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Publisher: John Wiley and Sons   (Total: 1592 journals)

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Showing 1 - 200 of 1592 Journals sorted alphabetically
Abacus     Hybrid Journal   (Followers: 13, SJR: 0.48, h-index: 22)
About Campus     Hybrid Journal   (Followers: 5)
Academic Emergency Medicine     Hybrid Journal   (Followers: 66, SJR: 1.385, h-index: 91)
Accounting & Finance     Hybrid Journal   (Followers: 47, SJR: 0.547, h-index: 30)
ACEP NOW     Free   (Followers: 1)
Acta Anaesthesiologica Scandinavica     Hybrid Journal   (Followers: 54, SJR: 1.02, h-index: 88)
Acta Archaeologica     Hybrid Journal   (Followers: 173, SJR: 0.101, h-index: 9)
Acta Geologica Sinica (English Edition)     Hybrid Journal   (Followers: 3, SJR: 0.552, h-index: 41)
Acta Neurologica Scandinavica     Hybrid Journal   (Followers: 5, SJR: 1.203, h-index: 74)
Acta Obstetricia et Gynecologica Scandinavica     Hybrid Journal   (Followers: 14, SJR: 1.197, h-index: 81)
Acta Ophthalmologica     Hybrid Journal   (Followers: 6, SJR: 0.112, h-index: 1)
Acta Paediatrica     Hybrid Journal   (Followers: 56, SJR: 0.794, h-index: 88)
Acta Physiologica     Hybrid Journal   (Followers: 6, SJR: 1.69, h-index: 88)
Acta Polymerica     Hybrid Journal   (Followers: 9)
Acta Psychiatrica Scandinavica     Hybrid Journal   (Followers: 37, SJR: 2.518, h-index: 113)
Acta Zoologica     Hybrid Journal   (Followers: 7, SJR: 0.459, h-index: 29)
Acute Medicine & Surgery     Hybrid Journal   (Followers: 5)
Addiction     Hybrid Journal   (Followers: 36, SJR: 2.086, h-index: 143)
Addiction Biology     Hybrid Journal   (Followers: 15, SJR: 2.091, h-index: 57)
Adultspan J.     Hybrid Journal   (SJR: 0.127, h-index: 4)
Advanced Energy Materials     Hybrid Journal   (Followers: 26, SJR: 6.411, h-index: 86)
Advanced Engineering Materials     Hybrid Journal   (Followers: 26, SJR: 0.81, h-index: 81)
Advanced Functional Materials     Hybrid Journal   (Followers: 51, SJR: 5.21, h-index: 203)
Advanced Healthcare Materials     Hybrid Journal   (Followers: 14, SJR: 0.232, h-index: 7)
Advanced Materials     Hybrid Journal   (Followers: 280, SJR: 9.021, h-index: 345)
Advanced Materials Interfaces     Hybrid Journal   (Followers: 6, SJR: 1.177, h-index: 10)
Advanced Optical Materials     Hybrid Journal   (Followers: 7, SJR: 2.488, h-index: 21)
Advanced Science     Open Access   (Followers: 5)
Advanced Synthesis & Catalysis     Hybrid Journal   (Followers: 18, SJR: 2.729, h-index: 121)
Advances in Polymer Technology     Hybrid Journal   (Followers: 13, SJR: 0.344, h-index: 31)
Africa Confidential     Hybrid Journal   (Followers: 21)
Africa Research Bulletin: Economic, Financial and Technical Series     Hybrid Journal   (Followers: 13)
Africa Research Bulletin: Political, Social and Cultural Series     Hybrid Journal   (Followers: 11)
African Development Review     Hybrid Journal   (Followers: 33, SJR: 0.275, h-index: 17)
African J. of Ecology     Hybrid Journal   (Followers: 16, SJR: 0.477, h-index: 39)
Aggressive Behavior     Hybrid Journal   (Followers: 16, SJR: 1.391, h-index: 66)
Aging Cell     Open Access   (Followers: 11, SJR: 4.374, h-index: 95)
Agribusiness : an Intl. J.     Hybrid Journal   (Followers: 3, SJR: 0.627, h-index: 14)
Agricultural and Forest Entomology     Hybrid Journal   (Followers: 16, SJR: 0.925, h-index: 43)
Agricultural Economics     Hybrid Journal   (Followers: 45, SJR: 1.099, h-index: 51)
AIChE J.     Hybrid Journal   (Followers: 32, SJR: 1.122, h-index: 120)
Alcoholism and Drug Abuse Weekly     Hybrid Journal   (Followers: 7)
Alcoholism Clinical and Experimental Research     Hybrid Journal   (Followers: 7, SJR: 1.416, h-index: 125)
Alimentary Pharmacology & Therapeutics     Hybrid Journal   (Followers: 34, SJR: 2.833, h-index: 138)
Alimentary Pharmacology & Therapeutics Symposium Series     Hybrid Journal   (Followers: 3)
Allergy     Hybrid Journal   (Followers: 51, SJR: 3.048, h-index: 129)
Alternatives to the High Cost of Litigation     Hybrid Journal   (Followers: 3)
American Anthropologist     Hybrid Journal   (Followers: 154, SJR: 0.951, h-index: 61)
American Business Law J.     Hybrid Journal   (Followers: 24, SJR: 0.205, h-index: 17)
American Ethnologist     Hybrid Journal   (Followers: 94, SJR: 2.325, h-index: 51)
American J. of Economics and Sociology     Hybrid Journal   (Followers: 29, SJR: 0.211, h-index: 26)
American J. of Hematology     Hybrid Journal   (Followers: 35, SJR: 1.761, h-index: 77)
American J. of Human Biology     Hybrid Journal   (Followers: 13, SJR: 1.018, h-index: 58)
American J. of Industrial Medicine     Hybrid Journal   (Followers: 16, SJR: 0.993, h-index: 85)
American J. of Medical Genetics Part A     Hybrid Journal   (Followers: 17, SJR: 1.115, h-index: 61)
American J. of Medical Genetics Part B: Neuropsychiatric Genetics     Hybrid Journal   (Followers: 4, SJR: 1.771, h-index: 107)
American J. of Medical Genetics Part C: Seminars in Medical Genetics     Partially Free   (Followers: 6, SJR: 2.315, h-index: 79)
American J. of Physical Anthropology     Hybrid Journal   (Followers: 38, SJR: 1.41, h-index: 88)
American J. of Political Science     Hybrid Journal   (Followers: 298, SJR: 5.101, h-index: 114)
American J. of Primatology     Hybrid Journal   (Followers: 15, SJR: 1.197, h-index: 63)
American J. of Reproductive Immunology     Hybrid Journal   (Followers: 4, SJR: 1.347, h-index: 75)
American J. of Transplantation     Hybrid Journal   (Followers: 18, SJR: 2.792, h-index: 140)
American J. on Addictions     Hybrid Journal   (Followers: 10, SJR: 0.843, h-index: 57)
Anaesthesia     Hybrid Journal   (Followers: 141, SJR: 1.404, h-index: 88)
Analyses of Social Issues and Public Policy     Hybrid Journal   (Followers: 10, SJR: 0.397, h-index: 18)
Analytic Philosophy     Hybrid Journal   (Followers: 20)
Anatomia, Histologia, Embryologia: J. of Veterinary Medicine Series C     Hybrid Journal   (Followers: 3, SJR: 0.295, h-index: 27)
Anatomical Sciences Education     Hybrid Journal   (Followers: 1, SJR: 0.633, h-index: 24)
Andrologia     Hybrid Journal   (Followers: 2, SJR: 0.528, h-index: 45)
Andrology     Hybrid Journal   (Followers: 2, SJR: 0.979, h-index: 14)
Angewandte Chemie     Hybrid Journal   (Followers: 168)
Angewandte Chemie Intl. Edition     Hybrid Journal   (Followers: 237, SJR: 6.229, h-index: 397)
Animal Conservation     Hybrid Journal   (Followers: 41, SJR: 1.576, h-index: 62)
Animal Genetics     Hybrid Journal   (Followers: 8, SJR: 0.957, h-index: 67)
Animal Science J.     Hybrid Journal   (Followers: 6, SJR: 0.569, h-index: 24)
Annalen der Physik     Hybrid Journal   (Followers: 5, SJR: 1.46, h-index: 40)
Annals of Anthropological Practice     Partially Free   (Followers: 2, SJR: 0.187, h-index: 5)
Annals of Applied Biology     Hybrid Journal   (Followers: 7, SJR: 0.816, h-index: 56)
Annals of Clinical and Translational Neurology     Open Access   (Followers: 1)
Annals of Human Genetics     Hybrid Journal   (Followers: 9, SJR: 1.191, h-index: 67)
Annals of Neurology     Hybrid Journal   (Followers: 49, SJR: 5.584, h-index: 241)
Annals of Noninvasive Electrocardiology     Hybrid Journal   (Followers: 1, SJR: 0.531, h-index: 38)
Annals of Public and Cooperative Economics     Hybrid Journal   (Followers: 8, SJR: 0.336, h-index: 23)
Annals of the New York Academy of Sciences     Hybrid Journal   (Followers: 5, SJR: 2.389, h-index: 189)
Annual Bulletin of Historical Literature     Hybrid Journal   (Followers: 12)
Annual Review of Information Science and Technology     Hybrid Journal   (Followers: 14)
Anthropology & Education Quarterly     Hybrid Journal   (Followers: 26, SJR: 0.72, h-index: 31)
Anthropology & Humanism     Hybrid Journal   (Followers: 18, SJR: 0.137, h-index: 3)
Anthropology News     Hybrid Journal   (Followers: 15)
Anthropology of Consciousness     Hybrid Journal   (Followers: 11, SJR: 0.172, h-index: 5)
Anthropology of Work Review     Hybrid Journal   (Followers: 11, SJR: 0.256, h-index: 5)
Anthropology Today     Hybrid Journal   (Followers: 93, SJR: 0.545, h-index: 15)
Antipode     Hybrid Journal   (Followers: 53, SJR: 2.212, h-index: 69)
Anz J. of Surgery     Hybrid Journal   (Followers: 8, SJR: 0.432, h-index: 59)
Anzeiger für Schädlingskunde     Hybrid Journal   (Followers: 1)
Apmis     Hybrid Journal   (Followers: 1, SJR: 0.855, h-index: 73)
Applied Cognitive Psychology     Hybrid Journal   (Followers: 73, SJR: 0.754, h-index: 69)
Applied Organometallic Chemistry     Hybrid Journal   (Followers: 7, SJR: 0.632, h-index: 58)
Applied Psychology     Hybrid Journal   (Followers: 180, SJR: 1.023, h-index: 64)
Applied Psychology: Health and Well-Being     Hybrid Journal   (Followers: 51, SJR: 0.868, h-index: 13)
Applied Stochastic Models in Business and Industry     Hybrid Journal   (Followers: 5, SJR: 0.613, h-index: 24)
Aquaculture Nutrition     Hybrid Journal   (Followers: 13, SJR: 1.025, h-index: 55)
Aquaculture Research     Hybrid Journal   (Followers: 31, SJR: 0.807, h-index: 60)
Aquatic Conservation Marine and Freshwater Ecosystems     Hybrid Journal   (Followers: 36, SJR: 1.047, h-index: 57)
Arabian Archaeology and Epigraphy     Hybrid Journal   (Followers: 11, SJR: 0.453, h-index: 11)
Archaeological Prospection     Hybrid Journal   (Followers: 12, SJR: 0.922, h-index: 21)
Archaeology in Oceania     Hybrid Journal   (Followers: 13, SJR: 0.745, h-index: 18)
Archaeometry     Hybrid Journal   (Followers: 30, SJR: 0.809, h-index: 48)
Archeological Papers of The American Anthropological Association     Hybrid Journal   (Followers: 15, SJR: 0.156, h-index: 2)
Architectural Design     Hybrid Journal   (Followers: 27, SJR: 0.261, h-index: 9)
Archiv der Pharmazie     Hybrid Journal   (Followers: 3, SJR: 0.628, h-index: 43)
Archives of Drug Information     Hybrid Journal   (Followers: 5)
Archives of Insect Biochemistry and Physiology     Hybrid Journal   (SJR: 0.768, h-index: 54)
Area     Hybrid Journal   (Followers: 13, SJR: 0.938, h-index: 57)
Art History     Hybrid Journal   (Followers: 269, SJR: 0.153, h-index: 13)
Arthritis & Rheumatology     Hybrid Journal   (Followers: 55, SJR: 1.984, h-index: 20)
Arthritis Care & Research     Hybrid Journal   (Followers: 27, SJR: 2.256, h-index: 114)
Artificial Organs     Hybrid Journal   (Followers: 1, SJR: 0.872, h-index: 60)
ASHE Higher Education Reports     Hybrid Journal   (Followers: 15)
Asia & the Pacific Policy Studies     Open Access   (Followers: 16)
Asia Pacific J. of Human Resources     Hybrid Journal   (Followers: 327, SJR: 0.494, h-index: 19)
Asia Pacific Viewpoint     Hybrid Journal   (Followers: 1, SJR: 0.616, h-index: 26)
Asia-Pacific J. of Chemical Engineering     Hybrid Journal   (Followers: 8, SJR: 0.345, h-index: 20)
Asia-pacific J. of Clinical Oncology     Hybrid Journal   (Followers: 6, SJR: 0.554, h-index: 14)
Asia-Pacific J. of Financial Studies     Hybrid Journal   (SJR: 0.241, h-index: 7)
Asia-Pacific Psychiatry     Hybrid Journal   (Followers: 4, SJR: 0.377, h-index: 7)
Asian Economic J.     Hybrid Journal   (Followers: 8, SJR: 0.234, h-index: 21)
Asian Economic Policy Review     Hybrid Journal   (Followers: 4, SJR: 0.196, h-index: 12)
Asian J. of Control     Hybrid Journal   (SJR: 0.862, h-index: 34)
Asian J. of Endoscopic Surgery     Hybrid Journal   (Followers: 1, SJR: 0.394, h-index: 7)
Asian J. of Organic Chemistry     Hybrid Journal   (Followers: 6, SJR: 1.443, h-index: 19)
Asian J. of Social Psychology     Hybrid Journal   (Followers: 5, SJR: 0.665, h-index: 37)
Asian Politics and Policy     Hybrid Journal   (Followers: 12, SJR: 0.207, h-index: 7)
Asian Social Work and Policy Review     Hybrid Journal   (Followers: 5, SJR: 0.318, h-index: 5)
Asian-pacific Economic Literature     Hybrid Journal   (Followers: 5, SJR: 0.168, h-index: 15)
Assessment Update     Hybrid Journal   (Followers: 4)
Astronomische Nachrichten     Hybrid Journal   (Followers: 3, SJR: 0.701, h-index: 40)
Atmospheric Science Letters     Open Access   (Followers: 29, SJR: 1.332, h-index: 27)
Austral Ecology     Hybrid Journal   (Followers: 15, SJR: 1.095, h-index: 66)
Austral Entomology     Hybrid Journal   (Followers: 9, SJR: 0.524, h-index: 28)
Australasian J. of Dermatology     Hybrid Journal   (Followers: 8, SJR: 0.714, h-index: 40)
Australasian J. On Ageing     Hybrid Journal   (Followers: 6, SJR: 0.39, h-index: 22)
Australian & New Zealand J. of Statistics     Hybrid Journal   (Followers: 14, SJR: 0.275, h-index: 28)
Australian Accounting Review     Hybrid Journal   (Followers: 3, SJR: 0.709, h-index: 14)
Australian and New Zealand J. of Family Therapy (ANZJFT)     Hybrid Journal   (Followers: 3, SJR: 0.382, h-index: 12)
Australian and New Zealand J. of Obstetrics and Gynaecology     Hybrid Journal   (Followers: 47, SJR: 0.814, h-index: 49)
Australian and New Zealand J. of Public Health     Hybrid Journal   (Followers: 13, SJR: 0.82, h-index: 62)
Australian Dental J.     Hybrid Journal   (Followers: 6, SJR: 0.482, h-index: 46)
Australian Economic History Review     Hybrid Journal   (Followers: 6, SJR: 0.171, h-index: 12)
Australian Economic Papers     Hybrid Journal   (Followers: 31, SJR: 0.23, h-index: 9)
Australian Economic Review     Hybrid Journal   (Followers: 6, SJR: 0.357, h-index: 21)
Australian Endodontic J.     Hybrid Journal   (Followers: 3, SJR: 0.513, h-index: 24)
Australian J. of Agricultural and Resource Economics     Hybrid Journal   (Followers: 3, SJR: 0.765, h-index: 36)
Australian J. of Grape and Wine Research     Hybrid Journal   (Followers: 5, SJR: 0.879, h-index: 56)
Australian J. of Politics & History     Hybrid Journal   (Followers: 15, SJR: 0.203, h-index: 14)
