Academic Emergency Medicine (Acad Emerg Med)

Publications in this journal

• Article: Improving Telephone Follow-up for Patients Discharged from the Emergency Department: Results of a Randomized Controlled Trial.

  Michael Menchine, Stephanie Oberfoell, David Schriger, Christopher Walker, Jeff Riddell, Sanjay Arora
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  ABSTRACT: OBJECTIVES: Reliable telephone follow-up offers physicians a timely method to notify patients of unexpected laboratory and imaging results, clarify discharge instructions, evaluate health status changes, and potentially boost patient satisfaction. This study sought to determine if verifying telephone numbers, obtaining best contact times, and informing patients that they will be contacted would increase the proportion of emergency department (ED) patients contacted at 48 to 72 hours postdischarge. Secondary outcomes included estimating successful postdischarge follow-up across demographic categories. METHODS: This was a prospective, randomized controlled trial of adult patients in an inner-city, public hospital ED. Patients were excluded for critical illness, no telephone number, non-English- or non-Spanish-speaking, or anyone admitted as an inpatient. All subjects completed a demographic questionnaire. In the intervention arm, research assistants (RAs) verified the telephone number, obtained best contact times, and informed subjects that they would be called. In the control arm, telephone numbers were obtained from registration materials and were not verified, and subjects were not informed that postdischarge telephone calls were planned. RAs made four telephone attempts to contact each subject 48 to 72 hours after discharge. RESULTS: The intervention did not significantly improve postdischarge contact. Most subjects, 72.8% in the intervention group and 68.2% in the control group, were successfully contacted (difference = 4.6%, 95% confidence interval [CI] = -2.2% to 11.4%). On multivariate analysis, Hispanic ethnicity and owning a mobile phone were associated with increased odds of successful postdischarge follow-up. CONCLUSIONS: Verifying contact information, obtaining best contact times, and notifying patients of impending follow-up calls did not substantially improve postdischarge telephone contact rates.
  Academic Emergency Medicine 05/2013; 20(5):456-462.
• Article: Prevalence and Clinical Importance of Alternative Causes of Symptoms Using a Renal Colic Computed Tomography Protocol in Patients With Flank or Back Pain and Absence of Pyuria.

  Chris L Moore, Brock Daniels, Dinesh Singh, Seth Luty, Annette Molinaro
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  ABSTRACT: OBJECTIVES: The study was undertaken to determine the prevalence and clinical importance of alternative causes of symptoms discovered in patients undergoing flank pain protocol (FPP) computed tomography (CT) scans in patients with classic symptoms of kidney stone (flank pain, back pain, or both) without evidence of urine infection. METHODS: This was a retrospective observational analysis of all adult patients undergoing FPP CT scans at two emergency departments (EDs) between April 2005 and November 2010. All CTs (N = 5,383) were reviewed and categorized as "no cause of symptoms seen on CT," "ureteral stone as cause of symptoms," or "non-kidney stone cause of symptoms." Non-kidney stone scans were further categorized as "acutely important," "follow-up recommended," or "unimportant cause," based on a priori diagnostic classifications. All nonstone causes of pain and a random subset of subjects (n = 1,843; 34%) underwent full record review blinded to CT categorization to determine demographics, whether flank and/or back pain was present, and whether there was objective evidence of pyuria. RESULTS: Of all FPP CT scans during the study period, a ureteral stone was found to cause symptoms in 47.7% of CTs, with no cause of symptoms found in 43.3% of CTs. A non-kidney stone diagnosis was found in 9.0% of all CTs, with 6.1% being categorized as "acutely important," 2.2% as "follow-up recommended," and 0.65% with symptoms from an "unimportant cause." In the randomly selected subset undergoing full record review, categorizations were similar, with 49.0% of CTs showing kidney stone as cause of pain and 9.0% a non-kidney stone cause (5.9% "acutely important"). When subjects with evidence of urine infection or without flank or back pain were excluded, ureteral stone was identified as the cause of pain in 54.9% of CTs, while non-kidney stone cause of symptoms was found in 5.4% of scans and acutely important alternate causes in 2.8% of scans. CONCLUSIONS: While a non-kidney stone cause for a patient's symptoms are found in nearly 10% of CTs done using a FPP, acutely important findings occur in less than 3% of scans done in patients with flank or back pain and absence of pyuria.
  Academic Emergency Medicine 05/2013; 20(5):470-478.
• Article: National Growth in Intensive Care Unit Admissions From Emergency Departments in the United States from 2002 to 2009.

