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ABSTRACT: Research into emergency medicine (EM) diagnostic errors identified imaging as a contributing factor in 94% of cases. Discrepancies between the preliminary (trainee) and the final (attending) diagnostic imaging interpretation represent a system issue that is particularly prone to creating diagnostic errors. Understanding the types of systematic communication and documentation strategies developed by academic radiology departments to address differences between preliminary and final radiology interpretations to clinicians are threshold steps toward minimizing this risk. This study investigates policies and practices associated with the communication and documentation of preliminary and final radiologic interpretations among U.S. academic radiology departments through a questionnaire directed at radiology department chairs.
Journal of healthcare risk management: the journal of the American Society for Healthcare Risk Management 01/2011; 30(3):23-7.
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ABSTRACT: Emergency medicine (EM) in North America has been undergoing significant transformation since the new century. Recent health care reform has put it center stage. Access demand for acute care is increasing at the same time the number of qualified emergency physicians entering service has reached a plateau. Physician assistants (PAs), one alternative, are employed in emergency departments (EDs), but little is known about the impact of their role.
This was a literature review to identify the current role of PAs in patient treatment and the management of emergency services.
All publications and designs from 1970 through 2009 were identified using multiple science citation indices. Each author reviewed the literature, and categories were developed based on consensus.
Thirty-five articles and reports were sorted into categories of interest: prevalence of PAs in EDs, efficiency and quality of care, patient satisfaction, rural emergency care, and legal issues. Each category is summarized and discussed. Evidence comparing the clinical effectiveness of PAs to mainstream management of emergency care was only fair in methodologic quality.
The use of PAs in EDs is increasing, and this expansion is due to necessity in staffing and economy of scale. Unique uses of PAs include wound management, acute care transfer management to the wards, and rural health emergency staffing. While their role seems to be expanding, this assessment identified gaps in deployment research using appropriate outcome measures in the area of clinical effectiveness of PAs.
Academic Emergency Medicine 12/2010; 18(1):72-7. · 1.86 Impact Factor
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ABSTRACT: Estrogen and progesterone improve neurologic outcomes in experimental models of cardiac arrest and stroke. Our objective was to determine whether women of child-bearing age are more likely than men to survive to hospital discharge after in-hospital cardiac arrest.
Prospective, observational study.
Five hundred nineteen hospitals in the National Registry of Cardiopulmonary Resuscitation database.
Patients included 95,852 men and women 15-44 yrs and 56 yrs or older with pulseless cardiac arrests from January 1, 2000 through July 31, 2008.
Patients were stratified a priori by gender and age groups (15-44 yrs and > or =56 yrs). Fixed-effects regression conditioning on hospital was used to examine the relationship between age, gender, and survival outcomes. The unadjusted survival to discharge rate for younger women of child-bearing age (15-44 yrs) was 19% (940/4887) vs. 17% (1203/7025) for younger men (p = .013). The adjusted hospital discharge difference between these younger women and men was 2.8% (95% confidence interval, 1.0% to 4.6%; p = .002), and these younger women also had a 2.6% (95% confidence interval, 0.9% to 4.3%; p = .002) absolute increase in favorable neurologic outcome. For older women compared with men (> or =56 yrs), there were no demonstrable differences in discharge rates (18% vs. 18%; adjusted difference, -0.1%; 95% confidence interval, -0.9% to 0.6%; p = .68) or favorable neurologic outcome (14% vs. 14%; adjusted difference, -0.1%; 95% confidence interval, -0.7% to 0.5%; p = .74).
Women of child-bearing age were more likely than comparably aged men to survive to hospital discharge after in-hospital cardiac arrest, even after controlling for etiology of arrest and other important variables.
Critical care medicine 03/2010; 38(5):1254-60. · 6.37 Impact Factor
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Mary Ann Peberdy,
Joseph P Ornato, G Luke Larkin,
R Scott Braithwaite,
T Michael Kashner,
Scott M Carey,
Peter A Meaney,
Liyi Cen,
Vinay M Nadkarni,
Amy H Praestgaard,
Robert A Berg
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ABSTRACT: Occurrence of in-hospital cardiac arrest and survival patterns have not been characterized by time of day or day of week. Patient physiology and process of care for in-hospital cardiac arrest may be different at night and on weekends because of hospital factors unrelated to patient, event, or location variables.
To determine whether outcomes after in-hospital cardiac arrest differ during nights and weekends compared with days/evenings and weekdays.