Australian J. of Psychology     Hybrid Journal   (Followers: 18, SJR: 0.384, h-index: 30)
Australian J. of Public Administration     Hybrid Journal   (Followers: 432, SJR: 0.418, h-index: 29)
Australian J. of Rural Health     Hybrid Journal   (Followers: 6, SJR: 0.43, h-index: 34)
Australian Occupational Therapy J.     Hybrid Journal   (Followers: 74, SJR: 0.59, h-index: 29)
Australian Psychologist     Hybrid Journal   (Followers: 12, SJR: 0.331, h-index: 31)
Australian Veterinary J.     Hybrid Journal   (Followers: 23, SJR: 0.459, h-index: 45)
Autism Research     Hybrid Journal   (Followers: 37, SJR: 2.126, h-index: 39)
Autonomic & Autacoid Pharmacology     Hybrid Journal   (SJR: 0.371, h-index: 29)
Banks in Insurance Report     Hybrid Journal   (Followers: 1)
Basic & Clinical Pharmacology & Toxicology     Hybrid Journal   (Followers: 11, SJR: 0.539, h-index: 70)
Basic and Applied Pathology     Open Access   (Followers: 2, SJR: 0.113, h-index: 4)
Basin Research     Hybrid Journal   (Followers: 5, SJR: 1.54, h-index: 60)
Bauphysik     Hybrid Journal   (Followers: 2, SJR: 0.194, h-index: 5)
Bauregelliste A, Bauregelliste B Und Liste C     Hybrid Journal  
Bautechnik     Hybrid Journal   (Followers: 1, SJR: 0.321, h-index: 11)
Behavioral Interventions     Hybrid Journal   (Followers: 9, SJR: 0.297, h-index: 23)
Behavioral Sciences & the Law     Hybrid Journal   (Followers: 23, SJR: 0.736, h-index: 57)
Berichte Zur Wissenschaftsgeschichte     Hybrid Journal   (Followers: 10, SJR: 0.11, h-index: 5)
Beton- und Stahlbetonbau     Hybrid Journal   (Followers: 2, SJR: 0.493, h-index: 14)
Biochemistry and Molecular Biology Education     Hybrid Journal   (Followers: 6, SJR: 0.311, h-index: 26)
Bioelectromagnetics     Hybrid Journal   (Followers: 1, SJR: 0.568, h-index: 64)
Bioengineering & Translational Medicine     Open Access  
BioEssays     Hybrid Journal   (Followers: 10, SJR: 3.104, h-index: 155)
Bioethics     Hybrid Journal   (Followers: 14, SJR: 0.686, h-index: 39)
Biofuels, Bioproducts and Biorefining     Hybrid Journal   (Followers: 1, SJR: 1.725, h-index: 56)
Biological J. of the Linnean Society     Hybrid Journal   (Followers: 18, SJR: 1.172, h-index: 90)
Biological Reviews     Hybrid Journal   (Followers: 5, SJR: 6.469, h-index: 114)
Biologie in Unserer Zeit (Biuz)     Hybrid Journal   (Followers: 41, SJR: 0.12, h-index: 1)
Biology of the Cell     Full-text available via subscription   (Followers: 9, SJR: 1.812, h-index: 69)
Biomedical Chromatography     Hybrid Journal   (Followers: 6, SJR: 0.572, h-index: 49)
Biometrical J.     Hybrid Journal   (Followers: 5, SJR: 0.784, h-index: 44)
Biometrics     Hybrid Journal   (Followers: 37, SJR: 1.906, h-index: 96)
Biopharmaceutics and Drug Disposition     Hybrid Journal   (Followers: 10, SJR: 0.715, h-index: 44)
Biopolymers     Hybrid Journal   (Followers: 18, SJR: 1.199, h-index: 104)
Biotechnology and Applied Biochemistry     Hybrid Journal   (Followers: 44, SJR: 0.415, h-index: 55)
Biotechnology and Bioengineering     Hybrid Journal   (Followers: 158, SJR: 1.633, h-index: 146)
Biotechnology J.     Hybrid Journal   (Followers: 14, SJR: 1.185, h-index: 51)
Biotechnology Progress     Hybrid Journal   (Followers: 39, SJR: 0.736, h-index: 101)
Biotropica     Hybrid Journal   (Followers: 20, SJR: 1.374, h-index: 71)
Bipolar Disorders     Hybrid Journal   (Followers: 9, SJR: 2.592, h-index: 100)
Birth     Hybrid Journal   (Followers: 38, SJR: 0.763, h-index: 64)
Birth Defects Research Part A : Clinical and Molecular Teratology     Hybrid Journal   (Followers: 2, SJR: 0.727, h-index: 77)
Birth Defects Research Part B: Developmental and Reproductive Toxicology     Hybrid Journal   (Followers: 8, SJR: 0.468, h-index: 47)
Birth Defects Research Part C : Embryo Today : Reviews     Hybrid Journal   (SJR: 1.513, h-index: 55)
BJOG : An Intl. J. of Obstetrics and Gynaecology     Partially Free   (Followers: 251, SJR: 2.083, h-index: 125)

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Journal Cover Academic Emergency Medicine
  [SJR: 1.385]   [H-I: 91]   [66 followers]  Follow
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 1069-6563 - ISSN (Online) 1553-2712
   Published by John Wiley and Sons Homepage  [1592 journals]
  • Homelessness and Emergency Medicine: Where Do We Go From Here'
    • Authors: Kelly M. Doran; Maria C. Raven
      Abstract: In many emergency departments (EDs) around the country, providers care for patients experiencing homelessness on every single shift. Despite its proven impact on health, housing status is not a routine part of the history taken by most emergency providers, and in many cases providers are unaware that they are caring for someone who has no stable home. Patients experiencing homelessness have unique needs spanning acute and chronic illness, injury, behavioral health diagnoses, and material deprivation.This article is protected by copyright. All rights reserved.
      PubDate: 2018-02-17T22:50:22.972282-05:
      DOI: 10.1111/acem.13392
  • Hot off the Press: SGEM#197: Cannulation in the ED
    • Authors: Sahaana Rangarajan; Justin Morgenstern, William K Milne, Corey Heitz
      Abstract: This is a prospective before-after study comparing peripheral intravenous cannulation (PIVC) placement and usage rates following a 10 week long multimodal intervention provided to medical and nursing staff working in a tertiary emergency department (ED). The intervention focused on improving appropriate use of PIVCs in an emergency setting by emphasizing to clinicians that a PIVC should only be placed if it was believed there was more than an 80% chance that it would be used. Patients were eligible for the study if they presented to the ED and were>18 years of age. Patients were excluded from the study if they were triage category 1, already had a PIVC placed in an ambulance, or were transferred from another hospital. Among the 4172 patients included in the analysis, there was a 9.8% reduction in the number of PIVCs inserted (95% CI 6.8-12.87) and a 12% increase in PIVC usage (95% CI 8.7-17.0%) in the post-intervention cohort.This article is protected by copyright. All rights reserved.
      PubDate: 2018-02-16T02:10:50.346902-05:
      DOI: 10.1111/acem.13390
  • The accuracy and prognostic value of point-of-care ultrasound for
           nephrolithiasis in the emergency department: A Systematic Review and
    • Authors: Charles Wong; Braden Teitge, Marshall Ross, Paul Young, Helen Lee Robertson, Eddy Lang
      Abstract: IntroductionPoint-of-care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis, and 2) to assess its prognostic value in the management of renal colic.MethodsThe review protocol was registered to the PROSPERO database (CRD42016035331). An electronic database search of MEDLINE, EMBASE, and PubMed was conducted utilizing subject headings, keywords, and synonyms that address our research question. Bibliographies of included studies and narrative reviews were manually examined. Studies of adult emergency department patients with renal colic symptoms were included. Any degree of hydronephrosis was considered a positive POCUS finding. Accepted criterion standards were CT evidence of renal stone or hydronephrosis, direct stone visualization, or surgical findings. Screening of abstracts, quality assessment with the QUADAS-2 instrument, and data extraction were performed by two reviewers, with discrepancies resolved by consensus with a third reviewer.Test performance was assessed by pooled sensitivity and specificity, calculated likelihood ratios, and a summary receiver operator curve (SROC). The secondary objective of prognostic value was reported as a narrative summary.ResultsThe electronic search yielded 627 unique titles. After relevance screening, 26 papers underwent full-text review, and 9 articles met all inclusion criteria. Of these, 5 high-quality studies (N = 1773) were included in the meta-analysis for diagnostic accuracy, and the remaining yielded data on prognostic value. The pooled results for sensitivity and specificity were 70.2% (95% CI = 67.1% to 73.2%) and 75.4% (95% CI = 72.5% to 78.2%), respectively. The calculated positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated did not show evidence of a threshold effect. Two of the studies in the meta-analysis found that the finding of moderate or greater hydronephrosis yielded a specificity of 94.4% (95% CI = 92.7% to 95.8%).Four studies examining prognostic value noted a higher likelihood of a large stone when positive POCUS findings were present. The largest randomized trial showed lower cumulative radiation exposure and no increase in adverse events in those who received POCUS investigation as the initial renal colic investigation.ConclusionPoint-of-care ultrasound has modest diagnostic accuracy for diagnosing nephrolithiasis. The finding of moderate or severe hydronephrosis is highly specific for the presence of any stone, and the presence of any hydronephrosis is suggestive of a larger (>5mm) stone in those presenting with renal colic.This article is protected by copyright. All rights reserved.
      PubDate: 2018-02-10T05:08:25.610494-05:
      DOI: 10.1111/acem.13388
  • From Ruling Out to Ruling In: Putting POCUS in Focus
    • Authors: Arjun K. Venkatesh; Charles D. Scales, Marta E. Heilbrun
      Abstract: Over the past twenty years, the Emergency Department (ED) has transformed from a location that managed patients with acute life-threatening illness or injury to an acute diagnostic center. The advent of rapid and accurate imaging, novel biomarkers, and other innovations concurrent with effects from financial and social forces has supported the development of an acute care system focused on “ruling out” low-frequency, high-mortality events such as acute myocardial infarction, stroke, pulmonary embolism, and aortic dissection. This search for “true-negatives” may result from malpractice fears, readily available technology, or most likely, clinician and patient discomfort with uncertainty. As a result, diagnostic testing is ubiquitous and costs of care continue to rise. A notable example of this trend has been the rapid increase in computed tomography (CT) utilization for patients with renal colic despite little evidence of major improvements in outcomes.This article is protected by copyright. All rights reserved.
      PubDate: 2018-02-10T05:05:27.506278-05:
      DOI: 10.1111/acem.13389
  • Economic Analysis of Diagnostic Imaging in Pediatric Patients with
           Suspected Appendicitis
    • Authors: Anupam B. Kharbanda; Eric W. Christensen, Nanette C. Dudley, Lalit Bajaj, Michelle D. Stevenson, Charles G. Macias, Manoj K. Mittal, Richard G. Bachur, Jonathan E. Bennett, Kelly Sinclair, Brianna McMichael, Peter S. Dayan,
      Abstract: ObjectiveThe use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (ED). This study compares the cost of diagnosing and treating suspected appendicitis across a multi-center network of children's hospitals.MethodsThis study is a secondary analysis using de-identified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3-18 years old who presented to the ED with acute abdominal pain of < 96 hours duration.ResultsOur data-set contained 2300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p
      PubDate: 2018-02-10T04:55:21.240733-05:
      DOI: 10.1111/acem.13387
  • Prospective validation and refinement of a decision rule to obtain CXR in
           patients with non-traumatic chest pain in the ED
    • Authors: Case Newsom; Rebecca Jeanmonod, Wendy Woolley, Nirali Shah, Shellie Asher, Eric Bruno, Michael Silberman, Mark Reiter, Donald Jeanmonod
      Abstract: ObjectivesTo prospectively validate and refine previously published criteria to determine the potential utility of chest x-ray (CXR) in the evaluation and management of patients presenting to the emergency department (ED) with non-traumatic chest pain.MethodsA prospective observational study was performed of patients presenting to three EDs in the US with a chief complaint of non-traumatic chest pain. Previously defined high-risk history and exam elements were combined into a refined decision rule and these elements were recorded for each patient by the ED physician. CXR results were reviewed and analyzed to determine the presence of clinically significant findings including pneumonia, pleural effusion, pneumothorax, congestive heart failure, or the presence of a new mass. Odds ratios for each history and exam element were analyzed as well as sensitivity, specificity, and negative predictive value of the rule overall.Results1111 patients were enrolled and 1089 CXRs were analyzed. There were 70 (6.4%) patients with clinically relevant findings on CXR. The refined decision rule had a sensitivity of 92.9% (CI 83.4%-97.3%) and specificity of 30.4% (CI 27.6%-33.4%) to predict clinically relevant findings on CXR, with a negative predictive value of 98.4% (CI 96.1%-99.4%). Five CXRs with clinically significant findings would have been missed by application of the refined rule (3 pneumonias and 2 pleural effusions). Applying these criteria as a CXR decision rule to this population would have reduced CXR utilization by 28.9%.ConclusionsThis study validates previous research suggesting a low clinical yield for CXR in the setting of non-traumatic chest pain in the ED. This refined clinical decision rule has a favorable sensitivity and negative predictive value in a patient population with low incidence of disease. Further validation is needed prior to use in practice.This article is protected by copyright. All rights reserved.