  Peter M Mullins, Munish Goyal, Jesse M Pines
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  ABSTRACT: OBJECTIVES: The authors describe national trends in use, reasons for visit, most common diagnoses, and resource utilization in patients admitted to intensive care units (ICUs) from hospital-based emergency departments (EDs) in the United States. METHODS: This was an observational study using data from the National Hospital Ambulatory Care Survey, a nationally representative, weighted sample of U.S. hospital-based EDs from 2002 through 2009. The sample comprised a total of 4,267 patients aged 18 years or older admitted to the ICU from the ED, which represent over 14.5 million ED encounters from 2002 through 2009. RESULTS: Over the study period, ICU admissions from EDs increased from 2.79 million in 2002/2003, to 4.14 million in 2008/2009, an absolute increase of 48.8% and a mean biennial increase of 14.2%. By comparison, overall ED visits increased a mean of 5.8% per biennial period. The three most common diagnoses for ICU admissions were unspecified chest pain, congestive heart failure, and pneumonia. Utilization rates of most tests and services delivered to patients admitted to the ICU from the ED increased, with the largest increase occurring in computed tomography (CT) and magnetic resonance imaging (MRI), which increased from 16.8% in 2002/2003 to 37.4% in 2008/2009, a 6.9% mean biennial increase. Across all years, mean ED length of stay (LOS) for ICU admissions was 304 minutes (95% confidence interval [CI] = 286 to 323 minutes), and mean hospital LOS was 6.6 days (95% CI = 6.2 to 7.0 days). There was no significant change in either mean ED or hospital LOS over the study period. CONCLUSIONS: Intensive care unit admissions from EDs are increasing at a greater rate than both population growth and overall ED visits. ED resource use, specifically advanced diagnostic imaging, has increased markedly among ICU admissions. While mean ED and hospital LOS have not changed significantly, the mean ICU admission spends over 5 hours in the ED prior to transfer to an ICU bed. A greater emphasis on the ED-ICU interface and critical care delivered in the ED may be warranted.
  Academic Emergency Medicine 05/2013; 20(5):479-486.
• Article: Understanding Patient-Provider Conversations: What Are We Talking About?

  Danielle M McCarthy, Barbara A Buckley, Kirsten G Engel, Victoria E Forth, James G Adams, Kenzie A Cameron
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  ABSTRACT: OBJECTIVES: Effective patient-provider communication is a critical aspect of the delivery of high-quality patient care; however, research regarding the conversational dynamics of an overall emergency department (ED) visit remains unexplored. Identifying both patterns and relative frequency of utterances within these interactions will help guide future efforts to improve the communication between patients and providers within the ED setting. The objective of this study was to analyze complete audio recordings of ED visits to characterize these conversations and to determine the proportion of the conversation spent on different functional categories of communication. METHODS: Patients at an urban academic ED with four diagnoses (ankle sprain, back pain, head injury, and laceration) were recruited to have their ED visits audio recorded from the time of room placement until discharge. Patients were excluded if they were age < 18 years, were non-English-speaking, had significant history of psychiatric disease or cognitive impairment, or were medically unstable. Audio editing was performed to remove all silent downtime and non-patient-provider conversations. Audiotapes were analyzed using the Roter Interaction Analysis System (RIAS). RIAS is the most widely used medical interaction analysis system; coders assign each "utterance" (or complete thought) spoken by the patient or provider to one of 41 mutually exclusive and exhaustive categories. Descriptive statistics were calculated for all 41 categories and then grouped according to RIAS standards for "functional groupings." The percentage of total utterances in each functional grouping is reported. RESULTS: Twenty-six audio recordings were analyzed. Patient participants had a mean (±SD) age of 38.8 (±16.0) years, and 30.8% were male. Intercoder reliability was good, with mean intercoder correlations of 0.76 and 0.67 for all categories of provider and patient talk, respectively. Providers accounted for the majority of the conversation in the tapes (median = 239 utterances, interquartile range [IQR] = 168 to 308) compared to patients (median = 145 utterances, IQR = 80 to 198). Providers' utterances focused most on patient education and counseling (34%), followed by patient facilitation and activation (e.g., orienting the patient to the next steps in the ED or asking if the patient understood; 30%). Approximately 15% of the provider talk was spent on data gathering, with the majority (86%) focusing on biomedical topics rather than psychosocial topics (14%). Building a relationship with the patient (e.g., social talk, jokes/laughter, showing approval, or empathetic statements) constituted 22% of providers' talk. Patients' conversation was mainly focused in two areas: information giving (47% of patient utterances: 83% biomedical, 17% psychosocial) and building a relationship (45% of patient utterances). Only 5% of patients' utterances were devoted to question asking. Patient-centeredness scores were low. CONCLUSIONS: In this sample, both providers and patients spent a significant portion of their talk time providing information to one another, as might be expected in the fast-paced ED setting. Less expected was the result that a large percentage of both provider and patient utterances focused on relationship building, despite the lack of traditional, longitudinal provider-patient relationships.
  Academic Emergency Medicine 05/2013; 20(5):441-448.
• Article: Individual Lytic Efficacy of Recombinant Tissue Plasminogen Activator in an In Vitro Human Clot Model: Rate of "Nonresponse"