We examined survival from cardiac arrest in hourly time segments, defining day/evening as 7:00 am to 10:59 pm, night as 11:00 pm to 6:59 am, and weekend as 11:00 pm on Friday to 6:59 am on Monday, in 86,748 adult, consecutive in-hospital cardiac arrest events in the National Registry of Cardiopulmonary Resuscitation obtained from 507 medical/surgical participating hospitals from January 1, 2000, through February 1, 2007.
The primary outcome of survival to discharge and secondary outcomes of survival of the event, 24-hour survival, and favorable neurological outcome were compared using odds ratios and multivariable logistic regression analysis. Point estimates of survival outcomes are reported as percentages with 95% confidence intervals (95% CIs).
A total of 58,593 cases of in-hospital cardiac arrest occurred during day/evening hours (including 43,483 on weekdays and 15,110 on weekends), and 28,155 cases occurred during night hours (including 20,365 on weekdays and 7790 on weekends). Rates of survival to discharge (14.7% [95% CI, 14.3%-15.1%] vs 19.8% [95% CI, 19.5%-20.1%], return of spontaneous circulation for longer than 20 minutes (44.7% [95% CI, 44.1%-45.3%] vs 51.1% [95% CI, 50.7%-51.5%]), survival at 24 hours (28.9% [95% CI, 28.4%-29.4%] vs 35.4% [95% CI, 35.0%-35.8%]), and favorable neurological outcomes (11.0% [95% CI, 10.6%-11.4%] vs 15.2% [95% CI, 14.9%-15.5%]) were substantially lower during the night compared with day/evening (all P values < .001). The first documented rhythm at night was more frequently asystole (39.6% [95% CI, 39.0%-40.2%] vs 33.5% [95% CI, 33.2%-33.9%], P < .001) and less frequently ventricular fibrillation (19.8% [95% CI, 19.3%-20.2%] vs 22.9% [95% CI, 22.6%-23.2%], P < .001). Among in-hospital cardiac arrests occurring during day/evening hours, survival was higher on weekdays (20.6% [95% CI, 20.3%-21%]) than on weekends (17.4% [95% CI, 16.8%-18%]; odds ratio, 1.15 [95% CI, 1.09-1.22]), whereas among in-hospital cardiac arrests occurring during night hours, survival to discharge was similar on weekdays (14.6% [95% CI, 14.1%-15.2%]) and on weekends (14.8% [95% CI, 14.1%-15.2%]; odds ratio, 1.02 [95% CI, 0.94-1.11]).
Survival rates from in-hospital cardiac arrest are lower during nights and weekends, even when adjusted for potentially confounding patient, event, and hospital characteristics.
JAMA The Journal of the American Medical Association 03/2008; 299(7):785-92. · 30.03 Impact Factor
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ABSTRACT: To describe trends in anxiety-related mental health visits to U.S. emergency departments, an expanding portal of access for mental health care.
Data from 1992 through 2001 were obtained from the National Hospital Ambulatory Medical Care Survey using mental health-related ICD-9-CM, E- and V-codes as well as National Center for Health Statistics-assigned Patient Reason-for-Visit classification codes. Population-weighted anxiety-related emergency department visit rates were analyzed over time by age, gender, race, Hispanic ethnicity, insurance status, urban status, region of the country, urgency of presentation, and use of medication.
There were 53 million mental health-related visits, increasing from 4.9% to 6.3% of all emergency department visits (p = .003) and from 17.1 to 23.6 per 1000 U.S. population across the decade (p = .000). Anxiety-related visits were common (16% of all mental health visits) and increased significantly from 3.5 to 5.0 visits per 1000 U.S. population over the decade (p = .011). Anxiety-related visits increased significantly among non-Hispanic whites, children (< 15 years), adults younger than 49 years, and the privately insured; changes among Medicare, Medicaid, and self-pay patients were not significant. Overall hospitalization rates declined from 23% to 21% between 1992 and 2001 (p = .037), but they did not change significantly for anxiety-related visits (8%), which remained the least likely visit type to be admitted of all mental health visits for the entire decade. In contrast to rural emergency departments, urban emergency departments witnessed significant increases in anxiety-related visits, rising from 2.9 to 5.2 per 1000 U.S. population across the decade (p trend = 0.007). Regionally, anxiety-related visits were highest in the Northeast, lowest in the West, and increased significantly in only the South and Northeast.
During the decade, there was an expansion of anxiety-related visits to U.S. emergency departments, reflecting an increase in anxiety-related emergency department care-seeking, an increase in anxiety awareness among patients and practitioners, or both.