      PubDate: 2018-02-10T04:51:05.908342-05:
      DOI: 10.1111/acem.13386
  • Topical tranexamic acid for epistaxis in patients on antiplatelet drugs: a
           new use for an old drug
    • Authors: Michael S. Runyon
      Abstract: “The remedy is worse than the disease.” ― Francis BaconWhile Bacon may not have been referring specifically to antiplatelet drugs, one cannot blame the emergency physician expressing this same sentiment while caring for a patient presenting with epistaxis while on one of these medications. Achieving hemostasis in these cases can be challenging for the very best emergency physician, and a miserable experience for the most stoic of patients. In this issue of Academic Emergency Medicine, Zahed, et al.This article is protected by copyright. All rights reserved.
      PubDate: 2018-02-08T06:00:36.866916-05:
      DOI: 10.1111/acem.13385
  • Effectiveness of a specialized brief intervention for at-risk drinkers in
           an Emergency Department. Short term results of a randomized controlled
    • Authors: Pol Bruguera; Pablo Barrio, Clara Oliveras, Fleur Braddick, Carolina Gavotti, Carla Bruguera, Hugo López-Pelayo, Laia Miquel, Lídia Segura, Joan Colom, Lluisa Ortega, Eduard Vieta, Antoni Gual
      Abstract: Background and aimsSBIRT programmes (Screening Brief Intervention and Referral to Treatment) have been developed, evaluated and shown to be effective, particularly in primary care and general practice. Nevertheless, effectiveness of SBIRT in emergency departments (ED) has not been clearly established.We aimed to evaluate the feasibility and efficacy of an SBIRT programme conducted by highly specialized professionals in the ED of a tertiary hospital.MethodsWe conducted a randomized controlled trial to study the feasibility and efficacy of an SBIRT programme conducted by alcohol specialists for at-risk drinkers presenting to the ED, measured with the AUDIT-C. Patients were randomized to two groups, with the control group receiving two leaflets - one regarding alcohol use, and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use; and, where appropriate, a referral to specialised treatment. The primary outcomes were the proportion of at-risk alcohol use measured by AUDIT-C scale and the proportion of patients attending specialised treatment at 1.5 months.ResultsOf 3027 patients presenting to the ED, 2044 (67%) were potentially eligible to participate, 247 (12%) screened positive for at-risk drinking and 200 agreed to participate. 72% of the participating sample were men, and the mean age was 43 years. Follow-up rates were 76.5%. At 1.5 months, the intervention group showed greater reductions in alcohol consumption, and fewer patients continuing with at-risk alcohol use (27.8% vs 48.1%. P=0.01). The SBIRT programme also increased the probability of atending specialised treatment, compared to the control condition (23% vs 9.8%, p=0.0119)ConclusionThe SBIRT programme in the ED was found to be feasible and effective in identifying at-risk drinkers, reducing at-risk alcohol use and increasing treatment for alcohol problems.This article is protected by copyright. All rights reserved.
      PubDate: 2018-02-08T05:55:20.941767-05:
      DOI: 10.1111/acem.13384
  • Implementation of a Novel Algorithm to Decrease Unnecessary
           Hospitalizations in Patients Presenting to a Community Emergency
           Department with Atrial Fibrillation
    • Authors: Susanne DeMeester; Rebecca A Hess, Bradley Hubbard, Kara LeClerc, Jane Ferraro, Jeremy J Albright
      Abstract: ObjectivesAtrial fibrillation (AFib) is the most common dysrhythmia in the United States. Patients seen in the emergency department (ED) in rapid AFib are often started on intravenous rate controlling agents and admitted for several days. Although underlying and triggering illnesses must be addressed, AFib, intrinsically, is rarely life threatening and can often be safely managed in an outpatient setting. At our academic community hospital, we implemented an algorithm to decrease hospital admissions for individuals presenting with a primary diagnosis of AFib. We focused on lenient oral rate control and discharge home. Our study evaluates outcomes after implementation of this algorithm.MethodsStudy design is a retrospective cohort analysis pre and post implementation of the algorithm. The primary outcome was hospital admissions. Secondary outcomes were 3-day and 30-day ED visits and any associated hospital admissions. These outcomes were compared before (March 2013-February 2014) and after (March 2015-February 2016) implementation. Chi-square tests and logistic regressions were run to test for significant changes in the three outcome variables.ResultsA total of 1,108 individuals met inclusion criteria with 586 patients in the pre-implementation group and 522 in the post-implementation group. Cohorts were broadly comparable in terms of demographics and health histories. Admissions for persons presenting with AFib after implementation decreased significantly (80.4% pre vs 67.4% post, adjusted OR = 3.4, P < .001). Despite this difference there was no change in ED return rates within 3 or 30 days, adjusted ORs = 0.93 and 0.89, P = .91 and .73, respectively.ConclusionsImplementation of a novel algorithm to identify and treat low-risk patients with AFib can significantly decrease the rate of hospital admissions without increased emergency department returns. This simple algorithm could be adopted by other community hospitals and help lower costs.This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-31T18:35:23.946512-05:
      DOI: 10.1111/acem.13383
  • Déjà vu
    • Authors: Sarab Sodhi
      Abstract: “Respiratory distress. Four minutes out” crackled the radio. Terrified, I walked over to the resuscitation bay. It was my third day as an intern. An elderly man came in puffing away on BiPAP. His frail chest heaved about forty times a minute. My chief resident nudged me to the head of the bed, and told me to get set to intubate.This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-30T03:16:02.759368-05:
      DOI: 10.1111/acem.13382
  • A comparison of care delivered in hospital-based and freestanding
           emergency departments
    • Authors: Jesse M. Pines; Mark S. Zocchi, Bernard S Black
      Abstract: ObjectiveWe compare case-mix, hospitalization rates, length of stay (LOS), and resource use in independent freestanding emergency departments (FSEDs) and hospital-based emergency departments (H-EDs).MethodsData from 74 FSEDs (2013-5) in Texas and Colorado, were compared to H-ED data from the 2013-14 National Hospital Ambulatory Medical Care Survey. In the unrestricted sample, large differences in visit characteristics (e.g. payer and case mix) were found between patients that use FSEDs compared to H-EDs. Therefore, we restricted our analysis to patients commonly treated in both settings (
      PubDate: 2018-01-30T03:10:25.514815-05:
      DOI: 10.1111/acem.13381
  • Accuracy of Computed Tomography in Diagnosis of Intra-abdominal Injuries
           in Stable Patients with Anterior Abdominal Stab Wounds: A Systematic
           Review and Meta-Analysis
    • Authors: Bonny J Baron; Roshanak Benabbas, Casey Kohler, Carina Biggs, Valery Roudnitsky, Lorenzo Paladino, Richard Sinert
      Abstract: BackgroundWork-up for patients presenting to the Emergency Department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP), however, workup of stable, asymptomatic or non-peritoneal, patients is not clearly defined.ObjectivesTo evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intra-abdominal injuries requiring Therapeutic Laparotomy (THER-LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient'MethodsWe searched PUBMED, EMBASE, and Scopus from their inception until May 2017 for studies on ED patients with AASW. We defined the reference standard test as LAP for patients who were managed surgically and those with THER-LAP were considered as disease-positive. In those who were managed nonsurgically, inpatient observation was considered the reference standard. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate the risk of bias and applicability of the included studies. We attempted to compute the pooled sensitivity, specificity, Likelihood Ratios (LR+, LR-) using a random-effects model with MetaDiSc software and calculate testing and treatment thresholds for CT scan applying the Pauker and Kassirer model.ResultsSeven studies were included encompassing 575 patients. The weighted prevalence of THER-LAP was 34.3% (95% CI 30.5-38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were: sensitivity 50%-100%, specificity 39%-97%, LR+ 1.0-15.7 and LR- 0.07-1.0. The high heterogeneity (I-square>75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated.DiscussionThe articles revealed a high prevalence (8.7%, 95% CI 6.1-12.2%) of injuries requiring THER-LAP in patients with a negative CT scan and almost half (47%, 95% CI 30-64%) of those injuries involved the small bowel.ConclusionsIn stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intra-abdominal injuries.This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-25T10:45:02.628003-05:
      DOI: 10.1111/acem.13380
  • Emergency Department Patients With Acute Kidney Injury: Appropriately
           Discharged But Inadequately Followed-Up'
    • Authors: Rima Arbou-Arkoub; James C Worrall, Edward G Clark
      Abstract: Acute Kidney Injury (AKI), defined according to increases in serum creatinine level or decreased urine output,1 is a frequent occurrence amongst hospitalized patients worldwide.2 In particular, a marked increase in AKI incidence has occurred in recent years in developed countries.2 Causes may include an aging population and a concurrent rise in the many comorbidities that are risk factors for AKI.3This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-23T10:30:52.986794-05:
      DOI: 10.1111/acem.13379
  • Acute Kidney Injury: Who Should be Followed-up and by Whom'
    • Authors: Richard Sinert
      Abstract: The authors of “Emergency Department Patients with Acute Kidney Injury: Appropriately Discharged but Inadequately Followed-Up'” in this month's AEM reviewed two recent studies (Scheuermeyer et al and Acedillo et al) from the Nephrology literature describing the epidemiology and outcomes of discharged Emergency Department (ED) patients with Acute Kidney Injury (AKI). This review concludes that even mild AKI in discharged ED patients is associated with increased risks of End Stage Renal Disease (ESRD) and mortality.This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-23T10:15:26.908093-05:
      DOI: 10.1111/acem.13378
  • Scapular fractures in the Pan-scan Era
    • Authors: Cortlyn Brown; Karim Elmobdy, Ali S Raja, Robert M. Rodriguez
      Abstract: BackgroundScapular fractures have been traditionally taught to be associated with significant injuries and major morbidity. As we demonstrated with sternal fracture, pulmonary contusion and rib fracture, increased chest CT utilization and head-to-pelvis CT (pan-scan) protocols in blunt trauma evaluation, however, may diagnose minor, clinically irrelevant scapular fractures, possibly rendering previous teachings obsolete.ObjectivesTo determine the 1) percentages of scapular fractures seen on chest CT only (SOCTO) versus seen on both CXR and CT and of isolated scapular fracture (scapular fracture without other thoracic injuries), 2) frequencies of associated thoracic injury with scapular fracture, and 3) proportion of patients admitted, mortality, hospital length of stay, and injury severity scores (ISS), comparing four patient groups: scapular fracture, non-scapular fracture, scapular fracture SOCTO, and isolated scapular fracture.MethodsWe conducted a pre-planned analysis of patients prospectively enrolled in the NEXUS Chest CT study at nine Level 1 trauma centers with the following inclusion criteria: age> 14 years, blunt trauma within 6 hours of ED presentation, and receiving chest imaging during ED trauma evaluation.ResultsOf 11,477 subjects, 4501 (39.2%) patients who \had both CXR and chest CT and 2.7% of these had scapular fractures; 60.3% of these were SOCTO and 23 (19.0%) were isolated scapular fracture. The most commonly associated thoracic injuries were rib fracture, pulmonary contusion, pneumothorax, and thoracic spine fracture and all injuries were more common in scapular fracture patients than non-scapular fracture patients. Although scapular fracture patients had higher admission rates [86.8% versus 47.4%; difference in proportions 39.4% (95% CI 32.8-44.1%)], ISS (21 versus 5), and length of stay [9.2 days versus 5.6 days; mean difference 3.4 days (95% CI 2.1-4.7 days)] than patients without scapular fracture, their hospital mortality was not significantly different [5.6% versus 3.0%; difference in proportions 2.6% (95% CI -8.2-0.3%); unadjusted odds ratio 1.9 (95% CI 0.9-4.2)]. Patients with scapular fracture SOCTO and isolated scapular fracture had higher admission rates and median ISS than non-scapular fracture patients, but their mortality was similar.ConclusionsUnder current blunt trauma imaging protocols that commonly include chest CT, most scapular fractures are SOCTO and most are associated with other thoracic injuries. Although patients with scapular fracture SOCTO and isolated scapular fracture have higher admission rates and ISS than non-scapular fracture patients, their hospital mortality is similar.This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-11T02:45:22.407741-05:
      DOI: 10.1111/acem.13377
  • Effectiveness of interventions to decrease image ordering for low back
           pain presentations in the emergency department: a systematic review
    • Authors: Chaocheng Liu; Shashwat Desai, Lynette D. Krebs, Scott W. Kirkland, Diana Keto-Lambert, Brian H. Rowe,
      Abstract: BackgroundLow back pain (LBP) is an extremely frequent reason for patients to present to an emergency department (ED). Despite evidence against the utility of imaging, simple and advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging [MRI]) for patients with LBP has become increasingly frequent in the ED. The objective of this review was to identify and examine the effectiveness of interventions aimed at reducing image ordering in the ED for LBP patients.MethodsA protocol was developed a priori, following the PRISMA guidelines, and registered with PROSPERO. Six bibliographic databases (including MEDLINE, EMBASE, EBM Reviews, SCOPUS, CINAHL, and Dissertation s) and the grey literature were searched. Comparative studies assessing interventions that targeted image ordering in the ED for adult patients with LBP were eligible for inclusion. Two reviewers independently screened study eligibility and completed data extraction. Study quality was completed independently by two reviewers using the before-after quality assessment checklist, with a third party mediator resolving any differences. Due to a limited number of studies and significant heterogeneity, only a descriptive analysis was performed.ResultsThe search yielded 603 unique citations of which a total of five before-after studies were included. Quality assessment identified potential biases relating to comparability between the pre- and post-intervention groups, reliable assessment of outcomes, and an overall lack of information on the intervention (i.e., time point, description, intervention data collection). The type of interventions utilized included clinical decision support tools, clinical practice guidelines, a knowledge translation initiative, and multidisciplinary protocols. Overall, four studies reported a decrease in the relative percent change in imaging in a specific image modality (22.7% - 47.4%) following implementation of the interventions; however, one study reported a 35% increase in patient referrals to radiography, while another study reported a subsequent 15.4% increase in referrals to CT and myelography after implementing an intervention which reduced referrals for simple radiography.DiscussionWhile imaging of LBP has been identified as a key area of imaging overuse (e.g., Choosing Wisely® recommendation), evidence on interventions to reduce image ordering for ED patients with LBP is sparse. There is some evidence to suggest that interventions can reduce the use of simple imaging in LBP in the ED; however, a shift in imaging modality has also been demonstrated. Additional studies employing higher quality methods and measuring intervention fidelity are strongly recommended to further explore the potential of ED-based interventions to reduce image ordering for this patient population.This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-08T02:50:38.50982-05:0
      DOI: 10.1111/acem.13376
  • What happens next' Recurrence Rates for First Unprovoked Seizures in
    • Authors: Wendi-Jo L. Wendt; Louis T. Dang, Alexander J. Rogers
      Abstract: Seizures represent approximately 1% of all ED visits in the United States. 1 Unprovoked first seizures in children commonly present to the Emergency Department (ED), and even after the neurological exam normalizes, the prospect of recurrence can be a source of great anxiety for caregivers. 2 Compared to febrile seizures, unprovoked seizures carry a higher rate of recurrence and epilepsy. Previous studies focused on long term recurrence and the cumulative risk of a second seizure was 29%, 37%, 43%, and 46% at 1, 2, 5, and 10 years, respectively. 3 There has been limited information on the short-term risk of recurrence to guide emergency physicians.This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-02T01:25:40.219922-05:
      DOI: 10.1111/acem.13374
  • Dr. Rodgers’ Last Lessons: reflections after the death of a mentor
    • Authors: Josh Mugele; Katie E Pettit, Debra S Rusk, Joseph S Turner, Aloysius J Humbert
      Abstract: The Indiana University emergency medicine family is grieving. We, the residency program directors, are grieving. The Monday morning before Thanksgiving, Dr. Kevin Rodgers, KRodge, a lifelong educator and mentor to most of us, was killed in his home following his overnight shift. Kevin's death has shaken us deeply and we are tired from crying. As emergency physicians, we're supposed to know about death – we see it regularly; we write about it in our literature; we comfort the families of our dying patients. But when it is one of our own – a father-figure – we don't know how to react. We can't compartmentalize this. As a way to try to find meaning out of the senselessness, we've been reflecting on what it means to be an emergency medicine educator.This article is protected by copyright. All rights reserved.