  Jason M Meunier, Evan Wenker, Christopher J Lindsell, George J Shaw
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  ABSTRACT: OBJECTIVES: Recombinant tissue plasminogen activator (rt-PA) is a lytic medication widely used in the emergency department to treat acute thrombotic disorders such as ischemic stroke and myocardial infarction. It is known in the clinical use of this drug that it can be less effective in approximately 25% of individuals receiving such treatment. However, there are no data on the variation of lytic efficacy of rt-PA in decreasing individuals' clot size over time. In this study, in vitro lytic efficacy was determined by measuring the decrease in clot diameter after 30 minutes of drug exposure. The authors sought to explore whether there are individuals who do not respond to this lytic therapy and to estimate the rate of nonresponse. METHODS: Human whole blood clots were made from blood drawn from 22 adult volunteers. The only exclusion criterion was the use of aspirin within 72 hours of the blood draw. Blood clots were allowed to spontaneously form at room temperature and were then incubated at 37°C for 3 hours to ensure complete clot retraction. Sample clots from the same individuals were then exposed to human fresh-frozen plasma (hFFP) control or rt-PA in hFFP (rt-PA) at a concentration of 3.15 μg/mL. All clots were exposed at 37°C for 30 minutes, and clot diameter was measured as a function of time, using a microscopic imaging technique. The fractional clot loss (FCL), which is the percentage decrease in clot diameter at 30 minutes, was used as a measure of lytic efficacy. RESULTS: Means with standard deviation (SD) FCL values were 8.6% (±3.0%) for control and 20.6% (±9.3%) for rt-PA-treated clots. The mean (±SD) difference in FCL values was 12.0% (±8.8%) and was significant (p < 0.05, paired t-test). Five of the 22 subjects (23%) were "rt-PA nonresponders," in that their FCL (rt-PA) values fell within that of the FCL control values. CONCLUSIONS: Overall, rt-PA does not produce clot lysis in vitro in clots from a substantial minority of the population, likely due to individual variations in clot composition and structure.
  Academic Emergency Medicine 05/2013; 20(5):449-455.
• Article: Validation of the San Francisco Syncope Rule in Two Hospital Emergency Departments in an Asian Population.