The Journal of Clinical Psychiatry 02/2008; 69(2):286-94. · 5.80 Impact Factor
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ABSTRACT: Age is an important determinant of outcome from adult cardiac arrests but has not been identified previously as an important factor in pediatric cardiac arrests except among premature infants. Chest compressions can result in more effective blood flow during cardiac arrest in an infant than an older child or adult because of increased chest wall compliance. We, therefore, hypothesized that survival from cardiac arrest would be better among infants than older children.
We evaluated 464 pediatric ICU arrests from the National Registry of Cardiopulmonary Resuscitation from 2000 to 2002. NICU cardiac arrests were excluded. Data from each arrest include >200 variables describing facility, patient, prearrest, arrest intervention, outcome, and quality improvement data. Age was categorized as newborn (<1 month; N = 62), infant (1 month to <1 year; N = 105), younger child (1 year to <8 years; N = 90), and older child (8 years to <21 years; N = 207). Multivariable logistic regression was performed to examine the association between age and survival.
Overall survival was 22%, with 27% of newborns, 36% of infants, 19% of younger children and 16% of older children surviving to hospital discharge. Newborns and infants demonstrated double and triple the odds of surviving to hospital discharge from a cardiac arrest in an intensive care setting when compared with older children. When potential confounders were controlled, newborns increased their advantage to almost fivefold, while infants maintained their survival advantage to older children.
Survival from pediatric ICU cardiac arrest is age dependent. Newborns and infants have better survival rates even after adjusting for potential confounding variables.
PEDIATRICS 01/2007; 118(6):2424-33. · 4.47 Impact Factor
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ABSTRACT: Potential bioterrorism challenges policy makers to balance competing public health priorities. Earlier surveys showed low physician bioterrorism preparedness but did not assess physicians' general public health preparedness, compare the preparedness of emergency and primary care physicians, or assess temporal trends.
This was a national, cross-sectional, random-sample survey conducted in 2003.
Overall, 744 of 1,200 eligible physicians responded (response rate, 62%). Of these, 58% of emergency physician respondents and 48% of primary care physician respondents reported having learned a lot about responding to bioterror since September 11, 2001 (p < 0.01). However, only 43% of emergency physicians and 21% of primary care physicians agreed they are generally "well prepared to play a role in responding to a bioterror attack" (p < 0.001). Beliefs about balancing public health priorities were similar among emergency and primary care respondents. Seventy-eight percent of respondents believed that local health care systems need to be prepared for bioterrorism, and 92% believed that local health care systems need to be prepared for natural epidemics. By contrast, only 23% and 46% of respondents reported that their local health care systems are well prepared for bioterrorism and natural epidemics, respectively. Meanwhile, 77% agreed that "influenza is a greater threat to public health than bioterrorism," and 21% reported that bioterrorism preparedness efforts are diverting resources from more important public health problems.
In 2003, most emergency and primary care physicians reported that they and their local health care systems were not yet well prepared to respond to a bioterror attack, and many believed that more resources should go toward preparing for natural epidemics. These findings highlight the importance of expanding bioterrorism preparedness efforts to improve the public health system more broadly.
Academic Emergency Medicine 11/2006; 13(11):1238-41. · 1.86 Impact Factor
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ABSTRACT: Retrospective studies of patients with cocaine-associated chest pain suggest that a strategy of discharging patients from the emergency department after a 12-hour observation period if they do not have evidence of ischemia should be associated with a very low rate of complications.
We prospectively evaluated the safety of a 9-to-12-hour observation period in patients with cocaine-associated chest pain who were at low-to-intermediate risk of cardiovascular events. Consecutive patients who reported or tested positive for cocaine use and who received protocol-driven care in a chest-pain observation unit were included. Patients who had normal levels of troponin I, without new ischemic changes on electrocardiography, and who had no cardiovascular complications (dysrhythmias, acute myocardial infarction, or recurrent symptoms) during the 9-to-12-hour observation period were discharged from the unit. The main outcome was death from cardiovascular causes at 30 days.
Three hundred forty-four patients with cocaine-associated chest pain were evaluated. Forty-two of these patients (12 percent) were directly admitted to the hospital. The study cohort comprised the remaining 302 patients. During the 30-day follow-up period, none of the patients died of a cardiovascular event (0 percent; 95 percent confidence interval, 0 to 0.99), and only 4 of the 256 patients for whom detailed follow-up data were available had a nonfatal myocardial infarction (1.6 percent; 95 percent confidence interval, 0.1 to 3.1). All four nonfatal myocardial infarctions occurred in patients who continued to use cocaine.
Patients with cocaine-associated chest pain who do not have evidence of ischemia or cardiovascular complications over a 9-to-12-hour period in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge.
New England Journal of Medicine 03/2003; 348(6):510-7. · 53.30 Impact Factor