      PubDate: 2018-01-02T01:25:36.56342-05:0
      DOI: 10.1111/acem.13375
  • Issue Information
    • Pages: 103 - 107
      PubDate: 2018-02-08T10:41:40.189243-05:
      DOI: 10.1111/acem.13283
  • Development of a Patient Decision Aid for Syncope in the Emergency
           Department: the SynDA tool
    • Authors: Marc A. Probst; Erik P. Hess, Maggie Breslin, Dominick L Frosch, Benjamin C. Sun, Marie-Noelle Langan, Lynne D. Richardson
      Abstract: ObjectivesTo develop a patient decision aid to promote shared decision-making for stable, alert patients who present to the emergency department (ED) with syncope.MethodsUsing input from patients, clinicians, and experts in the field of syncope, health care design, and shared decision-making, we created a prototype of a paper-based decision aid to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted 1-on-1 semi-structured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted 1-on-1 directed interviews with 15 emergency care clinicians, 5 cardiologists, and 12 ED syncope patients to get detailed feedback on decision aid content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized.ResultsThe 11- x 17-inch, paper-based decision aid, titled SynDA, includes 4 sections: 1) Explanation of syncope, 2) Explanation of future risks, 3) Personalized 30-day risk estimate, and 4) Disposition options. The personalized risk estimate is calculated using a recently published syncope risk-stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100-person color-coded pictogram. Patient-oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the decision aid.ConclusionsWe iteratively developed an evidence-based decision aid to facilitate shared decision-making for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This decision aid has the potential to improve care for syncope patients and promote patient-centered care in emergency medicine.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-30T04:00:25.754245-05:
      DOI: 10.1111/acem.13373
  • The Focused History and Physical - circa 100 BCE
    • Authors: Katherine D. van Schaik
      Abstract: When modern physicians reflect on ‘ancient medicine’ or ‘Greek medicine,’ they typically think of Hippocrates and Galen. Few know of the raging, centuries-long intellectual debates among physicians about what exactly mattered in the treatment of illness, or about a group of physicians whose pattern-based, systematized approach to health and disease was a forerunner of how today's emergency medicine physicians evaluate and treat their patients.Methodist physicians (c. 100 BCE to 500 CE, active mostly in Rome but present throughout the Mediterranean world) were named after their “method” of healing.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-30T01:40:30.18919-05:0
      DOI: 10.1111/acem.13372
  • Sex Differences in Diagnoses, Treatment and Outcomes for Emergency
           Department Patients with Chest Pain and Elevated Cardiac Troponin
    • Authors: Karin H Humphries; May K Lee, Mona Izadnegahdar, Min Gao, Daniel T Holmes, Frank X Scheuermeyer, Martha Mackay, Andre Mattman, Eric Grafstein
      Abstract: ObjectiveWhile sex differences in the treatment and outcomes of subjects with acute coronary syndromes are well documented, little is known about the impact of cardiac troponin (cTn) levels obtained in the emergency department (ED) on the observed sex differences. We sought to determine whether cTn levels by chest pain features modify sex differences in diagnosis, treatment and outcomes in patients presenting with chest pain suggestive of ischemia.MethodsAll adults presenting to two hospitals in Vancouver, Canada between May 2008 and Mar 2013 with ischemic chest pain and with cTn testing were included in the study. Outcomes were obtained through data linkage with population-based administrative datasets, including Vital Statistics (death), discharge abstract database (hospitalizations) and PharmaNet (medications). Cumulative event rates for the composite MACE endpoint (death, MI, incident admission for heart failure or for angina requiring diagnostic catheterization or revascularization), were estimated for each sex and cTn level using the Kaplan-Meier method; Cox models were used to estimate hazard ratios (HR) and 95% CIs for one-year MACE and seven-day catheterization. Logistic models were used to estimate odds ratios (OR) and 95% CI for 90-day medication use.ResultsOver the five-year study period, 25,539 patients presented to the ED with chest pain of which 7,272 (2,933 females and 4,339 males) met the inclusion criteria. Among patients with chest pain with cardiac features/history and cTn> 99th percentile, females were less likely to be diagnosed with MI (46.4% vs. 57.5%). Females in the cTnI> 99th percentile group had the worst outcomes with a one-year MACE rate of 22.7% (95% CI 18.5, 27.7) versus 18.8% (95% CI 16.2, 21.6), though this difference was attenuated and not statistically significant after adjustment for baseline differences. Overall, females underwent fewer diagnostic catheterizations than males within seven days of admission to the ED. Even when cTn was above the 99th percentile and the chest pain was cardiac in nature, 48.4% of females underwent a diagnostic catheterization compared to 64.3% of males, p 99th percentile and when the chest pain was cardiac in nature; males filled 25% more prescriptions for statins than their female counterparts. Adjustment for baseline differences did not attenuate this difference.ConclusionsSex differences in diagnosis and treatment after presentation to the ED with chest pain are not explained by differences in chest pain features or levels of cTn. Even when females have cardiac chest pain and cTn levels> 99th percentile, they are less likely to be diagnosed with MI, less likely to undergo diagnostic cardiac catheterization within seven days, and less likely to use evidence-based cardiac medications, but they have the highest one-year MACE rate. The higher MACE rate appears to be driven by the higher burden of comorbid conditions.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-23T06:50:39.378515-05:
      DOI: 10.1111/acem.13371
  • ED Treatment of Opioid Addiction: An Opportunity to Lead
    • Authors: Alister Martin; Andreas Mitchell
      Abstract: Opioid use disorder (OUD) is the fastest growing substance use disorder in the United States and the main reason for seeking addiction treatment services for illicit drug use throughout the world. The emergency department (ED) is an important point of care for patients with OUD as these patients are often marginalized from traditional primary care services. EDs often serve their primary healthcare needs as well as offering overdose reversal, attention to injuries related to substance use, and entry points into OUD treatment. Unsurprisingly, ED visits for problems related to opioid use have risen by nearly 100% in the last decade compared to opioid-related inpatient stays which increased by 64%. As a result emergency physicians are thus uniquely positioned to intervene to help patients with OUD at a critical moment in their lives.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-21T09:55:19.005678-05:
      DOI: 10.1111/acem.13367
  • Material Needs of Emergency Department Patients: A Systematic Review
    • Authors: Patrick W. Malecha; James H. Williams, Nathan M. Kunzler, Lewis R. Goldfrank, Harrison J. Alter, Kelly M. Doran
      Abstract: BackgroundInterest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States.MethodsWe followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles.ResultsForty-three articles were eligible for inclusion. There was heterogeneity in study methods; single center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs.ConclusionsDespite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-21T09:50:29.230591-05:
      DOI: 10.1111/acem.13370
  • Opening of Psychiatric Observation Unit Eases Boarding Crisis
    • Authors: Bradford Tinloy; Arjun Venkatesh, Gail D'Onofrio, Matthew Goldenberg, Craig Rothenberg, Andrew Ulrich, Vivek Parwani
      Abstract: ObjectivesThe objective of this study was to evaluate the effect of a psychiatric observation unit in reducing ED boarding and length of stay for patients presenting with primary psychiatric chief complaints. A secondary outcome was to determine the effect of a psychiatric observation unit on inpatient psychiatric bed utilization.MethodsDesign and Setting: Before-and-after analysis conducted in a 1541-bed tertiary care academic medical center including an adult ED with annual census over 90,000 between February 2013 and July 2014. All adult patients (age>17) requiring evaluation by the acute psychiatry service in the crisis intervention unit (CIU) within the ED were included. Patients who left without being seen, left against medical advice, or were dispositioned to the pediatric hospital, hospice or court/law enforcement were excluded. In December 2013, a 12-bed locked psychiatric observation unit was opened that included dedicated behavioral health staff and was intended for psychiatric patients requiring up to 48 hours of care. The primary outcomes were ED Length of Stay (LOS), CIU LOS, and total LOS. Secondary outcomes included the hold rate defined as the proportion of acute psychiatry patients requiring subsequent observation or inpatient admission and the inpatient psychiatric admission rate. For the primary analysis we constructed ARIMA regression models that account for secular changes in the primary outcomes. We conducted two sensitivity analyses, first replicating the primary analysis after excluding patients with concurrent acute intoxication and second by comparing the 3 month period post intervention to the identical 3 month period of the prior year to account for seasonality.ResultsA total of 3501 patients were included pre-intervention and 3798 post-intervention. The median ED LOS for the pre-intervention period was 155 minutes [IQR: 19 –346] was lower than the median ED LOS for the post-intervention period was 35 minutes [IQR: 9 – 209], p
      PubDate: 2017-12-20T09:05:24.451395-05:
      DOI: 10.1111/acem.13369
  • Protocolized Laboratory Screening for the Medical Clearance of Psychiatric
           Patients in the Emergency Department: A Systematic Review
    • Authors: Alyssa Conigliaro; Roshanak Benabbas, Eric Schnitzer, Maria-Pamela Janairo, Richard Sinert
      Abstract: ObjectiveEmergency department (ED) patients with psychiatric chief complaints undergo medical screening to rule out underlying or comorbid medical illnesses prior to transfer to a psychiatric facility. This systematic review attempts to determine the clinical utility of protocolized laboratory screening for the streamlined medical clearance of ED psychiatric patients by determining the clinical significance of individual laboratory results.MethodsWe searched PUBMED, EMBASE and SCOPUS using the search terms “Emergency department, Psychiatry, Diagnostic tests, Laboratories, Studies, Testing, Screening, and Clearance” up to June 2017 for studies on adult psychiatric patients. This systematic review follows the recommendations of Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. The quality of each study was rated according to the Newcastle-Ottawa quality assessment scale. .ResultsFour independent reviewers identified 2,847 publications. We extracted data from 3 studies (n=629 patients). Included studies defined a abnormal test result as any lab result that falls out of the normal range. A laboratory test result was deemed as “clinically significant” only when patient disposition or treatment plan was changed because of that test result. Across the three studies the prevalence of clinically significant results were low (0.0%-0.4%).ConclusionsThe prevalence of clinically significant lab test results were low, suggesting that according to the available literature, routine laboratory testing does not significantly change patient disposition. Due to the paucity of available research on this subject, we could not determine the clinical utility of protocolized laboratory screening tests for medical clearance of psychiatric patients in the ED. Future research on the utility of routine laboratory testing is important in a move towards shared decision making and patient-centered healthcare.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-20T09:00:19.720942-05:
      DOI: 10.1111/acem.13368
  • Primary Spontaneous Pneumothorax: Looking Beyond the Usual
    • Authors: Nishant Gupta
      Abstract: Primary spontaneous pneumothorax (PSP) refers to a pneumothorax that occurs in patients without underlying pulmonary disease. Emergency physicians are often the first group of health care providers for patients presenting with a PSP. The currently recommended course of management for these patients involves conservative management either with observation (for small pneumothoraces) or simple aspiration/small bore chest tube placement (for larger/more symptomatic pneumothoraces).This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-19T10:35:18.598206-05:
      DOI: 10.1111/acem.13363
  • License
    • Authors: Alexa H. Gips
      Abstract: Sometimes, the ordinary patient strikes somewhere deep within you. She was, after all, no different from the hundreds of other drug users I've treated. Two and a half short years of residency, and already I'm numb to it. From shift to shift, we pass them off: sober re-eval, sober re-eval, sober re-eval. It's easy.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-19T10:30:20.933601-05:
      DOI: 10.1111/acem.13362
  • Letter to the editor, RE: The Hack Index
    • Authors: Karl Phillips; Paul McKenna, Jonathan de Olano, Robert S. Hoffman
      Abstract: We read Hack et al's recent work with great interest.(1) While we applaud the effort to objectively quantify degree of impairment of intoxicated patients using the Hack Impairment Index (HII) in the emergency department, there are some notable limitations to this study which require further discussion.The HII score had a strong agreement with nurses’ clinical assessments of intoxication. Despite the p value being impressive, their value for agreement was not indicated in the results.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-19T09:15:32.494189-05:
      DOI: 10.1111/acem.13366
  • Effectiveness of implementing evidence based interventions to reduce
           c-spine image ordering in the emergency department: a systematic review
    • Authors: Shashwat Desai; Chaocheng Liu, Scott W. Kirkland, Lynette D. Krebs, Diana Keto-Lambert, Brian H. Rowe
      Abstract: ObjectivesAppropriate use of imaging for adult patients with cervical spine (C-spine) injuries in the emergency department (ED) is a longstanding issue. Guidance for C-spine ordering exists; however, the effectiveness of the decision support implementation in the ED is not well studied. This systematic review examines the implementation and effectiveness of evidence-based interventions aimed at reducing C-spine imaging in adults presenting to the ED with neck trauma.MethodsSix electronic databases and the grey literature were searched. Comparative intervention studies were eligible for inclusion. Two independent reviewers screened for study eligibility, study quality, and extracted data. The change in imaging was reported using individual odds ratios (OR) with 95% confidence intervals (CI) using random effects.ResultsA total of 990 unique citations were screened for relevance of which six before-after studies and one randomized controlled trial were included. None of the studies were assessed as high quality. Interventions consisted primarily of locally developed guidelines or established clinical decision rules such as the NEXUS, or the Canadian C-spine rule. Overall, implementation of interventions aimed at reducing C-spine image ordering resulted in a statistically significant reduction in imaging (OR = 0.69; 95% CI: 0.51, 0.93); however, heterogeneity was high (I2 = 82%). Subgroup analysis revealed no differences between studies which specified to enrolling alert and stable patients compared to unspecified trauma (p=0.81), or between studies employing multifaceted versus non-multifaceted interventions (p=0.66) While studies generally provided details on implementation strategies (e.g., teaching sessions, pocket cards, posters, computerized decision support) the effectiveness of these implementation strategies were frequently not reported.ConclusionThere is moderate evidence regarding the effectiveness of interventions to reduce C-spine image ordering in adult patients seen in the ED with neck trauma. Given the national and international focus on improving appropriateness and reducing unnecessary C-spine imaging through campaigns such as Choosing Wisely©, additional interventional research in this field is warranted.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-19T08:41:10.371505-05:
      DOI: 10.1111/acem.13364
  • Hack's Impairment Index, Response to Comments
    • Authors: Jason B. Hack; Eric Goldlust, Dennis Ferrante, Brian Zink
      Abstract: The fact that alcohol intoxication is a tremendous problem with hundreds of thousands of patients presenting to EDs across the country with impairment as a chief complaint and no nationally recognized standard way of evaluating this state (or even language to formally describe their clinical status) emphasizes the importance of this paper. Although the paper describes the performance of Hack's Impairment Index (HII score) in the largest group of alcohol impaired ED patients ever formally assessed for degree of impairment and the first to include patients that ranged from unresponsive to unimpaired, the research was limited in several aspects by restrictions imposed by the hospital and IRB, and the nature of the study population, which all affected study design. Many of these limitations are inherent in any study exploring a new gold standard—in that there is no objective mean for the desired primary outcome of patient safety.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-19T08:41:08.190466-05:
      DOI: 10.1111/acem.13365
  • Key High Efficiency Practices of Emergency Department Providers: A Mixed
           Methods Study
    • Authors: Morgan R. Bobb; Azeemuddin Ahmed, Paul Van Heukelom, Rachel Tranter, Karisa K. Harland, Brady M. Firth, Randy Fry, Katherine Schneider, Kathryn K. Dierks, Sarah L. Miller, Nicholas M. Mohr
      Abstract: ObjectiveThe objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs).MethodsA mixed methods study design was utilized to identify key behaviors associated with efficiency:Stage 1. A convenience sample of sixteen participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semi-structured interviews. Ninety-nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes.Stage 2. An observational study of 35 providers was performed in four (30,000 to 55,000-visit) community EDs during two 4-hour periods and recorded in minute-by-minute observation logs.Stage 3. Each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (Relative Value Units [RVUs] per hour) using linear univariate generalized estimating equations (GEE) with an identity link, clustered on ED site.ResultsFive ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, “inefficiency practices”, demonstrated significant negative correlations: non-work-related tasks and documentation on patients no longer in the ED.ConclusionsAverage patient load, running the board, conversations with team member, and using names of team members is associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-18T23:50:23.986764-05:
      DOI: 10.1111/acem.13361
  • Clinical examination for acute aortic dissection: A systematic review and
    • Authors: Robert Ohle; Hashim Khaliq Kareemi, George Wells, Jeffrey J Perry
      Abstract: IntroductionAcute aortic dissection is a life-threatening condition due to a tear in the aortic wall. It is difficult to diagnose and if missed carries a significant mortality.MethodsWe conducted a librarian assisted systematic review of Pubmed, Medline, Embase and the Cochrane database from 1968 to July 2016. Titles and abstracts were reviewed and data extracted by two independent reviewers (agreement measured by Kappa). Studies were combined if low clinical and statistical heterogeonity (I2
      PubDate: 2017-12-18T23:45:25.254026-05:
      DOI: 10.1111/acem.13360
  • Hot off the Press: SGEM#196: Gastroparesis – I Feel Like Throwing Up
    • Authors: Corey Heitz; Justin Morgenstern, William K. Milne
      Abstract: This randomized controlled trial compared haloperidol along with conventional therapy to placebo along with conventional therapy for gastroparesis in the emergency department. The primary outcomes of pain and nausea scores at 1 hour were significantly improved in the haloperidol group, but not in the placebo group. In this summary, we discuss a quality assessment of the article and summarized the social media commentary from the blog post/podcast.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-15T17:25:25.011085-05:
      DOI: 10.1111/acem.13359
  • Homelessness and Emergency Medicine: A Review of the Literature
    • Authors: Bisan A. Salhi; Melissa H. White, Stephen R. Pitts, David W. Wright
      Abstract: ObjectivesWe aimed to synthesize the available evidence on the demographics, prevalence, and clinical characteristics, and evidence-based management of homeless persons in the Emergency Department (ED). Where appropriate, we highlight knowledge gaps and suggest directions for future research.MethodsWe conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990 and December 31, 2016. We supplemented this search by cross-referencing bibliographies of the retrieved publications. Peer-reviewed studies written in English and conducted in the United States (US) that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature.ResultsTwenty-eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) Prevalence and socio-demographic characteristics of homeless ED visits; 2) ED utilization by homeless adults; 3) Clinical characteristics of homeless ED visits; 4) Medical education and evidence-based management of homeless ED patients.ConclusionHomelessness may be under-recognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease-oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence-based treatment strategies in caring for this vulnerable population.