  Camlyn Tan, Tiong Beng Sim, Shin Ying Thng
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  ABSTRACT: OBJECTIVES: The objective was to externally validate the ability of the San Francisco Syncope Rule (SFSR) to accurately identify patients who will experience a 7-day serious clinical event in an Asian population. METHODS: This was a prospective cohort study, with a sample of adult patients with syncope and near-syncope enrolled. Patients 12 years old and below and patients with loss of consciousness after head trauma, a witnessed seizure, with known alcohol or illicit drug ingestion, and altered level of consciousness or persistent new neurologic deficits were excluded. The patients were evaluated for the presence of one or more of the five SFSR variables: shortness of breath, history of heart failure, hematocrit <30%, systolic blood pressure <90 mm Hg, and abnormal electrocardiogram (ECG). The patients were followed up by medical record review or telephone interview. Seven-day outcomes were death, arrhythmia, myocardial infarction, acute pulmonary edema, significant structural heart disease, pulmonary embolism, major cardiac procedure, stroke, subarachnoid hemorrhage, major bleeding, and anemia. RESULTS: A total of 1,250 patients from two centers were recruited. Fifty-six patients were excluded from primary analysis because of incomplete data (n = 55) and/or they were noncontactable for follow-up (n = 32). Of the 1,194 patients analyzed, 138 patients (11.6%) experienced adverse outcomes at 7 days. The rule performed with a sensitivity of 94.2% (95% confidence interval [CI] = 89.0% to 97.0%) and a specificity of 50.8% (95% CI = 47.7% to 53.8%). CONCLUSIONS: In this study, SFSR rule had a sensitivity of 94.2%. This suggests caution on the strict application of the rule to all patients presenting with syncope. It should only be used as an aide in clinical decision-making in this population.
  Academic Emergency Medicine 05/2013; 20(5):487-497.
• Article: Weekday Psychiatry Faculty Rounds on Emergency Department Psychiatric Patients Reduces Length of Stay.

  Howard Blumstein, Amy H Singleton, Charles W Suttenfield, Brian C Hiestand
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  ABSTRACT: OBJECTIVES: In the face of increasing volume of emergency department (ED) patients with primary psychiatric illness and increasing length of stay (LOS), a department of psychiatry initiated a program whereby faculty members of the department of psychiatry from a hospital conducted rounds in the ED each weekday on these patients. METHODS: A retrospective data review was performed to assess the effect of these rounds on the LOS and disposition of these patients. The LOS and dispositions of subjects before and after the initiation of psychiatry rounds were compared, with a 2-month washout period between. Subjects had a primary psychiatric diagnosis with a LOS of 12 hours or greater. The LOS and disposition of each subject was queried from the hospital data system. Quantile regression analysis and Fisher's exact test were used as appropriate. RESULTS: There were 355 subjects in the preimplementation period and 512 in the postimplementation period. The proportion of patients discharged remained unchanged (preimplementation 49.6%, 95% confidence interval [CI] = 44.3 to 54.9; postimplementation 49.0%, 95% CI = 44.6 to 53.4), but more patients were admitted to the hospital (24.2%, 95% CI = 19.9 to 29.0 vs. 32.8, 95% CI = 28.8 to 37.1) and fewer were transferred to other psychiatric facilities (25.6%, 95% CI = 21.2 to 30.5 vs. 18.0% 95% CI = 14.7 to 21.6; p = 0.005 by Fisher's exact test). Quantile regression demonstrated that among subjects with the longest LOS, those in the postimplementation group experienced a reduction in their waiting times. CONCLUSIONS: Weekday rounds in the ED by psychiatry faculty are associated with a reduction in the LOS for psychiatric patients, mainly due to reduced LOS of those patients with the longest stays.
  Academic Emergency Medicine 05/2013; 20(5):498-502.
• Article: Syncope Risk Stratification in the ED: Directions for Future Research.

  Benjamin Sun, Giorgio Costantino
  Academic Emergency Medicine 05/2013; 20(5):503-506.
• Article: Effect of Military Conflicts on the Formation of Emergency Medical Services Systems Worldwide.

  Mariusz Goniewicz
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  ABSTRACT: OBJECTIVES: This article briefly reviews the evolution of medical support during wars and conflicts from ancient to modern times and discusses the effect warfare has had on the development of civilian health care and emergency medical services (EMS). Medical breakthroughs and discoveries made of necessity during military conflicts have developed into new paradigms of medical care, including novel programs of triage and health assessment, emergency battlefield treatment and stabilization, anesthesia, and other surgical and emergency procedures. The critical role of organizations that provide proper emergency care to help the sick and injured both on the battlefield and in the civilian world is also highlighted.
  Academic Emergency Medicine 05/2013; 20(5):507-513.
• Article: Agreement Between Routine Emergency Department Care and Clinical Decision Support Recommended Care in Patients Evaluated for Mild Traumatic Brain Injury.

