and 41 minutes in ED LOS (95% CI: 16 to 65 minutes). Mean cost per patient was reduced by $197 (95% CI: $136 to $259). Total cost savings was $196,409 (95% CI: $135,592 to $258,223) over the 2 bronchiolitis seasons after guideline implementation. There were no significant differences in antibiotic use, admission rates, or returns resulting in admission within 72 hours of discharge. A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED.

Management and educational status of adult anaphylaxis patients at emergency department.

PubMed

Kim, Mi-Yeong; Park, Chan Sun; Jeong, Jae-Won

2017-12-28

We evaluated the management and educational status of adult anaphylaxis patients at emergency departments (EDs). Anaphylaxis patients who visited ED from 2011 to 2013 were enrolled from three hospitals. We analyzed clinical features, prior history of anaphylaxis, management and provided education for etiology and/or prevention. For analyzing associated factors with epinephrine injection, Pearson chi-square test was used by SPSS version 21 (IBM Co.). A total of 194 anaphylaxis patients were enrolled. Ninety-nine patients (51%) visited ED by themselves. Time interval from symptom onset to ED visit was 62 ± 70.5 minutes. Drug (56.2%) was the most frequent cause of anaphylaxis. Forty-seven patients (24.2%) had prior history of anaphylaxis and 33 patients had same suspicious cause with current anaphylaxis. Cutaneous (88.7%) and respiratory (72.7%) symptoms were frequent. Hypotension was presented in 114 patients (58.8%). Mean observation time in ED was 12 ± 25.7 hours and epinephrine was injected in 114 patients (62%). In 68 patients, epinephrine was injected intramuscularly with mean dose of 0.3 ± 0.10 mg. Associated factor with epinephrine injection was hypotension (p = 0.000). Twenty-three patients (13%) were educated about avoidance of suspicious agent. Epinephrine auto-injectors were prescribed only in five patients. Only 34 (19%) and 72 (40%) patients were consulted to allergist at ED and outpatient allergy department respectively. We suggested that management and education of anaphylaxis were not fully carried out in ED. An education and promotion program on anaphylaxis is needed for medical staff.

Gout and subsequent erectile dysfunction: a population-based cohort study from England.

PubMed

Abdul Sultan, Alyshah; Mallen, Christian; Hayward, Richard; Muller, Sara; Whittle, Rebecca; Hotston, Matthew; Roddy, Edward

2017-06-06

An association has been suggested between gout and erectile dysfunction (ED), however studies quantifying the risk of ED amongst gout patients are lacking. We aimed to precisely determine the population-level absolute and relative rate of ED reporting among men with gout over a decade in England. We utilised the UK-based Clinical Practice Research Datalink to identify 9653 men with incident gout age- and practice-matched to 38,218 controls. Absolute and relative rates of incident ED were calculated using Cox regression models. Absolute rates within specific time periods before and after gout diagnosis were compared to control using a Poisson regression model. Overall, the absolute rate of ED post-gout diagnosis was 193 (95% confidence interval (CI): 184-202) per 10,000 person-years. This corresponded to a 31% (hazard ratio (HR): 1.31 95%CI: 1.24-1.40) increased relative risk and 0.6% excess absolute risk compared to those without gout. We did not observe statistically significant differences in the risk of ED among those prescribed ULT within 1 and 3 years after gout diagnosis. Compared to those unexposed, the risk of ED was also high in the year before gout diagnosis (relative rate = 1.63 95%CI 1.27-2.08). Similar findings were also observed for severe ED warranting pharmacological intervention. We have shown a statistically significant increased risk of ED among men with gout. Our findings will have important implications in planning a multidisciplinary approach to managing patients with gout.

Leisure-Time Physical Activity and Sedentary Behavior and Their Cross-Sectional Associations with Excessive Daytime Sleepiness in the French SU.VI.MAX-2 Study.

PubMed

Andrianasolo, Roland M; Menai, Mehdi; Galan, Pilar; Hercberg, Serge; Oppert, Jean-Michel; Kesse-Guyot, Emmanuelle; Andreeva, Valentina A

2016-04-01

The potential benefit of physical activity in terms of decreasing excessive daytime sleepiness (EDS) prevalence is unclear, especially in aging adults. We aimed to elucidate the associations among physical activity, sedentariness, and EDS in middle-aged and older adults. We conducted a cross-sectional analysis using data from a subsample of participants in the SU.VI.MAX-2 observational study (2007-2009; N = 4179; mean age = 61.9 years). EDS was defined as a score >10 on the Epworth Sleepiness Scale. Leisure-time physical activity and different types of sedentary behavior were assessed with the Modifiable Activity Questionnaire. The associations were examined with multivariable logistic regression models. In the adjusted multivariable model, total leisure-time physical activity (modeled in quartiles, Q) was significantly, inversely associated with EDS (odds ratios (OR)Q4 vs Q1 = 0.70, 95 % confidence interval (CI) = 0.54-0.89). The association persisted in analyses restricted to individuals not taking sleep medication (ORQ4 vs Q1 = 0.72, 95 % CI = 0.54-0.95). In turn, time spent watching television and time spent reading appeared protective against EDS (ORQ4 vs Q1 = 0.73, 95 % CI = 0.57-0.94; ORQ4 vs Q1 = 0.76, 95 % CI = 0.60-0.97, respectively), whereas time spent on a computer appeared to confer an increased risk for EDS (ORQ4 vs Q1 = 1.30, 95 % CI = 1.05-1.62). When physical activity and sedentariness were modeled jointly, using WHO recommendation-based cutoffs for high/low levels, no significant associations were observed in the fully adjusted models. The findings reinforce public health recommendations promoting behavior modification and specifically moderate-intensity exercise in middle-aged and older adults. The association of high physical activity/low sedentariness with EDS, which was not supported by the data, merits further investigation before firm conclusions could be drawn.

The usefulness of rapid point-of-care creatinine testing for the prevention of contrast-induced nephropathy in the emergency department.

PubMed

You, Je Sung; Chung, Yong Eun; Park, Jong Woo; Lee, Woonhyoung; Lee, Hye-Jeong; Chung, Tae Nyoung; Chung, Sung Phil; Park, Incheol; Kim, Seungho

2013-07-01

Renal dysfunction is the most important factor to consider when predicting a patient's risk of developing contrast-induced nephropathy (CIN). Measurement of creatinine (Cr) via rapid point-of-care blood urea nitrogen/creatinine testing (POCT-BUN/Cr) to determine CIN risk could potentially reduce the time required to achieve an accurate diagnosis and to initiate and complete treatment in the emergency department (ED). The aim of our study was to compare the results of POCT-BUN/Cr and reference laboratory tests for BUN and serum Cr. A retrospective analysis of suspected stroke patients who presented between November 2009 and November 2010, and had BUN and Cr levels measured by POCT-BUN/Cr, and the reference laboratory tests performed with the blood sample which was transferred to the central laboratory by an air-shoot system. Two assays were conducted on the whole blood (POCT) and serum (reference) by trained technicians. The time interval from arrival at the ED to reporting of the results was assessed for both assays via a computerised physician order entry system. The mean standard deviation (SD) interval from arrival at the ED to reporting of the results was 11.4 (4.9) min for POCT-BUN/Cr and 46.8 (38.5) min for the serum reference laboratory tests (p<0.001). Intra-class correlation coefficient (ICC) analysis demonstrated a high level of agreement (the consistency agreement) between POCT and the serum reference tests for both BUN (ICC=0.914) and Cr (ICC=0.980). This study suggests that POCT-BUN/Cr results correlate well with those of serum reference tests in terms of BUN and Cr levels and, in turn, predicting CIN. POCT-BUN/Cr is easily performed with a rapid turnaround time, suggesting its use in the ED may have substantial clinical benefit.

The association between smoking prevalence and eating disorders: a systematic review and meta-analysis.

PubMed

Solmi, Marco; Veronese, Nicola; Sergi, Giuseppe; Luchini, Claudio; Favaro, Angela; Santonastaso, Paolo; Vancampfort, Davy; Correll, Christoph U; Ussher, Michael; Thapa-Chhetri, Nita; Fornaro, Michele; Stubbs, Brendon

2016-11-01

Cigarette smoking is associated with severe mental illness, including schizophrenia and bipolar disorder, and with morbidity and mortality, but the association with anorexia (AN), bulimia nervosa (BN) and binge eating disorder (BED) is unclear. This meta-analysis compared the odds of smoking in eating disorders (ED) (ED = AN or BN or BED) versus healthy controls (HC) and calculated the prevalence of smokers in people with ED. Three independent authors searched PubMed, MEDLINE and Scopus from database inception until 31 December 2015 for studies reporting data on life-time or current smoking prevalence in BED, BN and AN with or without control group. Meta-analyses were undertaken, calculating odds ratios (ORs) of life-time smoking in BED, BN, AN versus healthy controls (HCs) or prevalence of smoking in BED, BN and AN with 95% confidence intervals (CI). Thirty-one studies (ED = 8517, controls = 68 335) were meta-analysed. Compared with HCs, there were significantly more smokers among people with BN (life-time OR = 2.165) and BED (life-time OR = 1.792) but not AN (life-time OR = 0.927). BED was associated with smoking the most (life-time prevalence = 47.73%) followed by BN (life-time prevalence = 39.4%) and AN (life-time prevalence = 30.8%). In BN, life-time smoking prevalence was highest in Europe. In AN, higher age moderated both life-time and current smoking prevalence, and body mass index moderated higher life-time smoking prevalence. In BN, female sex moderated higher life-time smoking prevalence. People with binge eating disorder and bulimia nervosa are significantly more likely to be life-time smokers than healthy controls, which is not the case for anorexia nervosa. © 2016 Society for the Study of Addiction.

Decreasing triage time: effects of implementing a step-wise ESI algorithm in an EHR.

PubMed

Villa, Stephen; Weber, Ellen J; Polevoi, Steven; Fee, Christopher; Maruoka, Andrew; Quon, Tina

2018-06-01

To determine if adapting a widely-used triage scale into a computerized algorithm in an electronic health record (EHR) shortens emergency department (ED) triage time. Before-and-after quasi-experimental study. Urban, tertiary care hospital ED. Consecutive adult patient visits between July 2011 and June 2013. A step-wise algorithm, based on the Emergency Severity Index (ESI-5) was programmed into the triage module of a commercial EHR. Duration of triage (triage interval) for all patients and change in percentage of high acuity patients (ESI 1 and 2) completing triage within 15 min, 12 months before-and-after implementation of the algorithm. Multivariable analysis adjusted for confounders; interrupted time series demonstrated effects over time. Secondary outcomes examined quality metrics and patient flow. About 32 546 patient visits before and 33 032 after the intervention were included. Post-intervention patients were slightly older, census was higher and admission rate slightly increased. Median triage interval was 5.92 min (interquartile ranges, IQR 4.2-8.73) before and 2.8 min (IQR 1.88-4.23) after the intervention (P < 0.001). Adjusted mean triage interval decreased 3.4 min (95% CI: -3.6, -3.2). The proportion of high acuity patients completing triage within 15 min increased from 63.9% (95% CI 62.5, 65.2%) to 75.0% (95% CI 73.8, 76.1). Monthly time series demonstrated immediate and sustained improvement following the intervention. Return visits within 72 h and door-to-balloon time were unchanged. Total length of stay was similar. The computerized triage scale improved speed of triage, allowing more high acuity patients to be seen within recommended timeframes, without notable impact on quality.

The Impact on Emergency Department Visits for Respiratory Illness During the Southern California Wildfires

PubMed Central

Dohrenwend, Paul B.; Le, Minh V.; Bush, Jeff A.; Thomas, Cyril F.

2013-01-01

Introduction: In 2007 wildfires ravaged Southern California resulting in the largest evacuation due to a wildfire in American history. We report how these wildfires affected emergency department (ED) visits for respiratory illness. Methods: We extracted data from a Kaiser Permanente database for a single metropolitan community ED. We compared the number of visits due to respiratory illness at time intervals of 2 weeks before and during the time when the fires were burning. We counted the total number of patients with chief complaint of dyspnea, cough, and asthma and final international classification of disease 9 coding diagnosis of asthma, bronchitis, chronic obstructive pulmonary disease and respiratory syndrome, and analyzed data for both total number and proportion of ED visits. We evaluated the data using Early Aberration Reporting System software to determine significant single-visit increases compared to expected counts. We also analyzed the average length of ED stay. Data on air quality were extracted from the http://www.airnow.gov site. Results: There were significant differences between pre-fire and fire period average visit counts for the chief complaints of dyspnea and asthma. Dypnea complaints increased by 3.2 visits per day. During the fire the diagnoses of asthma increased significantly by 2.6 patients per day. Air quality reached air quality index values of 300, indicating very unhealthy conditions. Average ED length of stay times remained unchanged during the fire period compared to the pre-fire period. Conclusion: The 2007 Southern California wildfires caused significant surges in the volume of ED patients seeking treatment for respiratory illness. Disaster plans should prepare for these surges when future wildfires occur. PMID:23599837

Drinking Water Residence Time in Distribution Networks and Emergency Department Visits for Gastrointestinal Illness in Metro Atlanta, Georgia

PubMed Central

Moe, Christine L.; Klein, Mitchel; Flanders, W. Dana; Uber, Jim; Amirtharajah, Appiah; Singer, Philip; Tolbert, Paige E.

2013-01-01

We examined whether the average water residence time, the time it takes water to travel from the treatment plant to the user, for a zip code was related to the proportion of emergency department (ED) visits for gastrointestinal (GI) illness among residents of that zip code. Individual-level ED data were collected from all hospitals located in the five-county metro Atlanta area from 1993 to 2004. Two of the largest water utilities in the area, together serving 1.7 million people, were considered. People served by these utilities had almost three million total ED visits, 164,937 of them for GI illness. The relationship between water residence time and risk for GI illness was assessed using logistic regression, controlling for potential confounding factors, including patient age and markers of socioeconomic status (SES). We observed a modestly increased risk for GI illness for residents of zip codes with the longest water residence times compared to intermediate residence times (odds ratio (OR) for Utility 1 = 1.07, 95% confidence interval (CI) = 1.03, 1.10; OR for Utility 2 = 1.05, 95% CI = 1.02, 1.08). The results suggest that drinking water contamination in the distribution system may contribute to the burden of endemic GI illness. PMID:19240359

Drinking water residence time in distribution networks and emergency department visits for gastrointestinal illness in Metro Atlanta, Georgia.

PubMed

Tinker, Sarah C; Moe, Christine L; Klein, Mitchel; Flanders, W Dana; Uber, Jim; Amirtharajah, Appiah; Singer, Philip; Tolbert, Paige E

2009-06-01

We examined whether the average water residence time, the time it takes water to travel from the treatment plant to the user, for a zip code was related to the proportion of emergency department (ED) visits for gastrointestinal (GI) illness among residents of that zip code. Individual-level ED data were collected from all hospitals located in the five-county metro Atlanta area from 1993 to 2004. Two of the largest water utilities in the area, together serving 1.7 million people, were considered. People served by these utilities had almost 3 million total ED visits, 164,937 of them for GI illness. The relationship between water residence time and risk for GI illness was assessed using logistic regression, controlling for potential confounding factors, including patient age and markers of socioeconomic status (SES). We observed a modestly increased risk for GI illness for residents of zip codes with the longest water residence times compared with intermediate residence times (odds ratio (OR) for Utility 1 = 1.07, 95% confidence interval (CI) = 1.03, 1.10; OR for Utility 2 = 1.05, 95% CI = 1.02, 1.08). The results suggest that drinking water contamination in the distribution system may contribute to the burden of endemic GI illness.

The impact of short prehospital times on trauma center performance benchmarking: An ecologic study.

PubMed

Byrne, James P; Mann, N Clay; Hoeft, Christopher J; Buick, Jason; Karanicolas, Paul; Rizoli, Sandro; Hunt, John P; Nathens, Avery B

2016-04-01

Emergency medical service (EMS) prehospital times vary between regions, yet the impact of local prehospital times on trauma center (TC) performance is unknown. To inform external benchmarking efforts, we explored the impact of EMS prehospital times on the risk-adjusted rate of emergency department (ED) death and overall hospital mortality at urban TCs across the United States. We used a novel ecologic study design, linking EMS data from the National EMS Information System to TCs participating in the American College of Surgeons' Trauma Quality Improvement Program (TQIP) by destination zip code. This approach provided EMS times for populations of injured patients transported to TQIP centers. We defined the exposure of interest as the 90th percentile total prehospital time (PHT) for each TC. TCs were then stratified by PHT quartile. Analyses were limited to adult patients with severe blunt or penetrating trauma, transported directly by land to urban TQIP centers. Random-intercept multilevel modeling was used to evaluate the risk-adjusted relationship between PHT quartile and the outcomes of ED death and overall hospital mortality. During the study period, 119,740 patients met inclusion criteria at 113 TCs. ED death occurred in 1% of patients, and overall mortality was 7.2%. Across all centers, the median PHT was 61 minutes (interquartile range, 53-71 minutes). After risk adjustment, TCs in regions with the shortest quartile of PHTs (<53 minutes) had significantly greater odds of ED death compared with those with the longest PHTs (odds ratio, 2.00; 95% confidence interval, 1.43-2.78). However, there was no association between PHT and overall TC mortality. At urban TCs, local EMS prehospital times are a significant predictor of ED death. However, no relationship exists between prehospital time and overall TC risk-adjusted mortality. Therefore, there is no evidence for the inclusion of EMS prehospital time in external benchmarking analyses.

Hyperthyroidism and erectile dysfunction: a population-based case-control study.

PubMed

Keller, J; Chen, Y-K; Lin, H-C

2012-01-01

Dysthyroidism has been highlighted as a common endocrine disorder associated with erectile dysfunction (ED); however, to date, no large-scale population-based study has investigated the association between hyperthyroidism and ED. This case-control study aimed to explore the association between ED and hyperthyroidism using a population-based data set. In total, 6310 adult patients who received new diagnoses of ED were recruited as cases together with 18 930 matched enrollees with no history of ED who served as controls. Conditional logistic regressions were conducted to explore the association between ED and having been previously diagnosed with hyperthyroidism. In total, 569 (2.3%) of the 25 240 sampled subjects had been diagnosed with hyperthyroidism before the index date; hyperthyroidism was found in 207 (3.3%) cases and 362 (1.90%) controls. After adjusting for potential confounding factors, the odds ratio (OR) of prior hyperthyroidism among cases was 1.64 (95% confidence interval=1.37-1.96, P<0.001) than that of controls. No association was detected between prior hyperthyroidism and ED for the 18-30, 30-39 and >70 age groups. Subjects aged between 60 and 69 years had the highest ORs for prior hyperthyroidism among cases when compared to controls (OR=1.84; 95% confidence interval=1.20-2.84; P<0.001). Our study further confirms the existence of an association between ED and prior hyperthyroidism.

When Health Insurance Is Not a Factor: National Comparison of Homeless and Nonhomeless US Veterans Who Use Veterans Affairs Emergency Departments

PubMed Central

Doran, Kelly M.; Rosenheck, Robert A.

2013-01-01

Objectives. We examined the proportion of homeless veterans among users of Veterans Affairs (VA) emergency departments (EDs) and compared sociodemographic and clinical characteristics of homeless and nonhomeless VA emergency department users nationally. Methods. We used national VA administrative data from fiscal year 2010 for a cross-sectional study comparing homeless (n = 64 091) and nonhomeless (n = 866 621) ED users on sociodemographics, medical and psychiatric diagnoses, and other clinical characteristics. Results. Homeless veterans had 4 times the odds of using EDs than nonhomeless veterans. Multivariate analyses found few differences between homeless and nonhomeless ED users on the medical conditions examined, but homeless ED users were more likely to have been diagnosed with a drug use disorder (odds ratio [OR] = 4.12; 95% confidence interval [CI] = 3.97, 4.27), alcohol use disorder (OR = 3.67; 95% CI = 3.55, 3.79), or schizophrenia (OR = 3.44; 95% CI = 3.25, 3.64) in the past year. Conclusions. In a national integrated health care system with no specific requirements for health insurance, the major differences found between homeless and nonhomeless ED users were high rates of psychiatric and substance abuse diagnoses. EDs may be an important location for specialized homeless outreach (or “in” reach) services to address mental health and addictive disorders. PMID:24148061

Time-series Analysis of Heat Waves and Emergency Department Visits in Atlanta, 1993 to 2012

PubMed Central

Chen, Tianqi; Sarnat, Stefanie E.; Grundstein, Andrew J.; Winquist, Andrea

2017-01-01

Background: Heat waves are extreme weather events that have been associated with adverse health outcomes. However, there is limited knowledge of heat waves’ impact on population morbidity, such as emergency department (ED) visits. Objectives: We investigated associations between heat waves and ED visits for 17 outcomes in Atlanta over a 20-year period, 1993–2012. Methods: Associations were estimated using Poisson log-linear models controlling for continuous air temperature, dew-point temperature, day of week, holidays, and time trends. We defined heat waves as periods of ≥2 consecutive days with temperatures beyond the 98th percentile of the temperature distribution over the period from 1945–2012. We considered six heat wave definitions using maximum, minimum, and average air temperatures and apparent temperatures. Associations by heat wave characteristics were examined. Results: Among all outcome-heat wave combinations, associations were strongest between ED visits for acute renal failure and heat waves defined by maximum apparent temperature at lag 0 [relative risk (RR) = 1.15; 95% confidence interval (CI): 1.03–1.29], ED visits for ischemic stroke and heat waves defined by minimum temperature at lag 0 (RR = 1.09; 95% CI: 1.02–1.17), and ED visits for intestinal infection and heat waves defined by average temperature at lag 1 (RR = 1.10; 95% CI: 1.00–1.21). ED visits for all internal causes were associated with heat waves defined by maximum temperature at lag 1 (RR = 1.02; 95% CI: 1.00, 1.04). Conclusions: Heat waves can confer additional risks of ED visits beyond those of daily air temperature, even in a region with high air-conditioning prevalence. https://doi.org/10.1289/EHP44 PMID:28599264

Depression and eating disorders: treatment and course.

PubMed

Mischoulon, David; Eddy, Kamryn T; Keshaviah, Aparna; Dinescu, Diana; Ross, Stephanie L; Kass, Andrea E; Franko, Debra L; Herzog, David B

2011-05-01

We examined the course of major depressive disorder (MDD) and predictors of MDD recovery and relapse in a longitudinal sample of women with eating disorders (ED). 246 Boston-area women with DSM-IV anorexia nervosa-restricting (ANR; n=51), AN-binge/purge (ANBP; n=85), and bulimia nervosa (BN; n=110) were recruited between 1987 and 1991 and interviewed using the Eating Disorders Longitudinal Interval Follow-up Evaluation (LIFE-EAT-II) every 6-12 months for up to 12 years. 100 participants had MDD at study intake and 45 developed MDD during the study. Psychological functioning and treatment were assessed. Times to MDD onset (1 week-4.3 years), recovery (8 weeks-8.7 years), and relapse (1 week-5.2 years) varied. 70% recovered from MDD, but 65% subsequently relapsed. ANR patients were significantly less likely to recover from MDD than ANBP patients (p=0.029). Better psychological functioning and history of MDD were associated with higher chance of MDD recovery. Higher baseline depressive severity and full recovery from ED were associated with greater likelihood of MDD relapse; increased weight loss was somewhat protective. Adequate antidepressant treatment was given to 72% of patients with MDD and generally continued after MDD recovery. Time on antidepressants did not predict MDD recovery (p=0.27) or relapse (p=0.26). Small ED diagnostic subgroups; lack of non-ED control group. The course of MDD in EDs is protracted; MDD recovery may depend on ED type. Antidepressants did not impact likelihood of MDD recovery, nor protect against relapse, which may impact on treatment strategies for comorbid MDD and EDs. Copyright © 2010 Elsevier B.V. All rights reserved.

Time-series Analysis of Heat Waves and Emergency Department Visits in Atlanta, 1993 to 2012.

PubMed

Chen, Tianqi; Sarnat, Stefanie E; Grundstein, Andrew J; Winquist, Andrea; Chang, Howard H

2017-05-31

Heat waves are extreme weather events that have been associated with adverse health outcomes. However, there is limited knowledge of heat waves' impact on population morbidity, such as emergency department (ED) visits. We investigated associations between heat waves and ED visits for 17 outcomes in Atlanta over a 20-year period, 1993-2012. Associations were estimated using Poisson log-linear models controlling for continuous air temperature, dew-point temperature, day of week, holidays, and time trends. We defined heat waves as periods of consecutive days with temperatures beyond the 98th percentile of the temperature distribution over the period from 1945-2012. We considered six heat wave definitions using maximum, minimum, and average air temperatures and apparent temperatures. Associations by heat wave characteristics were examined. Among all outcome-heat wave combinations, associations were strongest between ED visits for acute renal failure and heat waves defined by maximum apparent temperature at lag 0 [relative risk (RR) = 1.15; 95% confidence interval (CI): 1.03-1.29], ED visits for ischemic stroke and heat waves defined by minimum temperature at lag 0 (RR = 1.09; 95% CI: 1.02-1.17), and ED visits for intestinal infection and heat waves defined by average temperature at lag 1 (RR = 1.10; 95% CI: 1.00-1.21). ED visits for all internal causes were associated with heat waves defined by maximum temperature at lag 1 (RR = 1.02; 95% CI: 1.00, 1.04). Heat waves can confer additional risks of ED visits beyond those of daily air temperature, even in a region with high air-conditioning prevalence. https://doi.org/10.1289/EHP44.

Emergency department performance measures updates: proceedings of the 2014 emergency department benchmarking alliance consensus summit.

PubMed

Wiler, Jennifer L; Welch, Shari; Pines, Jesse; Schuur, Jeremiah; Jouriles, Nick; Stone-Griffith, Suzanne

2015-05-01

The objective was to review and update key definitions and metrics for emergency department (ED) performance and operations. Forty-five emergency medicine leaders convened for the Third Performance Measures and Benchmarking Summit held in Las Vegas, February 21-22, 2014. Prior to arrival, attendees were assigned to workgroups to review, revise, and update the definitions and vocabulary being used to communicate about ED performance and operations. They were provided with the prior definitions of those consensus summits that were published in 2006 and 2010. Other published definitions from key stakeholders in emergency medicine and health care were also reviewed and circulated. At the summit, key terminology and metrics were discussed and debated. Workgroups communicated online, via teleconference, and finally in a face-to-face meeting to reach consensus regarding their recommendations. Recommendations were then posted and open to a 30-day comment period. Participants then reanalyzed the recommendations, and modifications were made based on consensus. A comprehensive dictionary of ED terminology related to ED performance and operation was developed. This article includes definitions of operating characteristics and internal and external factors relevant to the stratification and categorization of EDs. Time stamps, time intervals, and measures of utilization were defined. Definitions of processes and staffing measures are also presented. Definitions were harmonized with performance measures put forth by the Centers for Medicare and Medicaid Services (CMS) for consistency. Standardized definitions are necessary to improve the comparability of EDs nationally for operations research and practice. More importantly, clear precise definitions describing ED operations are needed for incentive-based pay-for-performance models like those developed by CMS. This document provides a common language for front-line practitioners, managers, health policymakers, and researchers. © 2015 by the Society for Academic Emergency Medicine.

A Profile of Indian Health Service Emergency Departments.

PubMed

Bernard, Kenneth; Hasegawa, Kohei; Sullivan, Ashley; Camargo, Carlos

2017-06-01

The Indian Health Service provides health care to eligible American Indians and Alaskan Natives. No published data exist on emergency services offered by this unique health care system. We seek to determine the characteristics and capabilities of Indian Health Service emergency departments (EDs). All Indian Health Service EDs were surveyed about demographics and operational characteristics for 2014 with the National Emergency Department Inventory survey (available at http://www.emnet-nedi.org/). Of the forty eligible sites, there were 34 respondents (85% response rate). Respondents reported a total of 637,523 ED encounters, ranging from 521 to 63,200 visits per site. Overall, 85% (95% confidence interval 70% to 94%) had continuous physician coverage. Of all physicians staffing the ED, a median of 13% (interquartile range 0% to 50%) were board certified or board prepared in emergency medicine. Overall, 50% (95% confidence interval 34% to 66%) of respondents reported that their ED was operating over capacity. Indian Health Service EDs varied widely in visit volume, with many operating over capacity. Most were not staffed by board-certified or -prepared emergency physicians. Most lacked access to specialty consultation and telemedicine capabilities. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

The ED95 of Nalbuphine in Outpatient-Induced Abortion Compared to Equivalent Sufentanil.

PubMed

Chen, Limei; Zhou, Yamei; Cai, Yaoyao; Bao, Nana; Xu, Xuzhong; Shi, Beibei

2018-04-07

This prospective study evaluated the 95% effective dose (ED 95 ) of nalbuphine in inhibiting body movement during outpatient-induced abortion and its clinical efficacy versus the equivalent of sufentanil. The study was divided into two parts. For the first part, voluntary first-trimester patients who needed induced abortions were recruited to measure the ED 95 of nalbuphine in inhibiting body movement during induced abortion using the sequential method (the Dixon up-and-down method). In the second part, this was a double-blind, randomized study. Sixty cases of first-trimester patients were recruited and were randomly divided into two groups (n = 30), including group N (nalbuphine at the ED 95 dose) and group S (sufentanil at an equivalent dose). Propofol was given to both groups as the sedative. The circulation, respiration and body movement of the two groups in surgery were observed. The amount of propofol, the awakening time, the time to leave the hospital and the analgesic effect were recorded. The ED 95 of nalbuphine in inhibiting body movement during painless surgical abortion was 0.128 mg/kg (95% confidence intervals 0.098-0.483 mg/kg). Both nalbuphine and the equivalent dose of sufentanil provided a good intraoperative and post-operative analgesic effect in outpatient-induced abortion. However, the post-operative morbidity of dizziness for nalbuphine was less than for sufentanil (p < 0.05), and the awakening time and the time to leave the hospital were significantly shorter than those of sufentanil (p < 0.05). Nalbuphine at 0.128 mg/kg was used in outpatient-induced abortion as an intraoperative and post-operative analgesic and showed a better effect compared with sufentanil. © 2018 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).

[Triage duration times: a prospective descriptive study in a level 1° emergency department].

PubMed

Bambi, Stefano; Ruggeri, Marco

2017-01-01

Triage is the most important tool for clinical risk management in emergency departments (ED). The timing measurement of its phases is fundamental to establish indicators and standards for the optimization of the system. To evaluate the duration time of the phases of triage; to evaluate some variables exerting influence on nurses' performance. prospective descriptive study performed in the ED of Careggi Teaching Hospital in Florence. 14 nurses enrolled by stratified randomization proportion (1/3 of the whole staff ), according to classes of length of service. Triage processes on 150 adult patients were recorded. The mean age of nurses was 39.7 years (SD ± 5.2, range 29-50); the average length of service was 10.3 years (SD ± 4.4, range 3-18); average of triage experience was 8.6 years (SD ± 4.3, range 2-13). The median time from patient's arrival to the end of the triage process was 04': 04" (range 00':47"- 18':08"); the median duration of triage was 01':11" (range 00':07" -11':27"). The length of service and triage experience did not influence the medians of recorded intervals of time, but there were some limitations due to the low sample size. Interruptions were observed 111 (74%) of triage cases. the recorded triage time intervals were similar to those reported in international literature. Actions are needed to reduce the impact of interruptions on triage process' times.

Emergency department presentation and readmission after index psychiatric admission: a data linkage study

PubMed Central

Li, Xue; Srasuebkul, Preeyaporn; Reppermund, Simone

2018-01-01

Objective To use linked administrative datasets to assess factors associated with emergency department (ED) presentation and psychiatric readmission in three distinctive time intervals after the index psychiatric admission. Design A retrospective data-linkage study. Setting Cohort study using four linked government minimum datasets including acute hospital care from July 2005 to June 2012 in New South Wales, Australia. Participants People who were alive and aged ≥18 years on 1 July 2005 and who had their index admission to a psychiatric ward from 1 July 2007 to 30 June 2010. Outcome measures ORs of factors associated with psychiatric admission and ED presentation were calculated for three intervals: 0–1 month, 2–5 months and 6–24 months after index separation. Results Index admission was identified in 35 056 individuals (51% -males) with a median age of 42 years. A total of 12 826 (37%) individuals had at least one ED presentation in the 24 months after index admission. Of those, 3608 (28%) presented within 0–1 month, 6350 (50%) within 2–5 months and 10 294 (80%) within 6–24 months after index admission. A total of 14 153 (40%) individuals had at least one psychiatric readmission in the first 24 months. Of those, 6808 (48%) were admitted within 0–1 month, 6433 (45%) within 2–5 months and 7649 (54%) within 6–24 months after index admission. Principal diagnoses and length of stay at index admission, sociodemographic factors, Charlson Comorbidity Index score, drug and alcohol comorbidity, intellectual disability and other inpatient service use were significantly associated with ED presentations and psychiatric readmissions, and these relationships varied somewhat over the intervals studied. Conclusion Social determinants of service use, drug and alcohol intervention, addressing needs of individuals with intellectual disability and recovery-oriented whole-person approaches at index admission are key areas for investment to improve trajectories after index admission. PMID:29490956

Effect of red bull energy drink on auditory reaction time and maximal voluntary contraction.

PubMed

Goel, Vartika; Manjunatha, S; Pai, Kirtana M

2014-01-01

The use of "Energy Drinks" (ED) is increasing in India. Students specially use these drinks to rejuvenate after strenuous exercises or as a stimulant during exam times. The most common ingredient in EDs is caffeine and a popular ED available and commonly used is Red Bull, containing 80 mg of caffeine in 250 ml bottle. The primary aim of this study was to investigate the effects of Red Bull energy drink on Auditory reaction time and Maximal voluntary contraction. A homogeneous group containing twenty medical students (10 males, 10 females) participated in a crossover study in which they were randomized to supplement with Red Bull (2 mg/kg body weight of caffeine) or isoenergetic isovolumetric noncaffeinated control drink (a combination of Appy Fizz, Cranberry juice and soda) separated by 7 days. Maximal voluntary contraction (MVC) was recorded as the highest of the 3 values of maximal isometric force generated from the dominant hand using hand grip dynamometer (Biopac systems). Auditory reaction time (ART) was the average of 10 values of the time interval between the click sound and response by pressing the push button using hand held switch (Biopac systems). The energy and control drinks after one hour of consumption significantly reduced the Auditory reaction time in males (ED 232 ± 59 Vs 204 ± 34 s and Control 223 ± 57 Vs 210 ± 51 s; p < 0.05) as well as in females (ED 227 ± 56 Vs 214 ± 48 s and Control 224 ± 45 Vs 215 ± 36 s; p < 0.05) but had no effect on MVC in either sex (males ED 381 ± 37 Vs 371 ± 36 and Control 375 ± 61 Vs 363 ± 36 Newton, females ED 227 ± 23 Vs 227 ± 32 and Control 234 ± 46 Vs 228 ± 37 Newton). When compared across the gender groups, there was no significant difference between males and females in the effects of any of the drinks on the ART but there was an overall significantly lower MVC in females compared to males. Both energy drink and the control drink significantly improve the reaction time but may not have any effect on muscular performance. Energy drink per se is no better than control drink, which may indicate that there is no role of caffeine in the beneficial effect seen after the drinks.

Interfacility transfers for US ischemic stroke and TIA, 2006-2014.

PubMed

George, Benjamin P; Doyle, Sara J; Albert, George P; Busza, Ania; Holloway, Robert G; Sheth, Kevin N; Kelly, Adam G

2018-05-01

To investigate changes in emergency department (ED) transfers for ischemic stroke (IS) and TIA. We performed a retrospective observational study using the US Nationwide Emergency Department Sample to identify changes in interfacility ED transfers for IS and TIA from the perspective of the transferring ED (2006-2014). We calculated nationwide transfer rates and individual ED transfer rates for IS/TIA by diagnosis and hospital characteristics. Hospital-level fractional logistic regression examined changes in transfer rates over time. The population-estimated number of transfers for IS/TIA increased from 22,576 patient visits in 2006 to 54,485 patient visits in 2014 ( p trend < 0.001). The rate of IS/TIA transfer increased from 3.4 (95% confidence interval [CI] 3.0-3.8) in 2006 to 7.6 (95% CI 7.2-7.9) in 2014 per 100 ED visits. Among individual EDs, mean transfer rates for IS/TIA increased from 8.2 per 100 ED visits (median 2.0, interquartile range [IQR] 0-10.2) to 19.4 per 100 ED visits (median 8.1, IQR 1.1-33.3) (2006-2014) ( p trend < 0.001). Transfers were more common among IS. Transfer rates were greatest among rural (adjusted odds ratio [AOR] 3.05, 95% CI 2.56-3.64) vs urban/teaching and low-volume EDs (AOR 7.49, 95% CI 6.58-8.53, 1st vs 4th quartile). The adjusted odds of transfer for IS/TIA increased threefold (2006-2014). Interfacility ED transfers for IS/TIA more than doubled from 2006 to 2014. Further work should determine the necessity of IS/TIA transfers and seek to optimize the US stroke care system. © 2018 American Academy of Neurology.

Quality of non-mydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study

PubMed Central

Lamirel, Cédric; Bruce, Beau B.; Wright, David W.; Delaney, Kevin P.; Newman, Nancy J.; Biousse, Valérie

2011-01-01

Objective Non-mydriatic fundus photography by non-ophthalmic trained personnel has recently been shown to be a potential alternative to direct ophthalmoscopy in the emergency department (ED). We evaluated the reliability of a novel quality rating scale and applied this scale to non-mydriatic fundus photographs taken during routine ED patient encounters to determine factors associated with diminished photograph quality. Design Prospective, cross-sectional Participants 350 patients enrolled in the Fundus photography vs. Ophthalmoscopy Trials Outcomes in the Emergency Department (FOTO-ED) study were photographed by nurse practitioners after <30 minutes of training followed by supervision. Methods Photographs of both eyes were graded for quality on two occasions by two neuro-ophthalmologists. Four regions were independently evaluated for quality: optic disc, macula, superior and inferior vascular arcades. Quality as a function of the number of photographs taken was evaluated by Kaplan-Meier analysis. Mixed effects ordinal logistic regression was used to evaluate for predictors of image quality while accounting for the repeated measures design. Main Outcome Measure Overall photographic quality (1–5 scale, 5 best). Results We evaluated 1734 photographs. Inter- and intra-observer agreements between neuro-ophthalmologists were very good (weighted kappa:0.84–0.87). Quality of the optic disc area was better than those of other retinal areas (p<0.002). Kaplan-Meier analysis showed that if a high-quality photograph of an eye was not obtained by the third attempt it was unlikely that one would be obtained at all. A 10 second increase in the inter-photograph interval before a total of forty seconds increased the odds of a one unit higher quality rating by 1.81 times (95%CI: 1.68–1.98), and a ten year increase in age decreased the odds by 0.76 times (95%CI: 0.69–0.85). Black patients had 0.42 times (95%CI: 0.28–0.63) the odds of a one unit higher quality rating compared to whites. Conclusions Our 5-point scale is a reliable measure of non-mydriatic photograph quality. The region of interest, interphotograph interval, age, and race are significant predictors of image quality for non-mydriatic photographs taken by nurse practitioners in the ED. Addressing these factors may have a direct impact on the successful implementation of non-mydriatic fundus photography into the ED. PMID:22218140

Predicting emergency department volume using forecasting methods to create a "surge response" for noncrisis events.

PubMed

Chase, Valerie J; Cohn, Amy E M; Peterson, Timothy A; Lavieri, Mariel S

2012-05-01

This study investigated whether emergency department (ED) variables could be used in mathematical models to predict a future surge in ED volume based on recent levels of use of physician capacity. The models may be used to guide decisions related to on-call staffing in non-crisis-related surges of patient volume. A retrospective analysis was conducted using information spanning July 2009 through June 2010 from a large urban teaching hospital with a Level I trauma center. A comparison of significance was used to assess the impact of multiple patient-specific variables on the state of the ED. Physician capacity was modeled based on historical physician treatment capacity and productivity. Binary logistic regression analysis was used to determine the probability that the available physician capacity would be sufficient to treat all patients forecasted to arrive in the next time period. The prediction horizons used were 15 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, and 12 hours. Five consecutive months of patient data from July 2010 through November 2010, similar to the data used to generate the models, was used to validate the models. Positive predictive values, Type I and Type II errors, and real-time accuracy in predicting noncrisis surge events were used to evaluate the forecast accuracy of the models. The ratio of new patients requiring treatment over total physician capacity (termed the care utilization ratio [CUR]) was deemed a robust predictor of the state of the ED (with a CUR greater than 1 indicating that the physician capacity would not be sufficient to treat all patients forecasted to arrive). Prediction intervals of 30 minutes, 8 hours, and 12 hours performed best of all models analyzed, with deviances of 1.000, 0.951, and 0.864, respectively. A 95% significance was used to validate the models against the July 2010 through November 2010 data set. Positive predictive values ranged from 0.738 to 0.872, true positives ranged from 74% to 94%, and true negatives ranged from 70% to 90% depending on the threshold used to determine the state of the ED with the 30-minute prediction model. The CUR is a new and robust indicator of an ED system's performance. The study was able to model the tradeoff of longer time to response versus shorter but more accurate predictions, by investigating different prediction intervals. Current practice would have been improved by using the proposed models and would have identified the surge in patient volume earlier on noncrisis days. © 2012 by the Society for Academic Emergency Medicine.

Predictors of emergency department attendance by people with dementia in their last year of life: Retrospective cohort study using linked clinical and administrative data.

PubMed

Sleeman, Katherine E; Perera, Gayan; Stewart, Robert; Higginson, Irene J

2018-01-01

A fall in hospital deaths in dementia has been interpreted as indicating an improvement in end-of-life care. Whether other indicators of quality of end-of-life care, such as emergency department (ED) attendance, show a similar trend is unclear. Retrospective cohort study using electronic medical records from a large mental health care provider, linked to national mortality and hospital use data (2008-2013). Of 4867 patients, 78.6% (3824) had at least one ED attendance during their last year of life (mean 2.13, standard deviation 2.34, range 0-54). ED attendance increased over the time period (incidence rate ratio 1.62, 95% confidence interval 1.46-1.80 for 2012-2013 compared with 2008-2009). ED attendance in the last year of life for people with dementia is common and is increasing. Policy makers must pay attention to a broader range of indicators of poor end-of-life care alongside the place of death. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Emergency Department Crowding and Time at the Bedside: A Wearable Technology Feasibility Study.

PubMed

Castner, Jessica; Suffoletto, Heidi

2018-04-25

ED crowding is a public health crisis, limiting quality and access to lifesaving care. The purpose of this study was to (1) evaluate the feasibility of radio-frequency identification tags to measure clinician-patient contact and (2) to test the relationship between ED occupancy and clinician-patient contact time. In this 4-week observational study, radio-frequency identification tags were worn by emergency clinicians in a 21-bay urban teaching hospital emergency department. The time-motion data were merged with electronic medical repository patient information (N = 3,237) to adjust for occupancy, age, gender, and acuity. Qualitative themes were generated from focus group (N = 39) debriefings of the quantitative results. Data were collected on 56,342 total clinician events. Adjusting for patient age, increasing ED occupancy increased the number of times the attending physician entered and left the patient room (b = 0 .008, 95% confidence interval [CI] = [0.001-0.016], P = 0.03). There was no relationship for patient gender, triage acuity, shift at arrival, disposition to home, or discharge diagnosis category with either total minutes or number of encounters per patient visit. No time-motion and occupancy associations were observed for nurses, residents, or nurse practitioners/physician assistants. Debriefings indicated occupancy influenced the quality of care, despite maintaining the same quantity of contact time. The physical environment and clinician privacy concerns limit the feasibility of wearable tracking technology in the emergency setting. Attending physician care becomes more fragmented with increasing ED occupancy. Other clinicians report changes in the quality of care, whereas the quantity of time and encounters were unchanged with occupancy rates. Copyright © 2018 Elsevier Inc. All rights reserved.

Management of patients brought in by ambulance to the emergency department: role of the Advanced Musculoskeletal Physiotherapist.

PubMed

Kinsella, Rita; Collins, Tom; Shaw, Bridget; Sayer, James; Cary, Belinda; Walby, Andrew; Cowan, Sallie

2017-05-09

Objective The aim of the present study was to evaluate the role of the Advanced Musculoskeletal Physiotherapist (AMP) in managing patients brought in by ambulance to the emergency department (ED). Methods This study was a dual-centre observational study. Patients brought in by ambulance to two Melbourne hospitals over a 12-month period and seen by an AMP were compared with a matched group seen by other ED staff. Primary outcome measures were wait time and length of stay (LOS) in the ED. Results Data from 1441 patients within the Australasian Triage Scale (ATS) Categories 3-5 with musculoskeletal complaints were included in the analysis. Subgroup analysis of 825 patients aged ≤65 years demonstrated that for Category 4 (semi-urgent) patients, the median wait time to see the AMP was 9.5min (interquartile range (IQR) 3.25-18.00min) compared with 25min (IQR 10.00-56.00min) to see other ED staff (P ≤ 0.05). LOS analysis was undertaken on patients discharged home and demonstrated that there was a 1.20 greater probability (95% confidence interval 1.07-1.35) that ATS Category 4 patients managed by the AMP were discharged within the 4-hour public hospital target compared with patients managed by other ED staff: 87.04% (94/108) of patients managed by the AMPs met this standard compared with 72.35% (123/170) of patients managed by other ED staff (P=0.002). Conclusions Patients aged ≤65 years with musculoskeletal complaints brought in by ambulance to the ED and triaged to ATS Category 4 are likely to wait less time to be seen and are discharged home more quickly when managed by an AMP. This study has added to the evidence that AMPs improve patient flow in the ED, freeing up time for other ED staff to see higher-acuity, more complex patients. What is known about the topic? There is a growing body of evidence establishing that AMPs improve the flow of patients presenting with musculoskeletal conditions to the ED through reduced wait times and LOS and, at the same time, providing good-quality care and enhanced patient satisfaction. What does this paper add? Within their primary contact capacity, AMPs also manage patients who are brought in by ambulance presenting with musculoskeletal conditions. To the authors' knowledge, there is currently no available literature documenting the performance of AMPs in the management of this cohort of patients. What are the implications for practitioners? This study has added to the body of evidence that AMPs improve patient flow in the ED and illustrates that AMPs, by seeing patients brought in by ambulance, are able to have a positive impact on the pressures increasingly facing the Victorian Ambulance Service and emergency hospital care.

Electroencephalography findings in patients presenting to the ED for evaluation of seizures.

PubMed

Kadambi, Pooja; Hart, Kimberly W; Adeoye, Opeolu M; Lindsell, Christopher J; Knight, William A

2015-01-01

Status epilepticus is a life-threatening, time-sensitive emergency. Acquiring an electroencephalogram (EEG) in the emergency department (ED) could impact therapeutic and disposition decisions for patients with suspected status epilepticus. The objective of this study is to estimate the proportion of EEGs diagnostic for seizures in patients presenting to an ED with a complaint of seizures. This retrospective chart review included adults presenting to the ED of an urban, academic, tertiary care hospital with suspected seizures or status epilepticus, who received an EEG within 24 hours of hospital admission. Data abstraction was performed by a single, trained, nonblinded abstractor. Seizures were defined as an epileptologist's diagnosis of either seizures or status epilepticus on EEG. The proportion of patients with seizures is given with confidence interval95 (CI95). Of 120 included patients, 67 (56%) had a history of epilepsy. Mean age was 52 years (SD, 16), 58% were White, and 61% were male. Within 24 hours, 3% had an EEG diagnostic for seizures. Electroencephalogram was obtained in the ED in 32 (27%) of 120 (CI95, 19%-35%), and 2 (6%) of 32 (CI95, 1%-19%) had seizures. Electroencephalogram was performed inpatient for 88 (73%) of 120 (CI95, 65%-81%), and 2 (2%) of 88 (CI95, 0.5%-7.1%) had seizures. Only 3% of ED patients with suspected seizures or status epilepticus had EEG confirmation of seizures within 24 hours. Early EEG acquisition in the ED may identify a group of patients amenable to ED observation and subsequent discharge from the hospital. Copyright © 2014 Elsevier Inc. All rights reserved.

Association of emergency department and hospital characteristics with elopements and length of stay.

PubMed

Handel, Daniel A; Fu, Rongwei; Vu, Eugene; Augustine, James J; Hsia, Renee Y; Shufflebarger, Charles M; Sun, Benjamin

2014-06-01

As the Centers for Medicare & Medicaid Services (CMS) core measures in 2013 compare Emergency Department (ED) treatment time intervals, it is important to identify ED and hospital characteristics associated with these metrics to facilitate accurate comparisons. The objective of this study is to assess differences in operational metrics by ED and hospital characteristics. ED-level characteristics included annual ED volume, percentage of patients admitted, percentage of patients presenting by ambulance, and percentage of pediatric patients. Hospital-level characteristics included teaching hospital status, trauma center status, hospital ownership (nonprofit or for-profit), inpatient bed capacity, critical access status, inpatient bed occupancy, and rural vs. urban location area. Data from the ED Benchmarking Alliance from 2004 to 2009 were merged with the American Hospital Association's Annual Survey Database to include hospital characteristics that may impact ED throughput. Overall median length of stay (LOS) and left before treatment is complete (LBTC) were the primary outcome variables, and a linear mixed model was used to assess the association between outcome variables and ED and hospital characteristics, while accounting for correlations among multiple observations within each hospital. All data were at the hospital level on a yearly basis. There were 445 EDs included in the analysis, from 2004 to 2009, with 850 observations over 6 years. Higher-volume EDs were associated with higher rates of LBTC and LOS. For-profit hospitals had lower LBTC and LOS. Higher inpatient bed occupancies were associated with a higher LOS. Increasing admission percentages were positively associated with overall LOS for EDs, but not with rates of LBTC. Higher-volume EDs are associated with higher LBTC and LOS, and for-profit hospitals appear more favorably in these metrics compared with their nonprofit counterparts. It is important to appreciate that hospitals have different baselines for performance that may be more tied to volume and capacity, and less to quality of care. Copyright © 2014 Elsevier Inc. All rights reserved.

Is the relationship between cigarette smoking and male erectile dysfunction independent of cardiovascular disease? Findings from a population-based cross-sectional study.

PubMed

Chew, Kew-Kim; Bremner, Alexandra; Stuckey, Bronwyn; Earle, Carolyn; Jamrozik, Konrad

2009-01-01

Cigarette smoking has been implicated in the pathophysiology of cardiovascular disease (CVD) and as a risk factor for erectile dysfunction (ED). However, various aspects of the associations between cigarette smoking, ED, and CVD need further elucidation. We explored the relationship between cigarette smoking, ED, and CVD using data from a population-based cross-sectional study of 1,580 participants. Postal questionnaires were sent to randomly selected age-stratified male population samples obtained from the Western Australia Electoral Roll. In addition to items covering sociodemographic and self-reported clinical information and smoking habits, the 5-item International Index of Erectile Function was used to assess erectile function. Compared with never smokers, the odds of ED, adjusted for age, square of age, and CVD, were significantly higher among current smokers (odds ratio [OR] = 1.40; 95% confidence interval [CI] 1.02, 1.92) and ever smokers (OR = 1.57; 95% CI 1.02, 2.42). Similarly, the adjusted odds of severe ED were significantly higher among former smokers. Albeit not statistically significant, the age-adjusted odds of ED among current smokers increased with the number of cigarettes smoked. Among former smokers, the age-adjusted odds of ED were significantly higher 6-10 years following cessation of smoking than < or = 5 or > 10 years. Compared with never smokers without CVD, the age-adjusted odds of ED among former smokers and ever smokers without CVD were about 1.6. Regardless of smoking, these odds were significantly higher among participants with CVD. Compared with never smokers, former smokers and ever smokers have significantly higher odds of ED. The relationship between smoking and ED is independent of that between smoking and CVD, and not because of confounding by CVD. Patterns of ED in former smokers suggest that there may be a latent interval between active smoking and symptomatic ED, involving a process initially triggered by smoking.

First experience with early dynamic (18)F-NaF-PET/CT in patients with chronic osteomyelitis.

PubMed

Freesmeyer, Martin; Stecker, Franz F; Schierz, Jan-Henning; Hofmann, Gunther O; Winkens, Thomas

2014-05-01

This study investigates whether early dynamic positron emission tomography/computed tomography (edPET/CT) using (18)F-sodium fluoride-((18)F-NaF) is feasible in depicting early phases of radiotracer distribution in patients with chronic osteomyelitis (COM). A total of 12 ed(18)F-NaF-PET/CT examinations were performed on 11 consecutive patients (2 female, 9 male; age 53 ± 12 years) in list mode over 5 min starting with radiopharmaceutical injection before standard late (18)F-NaF-PET/CT. Eight consecutive time intervals (frames) were reconstructed for each patient: four 15 s, then four 60 s. Several volumes of interest (VOI) were selected, representing the affected area as well as different reference areas within the bone and soft tissue. Maximum and mean ed standardized uptake values (edSUVmax, edSUVmean, respectively) were calculated in each VOI during each frame to measure early fluoride influx and accumulation. Results were compared between affected and non-affected (contralateral) bones. Starting in the 31-45 s frame, the affected bone area showed significantly higher edSUVmax and edSUVmean compared to the healthy contralateral region. The affected bone areas also significantly differed from non-affected contralateral regions in conventional late (18)F-NaF-PET/CT. This pilot study suggests that, in patients with COM, ed(18)F-NaF -PET offers additional information about early radiotracer distribution to standard (18)F-NaF -PET/CT, similar to a three-phase bone scan. The results should be validated in larger trials which directly compare ed(18)F-NaF-PET to a three-phase bone scan.

Comparison of yoga and walking-exercise on cardiac time intervals as a measure of cardiac function in elderly with increased pulse pressure.

PubMed

Patil, Satish Gurunathrao; Patil, Shankargouda S; Aithala, Manjunatha R; Das, Kusal Kanti

Arterial aging along with increased blood pressure(BP) has become the major cardiovascular(CV) risk in elderly. The aim of the study was to compare the effects of yoga program and walking-exercise on cardiac function in elderly with increased pulse pressure (PP). An open label, parallel-group randomized controlled study design was adopted. Elderly individuals aged ≥60 years with PP≥60mmHg were recruited for the study. Yoga (study) group (n=30) was assigned for yoga training and walking (exercise) group (n=30) for walking with loosening practices for one hour in the morning for 6days in a week for 3 months. The outcome measures were cardiac time intervals derived from pulse wave analysis and ECG: resting heart rate (RHR), diastolic time(DT), ventricular ejection time(LVET), upstroke time(UT), ejection duration index (ED%), pre-ejection period (PEP), rate pressure product (RPP) and percentage of mean arterial pressure (%MAP). The mean within-yoga group change in RHR(bpm) was 4.41 (p=0.031), PD(ms): -50.29 (p=0.042), DT(ms): -49.04 (p=0.017), ED%: 2.107 (p=0.001), ES(mmHg/ms): 14.62 (p=0.118), ET(ms): -0.66 (p=0.903), UT(ms): -2.54 (p=0.676), PEP(ms): -1.25 (p=0.11) and %MAP: 2.08 (p=0.04). The mean within-control group change in HR (bpm) was 0.35 (p=0.887), PD (ms): 11.15(p=0.717), DT (ms): 11.3 (p=0.706), ED%: -0.101 (p=0.936), ES (mmHg/ms): 0.75 (p=0.926), ET(ms): 2.2 (p=0.721), UT(ms):4.7(p=455), PEP (ms): 2.1(p=0.11), %MAP: 0.65 (p=0.451). A significant difference between-group was found in RHR (p=0.036), PD (p=0.02), ED% (p=0.049), LVET (p=0.048), DT (p=0.02) and RPP (p=0.001). Yoga practice for 3 months showed a significant improvement in diastolic function with a minimal change in systolic function. Yoga is more effective than walking in improving cardiac function in elderly with high PP. Copyright © 2017 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Alcohol intoxication in the context of major public holidays, sporting and social events: a time-series analysis in Melbourne, Australia, 2000-2009.

PubMed

Lloyd, Belinda; Matthews, Sharon; Livingston, Michael; Jayasekara, Harindra; Smith, Karen

2013-04-01

To assess the relationship between ambulance attendances, emergency department (ED) presentations and hospital admissions for acute alcohol intoxication and the timing of public holidays, sporting and social events. Time-series analysis was used to explore trends in intoxication in the context of major events. Population of Melbourne, Victoria, Australia between 2000 and 2009. All patients attended by ambulance, presenting to hospital EDs, or admitted to hospital who were classified as acutely alcohol intoxicated. Analysis of daily numbers of presentations for acute alcohol intoxication associated with major events were undertaken, including lead and lag effects. Analyses controlled for day of week and month of year to address temporal and seasonal variations. Alcohol intoxication presentations were significantly elevated the day before all public holidays, with intoxication cases on the day of public holidays only higher on New Year's Day (ambulance 6.57, 95% confidence intervals (CI): 3.4-9.74; ED 3.34, 95% CI: 1.28-5.4) and ANZAC Day (ambulance 3.71, 95% CI: 0.68-6.75). The Australian Football League (AFL) Grand Final (ED 2.37, 95% CI: 0.55-4.19), Commonwealth Games (ED 2.45, 95% CI: 0.6-4.3) and Melbourne Cup Day (ambulance 6.14, 95% CI: 2.42-9.85) represented the sporting events with significant elevations in acute intoxication requiring medical attention. The last working day before Christmas was the only social event where a significant increase in acute intoxication occurred (ambulance 8.98, 95% CI: 6.8-11.15). Acute alcohol intoxication cases requiring ambulance, emergency department and hospital in-patient treatment increase substantially on the day preceding public holidays and other major social events. © 2012 The Authors, Addiction © 2012 Society for the Study of Addiction.

The flex track: flexible partitioning between low- and high-acuity areas of an emergency department.

PubMed

Laker, Lauren F; Froehle, Craig M; Lindsell, Christopher J; Ward, Michael J

2014-12-01

Emergency departments (EDs) with both low- and high-acuity treatment areas often have fixed allocation of resources, regardless of demand. We demonstrate the utility of discrete-event simulation to evaluate flexible partitioning between low- and high-acuity ED areas to identify the best operational strategy for subsequent implementation. A discrete-event simulation was used to model patient flow through a 50-bed, urban, teaching ED that handles 85,000 patient visits annually. The ED has historically allocated 10 beds to a fast track for low-acuity patients. We estimated the effect of a flex track policy, which involved switching up to 5 of these fast track beds to serving both low- and high-acuity patients, on patient waiting times. When the high-acuity beds were not at capacity, low-acuity patients were given priority access to flexible beds. Otherwise, high-acuity patients were given priority access to flexible beds. Wait times were estimated for patients by disposition and Emergency Severity Index score. A flex track policy using 3 flexible beds produced the lowest mean patient waiting time of 30.9 minutes (95% confidence interval [CI] 30.6 to 31.2 minutes). The typical fast track approach of rigidly separating high- and low-acuity beds produced a mean patient wait time of 40.6 minutes (95% CI 40.2 to 50.0 minutes), 31% higher than that of the 3-bed flex track. A completely flexible ED, in which all beds can accommodate any patient, produced mean wait times of 35.1 minutes (95% CI 34.8 to 35.4 minutes). The results from the 3-bed flex track scenario were robust, performing well across a range of scenarios involving higher and lower patient volumes and care durations. Using discrete-event simulation, we have shown that adding some flexibility into bed allocation between low and high acuity can provide substantial reductions in overall patient waiting and a more efficient ED. Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Per capita increase in hospital presentations and admissions among children since the 1990s.

PubMed

Hardy, Andrew; Fuller, David G; Forrester, Mike; Anderson, Kym P; Cooper, Chris; Jenner, Bernard; Marshall, Isaac; Mccloskey, Kate; Sanderson, Christine; Standish, Jane; Vuillermin, Peter

2016-10-01

Data regarding temporal trends in per capita paediatric hospital presentations and admissions are required to inform health system and workforce planning. Emergency Department (ED) presentations and admissions to the University Hospital Geelong among patients aged 0 to 16 years over a 12-month period (2012-2013) were determined by review of hospital records and then compared with similar data collected during 1996/1997. 1 During each period, the Geelong region was serviced by a single ED, enabling us to estimate per capita presentation and admission rates. Since 1996/1997, per capita paediatric presentations to the ED increased from 643 to 1837 per 10 000 (186%; 95% confidence interval 181% to 191%). Moreover, the proportion of paediatric ED presentations resulting in hospital admission increased from 12.3% to 18.3% (49%; 95% confidence interval 39% to 59%). There has been a substantial absolute and per capita increase in paediatric ED presentations and hospital admissions since the 1990s. These trends place an increasing burden on the public hospital system, and strategies are required to promote paediatric acute care in the ambulatory setting. © 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments.

PubMed

Klein, Eili Y; Levin, Scott; Toerper, Matthew F; Makowsky, Michael D; Xu, Tim; Cole, Gai; Kelen, Gabor D

2017-11-01

A proposed benefit of expanding Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for primary care needs. Pre-ACA studies found that new Medicaid enrollees increased their ED utilization rates, but the effect on system-level ED visits was less clear. Our objective was to estimate the effect of Medicaid expansion on aggregate and individual-based ED utilization patterns within Maryland. We performed a retrospective cross-sectional study of ED utilization patterns across Maryland, using data from Maryland's Health Services Cost Review Commission. We also analyzed utilization differences between pre-ACA (July 2012 to December 2013) uninsured patients who returned post-ACA (July 2014 to December 2015). The total number of ED visits in Maryland decreased by 36,531 (-1.2%) between the 6 quarters pre-ACA and the 6 quarters post-ACA. Medicaid-covered ED visits increased from 23.3% to 28.9% (159,004 additional visits), whereas uninsured patient visits decreased from 16.3% to 10.4% (181,607 fewer visits). Coverage by other insurance types remained largely stable between periods. We found no significant relationship between Medicaid expansion and changes in ED volume by hospital. For patients uninsured pre-ACA who returned post-ACA, the adjusted visits per person during 6 quarters was 2.38 (95% confidence interval 2.35 to 2.40) for those newly enrolled in Medicaid post-ACA compared with 1.66 (95% confidence interval 1.64 to 1.68) for those remaining uninsured. There was a substantial increase in patients covered by Medicaid in the post-ACA period, but this did not significantly affect total ED volume. Returning patients newly enrolled in Medicaid visited the ED more than their uninsured counterparts; however, this cohort accounted for only a small percentage of total ED visits in Maryland. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Infection and natural history of emergency department-placed central venous catheters.

PubMed

LeMaster, Christopher H; Schuur, Jeremiah D; Pandya, Darshan; Pallin, Daniel J; Silvia, Jennifer; Yokoe, Deborah; Agrawal, Ashish; Hou, Peter C

2010-11-01

Central line-associated bloodstream infection (CLABSI, hereafter referred to in this paper as "bloodstream infection") is a leading cause of hospital-acquired infection. To our knowledge, there are no previously published studies designed to determine the rate of bloodstream infection among central venous catheters placed in the emergency department (ED). We design a retrospective chart review methodology to determine bloodstream infection and duration of catheterization for central venous catheters placed in the ED. Using hospital infection control, administrative, and ED billing databases, we identified patients with central venous catheters placed in the ED between January 1, 2007, and December 31, 2008, at one academic, urban ED with an annual census of 57,000. We performed a structured, explicit chart review to determine duration of catheterization and confirm bloodstream infection. We screened 4,251 charts and identified 656 patients with central venous catheters inserted in the ED, 3,622 catheter-days, and 7 bloodstream infections. The rate of bloodstream infection associated with central venous catheters placed in the ED was 1.93 per 1,000 catheter-days (95% confidence interval 0.50 to 3.36). The mean duration of catheterization was 5.5 days (median 4; range 1 to 29 days). Among infected central venous catheters, the mean duration of catheterization was 8.6 days (median 7; range 2 to 19 days). A total of 667 central venous catheters were placed in the internal jugular (392; 59%), subclavian (145; 22%), and femoral (130; 19%) veins. The sensitivity of using ED procedural billing code for identifying ED-placed central venous catheters among patients subsequently admitted to any ICU was 74.9% (95% confidence interval 71.4% to 78.3%). The rate of ED bloodstream infection at our institution is similar to current rates in ICUs. Central venous catheters placed in the ED remain in admitted patients for a substantial period. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Parental Language and Return Visits to the Emergency Department After Discharge.

PubMed

Samuels-Kalow, Margaret E; Stack, Anne M; Amico, Kendra; Porter, Stephen C

2017-06-01

Return visits to the emergency department (ED) are used as a marker of quality of care. Limited English proficiency, along with other demographic and disease-specific factors, has been associated with increased risk of return visit, but the relationship between language, short-term return visits, and overall ED use has not been well characterized. This is a planned secondary analysis of a prospective cohort examining the ED discharge process for English- or Spanish-speaking parents of children aged 2 months to 2 years with fever and/or respiratory illness. At 1 year after the index visit, a standardized chart review was performed. The primary outcome was the number of ED visits within 72 hours of the index visit. Multivariable logistic regression was used to examine the relative importance of predictor variables and adjust for confounders. There were 202 parents eligible for inclusion, of whom 23% were Spanish speaking. In addition, 6.9% of the sample had a return visit within 72 hours. After adjustment for confounders, Spanish language was associated with return visit within 72 hours (odds ratio, 3.49; 95% confidence interval, 1.02-11.90) but decreased risk of a second visit within the year (odds ratio, 0.28; 95% confidence interval, 0.12-0.66). Spanish-speaking parents are at an increased risk of 72-hour return ED visit but do not seem to be at increased risk of ED use during the year after their ED visit.

Depression and cardiac dysautonomia in eating disorders.

PubMed

Jelinek, Herbert F; Spence, Ian; Cornforth, David J; Tarvainen, Mika P; Russell, Janice

2018-06-01

Individuals with eating disorder (ED) are at an increased risk of cardiac arrhythmias due to cardiac dysautonomia, which may be exacerbated if depression is also present. The aim of the study was to use heart rate analysis as a marker for cardiac dysautonomia in patients with eating disorders and depression as a comorbidity. Clinical data, including presence of depression, was obtained from all participants. A three-lead ECG was used to determine interbeat intervals, and these were analyzed using time domain, frequency domain, and nonlinear heart rate variability measures. Thirty ED patients and 44 healthy controls participated in the research. The presence of depression was associated with additional decreased time domain (RMSSD 36.8 ± 26 vs. 22.9 ± 12.3; p < 0.05), frequency domain (HF power 788 ± 1075 vs. 279 ± 261; p < 0.05), and nonlinear domain (DFAα 2 0.82 ± 0.1 vs. 0.97 ± 0.1; p < 0.01) which results in the ED group compared to patients with no depression. The presence of depression in ED patients decreased HRV even further compared to the non-depressed patient group and controls, suggesting that higher vigilance and a holistic treatment approach may be required for these patients to avoid cardiac arrhythmia complications.

Scribes in an Australian private emergency department: A description of physician productivity.

PubMed

Walker, Katherine; Ben-Meir, Michael; O'Mullane, Phebe; Phillips, David; Staples, Margaret

2014-12-01

The study aims to determine if trained scribes in an Australian ED can assist emergency physicians (EPs) to work with increased productivity. This was a pilot, prospective, observational study conducted at a private ED in Melbourne. A scribe is a trained assistant who works with an EP and performs non-clinical tasks that reduce the time spent providing clinical care for patients. Shifts with and without a scribe were compared. The primary outcomes were patients per hour per doctor and billings per patient. Additional analyses included total patient time in ED; individual doctor productivity; time to see a doctor; time on ambulance bypass; and complaints/issues identified with scribes. There was an overall increase in doctor consultations per hour of 0.32 patients (95% confidence interval (CI) 0.17, 0.47). This varied between doctors from an increase in patients per hour of 0.16 (95% CI -0.09, 0.40) to 0.65 (95% CI 0.41, 0.89). Billings per patient were increased (AUD15.24; 95% CI -AUD18.51, AUD48.99), but the increase was not statistically significant; time to see a doctor reduced by 22 min (95% CI 11, 33); bypass episodes reduced by 66 min per shift (95% CI 11, 122), total patient ED stay remained constant. In this pilot study, scribe usage was feasible, and overall improvements in consultations per hour were seen. Overall income improved by AUD104.86 (95% CI AUD38.52, AUD171.21) per scribed hour. Further study is recommended to determine if results are sustained or improved over a longer period. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Implementation of the Canadian CT Head Rule and Its Association With Use of Computed Tomography Among Patients With Head Injury

PubMed Central

Sharp, Adam L.; Huang, Brian Z.; Tang, Tania; Shen, Ernest; Melnick, Edward R.; Venkatesh, Arjun K.; Kanter, Michael H.; Gould, Michael K.

2018-01-01

Study objective Approximately 1 in 3 computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the association of implementation of the Canadian CT Head Rule on head CT imaging in community emergency departments (EDs). Methods We conducted an interrupted time-series analysis of encounters from January 2014 to December 2015 in 13 Southern California EDs. Adult health plan members with a trauma diagnosis and Glasgow Coma Scale score at ED triage were included. A multicomponent intervention included clinical leadership endorsement, physician education, and integrated clinical decision support. The primary outcome was the proportion of patients receiving a head CT. The unit of analysis was ED encounter, and we compared CT use pre- and postintervention with generalized estimating equations segmented logistic regression, with physician as a clustering variable. Secondary analysis described the yield of identified head injuries pre- and postintervention. Results Included were 44,947 encounters (28,751 preintervention and 16,196 postintervention), resulting in 14,633 (32.6%) head CTs (9,758 preintervention and 4,875 postintervention), with an absolute 5.3% (95% confidence interval [CI] 2.5% to 8.1%) reduction in CT use postintervention. Adjusted pre-post comparison showed a trend in decreasing odds of imaging (odds ratio 0.98; 95% CI 0.96 to 0.99). All but one ED reduced CTs postintervention (0.3% to 8.7%, one ED 0.3% increase), but no interaction between the intervention and study site over time existed (P=.34). After the intervention, diagnostic yield of CT-identified intracranial injuries increased by 2.3% (95% CI 1.5% to 3.1%). Conclusion A multicomponent implementation of the Canadian CT Head Rule was associated with a modest reduction in CT use and an increased diagnostic yield of head CTs for adult trauma encounters in community EDs. PMID:28739290

Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department.

PubMed

Vinson, David R; Warton, E Margaret; Mark, Dustin G; Ballard, Dustin W; Reed, Mary E; Chettipally, Uli K; Singh, Nimmie; Bouvet, Sean Z; Kea, Bory; Ramos, Patricia C; Glaser, David S; Go, Alan S

2018-03-01

Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED). This prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation. Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82-0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10-3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35-5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient's outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm. Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.

Driver seat belt use indicates decreased risk for child passengers in a motor vehicle crash.

PubMed

Olsen, Cody S; Cook, Lawrence J; Keenan, Heather T; Olson, Lenora M

2010-03-01

We examined the association between driver restraint use and child emergency department (ED) evaluation following a motor vehicle crash (MVC). This cohort study included child passengers aged 0-12 years riding with an adult driver aged 21 years or older involved in a MVC in Utah from 1999 to 2004. The 6 years of Utah MVC records were probabilistically linked to statewide Utah ED records. We estimated the relative risk of ED evaluation following a MVC for children riding with restrained versus unrestrained drivers. Generalized estimating equations were used to calculate relative risks adjusted for child, driver, and crash characteristics. Six percent (6%) of children riding with restrained adult drivers were evaluated in the ED compared to twenty-two percent (22%) of children riding with unrestrained adult drivers following a MVC (relative risk 0.29, 95% confidence interval 0.26-0.32). After adjusting for child, vehicle, and crash characteristics, the relative risk of child ED evaluation associated with driver restraint remained significant (relative risk 0.82, 95% confidence interval 0.72-0.94). Driver restraint use was associated with child restraint use, less alcohol/drug involvement, and lower relative risk of severe collision types (head-on, rollover). Driver seat belt use is associated with decreased risk of ED evaluation for child passengers in the event of a MVC. Copyright 2009 Elsevier Ltd. All rights reserved.

Intimate partner violence among women with eating disorders during the perinatal period

PubMed Central

Easter, Abigail; Lewis, Rebecca; Howard, Louise M.; Micali, Nadia

2015-01-01

ABSTRACT Objective  Prevalence of intimate partner violence (IPV) during pregnancy is estimated to be 4%–8%. Women with mental health difficulties are at increased risk for IPV during the perinatal period. Prevalence of IPV is high among women with eating disorders (ED); however, prevalence of IPV during the perinatal period among women with ED is unknown. Method  We studied women from a population‐based cohort, the Avon Longitudinal Study of Parents and Children. Prevalence and odds of physical and emotional IPV during and after the perinatal period was investigated among women with lifetime ED, with (n = 174) or without pregnancy shape and weight concern and/or purging behaviors (n = 189), and women with no ED (n = 8723). Results  Women with lifetime ED showed higher prevalence of IPV during and after the perinatal period (physical = 9.6%–14.3% and emotional = 24.1%–28.1%). Lifetime ED was associated with higher odds of physical IPV during the perinatal period (odds ratio: 2.34, 95% confidence interval: 1.11–4.93, p = .03). Lifetime ED with and without pregnancy shape and weight concerns and/or purging was associated with higher odds of IPV after the perinatal period, and higher odds of reporting emotional IPV at all time points. Associations were moderated by partner's response to pregnancy and maternal experience of childhood sexual abuse. Discussion  Mothers with ED and their children may be vulnerable to negative effects due to maternal ED and IPV combined, both of which have been associated with severe and long‐lasting harmful consequences. Partner's response to pregnancy and maternal experience of childhood sexual abuse might contribute to the association between ED and IPV perinatally. © 2015 The Authors. International Journal of Eating Disorders published by Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:727–735) PMID:26032597

Mental Health-related Emergency Department Visits Associated With Cannabis in Colorado.

PubMed

Hall, Katelyn E; Monte, Andrew A; Chang, Tae; Fox, Jacob; Brevik, Cody; Vigil, Daniel I; Van Dyke, Mike; James, Katherine A

2018-02-24

Cannabis legalization in Colorado resulted in increased cannabis-associated health care utilization. Our objective was to examine cooccurrence of cannabis and mental health diagnostic coding in Colorado emergency department (ED) discharges and replicate the study in a subpopulation of ED visits where cannabis involvement and psychiatric diagnosis were confirmed through medical review. We collected statewide ED International Classification of Diseases, 9th Revision, Clinical Modification diagnoses from the Colorado Hospital Association and a subpopulation of ED visits from a large, academic hospital from 2012 to 2014. Diagnosis codes identified visits associated with mental health and cannabis. Codes for mental health conditions and cannabis were confirmed by manual records review in the academic hospital subpopulation. Prevalence ratios (PRs) of mental health ED discharges were calculated to compare cannabis-associated visits to those without cannabis. Rates of mental health and cannabis-associated ED discharges were examined over time. Statewide data demonstrated a fivefold higher prevalence of mental health diagnoses in cannabis-associated ED visits (PR = 5.35, 95% confidence interval [CI], 5.27-5.43) compared to visits without cannabis. The hospital subpopulation supported this finding with a fourfold higher prevalence of psychiatric complaints in cannabis attributable ED visits (PR = 4.87, 95% CI = 4.36-5.44) compared to visits not attributable to cannabis. Statewide rates of ED visits associated with both cannabis and mental health significantly increased from 2012 to 2014 from 224.5 to 268.4 per 100,000 (p < 0.0001). In Colorado, the prevalence of mental health conditions in ED visits with cannabis-associated diagnostic codes is higher than in those without cannabis. There is a need for further research determining if these findings are truly attributed to cannabis or merely coincident with concurrent increased use and availability. © 2018 by the Society for Academic Emergency Medicine.

A cost-effectiveness analysis of propofol versus midazolam for procedural sedation in the emergency department.

PubMed

Hohl, Corinne Michèle; Nosyk, Bohdan; Sadatsafavi, Mohsen; Anis, Aslam Hayat

2008-01-01

To determine the incremental cost-effectiveness of using propofol versus midazolam for procedural sedation (PS) in adults in the emergency department (ED). The authors conducted a cost-effectiveness analysis from the perspective of the health care provider. The primary outcome was the incremental cost (or savings) to achieve one additional successful sedation with propofol compared to midazolam. A decision model was developed in which the clinical effectiveness and cost of a PS strategy using either agent was estimated. The authors derived estimates of clinical effectiveness and risk of adverse events (AEs) from a systematic review. The cost of each clinical outcome was determined by incorporating the baseline cost of the ED visit, the cost of the drug, the cost of labor of physicians and nurses, the cost and probability of an AE, and the cost and probability of a PS failure. A standard meta-analytic technique was used to calculate the weighted mean difference in recovery times and obtain mean drug doses from patient-level data from a randomized controlled trial. Probabilistic sensitivity analyses were conducted to examine the uncertainty around the estimated incremental cost-effectiveness ratio using Monte Carlo simulation. Choosing a sedation strategy with propofol resulted in average savings of $17.33 (95% confidence interval [CI] = $24.13 to $10.44) per sedation performed. This resulted in an incremental cost-effectiveness ratio of -$597.03 (95% credibility interval -$6,434.03 to $6,113.57) indicating savings of $597.03 per additional successful sedation performed with propofol. This result was driven by shorter recovery times and was robust to all sensitivity analyses performed. These results indicate that using propofol for PS in the ED is a cost-saving strategy.

Post-licensure safety surveillance study of routine use of tetanus toxoid, reduced diphtheria toxoid and 5-component acellular pertussis vaccine.

PubMed

Baxter, Roger; Hansen, John; Timbol, Julius; Pool, Vitali; Greenberg, David P; Johnson, David R; Decker, Michael D

2016-11-01

An observational post-licensure (Phase IV) retrospective large-database safety study was conducted at Kaiser Permanente, a US integrated medical care organization, to assess the safety of Tetanus Toxoid, Reduced Diphtheria Toxoid and 5-Component Acellular Pertussis Vaccine (Tdap5) administered as part of routine healthcare among adolescents and adults. We evaluated incidence rates of various clinical events resulting in outpatient clinic, emergency department (ED), and hospital visits during various time intervals (windows) following Tdap5 vaccination using 2 pharmacoepidemiological methods (risk interval and historic cohort) and several screening thresholds. Plausible outcomes of interest with elevated incidence rate ratios (IRRs) were further evaluated by reviewing individual patient records to confirm the diagnosis, timing (temporal relationship), alternative etiology, and other health record details to discern possible relatedness of the health events to vaccination. Overall, 124,139 people received Tdap5 vaccine from September 2005 through mid-October 2006, and 203,154 in the comparison cohort received a tetanus and diphtheria toxoid adsorbed vaccine (and no live virus vaccine) during the year prior to initiation of this study. In the outpatient, ED and hospital databases, respectively, we identified 11/26, 179/700 and 187/700 unique health outcomes with IRRs significantly >1.0. Among the same unique health outcomes in the outpatient, ED, and hospital databases, 9, 146, and 385, respectively, had IRRs significantly <1.0. Further scrutiny of the outcomes with elevated IRRs did not reveal unexpected signals of adverse outcomes related to vaccination. In conclusion, Tdap5 vaccine was found to be safe among this large population of adolescents and adults.

Post-licensure safety surveillance study of routine use of tetanus toxoid, reduced diphtheria toxoid and 5-component acellular pertussis vaccine

PubMed Central

Baxter, Roger; Hansen, John; Timbol, Julius; Pool, Vitali; Greenberg, David P.; Johnson, David R.; Decker, Michael D.

2016-01-01

ABSTRACT An observational post-licensure (Phase IV) retrospective large-database safety study was conducted at Kaiser Permanente, a US integrated medical care organization, to assess the safety of Tetanus Toxoid, Reduced Diphtheria Toxoid and 5-Component Acellular Pertussis Vaccine (Tdap5) administered as part of routine healthcare among adolescents and adults. We evaluated incidence rates of various clinical events resulting in outpatient clinic, emergency department (ED), and hospital visits during various time intervals (windows) following Tdap5 vaccination using 2 pharmacoepidemiological methods (risk interval and historic cohort) and several screening thresholds. Plausible outcomes of interest with elevated incidence rate ratios (IRRs) were further evaluated by reviewing individual patient records to confirm the diagnosis, timing (temporal relationship), alternative etiology, and other health record details to discern possible relatedness of the health events to vaccination. Overall, 124,139 people received Tdap5 vaccine from September 2005 through mid-October 2006, and 203,154 in the comparison cohort received a tetanus and diphtheria toxoid adsorbed vaccine (and no live virus vaccine) during the year prior to initiation of this study. In the outpatient, ED and hospital databases, respectively, we identified 11/26, 179/700 and 187/700 unique health outcomes with IRRs significantly >1.0. Among the same unique health outcomes in the outpatient, ED, and hospital databases, 9, 146, and 385, respectively, had IRRs significantly <1.0. Further scrutiny of the outcomes with elevated IRRs did not reveal unexpected signals of adverse outcomes related to vaccination. In conclusion, Tdap5 vaccine was found to be safe among this large population of adolescents and adults. PMID:27388557

Relationship Between Physiological Parameters and Acute Coronary Syndrome in Patients Presenting to the Emergency Department With Undifferentiated Chest Pain.

PubMed

Greenslade, Jaimi H; Beamish, Daniel; Parsonage, William; Hawkins, Tracey; Schluter, Jessica; Dalton, Emily; Parker, Kate; Than, Martin; Hammett, Christopher; Lamanna, Arvin; Cullen, Louise

2016-01-01

The investigators of this study sought to examine whether abnormal physiological parameters are associated with increased risk for acute coronary syndrome (ACS) in patients presenting to the emergency department (ED) with chest pain. We used prospectively collected data on adult patients presenting with suspected ACS in 2 EDs in Australia and New Zealand. Trained research nurses collected physiological data including temperature, respiratory rate, heart rate, and systolic blood pressure (SBP) on presentation to the ED. The primary endpoint was ACS within 30 days of presentation, as adjudicated by cardiologists using standardized guidelines. The prognostic utility of physiological parameters for ACS was examined using risk ratios. Acute coronary syndrome was diagnosed in 384 of the 1951 patients (20%) recruited. Compared with patients whose SBP was between 100 and 140 mm Hg, patients with an SBP of lower than 100 mm Hg or higher than 140 mm Hg were 1.4 times (95% confidence interval, 1.2-1.7) more likely to have ACS. Similarly, compared with patients whose temperature was between 36.5°C and 37.5°C, patients with temperature of lower than 36.5°C or higher than 37.5°C were 1.4 times (95% confidence interval, 1.1-1.6) more likely to have ACS. Heart rate and respiratory rate were not predictors of ACS. Patients with abnormal temperature or SBP were slightly more likely to have ACS, but such risk was of too small a magnitude to be useful in clinical decision making. Other physiological parameters (heart rate and respiratory rate) had no prognostic value. The use of physiological parameters cannot reliably confirm or rule out ACS.

Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993-2008.

PubMed

Ting, Sarah A; Sullivan, Ashley F; Boudreaux, Edwin D; Miller, Ivan; Camargo, Carlos A

2012-01-01

The objective was to describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period. Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950-E959) during 1993-2008. Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury [1.50 (95% confidence interval, 1.33-1.67) visits per 1000 US population], and the average annual number for these ED visits more than doubled from 244,000 in 1993-1996 to 538,000 in 2005-2008. During the same time frame, ED visits for these injuries per 1000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82) and blacks (1.14 to 2.10). Visits were most common among ages 15-19, and the number of visits coded as urgent/emergent decreased from 0.95 in 1993-1996 to 0.70 in 2005-2008. ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs. Copyright © 2012 Elsevier Inc. All rights reserved.

Impact of an in-house emergency radiologist on report turnaround time.

PubMed

Lamb, Leslie; Kashani, Paria; Ryan, John; Hebert, Guy; Sheikh, Adnan; Thornhill, Rebecca; Fasih, Najla

2015-01-01

One of the many challenges facing emergency departments (EDs) across North America is timely access to emergency radiology services. Academic institutions, which are typically also regional referral centres, frequently require cross-sectional studies to be performed 24 hours a day with expedited final reports to accelerate patient care and ED flow. The purpose of this study was to determine if the presence of an in-house radiologist, in addition to a radiology resident dedicated to the ED, had a significant impact on report turnaround time. Preliminary and final report turnaround times, provided by the radiology resident and staff, respectively, for patients undergoing computed tomography or ultrasonography of their abdomen/pelvis in 2008 (before the implementation of emergency radiology in-house staff service) were compared to those performed during the same time frame in 2009 and 2010 (after staffing protocols were changed). A total of 1,624 reports were reviewed. Overall, there was no statistically significant decrease in the preliminary report turnaround times between 2008 and 2009 (p = 0.1102), 2009 and 2010 (p = 0.6232), or 2008 and 2010 (p = 0.0890), although times consistently decreased from a median of 2.40 hours to 2.08 hours to 2.05 hours (2008 to 2009 to 2010). There was a statistically significant decrease in final report turnaround times between 2008 and 2009 (p < 0.0001), 2009 and 2010 (p < 0.0011), and 2008 and 2010 (p < 0.0001). Median final report times decreased from 5.00 hours to 3.08 hours to 2.75 hours in 2008, 2009, and 2010, respectively. There was also a significant decrease in the time interval between preliminary and final reports between 2008 and 2009 (p < 0.0001) and 2008 and 2010 (p < 0.0001) but no significant change between 2009 and 2010 (p = 0.4144). Our results indicate that the presence of a dedicated ED radiologist significantly reduces final report turnaround time and thus may positively impact the time to ED patient disposition. Patient care is improved when attending radiologists are immediately available to read complex films, both in terms of health care outcomes and regarding the need for repeat testing. Providing emergency physicians with accurate imaging findings as rapidly as possible facilitates effective and timely management and thus optimizes patient care.

Increased Emergency Department Use in Illinois After Implementation of the Patient Protection and Affordable Care Act.

PubMed

Dresden, Scott M; Powell, Emilie S; Kang, Raymond; McHugh, Megan; Cooper, Andrew J; Feinglass, Joe

2017-02-01

We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid expansion state. Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates. Interrupted time-series analyses tested changes in ED visit rates and ED hospitalization rates by insurance type after ACA implementation. Average monthly ED visit volume increased by 14,080 visits (95% confidence interval [CI] 4,670 to 23,489), a 5.7% increase, after ACA implementation. Changes by payer were as follows: uninsured decreased by 24,158 (95% CI -27,037 to -21,279), Medicaid increased by 28,746 (95% CI 23,945 to 33,546), and private insurance increased by 9,966 (95% 6,241 to 13,690). The total monthly ED visit rate increased by 1.8 visits per 1,000 residents (95% CI 0.6 to 3.0). The monthly ED visit rate decreased by 8.7 visit per 1,000 uninsured residents (95% CI -11.1 to -6.3) and increased by 10.2 visit per 1,000 Medicaid beneficiaries (95% CI 4.4 to 16.1) and 1.3 visits per 1,000 privately insured residents (95% CI 0.6 to 1.9). After adjusting for baseline trends and season, these changes remained statistically significant. The total number of hospitalizations through the ED was unchanged. ED visits by adults aged 18 to 64 years in Illinois increased after ACA health insurance expansion. The increase in total ED visits was driven by an increase in visits resulting in discharge from the ED. A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients. These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before ACA implementation. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Critical pathways in the emergency department improve treatment modalities for patients with ST-elevation myocardial infarction in a European hospital.