      PubDate: 2017-12-09T19:45:27.857893-05:
      DOI: 10.1111/acem.13358
  • High risk clinical features for acute aortic dissection: A case control
    • Authors: Robert Ohle; Justin Um, Omar Anjum, Helena Bleeker, Lindy Luo, George Wells, Jeffrey J. Perry
      Abstract: BackgroundAcute aortic dissection (AAD) is a rare condition with a high mortality that is often missed. The objective of our study was to assess the diagnostic accuracy of clinical and laboratory findings for AAD, in confirmed cases of AAD and a low risk control group.MethodsHistorical matched case-control study: participants were adults>18 years old presenting to two tertiary care emergency departments (ED) or one regional cardiac referral center. Cases: new ED or in-hospital diagnosis of non-traumatic AAD confirmed by computed tomography or echocardiography. Controls: triage diagnosis of truncal pain (< 14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 1:4 ratio by sex and age. A sample size of 165 cases and 660 controls was calculated based on 80% power and confidence interval of 95% to detect an odds ratio of greater than 2.ResultsData were collected from 2002-2014 yielding 194 cases of AAD and 776 controls (mean age of 65(SD 14.1) and 66.7% male). Absence of abrupt-onset pain (Sensitivity 95.9% negative likelihood ratio (LR-) 0.07(0.03-0.14)) can help rule out AAD. Presence of tearing/ripping pain (Specificity 99.7%, LR+42.1 (9.9-177.5), aortic aneurysm (Specificity 97.8%, LR+6.35(3.54-11.42)), hypotension (Specificity 98.7%, LR+ 17.2(8.8-33.6)), pulse deficit (Specificity 99.3, LR+ 31.1(11.2-86.6)), neurological deficits (Specificity 96.9%, LR+ 5.26(2.9-9.3)), and a new murmur (Specificity 97.8%, LR+ 9.4(5.5-16.2)) can help rule in the diagnosis of AAD.ConclusionsPatients with one or more high-risk feature should be considered high risk, whereas patients with no high risk and multiple low risk features are at low risk for AAD.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-08T02:30:25.17127-05:0
      DOI: 10.1111/acem.13356
  • Impact of a Shared Decision Making Intervention on Healthcare Utilization:
           A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial
    • Authors: Jason T. Schaffer; Erik P. Hess, Judd E. Hollander, Jeffrey A. Kline, Carlos A. Torres, Deborah B. Diercks, Russell Jones, Kelly P. Owen, Zachary F. Meisel, Michel Demers, Annie Leblanc, Jonathan Inselman, Jeph Herrin, Victor M. Montori, Nilay D. Shah
      Abstract: BackgroundPatients at low risk for acute coronary syndrome (ACS) are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the healthcare system.ObjectivesThe purpose of this investigation was to measure the effect of the Chest Pain Choice decision aid (CPC) on overall healthcare utilization as well as utilization of specific services both during the index emergency department visit and in the subsequent 45 days.MethodsThis was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the emergency department with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by CPC decision aid to a control group receiving usual care (UC). Hospital-level billing data were used to measure utilization for the index emergency department visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording healthcare utilization over the same 45-day period. Outcomes assessed included length of time in the emergency department and observation, emergency department visits, office visits, hospitalizations, testing, imaging, and procedures.ResultsOf the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45-day health care diary review. There was no difference in patient reported healthcare utilization between the study arms. Hospital-level billing data were obtained for all 898 (100%) patients. During the initial emergency department visit the length of stay was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit length of stay was 95 minutes [95%CI 40.8, 149.8] shorter in the CPC arm and the mean number of tests was lower in the CPC arm [Decrease in 19.4 imaging studies per 100 patients, 95%CI 15.5, 23.3]. When evaluating the entire encounter and follow-up period, the intervention arm underwent fewer tests [Decrease in 125.6 tests per 100 patients, 95%CI 29.3, 221.6]. More specifically, there were fewer advanced cardiac imaging tests completed [25.8 fewer per 100 patients, 95% CI 3.74, 47.9] in the intervention arm.ConclusionsShared decision-making in low risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-08T02:13:18.214429-05:
      DOI: 10.1111/acem.13355
  • Regarding wellness and burnout initiatives in emergency medicine
    • Authors: Ravi Katari
      Abstract: The recent outpouring of scholarly and open-access content on resident wellness and occupational satisfaction with regards to Emergency Medicine (EM) has been an inspiration and welcome development. ACEP Wellness Week, EMRA Wellness Committee, the recently established ALiEM Wellness Think Tank are a handful of several great examples of the professional community coming together to address the challenging reality of burnout in EM. Indeed, that EM is uniquely affected among other specialties has been extensively documented to an impressive degree.This article is protected by copyright. All rights reserved.
      PubDate: 2017-12-01T07:05:37.537747-05:
      DOI: 10.1111/acem.13354
  • The decline of basic science publications in major emergency medicine
           journals and research conferences
    • Authors: Vinitha Jacob; Justin Belsky, David Cone
      Abstract: A recent publication reported on the decline of basic science publications in major medical journals in the last 20 years, making reference to the growing disconnect between basic science and clinical medicine1. Story Landis, former director of the National Institute of Neurological Disorders and Stroke also noted a striking decrease in grant applications for basic science projects in the same time period2.In the 1980s and 90s, a number of emergency physicians commented on the importance of basic science research to the future of emergency medicine3,4,5.This article is protected by copyright. All rights reserved.
      PubDate: 2017-11-27T02:40:22.648432-05:
      DOI: 10.1111/acem.13353
  • Past-year Prescription Drug Monitoring Program Opioid Prescriptions and
           Self-reported Opioid Use in an Emergency Department Population with Opioid
           Use Disorder
    • Authors: Kathryn Hawk; Gail D'Onofrio, David A. Fiellin, Marek C. Chawarski, Patrick G. O'Connor, Patricia H. Owens, Michael V. Pantalon, Steven L. Bernstein
      Abstract: BackgroundDespite increasing reliance on Prescription Drug Monitoring Programs (PDMPs) as a response to the opioid epidemic, the relationship between aberrant drug-related behaviors captured by the PDMP and opioid use disorder is incompletely understood. How PDMP data should guide Emergency Department (ED) assessment has not been studied.Study ObjectiveTo evaluate a relationship between PDMP opioid prescription records and self-reported non-medical opioid use of prescription opioids in a cohort of opioid dependent ED patients enrolled in a treatment trial.MethodsPDMP opioid prescription records during one year prior to study enrollment on 329 adults meeting Diagnostic and Statistical Manual IV criteria for opioid dependence entering a randomized clinical trial (RCT) in a large, urban ED were cross tabulated with data on 30-day non-medical prescription opioid use self-report. The association among these two types of data was assessed by the Goodman and Kruskal's Gamma; a logistic regression was used to explore characteristics of participants who had PDMP record of opioid prescriptions.ResultsDuring one year prior to study enrollment,118/329 (36%) patients had ≥ 1 opioid prescriptions (range 1-51) in our states’ PDMP. Patients who reported ≥15 out of 30 days of non-medical prescription opioid use were more likely to have ≥4 PDMP opioid prescriptions (20/38; 53%) than patients reporting 1-14 days (14/38, 37%) or zero days of non-medical prescription opioid use (4/38,11%); p=0.002. Female gender and having health insurance were significantly more represented in the PDMP (p
      PubDate: 2017-11-22T09:45:19.933993-05:
      DOI: 10.1111/acem.13352
  • Evaluation of a Low Risk Mild Traumatic Brain Injury and Intracranial
           Hemorrhage Emergency Department Observation Protocol
    • Authors: Brian J. Yun; Pierre Borczuk, Lulu Wang, Stephen Dorner, Benjamin A. White, Ali S. Raja
      Abstract: ObjectivesAmong emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH.MethodsThis retrospective cohort study was approved by the Institutional Review Board. Study subjects were patients ≥18 years of age with an International Classification of Diseases (ICD) code corresponding to a traumatic IC, and admitted to an ED observation unit (EDOU) of an urban, academic level 1 trauma center between February 1, 2015 and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record; imaging data from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU pre-post protocol implementation as a covariate, we sought to determine the pre-post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit (ICU), or operating room (OR) from the EDOU, and the proportion of patients with worsening findings on repeat CT head scan in the EDOU.ResultsA total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Interrater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the pre-protocol period; 153 post-protocol. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR 0.45, 95% confidence interval [CI] 0.25, 0.82, p=0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission pre-implementation of the protocol and 13% (20/153) of patients required an inpatient admission post-protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p=0.34).ConclusionsWhile there was no difference in EDOU LOS, implementing a low risk mild traumatic brain injury and intracranial hemorrhage protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results.This article is protected by copyright. All rights reserved.
      PubDate: 2017-11-20T20:25:35.83515-05:0
      DOI: 10.1111/acem.13350
  • A Randomized Double Blind Trial of Needle-free Injected Lidocaine Versus
           Topical Anesthesia for Infant Lumbar Puncture
    • Authors: Ryan Caltagirone; Vidya R. Raghavan, Kathleen Adelgais, Genie E. Roosevelt
      Abstract: ObjectivesLumbar punctures (LPs) are commonly performed in febrile infants to evaluate for meningitis, and local anesthesia increases the likelihood of LP success. Traditional methods of local anesthesia require injection which may be painful or topical application which is not effective immediately. Recent advances in needle-free jet injection may offer a rapid alternative to these modalities. We compared a needle-free jet-injection system (J-Tip™) with 1% buffered lidocaine to topical anesthetic (TA) cream for local anesthesia in infant LPs.MethodsSingle center randomized double-blind trial of J-Tip versus TA for infant LPs in an urban tertiary care Children's Hospital Emergency Department. A computer randomization model was used to allocate patients to either intervention. Patients aged 0-4 months were randomized to J-Tip syringe containing 1% lidocaine and a placebo topical anesthetic cream, or J-Tip syringe containing saline and TA. The primary outcome was the difference between the neonatal faces coding scale (NFCS) pre-procedure and during LP needle insertion. Secondary outcomes included changes in heart rate (HR) and NFCS throughout the procedure, difficulty with LP, number of LP attempts, provider impression of pain control, additional use of lidocaine, skin changes at LP site, and LP success.ResultsWe enrolled 66 subjects, 32 were randomized to J-Tip with lidocaine and 34 to EMLA. 6 participants were excluded from the final analysis due to age greater than 4 months, and the remaining 58 were analyzed in their respective groups (32 J-Tip, 34 TA). There was no difference detected in NFCS between the two treatment groups pre-procedure and during needle insertion for the LP (p=0.58, p=0.37). Neither HR nor NCFS differed among the groups throughout the procedure. Median perception of pain control by the provider and the need for additional lidocaine were comparable across groups. LPs performed with a J-Tip were twice as likely to be successful as compared to those performed using TA (RR 2.0; 95% CI 1.01, 3.93; p=0.04) with no difference in level of training or number of prior LPs performed by providers.ConclusionsIn a randomized controlled trial of two modalities for local anesthesia in infant lumbar punctures, J-Tip is not superior to topical anesthetic cream as measured by pain control or physiologic changes. Infant LPs performed with J-Tip were twice as likely to be successful.This article is protected by copyright. All rights reserved.