  Frederick K Korley, Melinda J Morton, Peter M Hill, Tichaendepi Mundangepfupfu, Tingting Zhou, Amir M Mohareb, Richard E Rothman
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  ABSTRACT: OBJECTIVES: Emergency department (ED) computed tomography (CT) use has increased significantly during the past decade. It has been suggested that adherence to clinical decision support (CDS) may result in a safe decrease in CT ordering. In this study, the authors quantified the percentage agreement between routine and CDS-recommended care and the anticipated consequence of strict adherence to CDS on CT use in mild traumatic brain injury (mTBI). METHODS: This was a prospective observational study of patients with mTBI who presented to an urban academic ED of a tertiary care hospital. Patients 18 years or older, presenting within 24 hours of nonpenetrating trauma to the head, from August 2010 to July 2011, were eligible for enrollment. Structured data forms were completed by trained research assistants (RAs). The primary outcome was the percentage agreement between routine head CT use and CDS-recommended head CT use. CDS examined were: the 2008 American College of Emergency Physicians [ACEP] neuroimaging, the New Orleans rule, and the Canadian head CT rule. Differences between outcome groups were assessed using the chi-square test for categorical variables and the Kruskal-Wallis rank test for continuous variables. The percentage agreement between routine practice and CDS-recommended practice was calculated. RESULTS: Of the 169 patients enrolled, 130 (76.9%) received head CT scans, and five of the 130 (3.8%) had acute traumatic intracranial findings. For all subjects, agreement between routine practice and CDS-recommended practice was 77.5, 65.7, and 78.1%, for the ACEP, Canadian, and New Orleans CDS, respectively. Strict adherence to the 2008 ACEP neuroimaging CDS would result in no statistically significant difference in head CT use (routine care, 76.9%; CDS-recommended, 82.8%; p = 0.17). Strict adherence to the New Orleans CDS would result in an increase in head CT use (routine care, 76.9%; CDS-recommended, 94.1%; p < 0.01). Strict adherence to the Canadian CDS would result in a decrease in head CT use (routine care, 76.9%; CDS-recommended, 56.8%; p < 0.01). CONCLUSIONS: There is a 60% to 80% agreement between routine and CDS-recommended head CT use. Of the three CDS systems examined, the only one that may result in a reduction in head CT use if strictly followed was the Canadian head CT CDS. Further studies are needed to examine reasons for the less than optimal agreement between routine care and care recommended by the Canadian head CT CDS.
  Academic Emergency Medicine 05/2013; 20(5):463-469.
• Article: Development of Emergency Medicine in Europe.

  Vicken Totten, Abdelouahab Bellou
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  ABSTRACT: Emergency medicine (EM) is emerging worldwide. Its development as a recognized specialty is proceeding at difference rates in different countries. Europe is a region with complex political affiliations and is composed of countries both within and outside the European Union (EU). Europe is seeking greater standardization (harmonization) for mutually improved economic development. Medicine in general, and EM in particular, is no exception. In Europe, as in other regions, EM is struggling for acceptance as a valid field of specialization. The European Union of Medical Specialists requires that once two-fifths of countries acknowledge a specialty, all EU countries must address the question. EM had achieved the needed majority by 2011. This article briefly describes the European road to specialty acceptance.
  Academic Emergency Medicine 05/2013; 20(5):514-521.
• Article: An Alternative Approach to the Bedside Assessment of Left Ventricular Systolic Function in the Emergency Department: Displacement of the Aortic Root