PubMed

Pelliccia, Francesco; Cartoni, Domenico; Verde, Monica; Salvini, Paolo; Mercuro, Giuseppe; Tanzi, Pietro

2004-12-01

The use of protocols for patients with ST-elevation myocardial infarction (MI) is growing, but no definite conclusion regarding the value of critical pathways in Europe has been drawn. The aim of this study was to investigate the impact of critical pathway on processes of care and outcome for patients presenting to the emergency department (ED) of a large urban European hospital because of possible ST-elevation MI. Critical pathways for management of acute chest pain at our ED were developed in 1998 and have been revised every year. Accordingly, the records of all patients referred in 1997 to the ED because of chest pain (before pathway implementation) and in 2001 (after last pathway revision) were reviewed. An ST-elevation MI was diagnosed at ED in 520 of 5,066 (10.3%) patients with chest pain in 1997, and in 452 of 4,843 (9.3%) patients with chest pain in 2001. Patients were managed according to the ED cardiologists' decisions in 1997, whereas they entered the pathways for ST-elevation MI in 2001, with predefined criteria for diagnosis, thrombolysis, percutaneous coronary intervention, and admission to the coronary care unit. Comparison of treatment modalities disclosed that more patients were given thrombolysis in 1997 (49 vs. 16%, p<0.05), whereas in 2001 more patients were sent to primary angioplasty (63 vs. 11%, p<0.05). Also in 2001, patients more often received aspirin (90 vs. 61%, p<0.05) and intravenous beta blockers (60 vs. 35%, p<0.05) soon after arrival at the ED. Comparison between 1997 and 2001 revealed that admission rates to the coronary care unit (69 vs. 78%, NS) and cardiac wards were similar (19 vs. 10%, NS). Conversely, compared with 1997, patients hospitalized in 2001 had a shorter length of stay (12 +/- 5 vs. 18 +/- 6 days, p<0.05), as well as fewer major adverse coronary events (21 vs. 30%, p<0.05) and lower all-cause in-hospital mortality (12 vs. 20%, p<0.05). The quality of care indicators improved with time, as door-to-electrocardiogram interval (10 +/- 6 vs. 19 +/- 9 min, p<0.05), door-to-needle time (25 +/- 10 vs. 35 +/- 10 min, p<0.05), and door-to-balloon interval (70 +/- 15 vs. 99 +/- 20 min, p<0.05) were shorter in 2001 than in 1997. A critical pathway for ST-elevation MI at the ED increases the use of evidence-based treatment strategies and improves outcome and quality of care of patients presenting to a European hospital because of acute chest pain.

Dose-response study of spinal hyperbaric ropivacaine for cesarean section

PubMed Central

Chen, Xin-zhong; Chen, Hong; Lou, Ai-fei; Lü, Chang-cheng

2006-01-01

Background: Spinal hyperbaric ropivacaine may produce more predictable and reliable anesthesia than plain ropivacaine for cesarean section. The dose-response relation for spinal hyperbaric ropivacaine is undetermined. This double-blind, randomized, dose-response study determined the ED50 (50% effective dose) and ED95 (95% effective dose) of spinal hyperbaric ropivacaine for cesarean section anesthesia. Methods: Sixty parturients undergoing elective cesarean section delivery with use of combined spinal-epidural anesthesia were enrolled in this study. An epidural catheter was placed at the L1~L2 vertebral interspace, then lumbar puncture was performed at the L3~L4 vertebral interspace, and parturients were randomized to receive spinal hyperbaric ropivacaine in doses of 10.5 mg, 12 mg, 13.5 mg, or 15 mg in equal volumes of 3 ml. Sensory levels (pinprick) were assessed every 2.5 min until a T7 level was achieved and motor changes were assessed by modified Bromage Score. A dose was considered effective if an upper sensory level to pin prick of T7 or above was achieved and no intraoperative epidural supplement was required. ED50 and ED95 were determined with use of a logistic regression model. Results: ED50 (95% confidence interval) of spinal hyperbaric ropivacaine was determined to be 10.37 (5.23~11.59) mg and ED95 (95% confidence interval) to be 15.39 (13.81~23.59) mg. The maximum sensory block levels and the duration of motor block and the rate of hypotension, but not onset of anesthesia, were significantly related to the ropivacaine dose. Conclusion: The ED50 and ED95 of spinal hyperbaric ropivacaine for cesarean delivery under the conditions of this study were 10.37 mg and 15.39 mg, respectively. Ropivacaine is suitable for spinal anesthesia in cesarean delivery. PMID:17111469

Pain management trend of vaso-occulsive crisis (VOC) at a community hospital emergency department (ED) for patients with sickle cell disease.

PubMed

Inoue, Susumu; Khan, Isra'a; Mushtaq, Rao; Sanikommu, Srinivasa Reddy; Mbeumo, Carline; LaChance, Jenny; Roebuck, Michael

2016-01-01

Pain management at the emergency department (ED) for vaso-occulsive crisis (VOC) for patients with sickle cell disease has not been optimum, with a long delay in giving the initial analgesic. We conducted a retrospective survey over a 7-year period to determine our ED's timing in giving pain medication to patients with VOC as a quality improvement project. We compared different periods, children vs adults, and the influence of gender in the analgesic administration timing. This is a retrospective chart review of three different periods: (1) years 2007-2008, (2) years 2011-2012, and (3) year 2013. We extracted relevant information from ED records. Data were analyzed using Student t test, chi-square analysis, and the Kruskal-Wallis test. There was a progressive improvement in the time interval to the 1st analgesic over these three periods. Children received analgesics more quickly than adults in all periods. Male adult patients received pain medication faster than female adult patients, although initial pain scores were higher in female than in male patients. Progressively fewer pediatric patients utilized ED over these three periods, but no difference for adult patients was observed. The proportion of pediatric patients admitted to the hospital increased with each period. The progressive decrease in both the number of patients and the number of visits to the ED by children suggested that the collective number of VOC in children has decreased, possibly secondary to the dissemination of hydroxyurea use. We failed to observe the same trend in adult patients. The need for IV access, and ordering laboratory tests or imaging studies tends to delay analgesic administration. Delay in administration of the first analgesic was more pronounced for female adult patients than male adult patients in spite of their higher pain score. Health care providers working in ED should make conscious efforts to respect pain in women as well as pain in men. Though not proven from this study, we believe that a significantly wider use of hydroxyurea by adult patients most likely would reduce their utilization of ED for the purpose of relief of pain, and further pediatric hematologists may be better positioned to increase hydroxyurea adherence by young adult patients, since they have had established rapport with them before transitioning to adult care.

Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions.

PubMed

Horwitz, Leora I; Parwani, Vivek; Shah, Nidhi R; Schuur, Jeremiah D; Meredith, Thom; Jenq, Grace Y; Kulkarni, Raghavendra G

2009-09-01

Communication failures contribute to errors in the transfer of patients from the emergency department (ED) to inpatient medicine units. Oral (synchronous) communication has numerous benefits but is costly and time consuming. Taped (asynchronous) communication may be more reliable and efficient but lacks interaction. We evaluate a new asynchronous physician-physician sign-out compared with the traditional synchronous sign-out. A voicemail-based, semistructured sign-out for routine ED admissions to internal medicine was implemented in October 2007 at an urban, academic medical center. Outcomes were obtained by pre- and postintervention surveys of ED and internal medicine house staff, physician assistants, and hospitalist attending physicians and by examination of access logs and administrative data. Outcome measures included utilization; physician perceptions of ease, accuracy, content, interaction, and errors; and rate of transfers to the ICU from the floor within 24 hours of ED admission. Results were analyzed both quantitatively and qualitatively with standard qualitative analytic techniques. During September to October 2008 (1 year postintervention), voicemails were recorded about 90.3% of medicine admissions; 69.7% of these were accessed at least once by admitting physicians. The median length of each sign-out was 2.6 minutes (interquartile range 1.9 to 3.5). We received 117 of 197 responses (59%) to the preintervention survey and 113 of 206 responses (55%) to the postintervention survey. A total of 73 of 101 (72%) respondents reported dictated sign-out was easier than oral sign-out and 43 of 101 (43%) reported it was more accurate. However, 70 of 101 (69%) reported that interaction among participants was worse. There was no change in the rate of ICU transfer within 24 hours of admission from the ED in April to June 2007 (65/6,147; 1.1%) versus April to June 2008 (70/6,263; 1.1%); difference of 0%, 95% confidence interval -0.4% to 0.3%. The proportion of internists reporting at least 1 perceived adverse event relating to transfer from the ED decreased a nonsignificant 10% after the intervention (95% confidence interval -27% to 6%), from 44% preintervention (32/72) to 34% postintervention (23/67). Voicemail sign-out for ED-internal medicine communication was easier than oral sign-out without any change in early ICU transfers or the perception of major adverse events. However, interaction among participants was reduced. Voicemail sign-out may be an efficient means of improving sign-out communication for stable ED admissions.

The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling.

PubMed

Katz, David A; Vander Weg, Mark W; Holman, John; Nugent, Andrew; Baker, Laurence; Johnson, Skyler; Hillis, Stephen L; Titler, Marita

2012-04-01

The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange) and 2) assess ED nurses' and physicians' perceptions of smoking cessation counseling. The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses' and physicians' self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates. Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses' self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in "pros" and "cons" attitudes toward smoking cessation in either ED nurses or physicians. Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED. © 2012 by the Society for Academic Emergency Medicine.

Base excess is an accurate predictor of elevated lactate in ED septic patients.

PubMed

Montassier, Emmanuel; Batard, Eric; Segard, Julien; Hardouin, Jean-Benoît; Martinage, Arnaud; Le Conte, Philippe; Potel, Gille

2012-01-01

Prior studies showed that lactate is a useful marker in sepsis. However, lactate is often not routinely drawn or rapidly available in the emergency department (ED). The study aimed to determine if base excess (BE), widely and rapidly available in the ED, could be used as a surrogate marker for elevated lactate in ED septic patients. This was a prospective and observational cohort study. From March 2009 to March 2010, consecutive patients 18 years or older who presented to the ED with a suspected severe sepsis were enrolled in the study. Lactate and BE measurements were performed. We defined, a priori, a clinically significant lactate to be greater than 3 mmol/L and BE less than -4 mmol/L. A total of 224 patients were enrolled in the study. The average BE was -4.5 mmol/L (SD, 4.9) and the average lactate was 3.5 mmol/L (SD, 2.9). The sensitivity of a BE less than -4 mmol/L in predicting elevated lactate greater than 3 mmol/L was 91.1% (95% confidence interval, 85.5%-96.6%) and the specificity was 88.6% (95% confidence interval, 83.0%-94.2%). The area under the curve was 0.95. Base excess is an accurate marker for the prediction of elevated lactate in the ED. The measurement of BE, obtained in a few minutes in the ED, provides a secure and quick method, similar to the electrocardiogram at triage for patients with chest pain, to determine the patients with sepsis who need an early aggressive resuscitation. Copyright © 2012 Elsevier Inc. All rights reserved.

[Prevalence of eating disorders in early adolescent students].

PubMed

Ruiz-Lázaro, P M; Comet, M P; Calvo, A I; Zapata, M; Cebollada, M; Trébol, L; Lobo, A

2010-01-01

To measure the prevalence of Eating Behavior Disorders (EBD) in Spanish early-adolescent students using standardized methods. A two-stage survey of prevalence of ED in a representative sample of 12 to 13 year old students in 2007 in Zaragoza (Spain). Standard evaluation: We used a two-phase cross sectional design, which involved the screening with questionnaires (EAT at a cutoff score of 20) and subsequent semi-structured interviews (SCAN) of screen-positive and screen-negative subjects. We calculated the sociodemographic characteristics, ED prevalence with their 95% confidence intervals (CI) with Confidence Interval Analysis (C.I.A.) disk version 2.0.0 (Altman et al, 2000). The study is financed by F.I.S. PI 05/2533 (Spain Health Department). In 2007 we studied 701 students seventh-grade, ages 12 to 13, girls and boys, in 9 public and private schools in Zaragoza (30 classrooms). In the second phase 164 preteens agreed to proceed with the clinical evaluation (63 at risk, high scorers; 101 selected sample not at risk). ED prevalence was 0.7% EDNOS F 50.9 (CI 95%: 0.3%-1.7%). The ICD-10 point prevalence rates of ED population in Spanish preteen students is similar to those reported for other developed countries. The prevalence of subclinical ED is substantially higher than that of full-syndrome.

Abstinence from prolonged ethanol exposure affects plasma corticosterone, glucocorticoid receptor signaling and stress-related behaviors.

PubMed

Somkuwar, Sucharita S; Vendruscolo, Leandro F; Fannon, McKenzie J; Schmeichel, Brooke E; Nguyen, Tran Bao; Guevara, Jasmin; Sidhu, Harpreet; Contet, Candice; Zorrilla, Eric P; Mandyam, Chitra D

2017-10-01

Alcohol dependence is linked to dysregulation of the hypothalamic-pituitary-adrenal axis. Here, we investigated effects of repeated ethanol intoxication-withdrawal cycles (using chronic intermittent ethanol vapor inhalation; CIE) and abstinence from CIE on peak and nadir plasma corticosterone (CORT) levels. Irritability- and anxiety-like behaviors as well as glucocorticoid receptors (GR) in the medial prefrontal cortex (mPFC) were assessed at various intervals (2h-28d) after cessation of CIE. Results show that peak CORT increased during CIE, transiently decreased during early abstinence (1-11d), and returned to pre-abstinence levels during protracted abstinence (17-27d). Acute withdrawal from CIE enhanced aggression- and anxiety-like behaviors. Early abstinence from CIE reduced anxiety-like behavior. mPFC-GR signaling (indexed by relative phosphorylation of GR at Ser211) was transiently decreased when measured at time points during early and protracted abstinence. Further, voluntary ethanol drinking in CIE (CIE-ED) and CIE-naïve (ED) rats, and effects of CIE-ED and ED on peak CORT levels and mPFC-GR were investigated during acute withdrawal (8h) and protracted abstinence (28d). CIE-ED and ED increased peak CORT during drinking. CIE-ED and ED decreased expression and signaling of mPFC-GR during acute withdrawal, an effect that was reversed by systemic mifepristone treatment. CIE-ED and ED demonstrate robust reinstatement of ethanol seeking during protracted abstinence and show increases in mPFC-GR expression. Collectively, the data demonstrate that acute withdrawal from CIE produces robust alterations in GR signaling, CORT and negative affect symptoms which could facilitate excessive drinking. The findings also show that CIE-ED and ED demonstrate enhanced relapse vulnerability triggered by ethanol cues and these changes are partially mediated by altered GR expression in the mPFC. Taken together, transition to alcohol dependence could be accompanied by alterations in mPFC stress-related pathways that may increase negative emotional symptoms and increase vulnerability to relapse. Copyright © 2017 Elsevier Ltd. All rights reserved.

Pubic Hair Grooming Injuries Presenting to U.S. Emergency Departments

PubMed Central

Glass, Allison S.; Bagga, Herman S.; Tasian, Gregory E.; Fisher, Patrick B.; McCulloch, Charles E.; Blaschko, Sarah D.; McAninch, Jack W.; Breyer, Benjamin N.

2013-01-01

OBJECTIVE To describe the demographics and mechanism of genitourinary (GU) injuries related to pubic hair grooming in patients who present to U.S. emergency departments (EDs). MATERIALS AND METHODS The National Electronic Injury Surveillance System contains prospectively collected data from patients who present to EDs with consumer product-related injuries. The National Electronic Injury Surveillance System is a stratified probability sample, validated to provide national estimates of all patients who present to U.S. EDs with an injury. We reviewed the National Electronic Injury Surveillance System to identify incidents of GU injury related to pubic hair grooming for 2002–2010. The variables reviewed included age, race, gender, injury type, location (organ) of injury, hospital disposition, and grooming product. RESULTS From 2002 to 2010, an observed 335 actual ED visits for GU injury related to grooming products provided an estimated 11,704 incidents (95% confidence interval 8430–15,004). The number of incidents increased fivefold during that period, amounting to an estimated increase of 247 incidents annually (95% confidence interval 110–384, P = .001). Of the cohort, 56.7% were women. The mean age was 30.8 years (95% confidence interval 28.8–32.9). Shaving razors were implicated in 83% of the injuries. Laceration was the most common type of injury (36.6%). The most common site of injury was the external female genitalia (36.0%). Most injuries (97.3%) were treated within the ED, with subsequent patient discharge. CONCLUSION Most GU injuries that result from the use of grooming products are minor and involve the use of razors. The demographics of patients with GU injuries from grooming products largely paralleled observations about cultural grooming trends in the United States. PMID:23040729

Pubic hair grooming injuries presenting to U.S. emergency departments.

PubMed

Glass, Allison S; Bagga, Herman S; Tasian, Gregory E; Fisher, Patrick B; McCulloch, Charles E; Blaschko, Sarah D; McAninch, Jack W; Breyer, Benjamin N

2012-12-01

To describe the demographics and mechanism of genitourinary (GU) injuries related to pubic hair grooming in patients who present to U.S. emergency departments (EDs). The National Electronic Injury Surveillance System contains prospectively collected data from patients who present to EDs with consumer product-related injuries. The National Electronic Injury Surveillance System is a stratified probability sample, validated to provide national estimates of all patients who present to U.S. EDs with an injury. We reviewed the National Electronic Injury Surveillance System to identify incidents of GU injury related to pubic hair grooming for 2002-2010. The variables reviewed included age, race, gender, injury type, location (organ) of injury, hospital disposition, and grooming product. From 2002 to 2010, an observed 335 actual ED visits for GU injury related to grooming products provided an estimated 11,704 incidents (95% confidence interval 8430-15,004). The number of incidents increased fivefold during that period, amounting to an estimated increase of 247 incidents annually (95% confidence interval 110-384, P = .001). Of the cohort, 56.7% were women. The mean age was 30.8 years (95% confidence interval 28.8-32.9). Shaving razors were implicated in 83% of the injuries. Laceration was the most common type of injury (36.6%). The most common site of injury was the external female genitalia (36.0%). Most injuries (97.3%) were treated within the ED, with subsequent patient discharge. Most GU injuries that result from the use of grooming products are minor and involve the use of razors. The demographics of patients with GU injuries from grooming products largely paralleled observations about cultural grooming trends in the United States. Published by Elsevier Inc.

Impact of Obesity on Clinical Outcomes in Urban Children Hospitalized for Status Asthmaticus.

PubMed

Aragona, Elena; El-Magbri, Eussra; Wang, Justin; Scheckelhoff, Tessa; Scheckelhoff, Trevor; Hyacinthe, Assata; Nair, Suja; Khan, Amina; Nino, Gustavo; Pillai, Dinesh K

2016-04-01

The prevalence of both childhood asthma and obesity remain at historically high levels and disproportionately affect urban children. Asthma is a common and costly cause for pediatric hospitalization. Our objective was to determine the effect of obesity on outcomes among urban children hospitalized with status asthmaticus. A retrospective cohort study was performed by using billing system data and chart review to evaluate urban children admitted for asthma. Demographics, asthma severity, reported comorbidities, and outcomes were assessed. Obesity was defined by BMI percentile (lean<85%, overweight 85%-95%, obese≥95%). Outcomes were length of stay, hospitalization charges, ICU stay, repeat admissions, and subsequent emergency department (ED) visits. Bivariate analysis assessed for differences between overweight/obese and lean children. Multivariable regression assessed the relationship between overweight status and primary outcomes while controlling for other variables. Post hoc age-stratified analysis was also performed. The study included 333 subjects; 38% were overweight/obese. Overweight/obese children admitted with asthma were more likely than lean children to have subsequent ED visits (odds ratio 1.6, 95% confidence interval 1.0-2.6). When stratified by age, overweight/obese preschool-age children (<5 years) were >2 times as likely to have repeat ED visits than lean preschool-age children (odds ratio 2.3, 95% confidence interval 1.0-5.6). There were no differences in the other outcomes between overweight/obese and lean individuals within the entire cohort or within other age groups. Copyright © 2016 by the American Academy of Pediatrics.

Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department.

PubMed

Hung, Shih-Chiang; Kung, Chia-Te; Hung, Chih-Wei; Liu, Ber-Ming; Liu, Jien-Wei; Chew, Ghee; Chuang, Hung-Yi; Lee, Wen-Huei; Lee, Tzu-Chi

2014-08-23

The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission varies across studies. This study proposed a model to define "delayed admission", and explored the effect of ICU-waiting time on patients' outcome. This retrospective cohort study included non-traumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU-waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cut-off point between "delayed" and "non-delayed", subsets from the overall data were made based on ICU-waiting time and the hazard ratio of ICU-waiting hour in each subset was iteratively calculated. The cut-off time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay. The final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU-waiting time in ED > 4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21 ventilator-days mortality and prolonged hospital stay, with odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively. For patients on mechanical ventilation at the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

No difference in emergency department length of stay for patients with limited proficiency in English.

PubMed

Wallbrecht, Joshua; Hodes-Villamar, Linda; Weiss, Steven J; Ernst, Amy A

2014-01-01

The population of the United States continues to diversify, with an increasing percentage of individuals who have limited English proficiency (LEP). A major concern facing emergency departments (EDs) around the country is increasing length of stay (LOS). Although multiple studies have shown racial and ethnic disparities in waiting time and LOS, no studies have examined specifically whether patients with LEP have a different LOS than English-speaking (ES) patients. In addition, no studies have examined whether the use of interpreters by patients with LEP has a significant impact on LOS. We hypothesized that there was a significant difference in LOS when comparing patients with LEP and ES patients and patients with LEP who used interpreters versus patients with LEP who did not. This was a prospective cohort study with LOS data collected from a level I ED patient tracking software program from October 2011 to December 2011. The primary language preferred by the patient was indicated at the time of triage and registration and the patient's use of an interpreter also was recorded. The patient's demographic data, ED visit information, and LOS were prospectively entered into an Excel spreadsheet. Percentages were compared using 95% confidence intervals and LOS was analyzed using the Student t test. With >100 subjects per group, our study had 80% power (ie, a power of 0.8) to determine a 15% difference in proportions between groups or a difference of 120 minutes (assuming a standard deviation of 300 minutes on both means). Data were collected from a total of 121 ES patients and 124 patients with LEP. In the LEP group were the languages of Spanish, Navajo, Vietnamese, Chinese, Arabic, and American Sign Language. Fifty-eight percent of patients with LEP used an interpreter. There were no differences between ES patients and patients with LEP in age, sex, mode of arrival, chief complaints, acuity, percentage admitted, percentage pediatric patients, or percentage of Medicaid/Medicare recipients. More patients with LEP were self-pay (36% vs 20%, diff 16, 95% confidence interval 2-31). There were no differences in mean LOS from time of arrival to time to being seen by a provider when comparing ES patients with patients with LEP or time of arrival to time to discharge or admission request. Comparing the patients with LEP who used interpreters with those who did not use interpreters, there was a significantly different LOS from time of arrival to time of discharge or admission request (958 ± 644 vs 628 ± 595 minutes, diff 330, 95% confidence interval 84-576). There was no difference in LOS for patients with LEP; however, patients with LEP who used interpreters had a significant increase in LOS compared with those who did not use interpreters.

Disparities in emergency department visits in American children with asthma: 2006-2010.

PubMed

Zhang, Qi; Lamichhane, Rajan; Diggs, Leigh Ann

2017-09-01

This article was to examine the trends in emergency department (ED) visits for asthma among American children in 2006-2010 across sociodemographic factors, parental smoking status, and children's body weight status. We analyzed 5,535 children aged 2-17 years with current asthma in the Asthma Call-Back Survey in 2006-2010. Multivariate log binomial regression was used to examine the disparities of ED visits by demographics, socioeconomic status, parental smoking status, children's body weight status, and the level of asthma control. We controlled for average state-level air pollutants. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were reported. Minority children with current asthma had higher risks of ED visits compared with white children in 2009 and 2010, e.g., the PR (95% CI) for black children in 2009 was 3.64 (1.79, 7.41). Children who had current asthma and more highly educated parents experienced a higher risk of ED visits in 2007 (PRs [95% CI] = 2.15 [1.02, 4.53] and 2.97 [1.29, 6.83] for children with some college or college-graduated parents), but not significant in other years. Children with uncontrolled asthma were significantly more likely to visit the ED in 2008 (PRs [95% CI] = 2.79 [1.44, 5.41] and 6.96 [3.55, 13.64] for not-well-controlled and very poorly controlled children with asthma). Minority children with current asthma or children with uncontrolled asthma were more likely to visit EDs for asthma treatment. However, the disparities in ED visits across sociodemographics, health status, or asthma control vary in scale and significance across time. More research is needed to explain these differences.

A generic method for evaluating crowding in the emergency department.

PubMed

Eiset, Andreas Halgreen; Erlandsen, Mogens; Møllekær, Anders Brøns; Mackenhauer, Julie; Kirkegaard, Hans

2016-06-14

Crowding in the emergency department (ED) has been studied intensively using complicated non-generic methods that may prove difficult to implement in a clinical setting. This study sought to develop a generic method to describe and analyse crowding from measurements readily available in the ED and to test the developed method empirically in a clinical setting. We conceptualised a model with ED patient flow divided into separate queues identified by timestamps for predetermined events. With temporal resolution of 30 min, queue lengths were computed as Q(t + 1) = Q(t) + A(t) - D(t), with A(t) = number of arrivals, D(t) = number of departures and t = time interval. Maximum queue lengths for each shift of each day were found and risks of crowding computed. All tests were performed using non-parametric methods. The method was applied in the ED of Aarhus University Hospital, Denmark utilising an open cohort design with prospectively collected data from a one-year observation period. By employing the timestamps already assigned to the patients while in the ED, a generic queuing model can be computed from which crowding can be described and analysed in detail. Depending on availability of data, the model can be extended to include several queues increasing the level of information. When applying the method empirically, 41,693 patients were included. The studied ED had a high risk of bed occupancy rising above 100 % during day and evening shift, especially on weekdays. Further, a 'carry over' effect was shown between shifts and days. The presented method offers an easy and generic way to get detailed insight into the dynamics of crowding in an ED.

Association between plasma fluorescent oxidation products and erectile dysfunction: A prospective study.

PubMed

Yang, Shuman; Giovannucci, Edward; Bracken, Bruce; Ho, Shuk-Mei; Wu, Tianying

2015-08-14

Existing epidemiological studies of the association between oxidative stress and erectile dysfunction (ED) are sparse and inconclusive, which is likely due to cross-sectional design and small sample size. Therefore, we investigated the association between biomarkers of oxidative stress and ED in prospective setting among a relatively large sample size of men. We conducted the prospective study among 917 men ages between 47 and 80 years at the time of blood draw, which is a part of nested prospective case-control study of prostate cancer in the Health Professionals Follow-up Study. Plasma fluorescent oxidation products (FlOPs), a global biomarker for oxidative stress, were measured at three excitation/emission wavelengths (360/420 nm named as FlOP_360; 320/420 nm named as FlOP_320 and 400/475 nm named as FlOP_400). Approximately 35% of men developed ED during follow-up. We did not find an independent association between FlOP_360, FlOP_320, FlOP_400 and risk of ED in the multivariable adjusted model (Tertile 3 vs. tertile 1: odds ratio [OR] = 0.90, 95% confidence interval [CI] = 0.61-1.34, P(trend) = 0.54 for FlOP_360; OR = 0.73, 95% CI = 0.49-1.07, P(trend) = 0.27 for FlOP_320; and OR = 0.98, 95% CI = 0.66-1.45, P(trend) = 0.72 for FlOP_400). Further analysis of the association between FlOPs and ED in the fasting samples or controls only (free of prostate cancer incidence) did not change the results appreciably. Plasma FlOPs were not associated with the risk of ED, suggesting oxidative stress may not be an independent risk factor for ED.

A phase II, single-blind, randomized, crossover evaluation of the safety and efficacy of avanafil using visual sexual stimulation in patients with mild to moderate erectile dysfunction.

PubMed

Hellstrom, Wayne J G; Freier, Matthew T; Serefoglu, Ege Can; Lewis, Ronald W; DiDonato, Karen; Peterson, Craig A

2013-01-01

To evaluate the safety, efficacy and time course of three doses of avanafil (50 mg, 100 mg and 200 mg) compared with sildenafil 50 mg or placebo, given in conjunction with visual sexual stimulation (VSS) videos in men with mild to moderate erectile dysfunction (ED). Male patients, 35-70 years of age, with mild to moderate ED of ≥6 months duration, were included in the study. During the course of the study, each patient received placebo, active control (sildenafil 50 mg), and one dose of avanafil (50 mg, 100 mg or 200 mg), all administered in random order at least 72 h apart. RigiScan® (Dacomed Corp., Minneapolis, MN, USA) monitoring was used in conjunction with 20-min VSS videos (20, 60, and 100 min after dosing) to determine the duration of and time to ≥60% penile rigidity, maximum rigidity, tumescent activity units (TAUs), rigidity activity units (RAUs), and responses to the five-point Erection Assessment Scale. Safety assessments included adverse events (AEs), vital sign changes in response to dosing, laboratory results (complete blood counts, chemistry panel, prostate-specific antigen, serum testosterone, prothrombin time and urine analysis) and physical examination findings. Eighty-three patients were randomized and received at least one dose of study medication; 82 patients completed the study. Peak response to avanafil occurred in the early interval (20-40 min after dosing), while peak response to sildenafil occurred either in the middle (60-80 min) or late (100-120 min) intervals after dosing. Results were qualitatively similar for all other efficacy endpoints. During the 20-40-min interval, the majority of values for TAUs and RAUs with the avanafil 50-mg, 100-mg and 200-mg treatments were significantly superior to placebo (P < 0.05). Avanafil treatment was generally well tolerated; facial flushing (7-15%) was the most commonly observed AE, and no visual disturbances were reported. A favourable safety profile and improvement in sexual function, coupled with rapid onset of action and durability of effect, make avanafil an attractive option for males with ED, especially in the setting of on-demand treatment. © 2012 BJU International.

Emergency department characteristics and capabilities in Beijing, China.

PubMed

Wen, Leana S; Xu, Jun; Steptoe, Anne P; Sullivan, Ashley F; Walline, Joseph H; Yu, Xuezhong; Camargo, Carlos A

2013-06-01

Emergency Departments (EDs) are a critical, yet heterogeneous, part of international emergency care. We sought to describe the characteristics, resources, capabilities, and capacity of EDs in Beijing, China. Beijing EDs accessible to the general public 24 h per day/7 days per week were surveyed using the National ED Inventories survey instrument (www.emnet-nedi.org). ED staff were asked about ED characteristics during the calendar year 2008. Thirty-six EDs participated (88% response rate). All were located in hospitals and were independent hospital departments. Participating EDs saw a median of 80,000 patients (interquartile range 40,000-118,508). The vast majority (91%; 95% confidence interval [CI] 78-98%) had a contiguous layout, with medical and surgical care provided in one area. Most EDs (55%) saw only adults; 39% saw both adults and children, and 6% saw only children. Availability of technological and consultant resource in EDs was high. The typical ED length of stay was between 1 and 6 h in 49% of EDs (95% CI 32-67%), whereas in the other half, patients reportedly remained for over 6 h; 36% (95% CI 21-54%) of respondents considered their ED over capacity. Beijing EDs have high volume, long length of stay, and frequent reports of EDs being over capacity. To meet its rapidly growing health needs in urban areas, China should consider improving urban ED capacity and training more Emergency Medicine specialists capable of efficiently staffing its crowded EDs. Copyright © 2013 Elsevier Inc. All rights reserved.

Internet overuse and excessive daytime sleepiness in adolescents.

PubMed

Choi, Kwisook; Son, Hyunsook; Park, Myunghee; Han, Jinkyu; Kim, Kitai; Lee, Byungkoo; Gwak, Hyesun

2009-08-01

The purpose of this study was to examine the association of Internet overuse with excessive daytime sleepiness (EDS). A total of 2336 high school students in South Korea (boys, 57.5%; girls, 42.5%) completed the structured questionnaire. The severity of Internet addiction was evaluated using Young's Internet addiction test. The proportions of boys who were classified as Internet addicts and possible Internet addicts were 2.5% and 53.7%, respectively. For girls, the corresponding proportions were 1.9% and 38.9%, respectively. The prevalence of EDS was 11.2% (boys, 11.2%; girls, 11.1%). When Internet addicts were compared with non-addicts, they consisted of more boys, drank alcohol more, and considered their own health condition as poor. But smoking was not related with Internet addiction. The prevalence rate of EDS for Internet addicts was 37.7%, whereas that for possible Internet addicts and non-addicts was 13.9% and 7.4%, respectively. The prevalence of insomnia, witnessed snoring, apnea, teeth grinding, and nightmares was highest in Internet addicts, middle in possible addicts, and lowest in non-addicts. With adjustment for duration of Internet use, duration of sleep time, age, gender, smoking, taking painkillers due to headache, insomnia symptoms, witnessed apnea, and nightmares, the odds of EDS were 5.2-fold greater (95% confidence interval [CI]: 2.7-10.2) in Internet addicts and 1.9-fold greater (95%CI: 1.4-2.6) in possible Internet addicts compared to non-addicts. Internet addiction is strongly associated with EDS in adolescents. Clinicians should consider examining Internet addiction in adolescent cases of EDS.

Reducing Blood Culture Contamination in the Emergency Department: An Interrupted Time Series Quality Improvement Study

PubMed Central

Self, Wesley H.; Speroff, Theodore; Grijalva, Carlos G.; McNaughton, Candace D.; Ashburn, Jacki; Liu, Dandan; Arbogast, Patrick G.; Russ, Stephan; Storrow, Alan B.; Talbot, Thomas R.

2012-01-01

Objectives Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED. Methods The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure, to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique), and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%. Results During the baseline period, 321 out of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p < 0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% CI = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period. Conclusions A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate. PMID:23570482

Successful Tobacco Dependence Treatment in Low-Income Emergency Department Patients: A Randomized Trial.

PubMed

Bernstein, Steven L; D'Onofrio, Gail; Rosner, June; O'Malley, Stephanie; Makuch, Robert; Busch, Susan; Pantalon, Michael V; Toll, Benjamin

2015-08-01

Tobacco use is common among emergency department (ED) patients, many of whom have low income. Our objective is to study the efficacy of an intervention incorporating motivational interviewing, nicotine replacement, and quitline referral for adult smokers in an ED. This was a 2-arm randomized clinical trial conducted from October 2010 to December 2012 in a northeastern urban US ED with 90,000 visits per year. Eligible subjects were aged 18 years or older, smoked, and were self-pay or had Medicaid insurance. Intervention subjects received a motivational interview by a trained research assistant, 6 weeks' worth of nicotine patches and gum initiated in the ED, a faxed referral to the state smokers' quitline, a booster call, and a brochure. Control subjects received the brochure, which provided quitline information. The primary outcome was biochemically confirmed tobacco abstinence at 3 months. Secondary endpoints included quitline use. Of 778 enrolled subjects, 774 (99.5%) were alive at 3 months. The prevalence of biochemically confirmed abstinence was 12.2% (47/386) in the intervention arm versus 4.9% (19/388) in the control arm, for a difference in quit rates of 7.3% (95% confidence interval 3.2% to 11.5%). In multivariable logistic modeling controlling for age, sex, and race or ethnicity, study subjects remained more likely to be abstinent than controls (odds ratio 2.72; 95% confidence interval 1.55 to 4.75). An intensive intervention improved tobacco abstinence rates in low-income ED smokers. Because approximately 20 million smokers, many of whom have low income, visit US EDs annually, these results suggest that ED-initiated treatment may be an effective technique to treat this group of smokers. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Enhanced understanding of the relationship between erection and satisfaction in ED treatment: application of a longitudinal mediation model.

PubMed

Bushmakin, A G; Cappelleri, J C; Symonds, T; Stecher, V J

2014-01-01

To apportion the direct effect and the indirect effect (through erections) that sildenafil (vs placebo) has on individual satisfaction and couple satisfaction over time, longitudinal mediation modeling was applied to outcomes on the Sexual Experience Questionnaire. The model included data from weeks 4 and 10 (double-blind phase) and week 16 (open-label phase) of a controlled study. Data from 167 patients with erectile dysfunction (ED) were available for analysis. Estimation of statistical significance was based on bootstrap simulations, which allowed inferences at and between time points. Percentages (and corresponding 95% confidence intervals) for direct and indirect effects of treatment were calculated using the model. For the individual satisfaction and couple satisfaction domains, direct treatment effects were negligible (not statistically significant) whereas indirect treatment effects via the erection domain represented >90% of the treatment effects (statistically significant). Week 4 vs week 10 percentages of direct and indirect effects were not statistically different, indicating that the mediation effects are longitudinally invariant. As there was no placebo arm in the open-label phase, mediation effects at week 16 were not estimable. In conclusion, erection has a crucial role as a mediator in restoring individual satisfaction and couple satisfaction in men with ED treated with sildenafil.

Development of key performance indicators for emergency departments in Ireland using an electronic modified-Delphi consensus approach.

PubMed

Wakai, Abel; O'Sullivan, Ronan; Staunton, Paul; Walsh, Cathal; Hickey, Fergal; Plunkett, Patrick K

2013-04-01

The objective of this study was to develop a consensus among emergency medicine (EM) specialists working in Ireland for emergency department (ED) key performance indicators (KPIs). The method employed was a three-round electronic modified-Delphi process. An online questionnaire with 54 potential KPIs was set up for round 1 of the Delphi process. The Delphi panel consisted of all registered EM specialists in Ireland. Each indicator on the questionnaire was rated using a five-point Likert-type rating scale. Agreement was defined as at least 70% of the responders rating an indicator as 'agree' or 'strongly agree' on the rating scale. Data were analysed using standard descriptive statistics. Data were also analysed as the mean of the Likert rating with 95% confidence intervals (95% CIs). Sensitivity of the ratings was examined for robustness by bootstrapping the original sample. Statistical analyses were carried out using SPSS version 16.0. The response rates in rounds 1, 2 and 3 were 86, 88 and 88%, respectively. Ninety-seven potential indicators reached agreement after the three rounds. In the context of the Donabedian structure-process-outcome framework of performance indicators, 41 (42%) of the agreed indicators were structure indicators, 52 (54%) were process indicators and four (4%) were outcome indicators. Overall, the top-three highest rated indicators were: presence of a dedicated ED clinical information system (4.7; 95% CI 4.6-4.9), ED compliance with minimum design standards (4.7; 95% CI 4.5-4.8) and time from ED arrival to first ECG in suspected cardiac chest pain (4.7; 95% CI 4.5-4.9). The top-three highest rated indicators specific to clinical care of children in EDs were: time to administration of antibiotics in children with suspected bacterial meningitis (4.6; 95% CI 4.5-4.8), separate area available within EDs (seeing both adults and children) to assess children (4.4; 95% CI 4.2-4.6) and time to administration of analgesia in children with forearm fractures (4.4; 95% CI 4.2-4.7). Employing a Delphi consensus process, it was possible to reach a consensus among EM specialists in Ireland on a suite of 97 KPIs for EDs.

The Value of Continuous ST-Segment Monitoring in the Emergency Department.

PubMed

Bovino, Leonie Rose; Funk, Marjorie; Pelter, Michele M; Desai, Mayur M; Jefferson, Vanessa; Andrews, Laura Kierol; Forte, Kenneth

2015-01-01

Practice standards for electrocardiographic monitoring recommend continuous ST-segment monitoring (C-STM) in patients presenting to the emergency department (ED) with signs and/or symptoms of acute coronary syndrome (ACS), but few studies have evaluated its use in the ED. We compared time to diagnosis and 30-day adverse events before and after implementation of C-STM. We also evaluated the diagnostic accuracy of C-STM in detecting ischemia and infarction. We prospectively studied 163 adults (preintervention: n = 78; intervention: n = 85) in a single ED and stratified them into low (n = 51), intermediate (n = 100), or high (n = 12) risk using History, ECG, Age, Risk factors, and Troponin (HEART) scores. The principal investigator monitored participants, activating C-STM on bedside monitors in the intervention phase. We used likelihood ratios (LRs) as the measure of diagnostic accuracy. Overall, 9% of participants were diagnosed with ACS. Median time to diagnosis did not differ before and after implementation of C-STM (5.55 vs. 5.98 hr; p = 0.43). In risk-stratified analyses, no significant pre-/postdifference in time to diagnosis was found in low-, intermediate-, or high-risk participants. There was no difference in the rate of 30-day adverse events before versus after C-STM implementation (11.5% vs. 10.6%; p = 0.85). The +LR and -LR of C-STM for ischemia were 24.0 (95% confidence interval [CI]: 1.4, 412.0) and 0.3 (95% CI: 0.02, 2.9), respectively, and for infarction were 13.7 (95% CI: 1.7, 112.3) and 0.7 (95% CI: 0.3, 1.5), respectively. Use of C-STM did not provide added diagnostic benefit for patients with signs and/or symptoms of myocardial ischemia in the ED.

Adverse drug event-related emergency department visits associated with complex chronic conditions.

PubMed

Feinstein, James A; Feudtner, Chris; Kempe, Allison

2014-06-01

Outpatient adverse drug events (ADEs) can result in serious outcomes requiring emergency department (ED) visits and hospitalizations. The incidence and severity of ADEs in children with complex chronic conditions (CCCs), who often take multiple medications, is unknown. We sought to describe the characteristics of ADE-related ED visits, including association with CCC status; determine the implicated medications; and determine if CCC status increased the risk of ADE-related admission. Retrospective cohort study of ED visits by patients aged 0 to 18 years using a national sample. ADEs were identified by external cause of injury codes; cases with overdose, wrongful administration, self-harm, or diagnosis of malignancy were excluded. Multivariable logistic regression was used to test outcomes of having an ADE-related ED visit and of subsequent admission. All statistics accounted for the complex survey design. Of 144 million ED visits, 0.5% were associated with ADEs. Adjusting for age, gender, insurance type, day of week, and location of hospital, ADEs were associated with the presence of a CCC (odds ratio 4.76; 95% confidence interval: 4.45-5.10). The implicated medications differed significantly by CCC status. Adjusting for the same variables, ADEs were associated with subsequent inpatient admission (odds ratio 2.18; 95% confidence interval: 2.04-2.32) for all children; an interaction between ADE and CCC status was not significant. ED visits associated with ADEs were more likely to occur for children with CCCs, and the implicated drugs differed, but ADE-related admissions were not differentially affected by CCC status. Copyright © 2014 by the American Academy of Pediatrics.

Effect of ambient temperature on emergency department visits in Shanghai, China: a time series study.

PubMed

Zhang, Yue; Yan, Chenyang; Kan, Haidong; Cao, Junshan; Peng, Li; Xu, Jianming; Wang, Weibing

2014-11-25

Many studies have examined the association between ambient temperature and mortality. However, less evidence is available on the temperature effects on gender- and age-specific emergency department visits, especially in developing countries. In this study, we examined the short-term effects of daily ambient temperature on emergency department visits (ED visits) in Shanghai. Daily ED visits and daily ambient temperatures between January 2006 and December 2011 were analyzed. After controlling for secular and seasonal trends, weather, air pollution and other confounding factors, a Poisson generalized additive model (GAM) was used to examine the associations between ambient temperature and gender- and age-specific ED visits. A moving average lag model was used to evaluate the lag effects of temperature on ED visits. Low temperature was associated with an overall 2.76% (95% confidence interval (CI): 1.73 to 3.80) increase in ED visits per 1°C decrease in temperature at Lag1 day, 2.03% (95% CI: 1.04 to 3.03) and 2.45% (95% CI: 1.40 to 3.52) for males and females. High temperature resulted in an overall 1.78% (95% CI: 1.05 to 2.51) increase in ED visits per 1°C increase in temperature on the same day, 1.81% (95% CI: 1.08 to 2.54) among males and 1.75% (95% CI: 1.03 to 2.49) among females. The cold effect appeared to be more acute among younger people aged <45 years, whereas the effects were consistent on individuals aged ≥65 years. In contrast, the effects of high temperature were relatively consistent over all age groups. These findings suggest a significant association between ambient temperature and ED visits in Shanghai. Both cold and hot temperatures increased the relative risk of ED visits. This knowledge has the potential to advance prevention efforts targeting weather-sensitive conditions.

Using the Hendrich II Inpatient Fall Risk Screen to Predict Outpatient Falls After Emergency Department Visits.

PubMed

Patterson, Brian W; Repplinger, Michael D; Pulia, Michael S; Batt, Robert J; Svenson, James E; Trinh, Alex; Mendonça, Eneida A; Smith, Maureen A; Hamedani, Azita G; Shah, Manish N

2018-04-01

To evaluate the utility of routinely collected Hendrich II fall scores in predicting returns to the emergency department (ED) for falls within 6 months. Retrospective electronic record review. Academic medical center ED. Individuals aged 65 and older seen in the ED from January 1, 2013, through September 30, 2015. We evaluated the utility of routinely collected Hendrich II fall risk scores in predicting ED visits for a fall within 6 months of an all-cause index ED visit. For in-network patient visits resulting in discharge with a completed Hendrich II score (N = 4,366), the return rate for a fall within 6 months was 8.3%. When applying the score alone to predict revisit for falls among the study population the resultant receiver operating characteristic (ROC) plot had an area under the curve (AUC) of 0.64. In a univariate model, the odds of returning to the ED for a fall in 6 months were 1.23 times as high for every 1-point increase in Hendrich II score (odds ratio (OR)=1.23 (95% confidence interval (CI)=1.19-1.28). When included in a model with other potential confounders or predictors of falls, the Hendrich II score is a significant predictor of a return ED visit for fall (adjusted OR=1.15, 95% CI=1.10-1.20, AUC=0.75). Routinely collected Hendrich II scores were correlated with outpatient falls, but it is likely that they would have little utility as a stand-alone fall risk screen. When combined with easily extractable covariates, the screen performs much better. These results highlight the potential for secondary use of electronic health record data for risk stratification of individuals in the ED. Using data already routinely collected, individuals at high risk of falls after discharge could be identified for referral without requiring additional screening resources. © 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

Association of positive responses to suicide screening questions with hospital admission and repeated emergency department visits in children and adolescents.

PubMed

Ballard, Elizabeth D; Horowitz, Lisa M; Jobes, David A; Wagner, Barry M; Pao, Maryland; Teach, Stephen J

2013-10-01

Although validated suicide screening tools exist for use among children and adolescents presenting to emergency departments (EDs), the associations between screening positive for suicide risk and immediate psychiatric hospital admission or subsequent ED use, stratified by age, have not been examined. This is a retrospective cohort study of a consecutive case series of patients aged 8 to 18 years presenting with psychiatric chief complaints during a 9-month period to a single urban tertiary care pediatric ED. Eligible patients were administered a subset of questions from the Risk of Suicide Questionnaire. Outcomes included the odds of psychiatric hospitalization at the index visit and repeated ED visits for psychiatric complaints within the following year, stratified by age. Of the 568 patients presenting during the study period, responses to suicide screening questions were available for 442 patients (78%). A total of 159 (36%) of 442 were hospitalized and 130 (29%) of 442 had 1 or more ED visits within the following year. The proportion of patients providing positive responses to 1 or more suicide screening questions did not differ between patients aged 8 to 12 years and those aged 13 to 18 years (77/154 [50%] vs 137/288 [48%], P = 0.63). A positive response to 1 or more of the questions was significantly associated with increased odds of psychiatric hospitalization in the older age group [adjusted odds ratio, 3.82; 95% confidence interval, 2.24-6.54) and with repeated visits to the ED in the younger age group (adjusted odds ratio, 3.55 95% confidence interval, 1.68-7.50). Positive responses to suicide screening questions were associated with acute psychiatric hospitalization and repeated ED visits. Suicide screening in a pediatric ED may identify children and adolescents with increased need of psychiatric resources.

Prenatal choline supplementation increases sensitivity to time by reducing non-scalar sources of variance in adult temporal processing

PubMed Central

Cheng, Ruey-Kuang; Meck, Warren H.

2009-01-01

Choline supplementation of the maternal diet has a long-term facilitative effect on timing and temporal memory of the offspring. To further delineate the impact of early nutritional status on interval timing, we examined effects of prenatal-choline supplementation on the temporal sensitivity of adult (6 mo) male rats. Rats that were given sufficient choline in their chow (CON: 1.1 g/kg) or supplemental choline added to their drinking water (SUP: 3.5 g/kg) during embryonic days (ED) 12–17 were trained with a peak-interval procedure that was shifted among 75%, 50%, and 25% probabilities of reinforcement with transitions from 18s –> 36s –>72s temporal criteria. Prenatal-choline supplementation systematically sharpened interval-timing functions by reducing the associative/non-temporal response enhancing effects of reinforcement probability on the Start response threshold, thereby reducing non-scalar sources of variance in the left-hand portion of the Gaussian-shaped response functions. No effect was observed for the Stop response threshold as a function of any of these manipulations. In addition, independence of peak time and peak rate was demonstrated as a function of reinforcement probability for both prenatal-choline supplemented and control rats. Overall, these results suggest that prenatal-choline supplementation facilitates timing by reducing impulsive responding early in the interval, thereby improving the superimposition of peak functions for different temporal criteria. PMID:17996223

Early variation of quick sequential organ failure assessment score to predict in-hospital mortality in emergency department patients with suspected infection.

PubMed

Najla, Lemachatti; Mar, Ortega; Andrea, Penaloza; Le Borgne, Pierrick; Claret, Pierre-Géraud; Occelli, Céline; Truchot, Jennifer; Dumas, Florence; Feral-Pierssens, Anne-Laure; Andrianjafy, Héry; Beaune, Sebastien; Yordanov, Youri; Hausfater, Pierre; Riou, Bruno; Bloom, Ben; Krastinova, Evguenia; Freund, Yonathan

2018-05-15

The quick sequential organ failure assessment (qSOFA) score showed good prognostic performance in patients with suspicion of infection in the emergency department (ED). However, previous studies only assessed the performance of individual values of qSOFA during the ED stay. As this score may vary over short timeframes, the optimal time of measurement, and the prognostic value of its variation are unclear. The objective of the present study was to prospectively assess the prognostic value of the change in qSOFA over the first 3 h (ΔqSOFA=qSOFA at 3 h-qSOFA at inclusion). This is an international prospective cohort study conducted in 17 EDs in France, Belgium, and Spain. From November 2016 to March 2017, patients with a suspected infection and a qSOFA score of 2 or higher were included and followed up until death or hospital discharge. qSOFA was measured at inclusion, 1 h and 3 h. Primary end point was in-hospital mortality, truncated at 28 days. Of 534 recruited patients, 512 were included in the analysis. The qSOFA was improved at 3 h (ΔqSOFA<0) in 287 (55%) patients. Overall in-hospital mortality was 27%: 44% when ΔqSOFA greater than 0, 36% when ΔqSOFA=0, and 18% when ΔqSOFA less than 0. A positive ΔqSOFA was independently associated with reduced in-hospital mortality (adjusted hazard ratio of 0.48, 95% confidence interval: 0.34-0.68). After modeling qSOFA kinetics in the first 3 h, there was a significant difference in adjusted slopes between patients who died and those who survived (0.15, 95% confidence interval: 0.09-0.22, P<0.001). In patients with suspected infection presenting to the ED with a qSOFA of 2 or higher, the early change in qSOFA is a strong independent predictor of mortality.

Information technology improves Emergency Department patient discharge instructions completeness and performance on a national quality measure: a quasi-experimental study.

PubMed

Bell, E J; Takhar, S S; Beloff, J R; Schuur, J D; Landman, A B

2013-01-01

To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19). We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated. The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 - 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% - 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% - 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats. With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure.

Effects of Simultaneous or Sequential Weight Loss Diet and Aerobic Interval Training on Metabolic Syndrome.

PubMed

Mora-Rodriguez, R; Ortega, J F; Guio de Prada, V; Fernández-Elías, V E; Hamouti, N; Morales-Palomo, F; Martinez-Vizcaino, V; Nelson, R K

2016-04-01

Our purpose in this study was to investigate efficient and sustainable combinations of exercise and diet-induced weight loss (DIET), in order to combat obesity in metabolic syndrome (MetS) patients. We examined the impact of aerobic interval training (AIT), followed by or concurrent to a DIET on MetS components. 36 MetS patients (54±9 years old; 33±4 BMI; 27 males and 9 females) underwent 16 weeks of AIT followed by another 16 weeks without exercise from the fall of 2013 to the spring of 2014. Participants were randomized to AIT without DIET (E CON, n=12), AIT followed by DIET (E-then-D, n=12) or AIT concurrent with DIET (E+D, n=12) groups. Body weight decreased below E CON similarly in the E-then-D and E+D groups (~5%). Training improved blood pressure and cardiorespiratory fitness (VO2peak) in all groups with no additional effect of concurrent weight loss. However, E+D improved insulin sensitivity (HOMA) and lowered plasma triglycerides and blood cholesterol below E CON and E-then-D (all P<0.05). Weight loss in E-then-D in the 16 weeks without exercise lowered HOMA to the E+D levels and maintained blood pressure at trained levels. Our data suggest that a new lifestyle combination consisting of aerobic interval training followed by weight loss diet is similar, or even more effective on improving metabolic syndrome factors than concurrent exercise plus diet. © Georg Thieme Verlag KG Stuttgart · New York.

Erectile dysfunction and fruit/vegetable consumption among diabetic Canadian men.

PubMed

Wang, Feng; Dai, Sulan; Wang, Mingdong; Morrison, Howard

2013-12-01

To evaluate the association between fruit/vegetable consumption and erectile dysfunction (ED) among Canadian men with diabetes. Data from the 2011 Survey on Living with Chronic Diseases in Canada - Diabetes Component were analyzed using Statistical Analysis System Enterprise Guide (SAS EG). Respondents were asked a series questions related to their sociodemographics, lifestyle, and chronic health conditions. The association between fruit/vegetable consumption and ED was examined using logistic regression after controlling for potential confounding factors. Bootstrap procedure was used to estimate sample distribution and calculate confidence intervals. Overall, 26.2% of respondents reported having ED. The prevalence increased with age and duration of diabetes. Compared with respondents without ED, those with ED were more likely to be obese, smokers, physically inactive, and either divorced, widowed, or separated. Diabetes complications such as nerve damage, circulation problems, and kidney failure or kidney disease were also significantly associated with ED. After controlling for potential confounding factors, a 10% risk reduction of ED was found with each additional daily serving of fruit/vegetable consumed. ED is common among Canadian men with diabetes. ED was highly associated with age, duration of diabetes, obesity, smoking, and the presence of other diabetes-related complications. Fruit and vegetable consumption might have a protective effect against ED. Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.

Elemental analysis using ED-XRF and 14C dating of Cuman wall paintings samples

NASA Astrophysics Data System (ADS)

Brocchieri, J.; Sabbarese, C.; Marzaioli, F.; Passariello, I.; Terrasi, F.; De Maio, C.; Ferrara, L.

2018-04-01

The aim of the present research was to analyse pigments and mortars of fresco fragments located at Cuma (Naples, Italy). The ED-XRF technique and 14C dating were used to establish the nature of the pigments and the age of mortars, respectively. ED-XRF results allowed to determine the elemental composition of the pigments that identified the colours and, hence, the historical period of completion. The 14C dating, applied to mortars using a particular preparation, provided results that are in accordance with the archaeological information within the 2σ interval range.

The impact of ED nurse manager leadership style on staff nurse turnover and patient satisfaction in academic health center hospitals.

PubMed

Raup, Glenn H

2008-10-01

Nurse managers with effective leadership skills are an essential component to the solution for ending the nursing shortage. Empirical studies of existing ED nurse manager leadership styles and their impact on key nurse management outcomes such as staff nurse turnover and patient satisfaction have not been performed. The specific aims of this study were to determine what types of leadership styles were used by ED nurse managers in academic health center hospitals and examine their influence on staff nurse turnover and patient satisfaction. ED nurse managers were asked to complete the Multifactor Leadership Questionnaire and a 10-item researcher defined nurse manager role and practice demographics survey. Completed surveys (15 managers and 30 staff nurses) representing 15 out of 98 possible U.S. academic health centers were obtained. Fisher's exact test with 95% confidence intervals were used to analyze the data. The sample percentage of managers who exhibited Transformational leadership styles and demographic findings of nurse manager age, total years experience and length of time in current position matched current reports in the literature. A trend of lower staff nurse turnover with Transformational leadership style compared to non-Trasformational leadership styles was identified. However, the type of leadership style did not appear to have an effect on patient satisfaction. The ED is an ever-changing, highly regulated, critical-care environment. Effective ED nurse manager leadership strategies are vital to maintaining the standards of professional emergency nursing practice to create an environment that can produce management outcomes of decreased staff nurse turnover, thereby enhancing staff nurse retention and potentially impacting patient satisfaction.

Can Nonurgent Emergency Department Care Costs be Reduced? Empirical Evidence from a U.S. Nationally Representative Sample.

PubMed

Xin, Haichang; Kilgore, Meredith L; Sen, Bisakha Pia; Blackburn, Justin

2015-09-01

A well-functioning primary care system has the capacity to provide effective care for patients to avoid nonurgent emergency department (ED) use and related costs. This study examined how patients' perceived deficiency in ambulatory care is associated with nonurgent ED care costs nationwide. This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. This study chose usual source of care, convenience of needed medical care, and patient evaluation of care quality as the main independent variables. The marginal effect following a multivariate logit model was employed to analyze the urgent vs. nonurgent ED care costs in 2011, after controlling for covariates in 2010. The endogeneity was accounted for by the time lag effect and controlling for education levels. Sample weights and variance were adjusted with the survey procedures to make results nationally representative. Patient-perceived poor and intermediate levels of primary care quality had higher odds of nonurgent ED care costs (odds ratio [OR] = 2.22, p = 0.035, and OR = 2.05, p = 0.011, respectively) compared to high-quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs. Costs related to these ambulatory care quality deficiencies amounted to $229 million for private plans (95% confidence interval [CI] $100 million-$358 million), $58.5 million for public plans (95% CI $33.9 million-$83.1 million), and an overall of $379 million (95% CI $229 million-$529 million) nationally. These findings highlight the improvement in ambulatory care quality as the potential target area to effectively reduce nonurgent ED care costs. Copyright © 2015 Elsevier Inc. All rights reserved.

Mobile Health Technology to Communicate Discharge and Follow-Up Information to Adolescents From the Emergency Department.

PubMed

Ray, Margaret; Dayan, Peter S; Pahalyants, Vartan; Chernick, Lauren S

2016-12-01

Adolescents are the largest users of mobile technology; yet, there are little data regarding their receptivity to the use of mobile health technology (mHealth) from the emergency department (ED). The objective of this study was to determine adolescents' preferences for receiving ED discharge and follow-up information via mHealth and factors associated with those preferences. We administered an anonymous self-reporting survey to patients aged 14 to 19 years discharged from an urban pediatric ED. We conducted exploratory bivariate analyses to evaluate differences in communication preferences based on patient characteristics. We used multivariable logistic regression to determine whether preference for health information via mHealth is associated with frequent information technology (IT) use, adjusting for age, sex, ethnicity, and insurance status. Four hundred thirty-nine adolescents completed the survey. Most were female (n = 279, 64%), 14 to 17 years old (n = 247, 57%), Hispanic (n = 359, 86%), and insured (n = 388, 88%). Adolescents used IT often, texting more than 30 times a day (58%) and emailing more than once a day (61%). Most (n = 335, 78%) were interested in electronic communication from the ED. Teens expressed particular interest in using email for discharge instructions (n = 196, 47%), physician referrals (n = 197, 48%), and test results (n = 201, 48%) and using texting for medication (n = 155, 38%) and appointment reminders (n = 170, 41%). Individuals tended to prefer communication with IT modes that they typically used, although only email was independently associated with preference for this mode (adjusted odds ratio, 2.8; 95% confidence interval, 1.5-5.3). Adolescent patients are interested in receiving health information from the ED, mainly via email and texting. Future ED interventions should evaluate the effectiveness of these modalities to communicate with patients after discharge.

Reducing Emergency Department Utilization Through Engagement in Telemedicine by Senior Living Communities.

PubMed

Gillespie, Suzanne M; Shah, Manish N; Wasserman, Erin B; Wood, Nancy E; Wang, Hongyue; Noyes, Katia; Nelson, Dallas; Dozier, Ann; McConnochie, Kenneth M

2016-06-01

High-intensity telemedicine has been shown to reduce the need for emergency department (ED) care for older adult senior living community (SLC) residents with acute illnesses. We evaluated the effect of SLC engagement in the telemedicine program on ED use rates. We performed a secondary analysis of data from a prospective cohort study evaluating the effectiveness of high-intensity telemedicine for SLC residents. We compared the annual rate of change in ED use among subjects who resided in SLC units that were more engaged in telemedicine services with that among subjects who resided in SLC units that were less engaged in telemedicine and control subjects who lived at facilities without access to telemedicine services. During the study, subjects had 503 telemedicine visits, with 362 (72.0%) in the more engaged SLCs and 141 (28.0%) in the less engaged SLCs. For subjects residing in more engaged SLCs, ED use decreased at an annualized rate of 28% (rate ratio [RR] = 0.72; 95% confidence interval [CI], 0.58-0.89), whereas in the less engaged (RR = 0.962; 95% CI, 0.776-1.19) and control (RR = 0.909, 95% CI, 0.822-1.07) groups there was no significant change in ED use (p = 0.036 for group × time interaction). Individuals residing in more engaged SLCs experienced a greater decrease in ED use compared with subjects residing in less engaged SLCs or those without access to high-intensity telemedicine for acute illnesses. We identified potential factors associated with more engaged SLCs, but further research is needed to understand resident and staff engagement and how to increase it.

Prevalence of Diagnosed and Undiagnosed Hepatitis C in a Midwestern Urban Emergency Department.

PubMed

Lyons, Michael S; Kunnathur, Vidhya A; Rouster, Susan D; Hart, Kimberly W; Sperling, Matthew I; Fichtenbaum, Carl J; Sherman, Kenneth E

2016-05-01

Targeted hepatitis C virus (HCV) screening is recommended. Implementation of screening in emergency department (ED) settings is challenging and controversial. Understanding HCV epidemiology in EDs could motivate and guide screening efforts. We characterized the prevalence of diagnosed and undiagnosed HCV in a Midwestern, urban ED. This was a cross-sectional seroprevalence study using de-identified blood samples and self-reported health information obtained from consecutively approached ED patients aged 18-64 years. Subjects consented to a "study of diseases of public health importance" and were compensated for participation. The Biochain ELISA kit for Human Hepatitis C Virus was used for antibody assay. Viral RNA was isolated using the Qiagen QIAamp UltraSens Virus kit, followed by real-time reverse transcription polymerase chain reaction using a Bio-Rad CFX96 SYBR Green UltraFast program with melt-curve analysis. HCV antibody was detected in 128 of 924 (14%; 95% confidence interval [CI], 12%-16%) samples. Of these, 44 (34%) self-reported a history of HCV or hepatitis of unknown type and 103 (81%; 95% CI, 73%-87%) were RNA positive. Two additional patients were antibody negative but RNA positive. Fully implemented birth cohort screening for HCV antibody would have missed 36 of 128 (28%) of cases with detectable antibody and 26 of 105 (25%) of those with replicative HCV infection. HCV infection is highly prevalent in EDs. Emergency departments are likely to be uniquely important for HCV screening, and logistical challenges to ED screening should be overcome. Birth cohort screening would have missed many patients, suggesting the need for complementary screening strategies applied to an expanded age range. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

Long-term Outcomes After Stepping Down Asthma Controller Medications: A Claims-Based, Time-to-Event Analysis.

PubMed

Rank, Matthew A; Johnson, Ryan; Branda, Megan; Herrin, Jeph; van Houten, Holly; Gionfriddo, Michael R; Shah, Nilay D

2015-09-01

Long-term outcomes after stepping down asthma medications are not well described. This study was a retrospective time-to-event analysis of individuals diagnosed with asthma who stepped down their asthma controller medications using a US claims database spanning 2000 to 2012. Four-month intervals were established and a step-down event was defined by a ≥ 50% decrease in days-supplied of controller medications from one interval to the next; this definition is inclusive of step-down that occurred without health-care provider guidance or as a consequence of a medication adherence lapse. Asthma stability in the period prior to step-down was defined by not having an asthma exacerbation (inpatient visit, ED visit, or dispensing of a systemic corticosteroid linked to an asthma visit) and having fewer than two rescue inhaler claims in a 4-month period. The primary outcome in the period following step-down was time-to-first asthma exacerbation. Thirty-two percent of the 26,292 included individuals had an asthma exacerbation in the 24-month period following step-down of asthma controller medication, though only 7% had an ED visit or hospitalization for asthma. The length of asthma stability prior to stepping down asthma medication was strongly associated with the risk of an asthma exacerbation in the subsequent 24-month period: < 4 months' stability, 44%; 4 to 7 months, 34%; 8 to 11 months, 30%; and ≥ 12 months, 21% (P < .001). In a large, claims-based, real-world study setting, 32% of individuals have an asthma exacerbation in the 2 years following a step-down event.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

PubMed

Neven, Darin; Paulozzi, Leonard; Howell, Donelle; McPherson, Sterling; Murphy, Sean M; Grohs, Becky; Marsh, Linda; Lederhos, Crystal; Roll, John

2016-11-01

Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing. Copyright © 2016 The Author(s). Published by Elsevier Inc. All rights reserved.

The effects of a physician slowdown on emergency department volume and treatment.

PubMed

Walsh, Brian; Eskin, Barnet; Allegra, John; Rothman, Jonathan; Junker, Elizabeth

2006-11-01

In February 2003, many physicians in New Jersey participated in a work slowdown to publicize large increases in malpractice premiums and generate support for legislative reform. It was anticipated that the community physician slowdown (hereafter referred to as "slowdown") would increase emergency department (ED) visits. The authors' goal was to help others prepare for anticipated increases in ED volumes by describing the preparatory staffing changes made and quantifying increases in ED volume. This was a retrospective cohort study performed at a New Jersey suburban teaching hospital with 70,000 annual visits. Consecutive patients seen by emergency physicians were enrolled. The authors extracted patient visit data from the computerized tracking system and analyzed hours worked by personnel, patient volumes, admission rates, and patient throughput times. Variables from each day of the slowdown with baseline values for the same day of the week for the four weeks before and after the slowdown were compared. A Bonferroni correction was used, with p < 0.01 considered statistically significant. Total patient volume increased 79% from baseline (95% confidence interval [CI] = 20% to 137%). Pediatric volume increased 223% (95% CI = 171% to 274%). Overall admission rate decreased 29% compared with baseline (95% CI = 8% to 51%). Patient throughput times did not change significantly. Similar results for these variables were found for the second through fourth days of the slowdown. Emergency department visits, especially pediatric visits, increased markedly during the community physician slowdown. Anticipatory increases in staffing effectively prevented increased throughput times.

Gender, Social Networks, and Stroke Preparedness in the Stroke Warning Information and Faster Treatment Study.

PubMed

Madsen, Tracy E; Roberts, Eric T; Kuczynski, Heather; Goldmann, Emily; Parikh, Nina S; Boden-Albala, Bernadette

2017-12-01

The study aimed to investigate the effect of gender on the association between social networks and stroke preparedness as measured by emergency department (ED) arrival within 3 hours of symptom onset. As part of the Stroke Warning Information and Faster Treatment study, baseline data on demographics, social networks, and time to ED arrival were collected from 1193 prospectively enrolled stroke/transient ischemic attack (TIA) patients at Columbia University Medical Center. Logistic regression was conducted with arrival to the ED ≤3 hours as the outcome, social network characteristics as explanatory variables, and gender as a potential effect modifier. Men who lived alone or were divorced were significantly less likely to arrive ≤3 hours than men who lived with a spouse (adjusted odds ratio [aOR]: .31, 95% confidence interval [CI]: .15-0.64) or were married (aOR: .45, 95% CI: .23-0.86). Among women, those who lived alone or were divorced had similar odds of arriving ≤3 hours compared with those who lived with a spouse (aOR: 1.25, 95% CI: .63-2.49) or were married (aOR: .73, 95% CI: .4-1.35). In patients with stroke/TIA, living with someone or being married improved time to arrival in men only. Behavioral interventions to improve stroke preparedness should incorporate gender differences in how social networks affect arrival times. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Association Between Maternal Comorbidities and Emergency Department Use Among a National Sample of Commercially Insured Pregnant Women.

PubMed

Cunningham, Shayna D; Magriples, Urania; Thomas, Jordan L; Kozhimannil, Katy B; Herrera, Carolina; Barrette, Eric; Shebl, Fatma M; Ickovics, Jeannette R

2017-08-01

Evidence suggests that, despite routine engagement with the health system, pregnant women commonly seek emergency care. The objectives of this study were to examine the association between maternal comorbidities and emergency department (ED) use among a national sample of commercially insured pregnant women. We conducted a retrospective cohort study using multipayer medical claims data maintained by the Health Care Cost Institute for women ages 18 to 44 years with a live singleton birth in 2011 (N = 157,786). The association between common maternal comorbidities (e.g., hypertension, gestational diabetes) and ED use during pregnancy was examined using multilevel models, while controlling for age, region, and residential zip code. Twenty percent (n = 31,413) of pregnant women had one or more ED visit (mean ± SD = 1.52 ± 1.15). Among those who used the ED, 29% had two or more visits, and 11% had three or more visits. Emergency care seekers were significantly more likely to have one or more comorbid condition compared to those with no emergency care: 30% versus 21%, respectively (p < 0.001). Pregnant women with asthma had 2.5 times the likelihood of having had any ED visit (adjusted odds ratio [AOR] = 2.46, 95% confidence interval [CI] = 2.32-2.62). There was a significant increase in the probability (approximately 50%) of ED use among pregnant women with diabetes (AOR = 1.47, 95% CI = 1.33-1.63) or hypertension (AOR = 1.49, 95% CI = 1.43-1.55) or who were obese (AOR = 1.55, 95% CI = 1.47-1.64). Increased odds associated with gestational diabetes were more modest, resulting in a 13% increased odds of using the ED (AOR = 1.13, 95% CI = 1.07-1.18). Less than 0.6% of pregnant women (n = 177) received emergency care that resulted in a hospital admission. The admission rate was 0.4% (189 admissions/47,608 ED visits). Among pregnant women, comorbidity burden was associated with more ED utilization. Efforts to reduce acute unscheduled care and improve care coordination during pregnancy should target interventions to patient comorbidity. © 2017 by the Society for Academic Emergency Medicine.

Effect of an independent-capacity protocol on overcrowding in an urban emergency department.

PubMed

Cha, Won Chul; Shin, Sang Do; Song, Kyoung Jun; Jung, Sung Koo; Suh, Gil Joon

2009-12-01

The authors hypothesized that a new strategy, termed the independent-capacity protocol (ICP), which was defined as primary stabilization at the emergency department (ED) and utilization of community resources via transfer to local hospitals, would reduce ED overcrowding without requiring additional hospital resources. This is a before-and-after trial that included all patients who visited an urban, tertiary care ED in Korea from July 2006 to June 2008. To improve ED throughput, introduction of the ICP gave emergency physicians (EPs) more responsibility and authority over patient disposition, even when the patients belonged to another specific clinical department. The ICP utilizes the ED as a temporary, nonspecific place that cares for any patient for a limited time period. Within 48 hours, EPs, associated specialists, and transfer coordinators perform secondary assessment and determine patient disposition. If the hospital is full and cannot admit these patients after 48 hours, the EP and transfer coordinators move the patients to other appropriate community facilities. We collected clinical data such as sex, age, diagnosis, and treatment. The main outcomes included ED length of stay (LOS), the numbers of admissions to inpatient wards, and the mortality rate. A total of 87,309 patients were included. The median number of daily patients was 114 (interquartile range [IQR] = 104 to 124) in the control phase and 124 (IQR = 112 to 135) in the ICP phase. The mean ED LOS decreased from 15.1 hours (95% confidence interval [CI] = 14.8 to 15.3) to 13.4 hours (95% CI = 13.2 to 13.6; p < 0.001). The mean LOS in the emergency ward decreased from 4.5 days (95% CI = 4.4 to 4.6 days) to 3.1 days (95% CI = 3.0 to 3.2 days; p < 0.001). The percentage of transfers from the ED to other hospitals decreased from 3.5% to 2.5% (p < 0.001). However, transfers from the emergency ward to other hospitals increased from 2.9% to 8.2% (p < 0.001). Admissions to inpatient wards from the ED were significantly reduced, and admission from the emergency ward did not change. The ED mortality and hospital mortality rates did not change (p = 0.15 and p = 0.10, respectively). After introduction of the ICP, ED LOS decreased without an increase in hospital capacity.

Emergency Department Use in a Cohort of Older Homeless Adults: Results from the HOPE HOME Study

PubMed Central

Raven, Maria C.; Tieu, Lina; Lee, Christopher T.; Ponath, Claudia; Guzman, David; Kushel, Margot

2018-01-01

Objective The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. Methods We recruited 350 participants who were homeless and 50 or older in Oakland, CA. We interviewed participants about residential history in the prior six months, health status, health-related behaviors, and health services use, and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior six months based on medical record review. We used negative binomial regression to examine factors associated with ED use. Results In the six months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered, 25.1% cycled through multiple institutions including shelters, hospitals and jails, 16.3% primarily stayed with family or friends, and 12.3% had become homeless recently after spending much of the prior six months housed. Half (49.7%) of participants made at least one ED visit in the past six months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08–4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17–4.48) had higher ED use rates than participants who had been housed for most of the prior six months. In addition, having health insurance/coverage (IRR= 2.6; CI = 1.5–4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09–2.99), and severe pain (IRR = 1.72; 95% CI = 1.07–2.76) were associated with higher ED visit rates. Conclusions A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior six months than the general US age-matched population. Within the sample, ED use rates varied based on individuals’ residential histories, suggesting that individuals’ ED use is related to exposure to homelessness. PMID:27520382

Effectiveness of a multidisciplinary critical pathway based on a computerised physician order entry system for ST-segment elevation myocardial infarction management in the emergency department: a retrospective observational study.

PubMed

Park, Yoo Seok; Chung, Sung Phil; You, Je Sung; Kim, Min Joung; Chung, Hyun Soo; Hong, Jung Hwa; Lee, Hye Sun; Wang, Jinwon; Park, Incheol

2016-08-16

The purpose of this study was to investigate whether a multidisciplinary organised critical pathway (CP) for ST-segment elevation myocardial infarction (STEMI) management can significantly attenuate differences in the duration from emergency department (ED) arrival to evaluation and treatment, regardless of the arrival time, by eliminating off-hour and weekend effects. Retrospective observational cohort study. 2 tertiary academic hospitals. Consecutive patients in the Fast Interrogation Rule for STEMI (FIRST) program. A study was conducted on patients in the FIRST program, which uses a computerised physician order entry (CPOE) system. The patient demographics, time intervals and clinical outcomes were analysed based on the arrival time at the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends. Clinical outcomes categorised according to 30-day mortality, in-hospital mortality and the length of stay. The duration from door-to-data or FIRST activation did not differ significantly among the 4 groups. The median duration between arrival and balloon placement during percutaneous coronary intervention did not significantly exceed 90 min, and the proportions (89.6-95.1%) of patients with door-to-balloon times within 90 min did not significantly differ among the 4 groups, regardless of the ED arrival time (p=0.147). Moreover, no differences in the 30-day (p=0.8173) and in-hospital mortality (p=0.9107) were observed in patients with STEMI. A multidisciplinary CP for STEMI based on a CPOE system can effectively decrease disparities in the door-to-data duration and proportions of patients with door-to-balloon times within 90 min, regardless of the ED arrival time. The application of a multidisciplinary CP may also help attenuate off-hour and weekend effects in STEMI clinical outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Screening for violence risk factors identifies young adults at risk for return emergency department visit for injury.

PubMed

Hankin, Abigail; Wei, Stanley; Foreman, Juron; Houry, Debra

2014-08-01

Homicide is the second leading cause of death among youth aged 15-24. Prior cross-sectional studies, in non-healthcare settings, have reported exposure to community violence, peer behavior, and delinquency as risk factors for violent injury. However, longitudinal cohort studies have not been performed to evaluate the temporal or predictive relationship between these risk factors and emergency department (ED) visits for injuries among at-risk youth. The objective was to assess whether self-reported exposure to violence risk factors in young adults can be used to predict future ED visits for injuries over a 1-year period. This prospective cohort study was performed in the ED of a Southeastern US Level I trauma center. Eligible participants were patients aged 18-24, presenting for any chief complaint. We excluded patients if they were critically ill, incarcerated, or could not read English. Initial recruitment occurred over a 6-month period, by a research assistant in the ED for 3-5 days per week, with shifts scheduled such that they included weekends and weekdays, over the hours from 8AM-8PM. At the time of initial contact in the ED, patients were asked to complete a written questionnaire, consisting of previously validated instruments measuring the following risk factors: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, e) community exposure to violence, and f) positive future outlook. At 12 months following the initial ED visit, the participants' medical records were reviewed to identify any subsequent ED visits for injury-related complaints. We analyzed data with chi-square and logistic regression analyses. Three hundred thirty-two patients were approached, of whom 300 patients consented. Participants' average age was 21.1 years, with 60.1% female, 86.0% African American. After controlling for participant gender, ethnicity, or injury complaint at time of first visit, return visits for injuries were significantly associated with: hostile/aggressive feelings (Odds ratio (OR) 3.5, 95% Confidence interval (CI): 1.3, 9.8), self-reported perceived likelihood of violence (OR 10.1, 95% CI: 2.5, 40.6), and peer group violence (OR 6.7, 95% CI: 2.0, 22.3). A brief survey of risk factors for violence is predictive of increased probability of a return visit to the ED for injury. These findings identify a potentially important tool for primary prevention of violent injuries among at-risk youth seen in the ED for trauma-related and non-traumatic complaints.

Frequency of Alcohol Use Among Injured Adult Patients Presenting to a Ghanaian Emergency Department.

PubMed

Forson, Paa Kobina; Gardner, Andrew; Oduro, George; Bonney, Joseph; Biney, Eno Akua; Oppong, Chris; Momade, Eszter; Maio, Ronald F

2016-10-01

Injuries are the cause of almost 6 million deaths annually worldwide, with 15% to 20% alcohol associated. The frequency of alcohol-associated injury varies among countries and is unknown in Ghana. We determined the frequency of positive alcohol test results among injured adults in a Ghanaian emergency department (ED). This is a cross-sectional chart review of consecutive injured patients aged 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within 8 hours of injury. Patients were tested for presence of alcohol with a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death before admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals were calculated. Injured adult patients (2,488) presented to the ED from November 2014 to April 2015, with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95% confidence interval 32% to 38%) tested alcohol positive. Forty-two percent of men (320/756), 40% of subjects aged 25 to 44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assault victims (82/166), 40% of those seriously injured (124/311), and 53% of subjects who died in the ED (8/15) had positive results for presence of alcohol. The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary care hospital ED. These findings have implications for health policy-, ED- and legislative-based interventions, and acute care. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Persistent pain after motor vehicle collision: comparative effectiveness of opioids vs nonsteroidal antiinflammatory drugs prescribed from the emergency department-a propensity matched analysis.

PubMed

Beaudoin, Francesca L; Gutman, Roee; Merchant, Roland C; Clark, Melissa A; Swor, Robert A; Jones, Jeffrey S; Lee, David C; Peak, David A; Domeier, Robert M; Rathlev, Niels K; McLean, Samuel A

2017-02-01

Each year millions of Americans present to the emergency department (ED) for care after a motor vehicle collision (MVC); the majority (>90%) are discharged to home after evaluation. Acute musculoskeletal pain is the norm in this population, and such patients are typically discharged to home with prescriptions for oral opioid analgesics or nonsteroidal antiinflammatory drugs (NSAIDs). The influence of acute pain management on subsequent pain outcomes in this common ED population is unknown. We evaluated the effect of opioid analgesics vs NSAIDs initiated from the ED on the presence of moderate to severe musculoskeletal pain and ongoing opioid use at 6 weeks in a large cohort of adult ED patients presenting to the ED after MVC (n = 948). The effect of opioids vs NSAIDs was evaluated using an innovative quasi-experimental design method using propensity scores to account for covariate imbalances between the 2 treatment groups. No difference in risk for moderate to severe musculoskeletal pain at 6 weeks was observed between those discharged with opioid analgesics vs NSAIDs (risk difference = 7.2% [95% confidence interval: -5.2% to 19.5%]). However, at follow-up participants prescribed opioids were more likely than those prescribed NSAIDs to report use of prescription opioids medications at week 6 (risk difference = 17.5% [95% confidence interval: 5.8%-29.3%]). These results suggest that analgesic choice at ED discharge does not influence the development of persistent moderate to severe musculoskeletal pain 6 weeks after an MVC, but may result in continued use of prescription opioids. Supported by NIAMS R01AR056328 and AHRQ 5K12HS022998.

National survey of emergency departments in Denmark.

PubMed

Wen, Leana S; Anderson, Philip D; Stagelund, Søren; Sullivan, Ashley F; Camargo, Carlos A

2013-06-01

Emergency departments (EDs) are the basic unit of emergency medicine, but often differ in fundamental features. We sought to describe and characterize EDs in Denmark. All EDs open 24/7 to the general public were surveyed using the National ED Inventories survey instrument (http://www.emnet-nedi.org). ED staff were asked about ED characteristics with reference to the calendar year 2008. Twenty-eight EDs participated (82% response). All were located in hospitals. Less than half [43%, 95% confidence interval (CI) 24-63%] were independent departments. Thirty-nine percent (95% CI 22-59%) had a contiguous layout, with medical and surgical care provided in one area. The vast majority of EDs saw both adults and children; only 10% saw adults only and none saw children only. The median number of annual visits was 32 000 (interquartile range, 14 700-47 000). The majority (68%, 95% CI 47-89%) believed that their ED was at good balance or capacity, with 22% responding that they were under capacity and 9% reporting overcapacity. Technological resources were generally available, with the exception of dedicated computed tomography scanners and negative-pressure rooms. Almost all common emergencies were identified as being treatable 24/7 in the EDs. Although there is some variation in their layout and characteristics, most Danish EDs have a high degree of resource availability and are able to treat common emergencies. As Denmark seeks to reform emergency care through ED consolidation, this national survey helps to establish a benchmark for future comparisons.

Safety and efficacy of antihypertensive prescription at emergency department discharge.

PubMed

Brody, Aaron; Rahman, Tahsin; Reed, Brian; Millis, Scott; Ference, Brian; Flack, John M; Levy, Phillip D

2015-05-01

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. The objective was to evaluate the safety and efficacy of prescribing antihypertensive therapy from the ED. 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. 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 was equivalent and low in both groups. No new neurological deficits, ischemic events, or life-threatening anaphylactic reactions were reported in either group. Prescription of antihypertensive medication from the ED is associated with significantly lower sBP at short-term outpatient follow-up. Antihypertensive therapy was not associated with an increased incidence of adverse events, and BP reduction did not exceed potentially harmful levels. Initiation of chronic antihypertensive therapy in the ED is safe and effective and may be a reasonable consideration for at-risk populations. © 2015 by the Society for Academic Emergency Medicine.

Symptom burden predicts hospitalization independent of comorbidity in community-dwelling older adults.

PubMed

Salanitro, Amanda H; Hovater, Martha; Hearld, Kristine R; Roth, David L; Sawyer, Patricia; Locher, Julie L; Bodner, Eric; Brown, Cynthia J; Allman, Richard M; Ritchie, Christine S

2012-09-01

To determine whether cumulative symptom burden predicts hospitalization or emergency department (ED) visits in a cohort of older adults. Prospective, observational study with a baseline in-home assessment of symptom burden. Central Alabama. Nine hundred eighty community-dwelling adults aged 65 and older (mean 75.3 ± 6.7) recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban/rural residence. Symptom burden score (range 0-10). One point was given for each symptom reported: shortness of breath, tiredness or fatigue, problems with balance or dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables were hospitalizations and ED visits, assessed every 6 months during the 8.5-year follow-up period. Using Cox proportional hazards models, time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit was determined. During the 8.5-year follow-up period, 545 (55.6%) participants were hospitalized or had an ED visit. Participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR) = 1.09, 95% confidence interval (CI) = 1.05-1.14) and hospitalization or ED visit (HR = 1.10, 95% CI = 1.06-1.14) than those with lower scores. Participants living in rural areas had significantly lower risk of hospitalization (HR = 0.83, 95% CI = 0.69-0.99) and hospitalization or ED visit (HR = 0.80, 95% CI = 0.70-0.95) than individuals in urban areas, independent of symptom burden and comorbidity. Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Healthcare providers treating older adults should consider symptom burden to be an additional risk factor for subsequent hospital utilization. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Symptom Burden Predicts Hospitalization Independent of Comorbidity in Community-Dwelling Older Adults

PubMed Central

Salanitro, Amanda H.; Hovater, Martha; Hearld, Kristine Ria; Roth, David L.; Sawyer, Patricia; Locher, Julie L.; Bodner, Eric; Brown, Cynthia J.; Allman, Richard M.; Ritchie, Christine S.

2012-01-01

OBJECTIVES To determine if cumulative symptom burden predicted hospitalizations or emergency department (ED) visits in a cohort of older adults. DESIGN Prospective, observational study with a baseline in-home assessment of symptom burden. SETTING Central Alabama. PARTICIPANTS 980 community-dwelling adults age 65 years or older recruited from a random sample of Medicare beneficiaries, stratified by sex, race, and urban/rural residence. MEASUREMENTS Symptom burden score (range 0–10). One point was added to the score for each symptom reported: shortness of breath, tiredness/fatigue, problems with balance/dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables: Hospitalizations and ED visits assessed every 6 months during the 8.5 year follow-up period. Using Cox proportional hazard models, we determined time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit. RESULTS During the 8.5 year follow up period, 545 (55.6%) participants were hospitalized or had an ED visit. The participants’ mean age was 75.3 years ± 6.7. Compared to those with lower scores, participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR)=1.09, 95% confidence interval=1.05–1.14) and hospitalization or ED visit (HR=1.10, 95% CI=1.06–1.14). Participants living in rural areas had significantly lower risk of hospitalization (HR=0.83, 95% CI= 0.69–0.99) and hospitalization or ED visit (HR=0.80, 95% CI=0.70–0.95) compared to individuals in urban areas, independent of symptom burden and comorbidity. CONCLUSION Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Health care providers treating older adults should consider symptom burden as an additional risk factor for subsequent hospital utilization. PMID:22985139

Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging.