      PubDate: 2017-11-20T20:20:23.997052-05:
      DOI: 10.1111/acem.13351
  • I thought he was going to set our house on fire
    • Authors: Nancy Lutwak
      Abstract: Recently the wife of an octogenarian suffering from dementia brought her husband to the emergency department stating, “I can't take care of him anymore. He is becoming more aggressive. I thought he was going to set our house on fire last night”. She recounted finding her husband in the kitchen at the range turning the dials.This article is protected by copyright. All rights reserved.
      PubDate: 2017-11-18T09:15:19.671683-05:
      DOI: 10.1111/acem.13349
  • Patient-level Factors and the Quality of Care Delivered in Pediatric
           Emergency Departments
    • Authors: James P. Marcin; Patrick S. Romano, Parul Dayal, Madan Dharmar, James M. Chamberlain, Nanette Dudley, Charles G. Macias, Lise E. Nigrovic, Elizabeth C. Powell, Alexander J. Rogers, Meridith Sonnett, Leah Tzimenatos, Elizabeth R. Alpern, Rebecca Andrews-Dickert, Dominic A Borgialli, Erika Sidney, T. Charles Casper, J. Michael Dean, Nathan Kuppermann,
      Abstract: ObjectiveQuality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient-level factors.MethodsThis was a retrospective, observational cohort study. Pediatric patients (
      PubDate: 2017-11-18T09:10:29.602838-05:
      DOI: 10.1111/acem.13347
  • Syncope Prognosis Based on Emergency Department Diagnosis: A Prospective
           Cohort Study
    • Authors: Cristian Toarta; Muhammad Mukarram, Kirtana Arcot, Soo-Min Kim, Sarah Gaudet, Marco L.A. Sivilotti, Brian H. Rowe, Venkatesh Thiruganasambandamoorthy
      Abstract: ObjectiveRelatively little is known about outcomes after disposition among syncope patients assigned various diagnostic categories during emergency department (ED) evaluation. We sought to measure the outcomes among these groups within 30 days of the initial ED visit.MethodsWe prospectively enrolled adult syncope patients at six EDs and excluded patients with pre-syncope, persistent mental status changes, intoxication, seizure, and major trauma. Patient characteristics, ED management, diagnostic impression (presumed vasovagal, orthostatic, cardiac, or other/unknown) at the end of the ED visit and physicians’ confidence in assigning the etiology were collected. Serious outcomes at 30-days included: death, arrhythmia, myocardial infarction, structural heart disease, pulmonary embolism, and hemorrhage.Results5,010 patients (mean age 53.4 years; 54.8% females) were enrolled; 3.5% suffered serious outcomes: deaths (0.3%), arrhythmias (1.8%), non-arrhythmic cardiac (0.5%) and non-cardiac (0.9%) including pulmonary embolism (0.2%). The cause of syncope was presumed as vasovagal among 53.3% and cardiac in 5.4% of patients. The proportion of patients with ED investigations (p
      PubDate: 2017-11-14T11:20:25.452075-05:
      DOI: 10.1111/acem.13346
  • A risk assessment score and initial high-sensitivity troponin combine to
           identify low-risk of acute myocardial infarction in the emergency
    • Authors: John W Pickering; Dylan Flaws, Stephen W Smith, Jaimi Greenslade, Louise Cullen, William Parsonage, Edward Carlton, A. Mark Richards, Richard Troughton, Christopher Pemberton, Peter M George, Martin P Than
      Abstract: ObjectivesEarly discharge of patients with presentations triggering assessment for possible acute coronary syndrome is safe when clinical assessment indicates low-risk, biomarkers are negative, and electrocardiograms (ECGs) are non-ischemic. We hypothesized that the Emergency Department Assessment of Chest Pain Score (EDACS) combined with a single measurement of high-sensitivity cardiac troponin (hs-cTn) could allow early discharge of a clinically meaningful proportion of patients.MethodsWe pooled data from 4 patient cohorts from New Zealand and Australia presenting to an ED with symptoms suggestive of ACS. The primary outcome was major adverse cardiac events (MACE) within 30 days of presentation. In patients with a non-ischemic ECG we evaluated the sensitivity for MACE and percentage low-risk of every combination of hs-cTnT concentration and hs-cTnI concentration with EDACS. We used a standard smoothing technique on the probability density function for hs-cTn and EDACS and applied bootstrapping to determine the optimal threshold combinations, namely the combination that maximized the percentage low-risk with ≥98.5% sensitivity for MACE.ResultsFrom 2536 patients, 2258 presented without an ischemic ECG of whom 272 (12.1%) had a MACE within 30 days. The optimal threshold for hs-cTnI was 7 ng/L combined with an EDACS threshold of 16 (36.8% patients low-risk). The optimal thresholds for hs-cTnT were 8 ng/L combined with an EDACS threshold of 15 (30.2% patients low-risk).ConclusionSingle measurements of both hs-cTnI and hs-cTnT at presentation combined with EDACS to identify over 30% of patients as low-risk and therefore eligible for safe early discharge after only one blood-draw.This article is protected by copyright. All rights reserved.
      PubDate: 2017-11-13T10:30:22.795297-05:
      DOI: 10.1111/acem.13343
  • Firearms and suicide: Finding the right words
    • Authors: Marian E. Betz
      Abstract: As emergency physicians, we're used to asking patients about sensitive topics. We overcame discomfort by practicing questions like “Do you have sex with men, women or both'” until the words flowed smoothly. In lectures, I urge providers to counsel suicidal patients about firearm access, given that reducing lethal means access can save lives.1,2 But early on, I didn't know how to talk about firearms without offending my patients.This article is protected by copyright. All rights reserved.
      PubDate: 2017-11-10T11:21:14.233582-05:
      DOI: 10.1111/acem.13344
  • Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment
           of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled
    • Authors: Reza Zahed; Mohammad Hossain Mousavi Jazayeri, Asieh Naderi, Zeinab Naderpour, Morteza Saeedi
      Abstract: ObjectiveWe evaluated the efficacy of topical application of the injectable form of tranexamic acid (TXA) compared with anterior nasal packing (ANP) for the treatment of epistaxis in patients taking antiplatelet drugs (Aspirin, Clopidegrol or both) who presented to the emergency department (ED).MethodsA randomized, parallel group clinical trial was conducted at 2 EDs. A total of 124 participants were randomized to receive topical TXA (500 mg in 5 ml) or ANP, 62 patients per group. The primary outcome was the proportion of patients in each group whose bleeding had stopped at 10 minutes. Secondary outcomes were the re-bleeding rate at 24 hours and one week, ED length of stay (LOS), and patient satisfaction.ResultsWithin 10 minutes of treatment, bleeding was stopped in 73% of the patients in the TXAgroup, compared with 29% in the ANP group (difference 44%, 95% confidence interval, 26%-57%; p
      PubDate: 2017-11-10T11:15:50.243643-05:
      DOI: 10.1111/acem.13345
  • Comparing state-wide and single-center data to predict high-frequency
           emergency department utilization among patients with asthma exacerbation
    • Authors: Margaret E. Samuels-Kalow; Mohammad K. Faridi, Janice A. Espinola, Jean E. Klig, Carlos A. Camargo
      Abstract: BackgroundPrevious studies examining high-frequency ED utilization have primarily used single-center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were (1) to create a predictive model to prospectively identify patients at risk of high-frequency ED utilization for asthma, and (2) to examine how that model differed using state-wide versus single-center data.MethodsTo track ED visits within a state, we analyzed 2011-2013 data from the New York State Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD). The first year of data (2011) was used to determine prior utilization; 2012 was used to identify index ED visits for asthma and for demographics; and 2013 was used for outcome ascertainment. High-frequency utilization was defined as 4+ ED visits for asthma within one year after the index visit. We performed analyses separately for children (age
      PubDate: 2017-11-04T03:55:26.416502-05:
      DOI: 10.1111/acem.13342
  • Early Recurrence of First Unprovoked Seizures in Children
    • Authors: Leah R Goldberg; Catherine G Kernie, Kathleen Lillis, Jonathan Bennett, Gregory Conners, Charles G. Macias, James Callahan, Cigdem Akman, W. Allen Hauser, Nathan Kuppermann, Peter S. Dayan
      Abstract: ObjectivesThe risk of early seizure recurrences after first unprovoked seizures in children is largely unknown. We aimed to determine the rate of seizure recurrence within 14 days of first, unprovoked seizures in children and identify associated risk factors. Secondarily, we aimed to determine the risk of recurrence at 48 hours and 4 months.MethodsWe conducted a secondary analysis of a multicenter cohort study of children 29 days-18 years with first, unprovoked seizures. Emergency department (ED) clinicians completed standardized histories and physical examinations. The primary outcome, recurrent seizure at 14 days, and the secondary outcomes, recurrence at 48 hours and 4 months, were assessed by telephone follow-up and medical record review. For each recurrence time point, we excluded those patients for whom no seizure had recurred but chronic antiepileptic drugs (AEDs) had been initiated.Results475 patients were enrolled in the parent study. Of evaluable patients for this secondary analysis, 26/392 (6.6%, 95% CI: 4.4-9.6%) had recurrences within 48 hours of the incident seizures, 58/366 (15.8%; 12.3-20.0%) had recurrences within 14 days, and 107/340 (31.5%; 26.6-36.7%) had recurrences within 4 months. On logistic regression analysis, age younger than 3 years was independently associated with a higher risk of 14-day recurrence (adjusted OR 2.1, 95% CI 1.2, 3.7; p=0.01). Having had more than 1 seizure within the 24 hours prior to ED presentation was independently associated with a higher risk of seizure recurrence at 48 hours (adjusted OR 4.3, 95% CI 1.9, 9.8; p
      PubDate: 2017-11-04T03:55:23.869728-05:
      DOI: 10.1111/acem.13341
  • Training and Assessing Critical Airway, Breathing and Hemorrhage Control
           Procedures for Trauma Care: Live Tissue versus Synthetic Models
    • Authors: Danielle Hart; Robert Rush, Gregory Rule, Joseph Clinton, Gregory Beilman, Shilo Anders, Rachel Brown, Mary Ann McNeil, Troy Reihsen, Jeffrey Chipman, Robert Sweet,
      Abstract: IntroductionOptimal teaching and assessment methods and models for emergency airway, breathing and hemorrhage interventions are not currently known. The University of Minnesota Combat Casualty Training consortium (UMN CCTC) was formed to explore the strengths and weaknesses of synthetic training models (STMs) versus Live tissue (LT) models. In this study, we compare the effectiveness of best in class STMs versus an anesthetized caprine (goat) model for training and assessing 7 procedures: Junctional hemorrhage control, Tourniquet (TQ) placement, Chest seal, Needle thoracostomy (NCD), Nasopharyngeal airway (NPA), Tube thoracostomy, and Cricothyrotomy (Cric).MethodsArmy combat medics were randomized to one of four groups: 1) Live tissue trained – live tissue tested (LT-LT), 2) live tissue trained – synthetic training model tested (LT-STM), 3) synthetic training model trained – live tissue tested (STM-LT), 4) synthetic training model trained – synthetic training model tested (STM-STM). Participants trained in small groups for 3-4 hours and were evaluated individually. LT-LT was the “control” to which other groups were compared, as this is the current military pre-deployment standard. The mean procedural scores (PS) were compared using a pairwise t-test with a Dunnett's correction. Logistic regression was used to compare critical fails (CF) and skipped tasks.ResultsThere were 559 subjects included. Junctional hemorrhage control revealed no difference in CFs, but LT tested subjects (LT-LT and STM-LT) skipped this task more than STM tested subjects (LT-STM and STM-STM) (p
      PubDate: 2017-10-27T10:10:30.515599-05:
      DOI: 10.1111/acem.13340
  • Communicating Value in Simulation: Cost Benefit Analysis and Return on
    • Authors: Carl V. Asche; Minchul Kim, Alisha Brown, Antoinette Golden, Torrey A. Laack, Javier Rosario, Christopher Strother, Vicken Y. Totten, Yasuharu Okuda
      Abstract: Value-based health care requires a balancing of medical outcomes with economic value. Administrators need to understand both the clinical and economic effects of potentially expensive simulation programs to rationalize the costs. Given the often-disparate priorities of clinical educators relative to health care administrators, justifying the value of simulation requires the use of economic analyses few physicians have been trained to conduct. Clinical educators need to be able to present thorough economic analyses demonstrating returns on investment and cost effectiveness to effectively communicate with administrators.At the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes”, our breakout session critically evaluated the cost benefit and return on investment of simulation. In this paper we provide an overview of some of the economic tools that a clinician may use to present the value of simulation training to financial officers and other administrators in the economic terms they understand. We also define three themes as a call to action for research related to cost benefit analysis in simulation as well as four specific research questions that will help guide educators and hospital leadership to make decisions on the value of simulation for their system or program.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-26T03:20:27.565758-05:
      DOI: 10.1111/acem.13336
  • Contributions of Academic Emergency Medicine Programs to US Healthcare:
           Summary of the AAAEM-AACEM Benchmarking Data
    • Authors: Martin A Reznek; James J Scheulen, Cathi A Harbertson, Kevin A Kotkowski, Gabor D Kelen, Gregory A Volturo
      Abstract: ObjectivesThe societal contribution of emergency care in the United States has been described. The role and impact of academic emergency departments (EDs) has been less clear. Our report summarizes the results of a benchmarking effort specifically focused on academic emergency medicine (EM) practices.MethodsFrom October through December of 2016, the Academy of Academic Administrators of Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) jointly administered a benchmarking survey to allopathic, academic departments and divisions of emergency medicine. Participation was voluntary and non-anonymous. The survey queried various aspects of the three components of the tripartite academic mission: clinical care, education and research, as well as faculty effort and compensation. Responses reflected a calendar year from July 1, 2015 to June 30, 2016.ResultsOf 107 eligible US allopathic, academic departments and divisions of emergency medicine, 79 (74%) responded to the survey overall, although individual questions were not always answered by all responding programs. The 79 responding programs reported 6,876,189 patient visits at 97 primary and affiliated academic clinical sites. A number of clinical operations metrics related to the care of these patients at these sites are reported in this study. All responding programs had active educational programs for emergency medicine residents, with a median of 37 residents per program. Nearly half of the overall respondents reported responsibility for teaching medical students in mandatory EM clerkships. Fifty-two programs reported research and publication activity, with a total of $129,494,676 of grant funding and 3,059 publications. Median faculty effort distribution was: clinical effort: 66.9%, education effort: 12.7%, administrative effort: 12.0%., and research effort: 6.9%. Median faculty salary was $277,045.ConclusionsAcademic EM programs are characterized by significant productivity in clinical operations, education and research. The survey results reported in this investigation provide appropriate benchmarking for academic EM programs because they allow for comparison of academic programs to each other, rather than non-academic programs which do not necessarily share the additional missions of research and education and may have dissimilar working environments.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-26T03:20:24.419944-05:
      DOI: 10.1111/acem.13337
  • Hot Off the Press: Prehospital Advanced Cardiac Life Support for
           Out-of-hospital Cardiac Arrest
    • Authors: Corey Heitz; Justin Morgenstern, William K. Milne
      Abstract: This retrospective cohort study examined the rate of survival to hospital discharge among adult patients with out of hospital cardiac arrest (OHCA), comparing patients who received care only from basic cardiac life support (BCLS) trained emergency medical service (EMS) crews to patients who had an advanced cardiac life support (ACLS) trained EMS crew on scene at some point during the resuscitation. There was no difference in the primary outcome of rate of survival to hospital discharge (10.9% with ACLS care and 10.6% with BCLS care, p = 0.67).This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-16T13:50:27.893371-05:
      DOI: 10.1111/acem.13334
  • Fluid Resuscitation in Patients with Severe Burns: A Meta-Analysis of
           Randomized Controlled Trials
    • Authors: Yuan Kao; El-Wui Loh, Chien-Chin Hsu, Hung-Jung Lin, Chien-Cheng Huang, Yun-Yun Chou, Chieh-Chun Lien, Ka-Wai Tam