  Erden Erol Ünlüer, Arif Karagöz, Serdar Bayata, Haldun Akoğlu
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  ABSTRACT: Objectives Left ventricular ejection fraction (LVEF) is a crucial parameter in the management of patients with dyspnea in the emergency department (ED). The use of techniques other than echocardiography such as nuclear or magnetic resonance imaging to measure LVEF is unsuitable in the ED because of time constraints. This study aimed to compare echocardiographic aortic root (AR) excursion and LVEF measurement using the modified Simpson's method (biplane method of disks) as recommended by the American Society of Echocardiography. Methods After 2 hours of theoretical video and hands-on training with 20 patients by an experienced echocardiographer, two emergency physicians prospectively evaluated patients with dyspnea. Two-dimensional echocardiograms of the parasternal long-axis view were obtained, and the displacement of the aortic root (DAR) was studied. M-mode DAR recordings were obtained, and distances were measured as the maximized anterior displacement of the AR from the horizontal axis at end-systole by using the leading-edge methodology. LVEF was measured by an experienced cardiologist using the modified Simpson's rule. The sensitivity, specificity, positive and negative likelihood ratios (LR+, LR–), and positive and negative predictive values (PPV, NPV) were analyzed. A new formula for the prediction of the ejection fraction (EF) with the aid of DAR was then created. Results The mean (±SD) age with of the 70 study patients was 69.7 (±11.91) years. In these patients, DAR was highly correlated with EF (point biserial correlation coefficient = 0.79, p < 0.001) and one-way analysis of variance (ANOVA) results were significant (F = 115.9; p < 0.001). The sensitivity was 94.4; specificity, 94.1; LR+, 16.6; LR–, 0.059; PPV, 94.4; and NPV, 94.1. Conclusions The results indicate that DAR is a sensitive index of left ventricular systolic function (SF) and can be used to reliably predict EF values using the rough formula of EF = 20 + 44 (DAR).
  Academic Emergency Medicine 04/2013;
• Article: Safety and Efficiency of Calcium Channel Blockers Versus Beta-blockers for Rate Control in Patients With Atrial Fibrillation and No Acute Underlying Medical Illness.

  Frank Xavier Scheuermeyer, Eric Grafstein, Rob Stenstrom, Jim Christenson, Claire Heslop, Brett Heilbron, Lorraine McGrath, Grant Innes
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  ABSTRACT: Many patients with atrial fibrillation (AF) are not candidates for rhythm control and may require rate control, typically with beta-blocking (BB) or calcium channel blocking (CCB) agents. Although these patients appear to have a low 30-day rate of stroke or death, it is unclear if one class of agent is safer or more effective. The objective was to determine whether BBs or CCBs would have a lower hospital admission rate and to measure 30-day safety outcomes including stroke, death, and emergency department (ED) revisits. This retrospective cohort study used a database from two urban EDs to identify consecutive patients with ED discharge diagnoses of AF from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with acute underlying medical conditions were excluded by predefined criteria. Patients managed only with rate control agents were eligible for review, and patients receiving BB agents were compared to those receiving CCB agents. The primary outcome was the proportion of patients requiring hospital admission; secondary outcomes included the ED length of stay (LOS), the proportion of patients having adverse events, the proportion of patients returning within 7 or 30 days, and the number of patients having a stroke or dying within 30 days. A total of 259 consecutive patients were enrolled, with 100 receiving CCBs and 159 receiving BBs. Baseline demographics and comorbidities were similar. Twenty-seven percent of BB patients were admitted, and 31.0% of CCB patients were admitted (difference = 4.0%, 95% confidence interval [CI] = -7.7% to 16.1%), and there were no significant differences in ED LOS, adverse events, or 7- or 30-day ED revisits. One patient who received metoprolol had a stroke, and one patient who received diltiazem died within 30 days. In this cohort of ED patients with AF and no acute underlying medical illness who underwent rate control only, patients receiving CCBs had similar hospital admission rates to those receiving BBs, while both classes of medications appeared equally safe at 30 days. Both CCBs and BBs are acceptable options for rate control.
  Academic Emergency Medicine 03/2013; 20(3):222-30.
• Article: Reduction in observation unit length of stay with coronary computed tomography angiography depends on time of emergency department presentation.