PubMed

Clemency, Brian M; Tanski, Christopher T; Gibson Chambers, Jennifer; O'Brien, Michael; Knapp, Andrew S; Clark, Alexander J; McGoff, Patrick; Innes, Johanna; Lindstrom, Heather A; Hostler, David

2018-02-15

Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging. This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016. There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02). A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

Predictors of Emergency Department Visits and Inpatient Admissions Among Homeless and Unstably Housed Adolescents and Young Adults.

PubMed

Mackelprang, Jessica L; Qiu, Qian; Rivara, Frederick P

2015-12-01

Individuals under age 25 years are estimated to comprise one third of the homeless population nationally. Understanding the reasons for utilization of hospitals by homeless youth is important for optimizing disposition planning. Objectives of the present study were to: (1) report prevalence of emergency department (ED) and inpatient admissions among homeless and unstably housed youth; (2) describe demographic characteristics of those youth who seek hospital care; (3) describe their patterns of injury, illness, psychiatric, and substance use conditions; and (4) identify demographic and diagnostic predictors of ED visit or hospital readmission. Retrospective cohort study of 15-25-year-olds (N=402) who were admitted to the ED or inpatient floors of 2 urban teaching hospitals in King County, WA between July 1, 2009 and June 30, 2012 and whose address was "homeless" or "none" or a homeless shelter or service agency (ie, homeless or unstably housed), during any recorded encounter between July 1, 2009 and June 30, 2012. A total of 1151 ED visits and 227 inpatient admissions were documented. Fifty percent of patients had an ED visit or hospital readmission within 1 year, with 43.1% receiving care within 30 days of discharge. Cox regression showed that female individuals with an injury diagnosis (hazard ratio=1.74, 95% confidence interval=1.06, 2.85) and male individuals with an acute medical condition (hazard ratio=1.59, 95% confidence interval=1.09, 2.32) at index visit were more likely to have an ED visit or hospital readmission during the following year, as were patients who provided a private address at their index visit. Homeless young people who seek hospital care demonstrate a high rate of ED visits and hospital readmissions, with unique predictors of utilization associated with sex and housing status. Additional research is necessary to determine how best to transition these young people from hospital-based to community-based care.

Emergency department characteristics and capabilities in Bogotá, Colombia.

PubMed

Bustos, Yury; Castro, Jenny; Wen, Leana S; Sullivan, Ashley F; Chen, Dinah K; Camargo, Carlos A

2015-12-01

Emergency departments (EDs) are a critical, yet heterogeneous, part of international emergency care. The National ED Inventories (NEDI) survey has been used in multiple countries as a standardized method to benchmark ED characteristics. We sought to describe the characteristics, resources, capabilities, and capacity of EDs in the densely populated capital city of Bogotá, Colombia. Bogotá EDs accessible to the general public 24/7 were surveyed using the 23-item NEDI survey used in several other countries ( www.emnet-nedi.org ). ED staff were asked about ED characteristics with reference to calendar year 2011. Seventy EDs participated (82 % response). Most EDs (87 %) were located in hospitals, and 83 % were independent hospital departments. The median annual ED visit volume was approximately 50,000 visits. Approximately 90 % (95 % confidence interval (CI) 80-96 %) had a contiguous layout, with medical and surgical care provided in one area. Almost all EDs saw both adults and children (91 %), while 6 % saw only adults and 3 % saw only children. Availability of technological and consultant resources in EDs was variable. Nearly every ED had cardiac monitoring (99 %, 95 % CI 92-100 %), but less than half had a dedicated CT scanner (39 %, 95 % CI 28-52 %). While most EDs were able to treat trauma 24/7 (81 %, 95 % CI 69-89 %), few could manage oncological (22 %, 95 % CI 13-34 %) or dental (3 %, 95 % CI 0-11 %) emergencies 24/7. The typical ED length-of-stay was between 1 and 6 h in 59 % of EDs (95 % CI, 46-70 %), while most others reported that patients remained for >6 h (39 %). Almost half of respondents (46 %, 95 % CI 34-59 %) reported their ED was over capacity. Bogotá EDs have high annual visit volumes and long length-of-stay, and half are over capacity. To meet the emergency care needs of people in Bogotá and other large cities, Colombia should consider improving urban ED capacity and training more emergency medicine specialists capable of efficiently staffing its large and crowded EDs.

Emergency department injury surveillance and aetiological research: bridging the gap with the two-stage case-control study design.

PubMed

Hagel, Brent E

2011-04-01

To provide an overview of the two-stage case-control study design and its potential application to ED injury surveillance data and to apply this approach to published ED data on the relation between brain injury and bicycle helmet use. Relevant background is presented on injury aetiology and case-control methodology with extension to the two-stage case-control design in the context of ED injury surveillance. The design is then applied to data from a published case-control study of the relation between brain injury and bicycle helmet use with motor vehicle involvement considered as a potential confounder. Taking into account the additional sampling at the second stage, the adjusted and corrected odds ratio and 95% confidence interval for the brain injury-helmet use relation is presented and compared with the estimate from the entire original dataset. Contexts where the two-stage case-control study design might be most appropriately applied to ED injury surveillance data are suggested. The adjusted odds ratio for the relation between brain injury and bicycle helmet use based on all data (n = 2833) from the original study was 0.34 (95% CI 0.25 to 0.46) compared with an estimate from a two-stage case-control design of 0.35 (95% CI 0.25 to 0.48) using only a fraction of the original subjects (n = 480). Application of the two-stage case-control study design to ED injury surveillance data has the potential to dramatically reduce study time and resource costs with acceptable losses in statistical efficiency.

Outcomes in EMS-transported attendees from events at a large indoor arena.

PubMed

Chan, Shu B; Quinn, James E

2003-01-01

Many emergency departments (EDs) receive patients from concert or other mass gathering events. The study objective was to determine whether routine emergency medical services (EMS) transport to a hospital from an indoor arena facility is warranted. Retrospective review of transport medical records from an approximately 20,000-seat arena in a major metropolitan area from January 1, 1998, to June 30, 1999. Outcomes studied included inpatient admission rate, diagnoses, treatments, and length of ED stay. The authors reviewed 96 patients transported from 29 separate concert or professional wrestling events. The mean age was 23.2 years (SD, 10.4 yr). Only three patients (3.1%, 95% confidence interval [CI], 0.65%-8.9%) required inpatient admission. The mean length of stay in the ED was 158 minutes (95% CI, 132-185). Thirty-one percent of the patients had diagnoses of alcohol or drug use; trauma accounted for 33%; and medical reasons represented 35% of transports. Alcohol and/or drug cases stayed in the ED 207 minutes (mean), which was 59% longer than trauma cases (130 min) and 47% longer than the 141 minutes for medical cases (p = 0.007). Rock concerts had 45% alcohol/drug-related cases versus 22% for pop concerts and 0% for professional wrestling events (p = 0.001). Patients transported from indoor arena events rarely result in inpatient admissions. Alcohol- and drug-related problems were the primary diagnoses in 31% of these patients and required the most time in the ED. Rock concerts had more alcohol and drug cases than other events.

Emergency department utilization and subsequent prescription drug overdose death

PubMed Central

Brady, Joanne E.; DiMaggio, Charles J.; Keyes, Katherine M.; Doyle, John J.; Richardson, Lynne D.; Li, Guohua

2015-01-01

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

The use of mechanical ventilation in the ED.

PubMed

Easter, Benjamin D; Fischer, Christopher; Fisher, Jonathan

2012-09-01

Although EDs are responsible for the initial care of critically ill patients and the amount of critical care provided in the ED is increasing, there are few data examining mechanical ventilation (MV) in the ED. In addition, characteristics of ED-based ventilation may affect planning for ventilator shortages during pandemic influenza or bioterrorist events. The study examined the epidemiology of MV in US EDs, including demographic, clinical, and hospital characteristics; indications for MV; ED length of stay (LOS); and in-hospital mortality. This study was a retrospective review of the 1993 to 2007 National Hospital Ambulatory Medical Care Survey ED data sets. Ventilated patients were compared with ED patients admitted to the intensive care unit (ICU) and to all other ED visits. There were 3.6 million ED MV visits (95% confidence interval [CI], 3.2-4.0 million) over the study period. Sex, age, race, and payment source were similar for mechanically ventilated and ICU patients (P > .05 for all). Approximately 12.5% of ventilated patients underwent cardiopulmonary resuscitation compared with 1.7% of ICU admissions and 0.2% of all other ED visits (P < .0001). Accordingly, in-hospital mortality was significantly higher for ventilated patients (24%; 95% CI, 13.1%-34.9%) than both comparison groups (9.3% and 2.5%, respectively). Median LOS for ventilated patients was 197 minutes (interquartile range, 112-313 minutes) compared with 224 minutes for ICU admissions and 140 minutes for all other ED visits. Patients undergoing ED MV have particularly high in-hospital mortality rates, but their ED LOS is sufficient for implementation of evidence-based ventilator interventions. Copyright © 2012 Elsevier Inc. All rights reserved.

Emergency Department Length of Stay: Accuracy of Patient Estimates

PubMed Central

Parker, Brendan T.; Marco, Catherine

2014-01-01

Introduction Managing a patient’s expectations in the emergency department (ED) environment is challenging. Previous studies have identified several factors associated with ED patient satisfaction. Lengthy wait times have shown to be associated with dissatisfaction with ED care. Understanding that patients are inaccurate at their estimation of wait time, which could lead to lower satisfaction, provides administrators possible points of intervention to help improve accuracy of estimation and possibly satisfaction with the ED. This study was undertaken to examine the accuracy of patient estimates of time periods in an ED and identify factors associated with accuracy. Method In this prospective convenience sample survey at UTMC ED, we collected data between March and July 2012. Outcome measures included duration of each phase of ED care and patient estimates of these time periods. Results Among 309 participants, the majority underestimated the total length of stay (LOS) in the ED (median difference −7 minutes (IQR −29-12)). There was significant variability in ED LOS (median 155 minutes (IQR 75–240)). No significant associations were identified between accuracy of time estimates and gender, age, race, or insurance status. Participants with longer ED LOS demonstrated lower patient satisfaction scores (p<0.001). Conclusion Patients demonstrated inaccurate time estimates of ED treatment times, including total LOS. Patients with longer ED LOS had lower patient satisfaction scores. PMID:24672606

The Natural Course of Bulimia Nervosa and Eating Disorder not Otherwise Specified is not Influenced by Personality Disorders

PubMed Central

Grilo, Carlos M.; Sanislow, Charles A.; Shea, M. Tracie; Skodol, Andrew E.; Stout, Robert L.; Pagano, Maria E.; Yen, Shirley; McGlashan, Thomas H.

2013-01-01

Objective To examine prospectively the natural course of bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) and to test the effects of personality disorder (PD) comorbidity on the outcomes. Method Ninety-two female patients with current BN (N = 23) or EDNOS (N = 69) were evaluated at baseline enrollment in the Collaborative Longitudinal Personality Disorders Study (CLPS). Eating disorders (EDs) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders. Personality disorders (PDs) were assessed with the Diagnostic Interview for DSM-IV PD (DIPD-IV). The course of BN and EDNOS was assessed with the Longitudinal Interval Follow-up Evaluation and the course of PDs was evaluated with the Follow-Along version of the DIPD-IV at 6, 12, and 24 months. Results Probability of remission at 24 months was 40% for BN and 59% for EDNOS. To test the effects of PD comorbidity on course, ED patients were divided into groups with no, one, and two or more PDs. Cox proportional regression analyses revealed that BN had a longer time to remission than EDNOS (p < .05). The number of PDs was not a significant predictor of time to remission, nor was the presence of Axis I psychiatric comorbidity or Global Assessment of Functioning scores. Analyses using proportional hazards regression with time-varying covariates revealed that PD instability was unrelated to changes in ED. Conclusions BN has a worse 24-month course (longer time to remission) than EDNOS. The natural course of BN and EDNOS is not influenced significantly by the presence, severity, or time-varying changes of co-occurring PDs, co-occurring Axis I disorders, or by global functioning. PMID:12949923

Trends and Characteristics of Emergency Department Visits for Fall-Related Injuries in Older Adults, 2003–2010

PubMed Central

Shankar, Kalpana N.; Liu, Shan W.; Ganz, David A.

2017-01-01

Introduction One third of older adults fall each year, and falls are costly to both the patient in terms of morbidity and mortality and to the health system. Given that falls are a preventable cause of injury, our objective was to understand the characteristics and trends of emergency department (ED) fall-related visits among older adults. We hypothesize that falls among older adults are increasing and examine potential factors associated with this rise, such as race, ethnicity, gender, insurance and geography. Methods We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine fall trends over time by examining changes in ED visit rates for falls in the United States between 2003 and 2010, detailing differences by gender, sociodemographic characteristics and geographic region. Results Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age ≥ 65 increased from 60.4 (95% confidence interval [CI][51.9–68.8]) to 68.8 (95% CI [57.8–79.8]) per 1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75–84 years increased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p = 0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the South increased from 54.4 to 71.1 (p=0.03). Conclusion ED visit rates for falls are increasing over time. There is a national movement to increase falls awareness and prevention. EDs are in a unique position to engage patients on future fall prevention and should consider ways they can also partake in such initiatives in a manner that is feasible and appropriate for the ED setting. PMID:28874929

Implementation of an Emergency Department Sepsis Bundle and System Redesign: A Process Improvement Initiative.

PubMed

McColl, Tamara; Gatien, Mathieu; Calder, Lisa; Yadav, Krishan; Tam, Ryan; Ong, Melody; Taljaard, Monica; Stiell, Ian

2017-03-01

In 2008-2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality. This before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use. We included a total of 167 and 185 patients in the pre- and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8-17.0; p=0.006). There was also a higher rate of sepsis protocol use in the post-intervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1-65.3; p<0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission. Interpretation The implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.

Forecasting Emergency Department Crowding: An External, Multi-Center Evaluation

PubMed Central

Hoot, Nathan R.; Epstein, Stephen K.; Allen, Todd L.; Jones, Spencer S.; Baumlin, Kevin M.; Chawla, Neal; Lee, Anna T.; Pines, Jesse M.; Klair, Amandeep K.; Gordon, Bradley D.; Flottemesch, Thomas J.; LeBlanc, Larry J.; Jones, Ian; Levin, Scott R.; Zhou, Chuan; Gadd, Cynthia S.; Aronsky, Dominik

2009-01-01

Objective To apply a previously described tool to forecast ED crowding at multiple institutions, and to assess its generalizability for predicting the near-future waiting count, occupancy level, and boarding count. Methods The ForecastED tool was validated using historical data from five institutions external to the development site. A sliding-window design separated the data for parameter estimation and forecast validation. Observations were sampled at consecutive 10-minute intervals during 12 months (n = 52,560) at four sites and 10 months (n = 44,064) at the fifth. Three outcome measures – the waiting count, occupancy level, and boarding count – were forecast 2, 4, 6, and 8 hours beyond each observation, and forecasts were compared to observed data at corresponding times. The reliability and calibration were measured following previously described methods. After linear calibration, the forecasting accuracy was measured using the median absolute error (MAE). Results The tool was successfully used for five different sites. Its forecasts were more reliable, better calibrated, and more accurate at 2 hours than at 8 hours. The reliability and calibration of the tool were similar between the original development site and external sites; the boarding count was an exception, which was less reliable at four out of five sites. Some variability in accuracy existed among institutions; when forecasting 4 hours into the future, the MAE of the waiting count ranged between 0.6 and 3.1 patients, the MAE of the occupancy level ranged between 9.0 and 14.5% of beds, and the MAE of the boarding count ranged between 0.9 and 2.7 patients. Conclusion The ForecastED tool generated potentially useful forecasts of input and throughput measures of ED crowding at five external sites, without modifying the underlying assumptions. Noting the limitation that this was not a real-time validation, ongoing research will focus on integrating the tool with ED information systems. PMID:19716629

Air pollution and acute respiratory infections among children 0-4 years of age: an 18-year time-series study.

PubMed

Darrow, Lyndsey A; Klein, Mitchel; Flanders, W Dana; Mulholland, James A; Tolbert, Paige E; Strickland, Matthew J

2014-11-15

Upper and lower respiratory infections are common in early childhood and may be exacerbated by air pollution. We investigated short-term changes in ambient air pollutant concentrations, including speciated particulate matter less than 2.5 μm in diameter (PM2.5), in relation to emergency department (ED) visits for respiratory infections in young children. Daily counts of ED visits for bronchitis and bronchiolitis (n = 80,399), pneumonia (n = 63,359), and upper respiratory infection (URI) (n = 359,246) among children 0-4 years of age were collected from hospitals in the Atlanta, Georgia, area for the period 1993-2010. Daily pollutant measurements were combined across monitoring stations using population weighting. In Poisson generalized linear models, 3-day moving average concentrations of ozone, nitrogen dioxide, and the organic carbon fraction of particulate matter less than 2.5 μm in diameter (PM2.5) were associated with ED visits for pneumonia and URI. Ozone associations were strongest and were observed at low (cold-season) concentrations; a 1-interquartile range increase predicted a 4% increase (95% confidence interval: 2%, 6%) in visits for URI and an 8% increase (95% confidence interval: 4%, 13%) in visits for pneumonia. Rate ratios tended to be higher in the 1- to 4-year age group compared with infants. Results suggest that primary traffic pollutants, ozone, and the organic carbon fraction of PM2.5 exacerbate upper and lower respiratory infections in early life, and that the carbon fraction of PM2.5 is a particularly harmful component of the ambient particulate matter mixture. © The Author 2014. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Magnet-related injury rates in children: a single hospital experience.

PubMed

Agbo, Chioma; Lee, Lois; Chiang, Vincent; Landscahft, Assaf; Kimia, Tomer; Monuteaux, Michael C; Kimia, Amir A

2013-07-01

The ingestion of multiple magnets simultaneously or the placement of magnets in both nares can lead to serious injury resulting from the attraction of the magnets across the tissues. The impact of mandatory standards for toys containing magnets has not been thoroughly investigated. The aim of the present study was to describe the emergency department (ED) visit rate for magnet-related injuries. We performed a retrospective study of children evaluated for magnet-related injuries from 1995 to 2012 in an urban tertiary care pediatric ED. We identified cases using a computerized text-search methodology followed by manual chart review. We included children evaluated for magnet ingestion or impaction in the ears, nose, vagina, or rectum. We assessed the type and number of magnets as well as management and required interventions. A Poisson regression model was used to analyze rates of injury over time. We identified 112 cases of magnet injuries. The median patient age was 6 years (IQR 3.5, 10), and 54% were male. Compared to before 2006, the rate for all magnet-related injuries in 2007-2012 (incidence rate ratio 3.44; 95% confidence interval 2.3-5.11) as well as multiple magnet-related injuries (incidence rate ratio 7.54; 95% confidence interval 3.51-16.19) increased. Swallowed magnets accounted for 86% of the injuries. Thirteen patients had endoscopy performed for magnet removal (12%), and 4 (4%) had a surgical intervention. Magnets from toys account for the majority of the injuries. The number of ED visits for magnet-related injuries in children may be rising and are underreported, with an increase in the proportion of multiple magnets involvement. In our case series, mandatory standard for toys had no mitigating effect.

Statistical analysis of low-voltage EDS spectrum images

DOE Office of Scientific and Technical Information (OSTI.GOV)

Anderson, I.M.

1998-03-01

The benefits of using low ({le}5 kV) operating voltages for energy-dispersive X-ray spectrometry (EDS) of bulk specimens have been explored only during the last few years. This paper couples low-voltage EDS with two other emerging areas of characterization: spectrum imaging of a computer chip manufactured by a major semiconductor company. Data acquisition was performed with a Philips XL30-FEG SEM operated at 4 kV and equipped with an Oxford super-ATW detector and XP3 pulse processor. The specimen was normal to the electron beam and the take-off angle for acquisition was 35{degree}. The microscope was operated with a 150 {micro}m diameter finalmore » aperture at spot size 3, which yielded an X-ray count rate of {approximately}2,000 s{sup {minus}1}. EDS spectrum images were acquired as Adobe Photoshop files with the 4pi plug-in module. (The spectrum images could also be stored as NIH Image files, but the raw data are automatically rescaled as maximum-contrast (0--255) 8-bit TIFF images -- even at 16-bit resolution -- which poses an inconvenience for quantitative analysis.) The 4pi plug-in module is designed for EDS X-ray mapping and allows simultaneous acquisition of maps from 48 elements plus an SEM image. The spectrum image was acquired by re-defining the energy intervals of 48 elements to form a series of contiguous 20 eV windows from 1.25 kV to 2.19 kV. A spectrum image of 450 x 344 pixels was acquired from the specimen with a sampling density of 50 nm/pixel and a dwell time of 0.25 live seconds per pixel, for a total acquisition time of {approximately}14 h. The binary data files were imported into Mathematica for analysis with software developed by the author at Oak Ridge National Laboratory. A 400 x 300 pixel section of the original image was analyzed. MSA required {approximately}185 Mbytes of memory and {approximately}18 h of CPU time on a 300 MHz Power Macintosh 9600.« less

Impact of an emergency medicine pharmacist on antibiotic dosing adjustment.

PubMed

DeWitt, Kyle M; Weiss, Steven J; Rankin, Shannon; Ernst, Amy; Sarangarm, Preeyaporn

2016-06-01

Overall medication-related errors in the emergency department (ED) are 13.5 times more likely to occur in the absence of an emergency medicine pharmacist (EMP). Although the effectiveness of pharmacist-driven renal dosing adjustment has been studied in the intensive care unit, data are lacking in the ED setting. The aim of our study was to evaluate the appropriateness of antibiotic dosing when an EMP is physically present in the ED compared to when absent. This was a retrospective cohort study of patients treated in a level I trauma center with 75 adult and 12 pediatric beds and an annual census of 90000 patients. The study period was from March 1 to September 30, 2014. An EMP was physically present in the ED from 11:00 to 01:30 and absent from 01:31 to 10:59. Male and female patients 18years and older were considered for inclusion if cefazolin, cefepime, ciprofloxacin, piperacillin-tazobactam, or vancomycin was ordered. The primary outcome was the composite rate of correct antibiotic dose and frequency. Statistics included a multivariable logistic regression using age, sex, presence of EMP, and creatinine clearance as independent predictors of correct antibiotic use. A total 210 cases were randomly chosen for evaluation, half during times when EMPs were present and half when they were absent. There were 130 males (62%) with an overall mean age of 54±18years. Overall, 178 (85%) of 210 of the antibiotic orders were appropriate, with 95% appropriate when an EMP was present compared to 74% when an EMP was absent (odds ratio, 6.9; 95% confidence interval, 2.5-18.8). In a logistic regression model, antibiotic appropriateness was independently associated with the presence of the EMP and creatinine clearance. Antibiotics that require renal and/or weight dosing adjustment are 6.5 times more likely to be appropriate in the ED when an EMP is present. Prevalence of antibiotic dosing error is related to both the presence of EMPs and the degree of renal impairment. Copyright © 2016 Elsevier Inc. All rights reserved.

Opioid-Sparing Effect of Cannabinoids: A Systematic Review and Meta-Analysis.

PubMed

Nielsen, Suzanne; Sabioni, Pamela; Trigo, Jose M; Ware, Mark A; Betz-Stablein, Brigid D; Murnion, Bridin; Lintzeris, Nicholas; Khor, Kok Eng; Farrell, Michael; Smith, Andrew; Le Foll, Bernard

2017-08-01

Cannabinoids, when co-administered with opioids, may enable reduced opioid doses without loss of analgesic efficacy (ie, an opioid-sparing effect). The aim of this study was to conduct a systematic review to determine the opioid-sparing potential of cannabinoids. Eligible studies included pre-clinical and clinical studies for which the outcome was either analgesia or opioid dose requirements. Clinical studies included controlled studies and case series. We searched Scopus, Cochrane Database of Systematic Reviews, Medline, and Embase. Nineteen pre-clinical and nine clinical studies met the search criteria. Seventeen of the 19 pre-clinical studies provided evidence of synergistic effects from opioid and cannabinoid co-administration. Our meta-analysis of pre-clinical studies indicated that the median effective dose (ED 50 ) of morphine administered in combination with delta-9-tetrahydrocannabinol (delta-9-THC) is 3.6 times lower (95% confidence interval (CI) 1.95, 6.76; n=6) than the ED 50 of morphine alone. In addition, the ED 50 for codeine administered in combination with delta-9-THC was 9.5 times lower (95% CI 1.6, 57.5, n=2) than the ED 50 of codeine alone. One case series (n=3) provided very-low-quality evidence of a reduction in opioid requirements with cannabinoid co-administration. Larger controlled clinical studies showed some clinical benefits of cannabinoids; however, opioid dose changes were rarely reported and mixed findings were observed for analgesia. In summary, pre-clinical studies provide robust evidence of the opioid-sparing effect of cannabinoids, whereas one of the nine clinical studies identified provided very-low-quality evidence of such an effect. Prospective high-quality-controlled clinical trials are required to determine the opioid-sparing effect of cannabinoids.

Temporal trends in emergency department visits for bronchiolitis in the United States, 2006 to 2010.

PubMed

Hasegawa, Kohei; Tsugawa, Yusuke; Brown, David F M; Mansbach, Jonathan M; Camargo, Carlos A

2014-01-01

To examine temporal trends in emergency departments (EDs) visits for bronchiolitis among US children between 2006 and 2010. Serial, cross-sectional analysis of the Nationwide Emergency Department Sample, a nationally representative sample of ED patients. We used International Classification of Diseases, Ninth Revision, Clinical Modification code 466.1 to identify children <2 years of age with bronchiolitis. Primary outcome measures were rate of bronchiolitis ED visits, hospital admission rate and ED charges. Between 2006 and 2010, weighted national discharge data included 1,435,110 ED visits with bronchiolitis. There was a modest increase in the rate of bronchiolitis ED visits, from 35.6 to 36.3 per 1000 person-years (2% increase; Ptrend = 0.008), due to increases in the ED visit rate among children from 12 months to 23 months (24% increase;Ptrend < 0.001). By contrast, there was a significant decline in the ED visit rate among infants (4% decrease; Ptrend < 0.001). Although unadjusted admission rate did not change between 2006 and 2010 (26% in both years), admission rate declined significantly after adjusting for potential patient- and ED-level confounders (adjusted odds ratio for comparison of 2010 with 2006, 0.84; 95% confidence interval: 0.76-0.93; P < 0.001). Nationwide ED charges for bronchiolitis increased from $337 million to $389 million (16% increase; Ptrend < 0.001), adjusted for inflation. This increase was driven by a rise in geometric mean of ED charges per case from $887 to $1059 (19% increase; Ptrend < 0.001). Between 2006 and 2010, we found a divergent temporal trend in the rate of bronchiolitis ED visits by age group. Despite a significant increase in associated ED charges, ED-associated hospital admission rates for bronchiolitis significantly decreased over this same period.

Randomized clinical trial of hydrocodone/acetaminophen versus codeine/acetaminophen in the treatment of acute extremity pain after emergency department discharge.

PubMed

Chang, Andrew K; Bijur, Polly E; Munjal, Kevin G; John Gallagher, E

2014-03-01

The objective was to test the hypothesis that hydrocodone/acetaminophen (Vicodin [5/500]) provides more efficacious analgesia than codeine/acetaminophen (Tylenol #3 [30/300]) in patients discharged from the emergency department (ED). Both are currently Drug Enforcement Administration (DEA) Schedule III narcotics. This was a prospective, randomized, double-blind, clinical trial of patients with acute extremity pain who were discharged home from the ED, comparing a 3-day supply of oral hydrocodone/acetaminophen (5 mg/500 mg) to oral codeine/acetaminophen (30 mg/300 mg). Pain was measured on a valid and reproducible verbal numeric rating scale (NRS) ranging from 0 to 10, and patients were contacted by telephone approximately 24 hours after being discharged. The primary outcome was the between-group difference in improvement in pain at 2 hours following the most recent ingestion of the study drug, relative to the time of phone contact after ED discharge. Secondary outcomes compared side-effect profiles and patient satisfaction. The median time from ED discharge to follow-up was 26 hours (interquartile range [IQR] = 24 to 39 hours). The mean NRS pain score before the most recent dose of pain medication after ED discharge was 7.6 NRS units for both groups. The mean decrease in pain scores 2 hours after pain medications were taken were 3.9 NRS units in the hydrocodone/acetaminophen group versus 3.5 NRS units in the codeine/acetaminophen group, for a difference of 0.4 NRS units (95% confidence interval [CI] = -0.3 to 1.2 NRS units). No differences were found in side effects or patient satisfaction. Both medications decreased NRS pain scores by approximately 50%. However, the oral hydrocodone/acetaminophen failed to provide clinically or statistically superior pain relief compared to oral codeine/acetaminophen when prescribed to patients discharged from the ED with acute extremity pain. Similarly, there were no clinically or statistically important differences in side-effect profiles or patient satisfaction. If the DEA reclassifies hydrocodone as a Schedule II narcotic, as recently recommended by its advisory board, our data suggest that the codeine/acetaminophen may be a clinically reasonable Schedule III substitute for hydrocodone/acetaminophen at ED discharge. These findings should be regarded as tentative and require independent validation in similar and other acute pain models. © 2014 by the Society for Academic Emergency Medicine.

A Prevalence and Management Study of Acute Pain in Children Attending Emergency Departments by Ambulance.

PubMed

Murphy, Adrian; McCoy, Siobhan; O'Reilly, Kay; Fogarty, Eoin; Dietz, Jason; Crispino, Gloria; Wakai, Abel; O'Sullivan, Ronan

2016-01-01

Pain is the most common symptom in the emergency setting and remains one of the most challenging problems for emergency care providers, particularly in the pediatric population. The primary objective of this study was to determine the prevalence of acute pain in children attending emergency departments (EDs) in Ireland by ambulance. In addition, this study sought to describe the prehospital and initial ED management of pain in this population, with specific reference to etiology of pain, frequency of pain assessment, pain severity, and pharmacological analgesic interventions. A prospective cross-sectional study was undertaken over a 12-month period of all pediatric patients transported by emergency ambulance to four tertiary referral hospitals in Ireland. All children (<16 years) who had pain as a symptom (regardless of cause) at any stage during the prehospital phase of care were included in this study. Over the study period, 6,371 children attended the four EDs by emergency ambulance, of which 2,635 (41.4%, 95% confidence interval 40.2-42.3%) had pain as a documented symptom on the ambulance patient care report (PCR) form. Overall 32% (n = 856) of children who complained of pain were subject to a formal pain assessment during the prehospital phase of care. Younger age, short transfer time to the ED, and emergency calls between midnight and 6 am were independently associated with decreased likelihood of having a documented assessment of pain intensity during the prehospital phase of care. Of the 2,635 children who had documented pain on the ambulance PCR, 26% (n = 689) received some form of analgesic agent prior to ED arrival. Upon ED arrival 54% (n = 1,422) of children had a documented pain assessment and some form of analgesic agent was administered to 50% (n = 1,324). Approximately 41% of children who attend EDs in Ireland by ambulance have pain documented as their primary symptom. This study suggests that the management of acute pain in children transferred by ambulance to the ED in Ireland is currently poor, with documentary evidence of only 26% receiving prehospital analgesic agents.

Emergency department waiting times: Do the raw data tell the whole story?

PubMed

Green, Janette; Dawber, James; Masso, Malcolm; Eagar, Kathy

2014-02-01

To determine whether there are real differences in emergency department (ED) performance between Australian states and territories. Cross-sectional analysis of 2009-10 attendances at an ED contributing to the Australian non-admitted patient ED care database. The main outcome measure was difference in waiting time across triage categories. There were more than 5.8 million ED attendances. Raw ED waiting times varied by a range of factors including jurisdiction, triage category, geographic location and hospital peer group. All variables were significant in a model designed to test the effect of jurisdiction on ED waiting times, including triage category, hospital peer group, patient socioeconomic status and patient remoteness. When the interaction between triage category and jurisdiction entered the model, it was found to have a significant effect on ED waiting times (P<0.001) and triage was also significant (P<0.001). Jurisdiction was no longer statistically significant (P=0.248 using all triage categories and 0.063 using only Australian Triage Scale 2 and 3). Although the Council of Australian Governments has adopted raw measures for its key ED performance indicators, raw waiting time statistics are misleading. There are no consistent differences in ED waiting times between states and territories after other factors are accounted for. WHAT IS KNOWN ABOUT THE TOPIC? The length of time patients wait to be treated after presenting at an ED is routinely used to measure ED performance. In national health agreements with the federal government, each state and territory in Australia is expected to meet waiting time performance targets for the five ED triage categories. The raw data indicate differences in performance between states and territories. WHAT DOES THIS PAPER ADD? Measuring ED performance using raw data gives misleading results. There are no consistent differences in ED waiting times between the states and territories after other factors are taken into account. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Judgements regarding differences in performance across states and territories for triage waiting times need to take into account the mix of patients and the mix of hospitals.

Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial.

PubMed

Richards, Doug; Meshkat, Nazanin; Chu, Jaqueline; Eva, Kevin; Worster, Andrew

2007-11-01

Numerous patients are assessed in the emergency department (ED) for chest pain suggestive of acute coronary syndrome (ACS) and subsequently discharged if found to be at low risk. Exercise stress testing is frequently advised as a follow-up investigation for low-risk patients; however, compliance with such recommendations is poorly understood. We sought to determine if compliance with follow-up for exercise stress testing is higher in patients for whom the investigation is ordered at the time of ED discharge, compared with patients who are advised to arrange testing through their family physician (FP). Low-risk chest pain patients being discharged from the ED for outpatient exercise stress test and FP follow-up were randomized into 2 groups. ED staff ordered an exercise stress test for the intervention group, and the control group was advised to contact their FP to arrange testing. The primary outcome was completion of an exercise stress test at 30 days, confirmed through both patient contact and stress test results. Patients were unaware that our primary interest was their compliance with the exercise stress testing recommendations. Two-hundred and thirty-one patients were enrolled and baseline characteristics were similar between the 2 groups. Completion of an exercise stress test at 30 days occurred in 87 out of 120 (72.5%) patients in the intervention group and 60 out of 107 (56.1%) patients in the control group. The difference in compliance rates (16.4%) between the 2 groups was statistically significant (Chi(2) = 6.69, p < 0.001) with a relative risk of 1.29 (95% confidence interval 1.18-1.40), and the results remained significant after a "worst case" sensitivity analysis involving 4 control group cases lost to follow-up. When subjects were contacted by telephone 30 days after the ED visit, 60% of those who were noncompliant patients felt they did not have a heart problem and that further testing was unnecessary. When ED staff order an outpatient exercise stress test following investigation for potential ACS, patients are more likely to complete the test if it is booked for them before ED discharge. After discharge, many low-risk chest pain patients feel they are not at risk and do not return to their FP for further testing in a timely manner as advised. Changing to a strategy of ED booking of exercise stress testing may help earlier identification of patients with coronary heart disease.

Multi-Sample Cluster Analysis Using Akaike’s Information Criterion.

DTIC Science & Technology

1982-12-20

Intervals. For more details on these test procedures refer to Gabriel [7J, Krishnaiah (CIlUj, [11]), Srivastava [16), and others. -3- As noted in Consul...723. (4] Consul, P. C. (1969), "The Exact Distributions of Likelihood Criteria for Different Hypotheses," in P. R. Krishnaiah (Ed.), Multivariate...1178. [7] Gabriel, K. R. (1969), "A Comparison of Some lethods of Simultaneous Inference in MANOVA," in P. R. Krishnaiah (Ed.), Multivariate Analysis-lI

Evaluating the effect of clinical decision units on patient flow in seven Canadian emergency departments.

PubMed

Schull, Michael J; Vermeulen, Marian J; Stukel, Therese A; Guttmann, Astrid; Leaver, Chad A; Rowe, Brian H; Sales, Anne

2012-07-01

To evaluate the effect of emergency department (ED) clinical decision units (CDUs) on overall ED patient flow in a pilot project funded in 2008 by the Ontario Ministry of Health and Long-Term Care (MOHLTC). A retrospective analysis of unscheduled ED visits at seven CDU pilot and nine control sites was conducted using administrative data. The authors examined trends in CDU utilization and compared outcomes between pilot-CDU and control sites 1 year prior to implementation, with the first 18 months of CDU operation. Sites that were unsuccessful in their applications for CDU program funding served as controls. Outcomes included ED length of stay (LOS), admission rates, and ED revisit rates. At CDU sites, roughly 4% of ED patients were admitted to CDUs. The presence of a pilot-CDU was independently associated with a small reduction in ED LOS for all low-acuity patients (-0.14 hour, 95% confidence interval [CI]=-0.22 to -0.07) and nonadmitted patients (-0.11 hour, 95% CI=-0.16 to -0.07). A small independent effect on absolute hospital admission rate for all high-acuity patients (-0.8%, 95% CI=-1.5% to -0.03%) and moderate-acuity patients (-0.6%, 95% CI=-1.1% to -0.2%) was also observed. Pilot-CDUs were not associated with changes in ED revisit rates. With only 4% of ED patients admitted to CDUs, the potential for efficiency gains in these EDs was limited. Nonetheless, these findings suggest small improvements in the operation of the ED through CDU implementation. Although marginal, the observed effects of CDU operation were in the desired direction of reduced ED LOS, reduced admission rate, and no increase in ED revisit rate. © 2012 by the Society for Academic Emergency Medicine.

Alcohol-related emergency department visits associated with collegiate football games.

PubMed

Shook, Janice; Hiestand, Brian C

2011-01-01

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 that alcohol-related visits should decline. ED patients during home game weekends. Retrospective cohort study comparing the 2002 and 2006 home games-similar seasons wherein the team went undefeated. Logistic regression assessed the impact of environmental and patient characteristics on the likelihood of an ED visit being alcohol related. In total 2,220 visits in 2002 and 2,146 visits in 2006 were reviewed. Alcohol-related visits increased from 2002 (7.9%) to 2006 (9.5%, p = .06). Despite community interventions, the odds of an ED visit being alcohol related increased (odds ratio [OR] 1.3, 95% confidence interval [CI₉₅] 1.06-1.64). Community measures did not reduce alcohol-related visits to the ED.

Automated data extraction from general practice records in an Australian setting: trends in influenza-like illness in sentinel general practices and emergency departments.

PubMed

Liljeqvist, Gösta T H; Staff, Michael; Puech, Michele; Blom, Hans; Torvaldsen, Siranda

2011-06-06

Influenza intelligence in New South Wales (NSW), Australia is derived mainly from emergency department (ED) presentations and hospital and intensive care admissions, which represent only a portion of influenza-like illness (ILI) in the population. A substantial amount of the remaining data lies hidden in general practice (GP) records. Previous attempts in Australia to gather ILI data from GPs have given them extra work. We explored the possibility of applying automated data extraction from GP records in sentinel surveillance in an Australian setting.The two research questions asked in designing the study were: Can syndromic ILI data be extracted automatically from routine GP data? How do ILI trends in sentinel general practice compare with ILI trends in EDs? We adapted a software program already capable of automated data extraction to identify records of patients with ILI in routine electronic GP records in two of the most commonly used commercial programs. This tool was applied in sentinel sites to gather retrospective data for May-October 2007-2009 and in real-time for the same interval in 2010. The data were compared with that provided by the Public Health Real-time Emergency Department Surveillance System (PHREDSS) and with ED data for the same periods. The GP surveillance tool identified seasonal trends in ILI both retrospectively and in near real-time. The curve of seasonal ILI was more responsive and less volatile than that of PHREDSS on a local area level. The number of weekly ILI presentations ranged from 8 to 128 at GP sites and from 0 to 18 in EDs in non-pandemic years. Automated data extraction from routine GP records offers a means to gather data without introducing any additional work for the practitioner. Adding this method to current surveillance programs will enhance their ability to monitor ILI and to detect early warning signals of new ILI events.

Short-term efficacy and safety of low-intensity extracorporeal shock wave therapy in erectile dysfunction: a systematic review and meta-analysis

PubMed Central

Zou, Zi-jun; Tang, Liang-you; Liu, Zhi-hong; Liang, Jia-yu; Zhang, Ruo-chen; Wang, Yu-jie; Tang, Yong-quan; Gao, Rui; Lu, Yi-ping

2017-01-01

ABSTRACT Aim: The role of low-intensity extracorporeal shock wave therapy (LI-ESWT) in erectile dysfunction (ED) is not clearly determined. The purpose of this study is to investigate the short-term efficacy and safety of LI-ESWT for ED patients. Materials and Methods: Relevant studies were searched in Medline, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), WANFANG and VIP databases. Effective rate in terms of International Index of Erectile Function-Erectile Function Domain (IIEF-EF) and Erectile Hardness Score (EHS) at about 1XSmonth after LI-ESWT was extracted from eligible studies for meta-analysis to calculate risk ratio (RR) of effective treatment in ED patients treated by LI-ESWT compared to those receiving sham-treatment. Results: Overall fifteen studies were included in the review, of which four randomized controlled trials (RCTs) were for meta-analysis. Effective treatment was 8.31 [95°/o confidence interval (CI): 3.88-17.78] times more effective in the LI-ESWT group (n=176) than in the sham-treatment group (n= 101) at about 1 month after the intervention in terms of EHS, while it was 2.50 (95% CI: 0.74–8.45) times more in the treatment group (n= 121) than in the control group (n=89) in terms of IIEF-EF. Nine-week protocol with energy density of 0.09mJ/mm2 and 1500 pluses seemed to have better therapeutic effect than five-week protocol. No significant adverse event was reported. Conclusion: LI-ESWT, as a noninvasive treatment, has potential short-term therapeutic effect on patients with organic ED irrespective of sensitivity to PDE5is. Owing to the limited number and quality of the studies, more large-scale, well-designed and longterm follow-up time studies are needed to confirm our analysis. PMID:28379665

Short-term efficacy and safety of low-intensity extracorporeal shock wave therapy in erectile dysfunction: a systematic review and meta-analysis.

PubMed

Zou, Zi-Jun; Tang, Liang-You; Liu, Zhi-Hong; Liang, Jia-Yu; Zhang, Ruo-Chen; Wang, Yu-Jie; Tang, Yong-Quan; Gao, Rui; Lu, Yi-Ping

2017-01-01

The role of low-intensity extracorporeal shock wave therapy (LI-ESWT) in erectile dysfunction (ED) is not clearly determined. The purpose of this study is to investigate the short-term efficacy and safety of LI-ESWT for ED patients. Relevant studies were searched in Medline, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), WANFANG and VIP databases. Effective rate in terms of International Index of Erectile Function-Erectile Function Domain (IIEF-EF) and Erectile Hardness Score (EHS) at about 1month after LI-ESWT was extracted from eligible studies for meta-analysis to calculate risk ratio (RR) of effective treatment in ED patients treated by LI-ESWT compared to those receiving sham-treatment. Overall fifteen studies were included in the review, of which four randomized controlled trials (RCTs) were for meta-analysis. Effective treatment was 8.31 [95% confidence interval (CI): 3.88-17.78] times more effective in the LI-ESWT group (n=176) than in the sham-treatment group (n=101) at about 1 month after the intervention in terms of EHS, while it was 2.50 (95% CI: 0.74-8.45) times more in the treatment group (n=121) than in the control group (n=89) in terms of IIEF-EF. Nine-week protocol with energy density of 0.09mJ/mm2 and 1500 pluses seemed to have better therapeutic effect than five-week protocol. No significant adverse event was reported. LI-ESWT, as a noninvasive treatment, has potential short-term therapeutic effect on patients with organic ED irrespective of sensitivity to PDE5is. Owing to the limited number and quality of the studies, more large-scale, well-designed and long-term follow-up time studies are needed to confirm our analysis. Copyright® by the International Brazilian Journal of Urology.

No regional difference in cisatracurium dose-response and time-course-of-action between patients in China and Bosnia.

PubMed

Dahaba, A A; Suljevic, I; Bornemann, H; Wu, X-M; Metzler, H

2011-03-01

Variability in drug response could result from a variety of genetic and environmental factors that are often hard to define or quantify. A number of studies demonstrated regional geographic variations in potency of neuromuscular blocking agents (NMBAs). The aim of our study was to compare dose-response and time-course-of-action of cisatracurium besylate, an NMBA eliminated via the Hoffman degradation, in two countries with different life habits, diet, and ambient conditions; being Han Chinese in China and Caucasians in Bosnia. Neuromuscular block of cisatracurium 20 µg kg(-1), followed by four incremental 10 µg kg(-1) doses, and the remainder of 100 µg kg(-1) was evaluated using the Relaxometer mechanomyograph (Groningen University, Groningen, The Netherlands). Dose-response curves were created using log-dose-probit-response transformation. There were no significant differences in cisatracurium mean (95% confidence intervals) ED(50), ED(90), and ED(95) (effective doses for 50%, 90%, and 95% first twitch depression) in Caucasian [39.1 (35.7-42.3), 50.6 (45.5-54.3), and 54.4 (49.8-58.9) µg kg(-1)] compared with Chinese patients [39.2 (35.1-43.1), 52.4 (47.9-56.8), and 56.9 (52.8-61.9) µg kg(-1)], respectively. There were no significant differences in mean (sd) Dur(25) and Dur(0.9) (time until 25% first twitch and 0.9 train-of-four ratio recoveries) in Caucasian [47.1 (6.4) and 77.5 (9.1) min)] compared with Chinese patients [(45.9 (4.7) and 72.3 (9.1) min)], respectively. Cisatracurium dose-response relationship and time-course-of-action were not influenced by geographic location. Thus, cisatracurium would not require dose adjustments between patients living in the two geographic locations.

Posted wait times an added advantage to multi-facility systems?

PubMed

2011-04-01

Methodist Le Bonheur Healthcare in Memphis, TN, is investigating whether posting ED wait times via the internet can positively impact patient flow in the six EDs the health system operates in the Memphis region. The health system began posting wait times in August 2010, resulting in increases in ED volume ranging from 6% to 10%. The health system is monitoring ED arrivals by zip code to assess any impact on load balancing between its busy EDs. One marketing challenge is that a competitor is posting ED wait times as well, but it is posting the time it takes for a patient to be placed in a bed as opposed to the door-to-provider time that Methodist Le Bonheur is posting. The approach has the most impact on lower-acuity patients, but experts worry that in the future, payers may not be reimbursed for ED care for these patients.

Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study.

PubMed

Raven, Maria C; Tieu, Lina; Lee, Christopher T; Ponath, Claudia; Guzman, David; Kushel, Margot

2017-01-01

The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use. In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates. A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness. © 2016 by the Society for Academic Emergency Medicine.

Comparison of associated features and drug treatment between co-occurring unipolar and bipolar disorders in depressed eating disorder patients.

PubMed

Tseng, Mei-Chih Meg; Chang, Chin-Hao; Liao, Shih-Cheng; Chen, Hsi-Chung

2017-02-27

To examine the differences of associated characteristics and prescription drug use between co-occurring unipolar and bipolar disorders in patients with eating disorders (EDs). Patients with EDs and major depressive episode (MDE) were recruited from psychiatric outpatient clinics. They were interviewed and completed self-administered measures assessing eating and general psychopathology. The prescribed drugs at the index outpatient visit were recorded. Clinical characteristics and prescription drugs of groups with major depressive disorder (ED-MDD), MDE with lifetime mania (ED-BP I), and MDE with lifetime hypomania (ED-BP II) were compared. Continuous variables between groups were compared using generalized linear regression with adjustments of age, gender, and ED subtype for pair-wise comparisons. Multivariate logistic regression with adjustments of age, gender, and ED subtype was employed to estimate adjusted odds ratios with 95% confidence intervals between groups. Two hundred and twenty-seven patients with EDs had a current MDE. Among them, 17.2% and 24.2% experienced associated manic and hypomanic episodes, respectively. Bipolar I and II patients displayed significantly poorer weight regulation, more severe impulsivity and emotional lability, and higher rates of co-occurring alcohol use disorders than ED-MDD patients. ED-BP I patients were found to have the lowest IQ, poorest working memory, and the most severe depression, suicidality and functional impairment among all patients. Patients with ED-BP II shared affect and behavioral dysregulations with ED-BP I, but had less severe degrees of cognitive and functional impairments than ED-BP I. Patients with ED-BP I were significantly less likely than those in the ED-MDD and ED-BP II groups to be on antidepressant monotherapy, but a great rate (27%) of ED-BP I individuals taking antidepressant monotherapy had potential risk of mood switch during the course of treatment. Our study identified discriminative features of bipolar I and II disorders from MDD among a group of depressed ED patients. We suggest that the associated mania, hypomania, and mood lability are predictors of clinical severity and should be identified from ED patients presented with depressive features. Accurate diagnosis of bipolar disorders may have implications for pharmacotherapy in patients with EDs.

Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department.

PubMed

Crisp, Jonathan G; Lovato, Luis M; Jang, Timothy B

2010-12-01

Compression ultrasonography of the lower extremity is an established method of detecting proximal lower extremity deep venous thrombosis when performed by a certified operator in a vascular laboratory. Our objective is to determine the sensitivity and specificity of bedside 2-point compression ultrasonography performed in the emergency department (ED) with portable vascular ultrasonography for the detection of proximal lower extremity deep venous thrombosis. We did this by directly comparing emergency physician-performed ultrasonography to lower extremity duplex ultrasonography performed by the Department of Radiology. This was a prospective, cross-sectional study and diagnostic test assessment of a convenience sample of ED patients with a suspected lower extremity deep venous thrombosis, conducted at a single-center, urban, academic ED. All physicians had a 10-minute training session before enrolling patients. ED compression ultrasonography occurred before Department of Radiology ultrasonography and involved identification of 2 specific points: the common femoral and popliteal vessels, with subsequent compression of the common femoral and popliteal veins. The study result was considered positive for proximal lower extremity deep venous thrombosis if either vein was incompressible or a thrombus was visualized. Sensitivity and specificity were calculated with the final radiologist interpretation of the Department of Radiology ultrasonography as the criterion standard. A total of 47 physicians performed 199 2-point compression ultrasonographic examinations in the ED. Median number of examinations per physician was 2 (range 1 to 29 examinations; interquartile range 1 to 5 examinations). There were 45 proximal lower extremity deep venous thromboses observed on Department of Radiology evaluation, all correctly identified by ED 2-point compression ultrasonography. The 153 patients without proximal lower extremity deep venous thrombosis all had a negative ED compression ultrasonographic result. One patient with a negative Department of Radiology ultrasonographic result was found to have decreased compression of the popliteal vein on ED compression ultrasonography, giving a single false-positive result, yet repeated ultrasonography by the Department of Radiology 1 week later showed a popliteal deep venous thrombosis. The sensitivity and specificity of ED 2-point compression ultrasonography for deep venous thrombosis were 100% (95% confidence interval 92% to 100%) and 99% (95% confidence interval 96% to 100%), respectively. Emergency physician-performed 2-point compression ultrasonography of the lower extremity with a portable vascular ultrasonographic machine, conducted in the ED by this physician group and in this patient sample, accurately identified the presence and absence of proximal lower extremity deep venous thrombosis. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Value of the Delta Neutrophil Index for Predicting 28-Day Mortality in Patients With Acute Pulmonary Embolism in the Emergency Department.

PubMed

Kong, Taeyoung; Park, Yoo Seok; Lee, Hye Sun; Kim, Sinae; Lee, Jong Wook; Yu, Gina; Eun, Claire; You, Je Sung; Chung, Hyun Soo; Park, Incheol; Chung, Sung Phil

2018-06-01

Acute pulmonary embolism (PE), frequently seen in the emergency department (ED), is a leading cause of cardiovascular morbidity and mortality. The delta neutrophil index (DNI) reflects the fraction of circulating immature granulocytes as a component of the systemic inflammatory response syndrome criteria. The pathogenesis of acute PE is significantly associated with inflammation. The aim of the study was to investigate the clinical usefulness of the DNI as a marker of severity in patients with acute PE admitted to the ED. We retrospectively analyzed the data of patients who were diagnosed with acute PE at a single ED, admitted from January 1, 2011 to June 30, 2017. The diagnosis of acute pulmonary embolism was confirmed using clinical, laboratory, and radiological findings. The DNI was determined at presentation. The clinical outcome was all-cause mortality within 28 days of emergency department admission. We included 447 patients in this study. The multivariate Cox regression model demonstrated that higher DNI values on ED admission were significantly associated with short-term mortality (hazard ratio, 1.107; 95% confidence interval, 1.042-1.177). The optimal cut-off DNI value, measured on ED admission, was 3.0%; this value was associated with an increased hazard of 28-day mortality following PE (HR, 7.447; 95% CI, 4.183-13.366; P < 0.001) CONCLUSION:: The DNI value, obtained as part of the complete blood count analysis, can be easily determined without additional burdens of cost or time. A high DNI is useful as a marker to predict 28-day mortality in patients with acute PE.

The impact of heatwaves on emergency department visits in Brisbane, Australia: a time series study.

PubMed

Toloo, Ghasem Sam; Yu, Weiwei; Aitken, Peter; FitzGerald, Gerry; Tong, Shilu

2014-04-09

The acute health effects of heatwaves in a subtropical climate and their impact on emergency departments (ED) are not well known. The purpose of this study is to examine overt heat-related presentations to EDs associated with heatwaves in Brisbane. Data were obtained for the summer seasons (December to February) from 2000-2012. Heatwave events were defined as two or more successive days with daily maximum temperature ≥34°C (HWD1) or ≥37°C (HWD2). Poisson generalised additive model was used to assess the effect of heatwaves on heat-related visits (International Classification of Diseases (ICD) 10 codes T67 and X30; ICD 9 codes 992 and E900.0). Overall, 628 cases presented for heat-related illnesses. The presentations significantly increased on heatwave days based on HWD1 (relative risk (RR) = 4.9, 95% confidence interval (CI): 3.8, 6.3) and HWD2 (RR = 18.5, 95% CI: 12.0, 28.4). The RRs in different age groups ranged between 3-9.2 (HWD1) and 7.5-37.5 (HWD2). High acuity visits significantly increased based on HWD1 (RR = 4.7, 95% CI: 2.3, 9.6) and HWD2 (RR = 81.7, 95% CI: 21.5, 310.0). Average length of stay in ED significantly increased by >1 hour (HWD1) and >2 hours (HWD2). Heatwaves significantly increase ED visits and workload even in a subtropical climate. The degree of impact is directly related to the extent of temperature increases and varies by socio-demographic characteristics of the patients. Heatwave action plans should be tailored according to the population needs and level of vulnerability. EDs should have plans to increase their surge capacity during heatwaves.

Creation of an intensive care unit and organizational changes in an adult emergency department: Impact on acute stroke management.

PubMed

Puy, Laurent; Lamy, Chantal; Canaple, Sandrine; Arnoux, Audrey; Laine, Nicolas; Iacob, Ella; Constans, Jean-Marc; Godefroy, Olivier

2017-05-01

Following the reorganization of a University Medical Center onto a single campus, an Intensive Care Unit was created within the adult Emergency Department (ED ICU). We assessed the effects of these organizational changes on acute stroke management and the intravenous administration of recombinant tissue plasminogen activator (IV rtPA), as characterized by the thrombolysis rate, door-to-needle time (DNT) and outcome at 3months. Between October 2013 and September 2015, we performed a retrospective, observational, single-center, comparative study of patients admitted for ischemic stroke and treated with IV rtPA during two 321-day periods (before and after the creation of the ED ICU). All patients with ischemic stroke were included. Multivariable logistic regression models were performed. The DNT was stratified according to a threshold of 60min. A favorable long-term outcome was defined as a modified Rankin score≤2 at 3months. A total of 1334 ischemic stroke patients were included. Among them, 101 patients received IV rtPA. The frequency of IV rtPA administration was 5.8% (39 out of 676) before the creation of the ED ICU, and 9.3% (62 out of 668) afterwards (odds ratio (OR) [95% confidence interval (CI)]: 1.67 [1.08-2.60]; p=0.02). Additionally, the DNT was shorter (OR [95%CI]: 4.30 [1.17-20.90]; p=0.04) and there was an improvement in the outcome (OR [95%CI]=1.30 [1.01-2.10]; p=0.045). Our results highlight the benefits of a separate ED ICU within conventional ED for acute stroke management, with a higher thrombolysis rate, reduced intrahospital delays and better safety. Copyright © 2017 Elsevier Inc. All rights reserved.

Does active dissemination of evidence result in faster knowledge transfer than passive diffusion?: An analysis of trends of the management of pediatric asthma and croup in US emergency departments from 1995 to 2009.

PubMed

Knapp, Jane F; Simon, Stephen D; Sharma, Vidya

2015-03-01

This study aimed to compare knowledge transfer (KT) in the emergency department (ED) management of pediatric asthma and croup by measuring trends in corticosteroid use for both conditions in EDs. A retrospective, cross-sectional study of the National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 of corticosteroid use at ED visits for asthma or croup was conducted. Odds ratios (OR) were calculated using logistic regression. Trends over time were compared using an interaction term between disease and year and were adjusted for all other covariates in the model. We included children aged 2 to 18 years with asthma who received albuterol and were triaged emergent/urgent. Children aged between 3 months to 6 years with croup were included. The main outcome measure was the administration of corticosteroids in the ED or as a prescription at the ED visit. The corticosteroid use in asthma visits increased from 44% to 67% and from 32% to 56% for croup. After adjusting for patient and hospital factors, this trend was significant both for asthma (OR, 1.07; 95% confidence interval [CI], 1.04-1.10) and croup (OR, 1.07; 95% CI, 1.03-1.12). There was no statistical difference between the 2 trends (P = 0.69). Hospital location in a metropolitan statistical area was associated with increased corticosteroid use in asthma (OR, 1.76; 95% CI, 1.10-2.82). Factors including sex, ethnicity, insurance, or region of the country were not significantly associated with corticosteroid use. During a 15-year period, knowledge transfer by passive diffusion or active guideline dissemination resulted in similar trends of corticosteroid use for the management of pediatric asthma and croup.

Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure

PubMed Central

Bell, E.J.; Takhar, S.S.; Beloff, J.R.; Schuur, J.D.; Landman, A.B.

2013-01-01

Summary Objective To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19). Methods We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated. Results The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 – 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% – 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% – 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats. Conclusion With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure. PMID:24454578

Performance of Emergency Department Screening Criteria for an Early ECG to Identify ST-Segment Elevation Myocardial Infarction.

PubMed

Yiadom, Maame Yaa A B; Baugh, Christopher W; McWade, Conor M; Liu, Xulei; Song, Kyoung Jun; Patterson, Brian W; Jenkins, Cathy A; Tanski, Mary; Mills, Angela M; Salazar, Gilberto; Wang, Thomas J; Dittus, Robert S; Liu, Dandan; Storrow, Alan B

2017-02-23

Timely diagnosis of ST-segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Obtaining this test within 10 minutes of ED arrival is critical to achieving the best outcomes. We investigated variability in the timely identification of STEMI across institutions and whether performance variation was associated with the ED characteristics, the comprehensiveness of screening criteria, and the STEMI screening processes. We examined STEMI screening performance in 7 EDs, with the missed case rate (MCR) as our primary end point. The MCR is the proportion of primarily screened ED patients diagnosed with STEMI who did not receive an ECG within 15 minutes of ED arrival. STEMI was defined by hospital discharge diagnosis. Relationships between the MCR and ED characteristics, screening criteria, and STEMI screening processes were assessed, along with differences in door-to-ECG times for captured versus missed patients. The overall MCR for all 7 EDs was 12.8%. The lowest and highest MCRs were 3.4% and 32.6%, respectively. The mean difference in door-to-ECG times for captured and missed patients was 31 minutes, with a range of 14 to 80 minutes of additional myocardial ischemia time for missed cases. The prevalence of primarily screened ED STEMIs was 0.09%. EDs with the greatest informedness (sensitivity+specificity-1) demonstrated superior performance across all other screening measures. The 29.2% difference in MCRs between the highest and lowest performing EDs demonstrates room for improving timely STEMI identification among primarily screened ED patients. The MCR and informedness can be used to compare screening across EDs and to understand variable performance. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Pediatric constipation in the emergency department: evaluation, treatment, and outcomes.

PubMed

Freedman, Stephen B; Thull-Freedman, Jennifer; Rumantir, Maggie; Eltorki, Mohamed; Schuh, Suzanne

2014-09-01

Limited knowledge exists surrounding the pharmacologic management of pediatric constipation in the emergency department (ED) setting and the success of interventions. Our primary objective was to determine whether enema administration is associated with 7-day ED revisits for persistent symptoms. Secondary objectives focused on assessing other predictors of ED revisits. We conducted a retrospective cohort study of children <18 years old, diagnosed as having constipation (International Classification of Diseases-10 codes F98.1 nonorganic encopresis, K59.0 constipation) in a pediatric ED in Toronto, Canada, between November 2008 and October 2010. A total of 3592 visits were included; 6% (n = 225) were associated with a revisit. Children with revisits more frequently had vomiting (28% vs 17%, P = 0.001), more pain (5.7 ± 3.6 vs 4.6-3.6 of 10, P = 0.01), and underwent more blood tests (19% 05, 11%, 95% confidence interval [CI] of the difference 3%-14%] and diagnostic imaging (62% vs 47%, 95% CI of the difference 9%-22%). Children administered an enema were 1.54 times more likely to revisit the ED than those who did not receive an enema (8.6% vs 5.5%, 95% CI of the difference 1.1%-5.2%, P = 0.001). Type of enema administered varied by age (P < 0.001). Regression analysis identified the following independent predictors of revisits: diagnostic imaging (odds ratio [OR] 1.54, 95% CI 1.15-2.06), vomiting (OR 1.45, 95% CI 1.07-1.98), enema administration (OR 1.40, 95% CI 1.05-1.88), and significant medical history (OR 1.26, 95% CI 1.04-1.53). Enema administration and diagnostic imaging are associated with revisits in children diagnosed with constipation. Their role in the ED management of pediatric constipation requires further evaluation.

Frequent methamphetamine injection predicts emergency department utilization among street-involved youth

PubMed Central

Marshall, B.D.L.; Grafstein, E.; Buxton, J.A.; Qi, J.; Wood, E.; Shoveller, J.A.; Kerr, T.

2011-01-01

SUMMARY Objectives Methamphetamine (MA) use has been associated with health problems that commonly present in the emergency department (ED). This study sought to determine whether frequent MA injection was a risk factor for ED utilization among street-involved youth. Study design Prospective cohort study. Methods Data were derived from a street-involved youth cohort known as the ‘At Risk Youth Study’. Behavioural data including MA use were linked to ED records at a major inner-city hospital. Kaplan-Meier and Cox proportional hazards methods were used to determine the risk factors for ED utilization. Results Between September 2005 and January 2007, 427 eligible participants were enrolled, among whom the median age was 21 (interquartile range 19–23) years and 154 (36.1%) were female. Within 1 year, 163 (38.2%) visited the ED, resulting in an incidence density of 53.7 per 100 person-years. ED utilization was significantly higher among frequent (i.e. ≥daily) MA injectors (log-rank P=0.004). In multivariate analysis, frequent MA injection was associated with an increased hazard of ED utilization (adjusted hazard ratio=1.84, 95% confidence interval 1.04–3.25; P=0.036). Conclusions Street-involved youth who frequently inject MA appear to be at increased risk of ED utilization. The integration of MA-specific addiction treatment services within emergency care settings for high-risk youth is recommended. PMID:22133669

Coffee Intake and Incidence of Erectile Dysfunction.

PubMed

Lopez, David S; Liu, Lydia; Rimm, Eric B; Tsilidis, Konstantinos K; de Oliveira Otto, Marcia; Wang, Run; Canfield, Steven; Giovannucci, Edward

2018-05-01

Coffee intake is suggested to have a positive impact on chronic diseases, yet its role in urological diseases such as erectile dysfunction (ED) remains unclear. We investigated the association of coffee intake with incidence of ED by conducting the Health Professionals Follow-Up Study, a prospective analysis of 21,403 men aged 40-75 years old. Total, regular, and decaffeinated coffee intakes were self-reported on food frequency questionnaires. ED was assessed by mean values of questionnaires in 2000, 2004 and 2008. Multivariable adjusted Cox proportional hazards models were used to compute hazard ratios for patients with incident ED (n = 7,298). No significant differences were identified for patients with incident ED after comparing highest (≥4 cups/day) with lowest (0 cups/day) categories of total (hazard ratio (HR) = 1.00, 95% confidence interval (CI): 0.90, 1.11) and regular coffee intakes (HR = 1.00, 95% CI: 0.89, 1.13). When comparing the highest category with lowest category of decaffeinated coffee intake, we found a 37% increased risk of ED (HR = 1.37, 95% CI: 1.08, 1.73), with a significant trend (P trend = 0.02). Stratified analyses also showed an association among current smokers (P trend = 0.005). Overall, long-term coffee intake was not associated with risk of ED in a prospective cohort study.

The impact of unstable housing on emergency department use in a cohort of HIV-positive people in a Canadian setting

PubMed Central

Chan, Keith; Milan, David; Grafstein, Eric; Palmer, Alexis K.; Rhodes, Chelsey; Montaner, Julio S.G.; Hogg, Robert S.

2014-01-01

The social-structural challenges experienced by people living with HIV (PHA) have been shown to contribute to increased use of the Emergency Department (ED). This study identified factors associated with frequent and non-urgent ED use within a cohort of people accessing antiretroviral therapy (ART) in a Canadian setting. Interviewer-administered surveys collected socio-demographic information; clinical variables were obtained through linkages with the provincial drug treatment registry; and ED admission data were abstracted from the Department of Emergency Medicine database. Multivariate logistic regression was used to compute odds of frequent and non-urgent ED use. Unstable housing was independently associated with ED use (adjusted odds ratio [AOR]=1.94, 95% confidence interval [CI] 1.24–3.04]), having three or more ED visits within 6 months of interview date [AOR: 2.03 (95% CI: 1.07–3.83)] and being triaged as non-urgent (AOR=2.71, 95% CI: 1.19–6.17). Frequent and non-urgent use of the ED in this setting is associated with conditions requiring interventions at the social-structural level. Supportive housing may contribute to decreased healthcare costs and improved health outcomes amongst marginalized PHA. PMID:23656484

Is Transcellular Potassium Shifting With Insulin, Albuterol, or Sodium Bicarbonate in Emergency Department Patients With Hyperkalemia Associated With Recurrent Hyperkalemia After Dialysis?

PubMed

Driver, Brian E; Klein, Lauren R; Chittineni, Chaitanya; Cales, Ellen K; Scott, Nathaniel

2018-04-13

Emergency department (ED) treatment of hyperkalemia often involves shifting potassium into the intracellular space. There is uncertainty whether transcellular shifting causes insufficient potassium removal during hemodialysis, resulting in a subsequent need for further medical therapy or multiple sessions of hemodialysis. We sought to determine whether transcellular potassium shifting in ED patients with hyperkalemia who undergo hemodialysis is associated with recurrent hyperkalemia with or without repeat hemodialysis within 24 h. This was a retrospective observational study of ED patients with a potassium value > 5.3 mmol/L and ≥1 hemodialysis run. Transcellular shifting medications were defined as albuterol, insulin, and sodium bicarbonate. Primary outcomes were recurrent hyperkalemia with and without repeat hemodialysis within 24 h of the initial dialysis run. Generalized estimating equation models were created for the outcomes using administration of a shifting medication as the primary predictor. Four hundred seventy-nine encounters were identified. In 238 (50%) encounters, a shifting medication was administered. There were 85 outcomes of recurrent hyperkalemia and 36 outcomes of recurrent hyperkalemia with repeat hemodialysis. After adjustment, administration of shifting medications was not associated with recurrent hyperkalemia (adjusted odds ratio 1.26, 95% confidence interval 0.71-2.23) or recurrent hyperkalemia with repeat dialysis (adjusted odds ratio 1.90, 95% confidence interval 0.80-4.48). Administration of transcellular shifting medications for hyperkalemia in the ED was not associated with either recurrent hyperkalemia after hemodialysis or the need for a second dialysis session within 24 h. Our findings address the uncertainty regarding transcellular potassium shifting before emergent dialysis and support safe ED administration of medications that shift potassium to the intracellular space. Copyright © 2018 Elsevier Inc. All rights reserved.

Specialized survivor clinic attendance is associated with decreased rates of emergency department visits in adult survivors of childhood cancer.

PubMed

Sutradhar, Rinku; Agha, Mohammad; Pole, Jason D; Greenberg, Mark; Guttmann, Astrid; Hodgson, David; Nathan, Paul C

2015-12-15

Survivors of childhood cancer are at considerable risk of experiencing treatment-related adverse health outcomes. To provide survivors with specialized care focused on these risks during adulthood, the government of Ontario funded a provincial network of specialized survivor clinics in 1999. The aim of this study was to determine whether prior attendance at survivor clinics by adult survivors of childhood cancer was associated with rates of emergency department (ED) visits. This was a population-based, retrospective cohort study using multiple linked administrative health databases. The cohort consisted of all adult survivors of childhood cancer diagnosed between January 1, 1986 and December 31, 2005 in Ontario, Canada. A recurrent event regression model was used to evaluate the association between prior attendance at survivor clinics and the rate of ED visits; adjustments were made for individual, demographic, treatment, and provider characteristics. The study consisted of 3912 adult survivors of childhood cancer. Individuals who had at least 1 prior visit to a survivor clinic had a 19% decreased rate of ED visits in comparison with individuals who had not visited a survivor clinic (adjusted relative rate, 0.81; 95% confidence interval, 0.78-0.85). Each additional prior visit to a survivor clinic was associated with a 5% decrease in the rate of ED visits (adjusted relative rate, 0.95; 95% confidence interval, 0.93-0.96). These results were independent of whether or not survivors received care from a primary care physician. Attendance at a specialized survivor clinic was significantly associated with decreased ED visits among adult survivors of childhood cancer. © 2015 American Cancer Society.

The effect of electronic health record implementation on community emergency department operational measures of performance.

PubMed

Ward, Michael J; Landman, Adam B; Case, Karen; Berthelot, Jessica; Pilgrim, Randy L; Pines, Jesse M

2014-06-01

We study the effect of an emergency department (ED) electronic health record implementation on the operational metrics of a diverse group of community EDs. We performed a retrospective before/after analysis of 23 EDs from a single management group that experienced ED electronic health record implementation (with the majority of electronic health records optimized specifically for ED use). We obtained electronic data for 4 length of stay measures (arrival to provider, admitted, discharged, and overall length of stay) and 4 measures of operational characteristics (left before treatment complete, significant returns, overall patient satisfaction, and provider efficiency). We compared the 6-month "baseline" period immediately before implementation with a "steady-state" period commencing 6 months after implementation for all 8 metrics. For the length of stay measures, there were no differences in the arrival-to-provider interval (difference of -0.02 hours; 95% confidence interval [CI] of difference -0.12 to 0.08), admitted length of stay (difference of 0.10 hours; 95% CI of difference -0.17 to 0.37), discharged length of stay (difference of 0.07 hours; 95% CI of difference -0.07 to 0.22), and overall length of stay (difference of 0.11 hours; 95% CI of difference -0.04 to 0.27). For operational characteristics, there were no differences in the percentage who left before treatment was complete (difference of 0.24%; 95% CI of difference -0.47% to 0.95%), significant returns (difference of -0.04%; 95% CI of difference -0.48% to 0.39%), overall percentile patient satisfaction (difference of -0.02%; 95% CI of difference -2.35% to 2.30%), and provider efficiency (difference of -0.05 patients/hour; 95% CI of difference -0.11 to 0.02). There is no meaningful difference in 8 measures of operational performance for community EDs experiencing optimized ED electronic health record implementation between a baseline and steady-state period. Copyright © 2014 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Impact of Standardizing Management of Atrial Fibrillation with Rapid Heart Rate in the Emergency Department

PubMed Central

de Leon, Ernesto; Duan, Lewei; Rippenberger, Ellen; Sharp, Adam L

2018-01-01

Context There is substantial variation in the emergency treatment of atrial fibrillation with tachycardia. A standardized treatment approach at an academic center decreased admissions without adverse outcomes, but this approach has not been evaluated in a community Emergency Department (ED). Objective To evaluate the implementation of a standardized treatment guideline for patients with atrial fibrillation and a rapid heart rate in a community ED. Design An observational pre-/postimplementation (August 2013 to July 2014 and August 2014 to July 2015, respectively) study at a community ED. The standardized treatment guideline encouraged early oral treatment with rate control medication, outpatient echocardiogram, and early follow-up. A multiple logistic regression model adjusting for patient characteristics was generated to investigate the association between the intervention and ED discharge rate. Main Outcome Measures The primary measure was ED discharge. Secondary measures included stroke or death, ED return visit, hospital readmission, length of stay, and use of oral rate control medications. Results A total of 199 (104 pre/95 post) ED encounters were evaluated. The ED discharge rate increased 14% after intervention (57.7% to 71.6%, p = 0.04), and use of rate control medications increased by 19.4% (p < 0.01). Adjusted multivariate results showed a nearly 2-fold likelihood of ED discharge after guideline implementation (odds ratio = 1.97, 95%confidence interval = 1.07–3.63). Length of stay, return visits, and hospital readmissionswere similar. Conclusion A standardized approach to ED patients with atrial fibrillation and tachycardia is associated with a decrease in hospital admissions without adversely affecting patient safety. PMID:29401054

Joint Effects of Ambient Air Pollutants on Pediatric Asthma ...

EPA Pesticide Factsheets

Background: Because ambient air pollution exposure occurs in the form of mixtures, consideration of joint effects of multiple pollutants may advance our understanding of air pollution health effects. Methods: We assessed the joint effect of selected ambient air pollutant combinations (groups of oxidant, secondary, traffic, power plant, and criteria pollutants constructed using combinations of criteria gases, fine particulate matter (PM2.5) and PM2.5 components) on warm season pediatric asthma emergency department (ED) visits in Atlanta during 1998-2004. Joint effects were assessed using multi-pollutant Poisson generalized linear models controlling for time trends, meteorology and daily non-asthma respiratory ED visit counts. Rate ratios (RR) were calculated for the combined effect of an interquartile-range increment in the concentration of each pollutant. Results: Increases in all of the selected pollutant combinations were associated with increases in pediatric asthma ED visits [e.g., joint effect rate ratio=1.13 (95% confidence interval 1.06-1.21) for criteria pollutants (including ozone, carbon monoxide, nitrogen dioxide, sulfur dioxide, and PM2.5)]. Joint effect estimates were smaller than estimates calculated based on summing results from single-pollutant models, due to control for confounding. Compared with models without interactions, joint effect estimates from models including first-order pollutant interactions were similar for oxidant a

A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients.

PubMed

Fox, Timothy R; Li, James; Stevens, Sandra; Tippie, Tracy

2013-09-01

In an effort to reduce prescription opioid abuse originating from our institution, we implement and measure the effect of a prescribing guideline on the rate of emergency department (ED) opioid prescriptions written for patients presenting with dental pain, a complaint previously associated with drug-seeking behavior. After implementing a departmental guideline on controlled substance prescriptions, we performed a structured before-and-after chart review of dental pain patients aged 16 and older. Before the guideline, the rate of opioid prescription was 59% (302/515). After implementation, the rate was 42% (65/153). The absolute decrease in rates was 17% (95% confidence interval 7% to 25%). Additionally, in comparing the 12-month period before and after implementation, the dental pain visit rate decreased from 26 to 21 per 1,000 ED visits (95% confidence interval of decrease 2 to 9 visits/1,000). A performance improvement program involving a departmental prescribing guideline was associated with a reduction in the rate of opioid prescriptions and visits for ED patients presenting with dental pain. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Emergency Department Visits for Nontraumatic Dental Problems: A Mixed-Methods Study

PubMed Central

Chi, Donald L.; Schwarz, Eli; Milgrom, Peter; Yagapen, Annick; Malveau, Susan; Chen, Zunqui; Chan, Ben; Danner, Sankirtana; Owen, Erin; Morton, Vickie; Lowe, Robert A.

2015-01-01

Objectives. We documented emergency department (ED) visits for nontraumatic dental problems and identified strategies to reduce ED dental visits. Methods. We used mixed methods to analyze claims in 2010 from a purposive sample of 25 Oregon hospitals and Oregon’s All Payer All Claims data set and interviewed 51 ED dental visitors and stakeholders from 6 communities. Results. Dental visits accounted for 2.5% of ED visits and represented the second-most-common discharge diagnosis in adults aged 20 to 39 years, were associated with being uninsured (odds ratio [OR] = 5.2 [reference: commercial insurance]; 95% confidence interval [CI] = 4.8, 5.5) or having Medicaid insurance (OR = 4.0; 95% CI = 3.7, 4.2), resulted in opioid (56%) and antibiotic (56%) prescriptions, and generated $402 (95% CI = $396, $408) in hospital costs per visit. Interviews revealed health system, community, provider, and patient contributors to ED dental visits. Potential solutions provided by interviewees included Medicaid benefit expansion, care coordination, water fluoridation, and patient education. Conclusions. Emergency department dental visits are a significant and costly public health problem for vulnerable individuals. Future efforts should focus on implementing multilevel interventions to reduce ED dental visits. PMID:25790415

Emergency Department Use and Risk Factors among Deaf American Sign Language Users

PubMed Central

McKee, Michael M.; Winters, Paul C.; Sen, Ananda; Zazove, Philip; Fiscella, Kevin

2015-01-01

Background Deaf American Sign Language (ASL) users comprise a linguistic minority population with poor health care access due to communication barriers and low health literacy. Potentially, these health care barriers could increase Emergency Department (ED) use. Objective To compare ED use between deaf and non-deaf patients. Method A retrospective cohort from medical records. The sample was derived from 400 randomly selected charts (200 deaf ASL users and 200 hearing English speakers) from an outpatient primary care health center with a high volume of deaf patients. Abstracted data included patient demographics, insurance, health behavior, and ED use in the past 36 months. Results Deaf patients were more likely to be never smokers and be insured through Medicaid. In an adjusted analysis, deaf individuals were significantly more likely to use the ED (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.11–3.51) over the prior 36 months. Conclusion Deaf American Sign Language users appear to be at greater odds for elevated ED utilization when compared to the general hearing population. Efforts to further understand the drivers for increased ED utilization among deaf ASL users are much needed. PMID:26166160

Emergency Department utilization among Deaf American Sign Language users.

PubMed

McKee, Michael M; Winters, Paul C; Sen, Ananda; Zazove, Philip; Fiscella, Kevin

2015-10-01

Deaf American Sign Language (ASL) users comprise a linguistic minority population with poor health care access due to communication barriers and low health literacy. Potentially, these health care barriers could increase Emergency Department (ED) use. To compare ED use between deaf and non-deaf patients. A retrospective cohort from medical records. The sample was derived from 400 randomly selected charts (200 deaf ASL users and 200 hearing English speakers) from an outpatient primary care health center with a high volume of deaf patients. Abstracted data included patient demographics, insurance, health behavior, and ED use in the past 36 months. Deaf patients were more likely to be never smokers and be insured through Medicaid. In an adjusted analysis, deaf individuals were significantly more likely to use the ED (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.11-3.51) over the prior 36 months. Deaf American Sign Language users appear to be at greater odds for elevated ED utilization when compared to the general hearing population. Efforts to further understand the drivers for increased ED utilization among deaf ASL users are much needed. Copyright © 2015 Elsevier Inc. All rights reserved.

Association between coronary heart disease and erectile dysfunction in Chinese Han population

PubMed Central

Tian, Guo-Xiang; Li, Sheng; Liu, Tong-Zu; Zeng, Xian-Tao; Wei, Wan-Lin; Wang, Xing-Huan

2017-01-01

To investigate the association between coronary heart disease (CHD) and erectile dysfunction (ED) in Chinese Han population. Patients who went to the andrological out-patient clinic of our hospital between August 1, 2015 and May 1, 2016 and met all eligible criteria were enrolled in this study. The patients diagnosed as ED using self-administered International Index of Erectile Function-5 (IIEF-5) questionnaire were considered as case group and others were considered as control. The cases were categorized as mild, moderate, and severe ED. Subjects were interviewed for the history of CHD. Uni- and multivariate logistic regression models were used to calculate odds ratios (ORs) and corresponding 95% confidence intervals (CIs) using the SPSS 18.0 software. A total of 240 participants (56 ED patients and 184 controls) were enrolled. CHD prevalence was higher in cases without statistical significance (OR = 1.20, 95%CI = 0.63-2.29; p = 0.58). Results of adjusted analysis also showed a non-significantly increased risk (OR = 1.25, 95%CI = 0.55-2.85; p = 0.59). Stratified analysis by severity of ED revealed similar results. This study suggests no significant association exists between CHD and ED in Chinese Han population. PMID:28903442

The Cost-Effectiveness of School-Based Eating Disorder Screening

PubMed Central

Austin, S. Bryn; LeAnn Noh, H.; Jiang, Yushan; Sonneville, Kendrin R.

2014-01-01

Objectives. We aimed to assess the value of school-based eating disorder (ED) screening for a hypothetical cohort of US public school students. Methods. We used a decision-analytic microsimulation model to model the effectiveness (life-years with ED and quality-adjusted life-years [QALYs]), total direct costs, and cost-effectiveness (cost per QALY gained) of screening relative to current practice. Results. The screening strategy cost $2260 (95% confidence interval [CI] = $1892, $2668) per student and resulted in a per capita gain of 0.25 fewer life-years with ED (95% CI = 0.21, 0.30) and 0.04 QALYs (95% CI = 0.03, 0.05) relative to current practice. The base case cost-effectiveness of the intervention was $9041 per life-year with ED avoided (95% CI = $6617, $12 344) and $56 500 per QALY gained (95% CI = $38 805, $71 250). Conclusions. At willingness-to-pay thresholds of $50 000 and $100 000 per QALY gained, school-based ED screening is 41% and 100% likely to be cost-effective, respectively. The cost-effectiveness of ED screening is comparable to many other accepted pediatric health interventions, including hypertension screening. PMID:25033131

Is there a relationship between chronic periodontitis and erectile dysfunction?

PubMed

Oğuz, Fatih; Eltas, Abubekir; Beytur, Ali; Akdemir, Ender; Uslu, Mustafa Özay; Güneş, Ali

2013-03-01

Chronic periodontitis (CP) is characterized with inflammation of the gingival tissues, which causes endothelial dysfunction in different organs. In this study, we investigated the association of CP with the erectile dysfunction (ED). The study group included 80 male patients with ED and 82 male patients without ED (control), aged between 30 and 40 years. The International Index of Erectile Function (IIEF) questionnaire was used to assess male sexual function, particularly the presence or absence of ED. The patients in the study and control groups were statistically compared according to their plaque index (PI), bleeding on probing (BoP), probing depth (PD), and clinical attachment level (CAL). In the non-ED and the ED groups, the mean age was 35.7 ± 4.8 and 34.9 ± 4.9 years, respectively. Patients' characteristics including body mass index, household income, and education status were similar in both groups (P > 0.05). Nineteen patients (23%) had severe CP in the non-ED group; 42 patients (53%) had severe CP in the ED group. Logistic regression analysis showed a significantly high association between ED and the severity of CP (odds ratio: 3.29, 95% confidence interval: 1.36-9.55, P < 0.01). The mean values of PI, BoP, and the percentages of sites with PD >4 mm and sites with CAL >4 mm were significantly higher in the ED group than in the control group (P < 0.05). The mean values of PD and CAL were not significantly different in the two groups (P > 0.05). The decayed, missing, filled teeth scores were also significantly higher in the ED group than in the non-ED group (P < 0.05).   Our results have suggested that CP had a high association with ED in young adults at 30-40 years. We think that it will be of benefit to consider periodontal disease as a causative clinical condition of ED in such patients. © 2012 International Society for Sexual Medicine.

Characterizing New England Emergency Departments by Telemedicine Use.

PubMed

Zachrison, Kori S; Hayden, Emily M; Schwamm, Lee H; Espinola, Janice A; Sullivan, Ashley F; Boggs, Krislyn M; Raja, Ali S; Camargo, Carlos A

2017-10-01

Telemedicine connects emergency departments (ED) with resources necessary for patient care; its use has not been characterized nationally, or even regionally. Our primary objective was to describe the prevalence of telemedicine use in New England EDs and the clinical applications of use. Secondarily, we aimed to determine if telemedicine use was associated with consultant availability and to identify ED characteristics associated with telemedicine use. We analyzed data from the National Emergency Department Inventory-New England survey, which assessed basic ED characteristics in 2014. The survey queried directors of every ED (n=195) in the six New England states (excluding federal hospitals and college infirmaries). Descriptive statistics characterized ED telemedicine use; multivariable logistic regression identified independent predictors of use. Of the 169 responding EDs (87% response rate), 82 (49%) reported using telemedicine. Telemedicine EDs were more likely to be rural (18% of users vs. 7% of non-users, p=0.03); less likely to be academic (1% of users vs. 11% of non-users, p=0.01); and less likely to have 24/7 access to neurology (p<0.001), neurosurgery (p<0.001), orthopedics (p=0.01), plastic surgery (p=0.01), psychiatry (p<0.001), and hand surgery (p<0.001) consultants. Neuro/stroke (68%), pediatrics (11%), psychiatry (11%), and trauma (10%) were the most commonly reported applications. On multivariable analysis, telemedicine was more likely in rural EDs (odds ratio [OR] 4.39, 95% confidence interval [CI] 1.30-14.86), and less likely in EDs with 24/7 neurologist availability (OR 0.21, 95% CI [0.09-0.49]), and annual volume <20,000 (OR 0.24, 95% CI [0.08-0.68]). Telemedicine is commonly used in New England EDs. In 2014, use was more common among rural EDs and EDs with limited neurology consultant availability. In contrast, telemedicine use was less common among very low-volume EDs.

Sex-related Differences in Emergency Department Renal Colic Management: Females Have Fewer Computed Tomography Scans but Similar Outcomes.