      Abstract: ObjectivesFluid resuscitation is the mainstay treatment to reconstitute intravascular volume and maintain end-organ perfusion in patients with severe burns. The use of a hyper-osmotic or iso-osmotic solution in fluid resuscitation to manage myocardial depression and increased capillary permeability during burn shock has been debated. We conducted a systematic review and meta-analysis to compare the efficacies of hyper-osmotic and iso-osmotic solutions in restoring hemodynamic stability after burn injuries.MethodsPubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials. gov registry were searched. Randomized control trials evaluating the efficacy and safety of hyper-osmotic and iso-osmotic fluid resuscitation in patients with burn injuries were selected. Eligible trials were abstracted and assessed for the risk of bias by 2 reviewers and results of hemodynamic indicators in the included trials were analyzed.ResultsTen trials including 502 participants were published between 1983 and 2013. Compared with iso-osmotic group, the hyper-osmotic group exhibited a significant decrease in the fluid load (vol/%TBSA/weight) at 24 h postinjury, with a mean difference of −0.54 (95% confidence interval = −0.92 to −0.17). No differences were observed in the urine output, creatinine level, and mortality at 24 h postinjury between groups.ConclusionsHyper-osmotic fluid resuscitation appears to be an attractive choice for severe burns in terms of total body surface area or burn depth. Further investigation is recommended before conclusive recommendation.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-11T10:55:23.219479-05:
      DOI: 10.1111/acem.13333
  • Behavioral Changes in Children after Emergency Department Procedural
    • Authors: Jean I. Pearce; David C. Brousseau, Ke Yan, Keri R. Hainsworth, Raymond G. Hoffmann, Amy L. Drendel
      Abstract: ObjectiveThe purpose of this study was to determine the proportion of children undergoing procedural sedation for fracture reduction in the emergency department (ED) observed to experience negative post-discharge behaviors. Predictors of negative behaviors were evaluated, including anxiety.MethodsThis was a prospective cohort study of children receiving intravenous ketamine sedation for ED fracture reduction. The child's anxiety prior to sedation was measured with the Modified Yale Preoperative Anxiety Scale. Negative behavioral changes were measured with the Post-Hospitalization Behavior Questionnaire 1-2 weeks after discharge. Descriptive statistics and odds ratios were calculated. Chi square test was used for comparisons between groups. Multivariable logistic regression models evaluated predictors of negative behavioral change after discharge.Results97 patients were enrolled, 82 (85%) completed follow-up. Overall, 33 (40%) children were observed to be highly anxious pre-sedation and 18 (22%) had significant negative behavior changes after ED discharge. Independent predictors for negative behaviors were high anxiety (OR=9.0, 95% CI 2.3-35.7) and non-white race (OR= 6.5, 95% CI 1.7-25.0).ConclusionFor children undergoing procedural sedation in the ED, two in five children have high pre-procedure anxiety and almost one in four have significant negative behaviors 1-2 weeks after discharge. Highly anxious and non-white children have increased risk of negative behavioral changes which have not been previously recognized in the ED setting.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-09T14:40:31.475182-05:
      DOI: 10.1111/acem.13332
  • Excited Delirium: A Systematic Review
    • Authors: Philippe Gonin; Nicolas Beysard, Bertrand Yersin, Pierre-Nicolas Carron
      Abstract: Study objectiveWe aimed to clarify the definition, epidemiology, and pathophysiology of excited delirium syndrome (ExDS) and to summarize evidence-based treatment recommendations.MethodsWe conducted a systematic literature search of MEDLINE, Ovid, Web of Knowledge, and Cochrane Library for articles published to March 18, 2017. We also searched the grey literature (Google Scholar) and official police or medical expert reports to complete specific epidemiological data. Search results and full-text articles were independently assessed by two investigators and agreements between reviewers assessed with K statistics. We classified articles by study type, setting, and evidence level.ResultsAfter reviewing the title and abstract of 3604 references, we fully reviewed 284 potentially relevant references, from which 66 were selected for final review. Six contributed to the definition of ExDS, 24 to its epidemiology, 38 to its pathophysiology, and 27 to its management. The incidence of ExDS varies widely with medical or medico-legal context. Mortality is estimated to be as much as 8.3 to 16.5%. Patients are predominantly male. Male gender, young age, African-American race, and being overweight are independent risk factors. Pathophysiology hypotheses mostly implicate dopaminergic pathways. Most cases occur with psychostimulant use or among psychiatric patients, or both. Proposed treatments are symptomatic, often with rapid sedation with benzodiazepines or antipsychotic agents. Ketamine is suggested as an alternative.ConclusionThe overall quality of studies was poor. A universally recognized definition is lacking, remaining mostly syndromic and based on clinical subjective criteria. High mortality rate may be due to definition inconsistency and reporting bias. Our results suggest that ExDS is a real clinical entity, that still kills people and that has probably specific mechanisms and risk factors. No comparative study has been done to conclude whether one treatment approach is preferable to another in the case of ExDS.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-09T03:33:15.923765-05:
      DOI: 10.1111/acem.13330
  • A collaborative in-situ simulation-based pediatric readiness improvement
           program for community emergency departments
    • Authors: Kamal Abulebda; Riad Lutfi, Travis Whitfill, Samer Abu-Sultaneh, Kellie J. Leeper, Elizabeth Weinstein, Marc A. Auerbach
      Abstract: BackgroundMore than 30 million children are cared for across 5,000 US emergency departments each year (ED). Most of these EDs are not facilities designed and operated solely for children. A web-based survey provided a national and state-by-state assessment of pediatric readiness and noted a national average score was 69 on a 100-point scale. This survey noted wide variations in ED readiness with scores ranging from 61 in low-pediatric-volume EDs to 90 in the high-pediatric-volume EDs. Additionally, the mean score at the state level ranged from 57 (Wyoming) to 83 (Florida) and for individual EDs ranged from 22 to 100. The majority of prior efforts made to improve pediatric readiness have involved providing web-based resources and online toolkits. This paper reports on the first year of a program that aimed to improve pediatric readiness across community hospitals in our state through in situ simulation-based assessment facilitated by our academic medical center. The primary aim was to improve the pediatric readiness scores in the ten participating hospitals. The secondary aim was to explore the correlation of simulation-based performance of hospital teams with pediatric readiness scores.MethodsThis interventional study measured the PRS prior to and after implementation of an improvement program. This program consisted of three components: (1) in-situ simulations; (2) report outs; and (3) access to online pediatric readiness resources and content experts. The simulations were conducted in situ (in the ED resuscitation bay) by multi-professional teams of doctors, nurses, respiratory therapists and technicians. Simulations and debriefings were facilitated by an expert team from a pediatric academic medical center. Three scenarios were conducted for all teams and include: a six-month-old with respiratory failure, an eight-year-old with diabetic ketoacidosis (DKA), and a six-month-old with supraventricular tachycardia (SVT). A performance score was calculated for each scenario. The improvement of PRS was compared before and after the simulation program. The correlation of the simulation performance of each hospital and the PRS was calculated.Results41 multi-professional teams from ten EDs in Indiana participated in the study, five were of medium pediatric volume and five were medium-high volume EDs. The PRS significantly improved from the first to the second on-site verification assessment (58.4±4.8 to 74.7±2.9, p=0.009). Total adherence scores to scenario guidelines were: 54.7%, 56.4% and 62.4% in the respiratory failure, DKA and SVT scenarios respectively. We found no correlation between simulation performance and PRS scores. Medium ED pediatric volume significantly predicted higher PRS scores compared to medium-high pediatric ED volume (β=8.7; CI: 0.72, 16.8, p=0.034).Conclusion(s)Our collaborative improvement program that involved simulation was associated with improvement in pediatric readiness scores in ten EDs participating statewide. Future work will focus on further expanding of the network and establishing a national model for pediatric readiness improvement.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-04T14:05:21.179288-05:
      DOI: 10.1111/acem.13329
  • Communicating Value in Simulation: Cost Benefit Analysis and Return on
    • Authors: Carl V. Asche; Minchul Kim, Alisha Brown, Antoinette Golden, Torrey A. Laack, Javier Rosario, Christopher Strother, Vicken Y. Totten, Yasuharu Okuda
      Abstract: Value-based health care requires a balancing of medical outcomes with economic value. Administrators need to understand both the clinical and economic effects of potentially expensive simulation programs to rationalize the costs. Given the often-disparate priorities of clinical educators relative to health care administrators, justifying the value of simulation requires the use of economic analyses few physicians have been trained to conduct. Clinical educators need to be able to present thorough economic analyses demonstrating returns on investment and cost effectiveness to effectively communicate with administrators.At the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes”, our breakout session critically evaluated the cost benefit and return on investment of simulation. In this paper we provide an overview of some of the economic tools that a clinician may use to present the value of simulation training to financial officers and other administrators in the economic terms they understand. We also define three themes as a call to action for research related to cost benefit analysis in simulation as well as four specific research questions that will help guide educators and hospital leadership to make decisions on the value of simulation for their system or program.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-01T07:30:35.453725-05:
      DOI: 10.1111/acem.13327
  • Simulation-based education to ensure provider competency within the
           healthcare system
    • Authors: Sharon Griswold; Alise Fralliccardi, John Boulet, Tiffany Moadel, Douglas Franzen, Marc Auerbach, Danielle Hart, Varsha Goswami, Joshua Hui, James A. Gordon
      Abstract: The acquisition and maintenance of individual competency is a critical component of effective emergency care systems. This article summarizes consensus working group deliberations and recommendations focusing on the topic: “Simulation-based education to ensure provider competency within the healthcare system.” The authors presented this work for discussion and feedback at the 2017 Academic Emergency Medicine Consensus Conference on ‘‘Catalyzing System Change through Healthcare Simulation: Systems, Competency, and Outcomes,’’ held on May 16, 2017, in Orlando, FL. Although simulation-based training is a quality and safety imperative in other high-reliability professions such as aviation, nuclear power, and the military, health care professions still lag behind in applying simulation more broadly. This is likely a result of a number of factors, including cost, assessment challenges, and resistance to change. This consensus subgroup focused on identifying current gaps in knowledge and process related to the use of simulation for developing, enhancing, maintaining individual provider competency. The resulting product is a research agenda informed by expert consensus and literature review.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-30T07:55:22.082089-05:
      DOI: 10.1111/acem.13322
  • Point-of-care cognitive support technology in emergency departments: A
           scoping review of technology acceptance by clinicians
    • Authors: Shelly Jun; Amy C Plint, Sandy M Campbell, Sarah Curtis, Kyrellos Sabir, Amanda S Newton
      Abstract: ObjectiveCognitive support technologies that support clinical decisions and practices in the emergency department (ED) have the potential to optimize patient care. However, limited uptake by clinicians can prevent successful implementation. A better understanding of acceptance of these technologies from the clinician perspective is needed. We conducted a scoping review to synthesize diverse, emerging evidence on clinicians’ acceptance of point-of-care (POC) cognitive support technology in the ED.MethodWe systematically searched 10 electronic databases and grey literature published from January 2006 to December 2016. Studies of any design assessing an ED-based POC cognitive support technology were considered eligible for inclusion. Studies were required to report outcome data for technology acceptance. Two reviewers independently screened studies for relevance and quality. Study quality was assessed using the Mixed Methods Appraisal Tool. A descriptive analysis of the features of POC cognitive support technology for each study is presented, illustrating trends in technology development and evaluation. A thematic analysis of clinician, technical, patient, and organizational factors associated with technology acceptance is also presented.ResultsOf the 1,563 references screened for eligibility, 24 met the inclusion criteria and were included in the review. Most studies were published from 2011 onwards (88%), scored high for methodological quality (79%) and examined POC technologies that were novel and newly introduced into the study setting (63%). Physician use of POC technology was the most commonly studied (67%). Technology acceptance was frequently conceptualized and measured by factors related to clinician attitudes and beliefs. Experience with the technology, intention to use, and actual use were also more common outcome measures of technology acceptance. Across studies, perceived usefulness was the most noteworthy factor impacting technology acceptance, and clinicians generally had positive perceptions of the use of POC cognitive support technology in the ED. However, the actual use of POC cognitive support technology reported by clinicians was low—use, by proportion of patient cases, ranged from 30% to 59%. Of the 24 studies, only 2 studies investigated acceptance of POC cognitive support technology currently implemented in the ED, offering ‘real world’ clinical practice data. All other studies focused on acceptance of novel technologies. Technical aspects such as an unfriendly user interface, presentation of redundant or ambiguous information, and required user effort had a negative impact on acceptance. Patient expectations were also found to have a negative impact, while patient safety implications had a positive impact. Institutional support was also reported to impact technology acceptance.ConclusionsFindings from this scoping review suggest that while ED clinicians acknowledge the utility and value of using POC cognitive support technology, actual use of such technology can be low. Further, few studies have evaluated the acceptance and use of POC technologies in routine care. Prospective studies that evaluate how ED clinicians appraise and consider POC technology use in clinical practice are now needed with diverse clinician samples. While this review identified multiple factors contributing to technology acceptance, determining how clinician, technical, patient, and organizational factors mediate or moderate acceptance should also be a priority.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-28T10:05:21.690371-05:
      DOI: 10.1111/acem.13325
  • Return Visit Admissions May Not Indicate Quality of Emergency Department
           Care for Children
    • Authors: Marion R. Sills; Michelle L. Macy, Keith E. Kocher, Amber K. Sabbatini
      Abstract: ObjectiveTo test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit.MethodsRetrospective analysis of ED visits by children age 0-17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as “ED return admissions” (discharged at ED index visit and admitted at return visit) or “readmissions” (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to “index admissions without return admission” (admitted at ED index visit without 7-day return visit admission).ResultsAmong 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions and 1,333 were readmissions. ED return admissions had lower intensive care unit (ICU) admission rates (11.0% versus 13.6%; adjusted odds ratio (AOR) 0.78, 95% confidence interval (CI) 0.71-0.85), longer length of stay (LOS, 3.51 vs. 3.38 days; difference 0.13 days; incidence rate ratio (IRR) 1.04; 95% CI 1.02-1.07), but no difference in mean hospital costs (($7138 vs. $7331; difference -$193; 95% CI -$479 to 93) compared to index admissions without return admission.ConclusionsCompared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-27T09:46:49.193368-05:
      DOI: 10.1111/acem.13324
  • EMR Stalking
    • Authors: Utsha G. Khatri
      Abstract: You arrived unannounced. I sloppily donned my protective costume while the hardened but tireless nurses ran out to fetch you from the driveway, as they had with hundreds of other police drop-offs before. I imagined your body being thrown from side to side, smearing blood onto the seat as you were sped through red lights to get to the hospital. Thrown onto a stretcher and rushed into the spotless and brightly lit trauma bay; it was there I that I reluctantly met you.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-27T09:40:18.898206-05:
      DOI: 10.1111/acem.13320
  • Alternative Markers of Performance in Simulation: Where We Are and Where
           We Need To Go
    • Authors: Ann M. Willemsen-Dunlap; Emily E. Binstadt, Michael C. Nguyen, Nicole C. Elliott, Alan R. Cheney, Ronald H. Stevens, Suzanne Dooley-Hash