  Simon A Mahler, Brian C Hiestand, Jamaji Nwanaji-Enwerem, David C Goff, Gregory L Burke, L Douglas Case, Bret Nicks, Chadwick D Miller
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  ABSTRACT: Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.
  Academic Emergency Medicine 03/2013; 20(3):231-9.
• Article: Focusing a gender lens on emergency medicine research: 2012 update.

  Alyson J McGregor, Marna Greenberg, Basmah Safdar, Todd Seigel, Robert Hendrickson, Stacey Poznanski, Moira Davenport, James Miner, Esther K Choo
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  ABSTRACT: The influence of sex and gender on patient care is just being recognized in emergency medicine (EM). Providers are realizing the need to improve outcomes for both men and women by incorporating sex- and gender-specific science into clinical practice, while EM researchers are now beginning to study novel sex- and gender-specific perspectives in the areas of acute care research. This article serves as an update on the sex differences in a variety of acute clinical care topics within the field of EM and showcases opportunities for improving patient care outcomes and expanding research to advance the science of gender-specific emergency care.
  Academic Emergency Medicine 03/2013; 20(3):313-20.
• Article: Assessing the validity evidence of an objective structured assessment tool of technical skills for neonatal lumbar punctures.

  Maya S Iyer, Sally A Santen, Michele Nypaver, Kavita Warrier, Stuart Bradin, Rachel Chapman, Jennifer McAllister, Jennifer Vredeveld, Joseph B House
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  ABSTRACT: The lumbar puncture (LP) is a procedural competency deemed necessary by the Accreditation Council for Graduate Medical Education and the Emergency Medicine and Pediatric Residency Review Committees. The emergency department (ED) is a primary site for residents to be evaluated performing neonatal LPs. Current evaluation methods lack validity evidence as assessment tools. This was a pilot study to develop an objective structured assessment of technical skills for neonatal LP (OSATS-LP) and to document validity evidence for the instrument in regard to five sources of test validity: content, response process, relation to other variables, inter-rater reliability, and consequences of testing. Pediatric residents were videotaped in the fall of 2011 for comparison of faculty evaluation of resident performance during a neonatal LP using a video-delayed format. Residents completed a demographic experience survey evaluating relations to other variables. Content and response process validity was obtained through expert panel meetings and resulted in the following seven domains of performance for the OSATS-LP: preparation, positioning, analgesia, needle insertion, cerebrospinal fluid (CSF) collection, management of laboratory studies, and sterility. t-tests assessed significance between level of training, previous intensive care unit experience, and residents' self-assessed confidence in comparison with their total performance score. The inter-rater agreement of the OSATS-LP was obtained using the Fleiss' kappa for each domain. Sixteen pediatric residents completed the simulation with six raters evaluating each resident (96 ratings). The domains of sterility and CSF collection had moderate statistical reliability (κ = 0.41 and 0.51, respectively). The domains of preparation, analgesia, and management of laboratories had substantial reliability (κ = 0.60, 0.62, and 0.62, respectively). The domains of positioning and needle insertion were less reliable (κ = 0.16 and 0.16, respectively). Individuals who had completed one or more rotations in the neonatal intensive care unit (NICU) had a higher total score (12.5 vs. 16.9; p < 0.01). The residents' own perception of ability to perform an LP unsupervised did not result in a higher total score. The OSATS-LP has reasonable evidence in four of the five sources for test validity. This study serves as a launching point for using this tool in clinical environments such as the ED and, therefore, has the potential to provide real-time formative and summative feedback to improve resident skills and ultimately lead to improvements in patient care.
  Academic Emergency Medicine 03/2013; 20(3):321-4.
• Article: Interpreting red blood cells in lumbar puncture: distinguishing true subarachnoid hemorrhage from traumatic tap.