PubMed

Innes, Grant D; Scheuermeyer, Frank X; Law, Michael R; McRae, Andrew D; Weber, Bryce A; Boyda, Heidi N; Lonergan, Kevin; Andruchow, James E

2016-10-01

Sex-related differences occur in many areas of medicine. Emergency department (ED) studies have suggested differences in access to care, diagnostic imaging use, pain management, and intervention. We investigated sex-based differences in the care and outcomes for ED patients with acute renal colic. This was a multicenter population-based retrospective observational cohort study using administrative data and supplemented by structured chart review. All patients seen in Calgary Health Region EDs between January 1 and December 31, 2014, with an ED diagnosis of renal colic based on the following ICD-10 codes were eligible for inclusion: calculus of kidney (N200), calculus of ureter (N201), calculus of kidney with calculus of ureter (N202), hydronephrosis with renal and ureteral calculous obstruction (N132), unspecified renal colic (N23), and unspecified urinary calculus (N209). ED visit data and test results were accessed in the regional ED clinical database. Stone characteristics were captured from diagnostic imaging reports. Regional hospital databases were used to identify subsequent ED encounters, hospital admissions, and surgical procedures within 60 days. Outcomes were stratified by sex. The primary outcome, intended as a marker of overall effectiveness of ED care, was the unscheduled 7-day ED revisit rate among patients who were discharged home after their index ED visit. Secondary outcomes included ED pain management as reflected by administration of narcotics or intravenous nonsteroidals, the performance of advanced imaging-either ultrasound (US) or computed tomography (CT), and the proportion of patients who required hospitalization or surgical intervention within 60 days. From January 1 to December 31, 2014, a total of 3,104 eligible patients were studied: 1,111 women (35.8%) and 1,993 men (64.2%). Baseline characteristics, access times, analgesic use, and admission rates were similar in both groups. Men were more likely to have CT (68.9% vs. 58.5%, difference = 10.4%, 95% confidence interval [CI] = 6.8 to 14.0) while women were more likely to have US (20.8% vs. 9.6%, difference = 11.2%, 95% CI = 8.4 to 13.9). At 7 days, 17.9% of women and 19.0% of men who were discharged after their index ED visit required an ED revisit (difference = 1.1%, 95% CI = -2.8 to 4.9). Men were more likely to be hospitalized at 7 days (9.8% vs. 6.5%, difference = 3.3%, 95% CI = 0.6 to 6.0). This study shows greater reliance on US in females but no other sex-specific differences in the management of ED patients with acute renal colic. Higher CT use in men was not associated with improved outcomes, and we found no important differences in access to care, diagnostic or treatment intensity, or revisit rates as a marker of care effectiveness. © 2016 by the Society for Academic Emergency Medicine.

US Emergency Department Trends in Imaging for Pediatric Nontraumatic Abdominal Pain.

PubMed

Niles, Lauren M; Goyal, Monika K; Badolato, Gia M; Chamberlain, James M; Cohen, Joanna S

2017-10-01

To describe national emergency department (ED) trends in computed tomography (CT) and ultrasound imaging for the evaluation of pediatric nontraumatic abdominal pain from 2007 through 2014. We used data from the National Hospital Ambulatory Medical Care Survey to measure trends in CT and ultrasound use among children with nontraumatic abdominal pain. We performed multivariable logistic regression to measure the strength of the association of ED type (pediatric versus general ED) with CT and ultrasound use adjusting for potential confounding variables. Of an estimated 21.1 million ED visits for nontraumatic abdominal pain, 14.6% (95% confidence interval [CI], 13.2%-16.0%) had CT imaging only, 10.9% (95% CI, 9.7%-12.1%) had ultrasound imaging only, and 1.9% (95% CI, 1.4%-2.4%) received both CT and ultrasound. The overall use of CT and ultrasound did not significantly change over the study period ( P trend .63 and .90, respectively). CT use was lower among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 0.34; 95% CI, 0.17-0.69). Conversely, ultrasound use was higher among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 2.14; 95% CI, 1.29-3.55). CT imaging for pediatric patients with nontraumatic abdominal pain has plateaued since 2007 after the steady increase seen in the preceding 9 years. Among this population, an increased likelihood of CT imaging was demonstrated in general EDs compared with pediatric EDs, in which there was a higher likelihood of ultrasound imaging. Dissemination of pediatric-focused radiology protocols to general EDs may help optimize radiation exposure in children. Copyright © 2017 by the American Academy of Pediatrics.

Implementation of an emergency department atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation, reduces length of stay and thirty-day revisit rates for congestive heart failure.

PubMed

Barbic, David; DeWitt, Chris; Harris, Devin; Stenstrom, Robert; Grafstein, Eric; Wu, Crane; Vadeanu, Cristian; Heilbron, Brett; Haaf, Jenelle; Tung, Stanley; Kalla, Dan; Marsden, Julian; Christenson, Jim; Scheuermeyer, Frank

2018-05-01

An evidence-based emergency department (ED) atrial fibrillation and flutter (AFF) pathway was developed to improve care. The primary objective was to measure rates of new anticoagulation (AC) on ED discharge for AFF patients who were not AC correctly upon presentation. This is a pre-post evaluation from April to December 2013 measuring the impact of our pathway on rates of new AC and other performance measures in patients with uncomplicated AFF solely managed by emergency physicians. A standardized chart review identified demographics, comorbidities, and ED treatments. The primary outcome was the rate of new AC. Secondary outcomes were ED length of stay (LOS), referrals to AFF clinic, ED revisit rates, and 30-day rates of return visits for congestive heart failure (CHF), stroke, major bleeding, and death. ED AFF patients totalling 301 (129 pre-pathway [PRE]; 172 post-pathway [POST]) were included; baseline demographics were similar between groups. The rates of AC at ED presentation were 18.6% (PRE) and 19.7% (POST). The rates of new AC on ED discharge were 48.6 % PRE (95% confidence interval [CI] 42.1%-55.1%) and 70.2% POST (62.1%-78.3%) (20.6% [p<0.01; 15.1-26.3]). Median ED LOS decreased from 262 to 218 minutes (44 minutes [p<0.03; 36.2-51.8]). Thirty-day rates of ED revisits for CHF decreased from 13.2% to 2.3% (10.9%; p<0.01; 8.1%-13.7%), and rates of other measures were similar. The evidence-based pathway led to an improvement in the rate of patients with new AC upon discharge, a reduction in ED LOS, and decreased revisit rates for CHF.

Parental language and dosing errors after discharge from the pediatric emergency department.

PubMed

Samuels-Kalow, Margaret E; Stack, Anne M; Porter, Stephen C

2013-09-01

Safe and effective care after discharge requires parental education in the pediatric emergency department (ED). Parent-provider communication may be more difficult with parents who have limited health literacy or English-language fluency. This study examined the relationship between language and discharge comprehension regarding medication dosing. We completed a prospective observational study of the ED discharge process using a convenience sample of English- and Spanish-speaking parents of children 2 to 24 months presenting to a single tertiary care pediatric ED with fever and/or respiratory illness. A bilingual research assistant interviewed parents to ascertain their primary language and health literacy and observed the discharge process. The primary outcome was parental demonstration of an incorrect dose of acetaminophen for the weight of his or her child. A total of 259 parent-child dyads were screened. There were 210 potential discharges, and 145 (69%) of 210 completed the postdischarge interview. Forty-six parents (32%) had an acetaminophen dosing error. Spanish-speaking parents were significantly more likely to have a dosing error (odds ratio, 3.7; 95% confidence interval, 1.6-8.1), even after adjustment for language of discharge, income, and parental health literacy (adjusted odds ratio, 6.7; 95% confidence interval, 1.4-31.7). Current ED discharge communication results in a significant disparity between English- and Spanish-speaking parents' comprehension of a crucial aspect of medication safety. These differences were not explained purely by interpretation, suggesting that interventions to improve comprehension must address factors beyond language alone.

Adult emergency department patients with sickle cell pain crisis: a learning collaborative model to improve analgesic management.

PubMed

Tanabe, Paula; Artz, Nicole; Mark Courtney, D; Martinovich, Zoran; Weiss, Kevin B; Zvirbulis, Elena; Hafner, John W

2010-04-01

The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative. A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data. A total of 155 patients met study criteria (median age = 32 years, IQR = 24-40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48-135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean +/- SD = 4.19 +/- 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean +/- SD = 5.77 +/- 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43). While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable.

Measures of crowding in the emergency department: a systematic review.

PubMed

Hwang, Ula; McCarthy, Melissa L; Aronsky, Dominik; Asplin, Brent; Crane, Peter W; Craven, Catherine K; Epstein, Stephen K; Fee, Christopher; Handel, Daniel A; Pines, Jesse M; Rathlev, Niels K; Schafermeyer, Robert W; Zwemer, Frank L; Bernstein, Steven L

2011-05-01

Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity. This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that "describe the theory, development, implementation, evaluation, or any other aspect of a 'crowding measurement/definition' instrument (qualitative or quantitative)" were included. A "measurement/definition" instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other). There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria. Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this "crowded" field of measures. © 2011 by the Society for Academic Emergency Medicine.

Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations.

PubMed

Moreira, Maria E; Hernandez, Caleb; Stevens, Allen D; Jones, Seth; Sande, Margaret; Blumen, Jason R; Hopkins, Emily; Bakes, Katherine; Haukoos, Jason S

2015-08-01

The Institute of Medicine has called on the US health care system to identify and reduce medical errors. Unfortunately, medication dosing errors remain commonplace and may result in potentially life-threatening outcomes, particularly for pediatric patients when dosing requires weight-based calculations. Novel medication delivery systems that may reduce dosing errors resonate with national health care priorities. Our goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared with conventional medication administration, in simulated pediatric emergency department (ED) resuscitation scenarios. We performed a prospective, block-randomized, crossover study in which 10 emergency physician and nurse teams managed 2 simulated pediatric arrest scenarios in situ, using either prefilled, color-coded syringes (intervention) or conventional drug administration methods (control). The ED resuscitation room and the intravenous medication port were video recorded during the simulations. Data were extracted from video review by blinded, independent reviewers. Median time to delivery of all doses for the conventional and color-coded delivery groups was 47 seconds (95% confidence interval [CI] 40 to 53 seconds) and 19 seconds (95% CI 18 to 20 seconds), respectively (difference=27 seconds; 95% CI 21 to 33 seconds). With the conventional method, 118 doses were administered, with 20 critical dosing errors (17%); with the color-coded method, 123 doses were administered, with 0 critical dosing errors (difference=17%; 95% CI 4% to 30%). A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by emergency physician and nurse teams during simulated pediatric ED resuscitations. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Genital image, sexual anxiety, and erectile dysfunction among young male military personnel.

PubMed

Wilcox, Sherrie L; Redmond, Sarah; Davis, Teaniese L

2015-06-01

More than a third of young military personnel report experiencing some level of erectile dysfunction (ED). Preoccupation with body image, particularly genitals, is a distraction that can influence sexual anxiety (SA) and sexual functioning problems (SFPs), particularly ED. This study assessed the relationships between male genital self-image (MGSI), SA, and ED in a sample of male military personnel age 40 or younger. Data were from a larger study on SFPs in military populations. This sample consisted of 367 male military personnel age 40 or younger. Hierarchical regression analyses and process modeling using mediation analysis were performed to examine the effects of MGSI on ED with SA as an intermediate variable. We predicted that SA would mediate the relationship between MGSI and ED. ED severity was assessed with the International Index of Erectile Function. MGSI was assessed using the MGSI Scale. SA was assessed with the SA subscale of the Sexual Needs Scale. As hypothesized, greater satisfaction with MGSI was predictive of significantly lower SA (F[8, 352] = 4.07, P = 0.001) and lower ED (F[8, 352] = 13.20, P = 0.001). Lower levels of SA were predictive of lower levels of ED (F[8, 354] = 21.35, P < 0.001). Additionally, results also revealed a significant indirect effect of MGSI on ED through SA (b = -0.07, standard error = 0.03, confidence interval = [-0.14,-0.02], P < 0.05), indicating mediation of MGSI on ED via SA. This study underscores the complex etiologic basis of SFPs, particularly ED, and highlights the importance of considering psychologic contributors to ED, such as SA and MGSI. Strategies aimed at reducing SA may be useful in improving ED in young military populations and are worth considering as complements to strategies that improve SFPs. © 2015 International Society for Sexual Medicine.

Estimates of electronic medical records in U.S. Emergency departments.

PubMed

Geisler, Benjamin P; Schuur, Jeremiah D; Pallin, Daniel J

2010-02-17

Policymakers advocate universal electronic medical records (EMRs) and propose incentives for "meaningful use" of EMRs. Though emergency departments (EDs) are particularly sensitive to the benefits and unintended consequences of EMR adoption, surveillance has been limited. We analyze data from a nationally representative sample of US EDs to ascertain the adoption of various EMR functionalities. We analyzed data from the National Hospital Ambulatory Medical Care Survey, after pooling data from 2005 and 2006, reporting proportions with 95% confidence intervals (95% CI). In addition to reporting adoption of various EMR functionalities, we used logistic regression to ascertain patient and hospital characteristics predicting "meaningful use," defined as a "basic" system (managing demographic information, computerized provider order entry, and lab and imaging results). We found that 46% (95% CI 39-53%) of US EDs reported having adopted EMRs. Computerized provider order entry was present in 21% (95% CI 16-27%), and only 15% (95% CI 10-20%) had warnings for drug interactions or contraindications. The "basic" definition of "meaningful use" was met by 17% (95% CI 13-21%) of EDs. Rural EDs were substantially less likely to have a "basic" EMR system than urban EDs (odds ratio 0.19, 95% CI 0.06-0.57, p = 0.003), and Midwestern (odds ratio 0.37, 95% CI 0.16-0.84, p = 0.018) and Southern (odds ratio 0.47, 95% CI 0.26-0.84, p = 0.011) EDs were substantially less likely than Northeastern EDs to have a "basic" system. EMRs are becoming more prevalent in US EDs, though only a minority use EMRs in a "meaningful" way, no matter how "meaningful" is defined. Rural EDs are less likely to have an EMR than metropolitan EDs, and Midwestern and Southern EDs are less likely to have an EMR than Northeastern EDs. We discuss the nuances of how to define "meaningful use," and the importance of considering not only adoption, but also full implementation and consequences.

Burden of uncontrolled epilepsy in patients requiring an emergency room visit or hospitalization.

PubMed

Manjunath, Ranjani; Paradis, Pierre Emmanuel; Parisé, Hélène; Lafeuille, Marie-Hélène; Bowers, Brian; Duh, Mei Sheng; Lefebvre, Patrick; Faught, Edward

2012-10-30

To quantify the clinical and economic burden of uncontrolled epilepsy in patients requiring emergency department (ED) visit or hospitalization. Health insurance claims from a 5-state Medicaid database (1997Q1-2009Q2) and 55 self-insured US companies ("employer," 1999Q1 and 2008Q4) were analyzed. Adult patients with epilepsy receiving antiepileptic drugs (AED) were selected. Using a retrospective matched-cohort design, patients were categorized into cohorts of "uncontrolled" (≥ 2 changes in AED therapy, then ≥ 1 epilepsy-related ED visit/hospitalization within 1 year) and "well-controlled" (no AED change, no epilepsy-related ED visit/hospitalization) epilepsy. Matched cohorts were compared for health care resource utilization and costs using multivariate conditional regression models and nonparametric methods. From 110,312 (Medicaid) and 36,529 (employer) eligible patients, 3,454 and 602 with uncontrolled epilepsy were matched 1:1 to patients with well-controlled epilepsy, respectively. In both populations, uncontrolled epilepsy cohorts presented about 2 times more fractures and head injuries (all p values < 0.0001) and higher health care resource utilization (ranges of adjusted incidence rate ratios [IRRs] [all-cause utilization]: AEDs = 1.8-1.9, non-AEDs = 1.3-1.5, hospitalizations = 5.4-6.7, length of hospital stays = 7.3-7.7, ED visits = 3.7-5.0, outpatient visits = 1.4-1.7, neurologist visits = 2.3-3.1; all p values < 0.0001) than well-controlled groups. Total direct health care costs were higher in patients with uncontrolled epilepsy (adjusted cost difference [95% confidence interval (CI)] Medicaid = $12,258 [$10,482-$14,083]; employer = $14,582 [$12,019-$17,097]) vs well-controlled patients. Privately insured employees with uncontrolled epilepsy lost 2.5 times more work days, with associated indirect costs of $2,857 (95% CI $1,042-$4,581). Uncontrolled epilepsy in patients requiring ED visit or hospitalization was associated with significantly greater health care resource utilization and increased direct and indirect costs compared to well-controlled epilepsy in both publicly and privately insured settings.

Association of emergency department albuterol dispensing with pediatric asthma revisits and readmissions.

PubMed

Hall, A Brad; Novotny, April; Bhisitkul, Donna M; Melton, James; Regan, Tim; Leckie, Maureen

2017-06-01

Although pediatric asthma continues to be a highly studied disease, data to suggest clear strategies to decrease asthma related revisits or readmissions is lacking. The purpose of our study was to assess the effect of emergency department (ED) direct dispensing of beta-agonist metered dose inhalers on pediatric asthma ED revisit and readmission rates. We conducted a retrospective cohort study of pediatric patients discharged from the pediatric ED with a diagnosis of asthma. Our primary outcome measured the rate of asthma revisits to the ED or admissions to the hospital within 28 days. Logistic regression analysis was used to assess ED beta-agonist MDI dispensing and revisit and/or readmission as the outcome. A total of 853 patients met eligibility for inclusion in the study, with 657 enrolled in the Baseline group and 196 enrolled in the ED-MDI group. The Baseline group experienced a revisit and readmission rate of 7.0% (46/657) versus 2.6% (5/196) in the ED-MDI group, (p = 0.026). ED direct dispensing of MDIs was found to be independently associated with a decreased risk of revisit or readmission (odds ratio 0.37; 95% confidence interval 0.14-0.95). In our study, ED direct dispensing of beta-agonist MDIs resulted in a reduction in 28-day revisit and readmission to the hospital. Further studies should be performed to evaluate the economic impact of reducing these revisits and readmissions against the costs of maintaining a dispensing program. Our findings may support modification of asthma programs to include dispensing MDIs from the emergency department.

Characteristics of COPD Patients Using United States Emergency Care or Hospitalization

PubMed Central

Kumbhare, Suchit D.; Beiko, Tatsiana; Wilcox, Susan R.; Strange, Charlie

2016-01-01

Rationale: Several chronic obstructive pulmonary disease (COPD) studies have evaluated risk factors for emergency department (ED) visits or hospitalizations, and found insufficient data available about social and demographic factors that drive these behaviors. This U.S. study was designed to describe the characteristics of COPD patients with ED visits or a hospitalization and to investigate how often common COPD comorbidities are present in these individuals. Methods: Data for 7180 COPD patients regarding demographic factors, comorbidities, smoking status, and ED visits or hospitalization was obtained from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. Logistic regression analysis was used to adjust demographic factors and smoking status to model the correlation between patients with ED visits or hospitalizations and morbidities generating odds ratios (OR) and confidence intervals (CI). Results: Among diagnosed COPD patients in the BRFSS, 16.5% had ED visits or hospitalization in the previous year. These individuals were younger, had a lower socio-economic status (lower education, lower income, and more often unemployed) and 23.4% of the individuals could not visit a doctor because of the financial difficulties compared to 16.7% who had no visit (p<0.0001 for all comparisons). The prevalence of comorbidities was higher in those with ED visits or hospitalization compared to those without. Conclusion: In a population representative of COPD patients, lower socio-economic status and higher comorbidities are associated with ED visits or hospitalization. Studies are needed to further elucidate the complex relationship between COPD, comorbidities, and ED visits or hospitalization. PMID:28848878

A twin study of erectile dysfunction.

PubMed

Fischer, Mary E; Vitek, Mary Ellen; Hedeker, Don; Henderson, William G; Jacobsen, Steven J; Goldberg, Jack

2004-01-26

The extent of genetic influence on erectile dysfunction (ED) is unknown. This study determines the contribution of heredity to ED in a sample of middle-aged men. A classical twin study was conducted in the Vietnam Era Twin Registry, a national sample of male-male pairs (mean birth year, 1949) who served on active duty during the Vietnam era (1965-1975). A 1999 male health survey was completed by 890 monozygotic (MZ) and 619 dizygotic (DZ) pairs. The prevalence and heritability of 2 self-report indicators of ED, difficulty in having an erection and in maintaining an erection, are estimated. The prevalence of difficulty in having an erection is 23.3% and in maintaining an erection is 26.7%. Twin correlations for dysfunction in having an erection are 0.35 (95% confidence interval [CI], 0.28-0.41) in MZ and 0.17 (95% CI, 0.09-0.27) in DZ pairs. For dysfunction in maintaining an erection, the twin correlations in MZ and DZ pairs are 0.39 (95% CI, 0.32-0.45) and 0.18 (95% CI, 0.09-0.27), respectively. The estimated heritability of liability for dysfunction in having an erection is 35% and in maintaining an erection is 42%. The heritable influence on ED remained significant after adjustment for ED risk factors. The present study demonstrates an ED-specific genetic component that is independent of genetic influences from numerous ED risk factors. The results suggest that future molecular genetic studies to identify ED-related polymorphisms are warranted.

Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion.

PubMed

Beck, Michael J; Okerblom, Davin; Kumar, Anika; Bandyopadhyay, Subhankar; Scalzi, Lisabeth V

2016-12-01

To determine if a lean intervention improved emergency department (ED) throughput and reduced ED boarding by improving patient discharge efficiency from a tertiary care children's hospital. The study was conducted at a tertiary care children's hospital to study the impact lean that changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics' service were compared to patients discharged from all other pediatric subspecialty services. The intervention was multifaceted. First, team staffing reconfiguration permitted all discharge work to be done at the patient's bedside using a new discharge checklist. The intervention also incorporated an afternoon interdisciplinary huddle to work on the following day's discharges. Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times. For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM. Lean principles implemented by one hospital service line improved patient discharge times enhanced patient ED throughput, and reduced ED boarding times.

Group A streptococcal necrotizing fasciitis in the emergency department.

PubMed

Lin, Jiun-Nong; Chang, Lin-Li; Lai, Chung-Hsu; Lin, Hsi-Hsun; Chen, Yen-Hsu

2013-11-01

Group A Streptococcal (GAS) necrotizing fasciitis is a critical emergency. Patients with necrotizing fasciitis principally present to emergency departments (EDs), but most studies are focused on hospitalized patients. An ED patient-based retrospective study was conducted to investigate the clinical characteristics, associated factors, and outcomes of GAS necrotizing fasciitis in the ED. Patients visiting the ED from January 2005 through December 2011 with the diagnosis of GAS necrotizing fasciitis were enrolled. All patients with the diagnosis of noninvasive skin and soft-tissue infections caused by GAS were included as the control group. During the study period, 75 patients with GAS necrotizing fasciitis were identified. Males accounted for 84% of patients. The most prevalent underlying disease was diabetes mellitus (45.3%). Bullae were recognized in 37.3% of patients. One third of cases were complicated by bacteremia. Polymicrobial infections were found in 30.7% of patients. Overall mortality rate for GAS necrotizing fasciitis was 16%. Patients aged >60 years with diabetes mellitus, liver cirrhosis, and gout were considerably more likely to have GAS necrotizing fasciitis than noninvasive infections. Patients presenting with bacteremia, shock, duration of symptoms/signs <5 days, low white blood cell count, low platelet count, and prolonged prothrombin time were associated with increased mortality. Surgery is a significantly negative factor for mortality of patients with GAS necrotizing fasciitis (odds ratio = 0.16; 95% confidence interval 0.002-0.16; p < 0.001). A better understanding of the associated factors and initiation of adequate treatments will allow for improved survival after GAS necrotizing fasciitis. Copyright © 2013 Elsevier Inc. All rights reserved.

Impact of season, weekends and bank holidays on emergency department transfers of nursing home residents.

PubMed

Fan, C W; Keating, T; Brazil, E; Power, D; Duggan, J

2016-08-01

For urgent, unexpected clinical events, nursing home (NH) residents are transferred to the acute hospital emergency department (ED). A previous study showed that a third of transfers occurred during working hours. Our aims were to profile a one-year NH transfers to the ED and to examine the re-presentation, patient-oriented outcome and the impact of season, weekends and bank holidays on NH transfers. All NH transfers from a catchment to an ED over one year were identified using electronic patient record. Age, gender, reason for presentation, patient-oriented outcome and date and time of presentation were recorded. Representation and the interval between transfers were calculated. Number of transfers was calculated for season, weekdays/weekends and bank holidays. Student t test, Chi-square statistics and one-way ANOVA were used. Significance was set at 0.05. There were 802 transfers from 465 NH residents over a year; 501 (62.5 %) resulted in admissions, 189 (40.6 %) residents represent to the service and 80 episodes occurred within a fortnight of the last attendance. The highest transfers occurred in May (2.81 patients/day), during working hours and on Wednesdays and Thursdays (>2.5 transfers/day). 'Unwell adult' and 'falls' were the two commonest reasons for presentation. Our study showed that NH transfers occurred mainly within working hours and during weekdays. Insights into the transfer pattern and the reasons for NH patients to utilise ED will facilitate improved design and operation of the department by creating care pathways for these patients.

Mental Health Services Use Trends in Canadian Veterans: A Population-Based Retrospective Cohort Study in Ontario.

PubMed

Mahar, Alyson L; Aiken, Alice B; Cramm, Heidi; Whitehead, Marlo; Groome, Patti; Kurdyak, Paul

2017-01-01

A substantial evidence base in the peer-reviewed literature exists investigating mental illness in the military, but relatively less is documented about mental illness in veterans. This study uses provincial, administrative data to study the use of mental health services by Canadian veterans in Ontario. This was a retrospective cohort study of Canadian Armed Forces and Royal Canadian Mounted Police veterans who were released between 1990 and 2013 and resided in Ontario. Mental health-related primary care physician, psychiatrist, emergency department (ED) visits, and psychiatric hospitalisations were counted. Repeated measures were presented in 5-year intervals, stratified by age at release. The cohort included 23,818 veterans. In the first 5 years following entry into the health care system, 28.9% of veterans had ≥1 mental health-related primary care physician visit, 5.8% visited a psychiatrist at least once, and 2.4% received acute mental health services at an ED. The use of mental health services was consistent over time. Almost 8% of veterans aged 30 to 39 years saw a psychiatrist in the first 5 years after release, compared to 3.5% of veterans aged ≥50 years at release. The youngest veterans at release (<30 years) were the most frequent users of ED services for a mental health-related reason (5.1% had at least 1 ED visit). Understanding how veterans use the health care system for mental health problems is an important step to ensuring needs are met during the transition to civilian life.

Adolescent Sexual Behavior and Emergency Department Use.

PubMed

Weisman, Julie; Chase, Alyse; Badolato, Gia M; Teach, Stephen J; Trent, Maria E; Chamberlain, James M; Goyal, Monika K

2018-03-28

The objective of this study was to determine whether adolescents in emergency departments (EDs) who report engaging in high-risk sexual behaviors are less likely to identify a primary care provider (PCP) and more likely to access the ED than their sexually inexperienced peers. This was a secondary analysis of adolescents presenting to a pediatric ED with non-sexually transmitted infection (STI)-related complaints who completed surveys to assess sexual behavior risk and health care access. We measured differences in self-reported PCP identification, preferential use of the ED, and number of ED visits over a 12-month period by sexual experience. Secondary outcomes included clinician documented sexual histories and STI testing. Of 758 patients meeting inclusion criteria, 341 (44.9%) were sexually experienced, and of those, 129 (37.8%) reported engaging in high-risk behavior. Participants disclosing high-risk behavior were less likely to identify a PCP (adjusted odds ratio, 0.5; 95% confidence interval [CI], 0.3-0.9), more likely to prefer the ED for acute care issues (adjusted odds ratio, 1.6; 95% CI, 1.0-2.6), and had a higher rate of ED visits (adjusted relative risk, 1.2; 95% CI, 1.0-1.3) compared with sexually inexperienced peers. Among patients disclosing high-risk behavior, 10.9% had clinician-documented sexual histories and 2.6% underwent STI testing. Adolescents who reported engaging in high-risk sexual behaviors were less likely to identify a PCP, as well as more likely to prefer ED-based care and make more ED visits. However, ED clinicians infrequently obtained sexual histories and performed STI testing in asymptomatic youth, thereby missing opportunities to screen high-risk adolescents who may lack access to preventive care.

A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

PubMed

Monuteaux, Michael C; Fleegler, Eric W; Lee, Lois K

2017-08-01

Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. Epidemiological study, level III.

A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

PubMed

Monuteaux, Michael C; Fleegler, Eric W; Lee, Lois K

2017-11-01

Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. Epidemiological study, level III.

Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases.

PubMed

Nikpay, Sayeh; Freedman, Seth; Levy, Helen; Buchmueller, Tom

2017-08-01

We assess whether the expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA) results in changes in emergency department (ED) visits or ED payer mix. We also test whether the size of the change in ED visits depends on the change in the size of the Medicaid population. Using all-capture, longitudinal, state data from the Agency for Healthcare Research and Quality's Fast Stats program, we implemented a difference-in-difference analysis, which compared changes in ED visits per capita and the share of ED visits by payer (Medicaid, uninsured, and private insurance) in 14 states that did and 11 states that did not expand Medicaid in 2014. Analyses controlled for state-level demographic and economic characteristics. We found that total ED use per 1,000 population increased by 2.5 visits more in Medicaid expansion states than in nonexpansion states after 2014 (95% confidence interval [CI] 1.1 to 3.9). Among the visit types that could be measured, increases in ED visits were largest for injury-related visits and for states with the largest changes in Medicaid enrollment. Compared with nonexpansion states, in expansion states the share of ED visits covered by Medicaid increased 8.8 percentage points (95% CI 5.0 to 12.6), whereas the uninsured share decreased by 5.3 percentage points (95% CI -1.7 to -8.9). The ACA's Medicaid expansion has resulted in changes in payer mix. Contrary to other studies of the ACA's effect on ED visits, our study found that the expansion also increased use of the ED, consistent with polls of emergency physicians. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Erectile Dysfunction Is Not a Predictor of Atrial Fibrillation: A Population-Based Propensity-Score Matched Cohort Study.

PubMed

Liu, Kuan-Liang; Ye, Ling-Long; Chou, Shing-Hsien; Tung, Ying-Chang; Lin, Yu-Sheng; Wu, Lung-Sheng; Lin, Chia-Pin; Shia, Ben-Chang; Chu, Pao-Hsien

2016-01-01

Erectile dysfunction (ED) has been regarded a marker of cardiovascular diseases. Nevertheless, the association between ED and incident atrial fibrillation (AF) remains unknown. To determine the association between ED and incident AF. This population-based cohort study was conducted using the National Health Insurance Research Database in Taiwan. In total, 6,273 of patients with ED without a prior diagnosis of AF were enrolled from January 1, 2001 through December 31, 2009, and a propensity-score matching method was used to identify 3,516 patients in the ED and control groups. Newly incident AF at follow-up was recorded as the end point. The mean age of the study population was 40.0 ± 17.1 years, and the follow-up period was 8.0 ± 0.5 years. Compared with the control group, patients with ED were older and had more of the following comorbidities: D'Hoore Charlson Comorbidity Index, hypertension, congestive heart failure, diabetes mellitus, dyslipidemia, chronic kidney disease, coronary artery disease, stroke, chronic lung disease, major depression disorder, obstructive sleep apnea, and hyperthyroidism. After adjusting for confounders, the ED group was not associated with more incident AF compared with the control group (hazard ratio = 1.031, 95% confidence interval = 0.674-1.578, P =.888). In these patients, ED of an organic origin was associated with a trend of having AF more often compared with ED of a psychosexual type (P =.272 by log-rank test). Although ED is known as a predictor of atherosclerotic cardiovascular diseases, it is not independently associated with incident AF in men. Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Alterations in collagen structure in hypermobility and Ehlers-Danlos syndromes detected by Raman spectroscopy in vivo

NASA Astrophysics Data System (ADS)

Johansson, Carina K.; Gniadecka, Monika; Ullman, Susanne; Halberg, Poul; Kobayasi, Takasi; Wulf, Hans Christian

2000-11-01

Patients with hypermobility syndrome (HS) and Ehlers-Danlos syndrome (EDS) were investigated by means of in vivo near- infrared Fourier-transform Raman spectroscopy. HS is a benign and common condition (up to 5 percent of the population of the Western World). EDS is a rare, inherited connective tissue disease characterized by joint hypermobility, skin hyperextensibility, and other, occasionally serious, organ changes. EDS and HS may be related disorders. We investigated 13 patients with HS, 8 patients with EDS, and 24 healthy volunteers by means of in vivo Raman spectroscopy. The patients were classified according to Beighton and Holzberg et al. No difference in age between the three groups was found (HS 41 (33-49), EDS 36 (25-47), controls 37 (31-42); mean, 95% confidence intervals, respectively). Spectral differences were found in the intensity of the amide-III bands around 1245 and 1270 cm-1 in HS and EDS compared with healthy skin (Kruskal-Wallis, p equals 0,02 for intensity ratios (I1245/I1270) between the investigated groups). To elucidate the character of the alterations in the amide-III bands a curve fitting procedure was applied. In conclusion, Raman spectroscopy may aid in the diagnosis of HS and EDS. Moreover the technique may be useful for analyzing the molecular changes occurring in these syndromes.

A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction.

PubMed

Takakuwa, Kevin M; Burek, Gregory A; Estepa, Adrian T; Shofer, Frances S

2009-10-01

The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients. This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders. A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (+/-standard deviation [SD]) age was 50 (+/-16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.

Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors.

PubMed

Micali, Nadia; Martini, Maria G; Thomas, Jennifer J; Eddy, Kamryn T; Kothari, Radha; Russell, Ellie; Bulik, Cynthia M; Treasure, Janet

2017-01-17

Eating disorders (EDs) are common amongst women; however, no research has specifically investigated the lifetime/12-month prevalence of eating disorders amongst women in mid-life (i.e., fourth and fifth decade of life) and the relevant longitudinal risk factors. We aimed to investigate the lifetime and 12-month prevalence of EDs and lifetime health service use and to identify childhood, parenting, and personality risk factors. This is a two-phase prevalence study, nested within an existing longitudinal community-based sample of women in mid-life. A total of 5658 women from the UK Avon Longitudinal Study of Parents and Children (ALSPAC; enrolled 20 years earlier) participated. ED diagnoses were obtained using validated structured interviews. Weighted analyses were carried out accounting for the two-phase methodology to obtain prevalence figures and to carry out risk factor regression analyses. By mid-life, 15.3% (95% confidence intervals, 13.5-17.4%) of women had met criteria for a lifetime ED. The 12-month prevalence of EDs was 3.6%. Childhood sexual abuse was prospectively associated with all binge/purge type disorders and an external locus of control was associated with binge-eating disorder. Better maternal care was protective for bulimia nervosa. Childhood life events and interpersonal sensitivity were associated with all EDs. By mid-life a significant proportion of women will experience an ED, and few women accessed healthcare. Active EDs are common in mid-life, both due to new onset and chronic disorders. Increased awareness of the full spectrum of EDs in this stage of life and adequate service provision is important. This is the first study to investigate childhood and personality risk factors for full threshold and sub-threshold EDs and to identify common predictors for full and sub-threshold EDs. Further research should clarify the role of preventable risk factors on both full and sub-threshold EDs.

Public health surveillance response following the southern Alberta floods, 2013.

PubMed

Sahni, Vanita; Scott, Allison N; Beliveau, Marie; Varughese, Marie; Dover, Douglas C; Talbot, James

2016-08-15

In June of 2013, southern Alberta underwent flooding that affected approximately 100,000 people. We describe the process put in place for public health surveillance and assessment of the impacts on health. Public health surveillance was implemented for the six-week period after the flood to detect anticipated health events, including injuries, mental health problems and infectious diseases. Data sources were emergency departments (EDs) for presenting complaints, public health data on the post-exposure administration of tetanus vaccine/immunoglobulin, administrative data on prescription drugs, and reportable diseases. An increase in injuries was detected through ED visits among Calgary residents (rate ratio [RR] 1.28, 95% confidence interval [CI]: 1.14-1.43) and was supported by a 75% increase in the average weekly administration of post-exposure prophylaxis against tetanus. Mental health impacts in High River residents were observed among females through a 1.64-fold (95% CI: 1.11-2.43) and 2.32-fold (95% CI: 1.45-3.70) increase in new prescriptions for anti-anxiety medication and sleep aids respectively. An increase in sexual assaults presenting to EDs (RR 3.18, 95% CI: 1.29-7.84) was observed among Calgary residents. No increases in infectious gastrointestinal disease or respiratory illness were identified. Timely identification and communication of surveillance alerts allowed for messaging around the use of personal protective equipment and precautions for personal safety. Existing data sources were used for surveillance following an emergency situation. The information produced, though limited, was sufficiently timely to inform public health decision-making.

Warm Season Temperatures and Emergency Department Visits in Atlanta, Georgia

PubMed Central

Winquist, Andrea; Grundstein, Andrew; Chang, Howard H.; Hess, Jeremy; Sarnat, Stefanie Ebelt

2016-01-01

Purpose Extreme heat events will likely increase in frequency with climate change. Heat-related health effects are better documented among the elderly than among younger age groups. We assessed associations between warm-season ambient temperature and emergency department (ED) visits across ages in Atlanta during 1993-2012. Methods We examined daily counts of ED visits with primary diagnoses of heat illness, fluid/electrolyte imbalances, renal disease, cardiorespiratory diseases, and intestinal infections by age group (0-4, 5-18, 19-64, 65+ years) in relation to daily maximum temperature (TMX) using Poisson time series models that included cubic terms for TMX at single-day lags of 0-6 days, controlling for maximum dew-point temperature, time trends, week day, holidays, and hospital participation periods. We estimated rate ratios (RRs) and 95% confidence intervals (CI) for TMX changes from 27 °C to 32 °C (25th to 75th percentile) and conducted extensive sensitivity analyses. Results We observed associations between TMX and ED visits for all internal causes, heat illness, fluid/electrolyte imbalances, renal diseases, asthma/wheeze, diabetes, and intestinal infections. Age groups with the strongest observed associations were 65+ years for all internal causes [lag 0 RR (CI)=1.022 (1.016-1.028)] and diabetes [lag 0 RR=1.050 (1.008-1.095)]; 19-64 years for fluid/electrolyte imbalances [lag 0 RR=1.170 (1.136-1.205)] and renal disease [lag 1 RR=1.082 (1.065-1.099)]; and 5-18 years for asthma/wheeze [lag 2 RR=1.059 (1.030-1.088)] and intestinal infections [lag 1 RR=1.120 (1.041-1.205)]. Conclusions Varying strengths of associations between TMX and ED visits by age suggest that optimal interventions and health-impact projections would account for varying heat health impacts across ages. PMID:26922412

Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model.

PubMed

Polevoi, Steven K; Jewel Shim, J; McCulloch, Charles E; Grimes, Barbara; Govindarajan, Prasanthi

2013-04-01

Patients with psychiatric emergencies often spend excessive time in an emergency department (ED) due to limited inpatient psychiatric bed capacity. The objective was to compare traditional resident consultation with a new model (comanagement) to reduce length of stay (LOS) for patients with psychiatric emergencies. The costs of this model were compared to those of standard care. This was a before-and-after study conducted in the ED of an urban academic medical center without an inpatient psychiatry unit from January 1, 2007, through December 31, 2009. Subjects were all adult patients seen by ED clinicians and determined to be a danger to self or others or gravely disabled. At baseline, psychiatry residents evaluated patients and made therapeutic recommendations after consultation with faculty. The comanagement model was fully implemented in September 2008. In this model, psychiatrists directly ordered pharmacotherapy, regularly monitored effects, and intensified efforts toward appropriate disposition. Additionally, increased attending-level involvement expedited focused evaluation and disposition of patients. An interrupted time series analysis was used to study the effects of this intervention on LOS for all psychiatric patients transferred for inpatient psychiatric care. Secondary outcomes included mean number of hours on ambulance diversion per month and the mean number of patients who left without being seen (LWBS) from the ED. A total of 1,884 patient visits were considered. Compared to the preintervention phase, median LOS for patients transferred for inpatient psychiatric care decreased by about 22% (p < 0.0005, 95% confidence interval [CI] = 15% to 28%) in the postintervention phase. Ambulance diversion hours increased by about 40 hours per month (p = 0.008, 95% CI = 11 to 69 hours) and the mean number of patients who LWBS decreased by about 26 per month (p = 0.106; 95% CI = -60 to 5.9 visits per month) in the postintervention phase. A comanagement model was associated with a marked reduction in the LOS for this patient population. © 2013 by the Society for Academic Emergency Medicine.

Trimming the fat: identification of risk factors associated with obesity in a pediatric emergency department.

PubMed

Thundiyil, Josef G; Christiano-Smith, Danielle; Greenberger, Sarah; Cramm, Kelly; Latimer-Pierson, Janese; Modica, Renee F

2010-10-01

The purpose of this study was to assess which knowledge deficits and dietary habits in an urban pediatric emergency department (ED) population are risk factors for obesity. This cross-sectional study in an urban pediatric ED used a modified version of the Diet and Health Knowledge Survey, an in-person interview questionnaire, to collect data on demographics, dietary knowledge, and practices. All patients aged 2 to 17 years were enrolled in the study over a 4-month period. Subjects were excluded if they were in extremis, pregnant, incarcerated, institutionalized, considered an emancipated minor, or consumed only a modified consistency diet. One hundred seventy-nine subjects were enrolled in this study. Based on body mass index, the prevalence of obesity in our study population was 24%. Parents with obese children answered a mean of 62.9% (95% confidence interval, 60.4%-65.5%) of knowledge questions correctly, whereas all others scored 60.3% (95% confidence interval, 58.3%-62.3%) correctly. Based on the univariate analysis, 10 predictors met inclusion criteria into logistic regression analysis: screen time (P = 0.03), race (P = 0.08), sex (P = 0.04), parental education (P = 0.08), parental estimation that child is overweight (P < 0.0001), parental estimation that child is underweight (P = 0.003), trimming fat from meat (P = 0.06), soft-drink consumption (P = 0.03), exercise (P = 0.07), and chip consumption (P = 0.04). In a multivariate analysis, only male sex, regularly trimming fat from meat, and parental assessment of obesity were independently associated with obesity. Knowledge deficiencies regarding healthy nutrition among parents in an urban pediatric ED population were not significantly associated with having obese children; however, specific habits were. Emergency physicians may provide a valuable role in identification and brief behavioral intervention in high-risk populations during the current epidemic of childhood obesity.

Association Between Objectively Measured Physical Activity and Erectile Dysfunction among a Nationally Representative Sample of American Men.

PubMed

Loprinzi, Paul D; Edwards, Meghan

2015-09-01

Emerging work suggests an inverse association between physical activity and erectile dysfunction (ED). The majority of this cross-sectional research comes from convenience samples and all studies on this topic have employed self-report physical activity methodology. Therefore, the purpose of this brief-report, confirmatory research study was to examine the association between objectively measured physical activity and ED in a national sample of Americans. Data from the 2003-2004 National Health and Nutrition Examination Survey were used. Six hundred ninety-two adults between the ages of 50 and 85 years (representing 33.2 million adults) constituted the analytic sample. Participants wore an ActiGraph 7164 accelerometer (ActiGraph, Pensacola, FL, USA) for up to 7 days with ED assessed via self-report. The main outcome measure used was ED assessed via self-report. After adjustments, for every 30 min/day increase in moderate-to-vigorous physical activity, participants had a 43% reduced odds of having ED (odds ratioadjusted  = 0.57; 95% confidence interval: 0.40-0.81; P = 0.004). This confirmatory study employing an objective measure of physical activity in a national sample suggests an inverse association between physical activity and ED. © 2015 International Society for Sexual Medicine.

A personality classification system for eating disorders: a longitudinal study.

PubMed

Thompson-Brenner, Heather; Eddy, Kamryn T; Franko, Debra L; Dorer, David J; Vashchenko, Maryna; Kass, Andrea E; Herzog, David B

2008-01-01

Studies of eating disorders (EDs) suggest that empirically derived personality subtypes may explain heterogeneity in ED samples that is not captured by the current diagnostic system. Longitudinal outcomes for personality subtypes have not been examined. In this study, personality pathology was assessed by clinical interview in 213 individuals with anorexia nervosa and bulimia nervosa at baseline. Interview data on EDs, comorbid diagnoses, global functioning, and treatment utilization were collected at baseline and at 6-month follow-up intervals over a median of 9 years. Q-factor analysis of the participants based on personality items produced a 5-prototype system, including high-functioning, behaviorally dysregulated, emotionally dysregulated, avoidant-insecure, and obsessional-sensitive types. Dimensional prototype scores were associated with baseline functioning and longitudinal outcome. Avoidant-Insecure scores showed consistent associations with poor functioning and outcome, including failure to show ED improvement, poor global functioning after 5 years, and high treatment utilization after 5 years. Behavioral dysregulation was associated with poor baseline functioning but did not show strong associations with ED or global outcome when histories of major depression and substance use disorder were covaried. Emotional dysregulation and obsessional-sensitivity were not associated with negative outcomes. High-functioning prototype scores were consistently associated with positive outcomes. Longitudinal results support the importance of personality subtypes to ED classification.

Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: clinical outcomes and radiographic features.

PubMed

Kreitzer, Natalie; Lyons, Michael S; Hart, Kim; Lindsell, Cristopher J; Chung, Sora; Yick, Andrew; Bonomo, Jordan

2014-10-01

Emergency department (ED) management of mild traumatic brain injury (TBI) patients with any form of traumatic intracranial hemorrhage (ICH) is variable. Since 2000, our center's standard practice has been to obtain a repeat head computed tomography (CT) at least 6 hours after initial imaging. Patients are eligible for discharge if clinical and CT findings are stable. Whether this practice is safe is unknown. This study characterized clinical outcomes in mild TBI patients with acute traumatic ICH seen on initial ED neuroimaging. This retrospective cohort study included patients presenting to the ED with blunt mild TBI with Glasgow Coma Scale (GCS) scores of 14 or 15 and stable vital signs, during the period from January 2001 to January 2010. Patients with any ICH on initial head CT and repeat head CT within 24 hours were eligible. Cases were excluded for initial GCS < 14, injury > 24 hours old, pregnancy, concomitant nonminor injuries, and coagulopathy. A single investigator abstracted data from records using a standardized case report form and data dictionary. Primary endpoints included death, neurosurgical procedures, and for discharged patients, return to the ED within 7 days. Differences in proportions were computed with 95% confidence intervals (CIs). Of 1,011 patients who presented to the ED and had two head CTs within 24 hours, 323 (32%) met inclusion criteria. The median time between CT scans was 6 hours (interquartile range = 5 to 7 hours). A total of 153 (47%) patients had subarachnoid hemorrhage, 132 (41%) patients had subdural hemorrhage, 11 (3%) patients had epidural hemorrhage, 78 (24%) patients had cerebral contusions, and 59 (18%) patients had intraparenchymal hemorrhage. Four of 323 (1.2%, 95% CI = 0.3% to 3.2%) patients died within 2 weeks of injury. Three of the patients who died had been admitted from the ED on their initial visits, and one had been discharged home. There were 206 patients (64%) discharged from the ED, 28 (13.6%) of whom returned to the ED within 1 week. Of the 92 who were hospitalized, three (0.9%, 95% CI = 0.2% to 2.7%) required neurosurgical intervention. Discharge after a repeat head CT and brief period of observation in the ED allowed early discharge of a cohort of mild TBI patients with traumatic ICH without delayed adverse outcomes. Whether this justifies the cost and radiation exposure involved with this pattern of practice requires further study. © 2014 by the Society for Academic Emergency Medicine.

Impact of seasonal and lunar cycles on psychological symptoms in the ED: an empirical investigation of widely spread beliefs.

PubMed

Belleville, Geneviève; Foldes-Busque, Guillaume; Dixon, Mélanie; Marquis-Pelletier, Evelyne; Barbeau, Sarah; Poitras, Julien; Chauny, Jean-Marc; Diodati, Jean G; Fleet, Richard; Marchand, André

2013-01-01

This study evaluates the impacts of seasonal and lunar cycles on anxiety and mood disorders, panic and suicidal ideation in patients consulting the emergency department (ED) with a complaint of unexplained chest pain (UCP). Patients with UCP were recruited from two EDs. Psychiatric diagnoses were evaluated with the Anxiety Disorders Interview Schedule for DSM-IV. Significant seasonal effects were observed on panic and anxiety disorders, with panic more frequently encountered during spring [odds ratio (OR)=1.378, 95% confidence interval (CI)=1.002-1.896] and anxiety disorders during summer (OR=1.586, 95% CI=1.037-2.425). Except for one significant finding, no significant effects of lunar cycles were observed. These findings encourage ED professionals and physicians to abandon their beliefs about the influence of lunar cycles on the mental health of their patients. Such unfounded beliefs are likely to be maintained by self-fulfilling prophecies. Copyright © 2013 Elsevier Inc. All rights reserved.

[Effects of sevoflurane and desflurane on pharmacodynamics of rocuronium in children].

PubMed

Kang, D X; Rao, Y Q; Ji, B; Li, J

2017-02-14

Objective: To observe the intraoperative influences on pharmacodynamics of rocuronium in children inhaling sevoflurane and desflurane for 40 min balance. Methods: Ninety children (ASAⅠ-Ⅱ) undergoing elective surgery with general anesthesia in Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University from July 2015 to May 2016 were randomly assigned into six groups ( n =15): Sevoflurane group (group S1 and S2), Desflurane group (group D1 and D2) and Propofol group (group P1 and P2). Children in group D1, S1 and P1 were allocated to research the dose-effect relationship of rocuronium, children in group D2, S2 and P2 were allocated to research the time-effect relationship of rocuronium. TOF-Watch SX monitor was used to exert a train-of-four stimulation (TOF) at ulnar nerve in wrist, then the adductor pollicis muscle appeared muscle twitch 4 times in turn which was recorded T(1, )T(2, )T(3) and T(4) respectively. After the success of the muscle relaxant calibration, 1.3 MAC sevoflurane and desflurane were inhaled and maintained for 40 min respectively in children in Sevoflurane group (group S1 and S2) and Desflurane group (group D1 and D2), Plasma target controlled infusion of 3.5-4.0 μg/ml propofol was always administered in Propofol group (group P1 and P2). 75 μg/kg rocuronium was injected each time in group S1, D1 and P1 respectively. Maximum inhibited effect of T(1) was recorded after every injection until inhibition of T(1) more than 95% eventually. The method of cumulative dose four times was used to calculate the efficiency curve of rocuronium[median effective dose (ED(50)), 90% effective dose (ED(90)) and 95% effective dose (ED(95))]. 0.6 mg/kg rocuronium was injected respectively through vein in group S2, D2 and P2. The recovery times of muscle relaxant were recorded which including time of T(1) disappeared (onset time), T(1) from 0% to 5% (peak effect time), T(1) from 0% to 25% (clinical effect time), T(1) from 25% to 75% (recovery index), T(1) from 0% to 70% (internal effect time), T(4)/T(1) (TOFr) from 0% to 70% and 90%. Results: ED(50, )ED(90) and ED(95) in group D1 were 128.73, 212.45 and 245.78 μg/kg respectively. ED(50, )ED(90) and ED(95) in group S1 were 132.46, 218.94 and 252.30 μg/kg respectively. ED(50, )ED(90) and ED(95) in group P1 were 230.56, 381.02 and 439.55 μg/kg respectively. ED(50, )ED(90) and ED(95) in group D1 and S1 were significantly lower than those in group P1 (all P <0.05), but there was no significant difference between D1 and S1 group ( P >0.05). Compared with group P2, the shorter onset time, the longer peak effect time and clinical effect time was observed in group D2 and S2, the longer recovery index, internal effect time and TOFr from 0% to 70% and 90% was observed in group S2 (all P <0.01). Conclusions: 1.3 MAC sevoflurane and desflurane inhaling for 40 min significantly reduces ED(50) and ED(95) of rocuronium, prolongs the onset time and action time of rocuronium in children. Sevoflurane can significantly prolong the recovery characteristics of rocuronium.

Computed tomography use among children presenting to emergency departments with abdominal pain.

PubMed

Fahimi, Jahan; Herring, Andrew; Harries, Aaron; Gonzales, Ralph; Alter, Harrison

2012-11-01

To evaluate trends in and factors associated with computed tomography (CT) use among children presenting to the emergency department (ED) with abdominal pain. This study was a cross-sectional, secondary analysis of the National Hospital Ambulatory Medical Care Survey data from 1998 to 2008. We identified ED patients aged <19 years with abdominal pain and collected patient demographic and hospital characteristics, and outcomes related to imaging, hospital admission, and diagnosis of appendicitis. Trend analysis was performed over the study period for the outcomes of interest, and a multivariate regression model was used to identify factors associated with CT use. Of all pediatric ED visits, 6.0% were for abdominal pain. We noted a rise in the proportion of these patients with CT use, from 0.9% in 1998 to 15.4% in 2008 (P < .001), with no change in ultrasound/radiograph use, diagnosis of appendicitis, or hospital admission. Older and male patients were more likely to have a CT scan, whereas black children were one-half as likely to undergo a CT scan compared with white children (odds ratio: 0.50 [95% confidence interval: 0.31-0.81]). Admitted children had much higher odds of undergoing a CT scan (odds ratio: 4.11 [95% confidence interval: 2.66-6.35]). There was a plateau in CT use in 2006 to 2008. There was a dramatic increase in the utilization of CT imaging in the ED evaluation of pediatric patients with abdominal pain. Some groups of children may have a differential likelihood of receiving CT scans.

Surface Current Skill Assessment of Global and Regional forecast models.

NASA Astrophysics Data System (ADS)

Allen, A. A.

2016-02-01

The U.S. Coast Guard has been using SAROPS since January 2007 at all fifty of its operational centers to plan search and rescue missions. SAROPS relies on an Environmental Data Server (EDS) that integrates global, national, and regional ocean and meteorological observation and forecast data. The server manages spatial and temporal aggregation of hindcast, nowcast, and forecast data so the SAROPS controller has the best available data for search planning. The EDS harvests a wide range of global and regional forecasts and data, including NOAA NCEP's global HYCOM model (RTOFS), the U.S. Navy's Global HYCOM model, the 5 NOAA NOS Great Lakes models and a suite of other reginal forecasts from NOS and IOOS Regional Associations. The EDS also integrates surface drifter data as the U.S. Coast Guard regularly deploys Self-Locating Datum Marker Buoys (SLDMBs) during SAR cases and a significant set of drifter data has been collected and the archive continues to grow. This data is critically useful during real-time SAR planning, but also represents a valuable scientific dataset for analyzing surface currents. In 2014, a new initiative was started by the U.S. Coast Guard to evaluate the skill of the various models to support the decision making process during search and rescue planning. This analysis falls into 2 categories: historical analysis of drifter tracks and model predictions to provide skill assessment of models in different regions and real-time analysis of models and drifter tracks during a SAR incident. The EDS, using Liu and Wiesberg's (2014) autonomously determines surface skill measurements of the co-located models' simulated surface trajectories versus the actual drift of the SLDMBs (CODE/Davis style surface drifters GPS positioned at 30min intervals). Surface skill measurements are archived in a database and are user retrieval by lat/long/time cubes. This paper will focus on the comparison of models from in the period from 23 August to 21 September 2015. Surface Skill was determined for the following regions: California Coast, Gulf of Mexico, South and Mid Atlantic Bights. Skill was determined for the two version of the NCEP Global RTOFS, Navy's Global HYCOM model, and where appropriated the local regional models

The association of ambient temperature with incidence of cardiac arrhythmias in a short timescale

NASA Astrophysics Data System (ADS)

Kim, Jayeun; Kim, Ho

2017-11-01

The body response time and an association between the exposure to outdoor temperature and cardiac arrhythmia were not fully understood. Hence, we further investigated the association between ambient temperature and the exacerbations of arrhythmia symptoms on a short timescale using the emergency department (ED) visit data. We used a total of 17,088 arrhythmia-related ED visits in Seoul, from 2008 to 2011 and fitted the model adjusting for other meteorological variables and air pollutants under the case-crossover analysis with the same year-month time stratification. The association was presented as an odds ratio (OR) with a 95% confidence interval (CI) by a 5 °C decrease in the ambient temperature. The delay time (h) between exposure and the onset of arrhythmia exacerbation was considered with time blocks for every 3 h as 1-3 h, up to 118-120 h; and daily lags (1 day), from 25-48 h to 97-120 h, as a multi-time average of exposures. The overall association was increased at lag 4-6 h and the increased association was statistically significant at lag 40-42 h (OR 1.027, 95% CI 1.003-1.051) and the adverse association continued at 97-120 h (OR 1.053, 95% CI 1.027-1.080). However, the delay of several days between ambient temperature and body response should be further investigated considering the modification according to varied demographic characteristics or different environmental circumstances.

Psychiatric patients turnaround times in the emergency department

PubMed Central

2005-01-01

Background To analyze the turnaround times of psychiatric patients within the Emergency Department (ED) from registration to discharge or hospitalization in a University Hospital in 2002. Methods Data from a one-year period of psychiatric admissions to the emergency service at a University Hospital were monitored and analyzed focused on turnaround times within the ED. Information on patients variables such as age, sex, diagnosis, consultations and diagnostic procedures were extracted from the patients' charts. Results From 34.058 patients seen in the ED in 2002, 2632 patients were examined by psychiatrists on duty. Mean turnaround time in the ED was 123 (SD 97) minutes (median 95). Patients to be hospitalized on a psychiatric ward stayed shorter within the ED, patients who later were admitted to another faculty, were treated longer in the ED. Patients with cognitive or substance related disorders stayed longer in the ED than patients with other psychiatric diagnoses. The number of diagnostic procedures and consultations increased the treatment time significantly. Conclusion As the number of patients within the examined ED increases every year, the relevant variables responsible for longer or complicated treatments were assessed in order to appropriately change routine procedures without loss of medical standards. Using this basic data, comparisons with the following years and other hospitals will help to define where the benchmark of turnaround times for psychiatric emergency services might be. PMID:16351721

Estimating the waiting time of multi-priority emergency patients with downstream blocking.

PubMed

Lin, Di; Patrick, Jonathan; Labeau, Fabrice

2014-03-01

To characterize the coupling effect between patient flow to access the emergency department (ED) and that to access the inpatient unit (IU), we develop a model with two connected queues: one upstream queue for the patient flow to access the ED and one downstream queue for the patient flow to access the IU. Building on this patient flow model, we employ queueing theory to estimate the average waiting time across patients. Using priority specific wait time targets, we further estimate the necessary number of ED and IU resources. Finally, we investigate how an alternative way of accessing ED (Fast Track) impacts the average waiting time of patients as well as the necessary number of ED/IU resources. This model as well as the analysis on patient flow can help the designer or manager of a hospital make decisions on the allocation of ED/IU resources in a hospital.

Acceptability and Reliability of a Novel Palliative Care Screening Tool Among Emergency Department Providers.

PubMed

Bowman, Jason; George, Naomi; Barrett, Nina; Anderson, Kelsey; Dove-Maguire, Kalie; Baird, Janette

2016-06-01

The Palliative Care and Rapid Emergency Screening (P-CaRES) Project is an initiative intended to improve access to palliative care (PC) among emergency department (ED) patients with life-limiting illness by facilitating early referral for inpatient PC consultations. In the previous two phases of this project, we derived and validated a novel PC screening tool. This paper reports on the third and final preimplementation phase. Examine the acceptability of the P-CaRES tool among PC and ED providers as well as test its reliability on case vignettes. Compare variations in reliability and acceptability of the tool based on ED providers' roles (attendings, residents, and nurses) and lengths of experience. A two-part electronic survey was distributed to ED providers at multiple sites across the United States. We tested the reliability of the tool in the first part of the survey, through a series of case vignettes. A criterion standard of correct responses was first defined by consensus input from expert PC physicians' interpretations of the vignettes. The experts' input was validated using the Gwet's AC1 coefficient for inter-rater reliability. ED providers were then presented with the case vignettes and asked to use the P-CaRES tool to correctly identify which patients had unmet PC needs. ED provider responses were compared both against the criterion standard and against different subsets of respondents (divided both by role and by level of experience). The second part of the survey assessed acceptability of the P-CaRES tool among ED providers using responses to questions from a modified Ottawa Acceptability of Decision Rules Instrument, based on a 1-5 Likert rating scale. Descriptive statistics were used to report all outcomes. In total, 213 ED providers employed in three different regions across the country responded to the survey (39.4%) and 185 (86.9%) of those completed it. The majority of providers felt that the tool would be useful in their practice (80.5%), agreed that the tool was clear and unambiguous (87.1%), thought that use of the tool would likely benefit patients (87.5%), and thought that it would result in improved use of resources to help severely ill patients (83.6%). Over three-quarters of ED providers (78.5%) also self-reported that they refer patients with unmet PC needs less than 10% of the time, and only 10.8% of respondents believed that they are already utilizing an effective strategy to screen or refer patients to PC. Applying our P-CaRES tool to case vignettes, ED providers generated PC referrals in concordance with PC experts over 88.7% of the time (95% confidence interval = 86.4% to 90.6%), with an overall sensitivity of more than 90%. These results varied minimally regardless of the respondent's role in the ED or their level of experience. Screening by emergency medicine providers for unmet PC needs using a brief, novel, content-validated screening tool is acceptable and is also reliable when applied to case vignettes-regardless of provider role or experience. Clinical trial and further study are warranted and are currently under way. © 2016 by the Society for Academic Emergency Medicine.

Tackling causes and costs of ED presentation for American football injuries: a population-level study.

PubMed

Smart, Blair J; Haring, R Sterling; Asemota, Anthony O; Scott, John W; Canner, Joseph K; Nejim, Besma J; George, Benjamin P; Alsulaim, Hatim; Kirsch, Thomas D; Schneider, Eric B

2016-07-01

American tackle football is the most popular high-energy impact sport in the United States, with approximately 9 million participants competing annually. Previous epidemiologic studies of football-related injuries have generally focused on specific geographic areas or pediatric age groups. Our study sought to examine patient characteristics and outcomes, including hospital charges, among athletes presenting for emergency department (ED) treatment of football-related injury across all age groups in a large nationally representative data set. Patients presenting for ED treatment of injuries sustained playing American tackle football (identified using International Classification of Diseases, Ninth Revision, Clinical Modification code E007.0) from 2010 to 2011 were studied in the Nationwide Emergency Department Sample. Patient-specific injuries were identified using the primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code and categorized by type and anatomical region. Standard descriptive methods examined patient demographics, diagnosis categories, and ED and inpatient outcomes and charges. During the study period 397363 football players presented for ED treatment, 95.8% of whom were male. Sprains/strains (25.6%), limb fractures (20.7%), and head injuries (including traumatic brain injury; 17.5%) represented the most presenting injuries. Overall, 97.9% of patients underwent routine ED discharge with 1.1% admitted directly and fewer than 11 patients in the 2-year study period dying prior to discharge. The proportion of admitted patients who required surgical interventions was 15.7%, of which 89.9% were orthopedic, 4.7% neurologic, and 2.6% abdominal. Among individuals admitted to inpatient care, mean hospital length of stay was 2.4days (95% confidence interval, 2.2-2.6) and 95.6% underwent routine discharge home. The mean total charge for all patients was $1941 (95% confidence interval, $1890-$1992) with substantial injury type-specific variability. Overall, at the US population, estimated total charges of $771299862 were incurred over the 2-year period. In this nationally representative sample, most ED-treated injuries associated with football were not acutely life threatening and very few required major therapeutic intervention. This study provides a cross-sectional overview of ED presentation for acute football-related injury across age groups at the population level in recent years. Longitudinal studies may be warranted to examine associations between the patterns of injury observed in this study and long-term outcomes among American tackle football players. Copyright © 2016 Elsevier Inc. All rights reserved.

Predictors and Outcomes of Revisits in Older Adults Discharged from the Emergency Department.

PubMed

de Gelder, Jelle; Lucke, Jacinta A; de Groot, Bas; Fogteloo, Anne J; Anten, Sander; Heringhaus, Christian; Dekkers, Olaf M; Blauw, Gerard J; Mooijaart, Simon P

2018-04-01

To study predictors of emergency department (ED) revisits and the association between ED revisits and 90-day functional decline or mortality. Multicenter cohort study. One academic and two regional Dutch hospitals. Older adults discharged from the ED (N=1,093). At baseline, data on demographic characteristics, illness severity, and geriatric parameters (cognition, functional capacity) were collected. All participants were prospectively followed for an unplanned revisit within 30 days and for functional decline and mortality 90 days after the initial visit. The median age was 79 (interquartile range 74-84), and 114 participants (10.4%) had an ED revisit within 30 days of discharge. Age (hazard ratio (HR)=0.96, 95% confidence interval (CI)=0.92-0.99), male sex (HR=1.61, 95% CI=1.05-2.45), polypharmacy (HR=2.06, 95% CI=1.34-3.16), and cognitive impairment (HR=1.71, 95% CI=1.02-2.88) were independent predictors of a 30-day ED revisit. The area under the receiver operating characteristic curve to predict an ED revisit was 0.65 (95% CI=0.60-0.70). In a propensity score-matched analysis, individuals with an ED revisit were at higher risk (odds ratio=1.99 95% CI=1.06-3.71) of functional decline or mortality. Age, male sex, polypharmacy, and cognitive impairment were independent predictors of a 30-day ED revisit, but no useful clinical prediction model could be developed. However, an early ED revisit is a strong new predictor of adverse outcomes in older adults. © 2018 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.

Effect of certificate of need law on emergency department length of stay.

PubMed

Paul, Jomon Aliyas; Ni, Huan; Bagchi, Aniruddha

2014-10-01

The impact of the Certificate of Need (CON) law on Emergency Department (ED) care remains elusive in the academic literature. We study the impact of CON law on ED Length of Stay (LOS). We examine ED LOS to detect any statistically significant difference between CON and non-CON states. We then estimate the effects of CON law on ED LOS by treating CON as an exogenous (endogenous) variable. We find that the CON legislation positively impacts ED care by reducing ED LOS (95% confidence interval [CI] -61.3 to -10.3), and we can't reject the hypothesis that the CON legislation can be treated as an exogenous variable in our model. An increase in the stringency of the CON law (measured by the threshold on equipment expenditure that is subject to a CON review) tends to diminish this positive impact on ED LOS (95% CI 9.9-68.0). The party affiliation of the Governor (95% CI 10.3-37.5), the political environment as a function of the agreement on voting between state senators (95% CI-64.8 to -12.9), proportion of young population (0-17 years) when compared with the elderly (>65 years) (95% CI-2299.7 to -184.1), proportion of population covered by privately purchased insurance (95% CI-819.3 to -59.9), etc., are found to significantly impact ED LOS in a state. This study provides a better understanding of the impact of CON law on ED care, which extends the previous literature that has mainly focused on CON effects on inpatient care. Copyright © 2014 Elsevier Inc. All rights reserved.

Preliminary program evaluation of emergency department HIV prevention counseling.

PubMed

Sitlinger, Andrea P; Lindsell, Christopher J; Ruffner, Andrew H; Wayne, D Beth; Hart, Kimberly W; Trott, Alexander T; Fichtenbaum, Carl J; Lyons, Michael S

2011-07-01

Controversy surrounds the linkage of prevention counseling with emergency department (ED)-based HIV testing. Further, the effectiveness and feasibility of prevention counseling in the ED setting is unknown. We investigate these issues by conducting a preliminarily exploration of several related aspects of our ED's HIV prevention counseling and testing program. Our urban, academic ED provides formal client-centered prevention counseling in conjunction with HIV testing. Five descriptive, exploratory observations were conducted, involving surveys and analysis of electronic medical records and programmatic data focused on (1) patient perception and feasibility of prevention counseling in the ED, (2) patient perceptions of the need to link prevention counseling with testing, and (3) potential effectiveness of providing prevention counseling in conjunction with ED-based HIV testing. Of 110 ED patients surveyed after prevention counseling and testing, 98% believed privacy was adequate, and 97% reported that their questions were answered. Patients stated that counseling would lead to improved health (80%), behavioral changes (72%), follow-up testing (77%), and discussion with partners (74%). However, 89% would accept testing without counseling, 32% were willing to seek counseling elsewhere, and 26% preferred not to receive the counseling. Correct responses to a 16-question knowledge quiz increased by 1.6 after counseling (95% confidence interval 1.3 to 12.0). The program completed counseling for 97% of patients tested; however, 6% of patients had difficulty recalling the encounter and 13% denied received testing. Among patients undergoing repeated testing, there was no consistent change in self-reported risk behaviors. Participants in the ED prevention counseling and testing program considered counseling acceptable and useful, though not required. Given adequate resources, prevention counseling can be provided in the ED, but it is unlikely that all patients benefit. Copyright © 2011. Published by Mosby, Inc.

The Effect of Acute Consumption of Energy Drinks on Blood Pressure, Heart Rate and Blood Glucose in the Group of Young Adults.

PubMed

Nowak, Dariusz; Gośliński, Michał; Nowatkowska, Kamila

2018-03-19

Energy drinks (EDs) are very popular among young people, who consume them for various reasons. A standard ED typically contains 80 mg of caffeine, as well as glucose, taurine, vitamins and other ingredients. Excessive consumption of EDs and accumulation of the above ingredients, as well as their mutual interactions, can be hazardous to the health of young adults. The purpose of this study was to assess the effect of acute consumption of energy drinks on blood pressure, heart rate and blood glucose. The study involved 68 volunteers, healthy young adults (mean age 25 years), who were divided into two groups: the first consumed three EDs at one-hour intervals, and the second drank the same amount of water. All participants had their blood pressure (BP)-systolic and diastolic (SBP and DBP)-as well as heart rate (HR) and blood glucose (BG) measured. In addition, participants could report any health problems before and after consuming each portion of ED. In the above experiment, having consumed three portions of ED (240 mg of caffeine), the participants presented a significant increase in DBP ( p = 0.003), by over 8%, which coincided with a lack of any significant impact on SBP ( p = 0.809). No significant changes were noted in HR ( p = 0.750). Consumption of EDs caused a significant increase ( p < 0.001) in BG, by ca. 21%, on average. Some participants reported various discomforts, which escalated after 2 and 3 EDs. Acute consumption of EDs contributed to increased diastolic blood pressure, blood glucose and level of discomfort in healthy young people. Our results reinforce the need for further studies on a larger population to provide sufficient evidence.

Excessive Daytime Sleepiness Predicts Neurodegeneration in Idiopathic REM Sleep Behavior Disorder.

PubMed

Zhou, Junying; Zhang, Jihui; Lam, Siu Ping; Chan, Joey Wy; Mok, Vincent; Chan, Anne; Li, Shirley Xin; Liu, Yaping; Tang, Xiangdong; Yung, Wing Ho; Wing, Yun Kwok

2017-05-01

To determine the association of excessive daytime sleepiness (EDS) with the conversion of neurodegenerative diseases in patients with idiopathic REM sleep behavior disorder (iRBD). A total of 179 patients with iRBD (79.1% males, mean age = 66.3 ± 9.8 years) were consecutively recruited. Forty-five patients with Epworth Sleepiness Scale score ≥14 were defined as having EDS. Demographic, clinical, and polysomnographic data were compared between iRBD patients with and without EDS. The risk of developing neurodegenerative diseases was examined using Cox proportional hazards model. After a mean follow-up of 5.8 years (SD = 4.3 years), 50 (27.9%) patients developed neurodegenerative diseases. There was a significantly higher proportion of conversion in patients with EDS compared to those without EDS (42.2 % vs. 23.1%, p = .01). EDS significantly predicted an increased risk of developing neurodegenerative diseases (adjusted hazard ratios [HR] = 2.56, 95% confidence interval [CI] 1.37 to 4.77) after adjusting for age, sex, body mass index, current depression, obstructive sleep apnea, and periodic limb movements during sleep. Further analyses demonstrated that EDS predicted the conversion of Parkinson's disease (PD) (adjusted HR = 3.55, 95% CI 1.59 to 7.89) but not dementia (adjusted HR = 1.48, 95% CI 0.44 to 4.97). EDS is associated with an increased risk of developing neurodegenerative diseases, especially PD, in patients with iRBD. Our findings suggest that EDS is a potential clinical biomarker of α-synucleinopathies in iRBD. © Sleep Research Society 2017. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.

Impact of a logistics management program on admitted patient boarders within an emergency department.

PubMed

Healy-Rodriguez, Mary Anne; Freer, Chris; Pontiggia, Laura; Wilson, Rula; Metraux, Steve; Lord, Lyndsey

2014-03-01

ED crowding is a public health issue, and hospitals across the country must pursue aggressive strategies to improve patient flow to help solve this growing problem. The logistics management program (LMP) is an expansion of the bed management process to include a systematic approach to patient flow management throughout the facility and a clinical liaison or field agent to drive throughput at all points of care. The purpose of this study was to examine the effects of an LMP on ED length of stay (ED evaluation times and ED placement times), as well as inpatient length of stay (IPLOS). This is a quasi-experimental study of 28,684 ED admissions in a suburban, tertiary medical center before and after implementing an LMP (2008 vs 2009). The median ED evaluation time was 219 minutes (interquartile range [IQR], 178 minutes) in 2008 versus 207 minutes (IQR, 171 minutes) in 2009 (P < .001). The median ED placement time was 219 minutes (IQR, 259 minutes) in 2008 versus 193 minutes (IQR, 158 minutes) in 2009 (P < .001). The median IPLOS was 3.93 days (IQR, 4.9 days) in 2008 versus 3.83 days (IQR, 4.7 days) in 2009 (P < .001), which represents a reduction of 1,483 inpatient days in 2009. The results provide strong evidence to support the impact of an LMP on decreasing ED evaluation times, ED placement times, and IPLOS. Further exploration is needed to examine the program as a best practice, as well as its applicability for other facilities. Copyright © 2014 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.

Self-reported sitting time and prevalence of erectile dysfunction in Japanese patients with type 2 diabetes mellitus: The Dogo Study.

PubMed

Furukawa, Shinya; Sakai, Takenori; Niiya, Tetsuji; Miyaoka, Hiroaki; Miyake, Teruki; Yamamoto, Shin; Kanzaki, Sayaka; Maruyama, Koutatsu; Tanaka, Keiko; Ueda, Teruhisa; Senba, Hidenori; Torisu, Masamoto; Minami, Hisaka; Tanigawa, Takeshi; Matsuura, Bunzo; Hiasa, Yoichi; Miyake, Yoshihiro

2017-01-01

No evidence exists regarding the association between sitting time and erectile dysfunction (ED) among patients with type 2 diabetes mellitus. The aim of this study was to evaluate the association between self-reported sitting time and ED among patients with type 2 diabetes mellitus. Study subjects were 430 male Japanese patients with type 2 diabetes mellitus (mean age, 60.5years). A self-administered questionnaire was used to collect information on the variables under study. The study subjects were asked about time spent sitting during typical 24-hour periods over the past 12months. Subjects were divided into four groups according to self-reported sitting time: 1) <5hours, 2) 5-7hours, 3) 7-9hours, and 4) ≥9hours. ED was defined as present when a subject had a Sexual Health Inventory for Men score <8. Adjustment was made for age, body mass index, duration of type 2 diabetes, current smoking, current drinking, hypertension, coronary artery disease, stroke, glycated hemoglobin, walking habit, and diabetic neuropathy. The prevalence values of moderate to severe ED and severe ED were 36.1% and 49.8%. At least 9hours sitting was independently positively associated with severe ED but not moderate to severe ED; the adjusted OR was 1.84 (95% CI: 1.06-3.33). In the multivariate model, there was a statistically significant inverse exposure-response relationship between the self-reported sitting time and severe ED (p for trend=0.029). Self-reported sitting time may be positively associated with ED in Japanese patients with type 2 diabetes mellitus. Copyright © 2017 Elsevier Inc. All rights reserved.

Association between ambulance diversion and survival among patients with acute myocardial infarction.

PubMed

Shen, Yu-Chu; Hsia, Renee Y

2011-06-15

Ambulance diversion, a practice in which emergency departments (EDs) are temporarily closed to ambulance traffic, might be problematic for patients experiencing time-sensitive conditions, such as acute myocardial infarction (AMI). However, there is little empirical evidence to show whether diversion is associated with worse patient outcomes. To analyze whether temporary ED closure on the day a patient experiences AMI, as measured by ambulance diversion hours of the nearest ED, is associated with increased mortality rates among patients with AMI. DESIGN, STUDY, AND PARTICIPANTS: A case-crossover design of 13,860 Medicare patients with AMI from 508 zip codes within 4 California counties (Los Angeles, San Francisco, San Mateo, and Santa Clara) whose admission date was between 2000 and 2005. Data included 100% Medicare claims data that covered admissions between 2000 and 2005, linked with date of death until 2006, and daily ambulance diversion logs from the same 4 counties. Among the hospital universe, 149 EDs were identified as the nearest ED to these patients. The percentage of patients with AMI who died within 7 days, 30 days, 90 days, 9 months, and 1 year from admission (when their nearest ED was not on diversion and when that same ED was exposed to <6, 6 to <12, and ≥12 hours of diversion out of 24 hours on the day of admission). Between 2000 and 2006, the mean (SD) daily diversion duration was 7.9 (6.1) hours. Based on analysis of 11,625 patients admitted to the ED between 2000 and 2005, and whose nearest ED had at least 3 diversion exposure levels (3541, 3357, 2667, and 2060 patients for no exposure, exposure to <6, 6 to <12, and ≥12 hours of diversion, respectively), there were no statistically significant differences in mortality rates between no diversion and exposure to less than 12 hours of diversion. Exposure to 12 or more hours of diversion was associated with higher 30-day mortality vs no diversion status (unadjusted mortality rate, 392 patients [19%] vs 545 patients [15%]; regression adjusted difference, 3.24 percentage points; 95% confidence interval [CI], 0.60-5.88); higher 90-day mortality (537 patients [26%] vs 762 patients [22%]; 2.89 percentage points; 95% CI, 0.13-5.64); higher 9-month mortality (680 patients [33%] vs 980 patients [28%]; 2.93 percentage points; 95% CI, 0.15-5.71); and higher 1-year mortality (731 patients [35%] vs 1034 patients [29%]; 3.04 percentage points; 95% CI, 0.33-5.75). Among Medicare patients with AMI in 4 populous California counties, exposure to at least 12 hours of diversion by the nearest ED was associated with increased 30-day, 90-day, 9-month, and 1-year mortality.

An analysis of ED utilization by adults with intellectual disability.

PubMed

Venkat, Arvind; Pastin, Rene B; Hegde, Gajanan G; Shea, John M; Cook, Jeffrey T; Culig, Carl

2011-05-01

We sought to identify factors increasing the odds of ED utilization among intellectually disabled (ID) adults and differentiate their discharge diagnoses from the general adult ED population. This was a retrospective, observational open cohort study of all ID adults residing at an intermediate care facility and their ED visits to a tertiary center (January 1, 2007-July 30, 2008). We abstracted from the intermediate care facility database subjects' demographic, ID, health and adaptive status variables, and their requirement of ED care/hospitalization. We obtained from the hospital database the primary International Classification of Diseases 9 ED/hospital discharge diagnoses for the study and general adult population. Using multivariate logistic regression, we computed odds ratios (OR) for ED utilization/hospitalization in the cohort. Using the conditional large-sample binomial test, we differentiated the study and general populations' discharge diagnoses. A total of 433 subjects met the inclusion criteria. Gastrostomy/jejunostomy increased the odds of ED utilization (OR, 4.16; confidence interval [CI], 1.64-10.58). Partial help to feed (OR, 2.59; CI, 1.14-5.88), gastrostomy/jejunostomy (OR, 3.26; CI, 1.30-8.18), and increasing number of prescribed medications (OR, 1.08; CI, 1.03-1.14) increased the odds of hospitalization. Auditory impairment (OR, 0.45; CI, 0.23-0.88) decreased the odds of hospitalization. For ED discharge diagnoses, ID adults were more likely (P < .05) than the general population to have diagnoses among digestive disorders and ill-defined symptoms/signs. For hospital discharge diagnoses, ID adults were more likely (P < .05) to have diagnoses among infectious/parasitic, nervous system, and respiratory disorders. Among ID adults, feeding status increased the odds of ED utilization, feeding status, and increasing number of prescribed medications of that hospitalization. Intellectually disabled adults' discharge diagnoses differed significantly from the general adult ED population. Copyright © 2011 Elsevier Inc. All rights reserved.

Does Orthopaedic Outpatient Care Reduce Emergency Department Utilization After Total Joint Arthroplasty?

PubMed

Chaudhary, Muhammad Ali; Lange, Jeffrey K; Pak, Linda M; Blucher, Justin A; Barton, Lauren B; Sturgeon, Daniel J; Koehlmoos, Tracey; Haider, Adil H; Schoenfeld, Andrew J

2018-05-22

Emergency department (ED) visits after elective surgical procedures are a potential target for interventions to reduce healthcare costs. More than 1 million total joint arthroplasties (TJAs) are performed each year with postsurgical ED utilization estimated in the range of 10%. We asked whether (1) outpatient orthopaedic care was associated with reduced ED utilization and (2) whether there were identifiable factors associated with ED utilization within the first 30 and 90 days after TJA. An analysis of adult TRICARE beneficiaries who underwent TJA (2006-2014) was performed. TRICARE is the insurance program of the Department of Defense, covering > 9 million beneficiaries. ED use within 90 days of surgery was the primary outcome and postoperative outpatient orthopaedic care the primary explanatory variable. Patient demographics (age, sex, race, beneficiary category), clinical characteristics (length of hospital stay, prior comorbidities, complications), and environment of care were used as covariates. Logistic regression adjusted for all covariates was performed to determine factors associated with ED use. We found that orthopaedic outpatient care (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.68-0.77) was associated with lower odds of ED use within 90 days. We also found that index hospital length of stay (OR, 1.07; 95% CI, 1.04-1.10), medical comorbidities (OR, 1.16; 95% CI, 1.08-1.24), and complications (OR, 2.47; 95% CI, 2.24-2.72) were associated with higher odds of ED use. When considering that at 90 days, only 3928 patients sustained a complication, a substantial number of ED visits (11,486 of 15,414 [75%]) after TJA may be avoidable. Enhancing access to appropriate outpatient care with improved discharge planning may reduce ED use after TJA. Further research should be directed toward unpacking the situations, outside of complications, that drive patients to access the ED and devise interventions that could mitigate such behavior. Level III, therapeutic study.

The association between crowding and mortality in admitted pediatric patients from mixed adult-pediatric emergency departments in Korea.

PubMed

Cha, Won Chul; Shin, Sang Do; Cho, Jin Sung; Song, Kyoung Jun; Singer, Adam J; Kwak, Young Ho

2011-12-01

We aimed to investigate the effect of crowding on the hospital mortality of pediatric patients from adult-pediatric mixed emergency departments (EDs). We used the National Emergency Department Information System database, which included demographic, clinical, diagnostic, and procedural information with all emergency patients visiting to 116 EDs from Korea since 2004. We enrolled EDs with mean length of stay of more than 6 hours. Study period was from January 2006 to December 2008. Pediatric patients younger than 15 years admitted from these EDs were study targets. We calculated the mean patient volume (mean number of patients in the ED) over 8-hour shift for each hospital. When the volume reached the highest quartile, the period was considered as crowded. Patients who came during the overcrowded period were defined as the crowded group. We performed a Kaplan-Meier analysis, and hazard ratio and 95% confidence intervals (95% CIs) were calculated using a Cox proportional hazards regression model. A total of 34 EDs and 125,031 admitted pediatric patients were included; 74,152 (59.3%) were male, and the mean age was 3.84 (95% CI, 3.82-3.86) years; 35,924 (28.7%) were determined as the crowded group. The 30-day mortality rates were 0.4% and 0.3% (P = 0.063) for the crowded group and for the noncrowded group, respectively. The hazard ratio for hospital mortality of the crowded group was 1.230 (95% CI, 1.019-1.558). The ED crowding was associated with increased hazard for hospital mortality for pediatric patients in mixed EDs.

Emergency medicine: an operations management view.

PubMed

Soremekun, Olan A; Terwiesch, Christian; Pines, Jesse M

2011-12-01

Operations management (OM) is the science of understanding and improving business processes. For the emergency department (ED), OM principles can be used to reduce and alleviate the effects of crowding. A fundamental principle of OM is the waiting time formula, which has clear implications in the ED given that waiting time is fundamental to patient-centered emergency care. The waiting time formula consists of the activity time (how long it takes to complete a process), the utilization rate (the proportion of time a particular resource such a staff is working), and two measures of variation: the variation in patient interarrival times and the variation in patient processing times. Understanding the waiting time formula is important because it presents the fundamental parameters that can be managed to reduce waiting times and length of stay. An additional useful OM principle that is applicable to the ED is the efficient frontier. The efficient frontier compares the performance of EDs with respect to two dimensions: responsiveness (i.e., 1/wait time) and utilization rates. Some EDs may be "on the frontier," maximizing their responsiveness at their given utilization rates. However, most EDs likely have opportunities to move toward the frontier. Increasing capacity is a movement along the frontier and to truly move toward the frontier (i.e., improving responsiveness at a fixed capacity), we articulate three possible options: eliminating waste, reducing variability, or increasing flexibility. When conceptualizing ED crowding interventions, these are the major strategies to consider. © 2011 by the Society for Academic Emergency Medicine.

New Zealand's emergency department target - did it reduce ED length of stay, and if so, how and when?

PubMed

Tenbensel, Tim; Chalmers, Linda; Jones, Peter; Appleton-Dyer, Sarah; Walton, Lisa; Ameratunga, Shanthi

2017-09-26

In 2009, the New Zealand government introduced a hospital emergency department (ED) target - 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when. We adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing. Reported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing. While the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in 'standing for' improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain.

Health information exchange reduces repeated diagnostic imaging for back pain.

PubMed

Bailey, James E; Pope, Rebecca A; Elliott, Elizabeth C; Wan, Jim Y; Waters, Teresa M; Frisse, Mark E

2013-07-01

This study seeks to determine whether health information exchange reduces repeated diagnostic imaging and related costs in emergency back pain evaluation. This was a longitudinal data analysis of health information exchange patient-visit data. All repeated emergency department (ED) patient visits for back pain with previous ED diagnostic imaging to a Memphis metropolitan area ED between August 1, 2007, and July 31, 2009, were included. Use of a regional health information exchange by ED personnel to access the patient's record during the emergency visit was the primary independent variable. Main outcomes included repeated lumbar or thoracic diagnostic imaging (radiograph, computed tomography [CT], or magnetic resonance imaging [MRI]) and total patient-visit estimated cost. One hundred seventy-nine (22.4%) of the 800 qualifying repeated back pain visits resulted in repeated diagnostic imaging (radiograph 84.9%, CT 6.1%, and MRI 9.5%). Health information exchange use in the study population was low, at 12.5%, and health care providers as opposed to administrative/nursing staff accounted for 80% of the total health information exchange use. Health information exchange use by any ED personnel was associated with reduced repeated diagnostic imaging (odds ratio 0.36; 95% confidence interval 0.18 to 0.71), as was physician or nurse practitioner health information exchange use (odds ratio 0.47; 95% confidence interval 0.23 to 0.96). No cost savings were associated with health information exchange use because of increased CT imaging when health care providers used health information exchange. Health information exchange use is associated with 64% lower odds of repeated diagnostic imaging in the emergency evaluation of back pain. Health information exchange effect on estimated costs was negligible. More studies are needed to evaluate specific strategies to increase health information exchange use and further decrease potentially unnecessary diagnostic imaging and associated costs of care. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Association of Areca Nut Chewing With Risk of Erectile Dysfunction.