      Abstract: This article on alternative markers of performance in simulation is the product of a session held during the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes.” There is a dearth of research on the use of performance markers other than checklists, holistic ratings, and behaviorally-anchored rating scales in the simulation environment. Through literature review, group discussion, and consultation with experts prior to the conference, the working group defined five topics for discussion: 1. establishing a working definition for alternative markers of performance; 2. defining goals for using alternative performance markers; 3. implications for measurement when using alternative markers; 4. identifying practical concerns related to the use of alternative performance markers; and 5. identifying potential for alternative markers of performance to validate simulation scenarios. Five research propositions also emerged, and are summarized in the paper.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-26T08:00:20.998972-05:
      DOI: 10.1111/acem.13321
  • Human factors and simulation in emergency medicine
    • Authors: Emily M. Hayden; Ambrose H. Wong, Jeremy Ackerman, Margaret K. Sande, Charles Lei, Leo Kobayashi, Michael Cassara, Dylan D Cooper, Kimberly Perry, William E. Lewandowski, Mark W Scerbo
      Abstract: This consensus group from the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes” held in Orlando, Florida on May 16, 2017 focused on the use of human factors and simulation in the field of emergency medicine. The human factors discipline is often underutilized within emergency medicine but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of human factors, its benefits in medicine, how simulation can be a catalyst for human factors work in emergency medicine, and how emergency medicine can collaborate with human factors professionals to affect change. Implementing human factors in emergency medicine through healthcare simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between human factors professionals and emergency medicine, such as in this breakout group.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-19T05:15:29.92998-05:0
      DOI: 10.1111/acem.13315
  • Lessons Learned from the Development and Parameterization of a Computer
           Simulation Model to Evaluate Task Modification for Healthcare Providers
    • Authors: Parastu Kasaie; W. David Kelton, Rachel M. Ancona, Michael J. Ward, Craig M. Froehle, Michael S. Lyons
      Abstract: Computer simulation is a highly advantageous method for understanding and improving healthcare operations with a wide variety of possible applications. Most computer-simulation studies in emergency medicine have sought to improve allocation of resources to meet demand, or to assess the impact of hospital and other system policies on emergency department (ED) throughput. These models have enabled essential discoveries that can be used to improve the general structure and functioning of EDs. Theoretically, computer simulation could also be used to examine the impact of adding or modifying specific provider tasks. Doing so involves a number of unique considerations, particularly in the complex environment of acute-care settings. In this paper, we describe conceptual advances and lessons learned during the design, parameterization, and validation of a computer-simulation model constructed to evaluate changes in ED provider activity. We illustrate these concepts using examples from a study focused on the operational effects of HIV-screening implementation in the ED. Presentation of our experience should emphasize the potential for application of computer simulation to study changes in healthcare-provider activity and facilitate the progress of future investigators in this field.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-19T05:15:24.151128-05:
      DOI: 10.1111/acem.13314
  • Implementation and preliminary clinical outcomes of a pharmacist-managed
           venous thromboembolism clinic for patients treated with rivaroxaban post
           emergency department discharge
    • Authors: Baely M. DiRenzo; Daren M. Beam, Jeffrey A. Kline, Karishma S. Deodhar, Christina M. Davis, Zachary A. Weber, Todd A. Walroth
      Abstract: ObjectiveTo describe the implementation, work flow, and differences in outcomes between a pharmacist-managed clinic for the outpatient treatment of venous thromboembolism (VTE) using rivaroxaban versus care by a primary care provider.InterventionsPatients in the studied health system that are diagnosed with low-risk VTE in the emergency department are often discharged without hospital admission. These patients are treated with rivaroxban and follow up either in a pharmacist-managed VTE clinic or with their primary care provider. Pharmacists in the VTE clinic work independently under a collaborative practice agreement. An evaluation of thirty-four patients, seventeen in each treatment arm, was conducted to compare the differences in treatment-related outcomes of rivaroxaban when managed by a pharmacist versus a primary care provider.ResultsThe primary endpoint was a six month composite of anticoagulation treatment-related complications that included a diagnosis of major bleeding, recurrent thromboembolism, or fatality due to either major bleeding or recurrent thromboembolism. Secondary endpoints included number of hospitalizations, adverse events, and medication adherence. There was no difference in the primary endpoint between groups with one occurrence of the composite endpoint in each treatment arm (p=1.000), both of which were recurrent thromboembolic events. Medication adherence assessment was formally performed in 8 patients in the pharmacist group versus 0 patients in the control group. No differences were seen amongst other secondary endpoints.ConclusionsThe pharmacist-managed clinic is a novel expansion of clinical pharmacy services that treats patients with low-risk VTEs with rivaroxaban in the outpatient setting. The evaluation of outcomes provides support that pharmacist-managed care utilizing standardized protocols under a collaborative practice agreement may be as safe as care by a primary care provider.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-16T09:30:20.585967-05:
      DOI: 10.1111/acem.13311
  • Using Virtual Reality Simulation Environments to Assess Competence for
           Emergency Medicine Learners
    • Authors: Jillian L. McGrath; Jeffrey M. Taekman, Parvati Dev, Douglas R. Danforth, Deepika Mohan, Nicholas Kman, Amanda Crichlow, William F. Bond
      Abstract: Immersive learning environments that use virtual simulation technology are increasingly relevant as medical learners train in an environment of restricted clinical training hours and a heightened focus on patient safety. We conducted a consensus process with a breakout group of the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes.” This group examined the current uses of virtual simulation in training and assessment, including limitations and challenges in implementing virtual simulation into medical education curricula. We discuss the role of virtual environments in formative and summative assessment. Finally, we offer recommended areas of focus for future research examining virtual simulation technology for assessment, including high stakes assessment in medical education. Specifically, we discuss needs for determination of areas of focus for virtual simulation training and assessment, development and exploration of virtual platforms, automated feedback within such platforms, and evaluation of effectiveness and validity of virtual simulation education.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-09T10:20:23.70804-05:0
      DOI: 10.1111/acem.13308
  • The 2017 Academic Emergency Medicine Consensus Conference: Catalyzing
           System Change through Healthcare Simulation: Systems, Competency, and
    • Authors: William Bond; Joshua Hui, Rosemarie Fernandez
      Abstract: Over the past decade, emergency medicine took a lead role in healthcare simulation in part due to its demands for successful interprofessional and multidisciplinary collaboration, along with educational needs in a diverse array of cognitive and procedural skills. Simulation-based methodologies have the capacity to support training and research platforms that model micro-, meso- and macro- systems of healthcare. To fully capitalize on the potential of simulation-based research to improve emergency healthcare delivery will require the application of rigorous methods from engineering, social science, and basic science disciplines. The Academic Emergency Medicine (AEM) Consensus Conference, “Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcome” was conceived to foster discussion among experts in emergency medicine, engineering, and social sciences, focusing on key barriers and opportunities in simulation-based research. This executive summary describes the overall rationale for the conference, conference planning, consensus-building approaches, and outlines the focus of the eight breakout sessions. The consensus outcomes from each breakout session are summarized in Proceedings papers published in this issue of Academic Emergency Medicine. Each paper provides an overview of methodological and knowledge gaps in simulation research and identifies future research targets aimed at improving the safety and quality of healthcare.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-29T17:51:06.567883-05:
      DOI: 10.1111/acem.13302
  • Mannequin-based telesimulation: Increasing access to simulation-based
    • Authors: Emily M. Hayden; Avni Khatri, Hillary R. Kelly, Phoebe H. Yager, Gloria M. Salazar
      Abstract: The 2017 Academic Emergency Medicine Consensus Conference, “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes,” highlights how simulation can improve the delivery of health care across larger systems; however, how can systems change when valuable educational interventions reach only limited populations' Studies have demonstrated the benefit of simulation education1,2 but have questioned the use of simulation in a system with limited financial resources.3 Most academic medical centers have mannequin-based simulation technology;4 yet, it is unclear from the literature how many community hospitals, especially in rural areas, have a simulation center or mannequins.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-28T08:55:24.856362-05:
      DOI: 10.1111/acem.13299
  • Simulation for Assessment of Milestones in Emergency Medicine Residents
    • Authors: Danielle Hart; William Bond, Jeffery Siegelman, Daniel Miller, Michael Cassara, Lisa Barker, Shilo Anders, James Ahn, Hubert Huang, Christopher Strother, Joshua Hui
      Abstract: IntroductionAll residency programs in the United States are required to report their residents’ progress on the Milestones to the Accreditation Council for Graduate Medical Education (ACGME) biannually. Since the development and institution of this competency-based assessment framework, residency programs have been attempting to ascertain the best ways to assess resident performance on these metrics. Simulation was recommended by the ACGME as one method of assessment for many of the milestone subcompetencies. We developed 3 simulation scenarios with scenario specific Milestone based assessment tools. We aimed to gather validity evidence for this tool.MethodsWe conducted a prospective observational study to investigate the validity evidence for 3 mannequin-based simulation scenarios for assessing individual residents on Emergency Medicine (EM) milestones. The subcompetencies (i.e. PC1, PC2, PC3) included were identified via a modified Delphi technique using a group of experienced EM simulationists. The scenario specific checklist items were designed based on the individual milestone items within each EM subcompetency chosen for assessment and reviewed by experienced EM simulationists. Two independent live raters who were EM faculty at the respective study sites scored each scenario following brief rater training. The interrater reliability (IRR) of the assessment tool was determined by measuring intraclass correlation coefficient (ICC) for the sum of the checklist (CL) items as well as the global rating scales (GRS) for each scenario. Comparing GRS and CL scores between various PGY levels was performed with ANOVA.ResultsEight subcompetencies were chosen to assess with 3 simulation cases, using 118 subjects. Evidence of test content, internal structure, response process and relations with other variables were found. The ICCs for the sum of the CL items and the GRSs were> 0.8 for all cases, with one exception (clinical management GRS 0.74 in sepsis case). The Sum of Checklist items and GRSs (p
      PubDate: 2017-08-20T06:25:21.460196-05:
      DOI: 10.1111/acem.13296
  • Understanding Emergency Care Delivery through Computer Simulation Modeling
    • Authors: Lauren F. Laker; Elham Torabi, Daniel J. France, Craig M. Froehle, Eric J. Goldlust, Nathan R. Hoot, Parastu Kasaie, Michael S. Lyons, Laura H. Barg-Walkow, Michael J. Ward, Robert L. Wears
      Abstract: In 2017, Academic Emergency Medicine convened a consensus conference entitled, “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes.” This manuscript, a product of the breakout session on “understanding complex interactions through systems modeling,” explores the role that computer simulation modeling can and should play in research and development of emergency care delivery systems. This manuscript discusses areas central to the use of computer simulation modeling in emergency care research. The four central approaches to computer simulation modeling are described (Monte Carlo Simulation, System Dynamics modeling, Discrete-Event Simulation, and Agent Based Simulation), along with problems amenable to their use and relevant examples to emergency care. Also discussed is an introduction to available software modeling platforms and how to explore their use for research, along with a research agenda for computer simulation modeling. Through this manuscript, our goal is to enhance adoption of computer simulation, a set of methods which hold great promise in addressing emergency care organization and design challenges.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-10T07:05:28.304166-05:
      DOI: 10.1111/acem.13272
  • Changing Systems Through Effective Teams: A Role for Simulation
    • Authors: Elizabeth D. Rosenman; Rosemarie Fernandez, Ambrose H. Wong, Michael Cassara, Dylan D. Cooper, Maybelle Kou, Torrey A. Laack, Ivette Motola, Jessica R. Parsons, Benjamin R. Levine, James A. Grand
      Abstract: Teams are the building blocks of the healthcare system, with growing evidence linking the quality of health care to team effectiveness, and team effectiveness to team training. Simulation has been identified as an effective modality for team training and assessment. Despite this, there are gaps in methodology, measurement, and implementation that prevent maximizing the impact of simulation modalities on team performance. As part of the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes,” we explored the impact of simulation on various aspects of team effectiveness. The consensus process included an extensive literature review, group discussions, and the conference “work-shop” involving emergency medicine physicians, medical educators, and team science experts. The objectives of this work are to: (1) explore the antecedents and processes that support team effectiveness, (2) summarize the current role of simulation in developing and understanding team effectiveness, and (3) identify research targets to further improve team-based training and assessment, with the ultimate goal of improving health care systems.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-20T04:17:57.47012-05:0
      DOI: 10.1111/acem.13260
  • A simulation-based approach to measuring team situational awareness in
           emergency medicine: A multicenter, observational study
    • Authors: Elizabeth D. Rosenman; Aurora J. Dixon, Jessica M. Webb, Sarah Brolliar, Simon J. Golden, Kerin A. Jones, Sachita Shah, James A. Grand, Steve W.J. Kozlowski, Georgia T. Chao, Rosemarie Fernandez
      Abstract: ObjectivesTeam situational awareness (TSA) is critical for effective teamwork and supports dynamic decision-making in unpredictable, time-pressured situations. Simulation provides a platform for developing and assessing TSA; but these efforts are limited by suboptimal measurement approaches. The objective of this study was to develop and evaluate a novel approach to TSA measurement in interprofessional emergency medicine teams.MethodsWe performed a multicenter, prospective, simulation-based observational study to evaluate an approach to TSA measurement. Interprofessional emergency medical teams, consisting of emergency medicine resident physicians, nurses, and medical student, were recruited from the University of Washington (Seattle, WA) and Wayne State University (Detroit, MI). Each team completed a simulated emergency resuscitation scenario. Immediately following the simulation, team members completed a TSA measure, a team perception of shared understanding item, and a team leader effectiveness measure. Subject matter expert reviews and pilot testing of the TSA measure provided evidence of content and response process validity. Simulations were recorded and independently coded for team performance using a previously validated measure. The relationships between the TSA measure other variables (team clinical performance, team perception of shared understanding, team leader effectiveness, and team experience) were explored. The TSA agreement metric was indexed by averaging the pairwise agreement for each dyad on a team, and then averaging across dyads to yield agreement at the team level. For the team perception of shared understanding and team leadership effectiveness measures, individual team member scores were aggregated within a team to create a single team score. We computed descriptive statistics for all outcomes. We calculated Pearson's Product-Moment Correlations to determine bivariate correlations between outcome variables with two-tailed significance testing (p < 0.05).ResultsA total of 123 participants were recruited and formed 3-person teams (n = 41 teams). All teams completed the assessment scenario and post-simulation measures. Team situational awareness agreement ranged from 0.19 to 0.9 and had a mean (SD) of 0.61 (0.17). Team situational awareness correlated with team clinical performance (p
      PubDate: 2017-07-17T08:07:23.008638-05:
      DOI: 10.1111/acem.13257
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