  Amanda D Czuczman, Lisa E Thomas, Alyson B Boulanger, David A Peak, Emily L Senecal, David F Brown, Keith A Marill
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  ABSTRACT: The study purpose was to determine the optimal use of lumbar puncture (LP) red blood cell (RBC) counts to identify subarachnoid hemorrhage (SAH) when some blood remains in the final tube. A case series was performed at a tertiary emergency department (ED). Records of 4,496 consecutive adult patients billed for LPs between 2001 and 2009 were reviewed. Inclusion criteria were headache (HA), final tube RBCs ≥ 5, and neurovascular imaging within 2 weeks of the visit. Demographics, relevant history and physical examination components, LP results, and neuroimaging findings were recorded for 280 patients. True-positive (TP) and true-negative (TN) SAH were strictly defined. Primary outcomes were the areas under the receiver operating characteristic curves (AUC) for final tube RBC count, differential RBC count between the final and initial tubes, and absolute differential RBC count between the final and initial tubes divided by the mean RBC count of the two tubes (also called the percent change in RBC count). There were 26 TP and 196 TN results; 58 patients were neither. The TP group consisted of 19 patients with visible or possible SAH on imaging (17 on noncontrast head computed tomography [CT; 12 definite and five possible] and two on magnetic resonance imaging), six with xanthochromia and a vascular lesion (aneurysm or arteriovenous malformation [AVM] > 2 mm), and one with xanthochromia and polymerase chain reaction (PCR)-positive meningitis. As a test for SAH, final tube RBC AUC was 0.85 (95% confidence interval [CI] = 0.80 to 0.91). Interval likelihood ratios (LRs) for final tube RBC count were LR 0 (95% CI = 0 to 0.3) for RBCs < 100, LR 1.6 (95% CI = 1.1 to 2.3) for 100 < RBCs < 10,000, and LR 6.3 (95% CI = 4.8 to 23.4) for RBCs > 10,000. Differential RBC count was not associated with SAH, with AUC 0.45 (95% CI = 0.31 to 0.60). However, the percent change in RBC count between the final and initial tubes had an AUC 0.84 (95% CI = 0.78 to 0.90), and the optimal test threshold for SAH was 0.63, with positive LR 3.6 (95% CI = 2.7 to 4.7) and negative LR 0.10 (95% CI = 0.03 to 0.4) for percent change <63% and >63%, respectively. This test added additional independent information to the final tube RBC count based on improved logistic regression model fit and discriminatory ability as measured by the LR test and c statistic, respectively. Final LP tube RBC count and the percent change in RBC count, but not the simple differential count between the final and initial tubes, were associated with SAH. In this sample, there were no patients with SAH who had RBCs < 100 in the final tube, and RBCs > 10,000 increased the odds of SAH by a factor of 6.
  Academic Emergency Medicine 03/2013; 20(3):247-56.
• Article: Emergency department management of childhood pneumonia in the United States prior to publication of national guidelines.

  Mark I Neuman, Samir S Shah, Daniel J Shapiro, Adam L Hersh
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  ABSTRACT: Recent publication of national guidelines by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) provide recommendations around diagnostic testing and antibiotic treatment for children with community-acquired pneumonia (CAP). These guidelines emphasize limited use of chest radiograph (CXR) and complete blood count (CBC) and routinely performing viral testing and use of narrow-spectrum antibiotics. The objective was to estimate the rate of emergency department (ED) visits for pediatric CAP in the United States and to describe management of patients prior to publication of consensus national guidelines. Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits from 2001 through 2009 for children with CAP. During the study period there were an estimated 375,000 ED visits for CAP annually; 85% occurred within a general, rather than pediatric, ED. Overall, 20% of children with CAP were hospitalized. Among children discharged from EDs with CAP, CBC was performed during 30% of visits, CXR during 83%, and viral testing in only 13%. Twelve percent of children discharged from EDs with CAP had blood cultures obtained. No major differences were observed in the rates of laboratory testing or antibiotic administration between children treated in general versus pediatric EDs. During the study period, only 21% of children discharged from EDs with CAP received amoxicillin, the guideline-recommended antibiotic. Most ED visits for CAP in the United States occur in general EDs. To encourage care that is consistent with national guidelines, efforts should be made to reduce the performance of certain diagnostic testing, such as CBC and CXR, among children discharged from EDs with CAP. Additionally, the use of narrow-spectrum antibiotics should be encouraged.
  Academic Emergency Medicine 03/2013; 20(3):240-6.
• Article: Uncomfortable.

  Rebekah Mannix, Vincent Chiang
  Academic Emergency Medicine 03/2013; 20(3):325-6.