PubMed

Huang, Yung-Jui; Jiann, Bang-Ping

2017-09-01

Areca nut chewing has been shown to increase the risk of cardiovascular disease, but its association with erectile dysfunction (ED) has not been investigated. To investigate the association between areca nut chewing and risk of ED. Consecutive men at public health centers for oral malignancy screening or health checkup were invited to complete a questionnaire. The Sexual Health Inventory for Men (SHIM). Of the 2,652 respondents, 1,038 (mean age = 43.8 ± 11.1 years) were eligible for the areca nut chewing group and 1,090 non-areca nut chewers were selected as the age-matched control group. In the areca nut group, the mean duration of chewing was 13.2 ± 9.6 years, 61.7% consumed more than 10 portions per day, and 76.2% used it with betel leaf, 16.7% used it with betel inflorescence, and 7.1% used it with betel leaf and inflorescence. Smoking, alcohol drinking, obesity, hypertension, and diabetes were more predominant in areca nut chewers compared with controls. ED defined by self-report and by SHIM score was more prevalent in areca nut chewers than in controls (13.7% vs 9.8% and 48.7% vs 43.3%, respectively; P < .05 for the two comparisons). Areca nut use with betel inflorescence was associated with a higher risk of ED (odds ratio = 2.25, 95% confidence interval = 1.55-3.28) with a dose-dependent effect, whereas using it with betel leaf was not (odds ratio = 1.00, 95% confidence interval = 0.79-1.26) after adjustment of possible confounders. Areca nut chewing with betel inflorescence was associated with an increased risk of ED. These findings warrant further studies. Huang Y-J, Jiann B-P. Association of Areca Nut Chewing With Risk of Erectile Dysfunction. Sex Med 2017;5:e163-e168. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study.

PubMed

Grewal, Keerat; Austin, Peter C; Kapral, Moira K; Lu, Hong; Atzema, Clare L

2015-01-01

The purpose of this study was to determine the proportion of emergency department (ED) patients with a diagnosis of peripheral vertigo who received computed tomography (CT) head imaging in the ED and to examine whether strokes were missed using CT imaging. This population-based retrospective cohort study assessed patients who were discharged from an ED in Ontario, Canada, with a diagnosis of peripheral vertigo, April 2006 to March 2011. Patients who received CT imaging (exposed) were matched by propensity score methods to patients who did not (unexposed). If performed, CT imaging was presumed to be negative for stroke because brain stem/cerebellar stroke would result in hospitalization. We compared the incidence of stroke within 30, 90, and 365 days subsequent to ED discharge between groups, to determine whether the exposed group had a higher frequency of early strokes than the matched unexposed group. Among 41 794 qualifying patients, 8596 (20.6%) received ED head CT imaging, and 99.8% of these patients were able to be matched to a control. Among exposed patients, 25 (0.29%) were hospitalized for stroke within 30 days when compared with 11 (0.13%) among matched nonexposed patients. The relative risk of a 30- and 90-day stroke among exposed versus unexposed patients was 2.27 (95% confidence interval, 1.12-4.62) and 1.94 (95% confidence interval, 1.10-3.43), respectively. There was no difference between groups at 1 year. Strokes occurred at a median of 32.0 days (interquartile range, 4.0-33.0 days) in exposed patients, compared with 105 days (interquartile range, 11.5-204.5) in unexposed patients. One fifth of patients diagnosed with peripheral vertigo in Ontario received imaging that is not recommended in guidelines, and that imaging was associated with missed strokes. © 2014 American Heart Association, Inc.

Phenotypic characterization of mononuclear inflammatory cells following equine hydroxyapatite/collagen block grafting in rats.

PubMed

Alsuwaiyan, Asim; Wang, Bing-Yan; Cohen, Robert E

2012-12-01

To measure the inflammatory changes associated with the implantation of an equine hydroxyapatite and collagen-containing block graft (eHAC block) in a rodent model system, an eHAC block graft was implanted subcutaneously in rats. Control groups included saline, turpentine oil, and human mineralized particulate allograft (hMPA). Animals were sacrificed and tissue samples obtained after three days, as well as after 1, 2, 4 and 8 weeks. A panel of immunologic probes was used to identify circulatory monocytic cells (ED1), resident mononuclear phagocytes (ED2), mononuclear phagocytes of lymphoid origin (ED3), expression of Ia antigen (OX6), T-cells (OX19), and B-cells (OX33). Immunocytochemical localization was performed and mononuclear cells localized with each immunologic probe counted. Rat sera obtained after eight weeks were used for nitrocellulose dot-blotting to assess circulating anti-equine immunoglobulins. Statistical analysis was performed using two-way analysis of variance, in conjunction with the Bonferroni correction to account for multiple comparisons. A transient increase in monocytes at 3 days and 1 week was observed in all groups, but was significantly higher in the turpentine control (P < 0.0001). A significant increase in the numbers of mononuclear cells detected with clones ED2 and ED3 was observed in specimens from the turpentine group, in contrast to the other groups in the 3 day to 4 week interval (P < 0.0001), as well as within all time periods (P < 0.0001). A statistically significant difference in numbers of ED3-positive cells was observed in the hMPA group compared to the saline and the eHAC block groups after one week (P < 0.0001). Significantly more OX6-positive cells were observed in the turpentine group, compared to other groups (3 days to 1 week; P < 0.0001). T-lymphocytes were essentially absent except for rats given turpentine (after 1 week). No B-lymphocyte response was found and none of the rats developed systemic anti-equine antibodies. These data indicate that a cellular immune response is not elicited following implantation with the eHAC block graft, which might serve as an alternative material for regenerative therapy.

Validation of the Brief Confusion Assessment Method for Screening Delirium in Elderly Medical Patients in a German Emergency Department.

PubMed

Baten, Verena; Busch, Hans-Jörg; Busche, Caroline; Schmid, Bonaventura; Heupel-Reuter, Miriam; Perlov, Evgeniy; Brich, Jochen; Klöppel, Stefan

2018-05-08

Delirium is frequent in elderly patients presenting in the emergency department (ED). Despite the severe prognosis, the majority of delirium cases remain undetected by emergency physicians (EPs). At the time of our study there was no valid delirium screening tool available for EDs in German-speaking regions. We aimed to evaluate the brief Confusion Assessment Method (bCAM) for a German ED during the daily work routine. We implemented the bCAM into practice in a German interdisciplinary high-volume ED and evaluated the bCAM's validity in a convenience sample of medical patients aged ≥ 70 years. The bCAM, which assesses four core features of delirium, was performed by EPs during their daily work routine and compared to a criterion standard based on the criteria for delirium as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Compared to the criterion standard, delirium was found to be present in 46 (16.0%) of the 288 nonsurgical patients enrolled. The bCAM showed 93.8% specificity (95% confidence interval [CI] = 90.0%-96.5%) and 65.2% sensitivity (95% CI = 49.8%-78.7%). Positive and negative likelihood ratios were 10.5 and 0.37, respectively, while the odds ratio was 28.4. Delirium was missed in 10 of 16 cases, since the bCAM did not indicate altered levels of consciousness and disorganized thinking. The level of agreement with the criterion standard increased for patients with low cognitive performance. This was the first study evaluating the bCAM for a German ED and when performed by EPs during routine work. The bCAM showed good specificity, but only moderate sensitivity. Nevertheless, application of the bCAM most likely improves the delirium detection rate in German EDs. However, it should only be applied by trained physicians to maximize diagnostic accuracy and hence improve the bCAM's sensitivity. Future studies should refine the bCAM. © 2018 by the Society for Academic Emergency Medicine.

Personality prototype as a risk factor for eating disorders.

PubMed

Sanchez-Guarnido, Antonio J; Pino-Osuna, Maria J; Herruzo-Cabrera, Francisco J

2015-01-01

To establish whether the risk of suffering from an eating disorder (ED) is associated with the high-functioning, undercontrolled, or overcontrolled personality prototype groups. The Revised NEO Personality Inventory (NEO-PI-R) and the Eating Disorder Inventory 2 (EDI-2) were administered to 69 patients diagnosed as suffering from EDs (cases) and 89 people free of any ED symptoms (control group). A cluster analysis was carried out to divide the participants into three groups based on their scores in the Big Five personality dimensions. A logistic regression model was then created. Participants in the undercontrolled group had a risk of suffering from an ED 6.517 times higher than those in the high-functioning group (p = 0.019; odds ratio [OR] = 6.517), while those in the overcontrolled subgroup had a risk of ED 15.972 times higher than those in the high-functioning group. Two personality subtypes were identified in which the risk of EDs was six times higher (the undercontrolled group) and almost 16 times higher (the overcontrolled group). Prevention and treatment programs for ED could benefit from focusing on the abovementioned personality profiles.

A comparison of continuous- and discrete- time three-state models for rodent tumorigenicity experiments.

PubMed Central

Lindsey, J C; Ryan, L M

1994-01-01

The three-state illness-death model provides a useful way to characterize data from a rodent tumorigenicity experiment. Most parametrizations proposed recently in the literature assume discrete time for the death process and either discrete or continuous time for the tumor onset process. We compare these approaches with a third alternative that uses a piecewise continuous model on the hazards for tumor onset and death. All three models assume proportional hazards to characterize tumor lethality and the effect of dose on tumor onset and death rate. All of the models can easily be fitted using an Expectation Maximization (EM) algorithm. The piecewise continuous model is particularly appealing in this context because the complete data likelihood corresponds to a standard piecewise exponential model with tumor presence as a time-varying covariate. It can be shown analytically that differences between the parameter estimates given by each model are explained by varying assumptions about when tumor onsets, deaths, and sacrifices occur within intervals. The mixed-time model is seen to be an extension of the grouped data proportional hazards model [Mutat. Res. 24:267-278 (1981)]. We argue that the continuous-time model is preferable to the discrete- and mixed-time models because it gives reasonable estimates with relatively few intervals while still making full use of the available information. Data from the ED01 experiment illustrate the results. PMID:8187731

Cost-Sharing for Emergency Care and Unfavorable Clinical Events: Findings from the Safety and Financial Ramifications of ED Copayments Study

PubMed Central

Hsu, John; Price, Mary; Brand, Richard; Ray, G Thomas; Fireman, Bruce; Newhouse, Joseph P; Selby, Joseph V

2006-01-01

Objective To evaluate the effect of emergency department (ED) copayment levels on ED use and unfavorable clinical events. Data Source/Study Setting Kaiser Permanente–Northern California (KPNC), a prepaid integrated delivery system. Study Design In a quasi-experimental longitudinal study with concurrent controls, we estimated rates of ED visits, hospitalizations, ICU admissions, and deaths associated with higher ED copayments relative to no copayment, using Poisson random effects and proportional hazard models, controlling for patient characteristics. The study period began in January 1999; more than half of the population experienced an employer-chosen increase in their ED copayment in January 2000. Data Collection/Extraction Methods Using KPNC automated databases, the 2000 U.S. Census, and California state death certificates, we collected data on ED visits and unfavorable clinical events over a 36-month period (January 1999 through December 2001) among 2,257,445 commercially insured and 261,091 Medicare insured health system members. Principal Findings Among commercially insured subjects, ED visits decreased 12 percent with the $20–35 copayment (95 percent confidence interval [CI]: 11–13 percent), and 23 percent with the $50–100 copayment (95 percent CI: 23–24 percent) compared with no copayment. Hospitalizations, ICU admissions, and deaths did not increase with copayments. Hospitalizations decreased 4 percent (95 percent CI: 2–6 percent) and 10 percent (95 percent CI: 7–13 percent) with ED copayments of $20–35 and $50–100, respectively, compared with no copayment. Among Medicare subjects, ED visits decreased by 4 percent (95 percent CI: 3–6 percent) with the $20–50 copayments compared with no copayment; unfavorable clinical events did not increase with copayments, e.g., hospitalizations were unchanged (95 percent CI: −3 percent to +2 percent) with $20–50 ED copayments compared with no copayment. Conclusions Relatively modest levels of patient cost-sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events. PMID:16987303

Effectiveness of Emergency Department Based Palliative Care for Adults with Advanced Disease: A Systematic Review

PubMed Central

Nunes, Cristina Moura; Gomes, Barbara

2016-01-01

Abstract Background: Emergency departments (EDs) are seeing more patients with palliative care (PC) needs, but evidence on best practice is scarce. Objectives: To examine the effectiveness of ED-based PC interventions on hospital admissions (primary outcome), length of stay (LOS), symptoms, quality of life, use of other health care services, and PC referrals for adults with advanced disease. Methods: We searched five databases until August 2014, checked reference lists/conference abstracts, and contacted experts. Eligible studies were controlled trials, pre-post studies, cohort studies, and case series reporting outcomes of ED-based PC. Results: Five studies with 4374 participants were included: three case series and two cohort studies. Interventions included a screening tool, traditional ED-PC, and integrated ED-PC. Two studies reported on hospital admissions: in one study there was no statistically significant difference in 90-day readmission rates between patients who initiated integrated PC at the ED (11/50 patients, 22%) compared to those who initiated PC after hospital admission (179/1385, 13%); another study showed a high admission rate (90%) in 14 months following ED-PC, but without comparison. One study showed an LOS reduction (mean 4.32 days in ED-initiated PC group versus 8.29 days in postadmission-initiated group; p < 0.01). There was scarce evidence on other outcomes except for conflicting findings on survival: in one study, ED-PC patients were more likely to experience an interval between ED presentation and death >9 hours (OR 2.75, 95% CI 2.21–3.41); another study showed increased mortality risk in the intervention group; and a case series described a higher in-hospital death rate when PC was ED-initiated (62%), compared to ward (16%) or ICU (50%) (unknown p-value). Conclusions: There is yet no evidence that ED-based PC affects patient outcomes except for indication from one study of no association with 90-day hospital readmission but a possible reduction in LOS if integrated PC is introduced early at ED rather than after hospital admission. There is an urgent need for trials to confirm these findings alongside other potential benefits and survival effects. PMID:27115914

Code Help: Can This Unique State Regulatory Intervention Improve Emergency Department Crowding?

PubMed

Michael, Sean S; Broach, John P; Kotkowski, Kevin A; Brush, D Eric; Volturo, Gregory A; Reznek, Martin A

2018-05-01

Emergency department (ED) crowding adversely affects multiple facets of high-quality care. The Commonwealth of Massachusetts mandates specific, hospital action plans to reduce ED boarding via a mechanism termed "Code Help." Because implementation appears inconsistent even when hospital conditions should have triggered its activation, we hypothesized that compliance with the Code Help policy would be associated with reduction in ED boarding time and total ED length of stay (LOS) for admitted patients, compared to patients seen when the Code Help policy was not followed. This was a retrospective analysis of data collected from electronic, patient-care, timestamp events and from a prospective Code Help registry for consecutive adult patients admitted from the ED at a single academic center during a 15-month period. For each patient, we determined whether the concurrent hospital status complied with the Code Help policy or violated it at the time of admission decision. We then compared ED boarding time and overall ED LOS for patients cared for during periods of Code Help policy compliance and during periods of Code Help policy violation, both with reference to patients cared for during normal operations. Of 89,587 adult patients who presented to the ED during the study period, 24,017 (26.8%) were admitted to an acute care or critical care bed. Boarding time ranged from zero to 67 hours 30 minutes (median 4 hours 31 minutes). Total ED LOS for admitted patients ranged from 11 minutes to 85 hours 25 minutes (median nine hours). Patients admitted during periods of Code Help policy violation experienced significantly longer boarding times (median 20 minutes longer) and total ED LOS (median 46 minutes longer), compared to patients admitted under normal operations. However, patients admitted during Code Help policy compliance did not experience a significant increase in either metric, compared to normal operations. In this single-center experience, implementation of the Massachusetts Code Help regulation was associated with reduced ED boarding time and ED LOS when the policy was consistently followed, but there were adverse effects on both metrics during violations of the policy.

Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive, Comparative Analysis Over Time.

PubMed

Fruth, Stacie J; Wiley, Steve

2016-09-01

Emergency department (ED) use in the United States is expected to rapidly increase. Nearly half of all ED visits are classified as semiurgent or nonurgent, and many fall into the musculoskeletal category. Despite growing international evidence that patients are appropriately and safely managed by ED physical therapists in a time-efficient manner, physical therapist practice in EDs is not widely understood or utilized in the United States. To date, no studies have reported the impressions of ED physicians about this practice. The purposes of this study were: (1) to assess ED physicians' impressions of ED physical therapist practice 2 years after practice was initiated and (2) to determine whether physicians' impressions changed 7 years later. All ED staff physicians and medical residents at a level I trauma hospital were invited to complete a survey in 2004 and 2011. In both years, a majority of physicians reported favorable impressions of ED physical therapist practice. Physical therapists were valued for educating patients about safety and injury prevention, providing appropriate gait training, assisting with disposition planning, and providing interventions as alternatives to pain medication. Many physicians supported standing physical therapist orders for certain musculoskeletal conditions. The most common concern was the additional time that patients spend in the ED for a physical therapist consult. The results of this study may not reflect the impressions of physicians in all EDs that employ physical therapists. Emergency department physicians reported favorable impressions of ED physical therapist practice 2 years and 9 years following its implementation in this hospital. This study showed that ED physicians support standing physical therapist orders for certain musculoskeletal conditions, which suggests that direct triage to ED physical therapists for these conditions could be considered. © 2016 American Physical Therapy Association.

Applying the Lean principles of the Toyota Production System to reduce wait times in the emergency department.

PubMed

Ng, David; Vail, Gord; Thomas, Sophia; Schmidt, Nicki

2010-01-01

In recognition of patient wait times, and deteriorating patient and staff satisfaction, we set out to improve these measures in our emergency department (ED) without adding any new funding or beds. In 2005 all staff in the ED at Hôtel-Dieu Grace Hospital began a transformation, employing Toyota Lean manufacturing principles to improve ED wait times and quality of care. Lean techniques such as value-stream mapping, just-in-time delivery techniques, workplace organization, reduction of systemic wastes, use of the worker as the source of quality improvement and ongoing refinement of our process steps formed the basis of our project. Our ED has achieved major improvements in departmental flow without adding any additional ED or inpatient beds. The mean registration to physician time has decreased from 111 minutes to 78 minutes. The number of patients who left without being seen has decreased from 7.1% to 4.3%. The length of stay (LOS) for discharged patients has decreased from a mean of 3.6 to 2.8 hours, with the largest decrease seen in our patients triaged at levels 4 or 5 using the Canadian Emergency Department Triage and Acuity Scale. We noted an improvement in ED patient satisfaction scores following the implementation of Lean principles. Lean manufacturing principles can improve the flow of patients through the ED, resulting in greater patient satisfaction along with reduced time spent by the patient in the ED.

Internet access and electronic communication among families in an urban pediatric emergency department.

PubMed

Saidinejad, Mohsen; Teach, Stephen J; Chamberlain, James M

2012-06-01

The Internet may represent an opportunity for health care providers in the emergency department (ED) to deliver discharge instructions and after-care educational materials electronically to patients and their caregivers. The objectives of this study were to determine the prevalence of Internet access and use among caregivers of children who visit the ED and to evaluate their interest in receiving after-care communication and educational material electronically. We distributed a self-administered survey to a convenience sample of English-speaking caregivers of children who presented to the ED of an urban, academic, pediatric hospital during November and December 2009. The survey was distributed to and completed by 509 English-speaking respondents. Of the participants, 423 (83.1%) of 509 identified themselves as black/African American, and 397 (77.9%) of 509 were publicly insured. Of the participants, 503 of 509 (98.9%; 95% confidence interval [CI], 97.9%-99.8%) reported that they have access to the Internet. Of the participants with Internet access, 312 of 503 (62.0%; 95% CI, 57.8%-66.3%) have access at home, 166 of 503 (33.0%; 95% CI, 28.9%-33.1%) have access at work, and 112 of 503 (22.3%; 95% CI, 18.6%-25.9%) have access by mobile phone. When asked about electronic communication and social networking, 483 of 503 (96.0%; 95% CI, 94.3%-97.7%) have an e-mail account, and 304 of 503 (60.4%; 95% CI, 56.2%-64.7%) have a Facebook account. Furthermore, 353 of 503 (70.1%; 95% CI, 66.2%-74.2%) reported accessing the Internet daily, whereas 128 of 503 (25.4%; 95% CI, 21.6%-29.3%) access the Internet at least 2 to 6 times per week. Among all respondents, interest in receiving communication from the ED only electronically was expressed by 259 of 509 participants (50.9%; 95% CI, 46.5%-55.2%). Approximately one third of the participants (173/509 [34%; 95% CI, 29.9%-38.1%]) expressed interest in an electronic channel for communication between the ED and their child's patient primary care provider. In this predominantly minority and economically disadvantaged population of caregivers presenting to an urban pediatric ED, a large majority reported regular access to the Internet and willingness and ability to receive communication from the ED via electronic means.

Association between reported screening and counseling about energy drinks and energy drink intake among U.S. adolescents.

PubMed

Kumar, Gayathri Suresh; Park, Sohyun; Onufrak, Stephen

2014-02-01

Possible adverse health consequences of excessive energy drink (ED) consumption have led to recommendations by the American Academy of Pediatrics discouraging ED intake by youth. However, limited information on ED counseling by health care providers exists. Data was obtained from the 2011 YouthStyles Survey administered to youth aged 12-17 (n=815). The outcome variable was ED consumption (none vs. ≥1 time/week) and exposure variables were screening and counseling about ED (if doctor/nurse asked about ED consumption and if doctor/nurse recommended against ED consumption). Approximately 8.5% of youth consumed energy drinks weekly, 11.5% reported being asked by their doctor/nurse about frequency of ED consumption, and 11.1% were advised by their doctor/nurse against ED intake. Multivariable logistic regression analysis revealed that the odds for drinking ED ≥1 time/week was significantly higher in youth who were asked how often they drank ED by their doctor/nurse (odds ratio=2.46) vs. those who were not asked. About 1 in 9 youth reported receiving counseling discouraging ED consumption from their doctor/nurse, and a greater proportion of youth who were screened about ED also reported ED consumption. Efforts by health care providers to educate youth about potential harms of consuming ED are needed. Published by Elsevier Ireland Ltd.

Emergency Heart Failure Mortality Risk Grade score performance for 7-day mortality prediction in patients with heart failure attended at the emergency department: validation in a Spanish cohort.

PubMed

Gil, Víctor; Miró, Òscar; Schull, Michael J; Llorens, Pere; Herrero-Puente, Pablo; Jacob, Javier; Ríos, José; Lee, Douglas S; Martín-Sánchez, Francisco J

2018-06-01

The Emergency Heart Failure Mortality Risk Grade (EHMRG) scale, derived in 86 Canadian emergency departments (EDs), stratifies patients with acute-decompensated heart failure (ADHF) according to their 7-day mortality risk. We evaluated its external validity in a Spanish cohort. We applied the EHMRG scale to ADHF patients consecutively included in the Epidemiology of Acute Heart Failure in Emergency departments (EAHFE) registry (29 Spanish EDs) and measured its performance. Patients were distributed into quintiles according to the original and their self-defined score cutoffs. The 7-day mortality rates were compared internally among different categories and with categories of Canadian cohorts. The EAHFE group [n: 1553 patients; 80 (10) years; 55.6% women] had a 5.5% 7-day mortality rate and the EHMRG scale c-statistic was 0.741 (95% confidence interval: 0.688-0.793) compared with 0.807 (0.761-0.842) and 0.804 (0.763-0.840) obtained in the Canadian derivation and validation cohorts. The mortality rate of the EAHFE group mortality increased progressively as the quintile categories increased using intervals defined by either the Canadian or the Spanish EHMRG score cutoffs, although with more regular increments with the EAHFE-defined intervals; using the latter, patients at quintiles 2, 3, 4, 5a and 5b had (compared with quintile 1) odds ratios of 1.77, 3.36, 4.44, 9.39 and 16.19, respectively. The EHMRG scale stratified risk in an ADHF cohort that included both palliative and nonpalliative patients in Spanish EDs, showing an extrapolation to a higher mortality risk cohort than the original derivation sample. Stratification improved when the score was recalibrated in the Spanish cohort.

Validation of Rules to Predict Emergent Surgical Intervention in Pediatric Trauma Patients

PubMed Central

Boatright, Dowin H; Byyny, Richard L; Hopkins, Emily; Bakes, Katherine; Hissett, Jennifer; Tunson, Java; Easter, Joshua S; Vogel, Jody A; Bensard, Denis; Haukoos, Jason S

2014-01-01

Background Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it to the American College of Surgeons’ Major Resuscitation Criteria (MRC). Study Design We used data from 1993 through 2010 from two Level 1 trauma centers in Denver, Colorado. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within one hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED) was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals (CIs) were calculated. Results 8,078 patients were included and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (IQR: 7–14), 70% were male, 30% had penetrating mechanisms, and the median ISS was 25 (IQR: 9–41). At the two institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI: 45%–94%) and 76% (95% CI: 69%–83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI: 70%–92%) and 81% (95% CI: 77%–85%), respectively. Conclusions Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use. PMID:23623222

Temporal Processing of Joyful and Disgusting Food Pictures by Women With an Eating Disorder

PubMed Central

Gagnon, Caroline; Bégin, Catherine; Laflamme, Vincent; Grondin, Simon

2018-01-01

The present study used the presentation of food pictures and judgements about their duration to assess the emotions elicited by food in women suffering from an eating disorder (ED). Twenty-three women diagnosed with an ED, namely anorexia (AN) or bulimia nervosa (BN), and 23 healthy controls (HC) completed a temporal bisection task and a duration discrimination task. Intervals were marked with emotionally pre-rated pictures of joyful and disgusting food, and pictures of neutral objects. The results showed that, in the bisection task, AN women overestimated the duration of food pictures in comparison to neutral ones. Also, compared to participants with BN, they perceived the duration of joyful food pictures as longer, and tended to overestimate the duration of the disgusting ones. These effects on perceived duration suggest that AN women experienced an intense reaction of fear when they were confronted to food pictures. More precisely, by having elevated the arousal level and activated the defensive system, food pictures seemed to have speeded up the rhythm of the AN participants’ internal clock, which led to an overestimation of images’ duration. In addition, the results revealed that, in both tasks, ED women presented a lower temporal sensitivity than HC, which was related to their ED symptomatology (i.e., BMI, restraint and concern) and, particularly, to their weaker cognitive abilities in terms of attention, processing speed and working memory. Considered all together, the findings of the present experiment highlight the role of fear and anxiety in the manifestations of AN and point out the importance of considering non-temporal factors in the interpretation of time perception performance. PMID:29681806

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals.

PubMed

Thompson, Graham C; Schuh, Suzanne; Gravel, Jocelyn; Reid, Sarah; Fitzpatrick, Eleanor; Turner, Troy; Bhatt, Maala; Beer, Darcy; Blair, Geoffrey; Eccles, Robin; Jones, Sarah; Kilgar, Jennifer; Liston, Natalia; Martin, John; Hagel, Brent; Nettel-Aguirre, Alberto

2015-07-01

The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes. © 2015 by the Society for Academic Emergency Medicine.

Missed Fractures in Infants Presenting to the Emergency Department With Fussiness.

PubMed

Kondis, Jamie S; Muenzer, Jared; Luhmann, Janet D

2017-08-01

The aim of this study was to evaluate incidence of prior fussy emergency visits in infants with subsequently diagnosed fractures suggestive of abuse. This was a retrospective chart review of infants younger than 6 months who presented to the pediatric emergency department (ED) between January 1, 2006, and December 31, 2011. Inclusion criteria included age 0 to 6 months, discharge diagnosis including "fracture," "broken" (or break), or "trauma" or any child abuse diagnosis or chief complaint of "fussy" or "crying" as documented in the electronic medical record by the triage nurse. Three thousand seven hundred thirty-two charts were reviewed, and 279 infants with fractures were identified. Eighteen (6.5%) of 279 infants had a prior ED visit for fussiness without an obvious source. Of these, 2 had a witnessed event causing their fracture, and therefore the fracture was not considered concerning for abuse. The remaining 16 had fractures concerning for abuse. Mean age was 2.5 (SD, 1.2) months. Fifteen (83%) of 18 infants were 3 months or younger at the time of the fussy visit. The mean interval between the first and second ED visits was 27 days (median, 20 days). Thirty-nine percent were evaluated by a pediatric emergency medicine-trained physician during their initial fussy visit, whereas 78% were evaluated by pediatric emergency medicine-trained physician during their subsequent visit. Most common injuries were multiple types of fractures followed by extremity and rib fractures. Fractures concerning for child abuse are an important cause of unexplained fussiness in infants presenting to the pediatric ED. A high index of suspicion is essential for prompt diagnosis and likely prevention of other abuse.

Inhibitor development in non-severe haemophilia across Europe.

PubMed

Fischer, Kathelijn; Iorio, Alfonso; Lassila, Riitta; Peyvandi, Flora; Calizzani, Gabriele; Gatt, Alex; Lambert, Thierry; Windyga, Jerzy; Gilman, Estelle A; Hollingsworth, R; Makris, Michael

2015-10-01

Evidence about inhibitor formation in non-severe haemophilia and the potential role for clotting factor concentrate type is scant. It was the aim of this study to report inhibitor development in non-severe haemophilia patients enrolled in the European Haemophilia Safety Surveillance (EUHASS) study. Inhibitors are reported quarterly and total treated patients annually. Incidence rates and 95% confidence intervals (95% CI) were calculated according to diagnosis and concentrate used. Between 1-10-2008 and 31-12-2012, 68 centres reported on 7,969 patients with non-severe haemophilia A and 1,863 patients with non-severe haemophilia B. For haemophilia A, 37 inhibitors occurred in 8,622 treatment years, resulting in an inhibitor rate of 0.43/100 treatment years (95% CI 0.30-0.59). Inhibitors occurred at a median age of 35 years, after a median of 38 exposure days (EDs; P25-P75: 20-80); with 72% occurring within the first 50 EDs. In haemophilia B, one inhibitor was detected in 2,149 treatment years, resulting in an inhibitor rate of 0.05/100 years (95% CI 0.001-0.26). This inhibitor developed at the age of six years, after six EDs. The rate of inhibitors appeared similar across recombinant and plasma derived factor VIII (FVIII) concentrates. Rates for individual concentrates could not be calculated at this stage due to low number of events. In conclusion, inhibitors in non-severe haemophilia occur three times more frequently than in previously treated patients with severe haemophilia at a rate of 0.43/100 patient years (haemophilia A) and 0.05/100 years (haemophilia B). Although the majority of inhibitors developed in the first 50 EDs, inhibitor development continued with increasing exposure to FVIII.

Temporal Processing of Joyful and Disgusting Food Pictures by Women With an Eating Disorder.

PubMed

Gagnon, Caroline; Bégin, Catherine; Laflamme, Vincent; Grondin, Simon

2018-01-01

The present study used the presentation of food pictures and judgements about their duration to assess the emotions elicited by food in women suffering from an eating disorder (ED). Twenty-three women diagnosed with an ED, namely anorexia (AN) or bulimia nervosa (BN), and 23 healthy controls (HC) completed a temporal bisection task and a duration discrimination task. Intervals were marked with emotionally pre-rated pictures of joyful and disgusting food, and pictures of neutral objects. The results showed that, in the bisection task, AN women overestimated the duration of food pictures in comparison to neutral ones. Also, compared to participants with BN, they perceived the duration of joyful food pictures as longer, and tended to overestimate the duration of the disgusting ones. These effects on perceived duration suggest that AN women experienced an intense reaction of fear when they were confronted to food pictures. More precisely, by having elevated the arousal level and activated the defensive system, food pictures seemed to have speeded up the rhythm of the AN participants' internal clock, which led to an overestimation of images' duration. In addition, the results revealed that, in both tasks, ED women presented a lower temporal sensitivity than HC, which was related to their ED symptomatology (i.e., BMI, restraint and concern) and, particularly, to their weaker cognitive abilities in terms of attention, processing speed and working memory. Considered all together, the findings of the present experiment highlight the role of fear and anxiety in the manifestations of AN and point out the importance of considering non-temporal factors in the interpretation of time perception performance.

Modification of the effect of ambient air pollution on pediatric asthma emergency visits: susceptible subpopulations

PubMed Central

Strickland, Matthew J; Klein, Mitchel; Flanders, W Dana; Chang, Howard H; Mulholland, James A; Tolbert, Paige E; Darrow, Lyndsey A

2016-01-01

Background Children may have differing susceptibility to ambient air pollution concentrations depending on various background characteristics of the children. Methods Using emergency department (ED) data linked with birth records from Atlanta, Georgia, we identified ED visits for asthma or wheeze among children aged 2–16 years from 1 January 2002 through 30 June 2010 (n=109,758). We stratified by preterm delivery, term low birth weight, maternal race, Medicaid status, maternal education, maternal smoking, delivery method, and history of a bronchiolitis ED visit. Population-weighted daily average concentrations were calculated for 1-hour maximum carbon monoxide and nitrogen dioxide; 8-hour maximum ozone; and 24-hour average particulate matter less than 10 microns in diameter, particulate matter less than 2.5 microns in diameter (PM2.5), and the PM2.5 components sulfate, nitrate, ammonium, elemental carbon, and organic carbon, using measurements from stationary monitors. Poisson time-series models were used to estimate rate ratios for associations between three-day moving average pollutant concentrations and daily ED visit counts and to investigate effect-measure modification by the stratification factors. Results Associations between pollutant concentrations and asthma exacerbations were larger among children born preterm and among children born to African American mothers. Stratification by race and preterm status together suggested that both factors affected susceptibility. The largest estimated effect size (for an interquartile-range increase in pollution) was observed for ozone among preterm births to African American mothers: rate ratio=1.138 (95% confidence interval=1.077–1.203). In contrast, the rate ration for the ozone association among full-term births to mothers of other races was 1.025 (0.970–1.083). Conclusions Results support the hypothesis that children vary in their susceptibility to ambient air pollutants. PMID:25192402

Inappropriately Timed Pediatric Orthopaedic Referrals From the Emergency Department Result in Unnecessary Appointments and Financial Burden for Patients.

PubMed

Jackson, Taylor J; Blumberg, Todd J; Shah, Apurva S; Sankar, Wudbhav N

2018-03-01

Musculoskeletal injuries are among the most common reasons for emergency department (ED) visits in the pediatric population. Many such injuries can be managed with a single follow-up outpatient visit. However, untimely (ie, premature) referrals by emergency physicians to orthopaedic surgeons are common and may inadvertently create need for a second visit, generating unnecessary expenditures. We sought to elucidate the cost of premature musculoskeletal follow-up visits to the patients, families, and the health care system. We performed a retrospective review of pediatric patients with acute musculoskeletal injuries referred from our ED (without a formal orthopaedic consult) to our outpatient clinic. Patients were retrospectively reviewed in a consecutive fashion. The appropriateness of the recommended follow-up time interval was determined for each patient, and the direct and indirect cost of the inappropriate services were calculated utilizing a combination of traditional cost accounting techniques and time-driven activity-based costing. The characteristics of patients with appropriate and untimely follow-up referrals were compared. Two hundred consecutive referrals from the ED were reviewed. Overall, 96.5% of the follow-up visits recommended by the ED were premature, which led 106 (53%) patients to require a second visit to complete their clinical care. Patients who required a second visit were significantly younger (P=0.005), more likely to be male (P=0.042), more likely to have a fracture (P<0.001), and less likely to have a sprain (P<0.001) or dislocation/subluxation (P<0.001). Over 40% of second visits were accounted for by 3 diagnoses (distal radius buckle fractures, nondisplaced Salter-Harris 1 fractures of the ankle, and buckle fractures of the finger). Across the whole cohort, the total financial impact of untimely visits was $36,265.78, representing an average cost of $342.93 per patient. Untimely referrals for follow-up of acute pediatric musculoskeletal conditions are very common and represent a significant financial burden to patients, families, and the health care system. Over 40% of unnecessary visits resulted from just 3 diagnoses. Improved orthopaedic follow-up guidelines, particularly for these readily recognizable conditions, and feedback to referring providers may reduce poorly timed clinic visits and decrease costs in the treatment of common orthopaedic injuries in pediatric patients. Level III.

Safety of an ED High-Dose Opioid Protocol for Sickle Cell Disease Pain.

PubMed

Tanabe, Paula; Martinovich, Zoran; Buckley, Barbara; Schmelzer, Annie; Paice, Judith A

2015-05-01

A nurse-initiated high dose, opioid protocol for vaso-occlusive crisis (VOC) was implemented. Total intravenous morphine sulfate equivalents (IVMSE) in mgs] and safety was evaluated. A medical record review was conducted for all ED visits in adult patients with VOC post protocol implementation. Opioids doses and routes administered during the ED stay, and six hours into the hospital admission were abstracted and total IVMSE administered calculated. Oxygen saturation (SPO2), respiratory rate (RR), administration of naloxone or vasoactive medications, evidence of respiratory arrest, or any other types of resuscitation effort were abstracted. A RR of <10 or SPO2 <92% were coded as abnormal. Descriptive statistics report the total dose. Logistic regression was used to predict abnormal events. Predictors were age, gender, ED dose (10 mg increments) administered, and time from 1st dose to discharge from ED. 72 patients, 603 visits, 276 admitted. The total (ED & hospital dose) mean (95% CI) mg IVMSE administered for all visits was 93 mg (CI 86, 100), ED visit 63 mg (CI 59, 67) and hospital 66 mg (CI 59, 72). The mean (SD) time from administration of 1st analgesic dose to discharge from the ED was 203 (143) minutes, (range = 30-1396 minutes). During two visits, patients experienced a RR <10; while 61 visits were associated with a SPO2 <92%. No medications were administered, or resuscitative measures required. Controlling for demographics and evaluated at the average total ED dose, the longer patients were in the ED, patients were 1.359 times more likely to experience an abnormal vital sign. Controlling for demographics and evaluated at the average total time in the ED, for every 10 mg increase in IVMSE, patients were 1.057 times more likely to experience an abnormal vital sign. The effect of ED dose on the odds of experiencing an abnormal vital sign decreased by a multiplicative factor of 0.0970 for every 1 hour increase in time until discharge. The larger the dose administered in less time, the more likely patients experienced an abnormal vital sign. High opioid doses were safely administered to patients with sickle cell disease. Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

Enhanced Application of 18F-FDG PET/CT in Bladder Cancer by Adding Early Dynamic Acquisition to a Standard Delayed PET Protocol.

PubMed

Yoon, Hai-Jeon; Yoo, Jang; Kim, Yemi; Lee, Dong Hyeon; Kim, Bom Sahn

2017-10-01

We investigated the value of early dynamic (ED) PET for the detection and characterization of bladder cancer. Fifty-two bladder cancer patients were prospectively enrolled. The study protocol was composed of ED, whole-body (WB, 60 minutes after injection), and additional delayed (AD, 120 minutes after injection) PET acquisition. Early dynamic PET was acquired for 10 minutes and reconstructed as 5 frames at 2-minute intervals. A focal radiotracer accumulation confined to the bladder wall was considered as PET positive and referred for further quantitative measurement. SUVmax on ED (SUVmax, SUVmax, SUVmax, SUVmax, and SUVmax for 5 frames), WB (SUVmax), and AD PET (SUVmax) were measured. PET results were correlated with bladder cancer pathology variables. The sensitivities of ED, WB, and AD PET for bladder cancer were 84.6%, 57.7%, and 61.2%, respectively. The sensitivity of ED PET was significantly higher than that of WB (P = 0.002) and AD PET (P = 0.008). On ED PET, SUVmax was significantly correlated with muscle invasiveness, histological grade, and pathological tumor size (P = 0.018, P = 0.030, and P = 0.030). On WB and AD PET, only pathological tumor size showed significant positive correlation with SUVmax and SUVmax (P = 0.043 and P = 0.007). Early dynamic PET can help to detect and characterize bladder cancer.

Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013.

PubMed

Ngo, Hanh; Forero, Roberto; Mountain, David; Fatovich, Daniel; Man, Wing Nicola; Sprivulis, Peter; Mohsin, Mohammed; Toloo, Sam; Celenza, Antonio; Fitzgerald, Gerard; McCarthy, Sally; Hillman, Ken

2018-01-01

In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. The FHR had a consistent effect on 'flow' measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.

Safety and efficiency of emergency department interrogation of cardiac devices

PubMed Central

Neuenschwander, James F.; Peacock, W. Frank; Migeed, Madgy; Hunter, Sara A.; Daughtery, John C.; McCleese, Ian C.; Hiestand, Brian C.

2016-01-01

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

Safety and efficiency of emergency department interrogation of cardiac devices.

PubMed

Neuenschwander, James F; Peacock, W Frank; Migeed, Madgy; Hunter, Sara A; Daughtery, John C; McCleese, Ian C; Hiestand, Brian C

2016-12-01

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. 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. 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. ED staff cardiac device interrogations are faster, and with similar 30-day outcomes, as compared to SP.

Safety of a Brief Emergency Department Observation Protocol for Patients With Presumed Fentanyl Overdose.

PubMed

Scheuermeyer, Frank X; DeWitt, Christopher; Christenson, Jim; Grunau, Brian; Kestler, Andrew; Grafstein, Eric; Buxton, Jane; Barbic, David; Milanovic, Stefan; Torkjari, Reza; Sahota, Indy; Innes, Grant

2018-03-09

Fentanyl overdoses are increasing and few data guide emergency department (ED) management. We evaluate the safety of an ED protocol for patients with presumed fentanyl overdose. At an urban ED, we used administrative data and explicit chart review to identify and describe consecutive patients with uncomplicated presumed fentanyl overdose (no concurrent acute medical issues) from September to December 2016. We linked regional ED and provincial vital statistics databases to ascertain admissions, revisits, and mortality. Primary outcome was a composite of admission and death within 24 hours. Other outcomes included treatment with additional ED naloxone, development of a new medical issue while in the ED, and length of stay. A prespecified subgroup analysis assessed low-risk patients with normal triage vital signs. There were 1,009 uncomplicated presumed fentanyl overdose, mainly by injection. Median age was 34 years, 85% were men, and 82% received out-of-hospital naloxone. One patient was hospitalized and one discharged patient died within 24 hours (combined outcome 0.2%; 95% confidence interval [CI] 0.04% to 0.8%). Sixteen patients received additional ED naloxone (1.6%; 95% CI 1.0% to 2.6%), none developed a new medical issue (0%; 95% CI 0% to 0.5%), and median length of stay was 173 minutes (interquartile range 101 to 267). For 752 low-risk patients, no patients were admitted or developed a new issue, and one died postdischarge; 3 (0.4%; 95% CI 0.01% to 1.3%) received ED naloxone. In our cohort of ED patients with uncomplicated presumed fentanyl overdose-typically after injection-deterioration, admission, mortality, and postdischarge complications appear low; the majority can be discharged after brief observation. Patients with normal triage vital signs are unlikely to require ED naloxone. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Emergency department presentations in infants: Predictors from an Australian birth cohort.

PubMed

Crilly, Julia; Cameron, Cate M; Scuffham, Paul A; Good, Norm; Scott, Rani; Mihala, Gabor; Sweeny, Amy; Keijzers, Gerben

2017-10-01

Infants under 12 months of age are disproportionately represented amongst emergency department (ED) presentations, and infants are more likely to be frequent ED users. This study aimed to describe and identify psychosocial predictors of ED presentation in infants. A prospective birth cohort from Queensland and New South Wales (Environments for Healthy Living) was used to understand infant health service use. Baseline and 12-month questionnaire data pertaining to children born between 2006 and 2011 were used to identify predictors of ED presentation, using multiple regression analysis. Of the 2184 children in the cohort with available baseline and 12-month data, 579 (27%) presented at least once to an ED during their first 12 months of life. Statistically significant predictors of ED presentation in the multivariate analysis included the mother having asthma (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.15-2.39) and a higher Kessler-6 score (a measure of psychological distress) of the primary carer at baseline (OR 1.04, 95% CI 1.01-1.08). Maternal education level was not associated with ED presentations of infants. This study describes maternal and child factors of children who present to the ED in the first year of life. Factors related to an infant's support system were found to be predictors for an ED presentation in the first year of life. This study emphasises the need to review the maternal medical history and psychosocial situation. There may be benefits for health-care practitioners to take the opportunity (such as during routine childhood immunisation) to perform a brief screening tool (such as the Kessler-6) to understand psychological distress experienced by mothers. This may influence the likelihood of a child presenting to an ED within the first 12 months of life. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Diagnosis of Elder Abuse in U.S. Emergency Departments.

PubMed

Evans, Christopher S; Hunold, Katherine M; Rosen, Tony; Platts-Mills, Timothy F

2017-01-01

To estimate the proportion of visits to U.S. emergency departments (EDs) in which a diagnosis of elder abuse is reached using two nationally representative datasets. Retrospective cross-sectional analysis. U.S. ED visits recorded in the 2012 Nationwide Emergency Department Sample (NEDS) or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). All ED visits of individuals aged 60 and older. The primary outcome was elder abuse defined according to International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (ORs) were calculated to identify demographic characteristics and common ED diagnoses associated with elder abuse. In 2012, NEDS contained information on 6,723,667 ED visits of older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% confidence interval (CI) = 0.012-0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed greater weighted odds of elder abuse diagnosis in women (odds ratio (OR) = 1.95, 95% CI = 1.68-2.26) and individuals with contusions (OR = 2.91, 95% CI = 2.36-3.57), urinary tract infection (OR = 2.21, 95% CI = 1.84-2.65), and septicemia (OR = 1.92, 95% CI = 1.44-2.55). In the 2011 NHAMCS dataset, no cases of elder abuse were recorded for the 5,965 older adult ED visits. The proportion of U.S. ED visits by older adults receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Diagnosis of Elder Abuse in US Emergency Departments

PubMed Central

Evans, Christopher S.; Hunold, Katherine M.; Rosen, Tony; Platts-Mills, Timothy F.

2016-01-01

OBJECTIVE To estimate the proportion of visits to United States emergency departments (EDs) receiving a diagnosis of elder abuse using two nationally representative datasets. DESIGN Retrospective cross-sectional analysis. SETTING U.S. ED visits recorded in either the 2012 Nationwide Emergency Department Sample (NEDS), or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). PARTICIPANTS All ED visits by patients aged 60 years and older. MEASUREMENTS The primary outcome was elder abuse as defined by ICD-9-CM diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (OR) were calculated to identify patient demographics and common ED diagnoses associated with elder abuse. RESULTS In 2012, NEDS contained 6,723,667 ED visits by older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% Confidence Interval (CI) 0.012– 0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed increased weighted odds of elder abuse diagnosis in females (OR 1.95, 95% CI 1.68–2.26), and patients with contusion (OR 2.91, 95% CI 2.36–3.57), urinary tract infection (OR 2.21, 95% CI 1.84–2.65), or septicemia (OR 1.92, 95% CI 1.44–2.55). In the 2011 NHAMCS dataset, zero cases of elder abuse were recorded among the 5,965 older adult ED visits. CONCLUSION Among US ED visits by older adults, the proportion of visits receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted. PMID:27753066

Incidence and outcome of subarachnoid haemorrhage in the general and emergency department populations in Queensland from 2010 to 2014.

PubMed

Chu, Kevin H; Mahmoud, Ibrahim; Hou, Xiang-Yu; Winter, Craig D; Jeffree, Rosalind L; Brown, Nathan J; Brown, Anthony Ft

2018-02-05

To determine: (i) incidence and outcome of subarachnoid haemorrhage (SAH) in the general population; and (ii) proportions of SAH in both the general ED population and in ED patients presenting with headache. A population-based study in Queensland from January 2010 to December 2014 was conducted. Data were sourced from the Australian Bureau of Statistics, Queensland Hospital Admitted Patient Data Collection linked to the Queensland death registry and ED Information System. Admitted patients with SAH were identified from ICD-10-AM codes. Inter-hospital transfers and repeat admissions for previously diagnosed SAH were excluded. Pre-hospital deaths from SAH were included. ED patients with headache were identified from ICD-10-AM codes and finding 'headache' in the triage free-text entry. The incidence of SAH, in-hospital mortality, proportions of SAH in the general ED population and ED patients with headache were calculated. There were 1975 incident cases of SAH in admitted patients and 294 pre-hospital deaths from SAH. The incidence of SAH was 9.9 (95% confidence interval [CI] 9.5-10.4) per 100 000 person-years. The incidence standardised to the 'World Standard Population' was 7.0 per 100 000 person-years. The in-hospital mortality was 23.8% (95% CI 22.0-25.8%). SAH was found in 1407 (1.9%, 95% CI 1.8-2.0) of ED patients with headache. Overall, there were 2.4 (95% CI 2.3-2.5) SAH per 10 000 of all ED attendances. The incidence of SAH was similar to that previously reported for Australia. One in 50 ED patients with headache had SAH. Ten in 50 000 ED attendances had a SAH. These estimates can assist in the risk assessment for SAH. © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Eldecalcitol improves chair-rising time in postmenopausal osteoporotic women treated with bisphosphonates

PubMed Central

Iwamoto, Jun; Sato, Yoshihiro

2014-01-01

An open-label randomized controlled trial was conducted to clarify the effect of eldecalcitol (ED) on body balance and muscle power in postmenopausal osteoporotic women treated with bisphosphonates. A total of 106 postmenopausal women with osteoporosis (mean age 70.8 years) were randomly divided into two groups (n=53 in each group): a bisphosphonate group (control group) and a bisphosphonate plus ED group (ED group). Biochemical markers, unipedal standing time (body balance), and five-repetition chair-rising time (muscle power) were evaluated. The duration of the study was 6 months. Ninety-six women who completed the trial were included in the subsequent analyses. At baseline, the age, body mass index, bone mass indices, bone turnover markers, unipedal standing time, and chair-rising time did not differ significantly between the two groups. During the 6-month treatment period, bone turnover markers decreased significantly from the baseline values similarly in the two groups. Although no significant improvement in the unipedal standing time was seen in the ED group, compared with the control group, the chair-rising time decreased significantly in the ED group compared with the control group. The present study showed that ED improved the chair-rising time in terms of muscle power in postmenopausal osteoporotic women treated with bisphosphonates. PMID:24476669

Ways to reduce patient turnaround time and improve service quality in emergency departments.

PubMed

Sinreich, David; Marmor, Yariv

2005-01-01

Recent years have witnessed a fundamental change in the function of emergency departments (EDs). The emphasis of the ED shifts from triage to saving the lives of shock-trauma rooms equipped with state-of-the-art equipment. At the same time walk-in clinics are being set up to treat ambulatory type patients. Simultaneously ED overcrowding has become a common sight in many large urban hospitals. This paper recognises that in order to provide quality treatment to all these patient types, ED process operations have to be flexible and efficient. The paper aims to examine one major benchmark for measuring service quality--patient turnaround time, claiming that in order to provide the quality treatment to which EDs aspire, this time needs to be reduced. This study starts by separating the process each patient type goes through when treated at the ED into unique components. Next, using a simple model, the impact each of these components has on the total patient turnaround time is determined. This in turn, identifies the components that need to be addressed if patient turnaround time is to be streamlined. The model was tested using data that were gathered through a comprehensive time study in six major hospitals. The analysis reveals that waiting time comprises 51-63 per cent of total patient turnaround time in the ED. Its major components are: time away for an x-ray examination; waiting time for the first physician's examination; and waiting time for blood work. The study covers several hospitals and analyses over 20,000 process components; as such the common findings may serve as guidelines to other hospitals when addressing this issue.

Time-trends, Predictors and Outcome of Emergency Department Utilization for Gout: A Nationwide U.S. Study

PubMed Central

Singh, Jasvinder A.; Yu, Shaohua

2016-01-01

Objective To assess gout-related emergency department (ED) utilization/charges and discharge disposition. Methods We used the U.S. National ED Sample (NEDS) data to examine the time-trends in total ED visits and charges and ED-related hospitalizations with gout as the primary diagnosis. We assessed multivariable-adjusted predictors of ED charges and hospitalization for gout-related visits using the 2012 NEDS data. Results There were 180,789, 201,044 and 205,152 ED visits in years 2009, 2010 and 2012 with gout as the primary diagnosis, with total ED charges of $195, $239 and $287 million, respectively; these accounted for 0.14-0.16% of all ED visits. Mean/median 2012 ED charges/visit were $1,398/$956. Of all gout-related ED visits, 7.7% were admitted to the hospital in 2012. Mean/median length of hospital stay was 3.9/2.6 days and mean/median inpatient charge/admission was $22,066/$15,912 in 2012. In multivariable-adjusted analyses, older age, female gender, highest income quartile, being uninsured, metropolitan residence, Western U.S. hospital location, heart disease, renal failure, congestive heart failure (CHF), hypertension, diabetes, osteoarthritis and chronic obstructive pulmonary disease (COPD) were associated with higher ED charges. Older age, Northeast location, Metropolitan teaching hospital, higher income quartile, heart disease, renal failure, CHF, hyperlipidemia, hypertension, diabetes, COPD, and osteoarthritis were associated with higher odds where as self-pay insurance status was associated with lower odds of hospitalization following an ED visit for gout. Conclusions Absolute ED utilization and charges for gout increased over time, but relative utilization remained stable. Modifiable comorbidity factors associated with higher gout-related utilization should be targeted to reduce morbidity and healthcare utilization. PMID:27134260

Use of observed within-person variation of cardiac troponin in emergency department patients for determination of biological variation and percentage and absolute reference change values.

PubMed

Simpson, Aaron J; Potter, Julia M; Koerbin, Gus; Oakman, Carmen; Cullen, Louise; Wilkes, Garry J; Scanlan, Samuel L; Parsonage, William; Hickman, Peter E

2014-06-01

Many patients presenting to the emergency department (ED) for assessment of possible acute coronary syndrome (ACS) have low cardiac troponin concentrations that change very little on repeat blood draw. It is unclear if a lack of change in cardiac troponin concentration can be used to identify acutely presenting patients at low risk of ACS. We used the hs-cTnI assay from Abbott Diagnostics, which can detect cTnI in the blood of nearly all people. We identified a population of ED patients being assessed for ACS with repeat cTnI measurement who ultimately were proven to have no acute cardiac disease at the time of presentation. We used data from the repeat sampling to calculate total within-person CV (CV(T)) and, knowing the assay analytical CV (CV(A)), we could calculate within-person biological variation (CV(i)), reference change values (RCVs), and absolute RCV delta cTnI concentrations. We had data sets on 283 patients. Men and women had similar CV(i) values of approximately 14%, which was similar at all concentrations <40 ng/L. The biological variation was not dependent on the time interval between sample collections (t = 1.5-17 h). The absolute delta critical reference change value was similar no matter what the initial cTnI concentration was. More than 90% of subjects had a critical reference change value <5 ng/L, and 97% had values of <10 ng/L. With this hs-cTnI assay, delta cTnI seems to be a useful tool for rapidly identifying ED patients at low risk for possible ACS. © 2014 The American Association for Clinical Chemistry.

Is computed tomography-defined obstruction a predictor of urological intervention in emergency department patients presenting with renal colic?

PubMed Central

Massaro, Peter Alexander; Kanji, Avinash; Atkinson, Paul; Pawsey, Ryan; Whelan, Tom

2017-01-01

Introduction Our objective was to determine whether unilateral calculus-induced ureteric obstruction on computed tomography (CT) was independently associated with the need for urological intervention and 30-day return to the emergency department (ED). Methods We performed a retrospective cohort study of patients with symptomatic urinary calculi diagnosed by unenhanced helical CT. Stepwise regression analysis was used to determine the predictors of urological intervention and 30-day return to the ED. Potential predictors assessed included: patient demographics, calculus size, calculus location, degree of obstruction, analgesic doses, signs and symptoms of infection, serum creatinine, cumulative intravenous fluid administered, and the prescription of medical expulsive therapy. Results Of 195 patients, 81 (41.5%) underwent urological intervention. The size of the calculus, its location, and the cumulative opioid dose were all independent predictors for urological intervention. Every 1 mm increase in calculus size increased the likelihood of intervention 2.2 times (odds ratio [OR] 2.17; 95% confidence interval [CI] 1.67–2.85). Proximal stones were 4.7 times more likely to require intervention than distal calculi (OR 0.21; 95% CI 0.09–0.49). Every 10 mg increase in morphine was associated with a 30% increase in the odds of intervention (OR 1.30; 95% CI 1.07–1.58). Degree of obstruction was not associated with the need for urological intervention. Finally, none of the variables were predictors for 30-day return to the ED. Conclusions Although stone size, proximal location, and severe pain, as indicated by higher opioid doses, were associated with the need for intervention, the degree of obstruction did not influence the management of patients with CT-defined urinary calculi. PMID:28515805

Adherence to national exercise guidelines by patients attending emergency departments: A multi-site survey.

PubMed

Berlingeri, Paul; Cunningham, Neil; Taylor, David McD; Knott, Jonathan; McLean, Daniel; Gavan, Rex; Plant, Luke; Chen, Hayley; Weiland, Tracey

2017-06-01

The proportion of adults in Australia meeting or exceeding the national guidelines for physical activity has remained relatively static over the past 10 years. The research objective was to measure self-reported physical activity and sedentary behaviour among ED patients in accordance with Australia's current physical activity and sedentary behaviour guidelines, revised in 2014. A convenience sample of participants was recruited from three EDs in Melbourne between February and May 2016. Eligible participants were administered the International Physical Activity Questionnaire - Short Form plus researcher-derived questions. Participants were assessed as whether meeting the physical activity guidelines or not, using pre-defined criteria. The proportion of 18-64 year olds meeting all of the physical activity guidelines was 19.0% (95% confidence interval [CI] 15.2-22.8). A majority of participants (63.1%, 95% CI 58.5-67.7) met the aerobic component of the guidelines although only 28.9% (95% CI 24.5-33.3) of participants reported undertaking strength building exercises two or more times per week. Adults in the oldest age group were found to be less likely to engage in muscle strengthening exercises (23.3%, n = 30) than those in the youngest age group (40.0%, n = 60, P = 0.005). Average daily sitting time (minutes) did not differ between men (median = 300) and women (median = 360, P = 0.118). Overall adherence with physical activity guidelines is low among adults attending the ED. All adults need to be encouraged to undertake muscle strengthening activities, especially adults in older age groups. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Nursing care as a predictor of phlebitis related to insertion of a peripheral venous cannula in emergency departments: findings from a prospective study.

PubMed

Palese, A; Ambrosi, E; Fabris, F; Guarnier, A; Barelli, P; Zambiasi, P; Allegrini, E; Bazoli, L; Casson, P; Marin, M; Padovan, M; Picogna, M; Taddia, P; Salmaso, D; Chiari, P; Marognolli, O; Canzan, F; Saiani, L

2016-03-01

To date, few studies have investigated the occurrence of phlebitis related to insertion of a peripheral venous cannula (PVC) in an emergency department (ED). To describe the natural history of ED-inserted PVC site use; the occurrence and severity of PVC-related phlebitis; and associations with patient, PVC and nursing care factors. A prospective study was undertaken of 1262 patients treated as urgent cases in EDs who remained in a medical unit for at least 24h. The first PVC inserted was observed daily until its removal; phlebitis was measured using the Visual Infusion Phlebitis Scale. Data on patient, PVC, nursing care and organizational variables were collected, and a time-to-event analysis was performed. The prevalence of PVC-related phlebitis was 31%. The cumulative incidence (78/391) was almost 20% three days after insertion, and reached >50% (231/391) five days after insertion. Being in a specialized hospital [hazard ratio (HR) 0.583, 95% confidence interval (CI) 0.366-0.928] and receiving more nursing care (HR 0.988, 95% CI 0.983-0.993) were protective against PVC-related phlebitis at all time points. Missed nursing care increased the incidence of PVC-related phlebitis by approximately 4% (HR 1.038, 95% CI 1.001-1.077). Missed nursing care and expertise of the nurses caring for the patient after PVC insertion affected the incidence of phlebitis; receiving more nursing care and being in a specialized hospital were associated with lower risk of PVC-related phlebitis. These are modifiable risk factors of phlebitis, suggesting areas for intervention at both hospital and unit level. Copyright © 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Using demand analysis and system status management for predicting ED attendances and rostering.

PubMed

Ong, Marcus Eng Hock; Ho, Khoy Kheng; Tan, Tiong Peng; Koh, Seoh Kwee; Almuthar, Zain; Overton, Jerry; Lim, Swee Han

2009-01-01

It has been observed that emergency department (ED) attendances are not random events but rather have definite time patterns and trends that can be observed historically. To describe the time demand patterns at the ED and apply systems status management to tailor ED manpower demand. Observational study of all patients presenting to the ED at the Singapore General Hospital during a 3-year period was conducted. We also conducted a time series analysis to determine time norms regarding physician activity for various severities of patients. The yearly ED attendances increased from 113387 (2004) to 120764 (2005) and to 125773 (2006). There was a progressive increase in severity of cases, with priority 1 (most severe) increasing from 6.7% (2004) to 9.1% (2006) and priority 2 from 33.7% (2004) to 35.1% (2006). We noticed a definite time demand pattern, with seasonal peaks in June, weekly peaks on Mondays, and daily peaks at 11 to 12 am. These patterns were consistent during the period of the study. We designed a demand-based rostering tool that matched doctor-unit-hours to patient arrivals and severity. We also noted seasonal peaks corresponding to public holidays. We found definite and consistent patterns of patient demand and designed a rostering tool to match ED manpower demand.

Health Information Technology Adoption in the Emergency Department.

PubMed

Selck, Frederic W; Decker, Sandra L

2016-02-01

To describe the trend in health information technology (IT) systems adoption in hospital emergency departments (EDs) and its effect on ED efficiency and resource use. 2007-2010 National Hospital Ambulatory Medical Care Survey - ED Component. We assessed changes in the percent of visits to EDs with health IT capability and the estimated effect on waiting time to see a provider, visit length, and resource use. The percent of ED visits that took place in an ED with at least a basic health IT or an advanced IT system increased from 25.2 and 3.1 percent in 2007 to 69.1 and 30.6 percent in 2010, respectively (p < .05). Controlling for ED fixed effects, waiting times were reduced by 6.0 minutes in advanced IT-equipped EDs (p < .05), and the number of tests ordered increased by 9 percent (p < .01). In models using a 1-year lag, advanced systems also showed an increase in the number of medications and images ordered per visit. Almost a third of visits now occur in EDs with advanced IT capability. While advanced IT adoption may decrease wait times, resource use during ED visits may also increase depending on how long the system has been in place. We were not able to determine if these changes indicated more appropriate care. © Health Research and Educational Trust.

Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program

PubMed Central

2009-01-01

Background This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD). Methods All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables. Results Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect. Conclusion Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care. PMID:19968871

Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program.

PubMed

Chiou, Shang-Jyh; Campbell, Claudia; Horswell, Ronald; Myers, Leann; Culbertson, Richard

2009-12-07

This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD). All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables. Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect. Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care.

Reducing Head CT Use for Children With Head Injuries in a Community Emergency Department.

PubMed

Jennings, Rebecca M; Burtner, Jennifer J; Pellicer, Joseph F; Nair, Deepthi K; Bradford, Miranda C; Shaffer, Michele; Uspal, Neil G; Tieder, Joel S

2017-04-01

Clinical decision rules have reduced use of computed tomography (CT) to evaluate minor pediatric head injury in pediatric emergency departments (EDs). CT use remains high in community EDs, where the majority of children seek medical care. We sought to reduce the rate of CT scans used to evaluate pediatric head injury from 29% to 20% in a community ED. We evaluated a quality improvement (QI) project in a community ED aimed at decreasing the use of head CT scans in children by implementing a validated head trauma prediction rule for traumatic brain injury. A multidisciplinary team identified key drivers of CT use and implemented decision aids to improve the use of prediction rules. The team identified and mitigated barriers. An affiliated children's hospital offered Maintenance of Certification credit and QI coaching to participants. We used statistical process control charts to evaluate the effect of the intervention on monthly CT scan rates and performed a Wald test of equivalence to compare preintervention and postintervention CT scan proportions. The baseline period (February 2013-July 2014) included 695 patients with a CT scan rate of 29.2% (95% confidence interval, 25.8%-32.6%). The postintervention period (August 2014-October 2015) included 651 patients with a CT scan rate of 17.4% (95% confidence interval, 14.5%-20.2%, P < .01). Barriers included targeting providers with variable pediatric experience and parental imaging expectations. We demonstrate that a Maintenance of Certification QI project sponsored by a children's hospital can facilitate evidence-based pediatric care and decrease the rate of unnecessary CT use in a community setting. Copyright © 2017 by the American Academy of Pediatrics.

Improving geriatric trauma outcomes: A small step toward a big problem.

PubMed

Hammer, Peter M; Storey, Annika C; Bell, Teresa; Bayt, Demetria; Hockaday, Melissa S; Zarzaur, Ben L; Feliciano, David V; Rozycki, Grace S

2016-07-01

Because of the unique physiology and comorbidities of injured geriatric patients, specific interventions are needed to improve outcomes. The purpose of this study was to assess the effect of a change in triage criteria for injured geriatric patients evaluated at an American College of Surgeons Level I trauma center. As of October 1, 2013, all injured patients 70 years or older were mandated to have the highest-level trauma activation upon emergency department (ED) arrival regardless of physiology or mechanism of injury. Patients admitted before that date were designated as PRE; those admitted after were designated as POST. The study period was from October 1, 2011, through April 30, 2015. Data collected included demographics, mechanism of injury, hypotension on admission, comorbidities, Injury Severity Score (ISS), ED length of stay (LOS), complications, and mortality. Bivariate and multivariable analyses were used to compare outcomes between the study groups (p < 0.05 was considered significant). χ or Fisher's exact test was used as appropriate for bivariate analyses of categorical variables; patients' ages were compared using the Wilcoxon rank-sum test. A total of 2,269 patients (mean, 80.63 years; mean ISS, 12.2; PRE, 1,271; POST, 933) were included in the study. On multivariable analysis, increasing age, higher ISS, and hypotension were associated with higher mortality. POST patients were more likely to have an ED LOS of 2 hours or shorter (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) after controlling for hypotension, ISS, and comorbidities. POST mortality significantly decreased (odds ratio, 0.689; 95% confidence interval, 0.484-0.979). Based on age alone, the focused intervention of a higher level of trauma activation decreased ED LOS and mortality in injured geriatric patients. Therapeutic/care management study, level IV.

Allergy Testing in Children With Low-Risk Penicillin Allergy Symptoms.

PubMed

Vyles, David; Adams, Juan; Chiu, Asriani; Simpson, Pippa; Nimmer, Mark; Brousseau, David C

2017-08-01

Penicillin allergy is commonly reported in the pediatric emergency department (ED). True penicillin allergy is rare, yet the diagnosis results from the denial of first-line antibiotics. We hypothesize that all children presenting to the pediatric ED with symptoms deemed to be low-risk for immunoglobulin E-mediated hypersensitivity will return negative results for true penicillin allergy. Parents of children aged 4 to 18 years old presenting to the pediatric ED with a history of parent-reported penicillin allergy completed an allergy questionnaire. A prespecified 100 children categorized as low-risk on the basis of reported symptoms completed penicillin allergy testing by using a standard 3-tier testing process. The percent of children with negative allergy testing results was calculated with a 95% confidence interval. Five hundred ninety-seven parents completed the questionnaire describing their child's reported allergy symptoms. Three hundred two (51%) children had low-risk symptoms and were eligible for testing. Of those, 100 children were tested for penicillin allergy. The median (interquartile range) age at testing was 9 years (5-12). The median (interquartile range) age at allergy diagnosis was 1 year (9 months-3 years). Rash (97 [97%]) and itching (63 [63%]) were the most commonly reported allergy symptoms. Overall, 100 children (100%; 95% confidence interval 96.4%-100%) were found to have negative results for penicillin allergy and had their labeled penicillin allergy removed from their medical record. All children categorized as low-risk by our penicillin allergy questionnaire were found to have negative results for true penicillin allergy. The utilization of this questionnaire in the pediatric ED may facilitate increased use of first-line penicillin antibiotics. Copyright © 2017 by the American Academy of Pediatrics.

Diazepam and Meclizine Are Equally Effective in the Treatment of Vertigo: An Emergency Department Randomized Double-Blind Placebo-Controlled Trial.

PubMed

Shih, Richard D; Walsh, Brian; Eskin, Barnet; Allegra, John; Fiesseler, Frederick W; Salo, Dave; Silverman, Michael

2017-01-01

Vertigo is a debilitating disease that is commonly encountered in the emergency department (ED). Diazepam and meclizine are oral medications that are commonly used to alleviate symptoms. We sought to determine whether meclizine or diazepam is superior in the treatment of patients with peripheral vertigo in the ED. We performed a double-blind clinical trial at a suburban, teaching ED. We randomized a convenience sample of adult patients with acute peripheral vertigo (APV) to diazepam 5 mg or meclizine 25 mg orally. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of vertigo on a 100-mm visual analog scale (VAS) and after 30 min (t30) and 60 min (t60). The primary outcome parameter was the mean change in VAS score from t0 to t60. Differences between groups and 95% confidence intervals were calculated. Our a priori power calculation estimated that a sample size of 20 patients in each group was required to have an 80% power to detect a difference of 20 mm between treatment groups. There were 20 patients in the diazepam group and 20 in the meclizine group. The two groups were similar with respect to patient demographics and presenting signs and symptoms. At t60, the mean improvements in the diazepam and meclizine groups were 36 and 40, respectively (difference -4; 95% confidence interval -20 to 12; p = 0.60). We found no difference between oral diazepam and oral meclizine for the treatment of ED patients with acute peripheral vertigo. Copyright © 2016 Elsevier Inc. All rights reserved.

Cost-effectiveness of oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin in the emergency department.

PubMed

Rudis, Maria I; Touchette, Daniel R; Swadron, Stuart P; Chiu, Amy P; Orlinsky, Michael

2004-03-01

Oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin are all commonly used for loading phenytoin in the emergency department (ED). The cost-effectiveness of each was compared for patients presenting with seizures and subtherapeutic phenytoin concentrations. A simple decision tree was developed to determine the treatment costs associated with each of 3 loading techniques. We determined effectiveness by comparing adverse event rates and by calculating the time to safe ED discharge. Time to safe ED discharge was defined as the time at which therapeutic concentrations of phenytoin (>or=10 mg/L) were achieved with an absence of any adverse events that precluded discharge. The comparative cost-effectiveness of alternatives to oral phenytoin was determined by combining net costs and number of adverse events, expressed as cost per adverse events avoided. Cost-effectiveness was also determined by comparing the net costs of each loading technique required to achieve the time to safe ED discharge, expressed as cost per hour of ED time saved. The outcomes and costs were primarily derived from a prospective, randomized controlled trial, augmented by time-motion studies and alternate-cost sources. Costs included the cost of drugs, supplies, and personnel. Analyses were also performed in scenarios incorporating labor costs and savings from using a lower-urgency area of the ED. The mean number of adverse events per patient for oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin was 1.06, 1.93, and 2.13, respectively. Mean time to safe ED discharge in the 3 groups was 6.4 hours, 1.7 hours, and 1.3 hours. Cost per patient was 2.83 dollars, 21.16 dollars, and 175.19 dollars, respectively, and did not differ substantially in the Labor and Triage (lower-urgency area of ED) scenarios. When the measure of effectiveness was adverse events, oral phenytoin dominated intravenous phenytoin and intravenous fosphenytoin, with a lower cost and number of adverse events. With time to safe ED discharge as the outcome measure, the incremental cost-effectiveness ratios were 3.90 dollars and 387.27 dollars per hour of ED time saved for oral phenytoin versus intravenous phenytoin and for intravenous fosphenytoin versus intravenous phenytoin, respectively. Oral phenytoin is the most cost-effective loading method in most settings. Intravenous phenytoin is preferred if one is willing to pay an additional 20.65 dollars to 44.25 dollars per patient and willing to have more adverse events for a quicker average time to safe ED discharge. It is unlikely that intravenous fosphenytoin is justifiable in any setting.

Integrating Point-of-Care Testing into a Community Emergency Department: A Mixed-Methods Evaluation.

PubMed

Pines, Jesse M; Zocchi, Mark S; Carter, Caitlin; Marriott, Charles Z; Bernard, Matthew; Warner, Leah H

2018-05-13

Point-of-care testing (POCT) is a commonly used technology that hastens the time to laboratory results in emergency departments (ED). We evaluated an ED-based POCT program on ED length of stay and time to care, coupled with qualitative interviews of local ED stakeholders. We conducted a mixed-methods study (2012-16) to examine the impact of point-of-care testing in a single, community ED. The quantiative analysis involved an observational before-after study comparing time to laboratory test result (POC troponin or POC chemistry) and ED length of stay after implementation of POCT, using a propensity-weighted interrupted time series analysis (ITSA). A complementary qualitative analysis involved five semi-structured interviews with staff using grounded theory on the benefits and challenges to ED POCT. A total of 47,399 ED visits were included in the study (24,705 in pre-intervention period and 22,694 in post-intervention). After POCT implementation, overall laboratory testing increased marginally from 61 to 62%. Central laboratory troponin and chemistry declined by >50% and was replaced by POCT. Prior to POCT implementation, time to troponin and chemistry had declined steadily due to other improvements in laboratory efficiency. After POCT implementation, there was an immediate 20 minute further decline (p<0.001) in both time to troponin and time to chemistry results using the propensity-weighted comparisons. However, the declining trend observed prior to POCT implementation did not continue at the same rate post implementation. Similarly, prior to POCT implementation, ED length of stay (LOS) declined due to other quality improvements. After POCT implementation, LOS continued declined at a similar rate. Because of this prior trend, the ITSA did not show a significant decline in LOS attributable to POCT. Common benefits of POCT perceived by staff in qualitative interviews included improved quality of care (64%), and reductions in time to test results (44%). Common challenges included concerns over POCT accuracy (32%), and technical barriers (29%). In the study ED, implementation of POCT was associated with a reduction in time to test result for both troponin and chemistry. Local staff felt that faster time to test result improved quality of care; however, concerns were raised with POCT accuracy. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Emergency Department Waiting Times (EDWaT): A Patient Flow Management and Quality of Care Rating mHealth Application.

PubMed

Househ, Mowafa; Yunus, Faisel

2014-01-01

Saudi hospital emergency departments (ED) have suffered from long waiting times, which have led to a delay in emergency patient care. The increase in the population of Saudi Arabia is likely to further stretch the healthcare services due to overcrowding leading to decreased healthcare quality, long patient waits, patient dissatisfaction, ambulance diversions, decreased physician productivity, and increased frustration among medical staff. This will ultimately put patients at risk for poor health outcomes. Time is of the essence in emergencies and to get to an ED that has the shortest waiting time can mean life or death for a patient, especially in cases of stroke and myocardial infarction. In this paper, we present our work on the development of a mHealth Application - EDWaT - that will: provide patient flow information to the emergency medical services staff, help in quick routing of patients to the nearest hospital, and provide an opportunity for patients to review and rate the quality of care received at an ED, which will then be forwarded to ED services administrators. The quality ratings will help patients to choose between two EDs with the same waiting time and distance from their location. We anticipate that the use of EDWaT will help improve ED wait times and the quality of care provision in Saudi hospitals EDs.

Predicting Geriatric Falls Following an Episode of Emergency Department Care: A Systematic Review

PubMed Central

Carpenter, Christopher R.; Avidan, Michael S.; Wildes, Tanya; Stark, Susan; Fowler, Susan A.; Lo, Alexander X.

2015-01-01

Background Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. Objectives This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor’s accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. Methods A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. Results A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. Conclusions This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk PMID:25293956

Predicting geriatric falls following an episode of emergency department care: a systematic review.

PubMed

Carpenter, Christopher R; Avidan, Michael S; Wildes, Tanya; Stark, Susan; Fowler, Susan A; Lo, Alexander X

2014-10-01

Falls are the leading cause of traumatic mortality in geriatric adults. Despite recent multispecialty guideline recommendations that advocate for proactive fall prevention protocols in the emergency department (ED), the ability of risk factors or risk stratification instruments to identify subsets of geriatric patients at increased risk for short-term falls is largely unexplored. This was a systematic review and meta-analysis of ED-based history, physical examination, and fall risk stratification instruments with the primary objective of providing a quantitative estimate for each risk factor's accuracy to predict future falls. A secondary objective was to quantify ED fall risk assessment test and treatment thresholds using derived estimates of sensitivity and specificity. A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED, EMBASE, CINAHL, CENTRAL, DARE, the Cochrane Registry, and Clinical Trials. Unpublished research was located by a hand search of emergency medicine (EM) research abstracts from national meetings. Inclusion criteria for original studies included ED-based assessment of pre-ED or post-ED fall risk in patients 65 years and older with sufficient detail to reproduce contingency tables for meta-analysis. Original study authors were contacted for additional details when necessary. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality for those studies that met inclusion criteria. When more than one qualitatively similar study assessed the same risk factor for falls at the same interval following an ED evaluation, then meta-analysis was performed using Meta-DiSc software. The primary outcomes were sensitivity, specificity, and likelihood ratios for fall risk factors or risk stratification instruments. Secondary outcomes included estimates of test and treatment thresholds using the Pauker method based on accuracy, screening risk, and the projected benefits or harms of fall prevention interventions in the ED. A total of 608 unique and potentially relevant studies were identified, but only three met our inclusion criteria. Two studies that included 660 patients assessed 29 risk factors and two risk stratification instruments for falls in geriatric patients in the 6 months following an ED evaluation, while one study of 107 patients assessed the risk of falls in the preceding 12 months. A self-report of depression was associated with the highest positive likelihood ratio (LR) of 6.55 (95% confidence interval [CI] = 1.41 to 30.48). Six fall predictors were identified in more than one study (past falls, living alone, use of walking aid, depression, cognitive deficit, and more than six medications) and meta-analysis was performed for these risk factors. One screening instrument was sufficiently accurate to identify a subset of geriatric ED patients at low risk for falls with a negative LR of 0.11 (95% CI = 0.06 to 0.20). The test threshold was 6.6% and the treatment threshold was 27.5%. This study demonstrates the paucity of evidence in the literature regarding ED-based screening for risk of future falls among older adults. The screening tools and individual characteristics identified in this study provide an evidentiary basis on which to develop screening protocols for geriatrics adults in the ED to reduce fall risk. © 2014 by the Society for Academic Emergency Medicine.

Antenatal and Postnatal Psychopathology Among Women with Current and Past Eating Disorders: Longitudinal Patterns

PubMed Central

Easter, Abigail; Solmi, Francessca; Bye, Amanda; Taborelli, Emma; Corfield, Freya; Schmidt, Ulrike; Treasure, Janet; Micali, Nadia

2015-01-01

This study aims to investigate longitudinal patterns of psychopathology during the antenatal and postnatal periods among women with current (C-ED) and past (P-ED) eating disorders. Women were recruited to a prospective longitudinal study: C-ED (n = 31), P-ED (n = 29) and healthy control (HC; n = 57). Anxiety, depression and ED symptoms were measured at four time points: first/second trimester, third trimester, 8 weeks and 6 months postpartum. Linear mixed effects models were used to test for group differences. Women with C-ED and P-ED, in all diagnostic categories, had significantly higher levels of psychopathology at all time points. ED symptoms decreased in the C-ED group, compared with an overall increase in the other two groups but subsequently increased after pregnancy. Overall, depression and state and trait anxiety scores decreased in the C-ED group compared with the HC group throughout the antenatal and postnatal periods. High levels of psychopathology are common throughout the antenatal and postnatal periods among women with current and past ED, and despite some overall reductions, symptoms remain clinically significant. © 2014 The Authors. European Eating Disorders Review published by John Wiley & Sons, Ltd. PMID:25345371

Overall ED efficiency is associated with decreased time to percutaneous coronary intervention for ST-segment elevation myocardial infarction.

PubMed

Jones, Christopher W; Sonnad, Seema S; Augustine, James J; Reese, Charles L

2014-10-01

Performance of percutaneous coronary intervention (PCI) within 90 minutes of hospital arrival for ST-segment elevation myocardial infarction patients is a commonly cited clinical quality measure. The Centers for Medicare and Medicaid Services use this measure to adjust hospital reimbursement via the Value-Based Purchasing Program. This study investigated the relationship between hospital performance on this quality measure and emergency department (ED) operational efficiency. Hospital-level data from Centers for Medicare and Medicaid Services on PCI quality measure performance was linked to information on operational performance from 272 US EDs obtained from the Emergency Department Benchmarking Alliance annual operations survey. Standard metrics of ED size, acuity, and efficiency were compared across hospitals grouped by performance on the door-to-balloon time quality measure. Mean hospital performance on the 90-minute arrival to PCI measure was 94.0% (range, 42-100). Among hospitals failing to achieve the door-to-balloon time performance standard, median ED length of stay was 209 minutes, compared with 173 minutes among those hospitals meeting the benchmark standard (P < .001). Similarly, median time from ED patient arrival to physician evaluation was 39 minutes for hospitals below the performance standard and 23 minutes for hospitals at the benchmark standard (P < .001). Markers of ED size and acuity, including annual patient volume, admission rate, and the percentage of patients arriving via ambulance did not vary with door-to-balloon time. Better performance on measures associated with ED efficiency is associated with more timely PCI performance. Copyright © 2014 Elsevier Inc. All rights reserved.

Obstructive sleep apnea with excessive daytime sleepiness is associated with non-alcoholic fatty liver disease regardless of visceral fat

PubMed Central

Yu, Ji Hee; Ahn, Jae Hee; Yoo, Hye Jin; Seo, Ji A; Kim, Sin Gon; Choi, Kyung Mook; Baik, Sei Hyun; Choi, Dong Seop; Shin, Chol; Kim, Nan Hee

2015-01-01

Background/Aims: Obstructive sleep apnea (OSA) is associated with an increased risk of obesity and non-alcoholic fatty liver disease (NAFLD), but it remains unclear whether the risk of NAFLD is independently related to OSA regardless of visceral obesity. Thus, the aim of the present study was to examine whether OSA alone or in combination with excessive daytime sleepiness (EDS) or short sleep duration was associated with NAFLD independent of visceral fat in Korean adults. Methods: A total of 621 participants were selected from the Korean Genome and Epidemiology Study (KoGES). The abdominal visceral fat area (VFA) and hepatic fat components of the participants were assessed using computed tomography scans and they were then categorized into four groups depending on the presence of OSA and EDS. Results: The proportions of NAFLD were 21.1%, 18.5%, 32.4%, and 46.7% in participants without OSA/EDS, with only EDS, with only OSA, and with both OSA and EDS, respectively. A combination of OSA and EDS increased the odds ratio (OR) for developing NAFLD (OR, 2.75; 95% confidence interval [CI], 1.21 to 6.28) compared to those without OSA/EDS, and this association remained significant (OR, 2.38; 95% CI, 1.01 to 5.59) even after adjusting for VFA. In short sleepers (< 5 hours) with OSA, the adjusted OR for NAFLD was 2.50 (95% CI, 1.08 to 5.75) compared to those sleeping longer than 5 hours without OSA. Conclusions: In the present study, OSA was closely associated with NAFLD in Korean adults. This association was particularly strong in those with EDS or short sleep duration regardless of VFA. PMID:26552460

Evaluating the HATCH score for predicting progression to sustained atrial fibrillation in ED patients with new atrial fibrillation.

PubMed

Barrett, Tyler W; Self, Wesley H; Wasserman, Brian S; McNaughton, Candace D; Darbar, Dawood

2013-05-01

Atrial fibrillation (AF) is often first detected in the emergency department (ED). Not all AF patients progress to sustained AF (ie, episodes lasting >7 days), which is associated with increased morbidity. The HATCH score stratifies patients with paroxysmal AF according to their risk for progression to sustained AF within 1 year. The HATCH score has previously never been tested in ED patients. We evaluated the accuracy of the HATCH score to predict progression to sustained AF within 1 year of initial AF diagnosis in the ED. We conducted a retrospective cohort study of 253 ED patients with new onset AF and known rhythm status for 1 year following the initial AF detection. The exposure variable was the HATCH score at initial ED evaluation. The primary outcome was rhythm status at 1 year following initial AF diagnosis. We constructed a receiver operating characteristic curve and calculated the area under the curve to estimate the HATCH score's accuracy of predicting progression to sustained AF. Overall, 61 (24%) of 253 of patients progressed to sustained AF within 1 year of initial detection, and the HATCH score receiver operating characteristic area under the curve was 0.62 (95% confidence interval, 0.54-0.70). Among ED patients with new onset AF, the HATCH score was a modest predictor of progression to sustained AF. Because only 2 patients had a HATCH greater than 5, this previously recommended cut-point was not useful in identifying high-risk patients in this cohort. Refinement of this decision aid is needed to improve its prognostic accuracy in the ED population. Copyright © 2013 Elsevier Inc. All rights reserved.

Lifetime prevalence of non-suicidal self-injury in patients with eating disorders: a systematic review and meta-analysis.

PubMed

Cucchi, A; Ryan, D; Konstantakopoulos, G; Stroumpa, S; Kaçar, A Ş; Renshaw, S; Landau, S; Kravariti, E

2016-05-01

Against a backdrop of increasing research, clinical and taxonomic attention in non-suicidal self-injury (NSSI), evidence suggests a link between NSSI and eating disorders (ED). The frequency estimates of NSSI in ED vary widely. Little is known about the sources of this variation, and no meta-analysis has quantified the association between ED and NSSI. Using random-effects meta-analyses, meta-regression analyses, and 1816-6466 unique participants with various ED, we estimated the weighted average percentage of individuals with ED, those with anorexia nervosa (AN) and those with bulimia nervosa (BN) who are reported to have a lifetime history of NSSI across studies. We further examined predictors of NSSI in ED. The weighted average percentage of patients with a lifetime history of NSSI was 27.3% [95% confidence interval (CI) 23.8-31.0%] for ED, 21.8% (95% CI 18.5-25.6%) for AN, and 32.7% (95% CI 26.9-39.1%) for BN. The difference between BN and AN was statistically significant [odds ratio (OR) 1.77, 95% CI 1.14-2.77, p = 0.013]. The odds of NSSI increased by 24% for every 10% increase in the percentage of participants with histories of suicide attempts (OR 1.24, 95% CI 1.04-1.48, p = 0.020) and decreased by 26% for every 10% increase in the percentage of participants with histories of substance abuse (OR 0.74, 95% CI 0.58-0.95, p = 0.023). In the specific context of ED, NSSI is highly prevalent and correlates positively with attempted suicide, urging for NSSI-focused treatments. A novel finding is that NSSI is potentially antagonized by substance abuse.

The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events.

PubMed

Barrett, Tyler W; Storrow, Alan B; Jenkins, Cathy A; Abraham, Robert L; Liu, Dandan; Miller, Karen F; Moser, Kelly M; Russ, Stephan; Roden, Dan M; Harrell, Frank E; Darbar, Dawood

2015-03-15

There is wide variation in the management of patients with atrial fibrillation (AF) in the emergency department (ED). We aimed to derive and internally validate the first prospective, ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events. We performed a prospective cohort study at a university-affiliated tertiary-care ED. Patients were enrolled from June 9, 2010, to February 28, 2013, and followed for 30 days. We enrolled a convenience sample of patients in ED presenting with symptomatic AF. Candidate predictors were based on ED data available in the first 2 hours. The decision aid was derived using model approximation (preconditioning) followed by strong bootstrap internal validation. We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation. Of 497 patients enrolled, stroke and AF-related death occurred in 13 (3%) and 4 (<1%) patients, respectively. The decision aid included the following: age, triage vitals (systolic blood pressure, temperature, respiratory rate, oxygen saturation, supplemental oxygen requirement), medical history (heart failure, home sotalol use, previous percutaneous coronary intervention, electrical cardioversion, cardiac ablation, frequency of AF symptoms), and ED data (2 hours heart rate, chest radiograph results, hemoglobin, creatinine, and brain natriuretic peptide). The decision aid's c-statistic in predicting any 30-day adverse event was 0.7 (95% confidence interval 0.65, 0.76). In conclusion, in patients with AF in the ED, Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence-based decision aid for identifying patients who are at low risk for 30-day adverse events and candidates for safe discharge. Copyright © 2015 Elsevier Inc. All rights reserved.

Sleep duration and consumption of sugar-sweetened beverages and energy drinks among adolescents.

PubMed

Sampasa-Kanyinga, Hugues; Hamilton, Hayley A; Chaput, Jean-Philippe

2018-04-01

To examine the relationship between sleep duration and consumption of sugar sweetened beverages (SSBs) and energy drinks (EDs) among adolescents. Data on 9,473 adolescents aged 11-20 years were obtained from the 2015 cycle of the Ontario Student Drug Use and Health Survey, a province-wide and cross-sectional school based survey of students in middle and high school. Respondents self-reported their sleep duration and consumption of SSBs and EDs. Those who did not meet the age-appropriate sleep duration recommendation were considered short sleepers. Overall, 81.4% and 12.0% of respondents reported that they had at least one SSBs and EDs in the past week, respectively. Males were more likely than females to consume SSBs and EDs. High school students were more likely than those in middle school to report drinking EDs. After adjusting for multiple covariates, results from logistic regression analyses indicated that short sleep duration was associated with greater odds of SSB consumption in middle school students (odd ratio (OR) = 1.64, 95% confidence interval (CI) = 1.18-2.11), but not those in high school (OR = 1.06, 95% CI = 0.86-1.31). Short sleep duration was associated with greater odds of ED consumption in both middle (OR = 1.60, 95% CI = 1.10-2.34) and high school (OR = 1.78, 95% CI = 1.38-2.30) students. Short sleep duration was associated with consumption of EDs in middle and high school students and with SSBs in middle school students only. Future studies are needed to establish causality and to determine whether improving sleep patterns can reduce the consumption of SSBs and EDs among adolescents. Copyright © 2017 Elsevier Inc. All rights reserved.

Nationwide population-based cohort study of psychiatric disorders in individuals with Ehlers-Danlos syndrome or hypermobility syndrome and their siblings.

PubMed

Cederlöf, Martin; Larsson, Henrik; Lichtenstein, Paul; Almqvist, Catarina; Serlachius, Eva; Ludvigsson, Jonas F

2016-07-04

To assess the risk of psychiatric disorders in Ehlers-Danlos syndrome (EDS) and hypermobility syndrome. Nationwide population-based matched cohort study. EDS, hypermobility syndrome and psychiatric disorders were identified through Swedish national registries. Individuals with EDS (n = 1,771) were matched with comparison individuals (n = 17,710). Further, siblings to individuals with EDS who did not have an EDS diagnosis themselves were compared with matched comparison siblings. Using conditional logistic regression, risk of autism spectrum disorder (ASD), bipolar disorder, attention deficit hyperactivity disorder (ADHD), depression, attempted suicide, suicide and schizophrenia were estimated. The same analyses were conducted in individuals with hypermobility syndrome (n = 10,019) and their siblings. EDS was associated with ASD: risk ratio (RR) 7.4, 95 % confidence interval (95 % CI) 5.2-10.7; bipolar disorder: RR 2.7, CI 1.5-4.7; ADHD: RR 5.6, CI 4.2-7.4; depression: RR 3.4, 95 % CI 2.9-4.1; and attempted suicide: RR 2.1, 95 % CI 1.7-2.7, but not with suicide or schizophrenia. EDS siblings were at increased risk of ADHD: RR 2.1, 95 % CI 1.4-3.3; depression: RR 1.5, 95 % CI 1.1-1.8; and suicide attempt: RR 1.8, 95 % CI 1.4-2.3. Similar results were observed for individuals with hypermobility syndrome and their siblings. Individuals with EDS and hypermobility syndrome are at increased risks of being diagnosed with psychiatric disorders. These risk increases may have a genetic and/or early environmental background as suggested by evidence showing that siblings to patients have elevated risks of certain psychiatric disorders.

Disease spread models to estimate highly uncertain emerging diseases losses for animal agriculture insurance policies: an application to the U.S. farm-raised catfish industry.

PubMed

Zagmutt, Francisco J; Sempier, Stephen H; Hanson, Terril R

2013-10-01

Emerging diseases (ED) can have devastating effects on agriculture. Consequently, agricultural insurance for ED can develop if basic insurability criteria are met, including the capability to estimate the severity of ED outbreaks with associated uncertainty. The U.S. farm-raised channel catfish (Ictalurus punctatus) industry was used to evaluate the feasibility of using a disease spread simulation modeling framework to estimate the potential losses from new ED for agricultural insurance purposes. Two stochastic models were used to simulate the spread of ED between and within channel catfish ponds in Mississippi (MS) under high, medium, and low disease impact scenarios. The mean (95% prediction interval (PI)) proportion of ponds infected within disease-impacted farms was 7.6% (3.8%, 22.8%), 24.5% (3.8%, 72.0%), and 45.6% (4.0%, 92.3%), and the mean (95% PI) proportion of fish mortalities in ponds affected by the disease was 9.8% (1.4%, 26.7%), 49.2% (4.7%, 60.7%), and 88.3% (85.9%, 90.5%) for the low, medium, and high impact scenarios, respectively. The farm-level mortality losses from an ED were up to 40.3% of the total farm inventory and can be used for insurance premium rate development. Disease spread modeling provides a systematic way to organize the current knowledge on the ED perils and, ultimately, use this information to help develop actuarially sound agricultural insurance policies and premiums. However, the estimates obtained will include a large amount of uncertainty driven by the stochastic nature of disease outbreaks, by the uncertainty in the frequency of future ED occurrences, and by the often sparse data available from past outbreaks. © 2013 Society for Risk Analysis.

CURB-65 Performance Among Admitted and Discharged Emergency Department Patients With Community-acquired Pneumonia.

PubMed

Sharp, Adam L; Jones, Jason P; Wu, Ivan; Huynh, Dan; Kocher, Keith E; Shah, Nirav R; Gould, Michael K

2016-04-01

Pneumonia severity tools were primarily developed in cohorts of hospitalized patients, limiting their applicability to the emergency department (ED). We describe current community ED admission practices and examine the accuracy of the CURB-65 to predict 30-day mortality for patients, either discharged or admitted with community-acquired pneumonia (CAP). A retrospective, observational study of adult CAP encounters in 14 community EDs within an integrated healthcare system. We calculated CURB-65 scores for all encounters and described the use of hospitalization, stratified by each score (0-5). We then used each score as a cutoff to calculate sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratios, and negative likelihood ratios for predicting 30-day mortality. The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 for predicting 30-day mortality in the full sample was 0.761 (95% confidence interval [CI], 0.747-0.774). The C-statistic was 0.864 (95% CI, 0.821-0.906) among patients discharged from the ED compared with 0.689 (95% CI, 0.672-0.705) among patients who were admitted. Among all ED encounters a CURB-65 threshold of ≥1 was 92.8% sensitive and 38.0% specific for predicting mortality, with a 99.9% NPV. Among all encounters, 62.5% were admitted, including 36.2% of those at lowest risk (CURB-65 = 0). CURB-65 had very good accuracy for predicting 30-day mortality among patients discharged from the ED. This severity tool may help ED providers risk stratify patients to assist with disposition decisions and identify unwarranted variation in patient care. © 2016 by the Society for Academic Emergency Medicine.

Obstructive sleep apnea with excessive daytime sleepiness is associated with non-alcoholic fatty liver disease regardless of visceral fat.

PubMed

Yu, Ji Hee; Ahn, Jae Hee; Yoo, Hye Jin; Seo, Ji A; Kim, Sin Gon; Choi, Kyung Mook; Baik, Sei Hyun; Choi, Dong Seop; Shin, Chol; Kim, Nan Hee

2015-11-01

Obstructive sleep apnea (OSA) is associated with an increased risk of obesity and non-alcoholic fatty liver disease (NAFLD), but it remains unclear whether the risk of NAFLD is independently related to OSA regardless of visceral obesity. Thus, the aim of the present study was to examine whether OSA alone or in combination with excessive daytime sleepiness (EDS) or short sleep duration was associated with NAFLD independent of visceral fat in Korean adults. A total of 621 participants were selected from the Korean Genome and Epidemiology Study (KoGES). The abdominal visceral fat area (VFA) and hepatic fat components of the participants were assessed using computed tomography scans and they were then categorized into four groups depending on the presence of OSA and EDS. The proportions of NAFLD were 21.1%, 18.5%, 32.4%, and 46.7% in participants without OSA/EDS, with only EDS, with only OSA, and with both OSA and EDS, respectively. A combination of OSA and EDS increased the odds ratio (OR) for developing NAFLD (OR, 2.75; 95% confidence interval [CI], 1.21 to 6.28) compared to those without OSA/EDS, and this association remained significant (OR, 2.38; 95% CI, 1.01 to 5.59) even after adjusting for VFA. In short sleepers (< 5 hours) with OSA, the adjusted OR for NAFLD was 2.50 (95% CI, 1.08 to 5.75) compared to those sleeping longer than 5 hours without OSA. In the present study, OSA was closely associated with NAFLD in Korean adults. This association was particularly strong in those with EDS or short sleep duration regardless of VFA.

Impact of a psychiatric unit's daily discharge rates on emergency department flow.

PubMed

Bastiampillai, Tarun; Schrader, Geoffrey; Dhillon, Rohan; Strobel, Jörg; Bidargaddi, Niranjan

2012-04-01

To investigate relationships between time spent in the emergency department (ED) in patients requiring admission to the psychiatric ward, the day of the week of presentation and the daily number of discharges from the psychiatric ward. Retrospective analysis of patient flow as a function of day of week, time of day (a.m., p.m.), number of patients requiring admission and number of ward discharges over a one-year period, for all mental health related presentations to the ED of the Queen Elizabeth Hospital in Adelaide, South Australia, before their admission to the psychiatric inpatient facility. The time spent by patients in the ED waiting for admission to the psychiatric ward was significantly greater on weekends. There were significantly fewer discharges from the psychiatric ward during weekends compared with weekdays. The average time spent by patients in the ED requiring admission to the psychiatric ward for those days when there were vacant beds was 17.9 hours (SD=14.5). More people presented to the ED with a psychiatric diagnosis in the afternoons. There was a significant inverse correlation between the time spent by patients in the ED requiring admission to the psychiatric ward per day and the number of discharges from the psychiatric ward per day. These findings demonstrate that patient flow is significantly slower on weekends because of fewer discharges from the ward, leading to longer times spent in the ED before ward transfer. Waiting times in the ED were very substantially greater than the proposed 4-hour target even when vacant beds were available, raising considerable doubt about that target being realistic for psychiatric patients.

Associations of work characteristics, employee strain and self-perceived quality of care in Emergency Departments: A cross-sectional study.

PubMed

Weigl, Matthias; Schneider, Anna

2017-01-01

The individual and shared effects of adverse work characteristics on patient care in Emergency Departments (ED) are yet not well understood. We investigated the associations of self-reported ED work characteristics, work-related strain, and perceived quality of care. Questionnaire-based survey with standardized measures among N=53 ED professionals (i.e., nurses, physicians, and administration staff). The study was conducted in the interdisciplinary ED of a German community hospital. A high prevalence of work-related strain was observed: 66.0% of ED professionals showed high levels of emotional exhaustion and 55.6% showed irritation scores above the cut-off value. ED staff reported high supervisor support and autonomy, paired with high time pressure and patient-related stressors. Multivariate analyses revealed that high time pressure and low supervisor support were associated with high work-related strain. Low staffing was related to inferior quality of ED care. ED work systems involve high competing demands for ED professionals with substantial risks for work-related strain. Moreover, adverse ED work characteristics comprise risks for high quality patient care. Our results suggest that promoting work characteristics might foster ED staff functioning on the job as well as improve ED patient care. Copyright © 2016 Elsevier Ltd. All rights reserved.

The effects of intracranial administration of hallucinogens on operant behavior in the rat. I. Lysergic acid diethylamide.

PubMed

Mokler, D J; Stoudt, K W; Sherman, L C; Rech, R H

1986-10-01

Lysergic acid diethylamide (LSD) was infused in one microliter volumes into discrete brain regions of rats trained to press a bar for food reinforcement. The sites were chosen as major areas of the brain 5-hydroxytryptamine (5HT) system: the dorsal and median raphe nuclei, dorsal hippocampus, lateral habenular nuclei, and the prefrontal cortex. Following training in a fixed ratio-40 (FR-40) operant behavior rats were implanted for the lateral habenular nuclei, dorsal hippocampus and the prefrontal cortex. Following recovery from surgery, LSD (8.6 to 86 micrograms) or vehicle was infused immediately before a daily operant session. Infusion of vehicle was inactive. LSD produced a dose-dependent decrease in reinforcements and an increase in 10-sec periods of non-responding (pause intervals). LSD was significantly more potent when infused into the dorsal raphe nucleus than following intracerebroventricular (ICV) administration, whereas LSD was less potent when infused into the median raphe, lateral habenula or dorsal hippocampus. ED50s for increases in pause intervals were 9, 13, 23, 25, and 54 micrograms for infusion into the dorsal raphe, prefrontal cortex, dorsal hippocampus, median raphe, and lateral habenular nuclei, respectively. The ED50 for ICV administration in a previous study was 15 micrograms. The ED50 of LSD placed into the prefrontal cortex did not differ significantly from that of the ICV infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Racial discrimination, response to unfair treatment, and depressive symptoms among pregnant black and African American women in the United States.

PubMed

Ertel, Karen A; James-Todd, Tamarra; Kleinman, Kenneth; Krieger, Nancy; Gillman, Matthew; Wright, Rosalind; Rich-Edwards, Janet

2012-12-01

To assess the association between self-reported racial discrimination and prenatal depressive symptoms among black women. Our study population consisted of two cohorts of pregnant women: the Asthma Coalition on Community, Environment, and Social Stress project (ACCESS) and Project Viva. We measured self-reported racial discrimination among black women using a modified Experiences of Discrimination scale (score 0-8). We assessed elevated depressive symptoms (EDS) with the Edinburgh Postnatal Depression Scale (≥13 on a 0-30 scale). Fifty-four percent of ACCESS and 78% of Viva participants reported experiencing racial discrimination. After adjusting for age, marital status, income, education, and nativity, a 1-U increment in Experiences of Discrimination score was associated with 48% increased odds of EDS (odds ratio, 1.48; 95% confidence interval, 1.24-1.76) for ACCESS participants but was not significantly associated among Viva participants (odds ratio, 1.12; 95% confidence interval, 0.92-1.37). In both cohorts, responding to unfair treatment by talking to others was associated with the lowest odds of EDS. Our findings suggest that higher levels of perceived racial discrimination may increase depressive symptoms during pregnancy among U.S. black women. Interventions involving talking to others may aid in reducing the risk of depressive symptoms among black women experiencing higher levels of racial discrimination. Copyright © 2012 Elsevier Inc. All rights reserved.

Effect of a pager notification system on Australasian Triage Scale category 2 patients in a paediatric emergency department.

PubMed

Cheng, Daryl R; McCartney, Laura E; West, Adam; Craig, Simon S

2016-08-01

Australasian EDs have introduced innovative processes to ensure safe and timely management of patients. Our ED introduced a dedicated pager system to provide rapid assessment of Australasian Triage Scale (ATS) category 2 patients in an attempt to expedite ED care. The present paper aims to evaluate the impact of this initiative on time to clinician, ED length of stay (LOS) and clinical outcomes in a tertiary paediatric ED. Retrospective structured chart review on patients presenting in a 2 month period before the intervention (August-September 2009) and the same time 1 year later. Patients were grouped into common ATS category 2 presentations and analysed in these subcategories. Clinical indicators of appropriate and timely performance were selected from best practice performance guidelines. 779 ATS category 2 patients were seen during the two periods: 370 pre-intervention and 409 post-intervention. The overall percentage of ATS category 2 patients seen within the target time increased by 22.3%, although there was no significant change in ED LOS. The median time for patients from triage to being seen by an ED clinician improved from 10 to 6 min (P < 0.01). However, we were unable to demonstrate an impact of the pager system on various clinical quality indicators. The rapid assessment pager system proved beneficial in reducing triage to clinician times for ATS category 2 patients but showed no improvement in overall ED LOS or disease-specific clinical quality indicators. Further research is needed to determine the influence of other components of ED functioning on clinical outcomes, as well as the overall clinical impact a pager system has on other measures of quality such as patient satisfaction and other subgroups of patients. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Web-Based Fully Automated Self-Help With Different Levels of Therapist Support for Individuals With Eating Disorder Symptoms: A Randomized Controlled Trial.

PubMed

Aardoom, Jiska J; Dingemans, Alexandra E; Spinhoven, Philip; van Ginkel, Joost R; de Rooij, Mark; van Furth, Eric F

2016-06-17

Despite the disabling nature of eating disorders (EDs), many individuals with ED symptoms do not receive appropriate mental health care. Internet-based interventions have potential to reduce the unmet needs by providing easily accessible health care services. This study aimed to investigate the effectiveness of an Internet-based intervention for individuals with ED symptoms, called "Featback." In addition, the added value of different intensities of therapist support was investigated. Participants (N=354) were aged 16 years or older with self-reported ED symptoms, including symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder. Participants were recruited via the website of Featback and the website of a Dutch pro-recovery-focused e-community for young women with ED problems. Participants were randomized to: (1) Featback, consisting of psychoeducation and a fully automated self-monitoring and feedback system, (2) Featback supplemented with low-intensity (weekly) digital therapist support, (3) Featback supplemented with high-intensity (3 times a week) digital therapist support, and (4) a waiting list control condition. Internet-administered self-report questionnaires were completed at baseline, post-intervention (ie, 8 weeks after baseline), and at 3- and 6-month follow-up. The primary outcome measure was ED psychopathology. Secondary outcome measures were symptoms of depression and anxiety, perseverative thinking, and ED-related quality of life. Statistical analyses were conducted according to an intent-to-treat approach using linear mixed models. The 3 Featback conditions were superior to a waiting list in reducing bulimic psychopathology (d=-0.16, 95% confidence interval (CI)=-0.31 to -0.01), symptoms of depression and anxiety (d=-0.28, 95% CI=-0.45 to -0.11), and perseverative thinking (d=-0.28, 95% CI=-0.45 to -0.11). No added value of therapist support was found in terms of symptom reduction although participants who received therapist support were significantly more satisfied with the intervention than those who did not receive supplemental therapist support. No significant differences between the Featback conditions supplemented with low- and high-intensity therapist support were found regarding the effectiveness and satisfaction with the intervention. The fully automated Internet-based self-monitoring and feedback intervention Featback was effective in reducing ED and comorbid psychopathology. Supplemental therapist support enhanced satisfaction with the intervention but did not increase its effectiveness. Automated interventions such as Featback can provide widely disseminable and easily accessible care. Such interventions could be incorporated within a stepped-care approach in the treatment of EDs and help to bridge the gap between mental disorders and mental health care services. Netherlands Trial Registry: NTR3646; http://www.trialregister.nl/trialreg/admin/ rctview.asp?TC=3646 (Archived by WebCite at http://www.webcitation.org/6fgHTGKHE).

Associations of Caffeinated Beverage Consumption and Screen Time with Excessive Daytime Sleepiness in Korean High School Students.

PubMed

Jun, Nuri; Lee, Aeri; Baik, Inkyung

2017-01-01

The present study investigated caffeinated beverage consumption and screen time in the association with excessive daytime sleepiness (EDS) and sleep duration. We conducted a cross-sectional study including 249 Korean male high school students. These participants responded to a questionnaire inquiring the information on lifestyle factors, consumption of caffeinated beverages, time spent for screen media, and sleep duration as well as to the Epworth Sleepiness Scale (ESS) questionnaire. EDS was defined as ESS scores of 9 or greater. Students with EDS consumed greater amount of chocolate/cocoa drinks and spent longer time for a TV and a mobile phone than those without EDS (p < 0.05). In addition, students with short sleep (≤ 6 hours) consumed greater amount of coffee than others whereas students with long sleep (> 8 hours) consumed greater amount of chocolate/cocoa drinks than others (p < 0.05). Screen time did not differ according to the categories of sleep duration. Although these findings do not support causal relationships, they suggest that screen time is associated with EDS, but not with sleep duration, and that consumption of certain types of caffeinated beverages is associated with EDS and sleep duration. Adolescents may need to reduce screen time and caffeine consumption to improve sleep quality and avoid daytime sleepiness.

A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization.

PubMed

Raven, Maria C; Steiner, Faye

2018-06-01

Many policymakers believe that expanding access to outpatient care will reduce emergency department (ED) use. However, outpatient health care providers often refer their patients to EDs for evaluation and management. We examine the factors underlying outpatient provider referral, its effect on ED visit volume, and whether referred ED visits are more likely to result in hospitalization than self-referred visits. We conducted a cross-sectional study of 19,342 adult (>18 years) respondents to the 2012 to 2014 National Health Interview Survey who reported they had visited an ED at least once in the past 12 months, representing an estimated 44,152,870 US adults. We categorized individuals as having been referred to the ED by an outside health care provider if they responded affirmatively to "your health care provider advised you to go" as a reason for their most recent ED visit. We performed descriptive analyses and logistic regressions to examine factors associated with outpatient health care provider referral to the ED. Respondents could choose multiple other reasons for their most recent ED visit, and we used existing Centers for Disease Control and Prevention guidelines to group these reasons into 2 categories: seriousness of the medical condition and lack of access to other providers. Our 2 main outcomes were whether an outpatient health care provider referred an individual to the ED and whether that ED visit resulted in hospitalization. Of the 44,152,870 US adults (18.58%; 95% confidence interval [CI] 18.21% to 18.95%) with one or more ED visits in the previous 12 months, 10,913,271 (24.72%; 95% CI 23.80% to 25.64%) were referred to the ED by an outpatient provider. Respondents who reported their ED visit was due to the seriousness of their medical condition were more likely to be referred to the ED (odds ratio [OR] 2.18; 95% CI 1.91 to 2.49), whereas those reporting a lack of access to other providers were less likely to be referred (OR 0.58; 95% CI 0.52 to 0.64). Visits referred to the ED were more likely to result in hospitalization than self-referrals (OR 2.07; 95% CI 1.87 to 2.31). Almost one quarter of individuals' most recent ED visits were driven by referrals from outpatient health care providers. Being referred to the ED by an outpatient provider is strongly associated with the seriousness of one's medical condition, which also increases the odds of hospitalization compared with ED discharge. After controlling for seriousness of medical condition, ED referral by an outpatient provider continues to have an independent association with hospitalization. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Dedicated Pediatricians in Emergency Department: Shorter Waiting Times and Lower Costs

PubMed Central

Melo, Manuel Rocha; Ferreira-Magalhães, Manuel; Flor-Lima, Filipa; Rodrigues, Mariana; Severo, Milton; Almeida-Santos, Luis; Caldas-Afonso, Alberto; Barros, Pedro Pita; Ferreira, António

2016-01-01

Background Dedicated pediatricians in emergency departments (EDs) may be beneficial, though no previous studies have assessed the related costs and benefits/harms. We aimed to evaluate the net benefits and costs of dedicated emergency pediatricians in a pediatric ED. Methods Cost-consequences analysis of visits to a pediatric ED of a tertiary hospital. Two pediatric ED Medical Teams (MT) were compared: MT-A (May–September 2012), with general pediatrics physicians only; and MT-B (May–September 2013), with emergency dedicated pediatricians. The main outcomes analyzed were relevant clinical outcomes, patient throughput time and costs. Results We included 8,694 children in MT-A and 9,417 in MT-B. Medication use in the ED increased from 42.3% of the children in MT-A to 49.6% in MT-B; diagnostic tests decreased from 24.2% in MT-A to 14.3% in MT-B. Hospitalization increased from 1.3% in MT-A to 3.0% in MT-B; however, there was no significant difference in diagnosis-related group relative weight of hospitalized children in MT-A and MT-B (MT-A, 0.979; MT-B, 1.075). No differences were observed in ED readmissions or in patients leaving without being seen by a physician. The patient throughput time was significantly shorter in MT-B, with faster times to first medical observation. Within the cost domains analyzed, the total expenditures per children observed in the ED were 16% lower in MT-B: 37.87 euros in MT-A; 31.97 euros in MT-B. Conclusion The presence of dedicated emergency pediatricians in a pediatric ED was associated with significantly lower waiting times in the ED, reduced costs, and similar clinical outcomes. PMID:27564093

Research in Stochastic Processes.

DTIC Science & Technology

1984-10-01

Handbook of Statistics, Volume 5: Time Series in Time Domain, E.J. Hannan, P.R. Krishnaiah and M.M. Rao, eds., North Holland, 1984, to appear. 5. J.A...designs for time series." S. Cambanis, Handbook of Statistics. Volume 5: Time Series in Time Domain, E.J. Hannan, P.R. Krishnaiah and M.M. Rao, eds... Krishnaiah and M.M. Rao, eds., North Holland, 1984, to appear. 59. "Ergodic properties of stationary stable processes." S. Cambanis, C.D. Hardin, and A

[Cardiovascular risk factors associated with erectile dysfunction in the region of Dakar, Senegal].

PubMed

Leye, M M M; Faye, A; Ka, O; Seck, I; Tal Dia, A

2016-06-01

Erectile dysfunction (ED) is often a reason for consultation revealing the existence of cardiovascular risk factors. The objective of this study was to determine the cardiovascular risk factors associated with ED in the Dakar region. A descriptive and analytical cross-sectional study was conducted from March 18 to June 2, 2013. The study population was composed of married male subjects who sought care at the Ouakam Geriatric and Gerontology Center and the Grand Yoff General Hospital. Erectile function was assessed with the International Index of Erectile Function using the simplified five-item questionnaire (IIEF 5). R 2.2.9 software was used for the logistic regression multivariate analysis. Associations were measured using the adjusted odds ratio (ORaj) with confidence intervals. A total of 253 men were surveyed during this period. Average age was 16.7±58.2 years, range 24-90 years; 47% were aged under 60 years. ED was diagnosed in 110 patients (43.5%). ED was considered mild (33.6%), moderate (5.5%) or severe (4.3%). ED was more severe in patients older than 60 years. Cardiovascular risk factors associated with ED were diabetes ORaj=2.4 (1.24-4.68), sedentary lifestyle ORaj=3.08 (1.69-5.61), and hypertension ORaj=2.53 (1.33-4.81). These results should prompt health care providers to target patients with diabetes, hypertension and sedentary lifestyle for systematic ED screening as a routine practice in order to ensure early and effective care. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial.

PubMed

Rice, Kathryn L; Dewan, Naresh; Bloomfield, Hanna E; Grill, Joseph; Schult, Tamara M; Nelson, David B; Kumari, Sarita; Thomas, Mel; Geist, Lois J; Beaner, Caroline; Caldwell, Michael; Niewoehner, Dennis E

2010-10-01

The effect of disease management for chronic obstructive pulmonary disease (COPD) is not well established. To determine whether a simplified disease management program reduces hospital admissions and emergency department (ED) visits due to COPD. We performed a randomized, adjudicator-blinded, controlled, 1-year trial at five Veterans Affairs medical centers of 743 patients with severe COPD and one or more of the following during the previous year: hospital admission or ED visit for COPD, chronic home oxygen use, or course of systemic corticosteroids for COPD. Control group patients received usual care. Intervention group patients received a single 1- to 1.5-hour education session, an action plan for self-treatment of exacerbations, and monthly follow-up calls from a case manager. We determined the combined number of COPD-related hospitalizations and ED visits per patient. Secondary outcomes included hospitalizations and ED visits for all causes, respiratory medication use, mortality, and change in Saint George's Respiratory Questionnaire. After 1 year, the mean cumulative frequency of COPD-related hospitalizations and ED visits was 0.82 per patient in usual care and 0.48 per patient in disease management (difference, 0.34; 95% confidence interval, 0.15-0.52; P < 0.001). Disease management reduced hospitalizations for cardiac or pulmonary conditions other than COPD by 49%, hospitalizations for all causes by 28%, and ED visits for all causes by 27% (P < 0.05 for all). A relatively simple disease management program reduced hospitalizations and ED visits for COPD. Clinical trial registered with www.clinicaltrials.gov (NCT00126776).

Methylphenidate and the risk of trauma.

PubMed

Man, Kenneth K C; Chan, Esther W; Coghill, David; Douglas, Ian; Ip, Patrick; Leung, Ling-Pong; Tsui, Matthew S H; Wong, Wilfred H S; Wong, Ian C K

2015-01-01

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are prone to sustaining trauma that requires emergency department (ED) admission. Methylphenidate (MPH) can reduce ADHD symptoms and may thus theoretically reduce the risk of trauma-related ED admission, but previous studies do not make this association clear. This study examines this association. A total of 17 381 patients aged 6 to 19 years who received MPH prescriptions were identified by using the Clinical Data Analysis & Reporting System (2001-2013). Using a self-controlled case series study design, the relative incidence of trauma-related ED admissions was compared with periods of patient exposure and nonexposure to MPH. Among 17 381 patients prescribed MPH, 4934 had at least 1 trauma-related ED admission. The rate of trauma-related ED admission was lower during exposed periods compared with nonexposed periods (incidence rate ratio [IRR]: 0.91 [95% confidence interval (CI): 0.86-0.97]). The findings were similar only when the incident trauma episode was assessed (IRR: 0.89 [95% CI: 0.82-0.96]). A similar protective association was found in both genders. In validation analysis using nontrauma-related ED admissions as a negative control outcome, no statistically significant association was found (IRR: 0.99 [95% CI: 0.95-1.02]). All sensitivity analyses demonstrated consistent results. This study supports the hypothesis that MPH is associated with a reduced risk of trauma-related ED admission in children and adolescents. A similar protective association was found in both male and female patients. This protective association should be considered in clinical practice. Copyright © 2015 by the American Academy of Pediatrics.

Multimedia education increases elder knowledge of emergency department care.

PubMed

Terndrup, Thomas E; Ali, Sameer; Hulse, Steve; Shaffer, Michele; Lloyd, Tom

2013-03-01

Elders who utilize the emergency department (ED) may have little prospective knowledge of appropriate expectations during an ED encounter. Improving elder orientation to ED expectations is important for satisfaction and health education. The purpose of this study was to evaluate a multi-media education intervention as a method for informing independently living elders about ED care. The program delivered messages categorically as, the number of tests, providers, decisions and disposition decision making. Interventional trial of representative elders over 59 years of age comparing pre and post multimedia program exposure. A brief (0.3 hour) video that chronicled the key events after a hypothetical 911 call for chest pain was shown. The video used a clinical narrator, 15 ED health care providers, and 2 professional actors for the patient and spouse. Pre- and post-video tests results were obtained with audience response technology (ART) assessed learning using a 4 point Likert scale. Valid data from 142 participants were analyzed pre to post rankings (Wilcoxon signed-rank tests). The following four learning objectives showed significant improvements: number of tests expected [median differences on a 4-point Likert scale with 95% confidence intervals: 0.50 (0.00, 1.00)]; number of providers expected 1.0 (1.00, 1.50); communications 1.0 (1.00, 1.50); and pre-hospital medical treatment 0.50 (0.00, 1.00). Elders (96%) judged the intervention as improving their ability to cope with an ED encounter. A short video with graphic side-bar information is an effective educational strategy to improve elder understanding of expectations during a hypothetical ED encounter following calling 911.

Identifying Potentially Preventable Emergency Department Visits by Nursing Home Residents in the United States.

PubMed

Burke, Robert E; Rooks, Sean P; Levy, Cari; Schwartz, Robert; Ginde, Adit A

2015-05-01

To identify and describe potentially preventable emergency department (ED) visits by nursing home (NH) residents in the United States. These visits are important because they are common, frequently lead to hospitalization, and can be associated with significant cost to the patient and the health care system. Retrospective analysis of the 2005-2010 National Hospital Ambulatory Care Survey (NHAMCS), comparing ED visits by nursing home residents that did not lead to hospital admission (potentially preventable) with those that led to admission (less likely preventable). Nationally representative sample of US EDs; federal hospitals and hospitals with fewer than 6 beds were excluded. Older (age ≥65 years) NH residents with an ED visit during this time period. Patient demographics, ED visit information including testing performed, interventions (both procedures and medications) provided, and diagnoses treated. Older NH residents accounted for 3857 of 208,956 ED visits during the time period of interest (1.8%). When weighted to be nationally representative, these represent 13.97 million ED visits, equivalent to 1.8 ED visits annually per NH resident in the United States. More than half of visits (53.5%) did not lead to hospital admission; of those discharged from the ED, 62.8% had normal vital signs on presentation and 18.9% did not have any diagnostic testing before ED discharge. Injuries were 1.78 times more likely to be discharged than admitted (44.8% versus 25.3%, respectively, P < .001), whereas infections were 2.06 times as likely to be admitted as discharged (22.9% versus 11.1%, respectively). Computed tomography (CT) scans were performed in 25.4% and 30.1% of older NH residents who were discharged from the ED and admitted to the hospital, respectively, and more than 70% of these were CTs of the head. NH residents received centrally acting, sedating medications before ED discharge in 9.4% of visits. This nationally representative sample of older NH residents suggests ED visits for injury, those that are associated with normal triage vital signs, and those that are not associated with any diagnostic testing are potentially preventable. Those discharged from the ED often undergo important testing and receive medications that may alter their physical examination on return to the nursing facility, highlighting the need for seamless communication of the ED course to NHs. Published by Elsevier Inc.

Can near real-time monitoring of emergency department diagnoses facilitate early response to sporadic meningococcal infection? - prospective and retrospective evaluations

PubMed Central

2010-01-01

Background Meningococcal infection causes severe, rapidly progressing illness and reporting of cases is mandatory in New South Wales (NSW), Australia. The NSW Department of Health operates near real-time Emergency Department (ED) surveillance that includes capture and statistical analysis of clinical preliminary diagnoses. The system can provide alerts in response to specific diagnoses entered in the ED computer system. This study assessed whether once daily reporting of clinical diagnoses of meningococcal infection using the ED surveillance system provides an opportunity for timelier public health response for this disease. Methods The study involved a prospective and retrospective component. First, reporting of ED diagnoses of meningococcal infection from the ED surveillance system prospectively operated in parallel with conventional surveillance which requires direct telephone reporting of this scheduled medical condition to local public health authorities by hospitals and laboratories when a meningococcal infection diagnosis is made. Follow-up of the ED diagnoses determined whether meningococcal infection was confirmed, and the time difference between ED surveillance report and notification by conventional means. Second, cases of meningococcal infection reported by conventional surveillance during 2004 were retrospectively matched to ED visits to determine the sensitivity and positive predictive value (PPV) of ED surveillance. Results During the prospective evaluation, 31 patients were diagnosed with meningococcal infection in participating EDs. Of these, 12 had confirmed meningococcal disease, resulting in a PPV of 38.7%. All confirmed cases were notified earlier to public health authorities by conventional reporting. Of 149 cases of notified meningococcal disease identified retrospectively, 130 were linked to an ED visit. The sensitivity and PPV of the ED diagnosis for meningococcal infection was 36.2% and 36.7%, respectively. Conclusions Based on prospective evaluation, it is reassuring that existing mechanisms for reporting meningococcal infection perform well and are timely. The retrospective evaluation found low sensitivity and PPV of ED diagnoses for meningococcal disease. Even if more rapid forwarding of ED meningococcal diagnoses to public health authorities were possible, the low sensitivity and PPV do not justify this. In this study, use of an ED surveillance system to augment conventional surveillance of this scheduled medical condition did not demonstrate a benefit. PMID:20979656

Predictive factors for erectile dysfunction in men with prostate cancer after brachytherapy: Is dose to the penile bulb important?

DOE Office of Scientific and Technical Information (OSTI.GOV)

Macdonald, A. Graham; Keyes, Mira; Kruk, Alexandra

2005-09-01

Purpose: To determine predictive factors for postimplant erectile dysfunction (ED) in a cohort of patients, according to prospectively collected data; specifically, to assess the impact of penile bulb volume and D50 and D95 (dose covering 50% and 95% of the penile bulb volume, respectively) on ED. Methods and Materials: Three hundred forty-two patients were identified who were potent before implant and who had at least 2 years' follow-up. Patient, tumor, treatment, and dosimetric data were collected on all patients. Postimplant ED was defined according to both physician-documented and patient-documented outcome data. Binary logistic regression analysis was used to create multivariablemore » models of predictors for ED at 1, 2, and 3 years after implant. Results: Physician-documented rates of ED were 57%, 48%, and 38% at 1, 2, and 3 years after implant, respectively. Patient-documented rates of ED were 70% and 66% at 1 and 2 years, respectively. Multivariable analyses revealed age and degree of preimplant erectile function to be consistently significant predictors of ED. Use of hormones was significant at the 1-year physician-documented ED endpoint but not thereafter, in keeping with the time course of testosterone recovery. Penile bulb volume, D50, and D95 were not found to be predictive for ED at any time point, in contrast to previous studies. In addition, planning ultrasound target volume, number of needles, and institutional case sequence number were significant predictors of ED at various time points, consistent with a traumatic etiology of ED. Conclusions: We found no evidence to support penile bulb dosimetry as an independent predictive factor for ED after implant, using physician-documented or patient-documented outcomes.« less

The financial consequences of lost demand and reducing boarding in hospital emergency departments.

PubMed

Pines, Jesse M; Batt, Robert J; Hilton, Joshua A; Terwiesch, Christian

2011-10-01

Some have suggested that emergency department (ED) boarding is prevalent because it maximizes revenue as hospitals prioritize non-ED admissions, which reimburse higher than ED admissions. We explore the revenue implications to the overall hospital of reducing boarding in the ED. We quantified the revenue effect of reducing boarding-the balance of higher ED demand and the reduction of non-ED admissions-using financial modeling informed by regression analysis and discrete-event simulation with data from 1 inner-city teaching hospital during 2 years (118,000 ED visits, 22% ED admission rate, 7% left without being seen rate, 36,000 non-ED admissions). Various inpatient bed management policies for reducing non-ED admissions were tested. Non-ED admissions generated more revenue than ED admissions ($4,118 versus $2,268 per inpatient day). A 1-hour reduction in ED boarding time would result in $9,693 to $13,298 of additional daily revenue from capturing left without being seen and diverted ambulance patients. To accommodate this demand, we found that simulated management policies in which non-ED admissions are reduced without consideration to hospital capacity (ie, static policies) mostly did not result in higher revenue. Many dynamic policies requiring cancellation of various proportions of non-ED admissions when the hospital reaches specific trigger points increased revenue. The optimal strategies tested resulted in an estimated $2.7 million and $3.6 in net revenue per year, depending on whether left without being seen patients were assumed to be outpatients or mirrored ambulatory admission rates, respectively. Dynamic inpatient bed management in inner-city teaching hospitals in which non-ED admissions are occasionally reduced to ensure that EDs have reduced boarding times is a financially attractive strategy. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Advertising emergency department wait times.

PubMed

Weiner, Scott G

2013-03-01

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.

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol

PubMed Central

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-01-01

Introduction Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. Methods and analysis The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics and dissemination Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. PMID:26463224

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol.

PubMed

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-10-13

Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Racial/ethnic disparities in emergency department waiting time for stroke patients in the United States.

PubMed

Karve, Sudeep J; Balkrishnan, Rajesh; Mohammad, Yousef M; Levine, Deborah A

2011-01-01

Emergency department waiting time (EDWT), the time from arrival at the ED to evaluation by an emergency physician, is a critical component of acute stroke care. We assessed racial/ethnic differences in EDWT in a national sample of patients with ischemic or hemorrhagic stroke. We identified 543 ED visits for ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 433.x1, 434.xx, and 436.xx) and hemorrhagic stroke (ICD-9-CM codes 430.xx, 431.xx, and 432.xx) in persons age ≥ 18 years representing 2.1 million stroke-related ED visits in the United States using the National Hospital Ambulatory Medical Care Survey for years 1997-2000 and 2003-2005. Using linear regression (outcome, log-transformed EDWT) and logistic regression (outcome, EDWT > 10 minutes, based on National Institute of Neurological Disorders and Stroke guidelines), we adjusted associations between EDWT and race/ethnicity (non-Hispanic whites [designated whites herein], non-Hispanic blacks [blacks], and Hispanics) for age, sex, region, mode of transportation, insurance, hospital characteristics, triage status, hospital admission, stroke type, and survey year. Compared with whites, blacks had a longer EDWT in univariate analysis (67% longer, P = .03) and multivariate analysis (62% longer, P = .03), but Hispanics had a similar EDWT in both univariate analysis (31% longer, P = .65) and multivariate analysis (5% longer, P = .91). Longer EDWT was also seen with nonambulance mode of arrival, urban hospitals, or nonemergency triage. Race was significantly associated with EDWT > 10 minutes (whites, 55% [referent]; blacks, 70% [P = .03]; Hispanics, 62% [P = .53]). These differences persisted after adjustment (blacks: odds ratio [OR] = 2.08, 95% confidence interval [CI] = 1.05-4.09; Hispanics: OR = 1.07, 95% CI = 0.52-2.22). Blacks, but not Hispanics, had significantly longer EDWT than whites. The longer EDWT in black stroke patients may lead to treatment delays and sub-optimal stroke care. Published by Elsevier Inc.

The organizational culture of emergency departments and the effect on care of older adults: a modified scoping study.

PubMed

Skar, Pål; Bruce, Anne; Sheets, Debra

2015-04-01

How does the organizational micro culture in emergency departments (EDs) impact the care of older adults presenting with a complaint or condition perceived as non-acute? This scoping study reviews the literature and maps three levels of ED culture (artifacts, values and beliefs, and assumptions). Findings on the artifact level indicate that EDs are poorly designed for the needs of older adults. Findings on the ED value and belief level indicate that EDs are for urgent cases (not geriatric care), that older adults do not receive the care and respect they should be given, that older adults require too much time, and that the basic nursing needs of older adults are not a priority for ED nurses. Finally, finding on the assumptions level underpinning ED behaviors suggest that older adults do not belong in the ED, most older adults in the ED are not critically ill and therefore can wait, and staff need to be available for acute cases at all times. A systematic review on the effect of ED micro culture on the quality of geriatric care is warranted. Copyright © 2014. Published by Elsevier Ltd.

Health outcomes associated with smoke exposure in Albuquerque, New Mexico, during the 2011 Wallow fire.

PubMed

Resnick, Adam; Woods, Brian; Krapfl, Heidi; Toth, Barbara

2015-01-01

This study examined the association between PM2.5 levels and emergency department (ED) visits for selected health outcomes in Albuquerque, New Mexico, during the Wallow fire of 2011. Measurements of 24-hour average concentrations of PM2.5 obtained from the City of Albuquerque were used to calculate wildfire smoke exposure in Albuquerque. Daily ED visits were collected by the New Mexico Department of Health from individual nonfederal licensed facilities in the Albuquerque area. Poisson regression was used to assess the relationship between ED visits for selected respiratory and cardiovascular conditions and varying levels of PM2.5 exposure. Albuquerque, New Mexico. Patients visiting an ED for select conditions before, during, and after the wildfire. Relative increase in ED visits for selected conditions during the wildfire period. Analysis of PM2.5 exposure data and ED visits in Albuquerque before and during the Wallow fire indicated that compared with the period prior to the fire, there was an increased risk of ED visits for some respiratory and cardiovascular conditions during heavy smoke conditions, and risk varied by age and sex. The population of 65+ years was especially at risk for increased ED visits. There was a significantly increased risk of ED visits among the 65+ population for asthma (RR [relative rate] = 1.73, 95% confidence interval [CI] = 1.03-2.93) and for diseases of the veins, lymphatic and circulatory system (RR = 1.56, 95% CI = 1.00-2.43). For the age group of 20 to 64 years, there was a statistically significant increase in ED visits for diseases of pulmonary circulation (RR = 2.64, 95% CI = 1.42-4.9) and for cerebrovascular disease (RR = 1.69, 95% CI = 1.03-2.77). High levels of PM2.5 exposure due to the Wallow fire were associated with increased ED visits for respiratory and cardiovascular conditions in Albuquerque. More effective and targeted preventive measures are necessary to reduce morbidity rates associated with wildfire smoke exposure among vulnerable populations.

The Association Between Limited English Proficiency and Unplanned Emergency Department Revisit Within 72 Hours.

PubMed

Ngai, Ka Ming; Grudzen, Corita R; Lee, Roy; Tong, Vicky Y; Richardson, Lynne D; Fernandez, Alicia

2016-08-01

Language barriers are known to negatively affect many health outcomes among limited English proficiency patient populations, but little is known about the quality of care such patients receive in the emergency department (ED). This study seeks to determine whether limited English proficiency patients experience different quality of care than English-speaking patients in the ED, using unplanned revisit within 72 hours as a surrogate quality indicator. We conducted a retrospective cohort study in an urban adult ED in 2012, with a total of 41,772 patients and 56,821 ED visits. We compared 2,943 limited English proficiency patients with 38,829 English-speaking patients presenting to the ED after excluding patients with psychiatric complaints, altered mental status, and nonverbal states, and those with more than 4 ED visits in 12 months. Two main outcomes-the risk of inpatient admission from the ED and risk of unplanned ED revisit within 72 hours-were measured with odds ratios from generalized estimating equation multivariate models. Limited English proficiency patients were more likely than English speakers to be admitted (32.0% versus 27.2%; odds ratio [OR]=1.20; 95% confidence interval [CI] 1.11 to 1.30). This association became nonsignificant after adjustments (OR=1.04; 95% CI 0.95 to 1.15). Included in the analysis of ED revisit within 72 hours were 32,857 patients with 45,546 ED visits; 4.2% of all patients (n=1,380) had at least 1 unplanned revisit. Limited English proficiency patients were more likely than English speakers to have an unplanned revisit (5.0% versus 4.1%; OR=1.19; 95% CI 1.02 to 1.45). This association persisted (OR=1.24; 95% CI 1.02 to 1.53) after adjustment for potential confounders, including insurance status. We found no difference in hospital admission rates between limited English proficiency patients and English-speaking patients. Yet limited English proficiency patients were 24% more likely to have an unplanned ED revisit within 72 hours, with an absolute difference of 0.9%, suggesting challenges in ED quality of care. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Can interprofessional teamwork reduce patient throughput times? A longitudinal single-centre study of three different triage processes at a Swedish emergency department

PubMed Central

Masiello, Italo; Ponzer, Sari; Farrokhnia, Nasim

2018-01-01

Objective To determine the impact on emergency department (ED) throughput times and proportion of patients who leave without being seen by a physician (LWBS) of two triage interventions, where comprehensive nurse-led triage was first replaced by senior physician-led triage and then by interprofessional teamwork. Design Single-centre before-and-after study. Setting Adult ED of a Swedish urban hospital. Participants Patients arriving on weekdays 08:00 to 21:00 during three 1-year periods in the interval May 2012 to November 2015. A total of 185 806 arrivals were included. Interventions Senior physicians replaced triage nurses May 2013 to May 2014. Interprofessional teamwork replaced the triage process on weekdays 08:00 to 21:00 November 2014 to November 2015. Main outcome measures Primary outcomes were the median time to physician (TTP) and the median length of stay (LOS). Secondary outcome was the LWBS rate. Results The crude median LOS was shortest for teamwork, 228 min (95% CI 226.4 to 230.5) compared with 232 min (95% CI 230.8 to 233.9) for nurse-led and 250 min (95% CI 248.5 to 252.6) for physician-led triage. The adjusted LOS for the teamwork period was 16 min shorter than for nurse-led triage and 23 min shorter than for physician-led triage. The median TTP was shortest for physician-led triage, 56 min (95% CI 54.5 to 56.6) compared with 116 min (95% CI 114.4 to 117.5) for nurse-led triage and 74 min (95% CI 72.7 to 74.8) for teamwork. The LWBS rate was 1.9% for nurse-led triage, 1.2% for physician-led triage and 3.2% for teamwork. All outcome measure differences had two-tailed p values<0.01. Conclusions Interprofessional teamwork had the shortest length of stay, a shorter time to physician than nurse-led triage, but a higher LWBS rate. Interprofessional teamwork may be a useful approach to reducing ED throughput times. PMID:29674366

Patient-Centered Care Transition for Patients Admitted through the ED: Improving Patient and Employee Experience

PubMed Central

Algauer, Andrea; Rivera, Stephanie; Faurote, Robert

2015-01-01

With increasing wait times in emergency departments (ED) across America, there is a need to streamline the inpatient admission process in order to decrease wait times and more important, to increase patient and employee satisfaction. One inpatient unit at New York-Presbyterian Weill Cornell Medical Center initiated a program to help expedite the inpatient admission process from the ED. The goal of the ED Bridge program is to ease the patient's transition from the ED to an inpatient unit by visiting the patient in the ED and introducing and setting expectations for the inpatient environment (i.e. telemetry alarms, roommates, hourly comfort rounds). Along with improving the patient experience, this program intends to improve the collaboration between ED nurses and inpatient nurses. With the continued support of our nurse management, hospital administrators and most important, our staff, this concept is aimed to increase patient satisfaction scores and subsequently employee satisfaction. PMID:28725813

Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013

PubMed Central

Ngo, Hanh; Forero, Roberto; Mountain, David; Fatovich, Daniel; Man, Wing Nicola; Sprivulis, Peter; Mohsin, Mohammed; Toloo, Sam; Celenza, Antonio; Fitzgerald, Gerard; McCarthy, Sally; Hillman, Ken

2018-01-01

Background In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. Methods A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. Findings There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most ‘crowded’ ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. Conclusions The FHR had a consistent effect on ‘flow’ measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia. PMID:29538401

Antenatal and postnatal psychopathology among women with current and past eating disorders: longitudinal patterns.

PubMed

Easter, Abigail; Solmi, Francessca; Bye, Amanda; Taborelli, Emma; Corfield, Freya; Schmidt, Ulrike; Treasure, Janet; Micali, Nadia

2015-01-01

This study aims to investigate longitudinal patterns of psychopathology during the antenatal and postnatal periods among women with current (C-ED) and past (P-ED) eating disorders. Women were recruited to a prospective longitudinal study: C-ED (n = 31), P-ED (n = 29) and healthy control (HC; n = 57). Anxiety, depression and ED symptoms were measured at four time points: first/second trimester, third trimester, 8 weeks and 6 months postpartum. Linear mixed effects models were used to test for group differences. Women with C-ED and P-ED, in all diagnostic categories, had significantly higher levels of psychopathology at all time points. ED symptoms decreased in the C-ED group, compared with an overall increase in the other two groups but subsequently increased after pregnancy. Overall, depression and state and trait anxiety scores decreased in the C-ED group compared with the HC group throughout the antenatal and postnatal periods. High levels of psychopathology are common throughout the antenatal and postnatal periods among women with current and past ED, and despite some overall reductions, symptoms remain clinically significant. © 2014 The Authors. European Eating Disorders Review published by John Wiley & Sons, Ltd. © 2014 The Authors. European Eating Disorders Review published by John Wiley & Sons, Ltd.

Optimizing patient/caregiver satisfaction through quality of communication in the pediatric emergency department.

PubMed

Locke, Robert; Stefano, Mariane; Koster, Alex; Taylor, Beth; Greenspan, Jay

2011-11-01

Optimizing patient/family caregiver satisfaction with emergency department (ED) encounters has advantages for improving patient health outcomes, adherence with medical plans, patient rights, and shared participation in care, provider satisfaction, improved health economics, institutional market share, and liability reduction. The variables that contribute to an optimal outcome in the pediatric ED setting have been less well investigated. The specific hypothesis tested was that patient/family caregiver-provider communication and 24-hour postdischarge phone contact would be associated with an increased frequency of highest possible satisfaction scores. A consecutive set of Press Ganey satisfaction survey responses between June and December 2009 in a large tertiary referral pediatric ED was evaluated. Press Ganey responses were subsequently linked to defined components of the electronic medical record associated with each survey respondent's ED visit to ascertain specific objective ED data. Multivariate modeling utilizing generalized linear equations was achieved to obtain a composite model of drivers of patient/caregiver satisfaction. Primary drivers of satisfaction and willingness to return or refer others to the ED were as follows: being informed about delays, ease of the insurance process, overall physician rating, registered nurse attention to needs, control of pain, and successful completion of postdischarge phone call to a family caregiver. Multiple wait time variables that were statistically significant in univariate modeling, including total length of time in the ED, time in waiting room, comfort of waiting room, time in treatment room, and play items, were not statistically significant once controlling for the other variables in the model. Type of insurance, race, patient age, or time of year did not influence the models. Achieving optimal patient/caregiver satisfaction scores in the pediatric ED is highly dependent on the quality of the interpersonal interaction and communication of ED activities. Wait time and other throughput variables are less important than perceived quality of the health interaction and interpersonal communication. Patient satisfaction has advantages greater than market share and should be considered a component of the care-delivery paradigm.

Whys and Hows of the Parameterized Interval Analyses: A Guide for the Perplexed

NASA Astrophysics Data System (ADS)

Elishakoff, I.

2013-10-01

Novel elements of the parameterized interval analysis developed in [1, 2] are emphasized in this response, to Professor E.D. Popova, or possibly to others who may be perplexed by the parameterized interval analysis. It is also shown that the overwhelming majority of comments by Popova [3] are based on a misreading of our paper [1]. Partial responsibility for this misreading can be attributed to the fact that explanations provided in [1] were laconic. These could have been more extensive in view of the novelty of our approach [1, 2]. It is our duty, therefore, to reiterate, in this response, the whys and hows of parameterization of intervals, introduced in [1] to incorporate the possibly available information on dependencies between various intervals describing the problem at hand. This possibility appears to have been discarded by the standard interval analysis, which may, as a result, lead to overdesign, leading to the possible divorce of engineers from the otherwise beautiful interval analysis.

Sex Hormones Predict the Incidence of Erectile Dysfunction: From a Population-Based Prospective Cohort Study (FAMHES).

PubMed

Luo, Yawen; Zhang, Haiying; Liao, Ming; Tang, Qin; Huang, Yuzhen; Xie, Jinling; Tang, Yan; Tan, Aihua; Gao, Yong; Lu, Zheng; Yao, Ziting; Jiang, Yonghua; Lin, Xinggu; Wu, Chunlei; Yang, Xiaobo; Mo, Zengnan

2015-05-01

The decline of testosterone has been known to be associated with the prevalence of erectile dysfunction (ED), but the causal relationship between sex hormones and ED is still uncertain. To prove the association between sex hormones and ED, we carried out a prospective cohort study based on our previous cross-sectional study. We performed a prospective cohort study of 733 Chinese men who participated in Fangchenggang Area Males Health and Examination Survey from September 2009 to December 2009 and were followed for 4 years. Erectile function was estimated by scores of the five-item International Index of Erectile Dysfunction (IIEF-5) and relative ratios (RRs) were estimated using the Cox proportional hazards regression model. Data were collected at follow-up visit and included sex hormone measurements, IIEF-5 scores, physical examination, and health questionnaires. Men with the highest tertile of free testosterone (FT) (RR = 0.21, 95% confidence interval [CI]: 0.09-0.46) and the lowest tertile of sex hormone-binding globulin (SHBG) (RR = 0.38, 95% CI: 0.19-0.73) had decreased risk of ED. In young men (aged 21-40), a decreased risk was observed with the increase of FT and bioavailable testosterone (BT) (adjusted RR and 95% CI: 0.78 [0.67-0.92] and 0.75 [0.62-0.95], respectively). Total testosterone (TT) (RR = 0.89, 95% CI: 0.81-0.98) was inversely associated with ED after adjusting for SHBG, while SHBG (RR = 1.04, 95% CI: 1.02-1.06) remained positively associated with ED after further adjusting for TT. Men with both low FT and high SHBG had highest ED risk (adjusted RR = 4.61, 95% CI: 1.33-16.0). High FT and BT levels independently predicted a decreased risk of ED in young men. Further studies are urgently needed to clarify the molecular mechanisms of testosterone acting on ED. © 2015 International Society for Sexual Medicine.

Efficiency of International Classification of Diseases, Ninth Revision, Billing Code Searches to Identify Emergency Department Visits for Blood or Body Fluid Exposures through a Statewide Multicenter Database

PubMed Central

Rosen, Lisa M.; Liu, Tao; Merchant, Roland C.

2016-01-01

BACKGROUND Blood and body fluid exposures are frequently evaluated in emergency departments (EDs). However, efficient and effective methods for estimating their incidence are not yet established. OBJECTIVE Evaluate the efficiency and accuracy of estimating statewide ED visits for blood or body fluid exposures using International Classification of Diseases, Ninth Revision (ICD-9), code searches. DESIGN Secondary analysis of a database of ED visits for blood or body fluid exposure. SETTING EDs of 11 civilian hospitals throughout Rhode Island from January 1, 1995, through June 30, 2001. PATIENTS Patients presenting to the ED for possible blood or body fluid exposure were included, as determined by prespecified ICD-9 codes. METHODS Positive predictive values (PPVs) were estimated to determine the ability of 10 ICD-9 codes to distinguish ED visits for blood or body fluid exposure from ED visits that were not for blood or body fluid exposure. Recursive partitioning was used to identify an optimal subset of ICD-9 codes for this purpose. Random-effects logistic regression modeling was used to examine variations in ICD-9 coding practices and styles across hospitals. Cluster analysis was used to assess whether the choice of ICD-9 codes was similar across hospitals. RESULTS The PPV for the original 10 ICD-9 codes was 74.4% (95% confidence interval [CI], 73.2%–75.7%), whereas the recursive partitioning analysis identified a subset of 5 ICD-9 codes with a PPV of 89.9% (95% CI, 88.9%–90.8%) and a misclassification rate of 10.1%. The ability, efficiency, and use of the ICD-9 codes to distinguish types of ED visits varied across hospitals. CONCLUSIONS Although an accurate subset of ICD-9 codes could be identified, variations across hospitals related to hospital coding style, efficiency, and accuracy greatly affected estimates of the number of ED visits for blood or body fluid exposure. PMID:22561713

Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey.

PubMed

Bauer, Greta R; Scheim, Ayden I; Deutsch, Madeline B; Massarella, Carys

2014-06-01

Transgender, transsexual, or transitioned (trans) people have reported avoiding medical care because of negative experiences or fear of such experiences. The extent of trans-specific negative emergency department (ED) experiences, and of ED avoidance, has not been documented. The Trans PULSE Project conducted a survey of trans people in Ontario, Canada (n=433) in 2009 to 2010, using respondent-driven sampling, a tracked network-based method for studying hidden populations. Weighted frequencies and bootstrapped 95% confidence intervals (CIs) were estimated for the trans population in Ontario and for the subgroup (n=167) reporting ED use in their felt gender. Four hundred eight participants completed the ED experience items. Trans people were young (34% aged 16 to 24 years and only 10% >55 years); approximately half were female-to-male and half male-to-female. Medically supervised hormones were used by 37% (95% CI 30% to 46%), and 27% (95% CI 20% to 35%) had at least 1 transition-related surgery. Past-year ED need was reported by 33% (95% CI 26% to 40%) of trans Ontarians, though only 71% (95% CI 40% to 91%) of those with self-reported need indicated that they were able to obtain care. An estimated 21% (95% CI 14% to 25%) reported ever avoiding ED care because of a perception that their trans status would negatively affect such an encounter. Trans-specific negative ED experiences were reported by 52% (95% CI 34% to 72%) of users presenting in their felt gender. This first exploratory analysis of ED avoidance, utilization, and experiences by trans persons documented ED avoidance and possible unmet need for emergency care among trans Ontarians. Additional research, including validation of measures, is needed. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Correlation of Level of Trauma Activation With Emergency Department Intervention.

PubMed

Cooper, Michael C; Srivastava, Geetanjali

2018-06-01

In-hospital trauma team activation criteria are formulated to identify severely injured patients requiring specialized multidisciplinary care. Efficacy of trauma activation (TA) criteria is commonly measured by emergency department (ED) disposition, injury severity score, and mortality. Necessity of critical ED interventions is another measure that has been proposed to evaluate the appropriateness of TA criteria. Two-year retrospective cohort study of 1715 patients from our trauma registry at a Level 1 pediatric trauma center. We abstracted data on acute interventions, level and criterion of TA, ED disposition, and mortality. We report odds ratio (OR) with 95% confidence intervals (CIs), positive predictive value, and frequency of acute interventions. Trauma activation was initiated for 947 (55%) of the 1715 patients. There were 426 ED interventions performed on 235 patients (14%); 67.8% were in level 1 activations; 17.6% in level 2, and 14.6% in level 3. Highest-level activations were highly associated with need for ED interventions (OR, 16.1; 95% CI, 11.5-22.4). The ORs for requiring an ED intervention were low for lower level activations (OR, 0.4; 95% CI, 0.3-0.5), trauma service consults (OR, 0.3; 95% CI, 0.2-0.4), and certain mechanism-based criteria. The ORs for ED intervention for isolated motor vehicle collision (0.2; 95% CI, 0.1-0.7), isolated all-terrain vehicle rollover (0.4; 95% CI, 0.1-1.7), and suspected spinal cord injury (0.5; 95% CI, 0.1-3.7) were significantly lower than 1. Highest-level activation criteria correlate with high utilization of ED resources and interventions. Lower level activation criteria and trauma service consult criteria are not highly correlated with need for ED interventions. Downgrading isolated motor vehicle collision and all-terrain vehicle rollovers and suspected spinal cord injury to lower level activations could decrease the overtriage rate, and adding age-specific bradycardia as a physiologic criterion could improve our undertriage rate.

The Dose-response of Intrathecal Ropivacaine Co-administered with Sufentanil for Cesarean Delivery under Combined Spinal-epidural Anesthesia in Patients with Scarred Uterus

PubMed Central

Xiao, Fei; Xu, Wen-Ping; Zhang, Yin-Fa; Liu, Lin; Liu, Xia; Wang, Li-Zhong

2015-01-01

Background: Spinal anesthesia is considered as a reasonable anesthetic option in lower abdominal and lower limb surgery. This study was to determine the dose-response of intrathecal ropivacaine in patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia. Methods: Seventy-five patients with scarred uterus undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized, double-blinded, dose-ranging study. Patients received 6, 8, 10, 12, or 14 mg intrathecal hyperbaric ropivacaine with 5 μg sufentanil. Successful spinal anesthesia was defined as a T4 sensory level achieved with no need for epidural supplementation. The 50% effective dose (ED50) and 95% effective dose (ED95) were calculated with a logistic regression model. Results: ED50 and ED95 of intrathecal hyperbaric ropivacaine for patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia (CSEA) were 8.28 mg (95% confidence interval [CI]: 2.28–9.83 mg) and 12.24 mg (95% CI: 10.53–21.88 mg), respectively. Conclusion: When a CSEA technique is to use in patients with scarred uterus for an elective cesarean delivery, the ED50 and ED95 of intrathecal hyperbaric ropivacaine along with 5 μg sufentanil were 8.28 mg and 12.24 mg, respectively. In addition, this local anesthetic is unsuitable for emergent cesarean delivery, but it has advantages for ambulatory patients. PMID:26415793

Ambient versus traditional environment in pediatric emergency department.

PubMed

Robinson, Patricia S; Green, Jeanette

2015-01-01

We sought to examine the effect of exposure to an ambient environment in a pediatric emergency department. We hypothesized that passive distraction from ambient lighting in an emergency department would lead to reduction in patient pain and anxiety and increased caregiver satisfaction with services. Passive distraction has been associated with lower anxiety and pain in patients and affects perception of wait time. A pediatric ED was designed that optimized passive distraction techniques using colorful ambient lighting. Participants were nonrandomly assigned to either an ambient ED environment or a traditional ED environment. Entry and exit questionnaires assessed caregiver expectations and experiences. Pain ratings were obtained with age-appropriate scales, and wait times were recorded. A total of 70 participants were assessed across conditions, that is, 40 in the ambient ED group and 30 in the traditional ED group. Caregivers in the traditional ED group expected a longer wait, had higher anxiety pretreatment, and felt more scared than those in the ambient ED group. Caregivers in the ambient ED group felt more included in the care of their child and rated quality of care higher than caregivers in the traditional ED group. Pain ratings and administrations of pain medication were lower in the ambient ED group. Mean scores for the ambient ED group were in the expected direction on several items measuring satisfaction with ED experiences. Results were suggestive of less stress in caregivers, less pain in patients, and higher satisfaction levels in the ambient ED group. © The Author(s) 2015.

Surface properties of sprayed and electrodeposited ZnO rod layers

NASA Astrophysics Data System (ADS)

Gromyko, I.; Krunks, M.; Dedova, T.; Katerski, A.; Klauson, D.; Oja Acik, I.

2017-05-01

Herein we present a comparative study on as-deposited, two-month-stored, and heat-treated ZnO rods obtained by spray pyrolysis (SP) at 550 °C, and electrodeposition (ED) at 80 °C. The aim of the study is to establish the reason for different behaviour of wettability and photocatalytic activity (PA) of SP and ED rods. Samples were studied using XPS, SEM, XRD, Raman, contact angle (CA) measurements and photocatalytic oxidation of doxycycline. Wettability and PA are mainly controlled by surface composition rather than by morphology. The relative amount of hydroxyl groups on the surface of as-deposited ED rods is four times higher compared to as-deposited SP rods. Opposite to SP rods, ED rods contain oxygen vacancy defects (Vo). Therefore, as-deposited ED rods are superhydrophilic (CA ∼ 3°) and show highest PA among studied samples, being three times higher compared to SP rods (removing of 75% of doxycycline after 30 min). It was revealed that as-deposited ED rods are inclined to faster contamination. The amount of Cdbnd C groups on the surface of aged ED rods is six times higher compared to aged SP rods. Stored ED samples become hydrophobic (CA ∼ 120°) and PA decreases sharply while SP rods remain hydrophilic (CA ∼ 50°), being more resistive to the contamination.

Admission time to hospital: a varying standard for a critical definition for admissions to an intensive care unit from the emergency department.

PubMed

Nanayakkara, Shane; Weiss, Heike; Bailey, Michael; van Lint, Allison; Cameron, Peter; Pilcher, David

2014-11-01

Time spent in the emergency department (ED) before admission to hospital is often considered an important key performance indicator (KPI). Throughout Australia and New Zealand, there is no standard definition of 'time of admission' for patients admitted through the ED. By using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, the aim was to determine the differing methods used to define hospital admission time and assess how these impact on the calculation of time spent in the ED before admission to an intensive care unit (ICU). Between March and December of 2010, 61 hospitals were contacted directly. Decision methods for determining time of admission to the ED were matched to 67,787 patient records. Univariate and multivariate analyses were conducted to assess the relationship between decision method and the reported time spent in the ED. Four mechanisms of recording time of admission were identified, with time of triage being the most common (28/61 hospitals). Reported median time spent in the ED varied from 2.5 (IQR 0.83-5.35) to 5.1 h (2.82-8.68), depending on the decision method. After adjusting for illness severity, hospital type and location, decision method remained a significant factor in determining measurement of ED length of stay. Different methods are used in Australia and New Zealand to define admission time to hospital. Professional bodies, hospitals and jurisdictions should ensure standardisation of definitions for appropriate interpretation of KPIs as well as for the interpretation of studies assessing the impact of admission time to ICU from the ED. WHAT IS KNOWN ABOUT THE TOPIC?: There are standards for the maximum time spent in the ED internationally, but these standards vary greatly across Australia. The definition of such a standard is critically important not only to patient care, but also in the assessment of hospital outcomes. Key performance indicators rely on quality data to improve decision-making. WHAT DOES THIS PAPER ADD?: This paper quantifies the variability of times measured and analyses why the variability exists. It also discusses the impact of this variability on assessment of outcomes and provides suggestions to improve standardisation. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: This paper provides a clearer view on standards regarding length of stay in the ICU, highlighting the importance of key performance indicators, as well as the quality of data that underlies them. This will lead to significant changes in the way we standardise and interpret data regarding length of stay.

Effects of single-shot and steady-state propofol anaesthesia on rocuronium dose-response relationship: a randomised trial.

PubMed

Stäuble, C G; Stäuble, R B; Schaller, S J; Unterbuchner, C; Fink, H; Blobner, M

2015-08-01

Similar to volatile anaesthetics, propofol may influence neuromuscular transmission. We hypothesised that the administration of propofol influenced the potency of rocuronium depending on the duration of the administration. After consent, patients scheduled for elective surgery randomly received rocuronium either after induction of anaesthesia with propofol (2 min of propofol, n = 36) or after 30 min of propofol infusion (30 min of propofol, n = 36). Remifentanil was given in both groups. Neuromuscular monitoring was performed by calibrated electromyography. The dose-response relationship of rocuronium was determined with a single-bolus technique (0.07, 0.1, 0.15, 0.2, 0.3 and 0.45 mg/kg rocuronium). The primary endpoints were the ED50 and ED95 of rocuronium after 2 and 30 min propofol. Data are presented as means with (95% confidence interval). The trial is registered with the Eudra-CT: 2009-012815-16. A total of 72 patients were included. Time to maximal neuromuscular blockade was significantly shorter in patients after 30 min of propofol [3.3 min (2.9-3.7)] compared with patients anaesthetised with 2 min of propofol [4.6 min (4.0-5.2)]. After 30 min of propofol, the slope of the dose-response curve was significantly steeper (30 min of propofol: 4.34 [3.62-5.05]; 2 min of propofol: [3.34 (2.72-3.96)], resulting in lower ED95 values of rocuronium (30 min of propofol: 0.287 mg/kg [0.221-0.368]; 2 min of propofol [0.391 mg/kg (0.296-0.520)]. The ED50 were not different between groups. The potency of rocuronium was significantly enhanced after propofol infusion for 30 min. Estimates of potency those are usually determined during steady-state anaesthesia might underestimate rocuronium requirements for endotracheal intubation at the time of induction. © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Emergency medicine in the Veterans Health Administration-results from a nationwide survey.

PubMed

Ward, Michael J; Collins, Sean P; Pines, Jesse M; Dill, Curt; Tyndall, Gary; Kessler, Chad S

2015-07-01

We describe emergency physician staffing, capabilities, and academic practices in US Veterans Health Administration (VHA) emergency departments (EDs). As part of an ongoing process improvement effort for the VHA emergency care system, VHA-wide surveys are conducted among ED medical directors every 3 years. Web-based surveys of VHA ED directors were conducted in 2013 on clinical operations and academic program development. We describe the results from the 2013 survey. When available, we compare responses with the previously administered survey from 2010. A total of 118 of 118 ED directors filled out the survey in 2013 (100% response rate). Respondents reported that 45.5% of VHA emergency physicians are board certified in emergency medicine, and 95% spend most their time in direct patient care. Clinical care is also provided by part-time (<0.5 full-time employee equivalent) emergency physicians in 59.3% of EDs. More than half of EDs (57%) provide on-site tissue plasminogen activator for acute ischemic stroke patients, and only 39% can administer tissue plasminogen activator 24 hours per day, 7 days per week. Less than half (48.3%) of EDs have emergency Obstetrics and Gynecology consultation availability. Most VHA EDs (78.8%) have a university affiliation, but only 21.5% participated in the respective academic emergency medicine program. Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having university affiliations, traditional academic activities (eg, teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women's health. Published by Elsevier Inc.

Advertising Emergency Department Wait Times

PubMed Central

Weiner, Scott G.

2013-01-01

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. PMID:23599836

’Exact’ Two-Sided Confidence Intervals on Nonnegative Linear Combinations of Variances.

DTIC Science & Technology

1980-07-01

Colorado State University ( 042_402) II. CONTrOLLING OFFICE NAME AND ADDRESS It. REPORT OAT Office of Naval Rsearch -// 1 Jul MjW80 Statistics and...MONNEGATIVE LINEAR COMBINATIONS OF VARIANCES by Franklin A. Graybill Colorado State University and Chih-Ming Wang SPSS Inc. 1. Introduction In a paper to soon...1 + a2’ called the Nodf Led Lace Sample (HLS) confidence interval, is in 2. Aoce-3Ion For DDC TAO u*.- *- -. n c edI Ju.-’I if iction_, i !~BV . . I

Development and validation of a risk-prediction nomogram for in-hospital mortality in adults poisoned with drugs and nonpharmaceutical agents

PubMed Central

Lionte, Catalina; Sorodoc, Victorita; Jaba, Elisabeta; Botezat, Alina

2017-01-01

Abstract Acute poisoning with drugs and nonpharmaceutical agents represents an important challenge in the emergency department (ED). The objective is to create and validate a risk-prediction nomogram for use in the ED to predict the risk of in-hospital mortality in adults from acute poisoning with drugs and nonpharmaceutical agents. This was a prospective cohort study involving adults with acute poisoning from drugs and nonpharmaceutical agents admitted to a tertiary referral center for toxicology between January and December 2015 (derivation cohort) and between January and June 2016 (validation cohort). We used a program to generate nomograms based on binary logistic regression predictive models. We included variables that had significant associations with death. Using regression coefficients, we calculated scores for each variable, and estimated the event probability. Model validation was performed using bootstrap to quantify our modeling strategy and using receiver operator characteristic (ROC) analysis. The nomogram was tested on a separate validation cohort using ROC analysis and goodness-of-fit tests. Data from 315 patients aged 18 to 91 years were analyzed (n = 180 in the derivation cohort; n = 135 in the validation cohort). In the final model, the following variables were significantly associated with mortality: age, laboratory test results (lactate, potassium, MB isoenzyme of creatine kinase), electrocardiogram parameters (QTc interval), and echocardiography findings (E wave velocity deceleration time). Sex was also included to use the same model for men and women. The resulting nomogram showed excellent survival/mortality discrimination (area under the curve [AUC] 0.976, 95% confidence interval [CI] 0.954–0.998, P < 0.0001 for the derivation cohort; AUC 0.957, 95% CI 0.892–1, P < 0.0001 for the validation cohort). This nomogram provides more precise, rapid, and simple risk-analysis information for individual patients acutely exposed to drugs and nonpharmaceutical agents, and accurately estimates the probability of in-hospital death, exclusively using the results of objective tests available in the ED. PMID:28328838

ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction (STAT-MI) trial.

PubMed

Dhruva, Vivek N; Abdelhadi, Samir I; Anis, Ather; Gluckman, William; Hom, David; Dougan, William; Kaluski, Edo; Haider, Bunyad; Klapholz, Marc

2007-08-07

Our goal was to examine the effects of implementing a fully automated wireless network to reduce door-to-intervention times (D2I) in ST-segment elevation myocardial infarction (STEMI). Wireless technologies used to transmit prehospital electrocardiograms (ECGs) have helped to decrease D2I times but have unrealized potential. A fully automated wireless network that facilitates simultaneous 12-lead ECG transmission from emergency medical services (EMS) personnel in the field to the emergency department (ED) and offsite cardiologists via smartphones was developed. The system is composed of preconfigured Bluetooth devices, preprogrammed receiving/transmitting stations, dedicated e-mail servers, and smartphones. The network facilitates direct communication between offsite cardiologists and EMS personnel, allowing for patient triage directly to the cardiac catheterization laboratory from the field. Demographic, laboratory, and time interval data were prospectively collected and compared with calendar year 2005 data. From June to December 2006, 80 ECGs with suspected STEMI were transmitted via the network. Twenty patients with ECGs consistent with STEMI were triaged to the catheterization laboratory. Improvement was seen in mean door-to-cardiologist notification (-14.6 vs. 61.4 min, p < 0.001), door-to-arterial access (47.6 vs. 108.1 min, p < 0.001), time-to-first angiographic injection (52.8 vs. 119.2 min, p < 0.001), and D2I times (80.1 vs. 145.6 min, p < 0.001) compared with 2005 data. A fully automated wireless network that transmits ECGs simultaneously to the ED and offsite cardiologists for the early evaluation and triage of patients with suspected STEMI can decrease D2I times to <90 min and has the potential to be broadly applied in clinical practice.

Usefulness of electromyography of the cavernous corpora (CC EMG) in the diagnosis of arterial erectile dysfunction.

PubMed

Virseda-Chamorro, M; Lopez-Garcia-Moreno, A M; Salinas-Casado, J; Esteban-Fuertes, M

2012-01-01

Electromyography (EMG) of the corpora cavernosa (CC-EMG) is able to record the activity of the erectile tissue during erection, and thus has been used as a diagnostic technique in patients with erectile dysfunction (ED). The present study examines the usefulness of the technique in the diagnosis of arterial ED. A cross-sectional study was made of 35 males with a mean age of 48.5 years (s.d. 11.34), referred to our center with ED for >1 year. The patients were subjected to CC-EMG and a penile Doppler ultrasound study following the injection of 20 μg of prostaglandin E1 (PGE1). The patients were divided into three groups according to their response to the intracavernous injection of PGE1: Group 1 (adequate erection and reduction/suppression of EMG activity); Group 2 (insufficient erection and persistence of EMG activity); and Group 3 (insufficient erection and reduction/suppression of EMG activity). Patient classification according to response to the intracavernous injection of PGE1 was as follows: Group 1: six patients (17%), Group 2: 18 patients (51%), and Group 3: 11 patients (31%). Patients diagnosed with arterial insufficiency according to Doppler ultrasound (systolic arterial peak velocity <30 mm s(-1) in both arteries) were significantly older than those without such damage (54.5 versus 41.8 years, respectively; s.d. 11.12). The patients in Group 3 showed a significantly lower maximum systolic velocity in both arteries than the subjects belonging to Group 2. Likewise, a statistically significant relationship was observed between the diagnosis of arterial insufficiency and patient classification in Group 3. The confirmation of insufficient erection associated with reduction/suppression of EMG activity showed a sensitivity of 66.7% (confidence interval between 50 and 84%) and a specificity of 92.9% (confidence interval between 84 and 100%) in the diagnosis of arterial ED. Owing to the high specificity of CC-EMG response to the injection of PGE1, this test is considered useful as a screening technique in the diagnosis of arterial ED.

Developing an emergency department crowding dashboard: A design science approach.

PubMed

Martin, Niels; Bergs, Jochen; Eerdekens, Dorien; Depaire, Benoît; Verelst, Sandra

2017-08-30

As an emergency department (ED) is a complex adaptive system, the analysis of continuously gathered data is valuable to gain insight in the real-time patient flow. To support the analysis and management of ED operations, relevant data should be provided in an intuitive way. Within this context, this paper outlines the development of a dashboard which provides real-time information regarding ED crowding. The research project underlying this paper follows the principles of design science research, which involves the development and study of artifacts which aim to solve a generic problem. To determine the crowding indicators that are desired in the dashboard, a modified Delphi study is used. The dashboard is implemented using the open source Shinydashboard package in R. A dashboard is developed containing the desired crowding indicators, together with general patient flow characteristics. It is demonstrated using a dataset of a Flemish ED and fulfills the requirements which are defined a priori. The developed dashboard provides real-time information on ED crowding. This information enables ED staff to judge whether corrective actions are required in an effort to avoid the adverse effects of ED crowding. Copyright © 2017 Elsevier Ltd. All rights reserved.

A flexible simulation platform to quantify and manage emergency department crowding.

PubMed

Hurwitz, Joshua E; Lee, Jo Ann; Lopiano, Kenneth K; McKinley, Scott A; Keesling, James; Tyndall, Joseph A

2014-06-09

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. 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. 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/. 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.

Cerebro- and Cardio-vascular Responses to Energy Drink in Young Adults: Is there a Gender Effect?

PubMed

Monnard, Cathríona R; Montani, Jean-Pierre; Grasser, Erik K

2016-01-01

Energy drinks (EDs) are suspected to induce potential adverse cardiovascular effects and have recently been shown to reduce cerebral blood flow velocity (CBFV) in young, healthy subjects. Gender differences in CBFV in response to EDs have not previously been investigated, despite the fact that women are more prone to cardiovascular disturbances such as neurocardiogenic syncope than men. Therefore, the aim of this study was to explore gender differences in cerebrovascular and cardiovascular responses to EDs. We included 45 subjects in a retrospective analysis of pooled data from two previous randomized trials carried out in our laboratory with similar protocols. Beat-to-beat blood pressure, impedance cardiography, transcranial Doppler, and end-tidal carbon dioxide (etCO2) measurements were made for at least 20 min baseline and for 80 min following the ingestion of 355 mL of a sugar-sweetened ED. Gender and time differences in cerebrovascular and cardiovascular parameters were investigated. CBFV was significantly reduced in response to ED, with the greatest reduction observed in women compared with men (-12.3 ± 0.8 vs. -9.7 ± 0.8%, P < 0.05). Analysis of variance indicated significant time (P < 0.01) and gender × time (P < 0.01) effects. The percentage change in CBFV in response to ED was independent of body weight and etCO2. No significant gender difference in major cardiovascular parameters in response to ED was observed. ED ingestion reduced CBFV over time, with a greater reduction observed in women compared with men. Our results have potential implications for women ED consumers, as well as high-risk individuals.

A sampling bias in identifying children in foster care using Medicaid data.

PubMed

Rubin, David M; Pati, Susmita; Luan, Xianqun; Alessandrini, Evaline A

2005-01-01

Prior research identified foster care children using Medicaid eligibility codes specific to foster care, but it is unknown whether these codes capture all foster care children. To describe the sampling bias in relying on Medicaid eligibility codes to identify foster care children. Using foster care administrative files linked to Medicaid data, we describe the proportion of children whose Medicaid eligibility was correctly encoded as foster child during a 1-year follow-up period following a new episode of foster care. Sampling bias is described by comparing claims in mental health, emergency department (ED), and other ambulatory settings among correctly and incorrectly classified foster care children. Twenty-eight percent of the 5683 sampled children were incorrectly classified in Medicaid eligibility files. In a multivariate logistic regression model, correct classification was associated with duration of foster care (>9 vs <2 months, odds ratio [OR] 7.67, 95% confidence interval [CI] 7.17-7.97), number of placements (>3 vs 1 placement, OR 4.20, 95% CI 3.14-5.64), and placement in a group home among adjudicated dependent children (OR 1.87, 95% CI 1.33-2.63). Compared with incorrectly classified children, correctly classified foster care children were 3 times more likely to use any services, 2 times more likely to visit the ED, 3 times more likely to make ambulatory visits, and 4 times more likely to use mental health care services (P < .001 for all comparisons). Identifying children in foster care using Medicaid eligibility files is prone to sampling bias that over-represents children in foster care who use more services.

Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care.

PubMed

Finnegan, Micaela A; Shaffer, Robyn; Remington, Austin; Kwong, Jereen; Curtin, Catherine; Hernandez-Boussard, Tina

2017-06-21

Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure. We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge. Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis. ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prevalence and predictors of erectile dysfunction in adult male outpatient clinic attendees in Johor, Malaysia.

PubMed

Nordin, Rusli Bin; Soni, Trived; Kaur, Amrina; Loh, Kean Por; Miranda, Shashi

2018-05-18

Erectile dysfunction (ED) is a serious burden globally that affects men as well as their partners. Therefore, the aim of this study was to determine the prevalence and predictors of ED among male outpatient clinic attendees in Johor, Malaysia. A cross-sectional study of Malaysian men aged 18 and older attending two major outpatient clinics in Johor Bahru and Segamat between 1 January and 31 March 2016 was undertaken. Subjects were chosen via simple random sampling and a sample size of 400 was recruited. The study instrument was a survey form that consisted of three sections: sociodemographic and comorbid profile, validated English and Malay version of the 15-item International Index of Erectile Function (IIEF-15) and 21-item Depression Anxiety and Stress Scale (DASS-21). The overall prevalence of self-reported ED was 81.5%. The prevalence of ED according to severity was as follows: mild (17%), mild to moderate (23.8%), moderate (11.3%), and severe (29.5%). Multivariate analysis showed that ED was associated with increasing age (odds ratio [OR] 4.023, 95% confidence interval [CI] 1.633-9.913), Indians as compared to Malays (OR 3.252, 95% CI 1.280-8.262), secondary as compared to tertiary education (OR 2.171, 95% CI 1.203-3.919), single as compared to married status (OR 6.119, 95% CI 2.542-14.734), and stress (OR 4.259, 95% CI 1.793-10.114). There is significant prevalence and severity of ED among adult male outpatient clinic attendees in Johor. Increasing age, Indian ethnicity, lower educational level, being single, and stress were significant predictors of ED.

The impact of post-discharge patient call back on patient satisfaction in two academic emergency departments.

PubMed

Guss, David A; Leland, Hyuma; Castillo, Edward M

2013-01-01

Patients' satisfaction is a common parameter tracked by health care systems and Emergency Departments (EDs). To determine whether telephone calls by health care providers to patients after discharge from the ED was associated with improved patient satisfaction. Retrospective analysis of Press Ganey (PG; Press Ganey Associates, South Bend, IN) surveys from two EDs operated by the University of California San Diego Health System. Responses to the YES/NO question, "After discharge, did you receive a phone call from an ED staff member?" was compared to the responses to the question "likelihood of recommending this ED to others" (LR). This variable could be ranked with a score of 1 (very poor) to 5 (very good). Responses were dichotomized into two groups, 1-4 and 5. Chi-squared was performed to assess LR between those answering YES vs. NO to the call back question. Differences in proportion, 95% confidence interval (CI), and p-value are reported. Rankings for percentage of 5s across all EDs in the PG database were compared based upon YES/NO responses. In the 12-month study period, about 30,000 surveys were mailed and 2250 (7.5%) were returned. Three hundred forty-seven (15.4%) checked off YES for the call back question. Percentage of 5s for LR for NO call back was 51.1% and for YES call back was 70.6% (difference = 19.5; 95% CI 14.0-24.6; p < 0.001).These values correlated with an ED ranking of 14(th) and 85(th) percentile, respectively. This retrospective study demonstrated a strong association between post-visit patient call back and LR. Further prospective study with control for co-variables is warranted. Copyright © 2013 Elsevier Inc. All rights reserved.

Effect of advanced age and vital signs on admission from an ED observation unit.

PubMed

Caterino, Jeffrey M; Hoover, Emily M; Moseley, Mark G

2013-01-01

The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol. Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14,000/mm(3) or greater (OR, 11.35; 95% CI, 3.42-37.72). Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion. Copyright © 2013 Elsevier Inc. All rights reserved.

[Mass media influence and risk of developing eating disorders in female students from Lima, Peru].

PubMed

Lazo Montoya, Yessenia; Quenaya, Alejandra; Mayta-Tristán, Percy

2015-12-01

Eating disorders (EDs) are a public health problem, and their relationship to mass media is still controversial. To assess whether there is an association between models of body image shown in mass media and the risk of developing EDs among female adolescent students from Lima, Peru. Cross-sectional study conducted in three schools located in the district of La Victoria, Lima, Peru. The risk of developing EDs was measured using the Eating Attitudes Test-26 (EAT-26), while mass media influence was measured using the Sociocultural Attitudes Towards Appearance Questionnaire-3 (SATAQ-3), which was categorized into tertiles both in the overall score and its subscales (information, pressure, general internalization, and athletic internalization). Adjusted prevalence ratios (aPR) for EDs were estimated. Four hundred and eighty-three students were included, their median age was 14 ? 3 years old. A risk of developing an ED was observed in 13.9% of them. Students who are more influenced by mass media (upper tertile of the SATAQ-3) have a higher probability of having a risk of developing an ED (aPR: 4.24; 95% confidence interval |-CI-|: 2.10-8.56), as well as those who have a greater access to information (PR: 1.89; 95% CI: 1.09-3.25), suffer more pressure (PR: 4.97; 95% CI: 2.31-10.69), show a greater general internalization (PR: 5.00; 95% CI: 2.39-10.43), and show a greater level of athletic internalization (PR: 4.35; 95% CI: 2.19-8-66). The greater the influence of mass media, the greater the probability of having a risk of developing an ED among female students from Lima, Peru.

Sleep-Disordered Breathing in Acute Ischemic Stroke: A Mechanistic Link to Peripheral Endothelial Dysfunction.

PubMed

Scherbakov, Nadja; Sandek, Anja; Ebner, Nicole; Valentova, Miroslava; Nave, Alexander Heinrich; Jankowska, Ewa A; Schefold, Jörg C; von Haehling, Stephan; Anker, Stefan D; Fietze, Ingo; Fiebach, Jochen B; Haeusler, Karl Georg; Doehner, Wolfram

2017-09-11

Sleep-disordered breathing (SDB) after acute ischemic stroke is frequent and may be linked to stroke-induced autonomic imbalance. In the present study, the interaction between SDB and peripheral endothelial dysfunction (ED) was investigated in patients with acute ischemic stroke and at 1-year follow-up. SDB was assessed by transthoracic impedance records in 101 patients with acute ischemic stroke (mean age, 69 years; 61% men; median National Institutes of Health Stroke Scale, 4) while being on the stroke unit. SDB was defined by apnea-hypopnea index ≥5 episodes per hour. Peripheral endothelial function was assessed using peripheral arterial tonometry (EndoPAT-2000). ED was defined by reactive hyperemia index ≤1.8. Forty-one stroke patients underwent 1-year follow-up (390±24 days) after stroke. SDB was observed in 57% patients with acute ischemic stroke. Compared with patients without SDB, ED was more prevalent in patients with SDB (32% versus 64%; P <0.01). After adjustment for multiple confounders, presence of SDB remained independently associated with ED (odds ratio, 3.1; [95% confidence interval, 1.2-7.9]; P <0.05). After 1 year, the prevalence of SDB decreased from 59% to 15% ( P <0.001). Interestingly, peripheral endothelial function improved in stroke patients with normalized SDB, compared with patients with persisting SDB ( P <0.05). SDB was present in more than half of all patients with acute ischemic stroke and was independently associated with peripheral ED. Normalized ED in patients with normalized breathing pattern 1 year after stroke suggests a mechanistic link between SDB and ED. URL: https://drks-neu.uniklinik-freiburg.de. Unique identifier: DRKS00000514. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Review article: Workplace violence in the emergency department: A systematic review and meta analysis.

PubMed

Nikathil, Shradha; Olaussen, Alexander; Gocentas, Robert A; Symons, Evan; Mitra, Biswadev

2017-06-01

Patient or visitor perpetrated workplace violence (WPV) has been reported to be a common occurrence within the ED. No universal definition of violence or recording of such events exists. In addition ED staff are often reluctant to report violent incidents. The true incidence of WPV is therefore unclear. This systematic review aimed to quantify WPV in EDs. The association of WPV to drug and alcohol exposure was explored. The databases MEDLINE, Embase, PsycInfo and the Cochrane Library were searched from their commencement to 10 March 2016. MeSH terms and text words for ED, violence and aggression were combined. A meta-analysis was conducted on the primary outcome variable-proportion of violent patients among total ED presentations. A secondary meta-analysis used studies reporting on proportion of drug and alcohol affected patients occurring within the violent population. The search yielded a total of 8720 records. A total of 7235 were unique and underwent abstract screening. A total of 22 studies were deemed relevant according to inclusion and exclusion criteria. Retrospective study design predominated, analysing mainly security records and incident reports. The rates of violence from individual studies ranged from 1 incident to 172 incidents per 10 000 presentations. The pooled incidence suggests there are 36 violent patients for every 10 000 presentations to the ED (95% confidence interval 0.0030-0.0043). WPV in the ED was commonly reported. There is wide heterogeneity across the study methodology, definitions and rates. More standardised recording and reporting may inform preventive measures and highlight effective management strategies. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Efficacy of the pentavalent rotavirus vaccine, RotaTeq®, in Finnish infants up to 3 years of age: the Finnish Extension Study.

PubMed

Vesikari, Timo; Karvonen, Aino; Ferrante, Shannon Allen; Ciarlet, Max

2010-11-01

Rotavirus Efficacy and Safety Trial (REST) enrolled nearly 70,000 infants, of whom more than 23,000 were from Finland. REST determined the efficacy of the pentavalent rotavirus vaccine (RV5) against rotavirus-related hospitalisations and emergency department (ED) visits in the first year after vaccination. Finnish infants initially in REST transitioned into the Finnish Extension Study (FES), where they were followed for rotavirus-related hospitalisations and ED visits through their second year of life and beyond. FES identified 150 (31%) additional rotavirus gastroenteritis (RVGE) cases beyond those identified in REST in the Finnish participants. Overall, RV5 reduced RVGE hospitalisations and ED visits, regardless of the rotavirus serotype, by 93.8% (95% confidence interval [CI]: 90.8-95.9%) for up to 3.1 years following the last vaccine dose. Vaccine efficacy against combined hospitalisations and ED visits between ages 4 months to 11 months, 12 months to 23 months, and 24 months to 35 months was 93.9% (95% CI: 89.1-96.9%), 94.4% (95% CI: 90.2-97.0%), and 85.9% (95% CI: 51.6-97.2%), respectively. The reduction of hospitalisations and ED visits due to any acute gastroenteritis, rotavirus or not, was 62.4% (95% CI: 57.6-66.6%) over the entire follow-up period. The results from FES confirm that RV5 induces high and sustained protection against rotavirus-related hospitalisations and ED visits, and has a very substantial impact on all gastroenteritis-related hospitalisations and ED visits into the third year of life in Finnish children.

Habitual Sleep Duration, Unmet Sleep Need, and Excessive Daytime Sleepiness in Korean Adults.

PubMed

Hwangbo, Young; Kim, Won Joo; Chu, Min Kyung; Yun, Chang Ho; Yang, Kwang Ik

2016-04-01

Sleep need differs between individuals, and so the same duration of sleep will lead to sleep insufficiency in some individuals but not others. The aim of this study was to determine the separate and combined associations of both sleep duration and unmet sleep need with excessive daytime sleepiness (EDS) in Korean adults. The participants comprised 2,769 Korean adults aged 19 years or older. They completed questionnaires about their sleep habits over the previous month. The question regarding sleep need was "How much sleep do you need to be at your best during the day?" Unmet sleep need was calculated as sleep need minus habitual sleep duration. Participants with a score of >10 on the Epworth Sleepiness Scale were considered to have EDS. The overall prevalence of EDS was 11.9%. Approximately one-third of the participants (31.9%) reported not getting at least 7 hours of sleep. An unmet sleep need of >0 hours was present in 30.2% of the participants. An adjusted multivariate logistic regression analysis revealed a significant excess risk of EDS in the groups with unmet sleep needs of ≥2 hours [odds ratio (OR), 1.80; 95% confidence interval (CI), 1.27-2.54] and 0.01-2 hours (OR, 1.42; 95% CI, 1.02-1.98). However, habitual sleep duration was not significantly related to EDS. EDS was found to be associated with unmet sleep need but not with habitual sleep duration when both factors were examined together. We suggest that individual unmet sleep need is more important than habitual sleep duration in terms of the relation to EDS.

Survey of alcohol-related presentations to Australasian emergency departments.

PubMed

Egerton-Warburton, Diana; Gosbell, Andrew; Wadsworth, Angela; Fatovich, Daniel M; Richardson, Drew B

2014-11-17

To determine the proportion of alcohol-related presentations to emergency departments (EDs) in Australia and New Zealand, at a single time point on a weekend night shift. A point prevalence survey of ED patients either waiting to be seen or currently being seen conducted at 02:00 local time on 14 December 2013 in 106 EDs in Australia and New Zealand. The number of ED presentations that were alcohol-related, defined using World Health Organization ICD-10 codes. At the 106 hospitals (92 Australia, 14 New Zealand) that provided data, 395 (14.3%; 95% CI, 13.0%-15.6%) of 2766 patients in EDs at the study time were presenting for alcohol-related reasons; 13.8% (95% CI, 12.5%-15.2%) in Australia and 17.9% (95% CI, 13.9%-22.8%) in New Zealand. The distribution was skewed left, with proportions ranging from 0 to 50% and a median of 12.5%. Nine Australian hospitals and one New Zealand hospital reported that more than a third of their ED patients had alcohol-related presentations; the Northern Territory (38.1%) and Western Australia (21.1%) reported the highest proportions of alcohol-related presentations. One in seven ED presentations in Australian and New Zealand at this 02:00 snapshot were alcohol-related, with some EDs seeing more than one in three alcohol-related presentations. This confirms that alcohol-related presentations to EDs are currently underreported and makes a strong case for public health initiatives.

Equivalent Dipole Vector Analysis for Detecting Pulmonary Hypertension

NASA Technical Reports Server (NTRS)

Harlander, Matevz; Salobir, Barbara; Toplisek, Janez; Schlegel, Todd T.; Starc, Vito

2010-01-01

Various 12-lead ECG criteria have been established to detect right ventricular hypertrophy as a marker of pulmonary hypertension (PH). While some criteria offer good specificity they lack sensitivity because of a low prevalence of positive findings in the PH population. We hypothesized that three-dimensional equivalent dipole (ED) model could serve as a better detection tool of PH. We enrolled: 1) 17 patients (12 female, 5 male, mean age 57 years, range 19-79 years) with echocardiographically detected PH (systolic pulmonary arterial pressure greater than 35 mmHg) and no significant left ventricular disease; and 2) 19 healthy controls (7 female, 12 male, mean age 44, range 31-53 years) with no known heart disease. In each subject we recorded a 5-minute high-resolution 12-lead conventional ECG and constructed principal signals using singular value decomposition. Assuming a standard thorax dimension of an adult person with homogenous and isotropic distribution of thorax conductance, we determined moving equivalent dipoles (ED), characterized by the 3D location in the thorax, dipolar strength and the spatial orientation, in time intervals of 5 ms. We used the sum of all ED vectors in the second half of the QRS complex to derive the amplitude of the right-sided ED vector (RV), if the orientation of ED was to the right side of the thorax, and in the first half the QRS to derive the amplitude of the left-sided vector (LV), if the orientation was leftward. Finally, the parameter RV/LV ratio was determined over an average of 256 complexes. The groups differed in age and gender to some extent. There was a non-significant trend toward higher RV in patients with PH (438 units 284) than in controls (280 plus or minus 140) (p = 0.066) but the overlap was such that RV alone was not a good predictor of PH. On the other hand, the RV/LV ratio was a better predictor of PH, with 11/17 (64.7%) of PH patients but only in 1/19 (5.3%) control subjects having RV/LV ratio greater than or equal to 0.70 (p less than 0.001). The use of ED for evaluating PH shows good specificity at a reasonable sensitivity. The results are limited due to the small study groups and differences in age and gender, but further investigations are warranted, including of ED's diagnostic accuracy for PH versus that of other proposed ECG and VCG criteria.

Effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ED performance.

PubMed

Vardy, J; Jenkins, P J; Clark, K; Chekroud, M; Begbie, K; Anthony, I; Rymaszewski, L A; Ireland, A J

2014-06-13

Collaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance. A retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change. An ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system. 2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol. Time for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance. Where plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment. This process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Mechanisms, injuries and helmet use in cyclists presenting to an inner city emergency department.

PubMed

Dinh, Michael M; Kastelein, Christopher; Hopkins, Roy; Royle, Timothy J; Bein, Kendall J; Chalkley, Dane R; Ivers, Rebecca

2015-08-01

The objectives of the present study were to describe the injury profiles of cyclists presenting to an ED and determine the risk of significant head injury associated with bicycle helmet use. This was a retrospective single trauma centre study of all adult cyclists presenting to an inner city ED and undergoing a trauma team review between January 2012 and June 2014. The outcome of interest was significant head injury defined as any head injury with an Abbreviated Injury Scale score of two or more. Variables analysed included demographic characteristics, helmet use at time of incident, location, time and the presence of intoxication. The most common body regions were upper limb injuries (57%), followed by head injuries (43%), facial injuries (30%) and lower limb injuries (24%). A lower proportion of people wearing helmets had significant head injury (17% vs 31%, P = 0.018) or facial injury (26% vs 48%, P = 0.0017) compared with non-helmet users. After adjustment for important covariates, helmet use was associated with a 70% decrease in the odds of significant head injury (odds ratio 0.34, 95% confidence interval 0.15, 0.76, P = 0.008). Head injuries were common after inner city cycling incidents. The use of helmets was associated with a reduction in significant head injury. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

A time-motion study of ambulance-to-emergency department radio communications.

PubMed

Penner, Mark S; Cone, David C; MacMillan, Don

2003-01-01

A prospective time-motion study of radio communication between inbound ambulances and emergency department (ED) triage personnel was conducted to assess hospital triage staff time utilized, and how often radio reports result in actions taken in the ED to prepare for patient arrival. The study hypothesis was that reports for "priority 2" (P2, nonemergent) patients rarely provide information that is acted upon in the ED prior to the patient's arrival. The study was conducted at an academic adult ED receiving 22,000 ambulances per year. An observer in the ED monitored and timed (to the second) all radio reports as well as the activities of triage nurses and arriving emergency medical services (EMS) personnel. A convenience sample of 437 reports was collected: 83 priority 1 (P1, emergent) and 354 P2. Average report times (minutes:seconds) with ranges were 0:53 (0:07-1:57) for P1, and 0:44 (0:04-3:50) for P2. Only 16% of the P2 reports resulted in any preparatory action, and 55% of these were requests to have hospital police officers available to receive intoxicated patients, as per local protocol. An in-person report was given in the ED for 61% of the P2 cases, and in 48% of these, the in-person report was longer than the radio report. In the system studied, P2 reports rarely provide information that is acted on prior to the patient's arrival. The time spent giving a radio report is frequently duplicated in the ED. Radio reports for low-priority patients may not be an efficient or productive use of providers' or nurses' time.

Dedication increases productivity: an analysis of the implementation of a dedicated medical team in the emergency department.

PubMed

Ramos, Pedro; Paiva, José Artur

2017-12-01

In several European countries, emergency departments (EDs) now employ a dedicated team of full-time emergency medicine (EM) physicians, with a distinct leadership and bed-side emergency training, in all similar to other hospital departments. In Portugal, however, there are still two very different models for staffing EDs: a classic model, where EDs are mostly staffed with young inexperienced physicians from different medical departments who take turns in the ED in 12-h shifts and a dedicated model, recently implemented in some hospitals, where the ED is staffed by a team of doctors with specific medical competencies in emergency medicine that work full-time in the ED. Our study assesses the effect of an intervention in a large academic hospital ED in Portugal in 2002, and it is the first to test the hypothesis that implementing a dedicated team of doctors with EM expertise increases the productivity and reduces costs in the ED, maintaining the quality of care provided to patients. A pre-post design was used for comparing the change on the organisational model of delivering care in our medical ED. All emergency medical admissions were tracked in 2002 (classic model with 12-h shift in the ED) and 2005/2006 (dedicated team with full-time EM physicians), and productivity, costs with medical human resources and quality of care measures were compared. We found that medical productivity (number of patients treated per hour of medical work) increased dramatically after the creation of the dedicated team (X 2 KW = 31.135; N = 36; p < 0.001) and costs with ED medical work reduced both in regular hours and overtime. Moreover, hospitalisation rates decreased and the length of stay in the ED increased significantly after the creation of the dedicated team. Implementing a dedicated team of doctors increased the medical productivity and reduced costs in our ED. Our findings have straightforward implication for Portuguese policymakers aiming at reducing hospital costs while coping with increased ED demand.

Withholding and withdrawing life-support therapy in an Emergency Department: prospective survey.

PubMed

Le Conte, Philippe; Baron, Denis; Trewick, David; Touzé, Marie Dominique; Longo, Céline; Vial, Irshaad; Yatim, Danielle; Potel, Gille

2004-12-01

Few studies have focused on decisions to withdraw or withhold life-support therapies in the emergency department. Our objectives were to identify clinical situations where life-support was withheld or withdrawn, the criteria used by physicians to justify their decisions, the modalities necessary to implement these decisions, patient disposition, and outcome. Prospective unicenter survey in an Emergency Department of a tertiary care teaching hospital. All non-trauma patients (n=119) for whom a decision to withhold or withdraw life-sustaining treatments was taken between January and September 1998. Choice of criteria justifying the decision to withhold or withdraw life-sustaining treatments, time interval from ED admission to the decision; type of decision implemented, outcome. Fourteen thousand eight hundred and seventy-five non-trauma patients were admitted during the study period, 119 were included, mean age 75+/-13 years. Resuscitation procedures were instituted for 96 (80%) patients before a subsequent decision was taken. Physicians chose on average 6+/-2 items to justify their decision; the principal acute medical disorder and futility of care were the two criteria most often used. Median time interval to reach the decision was 187 min. Withdrawal involved 37% of patients and withholding 63% of patients. The family was involved in the decision-making process in 72% of patients. The median time interval from the decision to death was 16 h (5 min to 140 days). Withdrawing and withholding life-support therapy involved elderly patients with underlying chronic cardiopulmonary disease or metastatic cancer or patients with acute non-treatable illness.

Emergency department crowding: a point in time.

PubMed

Schneider, Sandra M; Gallery, Michael E; Schafermeyer, Robert; Zwemer, Frank L

2003-08-01

This is a pilot study designed to assess the feasibility of a point prevalence study to assess the degree of crowding in hospital emergency departments (EDs). In addition, we sought to measure the degree of physical crowding and personnel shortage in our sample. A mail survey was sent to a random sample of 250 EDs chosen from a database compiled by the American College of Emergency Physicians of 5,064 EDs in the United States. In addition to demographic information, respondents were asked to count the patients and staff in their EDs at 7 PM local time on Monday, March 12, 2001 (index time). The response rate was 36%. At the index time, there was an average of 1.1 patients per treatment space, and 52% of EDs reported more than 1 patient per treatment space. There was also evidence of personnel shortage, with a mean of 4.2 patients per registered nurse and 49% of EDs having each registered nurse caring for more than 4 patients. There was a mean of 9.7 patients per physician. Sixty-eight percent of EDs had each physician caring for more than 6 patients. There was crowding present in all geographic areas and all hospital types (teaching-nonteaching status of the hospital). Consistent with the crowded conditions, 11% of institutions were on ambulance diversion and not accepting new acute patients. Delays in transfer of admitted patients out of the ED contributed to the physical crowding. Twenty-two percent of patients in the ED were already admitted and were awaiting transfer to an inpatient bed; 73% of EDs were boarding 2 or more inpatients. The amount of crowding quantified by this point prevalence study was confirmed by the amount of crowding reported for the previous week: 48% of EDs were boarding inpatients during the previous week for a mean of 8.9 hours, 4.2 days per week; 31% had been on diversion; 59% had been routinely using their halls for patients; 38% had been doubling their rooms; and 47% had been using nonclinical space for patient care. Our low response rate limits this pilot study. Nonetheless, this study, as well as others, demonstrates that EDs throughout the United States are severely crowded. Such crowding raises concerns about the ability of EDs to respond to mass casualty or volume surges.

Network analysis of team communication in a busy emergency department

PubMed Central

2013-01-01

Background The Emergency Department (ED) is consistently described as a high-risk environment for patients and clinicians that demands colleagues quickly work together as a cohesive group. Communication between nurses, physicians, and other ED clinicians is complex and difficult to track. A clear understanding of communications in the ED is lacking, which has a potentially negative impact on the design and effectiveness of interventions to improve communications. We sought to use Social Network Analysis (SNA) to characterize communication between clinicians in the ED. Methods Over three-months, we surveyed to solicit the communication relationships between clinicians at one urban academic ED across all shifts. We abstracted survey responses into matrices, calculated three standard SNA measures (network density, network centralization, and in-degree centrality), and presented findings stratified by night/day shift and over time. Results We received surveys from 82% of eligible participants and identified wide variation in the magnitude of communication cohesion (density) and concentration of communication between clinicians (centralization) by day/night shift and over time. We also identified variation in in-degree centrality (a measure of power/influence) by day/night shift and over time. Conclusions We show that SNA measurement techniques provide a comprehensive view of ED communication patterns. Our use of SNA revealed that frequency of communication as a measure of interdependencies between ED clinicians varies by day/night shift and over time. PMID:23521890

Patterns of Emergency Department Use Among Long-Stay Nursing Home Residents With Differing Levels of Dementia Severity.

PubMed

LaMantia, Michael A; Lane, Kathleen A; Tu, Wanzhu; Carnahan, Jennifer L; Messina, Frank; Unroe, Kathleen T

2016-06-01

To describe emergency department (ED) utilization among long-stay nursing home residents with different levels of dementia severity. Retrospective cohort study. Public Health System. A total of 4491 older adults (age 65 years and older) who were long-stay nursing home residents. Patient demographics, dementia severity, comorbidities, ED visits, ED disposition decisions, and discharge diagnoses. Forty-seven percent of all long-stay nursing home residents experienced at least 1 transfer to the ED over the course of a year. At their first ED transfer, 36.4% of the participants were admitted to the hospital, whereas 63.1% of those who visited the ED were not. The median time to first ED visit for the participants with advanced stage dementia was 258 days, whereas it was 250 days for the participants with early to moderate stage dementia and 202 days for the participants with no dementia (P = .0034). Multivariate proportional hazard modeling showed that age, race, number of comorbidities, number of hospitalizations in the year prior, and do not resuscitate status all significantly influenced participants' time to first ED visit (P < .05 for all). After accounting for these effects, dementia severity (P = .66), years in nursing home before qualification (P = .46), and gender (P = .36) lost their significance. This study confirms high rates of transfer of long-stay nursing home residents, with nearly one-half of the participants experiencing at least 1 ED visit over the course of a year. Although dementia severity is not a predictor of time to ED use in our analyses, other factors that influence ED use are readily identifiable. Nursing home providers should be aware of these factors when developing strategies that meet patient care goals and avoid transfer from the nursing home to the ED. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Work conditions, mental workload and patient care quality: a multisource study in the emergency department.

PubMed

Weigl, Matthias; Müller, Andreas; Holland, Stephan; Wedel, Susanne; Woloshynowych, Maria

2016-07-01

Workflow interruptions, multitasking and workload demands are inherent to emergency departments (ED) work systems. Potential effects of ED providers' work on care quality and patient safety have, however, been rarely addressed. We aimed to investigate the prevalence and associations of ED staff's workflow interruptions, multitasking and workload with patient care quality outcomes. We applied a mixed-methods design in a two-step procedure. First, we conducted a time-motion study to observe the rate of interruptions and multitasking activities. Second, during 20-day shifts we assessed ED staff's reports on workflow interruptions, multitasking activities and mental workload. Additionally, we assessed two care quality indicators with standardised questionnaires: first, ED patients' evaluations of perceived care quality; second, patient intrahospital transfers evaluated by ward staff. The study was conducted in a medium-sized community ED (16 600 annual visits). ED personnel's workflow was disrupted on average 5.63 times per hour. 30% of time was spent on multitasking activities. During 20 observations days, data were gathered from 76 ED professionals, 239 patients and 205 patient transfers. After aggregating daywise data and controlling for staffing levels, prospective associations revealed significant negative associations between ED personnel's mental workload and patients' perceived quality of care. Conversely, workflow interruptions were positively associated with patient-related information on discharge and overall quality of transfer. Our investigation indicated that ED staff's capability to cope with demanding work conditions was associated with patient care quality. Our findings contribute to an improved understanding of the complex effects of interruptions and multitasking in the ED environment for creating safe and efficient ED work and care systems. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Resuscitation quality of rotating chest compression providers at one-minute vs. two-minute intervals: A mannequin study.

PubMed

Kılıç, D; Göksu, E; Kılıç, T; Buyurgan, C S

2018-05-01

The aim of this randomized cross-over study was to compare one-minute and two-minute continuous chest compressions in terms of chest compression only CPR quality metrics on a mannequin model in the ED. Thirty-six emergency medicine residents participated in this study. In the 1-minute group, there was no statistically significant difference in the mean compression rate (p=0.83), mean compression depth (p=0.61), good compressions (p=0.31), the percentage of complete release (p=0.07), adequate compression depth (p=0.11) or the percentage of good rate (p=51) over the four-minute time period. Only flow time was statistically significant among the 1-minute intervals (p<0.001). In the 2-minute group, the mean compression depth (p=0.19), good compression (p=0.92), the percentage of complete release (p=0.28), adequate compression depth (p=0.96), and the percentage of good rate (p=0.09) were not statistically significant over time. In this group, the number of compressions (248±31 vs 253±33, p=0.01) and mean compression rates (123±15 vs 126±17, p=0.01) and flow time (p=0.001) were statistically significant along the two-minute intervals. There was no statistically significant difference in the mean number of chest compressions per minute, mean chest compression depth, the percentage of good compressions, complete release, adequate chest compression depth and percentage of good compression between the 1-minute and 2-minute groups. There was no statistically significant difference in the quality metrics of chest compressions between 1- and 2-minute chest compression only groups. Copyright © 2017 Elsevier Inc. All rights reserved.

Use of a clinical pathway to improve the acute management of vaso-occlusive crisis pain in pediatric sickle cell disease.

PubMed

Ender, Katherine L; Krajewski, Jennifer A; Babineau, John; Tresgallo, Mary; Schechter, William; Saroyan, John M; Kharbanda, Anupam

2014-04-01

The most common, debilitating morbidity of sickle cell disease (SCD) is vaso-occlusive crisis (VOC) pain. Although guidelines exist for its management, they are generally not well-followed, and research in other pediatric diseases has shown that clinical pathways improve care. The purpose of our study was to determine whether a clinical pathway improves the acute management of sickle cell vaso-occlusive crisis (VOC) pain in the pediatric emergency department (PED). Pain management practices were prospectively investigated before and after the initiation of a clinical pathway in the PED of an urban, tertiary care center with 50,000 ED visits per year and approximately 200 active sickle cell patients. The pathway included instructions for triage, monitoring, medication administration, and timing of assessments and interventions. Data were eligible from 35 pre-pathway and 33 post-pathway visits. Primary outcome was time interval to administration of first analgesic medication. Statistical analysis was by Student's t-test, using natural-log-transformed data for outcomes with skewed distribution curves. Time interval to first analgesic improved from 74 to 42 minutes (P = 0.012) and to first opioid from 94 to 46 minutes (P = 0.013). The percentage of patients who received ketorolac increased from 57% to 82% (P = 0.03). Decrease in time interval to subsequent pain score assessment was not statistically significant (110 to 72 minutes (P = 0.07)), and change in pain score was not different (P = 0.25). The use of a clinical pathway for sickle cell VOC in the PED can improve important aspects of pain management and merits further investigation and implementation. © 2013 Wiley Periodicals, Inc.

The Impact Factor: Measuring Student Professional Growth in an Online Doctoral Program

ERIC Educational Resources Information Center

Kumar, Swapna; Dawson, Kara

2014-01-01

This article describes the impact of an online Ed.D. in educational technology based on data collected from students at regular intervals during the program. It documents how students who were working professionals applied learning from the program within their practice, enculturated into the educational technology community, and grew…

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation.

PubMed

Schumacher, Jessica R; Lutz, Barbara J; Hall, Allyson G; Pines, Jesse M; Jones, Andrea L; Hendry, Phyllis; Kalynych, Colleen; Carden, Donna L

2017-06-01

Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients' care-seeking decisions. We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients' reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. PAM scores fell in both groups after the ED visit but fell significantly more in "usual care" (average decline -4.64) than "intervention" participants (average decline -2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare.

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

PubMed Central

Schumacher, Jessica R.; Lutz, Barbara J.; Hall, Allyson G.; Pines, Jesse M.; Jones, Andrea L.; Hendry, Phyllis; Kalynych, Colleen; Carden, Donna L.

2017-01-01

Introduction Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients’ care-seeking decisions. Methods We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients’ reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. Results PAM scores fell in both groups after the ED visit but fell significantly more in “usual care” (average decline −4.64) than “intervention” participants (average decline −2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. Conclusion The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare. PMID:28611897

Test-Retest Reliability of a Serious Game for Delirium Screening in the Emergency Department.

PubMed

Tong, Tiffany; Chignell, Mark; Tierney, Mary C; Lee, Jacques S

2016-01-01

Introduction: Cognitive screening in settings such as emergency departments (ED) is frequently carried out using paper-and-pencil tests that require administration by trained staff. These assessments often compete with other clinical duties and thus may not be routinely administered in these busy settings. Literature has shown that the presence of cognitive impairments such as dementia and delirium are often missed in older ED patients. Failure to recognize delirium can have devastating consequences including increased mortality (Kakuma et al., 2003). Given the demands on emergency staff, an automated cognitive test to screen for delirium onset could be a valuable tool to support delirium prevention and management. In earlier research we examined the concurrent validity of a serious game, and carried out an initial assessment of its potential as a delirium screening tool (Tong et al., 2016). In this paper, we examine the test-retest reliability of the game, as it is an important criterion in a cognitive test for detecting risk of delirium onset. Objective: To demonstrate the test-retest reliability of the screening tool over time in a clinical sample of older emergency patients. A secondary objective is to assess whether there are practice effects that might make game performance unstable over repeated presentations. Materials and Methods: Adults over the age of 70 were recruited from a hospital ED. Each patient played our serious game in an initial session soon after they arrived in the ED, and in follow up sessions conducted at 8-h intervals (for each participant there were up to five follow up sessions, depending on how long the person stayed in the ED). Results: A total of 114 adults (61 females, 53 males) between the ages of 70 and 104 years ( M = 81 years, SD = 7) participated in our study after screening out delirious patients. We observed a test-retest reliability of the serious game (as assessed by correlation r -values) between 0.5 and 0.8 across adjacent sessions. Conclusion: The game-based assessment for cognitive screening has relatively strong test-retest reliability and little evidence of practice effects among elderly emergency patients, and may be a useful supplement to existing cognitive assessment methods.

The Two-Bag Method for Treatment of Diabetic Ketoacidosis in Adults.

PubMed

Haas, Nathan L; Gianchandani, Roma Y; Gunnerson, Kyle J; Bassin, Benjamin S; Ganti, Arun; Hapner, Christopher; Boyd, Caryn; Cranford, James A; Whitmore, Sage P

2018-05-01

The "two-bag method" of management of diabetic ketoacidosis (DKA) allows for titration of dextrose delivery by adjusting the infusions of two i.v. fluid bags of varying dextrose concentrations while keeping fluid, electrolyte, and insulin infusion rates constant. We aimed to evaluate the feasibility and potential benefits of this strategy in adult emergency department (ED) patients with DKA. This is a before-and-after comparison of a protocol using the two-bag method operationalized in our adult ED in 2015. A retrospective electronic medical record search identified adult ED patients presenting with DKA from January 1, 2013 to June 30, 2016. Clinical and laboratory data, timing of medical therapies, and safety outcomes were collected and analyzed. Sixty-eight patients managed with the two-bag method (2B) and 107 patients managed with the one-bag method (1B) were identified. The 2B and 1B groups were similar in demographics and baseline metabolic derangements, though significantly more patients in the 2B group received care in a hybrid ED and intensive care unit setting (94.1% vs. 51.4%; p < 0.01). 2B patients experienced a shorter interval to first serum bicarbonate ≥ 18 mEq/L (13.4 vs. 20.0 h; p < 0.05), shorter duration of insulin infusion (14.1 vs. 21.8 h; p < 0.05), and fewer fluid bags were charged to the patient (5.2 vs. 29.7; p < 0.01). Frequency of any measured hypoglycemia or hypokalemia trended in favor of the 2B group (2.9% vs. 10.3%; p = 0.07; 16.2% vs. 27.1%; p = 0.09; respectively), though did not reach significance. The 2B method appears feasible for management of adult ED patients with DKA, and use was associated with earlier correction of acidosis, earlier discontinuation of insulin infusion, and fewer i.v. fluid bags charged than traditional 1B methods, while no safety concerns were observed. Copyright © 2018 Elsevier Inc. All rights reserved.

Enterovirus D68 Infection Among Children With Medically Attended Acute Respiratory Illness, Cincinnati, Ohio, July-October 2014.

PubMed

Biggs, Holly M; McNeal, Monica; Nix, W Allan; Kercsmar, Carolyn; Curns, Aaron T; Connelly, Beverly; Rice, Marilyn; Chern, Shur-Wern Wang; Prill, Mila M; Back, Nancy; Oberste, M Steven; Gerber, Susan I; Staat, Mary A

2017-07-15

Enterovirus D68 (EV-D68) caused a widespread outbreak of respiratory illness in the United States in 2014, predominantly affecting children. We describe EV-D68 rates, spectrum of illness, and risk factors from prospective, population-based acute respiratory illness (ARI) surveillance at a large US pediatric hospital. Children <13 years of age with ARI and residence in Hamilton County, Ohio were enrolled from the inpatient and emergency department (ED) settings at a children's hospital in Cincinnati, Ohio, from 1 July to 31 October 2014. For each participant, we interviewed parents, reviewed medical records, and tested nasal and throat swabs for EV-D68 using real-time reverse- transcription polymerase chain reaction assay. EV-D68 infection was detected in 51 of 207 (25%) inpatients and 58 of 505 (11%) ED patients. Rates of EV-D68 hospitalization and ED visit were 1.3 (95% confidence interval [CI], 1.0-1.6) and 8.4 per 1000 children <13 years of age, respectively. Preexisting asthma was associated with EV-D68 infection (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1). Compared with other ARI, children with EV-D68 were more likely to be admitted from the ED (P ≤ .001), receive supplemental oxygen (P = .001), and require intensive care unit admission (P = .04); however, mechanical ventilation was uncommon (2/51 inpatients; P = .64), and no deaths occurred. During the 2014 EV-D68 epidemic, high rates of pediatric hospitalizations and ED visits were observed. Children with asthma were at increased risk for medically attended EV-D68 illness. Preparedness planning for a high-activity EV-D68 season in the United States should take into account increased healthcare utilization, particularly among children with asthma, during the late summer and early fall. Published by Oxford University Press for the Infectious Diseases Society of America 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.

An examination of the role of feeding regimens in regulating metabolism during the broiler breeder grower period. 1. Hepatic lipid metabolism.

PubMed

de Beer, M; Rosebrough, R W; Russell, B A; Poch, S M; Richards, M P; Coon, C N

2007-08-01

A trial was conducted to determine the effects of feeding regimens on hepatic lipid metabolism in 16-wk-old broiler breeder pullets. A flock of 350 Cobb 500 breeder pullets was divided into 2 at 4 wk of age and fed either every day (ED) or skip-a-day (SKIP) from 4 to 16 wk of age. Total feed intake did not differ between the 2 groups. At 112 d, 52 randomly selected ED-fed pullets, and 76 SKIP-fed pullets were individually caged and fed a 74-g (ED) or 148-g (SKIP) meal. Four pullets from each group were killed at intervals after feeding and livers were collected, weighed, and snap-frozen for determination of lipogenic gene expression. Total RNA was isolated from livers using Trizol reagent and then quantitatively measured by noting the optical density 260:280 ratio and qualitatively measured by gel electrophoresis. The expression of certain regulatory genes in metabolism [acetyl coenzyme A carboxylase; fatty acid synthase; malic enzyme (MAE); isocitrate dehydrogenase (ICDH); and aspartate aminotransferase (AAT)] were determined by real-time reverse-transcription PCR. Remaining liver portions were analyzed for enzyme activity of MAE, ICDH, and AAT as well as glycogen and lipid contents. Liver weight was higher in SKIP than in ED birds. Feeding caused dramatic increases in liver weight, glycogen, and lipids of SKIP birds. Expression of acetyl coenzyme A carboxylase, FAS, and MAE genes were increased in SKIP birds 12 and 24 h after feeding, with the increases in MAE expression from 0 to 24 h after feeding being of the greatest magnitude. In contrast, SKIP decreased ICDH and AAT gene expression, which parallels findings noted in fasting-refeeding experiments conducted with much younger birds. Skip-a-day feeding resulted in far greater changes in gene expression compared with ED, which was indicative of the inconsistent supply of nutrients in such regimens. Enzyme activity of MAE, ICDH, and AAT was reflective of noted changes in gene expression. In summary, the feeding regimen greatly affected hepatic gene expression in breeder pullets.

Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients.

PubMed

Haukoos, Jason S; Hopkins, Emily; Conroy, Amy A; Silverman, Morgan; Byyny, Richard L; Eisert, Sheri; Thrun, Mark W; Wilson, Michael L; Hutchinson, Angela B; Forsyth, Jessica; Johnson, Steven C; Heffelfinger, James D

2010-07-21

The Centers for Disease Control and Prevention (CDC) recommends routine (nontargeted) opt-out HIV screening in health care settings, including emergency departments (EDs), where the prevalence of undiagnosed infection is 0.1% or greater. The utility of this approach in EDs remains unknown. To determine whether nontargeted opt-out rapid HIV screening in the ED was associated with identification of more patients with newly diagnosed HIV infection than physician-directed diagnostic rapid HIV testing. Quasi-experimental equivalent time-samples design in an urban public safety-net hospital with an approximate annual ED census of 55,000 patient visits. Patients were 16 years or older and capable of providing consent for rapid HIV testing. Nontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing alternated in sequential 4-month time intervals between April 15, 2007, and April 15, 2009. Number of patients with newly identified HIV infection and the association between nontargeted opt-out rapid HIV screening and identification of HIV infection. In the opt-out phase, of 28,043 eligible ED patients, 6933 patients (25%) completed HIV testing (6702 patients were screened; 231 patients were diagnostically tested). Ten of 6702 patients (0.15%; 95% CI, 0.07%-0.27%) who did not decline HIV screening in the opt-out phase had new HIV diagnoses, and 5 of 231 patients (2.2%; 95% CI, 0.7%-5.0%) who were diagnostically tested during the opt-out phase had new HIV diagnoses. In the diagnostic phase, of 29,925 eligible patients, 243 (0.8%) completed HIV testing. Of these, 4 patients (1.6%; 95% CI, 0.5%-4.2%) had new diagnoses. The prevalence of new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 15 in 28,043 (0.05%; 95% CI, 0.03%-0.09%) and 4 in 29,925 (0.01%; 95% CI, 0.004%-0.03%), respectively. Nontargeted opt-out HIV screening was independently associated with new HIV diagnoses (risk ratio, 3.6; 95% CI, 1.2-10.8) when adjusting for patient demographics, insurance status, and whether diagnostic testing was performed in the opt-out phase. The median CD4 cell count for those with new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 69/microL (IQR, 17-430) and 13/microL (IQR, 11-15) , respectively (P = .02). Nontargeted opt-out rapid HIV screening in the ED, vs diagnostic testing, was associated with identification of a modestly increased number of patients with new HIV diagnoses, most of whom were identified late in the course of disease.

Correlation of Physical Exam Findings with Fever in Patients with Skin and Soft Tissue Infections.

PubMed

Mongelluzzo, Jillian; Tu, Brian; Grimes, Barbara; Ziyeh, Sharvina; Fortman, Jonathan; Neilson, Jersey; Rodriguez, Robert M

2017-04-01

The objectives of this study were to determine the prevalence of fever in adult ED patients with skin and soft tissue infections (SSTI) and to determine which, if any, physical exam, radiograph and laboratory test findings were associated with fever. We conducted a prospective, observational study at an urban county trauma center of adults who presented to the ED for evaluation of suspected SSTI. ED providers measured area of erythema and induration using a tape measure, and completed data sheets indicating comorbid conditions and the presence or absence of physical exam findings. Fever was defined as any recorded temperature ≥ 38°C during the first six hours of ED evaluation. Of the 734 patients enrolled, 96 (13.1%) had fever. Physical and laboratory exam findings associated with the presence of a fever in multivariable logistic regression were the area of erythema, particularly the largest quartile of area of erythema, 144 - 5,000 cm 2 , (odd ratio [OR] = 2.9; 95% confidence interval [CI] [1.6 - 5.2]) and leukocytosis (OR = 4.4, 95% CI [2.7 - 7.0]). Bullae, necrosis, streaks, adenopathy, and bone involvement on imaging were not associated with fever. Fever is uncommon in patients presenting to the ED for evaluation of suspected SSTI. Area of erythema and leukocytosis were associated with fever and should be considered in future decision rules for the evaluation and treatment of SSTI.

New to care: demands on a health system when homeless veterans are enrolled in a medical home model.

PubMed

O'Toole, Thomas P; Bourgault, Claire; Johnson, Erin E; Redihan, Stephen G; Borgia, Matthew; Aiello, Riccardo; Kane, Vincent

2013-12-01

We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.

Is there still a place for emergency department thrombolysis following the introduction of the amended Joint Royal Colleges Ambulance Liaison Committee criteria for thrombolysis?

PubMed

Castle, N R; Owen, R C; Hann, M

2007-12-01

To apply the current (2004) and the amended (2006) Joint Royal Colleges Ambulance Liaison Committee (JRCALC) criteria for paramedic initiated thrombolysis to all patients who received thrombolytic treatment in an emergency department (ED) to determine if the amendments increase the proportion suitable for paramedic initiated thrombolysis. Retrospective descriptive analysis. The ED clinical notes, ambulance clinical record and the first recorded ECG (ED or ambulance) of all patients thrombolysed in the ED during a 12 month period were reviewed against the previous JRCALC guidelines (2004) and the amended JRCALC guidelines (2006) for thrombolysis. Using the JRCALC guidelines (2004), 26 of the 147 patients (17.7%) were eligible for paramedic initiated thrombolysis. Using the JRCALC guidelines (2006), this increased to 41 (27.9%). This difference was statistically significant (McNemar's I2 test with 1 degree of freedom = 15.00; p<0.001). The change to the blood pressure, age and pulse rate parameters has increased the percentage eligible for paramedic initiated thrombolysis by 10.2% (95% confidence interval 4.6% to 15.8%). The amended JRCALC guidelines (2006) for paramedic initiated thrombolysis have successfully increased the proportion of patients suitable for prehospital thrombolysis by approximately 10%, although the ED retains an important role in the provision of prompt thrombolytic treatment for a proportion of patients.

Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS - A Descriptive Study.

PubMed

Mix, Felicia M; Zielinski, Martin D; Myers, Lucas A; Berns, Kathy S; Luke, Anurahda; Stubbs, James R; Zietlow, Scott P; Jenkins, Donald H; Sztajnkrycer, Matthew D

2018-06-01

IntroductionHemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS). This was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90). A total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort. In this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system. MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital blood product administration opportunities in ground transport ALS EMS - a descriptive study. Prehosp Disaster Med. 2018;33(3):230-236.

Economic comparison of reproductive programs for dairy herds using estrus detection, timed artificial insemination, or a combination.

PubMed

Galvão, K N; Federico, P; De Vries, A; Schuenemann, G M

2013-04-01

The objective of this study was to compare the economic outcome of reproductive programs using estrus detection (ED), timed artificial insemination (TAI), or a combination of both (TAI-ED) using a stochastic dynamic Monte-Carlo simulation model. Programs evaluated were (1) ED only; (2) TAI: Presynch-Ovsynch for first AI, and Ovsynch for resynchronization of open cows at 32 d after AI; (3) TAI-ED: Presynch-Ovsynch for first AI, but cows underwent ED and AI after first AI, and cows diagnosed open 32 d after AI were resynchronized using Ovsynch. Evaluated were the effect of ED rate (40 vs. 60%; ED40 or ED60), accuracy of estrus detection (85 vs. 95%), compliance with the timed AI protocol (85 vs. 95%), and milk price ($0.33 vs. 0.44/kg). Conception rate to first service was set at 33.9% and then decreased by 2.6% for every subsequent service. Abortion was set at 11.3%. Cows were not AI after 366 d in milk, and open cows were culled after 450 d in milk. Culled cows were immediately replaced. Herd size was maintained at 1,000 cows, and the model accounted for all incomes and costs. Simulation was performed until steady state was reached (3,000 d), and then average daily values for the subsequent 2,000 d were used to calculate profit/cow per year. Net daily value was calculated by subtracting the costs (replacement, feeding, breeding, and other costs) from the daily income (milk sales, cow sales, and calf sales). The ED40 models resulted in greater profits than the TAI-85 model but lower profits than the TAI-95 model. Both ED60 models resulted in greater profits than the TAI-95 model. Combining TAI and ED increased profits within each level of accuracy or compliance. Adding TAI to ED would increase overall profit/cow per year by $46.8 to $74.7 with 40% ED, and by $8.9 to $30.5 with 60% ED. Adding ED to TAI would increase profit/cow per year by $64.2 to $99.4 with 85% compliance and by $31.8 to $59.7 with 95% compliance. Although combining TAI and ED increased profits within each level of accuracy or compliance, when evaluated separately, ED60 with 95% accuracy or TAI with 95% compliance were as profitable as or more profitable than TAI-ED with low ED, accuracy, or compliance. Therefore, producers can improve their profits by combining TAI and ED as reproductive management; however, if a herd can achieve high ED with high accuracy or have high compliance with injections, using only ED or TAI might be more profitable than trying to do both. Copyright © 2013 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.

Nocturnal emergency department visits, duration of symptoms and risk of hospitalisation among adults with asthma exacerbations: a multicentre observational study.

PubMed

Yasuda, Hideto; Hagiwara, Yusuke; Watase, Hiroko; Hasegawa, Kohei

2016-08-12

We sought to compare the characteristics of patients with asthma presenting to the emergency department (ED) during the night-time with those of patients presenting at other times of the day, and to determine whether the time of ED presentation is associated with the risk of hospitalisation. A multicentre chart review study of 23 EDs across Japan. Patients aged 18-54 years with a history of physician-diagnosed asthma, presented to the ED between January 2009 and December 2011 OUTCOME MEASURES: The outcome of interest was hospitalisation, including admissions to an observation unit, inpatient unit and intensive care unit. Among the 1354 patients (30.1% in the night-time group vs 69.9% in the other time group) included in this study, the median age was 34 years and ∼40% were male. Overall 145 patients (10.7%) were hospitalised. Patients in the night-time group were more likely to have a shorter duration of symptoms (≤3 hours) before ED presentation than those in the other time group (25.9% in night-time vs 13.4% in other times; p<0.001). In contrast, there were no significant differences in respiratory rate, initial peak expiratory flow or ED asthma treatment between the two groups (p>0.05). Similarly, the risk of hospitalisation did not differ between the two groups (11.3% in night-time vs 10.5% in other times; p=0.65). In a multivariable model adjusting for potential confounders, the risk of hospitalisation in the night-time group was not statistically different from the other time group (OR, 1.10; 95% CI 0.74 to 1.61; p=0.63). This multicentre study in Japan demonstrated no significant difference in the risk of hospitalisations according to the time of ED presentation. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Web-Based Fully Automated Self-Help With Different Levels of Therapist Support for Individuals With Eating Disorder Symptoms: A Randomized Controlled Trial

PubMed Central

Dingemans, Alexandra E; Spinhoven, Philip; van Ginkel, Joost R; de Rooij, Mark; van Furth, Eric F

2016-01-01

Background Despite the disabling nature of eating disorders (EDs), many individuals with ED symptoms do not receive appropriate mental health care. Internet-based interventions have potential to reduce the unmet needs by providing easily accessible health care services. Objective This study aimed to investigate the effectiveness of an Internet-based intervention for individuals with ED symptoms, called “Featback.” In addition, the added value of different intensities of therapist support was investigated. Methods Participants (N=354) were aged 16 years or older with self-reported ED symptoms, including symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder. Participants were recruited via the website of Featback and the website of a Dutch pro-recovery–focused e-community for young women with ED problems. Participants were randomized to: (1) Featback, consisting of psychoeducation and a fully automated self-monitoring and feedback system, (2) Featback supplemented with low-intensity (weekly) digital therapist support, (3) Featback supplemented with high-intensity (3 times a week) digital therapist support, and (4) a waiting list control condition. Internet-administered self-report questionnaires were completed at baseline, post-intervention (ie, 8 weeks after baseline), and at 3- and 6-month follow-up. The primary outcome measure was ED psychopathology. Secondary outcome measures were symptoms of depression and anxiety, perseverative thinking, and ED-related quality of life. Statistical analyses were conducted according to an intent-to-treat approach using linear mixed models. Results The 3 Featback conditions were superior to a waiting list in reducing bulimic psychopathology (d=−0.16, 95% confidence interval (CI)=−0.31 to −0.01), symptoms of depression and anxiety (d=−0.28, 95% CI=−0.45 to −0.11), and perseverative thinking (d=−0.28, 95% CI=−0.45 to −0.11). No added value of therapist support was found in terms of symptom reduction although participants who received therapist support were significantly more satisfied with the intervention than those who did not receive supplemental therapist support. No significant differences between the Featback conditions supplemented with low- and high-intensity therapist support were found regarding the effectiveness and satisfaction with the intervention. Conclusions The fully automated Internet-based self-monitoring and feedback intervention Featback was effective in reducing ED and comorbid psychopathology. Supplemental therapist support enhanced satisfaction with the intervention but did not increase its effectiveness. Automated interventions such as Featback can provide widely disseminable and easily accessible care. Such interventions could be incorporated within a stepped-care approach in the treatment of EDs and help to bridge the gap between mental disorders and mental health care services. Trial Registration Netherlands Trial Registry: NTR3646; http://www.trialregister.nl/trialreg/admin/ rctview.asp?TC=3646 (Archived by WebCite at http://www.webcitation.org/6fgHTGKHE) PMID:27317358

Modelling seasonal variations in presentations at a paediatric emergency department.

PubMed

Takase, Miyuki; Carlin, John

2012-09-01

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.

Improving ED efficiency to capture additional revenue.

PubMed

Mandavia, Sujal; Samaniego, Loretta

2016-06-01

An increase in the number of patients visiting emergency departments (EDs) presents an opportunity for additional revenue if hospitals take four steps to optimize resources: Streamline the patient pathway and reduce the amount of time each patient occupies a bed in the ED. Schedule staff according to the busy and light times for patient arrivals. Perform registration and triage bedside, reducing initial wait times. Create an area for patients to wait for test results so beds can be freed up for new arrivals.

Emergency department usage by community step-down facilities--patterns and recommendations.

PubMed

Lee, S W; Goh, C; Chan, Y H

2003-09-01

This study examines the interface between institutional community step-down facilities (CSDFs) and acute hospital's Emergency Department (ED). It also provides a comprehensive description of the usage of an ED's services by CSDFs in its vicinity. This is a prospective 12-week observational study conducted in the Accident and Emergency Department of Changi General Hospital in Singapore. All patients from CSDFs transferred to the department were eligible for the study. Hospital records were used to extract relevant clinical data after admission for the length of stay and final discharge diagnosis. There was a total of 201 referrals to the ED over the 3-month period. The age of the patients ranged from 32 to 107 years, with a median of 83 years. Ninety-two patients (45.8%) were male residents. There were more referrals from CSDF on weekdays than on weekends. In particular, the number of referrals from CSDFs on Mondays were significantly higher (P < 0.05, Poisson regression) than other days of the week. Fifty-one per cent of the ED visits occurred during regular working hours. Eighty-two per cent of the transfers were admitted. The main complaint was shortness of breath with cough, followed by fever and falls. The most common investigation ordered was chest radiograph, followed by electrocardiogram and other radiographs. The most common treatment procedure in the ED was placement of an intravenous line. For those admitted residents, average length of hospital stay was 8.27 +/- 8.19 days (median, 5 days). Seventeen patients (10.3%) died within 3 days of admission, while 31 patients (18.8%) stayed less than 3 days. The admitted residents had an average turnaround time (from time of registration to time of leaving the ED and proceeding to ward) of 97.94 minutes. For patients discharged from the ED, the average turnaround time (time from registration to time of leaving the ED) was 177 minutes. Residents from CSDFs are transferred to the ED for a variety of medical reasons. The most appropriate role of the ED in evaluation of residents of CSDFs is not yet clearly defined. There is increasing need to streamline processes in acute hospitals to cope with an increasing ageing population and to ensure that quality care is delivered to the institutionalised sick.

Emergency department presentations in early stage breast cancer patients receiving adjuvant and neoadjuvant chemotherapy.

PubMed

Tang, Monica; Horsley, Patrick; Lewis, Craig R

2018-05-01

(Neo)adjuvant chemotherapy for early stage breast cancer is associated with side-effects, resulting in increased emergency department (ED) presentations. Treatment-related toxicity can affect quality of life, compromise chemotherapy delivery and treatment outcomes, and increase healthcare use. We performed a retrospective study of ED presentations in patients receiving curative chemotherapy for early breast cancer to identify factors contributing to ED presentations. Of 102 patients, 39 (38%) presented to ED within 30 days of chemotherapy, resulting in 63 ED presentations in total. Most common reasons were non-neutropenic fever (17 presentations/27%), neutropenic fever (15/24%), pain (9/14%), drug reaction (6/10%) and infection (4/6%). Factors significantly associated with ED presentation were adjuvant chemotherapy timing compared to neoadjuvant timing (P = 0.031), prophylactic antibiotics (P = 0.045) and docetaxel-containing regimen (P = 0.018). © 2018 Royal Australasian College of Physicians.

Short- and long-term reliability of language fMRI.

PubMed

Nettekoven, Charlotte; Reck, Nicola; Goldbrunner, Roland; Grefkes, Christian; Weiß Lucas, Carolin

2018-08-01

When using functional magnetic resonance imaging (fMRI) for mapping important language functions, a high test-retest reliability is mandatory, both in basic scientific research and for clinical applications. We, therefore, systematically tested the short- and long-term reliability of fMRI in a group of healthy subjects using a picture naming task and a sparse-sampling fMRI protocol. We hypothesized that test-retest reliability might be higher for (i) speech-related motor areas than for other language areas and for (ii) the short as compared to the long intersession interval. 16 right-handed subjects (mean age: 29 years) participated in three sessions separated by 2-6 (session 1 and 2, short-term) and 21-34 days (session 1 and 3, long-term). Subjects were asked to perform the same overt picture naming task in each fMRI session (50 black-white images per session). Reliability was tested using the following measures: (i) Euclidean distances (ED) between local activation maxima and Centers of Gravity (CoGs), (ii) overlap volumes and (iii) voxel-wise intraclass correlation coefficients (ICCs). Analyses were performed for three regions of interest which were chosen based on whole-brain group data: primary motor cortex (M1), superior temporal gyrus (STG) and inferior frontal gyrus (IFG). Our results revealed that the activation centers were highly reliable, independent of the time interval, ROI or hemisphere with significantly smaller ED for the local activation maxima (6.45 ± 1.36 mm) as compared to the CoGs (8.03 ± 2.01 mm). In contrast, the extent of activation revealed rather low reliability values with overlaps ranging from 24% (IFG) to 56% (STG). Here, the left hemisphere showed significantly higher overlap volumes than the right hemisphere. Although mean ICCs ranged between poor (ICC<0.5) and moderate (ICC 0.5-0.74) reliability, highly reliable voxels (ICC>0.75) were found for all ROIs. Voxel-wise reliability of the different ROIs was influenced by the intersession interval. Taken together, we could show that, despite of considerable ROI-dependent variations of the extent of activation over time, highly reliable centers of activation can be identified using an overt picture naming paradigm. Copyright © 2018 Elsevier Inc. All rights reserved.

Preventing eating disorders among young elite athletes: a randomized controlled trial.

PubMed

Martinsen, Marianne; Bahr, Roald; Børresen, Runi; Holme, Ingar; Pensgaard, Anne Marte; Sundgot-Borgen, Jorunn

2014-03-01

To examine the effect of a 1-yr school-based intervention program to prevent the development of new cases of eating disorders (ED) and symptoms associated with ED among adolescent female and male elite athletes. All 16 Norwegian Elite Sport High Schools were included (intervention group [n = 9] and control group [n = 7]). In total, 465 (93.8%) first-year student athletes were followed during high school (2008-2011, three school years). The athletes completed the Eating Disorder Inventory 2 and questions related to ED before (pretest), immediately after (posttest 1), and 9 months after the intervention (posttest 2). Clinical interviews (Eating Disorder Examination) were conducted after the pretest (all with symptoms [n = 115, 97%] and a random sample without symptoms [n = 116, 97%]), and at posttest 2, all athletes were interviewed (n = 463, 99.6%). Among females, there were no new cases of ED in the intervention schools, while 13% at the control schools had developed and fulfilled the DSM-IV criteria for ED not otherwise specified (n = 7) or bulimia nervosa (n = 1), P = 0.001. The risk of reporting symptoms was lower in the intervention than in the control schools at posttest 1 (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.23-0.89). This effect was attenuated by posttest 2 (OR = 0.57, 95% CI = 0.29-1.09). The intervention showed a relative risk reduction for current dieting (OR = 0.10, 95% CI = 0.02-0.54) and three or more weight loss attempts (OR = 0.47, 95% CI = 0.25-0.90). Among males, there was one new case of ED at posttest 2 (control school) and no difference in the risk of reporting symptoms between groups at posttest 1 or 2. A 1-yr intervention program can prevent new cases of ED and symptoms associated with ED in adolescent female elite athletes.

Predictive validity of the identification of seniors at risk screening tool in a German emergency department setting.

PubMed

Singler, Katrin; Heppner, Hans Jürgen; Skutetzky, Andreas; Sieber, Cornel; Christ, Michael; Thiem, Ulrich

2014-01-01

The identification of patients at high risk for adverse outcomes [death, unplanned readmission to emergency department (ED)/hospital, functional decline] plays an important role in emergency medicine. The Identification of Seniors at Risk (ISAR) instrument is one of the most commonly used and best-validated screening tools. As to the authors' knowledge so far there are no data on any screening tool for the identification of older patients at risk for a negative outcome in Germany. To evaluate the validity of the ISAR screening tool in a German ED. This was a prospective single-center observational cohort study in an ED of an urban university-affiliated hospital. Participants were 520 patients aged ≥75 years consecutively admitted to the ED. The German version of the ISAR screening tool was administered directly after triage of the patients. Follow-up telephone interviews to assess outcome variables were conducted 28 and 180 days after the index visit in the ED. The primary end point was death from any cause or hospitalization or recurrent ED visit or change of residency into a long-term care facility on day 28 after the index ED visit. The mean age ± SD was 82.8 ± 5.0 years. According to ISAR, 425 patients (81.7%) scored ≥2 points, and 315 patients (60.5%) scored ≥3 points. The combined primary end point was observed in 250 of 520 patients (48.1%) on day 28 and in 260 patients (50.0%) on day 180. Using a continuous ISAR score the area under the curve on day 28 was 0.621 (95% confidence interval, CI 0.573-0.669) and 0.661 (95% CI 0.615-0.708) on day 180, respectively. The German version of the ISAR screening tool acceptably identified elderly patients in the ED with an increased risk of a negative outcome. Using the cutoff ≥3 points instead of ≥2 points yielded better overall results.

A case-control analysis on the association between erectile dysfunction and sudden sensorineural hearing loss in Taiwan.

PubMed

Keller, Joseph J; Chen, Yi-Kuang; Lin, Herng-Ching

2012-05-01

Although the cause of sudden sensorineural hearing loss (SSNHL) is yet to be elucidated, many theories have been proposed regarding potentially contributory etiologies. One increasingly well-supported theory purports an underlying vascular pathomechanism. If this is the case, SSNHL may also associate with conditions comorbid with vascular diseases, such as erectile dysfunction (ED). However, no studies to date have investigated the association between ED and SSNHL. This study set out to estimate a putative association between ED and having been previously diagnosed with SSNHL using a population-based dataset with a case-control design. This study used administrative claim data from the Taiwan National Health Insurance program. We identified 4,504 patients with ED as the study group and randomly selected 22,520 patients as the comparison group. Conditional logistic regression was used to examine the association between ED and having previously received a diagnosis of SSNHL. The prevalence and risk of SSNHL between cases and controls were calculated. Of the sampled patients, 41 (0.15%) had been diagnosed with SSNHL before the index date; 22 (0.49% of the cases) were from the study group and 19 (0.08% of controls) were from the control group. Conditional logistic regression analysis revealed that after adjusting for the patient's monthly income, geographic location, hypertension, diabetes, hyperlipidemia, coronary heart disease, obesity, and alcohol abuse/alcohol dependence syndrome status, patients with ED were more likely than controls to have been diagnosed with SSNHL before the index date (odds ratio = 6.06, 95% confidence interval = 3.25-11.29). There was an association between ED and prior SSNHL. The results of this study add to the evidence supporting an underlying vascular pathomechanism regarding the development of SSNHL and highlight a need for clinicians dealing with SSNHL patients to be alert to the development of ED. © 2012 International Society for Sexual Medicine.

Evaluation of a targeted prescriber education intervention on emergency department discharge oxycodone prescribing.

PubMed

Donaldson, Síne R; Harding, Andrew M; Taylor, Simone E; Vally, Hassan; Greene, Shaun L

2017-08-01

The objective of this study was to evaluate the impact of an educational intervention on ED discharge opioid analgesic (OA) prescribing. A brief, one-on-one, educational intervention was delivered to ED OA prescribers by an ED clinical champion. The percentage of patients receiving (i) written advice regarding appropriate oxycodone use, (ii) written or verbal advice regarding appropriate post-discharge follow up and (iii) written general practitioner notification that oxycodone had been prescribed were determined pre- and post-intervention, through review of electronic patient records and structured patient telephone interviews conducted 3-7 days after ED attendance. Secondary outcomes included total amount prescribed and use of non-OA therapies. ED OA prescribers were surveyed to evaluate perceived effectiveness and intervention acceptability. A total of 30 ED OA prescribers received the 5-min intervention. Pre- and post-intervention, 80 and 81 patients were interviewed, respectively. Percentage of patients given written OA information increased from 10% to 22% (P = 0.04) and those receiving follow-up advice increased from 61 to 94% (P < 0.01). General practitioner notification of OA prescription increased from 15% to 88% (P < 0.01). Risk ratio for achieving all three end-points was 7.5 (95% confidence interval 1.8-32, P = 0.01). Median total amount of oxycodone prescribed/patient decreased from 100mg to 50mg (P = 0.04). Non-OA therapies were used by 49% of pre-intervention and 85% of post-intervention patients (P = <0.01). All ED OA prescribers agreed the intervention would change their prescribing practices; 70% deemed the intervention appropriate for delivery in their work environment. A brief, one-on-one educational intervention targeting ED OA prescribers was well received by clinicians and associated with improved quality of OA prescribing. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Victims of bullying in the emergency department with behavioral issues.

PubMed

Waseem, Muhammad; Arshad, Arslan; Leber, Mark; Perales, Orlando; Jara, Fernando

2013-03-01

Bullying has become one of the most significant school problems experienced by our children. Victims of bullying are prone to a variety of psychological and behavioral symptoms. We noted that many children referred to the Emergency Department (ED) with behavioral symptoms provided a history of bullying. To measure the prevalence of bullying in children referred to the ED for behavioral symptoms and to determine its association with psychiatric disorders. A retrospective cohort study was conducted in an urban hospital, identifying children from 8 to 19 years of age who presented to the ED with behavioral symptoms. We reviewed the ED psychiatry notes to retrieve the report indicating whether these children were bullied and had previous psychiatric diagnoses. These children were classified into bullied and non-bullied groups. Over the study period, 591 children visited the ED with behavioral issues. Out of 591, 143 (24%) children reported bullying. More boys (100) than girls (43) reported bullying (p = 0.034). The mean age of children in the bullied group was 10.6 years (95% confidence interval 10.1-11.2). One hundred eleven (77.6%) children in the bullied group had a prior psychiatric diagnosis. Children in the bullied group were hospitalized significantly less than children in the non-bullied group (10/143 [7%] vs. 80/368 [18%]; p = 0.002). The prevalence of bullying among the ED children with behavioral symptoms is substantial. Every fourth child with behavioral symptoms reported bullying. Four in five children who reported bullying had a prior diagnosis of "disorder of behavior." Copyright © 2013 Elsevier Inc. All rights reserved.

Predictors of admission after emergency department discharge in older adults.

PubMed

Gabayan, Gelareh Z; Sarkisian, Catherine A; Liang, Li-Jung; Sun, Benjamin C

2015-01-01

To identify predictors of hospital inpatient admission of older Medicare beneficiaries after discharge from the emergency department (ED). Retrospective cohort study. Nonfederal California hospitals (n = 284). Visits of Medicare beneficiaries aged 65 and older discharged from California EDs in 2007 (n = 505,315). Using the California Office of Statewide Health Planning and Development files, predictors of hospital inpatient admission within 7 days of ED discharge in older adults (≥65) with Medicare were evaluated. Hospital inpatient admissions within 7 days of ED discharge occurred in 23,340 (4.6%) visits and were associated with older age (70-74: adjusted odds ratio (AOR) = 1.12, 95% confidence interval (CI) = 1.07-1.17; 75-79: AOR = 1.18, 95% CI = 1.13-1.23; ≥80: AOR = 1.4, 95% CI = 1.35-1.46), skilled nursing facility use (AOR = 1.82, 95% CI = 1.72-1.94), leaving the ED against medical advice (AOR = 1.82, 95% CI = 1.67-1.98), and the following diagnoses with the highest odds of admission: end-stage renal disease (AOR = 3.83, 95% CI = 2.42-6.08), chronic renal disease (AOR = 3.19, 95% CI = 2.26-4.49), and congestive heart failure (AOR = 3.01, 95% CI = 2.59-3.50). Five percent of older Medicare beneficiaries have a hospital inpatient admission after discharge from the ED. Chronic conditions such as renal disease and heart failure were associated with the greatest odds of admission. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Frequency of alcohol use among injured adult patients presenting to a Ghanaian emergency department

PubMed Central

Forson, Paa Kobina; Gardner, Andrew; Oduro, George; Bonney, Joseph; Biney, Eno Akua; Oppong, Chris; Momade, Ezster; Maio, Ronald F.

2016-01-01

Objective Injuries are the cause of almost six million deaths annually worldwide, with 15–20% alcohol-associated. The frequency of alcohol-associated injury varies among countries, and is unknown in Ghana. We determined the frequency of positive alcohol tests among injured adults in a Ghanaian Emergency Department (ED). Methods This is a cross-sectional chart review of consecutive injured patients 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within eight hours of injury. Patients were tested for alcohol using a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death prior to admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals (95%CIs) were calculated. Results 2,488 injured adult patients presented to the ED from November 2014 to April 2015 with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95%CI 32–38) tested alcohol positive. Forty-two percent of males (320/756), 40% of subjects 25–44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assaults (82/166), 40% of the seriously injured (124/311), and 53% of subjects who died in the ED (8/15) were positive for alcohol. Conclusions The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary hospital ED. These findings have implications for health policy, ED and legislative-based interventions, and acute care. PMID:27241887

Comparisons between Full-time and Part-time Pediatric Emergency Physicians in Pediatric Emergency Department.

PubMed

Huang, I-Anne; Tuan, Pao-Lan; Jaing, Tang-Her; Wu, Chang-Teng; Chao, Minston; Wang, Hui-Hsuan; Hsia, Shao-Hsuan; Hsiao, Hsiang-Ju; Chang, Yu-Ching

2016-10-01

Pediatric emergency medicine is a young field that has established itself in recent decades. Many unanswered questions remain regarding how to deliver better pediatric emergency care. The implementation of full-time pediatric emergency physicians is a quality improvement strategy for child care in Taiwan. The aim of this study is to evaluate the quality of care under different physician coverage models in the pediatric emergency department (ED). The medical records of 132,398 patients visiting the pediatric ED of a tertiary care university hospital during January 2004 to December 2006 were retrospectively reviewed. Full-time pediatric emergency physicians are the group specializing in the pediatric emergency medicine, and they only work in the pediatric ED. Part-time pediatricians specializing in other subspecialties also can work an extra shift in the pediatric ED, with the majority working in their inpatient and outpatient services. We compared quality performance indicators, including: mortality rate, the 72-hour return visit rate, length of stay, admission rate, and the rate of being kept for observation between full-time and part-time pediatric emergency physicians. An average of 3678 ± 125 [mean ± standard error (SE)] visits per month (with a range of 2487-6646) were observed. The trends in quality of care, observed monthly, indicated that the 72-hour return rate was 2-6% and length of stay in the ED decreased from 11.5 hours to 3.2 hours over the study period. The annual mortality rate within 48 hours of admission to the ED increased from 0.04% to 0.05% and then decreased to 0.02%, and the overall mortality rate dropped from 0.13% to 0.07%. Multivariate analyses indicated that there was no change in the 72-hour return visit rate for full-time pediatric emergency physicians; they were more likely to admit and keep patients for observation [odds ratio = 1.43 and odds ratio = 1.71, respectively], and these results were similar to those of senior physicians. Full-time pediatric emergency physicians in the pediatric ED decreased the mortality rate and length of stay in the ED, but had no change in the 72-hour return visit rate. This pilot study shows that the quality of care in pediatric ED after the implementation of full-time pediatric emergency physicians needs further evaluation. Copyright © 2016. Published by Elsevier B.V.

FACTORS ASSOCIATED WITH CLOSURES OF EMERGENCY DEPARTMENTS IN THE UNITED STATES

PubMed Central

Hsia, Renee Y.; Kellerman, Arthur L.; Shen, Yu-Chu

2014-01-01

Context Between 1998 and 2008, the number of hospital-based emergency departments (EDs) in the United States declined, while the number of ED visits increased, particularly visits by publicly-insured and uninsured patients. Little is known about the hospital, community, and market factors associated with ED closures. Federal law requiring EDs to treat all in need regardless of a patient’s ability to pay may make EDs more vulnerable to the market forces that govern US health care. Objective To determine hospital, community, and market factors associated with ED closures. Design ED and hospital organizational information from 1990 through 2009 was acquired from the American Hospital Association (AHA) Annual Surveys (annual response rates ranging from 84–92%) and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports. We evaluated 3 sets of risk factors: hospital characteristics (safety-net as defined by hospitals caring for more than double their Medicaid share of discharges, compared with other hospitals within a 15-mile radius) ownership, teaching status, system membership, hospital size, case-mix), county population demographics (race, poverty, uninsurance, elderly), and market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs). Setting All general, acute, non-rural, short-stay hospitals in the US with an operating ED anytime from 1990–2009. Main Outcome Closure of an emergency department anytime during the study period. Results The number of hospitals with EDs in non-rural areas declined from 2446 in 1990 to 1779 in 2009, with 1041 EDs closing and 374 hospitals opening EDs. Based on analysis of 2,814 urban acute care hospitals, constituting 36,335 hospital-year observations over an 18-year study interval (1990–2007), for-profit hospitals and those with low profit margins were more likely to close than their counterparts (26% vs 16%; HR 1.8, 95% CI 1.5 to 2.1 and 36% vs 18%; HR 1.9, 95% CI 1.6 to 2.3, respectively]. Hospitals in more competitive markets had a significantly higher risk of closing their EDs (34% vs 17%; HR 1.3, 95% CI 1.1 to 1.6), as did safety-net hospitals (10% vs 6%; HR 1.4, 95% CI 1.1 to 1.7) and those serving a higher share of populations in poverty (37% vs 31%; HR 1.4, 95% CI 1.1 to 1.7). Conclusion From 1990 to 2009, the number of hospital EDs in non-rural areas declined by 27%, with for-profit ownership, location in a competitive market, safety-net status, and low profit margin associated with increased risk of ED closure. PMID:21586713

Research on Advanced Nondestructive Evaluation (NDE) Methods for Aerospace Structures

DTIC Science & Technology

2004-03-01

al iz ed re sp on se (l in ea r s ca le ) N or m al iz ed re sp on se (l in ea...variations showed some differences after weathering (Figure 4.2.2-2). 0.0 1.0 2.0 0 1 2 3 4 5 Weathering time (hours) N or m al iz ed p ea k ar ea 0.0...1.0 2.0 0 1 2 3 4 5 Weathering time (hours)N or m al iz ed p ea k he ig ht s (A) (B) 52 Prior to weathering, the height variation

The effects of publishing emergency department wait time on patient utilization patterns in a community with two emergency department sites: a retrospective, quasi-experiment design.

PubMed

Xie, Bin; Youash, Sabrina

2011-06-14

Providing emergency department (ED) wait time information to the public has been suggested as a mechanism to reduce lengthy ED wait times (by enabling patients to select the ED site with shorter wait time), but the effects of such a program have not been evaluated. We evaluated the effects of such a program in a community with two ED sites. Descriptive statistics for wait times of the two sites before and after the publication of wait time information were used to evaluate the effects of the publication of wait time information on wait times. Multivariate logistical regression was used to test whether or not individual patients used published wait time to decide which site to visit. We found that the rates of wait times exceeding 4 h, and the 95th percentile of wait times in the two sites decreased after the publication of wait time information, even though the average wait times experienced a slight increase. We also found that after controlling for other factors, the site with shorter wait time had a higher likelihood of being selected after the publication of wait time information, but there was no such relationship before the publication. These findings were consistent with the hypothesis that the publication of wait time information leads to patients selecting the site with shorter wait time. While publishing ED wait time information did not improve average wait time, it reduced the rates of lengthy wait times.

Development and Validation of a Six-Item Version of the Interpersonal Dependency Inventory.

PubMed

McClintock, Andrew S; McCarrick, Shannon M; Anderson, Timothy; Himawan, Lina; Hirschfeld, Robert

2017-04-01

The Interpersonal Dependency Inventory (IDI) is a frequently used, 48-item measure of maladaptive dependency. Our goal was to develop and psychometrically evaluate a very brief version of the IDI. An exploratory factor analysis of the IDI in Study 1 ( N = 838) yielded a six-item IDI (IDI-6), with three items loading on an emotional dependency factor (IDI-6-ED), and the other three items loading on a functional dependency factor (IDI-6-FD). This factor solution was validated by confirmatory factor analysis in Study 2 ( N = 916). The IDI-6-ED and IDI-6-FD demonstrated good convergent and divergent validity in Study 3 ( N = 100). In Study 4 ( N = 22-43), the IDI-6-ED and IDI-6-FD were generally stable over 4-week and 8-week intervals and were found to be responsive to the effects of psychological treatment. These results have implications for dependency conceptualizations and support the IDI-6 as a brief, psychometrically sound instrument.

Primary health care providers surveyed commonly misinterpret 'first void urine' for chlamydia screening.

PubMed

Lusk, M Josephine; Uddin, Ruby; Ferson, Mark; Rawlinson, William; Konecny, Pam

2009-03-01

An open question survey of general practitioners (GP) and hospital emergency department (ED) doctors revealed that the term 'FVU' (first void urine) used for urine chlamydia testing, is ambiguous, potentially leading to incorrect urine sample collection and barriers to effective screening. The results of this survey indicate that only 4.3% (95% confidence interval [CI] 0.5-14.5%) of GP and 6.9% (95% CI 0.9-22.8%) of ED doctors respectively, correctly interpreted the meaning of FVU. The majority of clinicians surveyed misunderstood 'FVU' to require the first urine void of the day, accounting for 68.1% (95% CI 52.9-80.9%) of GP responses and 37.9% (95% CI 20.7-57.7%) of ED doctors responses. This highlights the need for clarification and standardisation of terminology used in urine chlamydia screening for health care providers, in order to optimise strategies for diagnosis and control of the ongoing chlamydia epidemic.

Incidence of cerebral infarction after radiotherapy for pituitary adenoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Flickinger, J.C.; Nelson, P.B.; Taylor, F.H.

1989-06-15

The incidence of cerebral infarction was studied in 156 patients irradiated for treatment of pituitary adenomas. Seven patients experienced strokes at intervals of 3.2 to 14.6 years after irradiation. The observed incidence was not significantly greater than the expected value of 3.5 strokes (P = 0.078). Six strokes occurred in patients receiving equivalent doses (ED) of 1070 ret or more (observed to expected ratio 3.87, significantly elevated; P less than 0.001). Univariate log-rank analysis showed that the risk of stroke was significantly higher (P = 0.010) in patients receiving an ED of 1070 ret or more (4180 cGy/22 fractions) thanmore » those receiving lower doses. Multivariate analysis, however, demonstrated that the increased risk of stroke was associated only with increasing age (P less than 0.0001), not ED (P = 0.148). Due to these inconsistent statistical results, no definitive conclusions could be reached about the relationship between radiation dose to the pituitary and subsequent cerebral infarction.« less

A Questionnaire Survey of the Type of Support Required by Yogo Teachers to Effectively Manage Students Suspected of Having an Eating Disorder.

PubMed

Seike, Kaoru; Hanazawa, Hisashi; Ohtani, Toshiyuki; Takamiya, Shizuo; Sakuta, Ryoichi; Nakazato, Michiko

2016-01-01

Many studies have focused on the decreasing age of onset of eating disorders (EDs). Because school-age children with EDs are likely to suffer worse physical effects than adults, early detection and appropriate support are important. The cooperation of Yogo teachers is essential in helping these students to find appropriate care. To assist Yogo teachers, it is helpful to clarify the encounter rates (the proportion of Yogo teachers who have encountered ED students) and kinds of requested support (which Yogo teachers felt necessary to support ED students). There are no studies that have surveyed the prevalence rates of ED children by ED type as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), nor were we able to find any quantitative study surveying the kinds of support Yogo teachers feel helpful to support ED students. A questionnaire survey was administered to 655 Yogo teachers working at elementary/junior high/senior high/special needs schools in Chiba Prefecture. The questionnaire asked if the respondents had encountered students with each of the ED types described in DSM-5 (anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), and other types of EDs (Others)), and the kinds of support they felt necessary to support these students. The encounter rates and the kinds of requested were obtained and compared, taking their confidence intervals into consideration. The encounter rates for AN, BN, BED, ARFID, and Others were 48.4, 14.0, 8.4, 10.7, and 4.6 %, respectively. When classified by school type, AN, BN, BED, and ARFID had their highest encounter rates in senior high schools. Special needs schools had the highest rate for Others. The support most required for all ED types was "a list of medical/consultation institutions." Our results have clarified how to support Yogo teachers in the early detection and support of ED students. We found that the encounter rate of AN was the highest, and that it is effective to offer "a list of medical/consultation institutions" to junior and senior high schools where the encounter rates for AN are high.

Normalized sensitivities and parameter identifiability of in situ diffusion experiments on Callovo Oxfordian clay at Bure site

NASA Astrophysics Data System (ADS)

Samper, J.; Dewonck, S.; Zheng, L.; Yang, Q.; Naves, A.

Diffusion of inert and reactive tracers (DIR) is an experimental program performed by ANDRA at Bure underground research laboratory in Meuse/Haute Marne (France) to characterize diffusion and retention of radionuclides in Callovo-Oxfordian (C-Ox) argillite. In situ diffusion experiments were performed in vertical boreholes to determine diffusion and retention parameters of selected radionuclides. C-Ox clay exhibits a mild diffusion anisotropy due to stratification. Interpretation of in situ diffusion experiments is complicated by several non-ideal effects caused by the presence of a sintered filter, a gap between the filter and borehole wall and an excavation disturbed zone (EdZ). The relevance of such non-ideal effects and their impact on estimated clay parameters have been evaluated with numerical sensitivity analyses and synthetic experiments having similar parameters and geometric characteristics as real DIR experiments. Normalized dimensionless sensitivities of tracer concentrations at the test interval have been computed numerically. Tracer concentrations are found to be sensitive to all key parameters. Sensitivities are tracer dependent and vary with time. These sensitivities are useful to identify which are the parameters that can be estimated with less uncertainty and find the times at which tracer concentrations begin to be sensitive to each parameter. Synthetic experiments generated with prescribed known parameters have been interpreted automatically with INVERSE-CORE 2D and used to evaluate the relevance of non-ideal effects and ascertain parameter identifiability in the presence of random measurement errors. Identifiability analysis of synthetic experiments reveals that data noise makes difficult the estimation of clay parameters. Parameters of clay and EdZ cannot be estimated simultaneously from noisy data. Models without an EdZ fail to reproduce synthetic data. Proper interpretation of in situ diffusion experiments requires accounting for filter, gap and EdZ. Estimates of the effective diffusion coefficient and the porosity of clay are highly correlated, indicating that these parameters cannot be estimated simultaneously. Accurate estimation of De and porosities of clay and EdZ is only possible when the standard deviation of random noise is less than 0.01. Small errors in the volume of the circulation system do not affect clay parameter estimates. Normalized sensitivities as well as the identifiability analysis of synthetic experiments provide additional insight on inverse estimation of in situ diffusion experiments and will be of great benefit for the interpretation of real DIR in situ diffusion experiments.

The expression of excessive exercise co-segregates with the risk of developing an eating disorder in women.

PubMed

Kostrzewa, Elzbieta; Eijkemans, Marinus J C; Kas, Martien J

2013-12-30

Excessive exercise (EE) is an important symptom of eating disorders (ED) and is a likely risk factor for developing ED, however, no population-based studies have been performed on the relationship between EE and obtaining ED diagnosis. The aim of this study was to examine the co-occurrence of EE and ED diagnosis in a general population of women. Data for 778 females (age min=30, max=55) from the Saint Thomas Twin Registry, London were used. Phenotypes analyzed included self-reported time spent on physical activity per week, ED diagnosis, Eating Disorder Inventory results (EDI-III), age, BMI and kinship (twin pair). Generalized Estimating Equation analysis showed that only EE (>5 h of exercise per week) and Bulimia Subscale of EDI-III were significantly associated with obtaining ED diagnosis throughout the life. These data revealed that the odds of ever being diagnosed with an ED are more than 2.5 times higher for excessive exercisers compared to individuals with lower activity levels. These data support the notion that EE may be an important risk factor for developing an ED in women. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Extraction of pacemaker and implantable cardioverter defibrillator leads: a single-centre study of electrosurgical and laser extraction.

PubMed

Scott, Paul A; Chow, Whitney; Ellis, Elizabeth; Morgan, John M; Roberts, Paul R

2009-11-01

Both electrosurgical dissection (EDS) and laser tools are effective in the extraction of chronic implanted endovascular leads. It is unclear which is superior. We undertook a retrospective single-centre study to assess this. In our institution from 2000 to 2004, all extractions requiring an ablative sheath were performed using the EDS system. In 2004, an excimer laser system was acquired, which became the first choice. Consecutive patients undergoing extraction requiring an ablative sheath (EDS or laser) were studied. From 2000 to 2007, 140 leads were extracted from 74 patients (EDS 31 and laser 43). Procedural success was non-significantly higher in the laser vs. the EDS group (95 vs. 87%). In the EDS group, one patient suffered tamponade requiring surgery; in the laser group, one patient suffered a significant pericardial effusion treated conservatively. There were no deaths. Procedure and fluoroscopy times were similar between groups. More patients were referred for primary surgical extraction in the EDS vs. the laser era (7 vs. 0, P = 0.003). Lead extraction using an ablative sheath is safe and effective. In our small study, there were no significant differences between EDS and laser sheaths in terms of success, time, or safety.

A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department.

PubMed

Gaffigan, Matthew E; Bruner, David I; Wason, Courtney; Pritchard, Amy; Frumkin, Kenneth

2015-09-01

Emergency Department (ED) headache patients are commonly treated with neuroleptic antiemetics like metoclopramide. Haloperidol has been shown to be effective for migraine treatment. Our study compared the use of metoclopramide vs. haloperidol to treat ED migraine patients. A prospective, double-blinded, randomized control trial of 64 adults aged 18-50 years with migraine headache and no recognized risks for QT-prolongation. Haloperidol 5 mg or metoclopramide 10 mg was given intravenously after 25 mg diphenhydramine. Pain, nausea, restlessness (akathisia), and sedation were assessed with 100-mm visual analog scales (VAS) at baseline and every 20 min, to a maximum of 80 min. The need for rescue medications, side effects, and subject satisfaction were recorded. QTc intervals were measured prior to and after treatment. Follow-up calls after 48 h assessed satisfaction and recurrent or persistent symptoms. Thirty-one subjects received haloperidol, 33 metoclopramide. The groups were similar on all VAS measurements, side effects, and in their satisfaction with therapy. Pain relief averaged 53 mm VAS over both groups, with equal times to maximum improvement. Subjects receiving haloperidol required rescue medication significantly less often (3% vs. 24%, p < 0.02). Mean QTcs were equal and normal in the two groups and did not change after treatment. In telephone follow-up, 90% of subjects contacted were "happy with the medication" they had received, with haloperidol-treated subjects experiencing more restlessness (43% vs. 10%). Intravenous haloperidol is as safe and effective as metoclopramide for the ED treatment of migraine headaches, with less frequent need for rescue medications. Published by Elsevier Inc.

Impact of an after-hours on-call emergency physician on ambulance transports from a county jail.

PubMed

Chan, Theodore C; Vilke, Gary M; Smith, Sue; Sparrow, William; Dunford, James V

2003-01-01

The authors sought to determine if the availability of an after-hours on-call emergency physician by telephone for consultation to the staff at a county jail would safely reduce ambulance emergency department (ED) transport of inmates in the community. The authors conducted a prospective comparison study during the first ten months of an emergency physician on-call program for the county jail in which prospective data were collected on all consultations, including reason for call and disposition (ambulance, deputy, or no ED transport of inmate). They compared this time with a similar period a year before the program in terms of total ambulance transports from the jail. They also reviewed all hospital and jail medical records to assess for any adverse consequences within one month, or subsequent ambulance transport within 24 hours as a result of inmate care after the consultation call. Total after-hours ambulance transports from the jail decreased significantly from 30.3 transports/month (95% confidence interval [CI], 21.0-39.6) to 9.1 transports/month (95% CI, 4.1-14.0) (p < 0.05). The most common reasons for consultation calls were chest pain (16%), trauma (15%), and abnormal laboratory or radiology results (14%). Of all calls, only 30% resulted in ambulance transport to the ED. On review of records, no adverse outcome or subsequent ambulance transport was identified. The initiation of an on-call emergency physician program for after-hours consultation to jail nursing and law enforcement staff safely reduced ambulance transports from a county jail with no adverse outcomes identified.

Generic substitution of lamotrigine among medicaid patients with diverse indications: a cohort-crossover study.

PubMed

Hartung, Daniel M; Middleton, Luke; Svoboda, Leanne; McGregor, Jessina C

2012-08-01

Controversy exists about the safety of substituting generic antiepileptic drugs (AEDs). Lamotrigine, the prototypical newer AED, is often used for psychiatric and neurological conditions other than epilepsy. The safety of generic substitution of lamotrigine in diverse populations of AED users is unclear. The objective of this study was to evaluate potential associations between generic substitution of lamotrigine and adverse consequences in a population of diverse users of this drug. This study was a retrospective cohort-crossover design using state Medicaid claims data from July 2006 through June 2009. Subjects were included in the cohort if they converted from brand to generic lamotrigine and had 2 years of lamotrigine use prior to conversion. The frequency of emergency department (ED) visits, hospitalizations and condition-specific ED visits or hospitalizations were recorded in the 60 days immediately following the conversion to generic lamotrigine, then compared with the incidence of the same events during a randomly selected time period indexed to one of the patient's past refills of branded lamotrigine. Multivariate conditional logistic regression was used to quantify the association between generic conversion and health services utilization while controlling for changes in lamotrigine dose and concurrent drug use. Of the 616 unique subjects included in this analysis, epilepsy was the most common diagnosis (41%), followed by bipolar disorder (32%), pain (30%) and migraine (18%). Conversion to generic lamotrigine was not associated with a statistically significant increase in the odds of an ED visit (adjusted odds ratio [AOR] = 1.35; 95% confidence interval [CI] 0.92, 1.97), hospitalization (AOR = 1.21; 95% CI 0.60, 2.50) or condition-specific encounter (AOR 1.75; 95 CI 0.87, 3.51). A statistically significant increase in ED visits, hospitalizations or condition-specific encounters was not observed following the switch from brand to generic lamotrigine, although a type II error cannot be ruled out.

Extreme climatic conditions and health service utilisation across rural and metropolitan New South Wales

NASA Astrophysics Data System (ADS)

Jegasothy, Edward; McGuire, Rhydwyn; Nairn, John; Fawcett, Robert; Scalley, Benjamin

2017-08-01

Periods of successive extreme heat and cold temperature have major effects on human health and increase rates of health service utilisation. The severity of these events varies between geographic locations and populations. This study aimed to estimate the effects of heat waves and cold waves on health service utilisation across urban, regional and remote areas in New South Wales (NSW), Australia, during the 10-year study period 2005-2015. We divided the state into three regions and used 24 over-dispersed or zero-inflated Poisson time-series regression models to estimate the effect of heat waves and cold waves, of three levels of severity, on the rates of ambulance call-outs, emergency department (ED) presentations and mortality. We defined heat waves and cold waves using excess heat factor (EHF) and excess cold factor (ECF) metrics, respectively. Heat waves generally resulted in increased rates of ambulance call-outs, ED presentations and mortality across the three regions and the entire state. For all of NSW, very intense heat waves resulted in an increase of 10.8% (95% confidence interval (CI) 4.5, 17.4%) in mortality, 3.4% (95% CI 0.8, 7.8%) in ED presentations and 10.9% (95% CI 7.7, 14.2%) in ambulance call-outs. Cold waves were shown to have significant effects on ED presentations (9.3% increase for intense events, 95% CI 8.0-10.6%) and mortality (8.8% increase for intense events, 95% CI 2.1-15.9%) in outer regional and remote areas. There was little evidence for an effect from cold waves on health service utilisation in major cities and inner regional areas. Heat waves have a large impact on health service utilisation in NSW in both urban and rural settings. Cold waves also have significant effects in outer regional and remote areas. EHF is a good predictor of health service utilisation for heat waves, although service needs may differ between urban and rural areas.

Anticipated changes in reimbursements for US outpatient emergency department encounters after health reform.

PubMed

Galarraga, Jessica E; Pines, Jesse M

2014-04-01

We study how reimbursements to emergency departments (EDs) for outpatient visits may be affected by the insurance coverage expansion of the Patient Protection and Affordable Care Act as previously uninsured patients gain coverage either through the Medicaid expansion or through health insurance exchanges. We conducted a secondary analysis of data (2005 to 2010) from the Medical Expenditure Panel Survey. We specified multiple linear regression models to examine differences in the payments, charges, and reimbursement ratios by insurance category. Comparisons were made between 2 groups to reflect likely movements in insurance status after the Patient Protection and Affordable Care Act implementation: (1) the uninsured who will be Medicaid eligible afterward versus Medicaid insured, and (2) the uninsured who will be Medicaid ineligible afterward versus the privately insured. From 2005 to 2010, as a percentage of total ED charges, outpatient ED encounters for Medicaid beneficiaries reimbursed 17% more than for uninsured individuals who will become Medicaid eligible after Patient Protection and Affordable Care Act implementation: 40.0% versus 34.0%, mean absolute difference=5.9%, 95% confidence interval 5.7% to 6.2%. During the same period, the privately insured reimbursed 39% more than for uninsured individuals who will not be Medicaid eligible after Patient Protection and Affordable Care Act implementation: 54.0% versus 38.8%, mean absolute difference=15.2%, 95% confidence interval 12.8% to 17.6%. Assuming historical reimbursement patterns remain after Patient Protection and Affordable Care Act implementation, outpatient ED encounters could reimburse considerably more for both the previously uninsured patients who will obtain Medicaid insurance and for those who move into private insurance products through health insurance exchanges. Although our study does provide insight into the future, multiple factors will ultimately influence reimbursements after implementation of the act. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Characterization of Thermally Activated Metalloenediyne Cytotoxicity in Human Melanoma Cells.

PubMed

Keller, Eric J; Porter, Meghan; Garrett, Joy E; Varie, Meredith; Wang, Haiyan; Pollok, Karen E; Turchi, John J; Zaleski, Jeffrey M; Dynlacht, Joseph R

2018-05-15

Enediynes are a highly cytotoxic class of compounds. However, metallation of these compounds may modulate their activation, and thus their cytotoxicity. We previously demonstrated that cytotoxicity of two different metalloenediynes, including (Z)-N,N'-bis[1-pyridyl-2-yl-meth-(E)-ylidene]octa-4-ene-2,6-diyne-1,8-diamine] (PyED), is potentiated when the compounds are administered to HeLa cells during hyperthermia treatment at concentrations that are minimally or not cytotoxic at 37°C. In this study, we further characterized the concentration, time and temperature dependence of cytotoxicity of PyED on human U-1 melanoma cells. We also investigated the potential mechanisms by which PyED cytotoxicity is enhanced during hyperthermia treatment. Cell killing with PyED was dependent on concentration, temperature during treatment and time of exposure. Potentiation of cytotoxicity was observed when cells were treated with PyED at temperatures ≥39.5°C, and enhancement of cell killing increased with temperature and with increasing time at a given temperature. All cells treated with PyED were shown to have DNA damage, but substantially more damage was observed in cells treated with PyED during heating. DNA repair was also inhibited in cells treated with the drug during hyperthermia. Thus, potentiation of PyED cytotoxicity by hyperthermia may be due to enhancement of drug-induced DNA lesions, and/or the inhibition of repair of sublethal DNA damage. While the selective thermal activation of PyED supports the potential clinical utility of metalloenediynes as cancer thermochemotherapeutic agents, therapeutic gain could be optimized by identifying compounds that produce minimal toxicity at 37°C but which become activated and show enhancement of cytotoxicity within a tumor subjected to localized hyperthermic or thermal ablative treatment, or which might act as bifunctional agents. We thus also describe the development and initial characterization of a novel cofactor complex of PyED, platinated PyED (Pt-PyED). Pt-PyED binds to DNA-like cisplatin, and much like PyED, cytotoxicity is greatly enhanced after treatment with the drug at elevated temperatures. However, in contrast to PyED, Pt-PyED is only minimally cytotoxic at 37°C, at concentrations at which cytotoxicity is enhanced by hyperthermia. Further development of cisplatin-based enediynes may result in compounds which, when activated, will possess multiple DNA binding modalities similar to cisplatin, but produce less side effects in tissues at normothermic temperatures.

The multiplicative effect of combining alcohol with energy drinks on adolescent gambling.

PubMed

Vieno, Alessio; Canale, Natale; Potente, Roberta; Scalese, Marco; Griffiths, Mark D; Molinaro, Sabrina

2018-07-01

There has been increased concern about the negative effects of adolescents consuming a combination of alcohol mixed with energy drinks (AmED). To date, few studies have focused on AmED use and gambling. The present study analyzed the multiplicative effect of AmED consumption, compared to alcohol alone, on the likelihood of at-risk or problem gambling during adolescence. Data from the ESPAD®Italia 2015 study, a cross-sectional survey conducted in a nationally representative sample of students (ages 15 to 19years) were used to examine the association between self-reported AmED use (≥6 times,≥10 times, and ≥20 times during the last month) and self-reported gambling severity. Multivariate models were used to calculate adjusted prevalence ratios to evaluate the association between alcohol use, AmED use, and gambling among a representative sample of adolescents who reported gambling in the last year and completed a gambling severity scale (n=4495). Among the 19% students classed as at-risk and problem gamblers, 43.9% were classed as AmED consumers, while 23.6% were classed as alcohol consumers (i.e. did not mix alcohol with energy drinks). In multivariate analyses that controlled for covariates, AmED consumers were three times more likely to be at-risk and problem gamblers (OR=3.05) compared to non-consuming adolescents, while the effect became less pronounced with considering those who consumed alcohol without the addition of energy drinks (OR=1.37). The present study clearly established that consuming AmED might pose a significantly greater risk of experiencing gambling-related problems among adolescents. Copyright © 2018 Elsevier Ltd. All rights reserved.

[Case-Mix of hospital emergencies in the Andalusian Health Service based on the 2012 Minimum Data Set. Spain].

PubMed

Goicoechea Salazar, Juan Antonio; Nieto García, María Adoración; Laguna Téllez, Antonio; Larrocha Mata, Daniel; Canto Casasola, Vicente David; Murillo Cabezas, Francisco

2013-01-01

The implementation of digital health records in emergency departments (ED) in hospitals in the Andalusian Health Service and the development of an automatic encoder for this area have allowed us to establish a Minimum Data Set for Emergencies (MDS-ED). The aim of this article is to describe the case mix of hospital EDs using various dimensions contained in the MDS-ED. 3.235.600 hospital emergency records in 2012 were classified in clinical categories from the ICD-9-CM codes generated by the automatic encoder. Operating rules to obtain response time and length of stay were defined. A descriptive analysis was carried out to obtain demographic and chronological indicators as well as hospitalization, return and death rates and response time and length of stay in the Eds. Women generated 54,26% of all occurrences and their average age (39,98 years) was higher than men's (37,61). Paediatric emergencies accounted for 21,49% of the total. The peak hours were from 10:00 to 13:00 and from 16:00 to 17:00. Patients who did not undergo observation (92,67%) remained in the ED an average of 153 minutes. Injuries and poisoning, respiratory diseases, musculoskeletal diseases and symptoms and signs generated over 50% of all visits. 79.191 cases of chest pain, 28.741 episodes of heart failure and 27.989 episodes of serious infections were identified among the most relevant disorders. The MDS-ED makes it possible to address systematically the analysis of hospital emergencies by identifying the activity developed, the case-mix attended, the response times, the time spent in ED and the quality of the care.

Efficient Round-Trip Time Optimization for Replica-Exchange Enveloping Distribution Sampling (RE-EDS).

PubMed

Sidler, Dominik; Cristòfol-Clough, Michael; Riniker, Sereina

2017-06-13

Replica-exchange enveloping distribution sampling (RE-EDS) allows the efficient estimation of free-energy differences between multiple end-states from a single molecular dynamics (MD) simulation. In EDS, a reference state is sampled, which can be tuned by two types of parameters, i.e., smoothness parameters(s) and energy offsets, such that all end-states are sufficiently sampled. However, the choice of these parameters is not trivial. Replica exchange (RE) or parallel tempering is a widely applied technique to enhance sampling. By combining EDS with the RE technique, the parameter choice problem could be simplified and the challenge shifted toward an optimal distribution of the replicas in the smoothness-parameter space. The choice of a certain replica distribution can alter the sampling efficiency significantly. In this work, global round-trip time optimization (GRTO) algorithms are tested for the use in RE-EDS simulations. In addition, a local round-trip time optimization (LRTO) algorithm is proposed for systems with slowly adapting environments, where a reliable estimate for the round-trip time is challenging to obtain. The optimization algorithms were applied to RE-EDS simulations of a system of nine small-molecule inhibitors of phenylethanolamine N-methyltransferase (PNMT). The energy offsets were determined using our recently proposed parallel energy-offset (PEOE) estimation scheme. While the multistate GRTO algorithm yielded the best replica distribution for the ligands in water, the multistate LRTO algorithm was found to be the method of choice for the ligands in complex with PNMT. With this, the 36 alchemical free-energy differences between the nine ligands were calculated successfully from a single RE-EDS simulation 10 ns in length. Thus, RE-EDS presents an efficient method for the estimation of relative binding free energies.

Supporting Patient Care in the Emergency Department with a Computerized Whiteboard System

PubMed Central

Aronsky, Dominik; Jones, Ian; Lanaghan, Kevin; Slovis, Corey M.

2008-01-01

Efficient information management and communication within the emergency department (ED) is essential to providing timely and high-quality patient care. The ED whiteboard (census board) usually serves as an ED’s central access point for operational and patient-related information. This article describes the design, functionality, and experiences with a computerized ED whiteboard, which has the ability to display relevant operational and patient-related information in real time. Embedded functionality, additional whiteboard views, and the integration with ED and institutional information system components, such as the computerized patient record or the provider order entry system, provide rapid access to more detailed information. As an information center, the computerized whiteboard supports our ED environment not only for providing patient care, but also for operational, educational, and research activities. PMID:18096913

Evaluation of a Damage Accumulation Monitoring System as an Individual Aircraft Tracking Concept

DTIC Science & Technology

1982-05-01

Mechanics, ASTM STP 677, C. W. Smith, Ed., American Society for Testing and Materials, 1979, pp. 320-338. Kaplan, M. P., Reiman , J. A., and Landy, M. A... Reiman , J. A., "Use of Fracture Mechanics in Estimating Structural Life and Inspection Intervals," Journal of Aircraft, Vol. 13, No. 2, February 1976

The impact of primary care on emergency department presentation and hospital admission with pneumonia: a case–control study of preschool-aged children

PubMed Central

Emery, Diane P; Milne, Tania; Gilchrist, Catherine A; Gibbons, Megan J; Robinson, Elizabeth; Coster, Gregor D; Forrest, Christopher B; Harnden, Anthony; Mant, David; Grant, Cameron C

2015-01-01

Background: In children, community-acquired pneumonia is a frequent cause of emergency department (ED) presentation and hospital admission. Quality primary care may prevent some of these hospital visits. Aims: The aim of this study was to identify primary care factors associated with ED presentation and hospital admission of preschool-aged children with community-acquired pneumonia. Methods: A case–control study was conducted by enrolling three groups: children presenting to the ED with pneumonia and admitted (n=326), or discharged home (n=179), and well-neighbourhood controls (n=351). Interviews with parents and primary care staff were conducted and health record review was performed. The association of primary care factors with ED presentation and hospital admission, controlling for available confounding factors, was determined using logistic regression. Results: Children were more likely to present to the ED with pneumonia if they did not have a usual general practitioner (GP) (odds ratio (OR)=2.50, 95% confidence interval (CI)=1.67–3.70), their GP worked ⩽20 h/week (OR=1.86, 95% CI=1.10–3.13) or their GP practice lacked an immunisation recall system (OR=5.44, 95% CI=2.26–13.09). Lower parent ratings for continuity (OR=1.63, 95% CI=1.01–2.62), communication (OR=2.01, 95% CI=1.29–3.14) and overall satisfaction (OR=2.16, 95% CI=1.34–3.47) increased the likelihood of ED presentation. Children were more likely to be admitted when antibiotics were prescribed in primary care (OR=2.50, 95% CI=1.43–4.55). Hospital admission was less likely if children did not have a usual GP (OR=0.22, 95% CI=0.11–0.40) or self-referred to the ED (OR=0.48, 95% CI=0.26–0.89). Conclusions: Accessible and continuous primary care is associated with a decreased likelihood of preschool-aged children with pneumonia presenting to the ED and an increased likelihood of hospital admission, implying more appropriate referral. Lower parental satisfaction is associated with an increased likelihood of ED presentation. PMID:25654661

The Economics of an Admissions Holding Unit.

PubMed

Schreyer, Kraftin E; Martin, Richard

2017-06-01

With increasing attention to the actual cost of delivering care, return-on-investment calculations take on new significance. Boarded patients in the emergency department (ED) are harmful to clinical care and have significant financial opportunity costs. We hypothesize that investment in an admissions holding unit for admitted ED patients not only captures opportunity cost but also significantly lowers direct cost of care. This was a three-phase study at a busy urban teaching center with significant walkout rate. We first determined the true cost of maintaining a staffed ED bed for one patient-hour and compared it to alternative settings. The opportunity cost for patients leaving without being seen was then conservatively estimated. Lastly, a convenience sample of admitted patients boarding in the ED was observed continuously from one hour after decision-to-admit until physical departure from the ED to capture a record of every interaction with a nurse or physician. Personnel costs per patient bed-hour were $58.20 for the ED, $24.80 for an inpatient floor, $19.20 for the inpatient observation unit, and $10.40 for an admissions holding area. An eight-bed holding unit operating at practical capacity would free 57.4 hours of bed space in the ED and allow treatment of 20 additional patients. This could yield increased revenues of $27,796 per day and capture opportunity cost of $6.09 million over 219 days, in return for extra staffing costs of $218,650. Analysis of resources used for boarded patients was determined by continuous observation of a convenience sample of ED-boarded patients, which found near-zero interactions with both nursing and physicians during the boarding interval. Resource expense per ED bed-hour is more than twice that in non-critical care inpatient units. Despite the high cost of available resources, boarded non-critical patients receive virtually no nursing or physician attention. An admissions holding unit is remarkably effective in avoiding the mismatch of the low-needs patients in high-cost care venues. Return on investment is enormous, but this assumes existing clinical space for this unit.

A retrospective analysis of biochemical and haematological parameters in patients with eating disorders.

PubMed

Barron, Leanne J; Barron, Robert F; Johnson, Jeremy C S; Wagner, Ingrid; Ward, Cameron J B; Ward, Shannon R B; Barron, Faye M; Ward, Warren K

2017-01-01

The objective of the study was to determine whether levels of biochemical and haematological parameters in patients with eating disorders (EDs) varied from the general population. Whilst dietary restrictions can lead to nutritional deficiencies, specific abnormalities may be relevant to the diagnosis, pathogenesis and treatment of EDs. With ethics approval and informed consent, a retrospective chart audit was conducted of 113 patients with EDs at a general practice in Brisbane, Australia. This was analysed first as a total group (TG) and then in 4 ED subgroups: Anorexia nervosa (AN), Bulimia nervosa (BN), ED Not Otherwise Specified (EDNOS), and AN/BN. Eighteen parameters were assessed at or near first presentation: cholesterol, folate, vitamin B12, magnesium, manganese, zinc, calcium, potassium, urate, sodium, albumin, phosphate, ferritin, vitamin D, white cell count, neutrophils, red cell count and platelets. Results were analysed using IBM SPSS 21 and Microsoft Excel 2013 by two-tailed, one-sample t-tests (TG and 4 subgroups) and chi-square tests (TG only) and compared to the population mean standards. Results for the TG and each subgroup individually were then compared with the known reference interval (RI). For the total sample, t-tests showed significant differences for all parameters ( p  < 0.05) except cholesterol. Most parameters gave results below population levels, but folate, phosphate, albumin, calcium and vitamin B12 were above. More patients than expected were below the RI for most parameters in the TG and subgroups. At diagnosis, in patients with EDs, there are often significant differences in multiple haematological and biochemical parameters. Early identification of these abnormalities may provide additional avenues of ED treatment through supplementation and dietary guidance, and may be used to reinforce negative impacts on health caused by the ED to the patient, their family and their treatment team (general practitioner, dietitian and mental health professionals). Study data would support routine measurement of a full blood count and electrolytes, phosphate, magnesium, liver function tests, ferritin, vitamin B12, red cell folate, vitamin D, manganese and zinc for all patients at first presentation with an ED.

Geriatric emergency department innovations: preliminary data for the geriatric nurse liaison model.

PubMed

Aldeen, Amer Z; Courtney, D Mark; Lindquist, Lee A; Dresden, Scott M; Gravenor, Stephanie J

2014-09-01

Older adults account for a large and growing segment of the emergency department (ED) population. They are often admitted to the hospital for nonurgent conditions such as dementia, impaired functional status, and gait instability. The aims of this geriatric ED innovations (GEDI) project were to develop GEDI nurse liaisons by training ED nurses in geriatric assessment and care coordination skills, describe characteristics of patients that these GEDI nurse liaisons see, and measure the admission rate of these patients. Four ED nurses participated in the GEDI training program, which consisted of 82 hours of clinical rotations in geriatrics and palliative medicine, 82 hours of didactics, and a pilot phase for refinement of the GEDI consultation process. Individuals were eligible for GEDI consultation if they had an Identification of Seniors At Risk (ISAR) score greater than 2 or at ED clinician request. GEDI consultation was available Monday through Friday from 9:00 a.m. to 8:00 p.m. An extensive database was set up to collect clinical outcomes data for all older adults in the ED before and after GEDI implementation. The liaisons underwent training from January through March 2013. From April through August 2013, 408 GEDI consultations were performed in 7,213 total older adults in the ED (5.7%, 95% confidence interval (CI) = 5.2-6.2%), 2,124 of whom were eligible for GEDI consultation (19.2%, 95% CI = 17.6-20.9%); 34.6% (95% CI = 30.1-39.3%) received social work consultation, 43.9% (95% CI = 39.1-48.7) received pharmacy consultation, and more than 90% received telephone follow-up. The admission rate for GEDI patients was 44.9% (95% CI = 40.1-49.7), compared with 60.0% (95% CI = 58.8-61.2) non-GEDI. ED nurses undergoing a 3-month training program can develop geriatric-specific assessment skills. Implementation of these skills in the ED may be associated with fewer admissions of older adults. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Potentially Missed Diagnosis of Ischemic Stroke in the Emergency Department in the Greater Cincinnati/Northern Kentucky Stroke Study.

PubMed

Madsen, Tracy E; Khoury, Jane; Cadena, Rhonda; Adeoye, Opeolu; Alwell, Kathleen A; Moomaw, Charles J; McDonough, Erin; Flaherty, Matthew L; Ferioli, Simona; Woo, Daniel; Khatri, Pooja; Broderick, Joseph P; Kissela, Brett M; Kleindorfer, Dawn

2016-10-01

Missed diagnoses of acute ischemic stroke (AIS) in the ED may result in lost opportunities to treat AIS. Our objectives were to describe the rate and clinical characteristics of missed AIS in the ED, to determine clinical predictors of missed AIS, and to report tissue plasminogen (tPA) eligibility among those with missed strokes. Among a population of 1.3 million in a five-county region of southwest Ohio and northern Kentucky, cases of AIS that presented to 16 EDs during 2010 were identified using ICD-9 codes followed by physician verification of cases. Missed ED diagnoses were physician-verified strokes that did not receive a diagnosis indicative of stroke in the ED. Bivariate analyses were used to compare clinical characteristics between patients with and without an ED diagnosis of AIS. Logistic regression was used to evaluate predictors of missed AIS diagnoses. Alternative diagnoses given to those with missed AIS were codified. Eligibility for tPA was reported between those with and without a missed stroke diagnosis. Of 2,027 AIS cases, 14.0% (n = 283) were missed in the ED. Race, sex, and stroke subtypes were similar between those with missed AIS diagnoses and those identified in the ED. Hospital length of stay was longer in those with a missed diagnosis (5 days vs. 3 days, p < 0.0001). Younger age (adjusted odds ratio [aOR] = 0.94, 95% confidence interval [CI] = 0.89 to 0.98) and decreased level of consciousness (LOC) (aOR = 3.58, 95% CI = 2.63 to 4.87) were associated with higher odds of missed AIS. Altered mental status was the most common diagnosis among those with missed AIS. Only 1.1% of those with a missed stroke diagnosis were eligible for tPA. In a large population-based sample of AIS cases, one in seven cases were not diagnosed as AIS in the ED, but the impact on acute treatment rates is likely small. Missed diagnosis was more common among those with decreased LOC, suggesting the need for improved diagnostic approaches in these patients. © 2016 by the Society for Academic Emergency Medicine.

An investigation of negative affect, reactivity, and distress tolerance as predictors of disordered eating attitudes across adolescence.

PubMed

Juarascio, Adrienne S; Felton, Julia W; Borges, Allison M; Manasse, Stephanie M; Murray, Helen B; Lejuez, Carl W

2016-06-01

The current study examined internalizing symptoms, affect reactivity, and distress intolerance as prospective predictors of increases in eating disorder (ED)-attitudes during adolescence. Adolescents (n = 206) took part in a six-year longitudinal study examining the development of psychopathology. Latent growth curve analysis was used to examine associations between predictors and later ED-attitudes. Distress intolerance and internalizing symptoms were associated with ED-attitudes at baseline, but did not predict increases over time. Affect reactivity, however, was significantly associated with increases in ED-attitudes over time. Baseline affect reactivity did not interact with baseline distress intolerance to predict increases in ED-attitudes; however higher baseline internalizing symptoms interacted with distress intolerance to predict increases in ED-attitudes across adolescence. These results are among the first to document that affect reactivity alone and the combined effect of high internalizing symptoms and high distress intolerance early in adolescence are risk factors for the later development of ED-attitudes. Copyright © 2016 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED.

PubMed

Zanobetti, Maurizio; Scorpiniti, Margherita; Gigli, Chiara; Nazerian, Peiman; Vanni, Simone; Innocenti, Francesca; Stefanone, Valerio T; Savinelli, Caterina; Coppa, Alessandro; Bigiarini, Sofia; Caldi, Francesca; Tassinari, Irene; Conti, Alberto; Grifoni, Stefano; Pini, Riccardo

2017-06-01

Acute dyspnea is a common symptom in the ED. The standard approach to dyspnea often relies on radiologic and laboratory results, causing excessive delay before adequate therapy is started. Use of an integrated point-of-care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis, while maintaining an acceptable safety profile. Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient; a sonographer performed an ultrasound evaluation of the lung, heart, and inferior vena cava, while the treating physician requested traditional tests as needed. Time needed to formulate the ultrasound and the ED diagnoses was recorded and compared. Accuracy and concordance of the ultrasound and the ED diagnoses were calculated. A total of 2,683 patients were enrolled. The average time needed to formulate the ultrasound diagnosis was significantly lower than that required for ED diagnosis (24 ± 10 min vs 186 ± 72 min; P = .025). The ultrasound and the ED diagnoses showed good overall concordance (κ = 0.71). There were no statistically significant differences in the accuracy of PoCUS and the standard ED evaluation for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax, and dyspnea from other causes. PoCUS was significantly more sensitive for the diagnosis of heart failure, whereas a standard ED evaluation performed better in the diagnosis of COPD/asthma and pulmonary embolism. PoCUS represents a feasible and reliable diagnostic approach to the patient with dyspnea, allowing a reduction in time to diagnosis. This protocol could help to stratify patients who should undergo a more detailed evaluation. Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Is there a relationship between wound infections and laceration closure times?

PubMed Central

2012-01-01

Background Lacerations account for a large number of ED visits. Is there a “golden period” beyond which lacerations should not be repaired primarily? What type of relationship exists between time of repair and wound infection rates? Is it linear or exponential? Currently, the influence of laceration age on the risk of infection in simple lacerations repaired is not clearly defined. We conducted this study to determine the influence of time of primary wound closure on the infection rate. Methods This is a prospective observational study of patients who presented to the Emergency Department (ED) with a laceration requiring closure from April 2009 to November 2010. The wound closure time was defined as the time interval from when the patient reported laceration occurred until the time of the start of the wound repair procedure. Univariate analysis was performed to determine the factors predictive of infection. A non-parametric Wilcoxon rank-sum test was performed to compare the median differences of time of laceration repair. Chi-square (Fisher's exact) tests were performed to test for infection differences with regard to gender, race, location of laceration, mechanism of injury, co-morbidities, type of anesthesia and type of suture material used. Results Over the study period, 297 participants met the inclusion criteria and were followed. Of the included participants, 224 (75.4%) were male and 73 (24.6%) were female. Ten patients (3.4%) developed a wound infection. Of these infections, five occurred on hands, four on extremities (not hands) and one on the face. One of these patients was African American, seven were Hispanic and two were Caucasian (p = 0.0005). Median wound closure time in the infection group was 867 min and in the non-infection group 330 min (p = 0.03). Conclusions Without controlling various confounding factors, the median wound closure time for the lacerations in the wound infection group was statistically significantly longer than in the non-infection group. PMID:22835090

Characteristics of seeking treatment among U.S. adolescents with eating disorders.

PubMed

Forrest, Lauren N; Smith, April R; Swanson, Sonja A

2017-07-01

The majority of persons with eating disorders (EDs) do not seek ED treatment, yet little is known about treatment-seeking barriers or facilitators. The aim of the study is to describe the characteristics associated with seeking ED treatment among U.S. adolescents with EDs. Data from a nationally representative cross-sectional study of U.S. adolescents ages 13-18 years were used for these analyses. Specifically, adolescents who met criteria for lifetime EDs (N = 281) were included. Sociodemographic information, characteristics of EDs, psychiatric comorbidities, and other mental health service use were assessed via interview. Only 20% of adolescents sought ED treatment. Females were 2.2 (95% CI 0.8, 6.4) times more likely to seek treatment than males (19.9% vs. 8.9%). Adolescents who met criteria for anorexia nervosa or bulimia nervosa were 2.4 (95% CI 0.9, 6.3) and 1.9 (95% CI 1.0, 3.8) times more likely to seek treatment than adolescents who met criteria for binge-eating disorder (27.5% and 22.3% vs. 11.6%). Specific ED behaviors (restriction and purging), ED-related impairment, and any mental health service use were also associated with adolescent treatment seeking. Adolescent treatment seeking was infrequent overall, with individuals with counter-stereotypic ED presentations least likely to have sought treatment. Adolescent treatment seeking could be promoted through increasing awareness among the public and healthcare professionals that EDs affect a heterogeneous group of people. More generally, research involving both treatment-seeking and non-treatment-seeking individuals holds great potential to refine the field's knowledge of ED etiology, prevalence, treatment, and prevention. © 2017 Wiley Periodicals, Inc.

Comparison of secure messaging application (WhatsApp) and standard telephone usage for consultations on Length of Stay in the ED. A prospective randomized controlled study.

PubMed

Gulacti, Umut; Lok, Ugur

2017-07-19

Consultation, the process of an Emergency Physician seeking an opinion from other specialties, occurs frequently in the Emergency Department (ED). The aim of this study was to determine the effect of secure messaging application (WhatsApp) usage for medical consultations on Emergency Department Length of Stay (ED LOS) and consult time. We conducted a prospective, randomized controlled trial in the ED using allocation concealment over three months. Consultations requested in the ED were allocated into two groups: consultations requested via the secure messaging application and consultations requested by telephone as verbal. A total of 439 consultations requested in the ED were assessed for eligibility and 345 were included in the final analysis: 173 consultations were conducted using secure messaging application and 172 consultations were conducted using standard telephone communications. The median ED LOS was 240 minutes (IQR:230-270, 95% CI:240 to 255.2) for patients in the secure messaging application group and 277 minutes (IQR:270-287.8, 95% CI:277 to 279) for patients in the telephone group. The median total ED LOS was significantly lower among consults conducted using Secure messaging application relative to consults conducted by telephone (median dif: -30, 95%CI:-37to-25, p<0.0001). The median consult time was 158 minutes (IQR:133 to 177.25, 95% CI:150 to 169) for patients in the Secure messaging application group and 170 minutes (IQR:165 to 188.5, 95% CI:170-171) for patients in the Telephone group (median dif: -12, 95%CI:-19 to-7,p<0.0001). Consultations completed without ED arrival was 61.8% in the secure messaging group and 33.1% in the Telephone group (dif: 28.7, 95% CI:48.3 to 66, p<0.001). Use of secure messaging application for consultations in the ED reduces the total ED LOS and consultation time. Consultation with secure messaging application eliminated more than half of in-person ED consultation visits.

A multivariate time series approach to modeling and forecasting demand in the emergency department.

PubMed

Jones, Spencer S; Evans, R Scott; Allen, Todd L; Thomas, Alun; Haug, Peter J; Welch, Shari J; Snow, Gregory L

2009-02-01

The goals of this investigation were to study the temporal relationships between the demands for key resources in the emergency department (ED) and the inpatient hospital, and to develop multivariate forecasting models. Hourly data were collected from three diverse hospitals for the year 2006. Descriptive analysis and model fitting were carried out using graphical and multivariate time series methods. Multivariate models were compared to a univariate benchmark model in terms of their ability to provide out-of-sample forecasts of ED census and the demands for diagnostic resources. Descriptive analyses revealed little temporal interaction between the demand for inpatient resources and the demand for ED resources at the facilities considered. Multivariate models provided more accurate forecasts of ED census and of the demands for diagnostic resources. Our results suggest that multivariate time series models can be used to reliably forecast ED patient census; however, forecasts of the demands for diagnostic resources were not sufficiently reliable to be useful in the clinical setting.

The Trail-making Test B and driver screening in the emergency department.

PubMed

Betz, Marian E; Fisher, Jonathan

2009-10-01

Emergency departments (EDs) rarely screen for older driving safety. The Trail-Making Test B (TMT-B) is a neuropsychological test that may predict ability to drive. We sought to examine the driving patterns of older ED patients and the feasibility of screening patients in the ED using the TMT-B. At a single ED at a tertiary care center, we administered the TMT-B and a survey of health status and driving habits to a convenience sample of adult (age 18 and older) ED patients. We excluded those with altered mentation, critical illness, or language barriers. The TMT-B, scored by the time of first attempt, requires connection of letters and numbers in sequence on paper, and a time > or = 180 s may suggest elevated driving risk. We compared time to complete the TMT-B among ED patients to published norms. Of 144 patients ages 18 to 95, 95 (72.2%) were current drivers, and 91.4 percent of drivers were able to complete the TMT-B; 47.1 percent of drivers were older (65+), and 88.8 percent of older drivers rated their ability as good or excellent. In multivariate logistic regression, neither TMT-B performance nor being older predicted a recent collision. The mean TMT-B completion time was 66.1 (SD = 36.3, median = 56) s among drivers under age 65 and 117.5 (SD = 79.2, median = 95) s among those 65 or older. Approximately 1.9 percent (95% CI: 0.04-10.2) of drivers under 65 and 14.0 percent (95% CI: 5.3-27.9%) of drivers 65 or older required 180 s or more for the TMT-B. Using unpaired T-tests, study TMT-B times were not significantly different from previously published norms except among 25- to 34-year-olds (79.2 versus 50.7 s; p < 0.05) and 80- to 84-year-olds (223.9 versus 146.8 s; p < 0.01). Many older ED patients drive, and relatively healthy ED patients are able to complete the TMT-B with results similar to standard nomograms. The TMT-B may prove useful as part of targeted driver screening programs in EDs.

Comparison of drug administration logistics between prothrombin complex concentrates and plasma in the emergency department.

PubMed

Alarfaj, Sumaiah J; Jarrell, Daniel H; Patanwala, Asad E

2018-03-24

Prothrombin complex concentrate (PCC) is used as an alternative to fresh frozen plasma (FFP) for emergency bleeding. The primary objective of this study was to compare the time from order to start of administration between 3-factor PCC (PCC3), 4-factor (PCC4), and FFP in the emergency department (ED). The secondary objective was to evaluate the effect of an ED pharmacist on time to administration of PCCs. This was a single center three-arm retrospective cohort study. Adult patients in the ED with bleeding were included. The primary outcome measure was the time from order to administration, which was compared between PCC3, PCC4, and FFP. The time from order to administration was also compared when the ED pharmacist was involved versus not involved in the care of patients receiving PCC. There were 90 patients included in the study cohort (30 in each group). The median age was 69years (IQR 57-82years), and 57% (n=52) were male. The median time from order to administration was 36min (IQR 20-58min) for PCC3, 34min (IQR 18-48min) for PCC4, and 92min (IQR 63-133) for FFP (PCC3 versus PCC4, p=0.429; PCC3 versus FFP, p<0.001; PCC4 versus FFP, p<0.001). The median time from order to administration was significantly decreased when the ED pharmacist was involved (24min [IQR 15-35min] versus 42min [IQR 32-59min], p<0.001). Time from order to administration is faster with PCC than FFP. ED pharmacist involvement decreases the time from order to administration of PCC. Copyright © 2018. Published by Elsevier Inc.

Neurobehavioural and cognitive development in infants born to mothers with eating disorders.

PubMed

Barona, Manuela; Taborelli, Emma; Corfield, Freya; Pawlby, Susan; Easter, Abigail; Schmidt, Ulrike; Treasure, Janet; Micali, Nadia

2017-08-01

Although recent research has focused on the effects of maternal eating disorders (EDs) on children, little is known about the effect of maternal EDs on neurobiological outcomes in newborns and infants. This study is the first to investigate neurobehavioural regulation and cognitive development in newborns and infants of mothers with EDs. Women with an active and past ED and healthy controls were recruited to a prospective longitudinal study during their first trimester or second trimester of pregnancy. Newborns and infants of mothers with ED were compared with newborns and infants of healthy controls on (a) neurobehavioural dysregulation using the Brazelton Neonatal Behavioural Assessment Scale at 8 days postpartum (active ED, n = 15; past ED, n = 20; healthy controls, n = 28); and (b) cognitive development using the Bayley Scales of Infant and Toddler Development at 1-year postpartum (active ED, n = 18; past ED, n = 19; healthy controls, n = 28). In order to maintain the largest possible sample at each time point, sample size varied across time points. Newborns of mothers with an active ED had worse autonomic stability when compared with newborns of healthy controls [B = -0.34 (-1.81, -0.26)]. Infants of mothers with a past ED had poorer language [B = -0.33 (-13.6, -1.9)] and motor development [B = -0.32 (-18.4, -1.3)] compared with healthy controls. Children of mothers with ED display neurobehavioural dysregulation early after birth and poorer language and motor development at 1 year. These characteristics suggest evidence of early neurobiological markers in children at risk. Differential outcomes in children of women with active versus past ED suggest that active symptomatology during pregnancy might have an effect on physiological reactivity while cognitive characteristics might be more stable markers of risk for ED. © 2017 Association for Child and Adolescent Mental Health.

Low-intensity Extracorporeal Shock Wave Treatment Improves Erectile Function: A Systematic Review and Meta-analysis.

PubMed

Lu, Zhihua; Lin, Guiting; Reed-Maldonado, Amanda; Wang, Chunxi; Lee, Yung-Chin; Lue, Tom F

2017-02-01

As a novel therapeutic method for erectile dysfunction (ED), low-intensity extracorporeal shock wave treatment (LI-ESWT) has been applied recently in the clinical setting. We feel that a summary of the current literature and a systematic review to evaluate the therapeutic efficacy of LI-ESWT for ED would be helpful for physicians who are interested in using this modality to treat patients with ED. A systematic review of the evidence regarding LI-ESWT for patients with ED was undertaken with a meta-analysis to identify the efficacy of the treatment modality. A comprehensive search of the PubMed and Embase databases to November 2015 was performed. Studies reporting on patients with ED treated with LI-ESWT were included. The International Index of Erectile Function (IIEF) and the Erection Hardness Score (EHS) were the most commonly used tools to evaluate the therapeutic efficacy of LI-ESWT. There were 14 studies including 833 patients from 2005 to 2015. Seven studies were randomized controlled trials (RCTs); however, in these studies, the setup parameters of LI-ESWT and the protocols of treatment were variable. The meta-analysis revealed that LI-ESWT could significantly improve IIEF (mean difference: 2.00; 95% confidence interval [CI], 0.99-3.00; p<0.0001) and EHS (risk difference: 0.16; 95% CI, 0.04-0.29; p=0.01). Therapeutic efficacy could last at least 3 mo. The patients with mild-moderate ED had better therapeutic efficacy after treatment than patients with more severe ED or comorbidities. Energy flux density, number of shock waves per treatment, and duration of LI-ESWT treatment were closely related to clinical outcome, especially regarding IIEF improvement. The number of studies of LI-ESWT for ED have increased dramatically in recent years. Most of these studies presented encouraging results, regardless of variation in LI-ESWT setup parameters or treatment protocols. These studies suggest that LI-ESWT could significantly improve the IIEF and EHS of ED patients. The publication of robust evidence from additional RCTs and longer-term follow-up would provide more confidence regarding use of LI-ESWT for ED patients. We reviewed 14 studies of men who received low-intensity extracorporeal shock wave treatment (LI-ESWT) for erectile dysfunction (ED). There was evidence that these men experienced improvements in their ED following LI-ESWT. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Time to cranial computerised tomography for acute traumatic brain injury in paediatric patients: Effect of the shorter stays in emergency departments target in New Zealand.

PubMed

Jones, Peter G; Kool, Bridget; Dalziel, Stuart; Shepherd, Michael; Le Fevre, James; Harper, Alana; Wells, Susan; Stewart, Joanna; Curtis, Elana; Reid, Papaarangi; Ameratunga, Shanthi

2017-07-01

Timely access to computerised tomography (CT) for acute traumatic brain injuries (TBIs) facilitates rapid diagnosis and surgical intervention. In 2009, New Zealand introduced a mandatory target for emergency department (ED) stay such that 95% of patients should leave ED within 6 h of arrival. This study investigated whether this target influenced the timeliness of cranial CT scanning in children who presented to ED with acute TBI. We retrospectively reviewed a random sample of charts of children <15 years with acute TBI from 2006 to 2012. Cases were identified using International Classification of Disease 10 codes consistent with TBI. General linear models investigated changes in time to CT and other indicators before and after the shorter stays in ED target was introduced in 2009. Among the 190 cases eligible for study (n = 91 pre-target and n = 99 post-target), no significant difference was found in time to CT scan pre- and post-target: least squares mean (LSM) with 95% confidence interval = 68 (56-81) versus 65 (53-78) min, respectively, P = 0.66. Time to neurosurgery (LSM 8.7 (5-15) vs. 5.1 (2.6-9.9) h, P = 0.19, or hospital length of stay (LSM: 4.9 (3.9-6.3) vs. 5.2 (4.1-6.7) days, P = 0.69) did not change significantly. However, ED length of stay decreased by 45 min in the post-target period (LSM = 211 (187-238) vs. 166 (98-160) min, P = 0.006). Implementation of the shorter stays in ED target was not associated with a change in the time to CT for children presenting with acute TBI, but an overall reduction in the time spent in ED was apparent. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block.

PubMed

Khanna, Sankalp; Boyle, Justin; Good, Norm; Lind, James

2012-10-01

To investigate the effect of hospital occupancy levels on inpatient and ED patient flow parameters, and to simulate the impact of shifting discharge timing on occupancy levels. Retrospective analysis of hospital inpatient data and ED data from 23 reporting public hospitals in Queensland, Australia, across 30 months. Relationships between outcome measures were explored through the aggregation of the historic data into 21 912 hourly intervals. Main outcome measures included admission and discharge rates, occupancy levels, length of stay for admitted and emergency patients, and the occurrence of access block. The impact of shifting discharge timing on occupancy levels was quantified using observed and simulated data. The study identified three stages of system performance decline, or choke points, as hospital occupancy increased. These choke points were found to be dependent on hospital size, and reflect a system change from 'business-as-usual' to 'crisis'. Effecting early discharge of patients was also found to significantly (P < 0.001) impact overcrowding levels and improve patient flow. Modern hospital systems have the ability to operate efficiently above an often-prescribed 85% occupancy level, with optimal levels varying across hospitals of different size. Operating over these optimal levels leads to performance deterioration defined around occupancy choke points. Understanding these choke points and designing strategies around alleviating these flow bottlenecks would improve capacity management, reduce access block and improve patient outcomes. Effecting early discharge also helps alleviate overcrowding and related stress on the system. © 2012 CSIRO. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Impact of a Community Dental Access Program on Emergency Dental Admissions in Rural Maryland.

PubMed

Rowland, Sandi; Leider, Jonathon P; Davidson, Clare; Brady, Joanne; Knudson, Alana

2016-12-01

To characterize the expansion of a community dental access program (CDP) in rural Maryland providing urgent dental care to low-income individuals, as well as the CDP's impact on dental-related visits to a regional emergency department (ED). We used de-identified CDP and ED claims data to construct a data set of weekly counts of CDP visits and dental-related ED visits among Maryland adults. A time series model examined the association over time between visits to the CDP and ED visits for fiscal years (FYs) 2011 through 2015. The CDP served approximately 1600 unique clients across 2700 visits during FYs 2011 through 2015. The model suggested that if the CDP had not provided services during that time period, about 670 more dental-related visits to the ED would have occurred, resulting in $215 000 more in charges. Effective ED dental diversion programs can result in substantial cost savings to taxpayers, and more appropriate and cost-effective care for the patient. Community dental access programs may be a viable way to patch the dental safety net in rural communities while holistic solutions are developed.

Impact of a Community Dental Access Program on Emergency Dental Admissions in Rural Maryland

PubMed Central

Rowland, Sandi; Davidson, Clare; Brady, Joanne; Knudson, Alana

2016-01-01

Objectives. To characterize the expansion of a community dental access program (CDP) in rural Maryland providing urgent dental care to low-income individuals, as well as the CDP’s impact on dental-related visits to a regional emergency department (ED). Methods. We used de-identified CDP and ED claims data to construct a data set of weekly counts of CDP visits and dental-related ED visits among Maryland adults. A time series model examined the association over time between visits to the CDP and ED visits for fiscal years (FYs) 2011 through 2015. Results. The CDP served approximately 1600 unique clients across 2700 visits during FYs 2011 through 2015. The model suggested that if the CDP had not provided services during that time period, about 670 more dental-related visits to the ED would have occurred, resulting in $215 000 more in charges. Conclusions. Effective ED dental diversion programs can result in substantial cost savings to taxpayers, and more appropriate and cost-effective care for the patient. Policy Implications. Community dental access programs may be a viable way to patch the dental safety net in rural communities while holistic solutions are developed. PMID:27736218

Extreme events as foundation of Lévy walks with varying velocity

NASA Astrophysics Data System (ADS)

Kutner, Ryszard

2002-11-01

In this work we study the role of extreme events [E.W. Montroll, B.J. West, in: J.L. Lebowitz, E.W. Montrell (Eds.), Fluctuation Phenomena, SSM, vol. VII, North-Holland, Amsterdam, 1979, p. 63; J.-P. Bouchaud, M. Potters, Theory of Financial Risks from Statistical Physics to Risk Management, Cambridge University Press, Cambridge, 2001; D. Sornette, Critical Phenomena in Natural Sciences. Chaos, Fractals, Selforganization and Disorder: Concepts and Tools, Springer, Berlin, 2000] in determining the scaling properties of Lévy walks with varying velocity. This model is an extension of the well-known Lévy walks one [J. Klafter, G. Zumofen, M.F. Shlesinger, in M.F. Shlesinger, G.M. Zaslavsky, U. Frisch (Eds.), Lévy Flights and Related Topics ion Physics, Lecture Notes in Physics, vol. 450, Springer, Berlin, 1995, p. 196; G. Zumofen, J. Klafter, M.F. Shlesinger, in: R. Kutner, A. Pȩkalski, K. Sznajd-Weron (Eds.), Anomalous Diffusion. From Basics to Applications, Lecture Note in Physics, vol. 519, Springer, Berlin, 1999, p. 15] introduced in the context of chaotic dynamics where a fixed value of the walker velocity is assumed for simplicity. Such an extension seems to be necessary when the open and/or complex system is studied. The model of Lévy walks with varying velocity is spanned on two coupled velocity-temporal hierarchies: the first one consisting of velocities and the second of corresponding time intervals which the walker spends between the successive turning points. Both these hierarchical structures are characterized by their own self-similar dimensions. The extreme event, which can appear within a given time interval, is defined as a single random step of the walker having largest length. By finding power-laws which describe the time-dependence of this displacement and its statistics we obtained two independent diffusion exponents, which are related to the above-mentioned dimensions and which characterize the extreme event kinetics. In this work we show the principal influence of extreme events on the basic quantities (one-step distributions and moments as well as two-step correlation functions) of the continuous-time random walk formalism. Besides, we construct both the waiting-time distribution and sojourn probability density directly in a real space and time in the scaling form by proper component analysis which takes into account all possible fluctuations of the walker steps in contrast to the extreme event analysis. In this work we pay our attention to the basic quantities, since the summarized multi-step ones were already discussed earlier [Physica A 264 (1999) 107; Comp. Phys. Commun. 147 (2002) 565]. Moreover, we study not only the scaling phenomena but also, assuming a finite number of hierarchy levels, the breaking of scaling and its dependence on control parameters. This seems to be important for studying empirical systems the more so as there are still no closed formulae describing this phenomenon except the one for truncated Lévy flights [Phys. Rev. Lett. 73 (1994) 2946]. Our formulation of the model made possible to develop an efficient Monte Carlo algorithm [Physica A 264 (1999) 107; Comp. Phys. Commun. 147 (2002) 565] where no MC step is lost.

Longer time to antibiotics and higher mortality among septic patients with non-specific presentations--a cross sectional study of Emergency Department patients indicating that a screening tool may improve identification.

PubMed

Wallgren, Ulrika Margareta; Antonsson, Viktor Erik; Castrén, Maaret Kaarina; Kurland, Lisa

2016-01-06

The presentation of sepsis is varied and our hypotheses were that septic patients with non-specific presentations such as decreased general condition (DGC) have a less favourable outcome, and that a screening tool could increase identification of these patients. We aimed to: 1) assess time to antibiotics and in-hospital mortality among septic patients with ED chief complaint DGC, as compared with septic patients with other ED chief complaints, and 2) determine whether a screening tool could improve identification of septic patients with non-specific presentations such as DGC. Cross sectional study comparing time to antibiotics (Mann Whitney and Kaplan-Meier tests), and in-hospital mortality (logistic regression), between 61 septic patients with ED chief complaint DGC and 516 septic patients with other ED chief complaints. The sensitivity and specificity of the modified Robson screening tool was compared with that of ED doctor clinical judgment (McNemar's two related samples test) among 122 patients presenting to the ED with chief complaint DGC, of which 61 were discharged with ICD code sepsis. Septic patients presenting to the ED with the chief complaint DGC had a longer median time to antibiotics (05:26 h:minutes; IQR 4:00-10:40, vs. 03:56 h:minutes; IQR 2:21-7:32) and an increased in-hospital mortality (crude OR = 4.01; 95% CI, 2.19-7.32), compared to septic patients with other ED chief complaints. This association remained significant when adjusting for sex, age, priority, comorbidity and fulfilment of the Robson score (OR 4.31; 95% CI, 2.12-8.77). The modified Robson screening tool had a higher sensitivity (63.0 vs. 24.6%, p < 0.001), but a lower specificity (68.3 vs. 100.0%, p < 0.001), as compared to clinical judgment. This is, to the best of our knowledge, the first study comparing outcome of septic patients according to ED chief complaint. Septic patients presenting with a non-specific ED presentation, here exemplified as the chief complaint DGC, have a less favourable outcome. Our results indicate that implementation of a screening tool may increase the identification of septic patients. The results indicate that septic patients presenting with ED chief complaint DGC constitute a vulnerable patient group with delayed time to antibiotics and high in-hospital mortality. Furthermore, the results support that implementation of a screening tool may be beneficial to improve identification of these patients.

Beyond the Binary: Differences in Eating Disorder Prevalence by Gender Identity in a Transgender Sample.

PubMed

Diemer, Elizabeth W; White Hughto, Jaclyn M; Gordon, Allegra R; Guss, Carly; Austin, S Bryn; Reisner, Sari L

2018-01-01

Purpose: To investigate whether the prevalence of eating disorders (EDs) differs across diverse gender identity groups in a transgender sample. Methods: Secondary analysis of data from Project VOICE, a cross-sectional study of stress and health among 452 transgender adults (ages 18-75 years) residing in Massachusetts. Age-adjusted logistic regression models were fit to compare the prevalence of self-reported lifetime EDs in female-to-male (FTM), male-to-female (MTF), and gender-nonconforming participants assigned male at birth (MBGNC) to gender-nonconforming participants assigned female at birth (FBGNC; referent). Results: The age-adjusted odds of self-reported ED in MTF participants were 0.14 times the odds of self-reported ED in FBGNC participants ( p =0.022). In FTM participants, the age-adjusted odds of self-reported ED were 0.46 times the odds of self-reported ED in FBGNC participants, a marginally significant finding ( p =0.068). No statistically significant differences in ED prevalence were found for MBGNC individuals. Conclusions: Gender nonconforming individuals assigned a female sex at birth appear to have heightened lifetime risk of EDs relative to MTF participants. Further research into specific biologic and psychosocial ED risk factors and gender-responsive intervention strategies are urgently needed. Training clinical providers and ensuring competency of treatment services beyond the gender binary will be vital to addressing this disparity.

Beyond the Binary: Differences in Eating Disorder Prevalence by Gender Identity in a Transgender Sample

PubMed Central

Diemer, Elizabeth W.; White Hughto, Jaclyn M.; Gordon, Allegra R.; Guss, Carly; Austin, S. Bryn; Reisner, Sari L.

2018-01-01

Abstract Purpose: To investigate whether the prevalence of eating disorders (EDs) differs across diverse gender identity groups in a transgender sample. Methods: Secondary analysis of data from Project VOICE, a cross-sectional study of stress and health among 452 transgender adults (ages 18–75 years) residing in Massachusetts. Age-adjusted logistic regression models were fit to compare the prevalence of self-reported lifetime EDs in female-to-male (FTM), male-to-female (MTF), and gender-nonconforming participants assigned male at birth (MBGNC) to gender-nonconforming participants assigned female at birth (FBGNC; referent). Results: The age-adjusted odds of self-reported ED in MTF participants were 0.14 times the odds of self-reported ED in FBGNC participants (p=0.022). In FTM participants, the age-adjusted odds of self-reported ED were 0.46 times the odds of self-reported ED in FBGNC participants, a marginally significant finding (p=0.068). No statistically significant differences in ED prevalence were found for MBGNC individuals. Conclusions: Gender nonconforming individuals assigned a female sex at birth appear to have heightened lifetime risk of EDs relative to MTF participants. Further research into specific biologic and psychosocial ED risk factors and gender-responsive intervention strategies are urgently needed. Training clinical providers and ensuring competency of treatment services beyond the gender binary will be vital to addressing this disparity. PMID:29359198

A clinical observational study analysing the factors associated with hyperventilation during actual cardiopulmonary resuscitation in the emergency department.

PubMed

Park, Sang O; Shin, Dong Hyuk; Baek, Kwang Je; Hong, Dae Young; Kim, Eun Jung; Kim, Sang Chul; Lee, Kyeong Ryong

2013-03-01

This is the first study to identify the factors associated with hyperventilation during actual cardiopulmonary resuscitation (CPR) in the emergency department (ED). All CPR events in the ED were recorded by video from April 2011 to December 2011. The following variables were analysed using review of the recorded CPR data: ventilation rate (VR) during each minute and its associated factors including provider factors (experience, advanced cardiovascular life support (ACLS) certification), clinical factors (auscultation to confirm successful intubation, suctioning, and comments by the team leader) and time factors (time or day of CPR). Fifty-five adult CPR cases including a total of 673 min sectors were analysed. The higher rates of hyperventilation (VR>10/min) were delivered by inexperienced (53.3% versus 14.2%) or uncertified ACLS provider (52.2% versus 10.8%), during night time (61.0 versus 34.5%) or weekend CPR (53.1% versus 35.6%) and when auscultation to confirm successful intubation was performed (93.5% versus 52.8%) than not (all p<0.0001). However, experienced (25.3% versus 29.7%; p=0.448) or certified ACLS provider (20.6% versus 31.3%; p<0.0001) could not deliver high rate of proper ventilation (VR 8-10/min). Comment by the team leader was most strongly associated with the proper ventilation (odds ratio 7.035, 95% confidence interval 4.512-10.967). Hyperventilation during CPR was associated with inexperienced or uncertified ACLS provider, auscultation to confirm intubation, and night time or weekend CPR. And to deliver proper ventilation, comments by the team leader should be given regardless of providers' expert level. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

New to Care: Demands on a Health System When Homeless Veterans Are Enrolled in a Medical Home Model

PubMed Central

Bourgault, Claire; Johnson, Erin E.; Redihan, Stephen G.; Borgia, Matthew; Aiello, Riccardo; Kane, Vincent

2013-01-01

Objectives. We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. Methods. We used case–control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. Results. We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. Conclusions. Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use. PMID:24148042

Non-invasive endothelial function assessment in patients with neurofibromatosis type 1: a cross-sectional study

PubMed Central

2013-01-01

Background Neurofibromatosis type 1 (NF1) is a multi-systemic disease caused by neurofibromin deficiency. The reduced life expectancy of patients with NF1 has been attributed to NF1-associated malignant neoplasms. However, an analysis of death certificates in the USA suggests that vascular disease could be an important cause of early death among these patients. Endothelial dysfunction (ED) is related to vasculopathy and is an early marker of subclinical atherosclerosis. Since neurofibromin has already been demonstrated to affect endothelial cell function, ED may be associated with NF1. The purpose of this study was to assess endothelial function in patients with NF1 using a non-invasive method. Methods NF1 patients and healthy control subjects, aged 18 to 35 years, were included. Subjects were excluded if they had any risk factor for vascular disease or any other condition known to affect endothelial function. Endothelial function was assessed using reactive hyperemia-peripheral arterial tone (RH-PAT) technology. ED was defined as a reactive hyperemia index (RHI) lower than 1.35. Results Four of the 29 (13.8%) NF1 patients and 1 of the 30 (3.3%) healthy volunteers had ED (p = 0.153). RHI medians and interquartile intervals were 1.8 (1.58-2.43) for the NF1 group and 2.02 (1.74 – 2.49) for the control group (p = 0.361). Conclusion The prevalence of ED was similar in NF1 patients and healthy controls. PMID:23497412

Study Protocol for a randomized controlled trial of mentalization based therapy against specialist supportive clinical management in patients with both eating disorders and symptoms of borderline personality disorder

PubMed Central

2014-01-01

Background The NOURISHED study: Nice OUtcomes for Referrals with Impulsivity, Self Harm and Eating Disorders. Eating Disorders (ED) and Borderline Personality Disorder (BPD) are both difficult to treat and the combination presents particular challenges. Both are associated with vulnerability to loss of mentalization (awareness of one’s own and others’ emotional state). In BPD, Mentalization Based therapy (MBT) has been found effective in reducing symptoms. In this trial we investigate the effectiveness and cost-effectiveness of MBT adapted for Eating disorders (Mentalization Based Therapy for Eating Disorders (MBT-ED)) compared to a standard comparison treatment, Specialist Supportive Clinical Management (SSCM-ED) in patients with a combination of an Eating Disorder and either a diagnosis of BPD or a history of self-harm and impulsivity in the previous 12 months. Methods/Design We will complete a multi-site single-blind randomized controlled trial (RCT) of MBT-ED vs SSCM-ED. Participants will be recruited from three Eating Disorder Services and two Borderline Personality Disorder Services in London. Participants allocated to MBT-ED will receive one year of weekly group and individual therapy and participants allocated to SSCM-ED will receive 20 sessions of individual therapy over 1 year. In addition, participants in both groups will have access to up to 5 hours of dietetic advice. The primary outcome measure is the global score on the Eating Disorders Examination. Secondary outcome measures include total score on the Zanarini BPD scale, the Object Relations Inventory, the Depression Anxiety Stress Scales, quality of life and cost-effectiveness. Measures are taken at recruitment and at 6 month intervals up to 18 months. Discussion This is the first Randomised Controlled Trial of MBT-ED in patients with eating disorders and symptoms of BPD and will provide evidence to inform therapy decisions in this group of patients. During MBT-ED mentalization is encouraged, while in SSCM-ED it is not overtly addressed. This study will help elucidate mechanisms of change in the two therapies and analysis of therapy and interview transcripts will provide qualitative information about the conduct of therapy and changes in mentalization and object relations. Trial registration ISRCTN51304415 PMID:24555511

Low-intensity extracorporeal shock wave therapy--a novel effective treatment for erectile dysfunction in severe ED patients who respond poorly to PDE5 inhibitor therapy.

PubMed

Gruenwald, Ilan; Appel, Boaz; Vardi, Yoram

2012-01-01

Low-intensity shock wave therapy (LI-ESWT) has been reported as an effective treatment in men with mild and moderate erectile dysfunction (ED). The aim of this study is to determine the efficacy of LI-ESWT in severe ED patients who were poor responders to phosphodiesterase type 5 inhibitor (PDE5i) therapy. This was an open-label single-arm prospective study on ED patients with an erection hardness score (EHS) ≤ 2 at baseline. The protocol comprised two treatment sessions per week for 3 weeks, which were repeated after a 3-week no-treatment interval. Patients were followed at 1 month (FU1), and only then an active PDE5i medication was provided for an additional month until final follow-up visit (FU2). At each treatment session, LI-ESWT was applied on the penile shaft and crus at five different anatomical sites (300 shocks, 0.09 mJ/mm(2) intensity at 120 shocks/min). Each subject underwent a full baseline assessment of erectile function using validated questionnaires and objective penile hemodynamic testing before and after LI-ESWT. Outcome measures used are changes in the International Index of Erectile Function-erectile function domain (IIEF-ED) scores, the EHS measurement, and the three parameters of penile hemodynamics and endothelial function. Twenty-nine men (mean age of 61.3) completed the study. Their mean IIEF-ED scores increased from 8.8 ± 1 (baseline) to 12.3 ± 1 at FU1 (P = 0.035). At FU2 (on active PDE5i treatment), their IIEF-ED further increased to 18.8 ± 1 (P < 0.0001), and 72.4% (P < 0.0001) reached an EHS of ≥ 3 (allowing full sexual intercourse). A significant improvement (P = 0.0001) in penile hemodynamics was detected after treatment and this improvement significantly correlated with increases in the IIEF-ED (P < 0.05). No noteworthy adverse events were reported. Penile LI-ESWT is a new modality that has the potential to treat a subgroup of severe ED patients. These preliminary data need to be reconfirmed by multicenter sham control studies in a larger group of ED patients. © 2011 International Society for Sexual Medicine.

Association of emergency department length of stay with safety net status

PubMed Central

Fee, Christopher; Burstin, Helen; Maselli, Judith H.; Hsia, Renee Y.

2013-01-01

Context Performance measures, particularly pay-for-performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients. Objective Describe emergency department (ED) compliance with proposed length of stay measures for admissions (8 hours) and discharges, transfers, and observations (4 hours) by safety-net status. Design, Setting, and Participants 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (CDC definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34,134 patient records. Visits were excluded for age <18, missing length of stay, or dispositions of: missing, “other”, left against medical advice, dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariate analyses determined associations with length of stay measure compliance. Results are presented as odds ratios with 95% confidence intervals. Main Outcome ED length of stay measure compliance by disposition and safety-net status. Results 27.87% of the 2008 ED visits from the weighted NHAMCS dataset were excluded leaving 72.13% for analysis. Of these, 42.3% were to safety-net and 57.7% to non-safety-net EDs. The median (interquartile range) ED lengths of stay for safety-net and non-safety-net ED visits respectively are as follows: 269 minutes (178, 397) and 281 (178, 401) for admissions, 156 (95, 239) and 148 (88, 238) for discharges, 355 (221, 675) and 298 (195, 440) for observations, and 235 (155, 378) and 239 (142, 368) for transfers. Safety-net status is not independently associated with compliance with ED length of stay measures for admissions (OR 0.83, [95%CI 0.52, 1.34]), discharges (1.03 [0.83, 1.27]), observations (1.05 [0.57, 1.95]), transfers (1.30 [0.70, 2.45]), or subcategories except psychiatric discharges (1.67 [1.02, 2.74]). Conclusion Compliance with proposed ED length of stay measures for admissions, discharges, transfers, and observations does not differ significantly between safety-net and non-safety-net hospitals. PMID:22298679

Ex vivo nonlinear microscopy imaging of Ehlers-Danlos syndrome-affected skin.

PubMed

Kiss, Norbert; Haluszka, Dóra; Lőrincz, Kende; Kuroli, Enikő; Hársing, Judit; Mayer, Balázs; Kárpáti, Sarolta; Fekete, György; Szipőcs, Róbert; Wikonkál, Norbert; Medvecz, Márta

2018-07-01

Ehlers-Danlos syndrome (EDS) is the name for a heterogenous group of rare genetic connective tissue disorders with an overall incidence of 1 in 5000. The histological characteristics of EDS have been previously described in detail in the late 1970s and early 1980s. Since that time, the classification of EDS has undergone significant changes, yet the description of the histological features of collagen morphology in different EDS subtypes has endured the test of time. Nonlinear microscopy techniques can be utilized for non-invasive in vivo label-free imaging of the skin. Among these techniques, two-photon absorption fluorescence (TPF) microscopy can visualize endogenous fluorophores, such as elastin, while the morphology of collagen fibers can be assessed by second-harmonic generation (SHG) microscopy. In our present work, we performed TPF and SHG microscopy imaging on ex vivo skin samples of one patient with classical EDS and two patients with vascular EDS and two healthy controls. We detected irregular, loosely dispersed collagen fibers in a non-parallel arrangement in the dermis of the EDS patients, while as expected, there was no noticeable impairment in the elastin content. Based on further studies on a larger number of patients, in vivo nonlinear microscopic imaging could be utilized for the assessment of the skin status of EDS patients in the future.

Insurance Expansion and Hospital Emergency Department Access: Evidence From the Affordable Care Act.

PubMed

Garthwaite, Craig; Gross, Tal; Notowidigdo, Matthew; Graves, John A

2017-02-07

Little is known about whether insurance expansion affects the location and type of emergency department (ED) use. Understanding these changes can inform state-level decisions about the Medicaid expansion under the Patient Protection and Affordable Care Act (ACA). To investigate the effect of the 2014 ACA Medicaid expansion on the location, insurance status, and type of ED visits. Quasi-experimental observational study from 2012 to 2014. 126 investor-owned, hospital-based EDs. Uninsured and Medicaid-insured adults aged 18 to 64 years. ACA expansion of Medicaid in January 2014. Number of ED visits overall, type of visit (for example, nondiscretionary or nonemergency), and average travel time to the ED. Interrupted time-series analyses comparing changes from the end of 2013 to end of 2014 for patients from Medicaid expansion versus nonexpansion states were done. There were 1.06 million ED visits among patients from 17 Medicaid expansion states, and 7.87 million ED visits among patients from 19 nonexpansion states. The EDs treating patients from Medicaid expansion states saw an overall 47.1% decrease in uninsured visits (95% CI, -65.0% to -29.3%) and a 125.7% (CI, 89.2% to 162.6%) increase in Medicaid visits after 12 months of ACA expansion. Average travel time for nondiscretionary conditions requiring immediate medical care decreased by 0.9 minutes (-6.2% [CI, -8.9% to -3.5%]) among all Medicaid patients from expansion states. We found little evidence of similar changes among patients from nonexpansion states. Results reflect shifts in ED care at investor-owned facilities, which limits generalizability to other hospital types. Meaningful changes in insurance status and location and type of ED visits in the first year of ACA Medicaid expansion were found, suggesting that expansion provides patients with a greater choice of hospital facilities. Robert Wood Johnson Foundation.

STEPS: lean thinking, theory of constraints and identifying bottlenecks in an emergency department.

PubMed

Ryan, A; Hunter, K; Cunningham, K; Williams, J; O'Shea, H; Rooney, P; Hickey, F

2013-04-01

This study aimed to identify the bottlenecks in patients' journeys through an emergency department (ED). For each stage of the patient journey, the average times were compared between two groups divided according to the four hour time frame and disproportionate delays were identified using a significance test These bottlenecks were evaluated with reference to a lean thinking value-stream map and the five focusing steps of the theory of constraints. A total of 434 (72.5%) ED patients were tracked over one week. Logistic regression showed that patients who had radiological tests, blood tests or who were admitted were 4.4, 4.1 and 7.7 times more likely, respectively, to stay over four hours in the ED than those who didn't The stages that were significantly delayed were the time spent waiting for radiology (p = 0.001), waiting for the in-patient team (p = 0.004), waiting for a bed (p < 0.001) and ED doctor turnaround time (p < 0.001).

Can interprofessional teamwork reduce patient throughput times? A longitudinal single-centre study of three different triage processes at a Swedish emergency department.

PubMed

Liu, Jenny; Masiello, Italo; Ponzer, Sari; Farrokhnia, Nasim

2018-04-19

To determine the impact on emergency department (ED) throughput times and proportion of patients who leave without being seen by a physician (LWBS) of two triage interventions, where comprehensive nurse-led triage was first replaced by senior physician-led triage and then by interprofessional teamwork. Single-centre before-and-after study. Adult ED of a Swedish urban hospital. Patients arriving on weekdays 08:00 to 21:00 during three 1-year periods in the interval May 2012 to November 2015. A total of 185 806 arrivals were included. Senior physicians replaced triage nurses May 2013 to May 2014. Interprofessional teamwork replaced the triage process on weekdays 08:00 to 21:00 November 2014 to November 2015. Primary outcomes were the median time to physician (TTP) and the median length of stay (LOS). Secondary outcome was the LWBS rate. The crude median LOS was shortest for teamwork, 228 min (95% CI 226.4 to 230.5) compared with 232 min (95% CI 230.8 to 233.9) for nurse-led and 250 min (95% CI 248.5 to 252.6) for physician-led triage. The adjusted LOS for the teamwork period was 16 min shorter than for nurse-led triage and 23 min shorter than for physician-led triage. The median TTP was shortest for physician-led triage, 56 min (95% CI 54.5 to 56.6) compared with 116 min (95% CI 114.4 to 117.5) for nurse-led triage and 74 min (95% CI 72.7 to 74.8) for teamwork. The LWBS rate was 1.9% for nurse-led triage, 1.2% for physician-led triage and 3.2% for teamwork. All outcome measure differences had two-tailed p values<0.01. Interprofessional teamwork had the shortest length of stay, a shorter time to physician than nurse-led triage, but a higher LWBS rate. Interprofessional teamwork may be a useful approach to reducing ED throughput times. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Comparative Analgesic Efficacy of Oxycodone/Acetaminophen Versus Hydrocodone/Acetaminophen for Short-term Pain Management in Adults Following ED Discharge.

PubMed

Chang, Andrew K; Bijur, Polly E; Holden, Lynne; Gallagher, E John

2015-11-01

The objective was to test the hypothesis that oxycodone/acetaminophen provides superior analgesia to hydrocodone/acetaminophen for the treatment of acute extremity pain following emergency department (ED) discharge. This was a prospective, randomized, double-blind clinical trial of nonelderly adult ED patients with acute musculoskeletal extremity pain, randomly allocated at discharge to receive oxycodone/acetaminophen (5 mg/325 mg) or hydrocodone/acetaminophen (5 mg/325 mg). The primary outcome was the between-group difference in improvement in numerical rating scale (NRS) pain scores over a 2-hour period following the most recent ingestion of study drug, obtained during telephone contact 24 hours after ED discharge. Secondary outcomes included proportionate decrease in pain, comparative side-effect profiles, and patient satisfaction. A total of 240 patients were enrolled. The final sample consisted of 220 patients, 107 randomly allocated to oxycodone/acetaminophen and 113 to hydrocodone/acetaminophen. At 24 hours after ED discharge, the mean NRS pain scores prior to the most recent dose of outpatient pain medication were 7.8 and 7.9 in the oxycodone/acetaminophen and hydrocodone/acetaminophen groups, respectively. The mean decreases in pain scores over 2 hours were 4.4 NRS units in the oxycodone/acetaminophen group versus 4.0 NRS units in the hydrocodone/acetaminophen group, for a difference of 0.4 NRS units (95% confidence interval = -0.2 to 1.1 NRS units). Satisfaction with the analgesics was similar. This study design could not detect a clinically or statistically significant difference in analgesic efficacy between oxycodone/acetaminophen (5 mg/325 mg) and hydrocodone/acetaminophen (5 mg/325 mg) for treatment of acute musculoskeletal extremity pain in adults following ED discharge. Both opioids reduced pain scores by approximately 50%. © 2015 by the Society for Academic Emergency Medicine.

Effect of advanced age and vital signs on admission from an emergency department observation unit

PubMed Central

Caterino, Jeffrey M.; Hoover, Emily; Moseley, Mark G.

2012-01-01

Objectives The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. Methods We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of ≥65 years. Vital signs were examined continuously and at commonly accepted cutoffs. We additionally controlled for demographics, co-morbid conditions, laboratory values, and observation protocol. Results Three hundred patients were enrolled, 12% (n=35) ≥65 years old and 11% (n=33) requiring admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07-14.9%) in older adults and 12.1% (95% CI, 8.4-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR] 0.30, 95% CI 0.05-1.67). Predictors of admission included: systolic pressure ≥180 mmHg (OR 4.19, 95% CI 1.08-16.30), log Charlson co-morbidity score (OR 2.93, 95% CI 1.57-5.46), and white blood cell count ≥14,000/mm3 (OR11.35, 95% CI 3.42-37.72). Conclusions Among patients placed in an ED observation unit, age ≥65 years is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure≥180 mmHg was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion. PMID:22386358

An effective dose of ketamine for eliminating pain during injection of propofol: a dose response study.

PubMed

Wang, M; Wang, Q; Yu, Y Y; Wang, W S

2013-09-01

Ketamine can completely eliminate pain associated with propofol injection. However, the effective dose of ketamine to eliminate propofol injection pain has not been determined. The purpose of this study was to determine the effective dose of ketamine needed to eliminate pain in 50% and 95% of patients (ED50 and ED95, respectively) during propofol injections. This study was conducted in a double-blinded fashion and included 50 patients scheduled for elective gynecological laparoscopy under general anesthesia. The initial dose of ketamine used in the first patient was 0.25mg/kg. The dosing modifications were in increments or decrements of 0.025 mg/kg. Ketamine was administered 15 seconds before injecting propofol (2.5mg/kg), which was injected at a rate of 1mL/s. Patients were asked to rate their pain during propofol injection every 5s econds using a 0-3 pain scale. The highest pain score was recorded. The ED50, ED95 and 95% confidence intervals (CI) were determined by probit analyses. The dose of ketamine ranged from 0.175 to 0.275 mg/kg. The ED50 and ED95 of ketamine for eliminating pain during propofol injection were 0.227 mg/kg and 0.283 mg/kg, respectively (95%CI: 0.211-0.243 mg/kg and 0.26-0.364 mg/kg, respectively). Ketamine at an approximate dose of 0.3mg/kg was effective in eliminating pain during propofol injection. Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

Comorbid Parkinson's disease, falls and fractures in the 2010 National Emergency Department Sample

PubMed Central

Beydoun, Hind A.; Beydoun, May A.; Mishra, Nishant K.; Rostant, Ola S.; Zonderman, Alan B.; Eid, Shaker M.

2017-01-01

Introduction Parkinson's disease (PD) is a progressive, neurodegenerative disorder of multifactorial etiology affecting ~1% of older adults. Research focused on linking PD to falls and bone fractures has been limited in Emergency Department (ED) settings, where most injuries are identified. We assessed whether injured U.S. ED admissions with PD diagnoses were more likely to exhibit comorbid fall- or non-fall related bone fractures and whether a PD diagnosis with a concomitant fall or bone fracture is linked to worse prognosis. Methods We performed secondary analyses of 2010 Healthcare Utilization Project National ED Sample from 4,253,987 admissions to U.S. EDs linked to injured elderly patients. ED discharges with ICD-9-CM code (332.0) were identified as PD and those with ICD-9-CM code (800.0–829.0) were used to define bone fracture location. Linear and logistic regression models were constructed to estimate slopes (B) and odds ratios (OR) with 95% confidence intervals (CI). Results PD admissions had 28% increased adjusted prevalence of bone fracture. Non-fall injuries showed stronger relationship between PD and bone fracture (ORadj = 1.33, 95% CI: 1.22–1.45) than fall injuries (ORadj = 1.06, 95% CI: 1.01–1.10). PD had the strongest impact on hospitalization length when bone fracture and fall co-occurred, and total charges were directly associated with PD only for fall injuries. Finally, PD status was not related to in-hospital death in this population. Conclusions Among injured U.S. ED elderly patient visits, those with PD had higher bone fracture prevalence and more resource utilization especially among fall-related injuries. No association of PD with in-hospital death was noted. PMID:27887896

Effect of Socioeconomic Status and Underlying Disease on the Association between Ambient Temperature and Ischemic Stroke.

PubMed

Cho, Seong Kyung; Sohn, Jungwoo; Cho, Jaelim; Noh, Juhwan; Ha, Kyoung Hwa; Choi, Yoon Jung; Pae, Sangjoon; Kim, Changsoo; Shin, Dong Chun

2018-07-01

Inconsistent findings have been reported regarding the effect of ambient temperature on ischemic stroke. Furthermore, little is known about how underlying disease and low socioeconomic status influence the association. We, therefore, investigated the relationship between ambient temperature and emergency department (ED) visits for ischemic stroke, and aimed to identify susceptible populations. Using medical claims data, we identified ED visits for ischemic stroke during 2005-2009 in Seoul, Korea. We conducted piecewise linear regression analyses to find optimum ambient temperature thresholds in summer and winter, and estimated the relative risks (RR) and 95% confidence intervals (CI) per a 1°C increase in temperature above/below the thresholds, adjusting for relative humidity, holidays, day of the week, and air pollutant levels. There were 63564 ED visits for ischemic stroke. In summer, the risk of ED visits for ischemic stroke was not significant, with the threshold at 26.8°C. However, the RRs were 1.055 (95% CI, 1.006-1.106) above 25.0°C in medical aid beneficiaries and 1.044 (1.007-1.082) above 25.8°C in patients with diabetes. In winter, the risk of ED visits for ischemic stroke significantly increased as the temperature decreased above the threshold at 7.2°C. This inverse association was significant also in patients with hypertension and diabetes mellitus above threshold temperatures. Ambient temperature increases above a threshold were positively associated with ED visits for ischemic stroke in patients with diabetes and medical aid beneficiaries in summer. In winter, temperature, to a point, and ischemic stroke visits were inversely associated. © Copyright: Yonsei University College of Medicine 2018.

Substance abuse and mental health visits among adolescents presenting to US emergency departments.

PubMed

Fahimi, Jahan; Aurrecoechea, Adrian; Anderson, Erik; Herring, Andrew; Alter, Harrison

2015-05-01

The objectives of the study were to identify factors associated with adolescent emergency department (ED) visits for substance abuse, including those complicated by mental health (dual diagnosis), and to analyze their effect on ED length of stay (LOS) and disposition. We performed a secondary analysis of ED visits by adolescents (age, 11-24) using the National Hospital Ambulatory Medical Care Survey (1997-2010) to identify visits for mental health, substance use, and dual diagnosis. Univariate and multivariate statistics were used to analyze demographic and visit-level factors, factors associated with substance use and dual diagnosis visits, as well as the effects of substance use and mental health conditions on ED LOS and disposition. Substance use and mental health accounted for 2.1% and 4.3% of all adolescent visits, respectively, with 20.9% (95% confidence interval [CI], 18.3%-23.5%) of substance abuse visits complicated by mental health. The factors significantly associated with substance use include the following: male sex, urban location, West region, ambulance arrival, night and weekend shift, anxiety disorders, mood disorders, and psychotic disorders. Additional LOS was 89.77 minutes for mental health, 71.33 minutes for substance use, and 139.97 minutes for dual diagnosis visits, as compared with visits where these conditions were not present. Both mental health and substance use were associated with admission/transfer as compared with other dispositions as follows: mental health odds ratio (OR), 5.93 (95% CI, 5.14-6.84); illicit drug use OR, 3.56 (95% CI 2.72-4.64); and dual diagnosis OR, 6.86 (95% CI, 4.67-10.09). Substance abuse and dual diagnosis are common among adolescent ED visits and are strongly associated with increased use of prehospital resources, ED LOS, and need for hospitalization.

Risk factors for apnea in pediatric patients transported by paramedics for out-of-hospital seizure.

PubMed

Bosson, Nichole; Santillanes, Genevieve; Kaji, Amy H; Fang, Andrea; Fernando, Tasha; Huang, Margaret; Lee, Jumie; Gausche-Hill, Marianne

2014-03-01

Apnea is a known complication of pediatric seizures, but patient factors that predispose children are unclear. We seek to quantify the risk of apnea attributable to midazolam and identify additional risk factors for apnea in children transported by paramedics for out-of-hospital seizure. This is a 2-year retrospective study of pediatric patients transported by paramedics to 2 tertiary care centers. Patients were younger than 15 years and transported by paramedics to the pediatric emergency department (ED) for seizure. Patients with trauma and those with another pediatric ED diagnosis were excluded. Investigators abstracted charts for patient characteristics and predefined risk factors: developmental delay, treatment with antiepileptic medications, and seizure on pediatric ED arrival. Primary outcome was apnea defined as bag-mask ventilation or intubation for apnea by paramedics or by pediatric ED staff within 30 minutes of arrival. There were 1,584 patients who met inclusion criteria, with a median age of 2.3 years (Interquartile range 1.4 to 5.2 years). Paramedics treated 214 patients (13%) with midazolam. Seventy-one patients had apnea (4.5%): 44 patients were treated with midazolam and 27 patients were not treated with midazolam. After simultaneous evaluation of midazolam administration, age, fever, developmental delay, antiepileptic medication use, and seizure on pediatric ED arrival, 2 independent risk factors for apnea were identified: persistent seizure on arrival (odds ratio [OR]=15; 95% confidence interval [CI] 8 to 27) and administration of field midazolam (OR=4; 95% CI 2 to 7). We identified 2 risk factors for apnea in children transported for seizure: seizure on arrival to the pediatric ED and out-of-hospital administration of midazolam. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Association of TLL1 gene polymorphism (rs1503298, T > C) with coronary heart disease in PREDICT, UDACS and ED cohorts.

PubMed

Zain, Maryam; Awan, Fazli Rabbi; Cooper, Jackie A; Li, Ka Wah; Palmen, Jutta; Acharya, Jay; Howard, Philip; Baig, Shahid M; Elkeles, Robert S; Stephens, Jeffrey W; Ireland, Helen; Humphries, Steve E

2014-09-01

To determine the sequence variant of TLL1 gene (rs1503298, T > C) in three British cohorts (PREDICT, UDACS and ED) of patients with type-2 Diabetes mellitus (T2DM) in order to assess its association with coronary heart disease (CHD). Analytical study. UCL, London, UK. Participants were genotyped in 2011-2012 for TLL1 SNP. Samples and related information were previously collected in 2001-2003 for PREDICT, and in 2001-2002 for UDACS and ED groups. Patients included in PREDICT (n=600), UDACS (n=1020) and ED (n=1240) had Diabetes. TLL1 SNP (rs1503298, T > C) was genotyped using TaqMan technology. Allele frequencies were compared using c2 test, and tested for Hardy-Weinberg equilibrium. The risk of disease was assessed from Odds ratios (OR) with 95% Confidence Intervals (95% CI). Moreover, for the PREDICT cohort, the SNP association was tested with Coronary Artery Calcification (CAC) scores. No significant association was found for this SNP with CHD or CAC scores in these cohorts. This SNP could not be confirmed as a risk factor for CHD in T2DM patients. However, the low power of thesmall sample size available is a limitation to the modest effect on risk. Further studies in larger samples would be useful.

Redesigning emergency department patient flows: application of Lean Thinking to health care.

PubMed

King, Diane L; Ben-Tovim, David I; Bassham, Jane

2006-08-01

To describe in some detail the methods used and outcome of an application of concepts from Lean Thinking in establishing streams for patient flows in a teaching general hospital ED. Detailed understanding was gained through process mapping with staff followed by the identification of value streams (those patients likely to be discharged from the ED, those who were likely to be admitted) and the implementation of a process of seeing those patients that minimized complex queuing in the ED. Streaming had a significant impact on waiting times and total durations of stay in the ED. There was a general flattening of the waiting time across all groups. A slight increase in wait for Triage categories 2 and 3 patients was offset by reductions in wait for Triage category 4 patients. All groups of patients spent significantly less overall time in the department and the average number of patients in the ED at any time decreased. There was a significant reduction in number of patients who do not wait and a slight decrease in access block. The streaming of patients into groups of patients cared for by a specific team of doctors and nurses, and the minimizing of complex queues in this ED by altering the practices in relation to the function of the Australasian Triage Scale improved patient flow, thereby decreasing potential for overcrowding.

Exploring the performance of the National Early Warning Score (NEWS) in a European emergency department.

PubMed

Alam, N; Vegting, I L; Houben, E; van Berkel, B; Vaughan, L; Kramer, M H H; Nanayakkara, P W B

2015-05-01

Several triage systems have been developed for use in the emergency department (ED), however they are not designed to detect deterioration in patients. Deteriorating patients may be at risk of going undetected during their ED stay and are therefore vulnerable to develop serious adverse events (SAEs). The national early warning score (NEWS) has a good ability to discriminate ward patients at risk of SAEs. The utility of NEWS had not yet been studied in an ED. To explore the performance of the NEWS in an ED with regard to predicting adverse outcomes. A prospective observational study. Patients Eligible patients were those presenting to the ED during the 6 week study period with an Emergency Severity Index (ESI) of 2 and 3 not triaged to the resuscitation room. NEWS was documented at three time points: on arrival (T0), hour after arrival (T1) and at transfer to the general ward/ICU (T2). The outcomes of interest were: hospital admission, ICU admission, length of stay and 30 day mortality. A total of 300 patients were assessed for eligibility. Complete data was able to be collected for 274 patients on arrival at the ED. NEWS was significantly correlated with patient outcomes, including 30 day mortality, hospital admission, and length of stay at all-time points. The NEWS measured at different time points was a good predictor of patient outcomes and can be of additional value in the ED to longitudinally monitor patients throughout their stay in the ED and in the hospital. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.