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Showing 1 - 200 of 1580 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: 65, 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: 52, SJR: 1.02, h-index: 88)
Acta Archaeologica     Hybrid Journal   (Followers: 158, 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: 15, 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: 35, SJR: 2.518, h-index: 113)
Acta Zoologica     Hybrid Journal   (Followers: 6, SJR: 0.459, h-index: 29)
Acute Medicine & Surgery     Hybrid Journal   (Followers: 4)
Addiction     Hybrid Journal   (Followers: 35, SJR: 2.086, h-index: 143)
Addiction Biology     Hybrid Journal   (Followers: 13, SJR: 2.091, h-index: 57)
Adultspan J.     Hybrid Journal   (SJR: 0.127, h-index: 4)
Advanced Energy Materials     Hybrid Journal   (Followers: 27, 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: 268, 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: 17, 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: 10)
African Development Review     Hybrid Journal   (Followers: 33, SJR: 0.275, h-index: 17)
African J. of Ecology     Hybrid Journal   (Followers: 15, SJR: 0.477, h-index: 39)
Aggressive Behavior     Hybrid Journal   (Followers: 15, 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: 6, 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: 31, 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: 33, 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: 145, 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: 90, SJR: 2.325, h-index: 51)
American J. of Economics and Sociology     Hybrid Journal   (Followers: 28, SJR: 0.211, h-index: 26)
American J. of Hematology     Hybrid Journal   (Followers: 33, SJR: 1.761, h-index: 77)
American J. of Human Biology     Hybrid Journal   (Followers: 12, 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: 16, 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: 37, SJR: 1.41, h-index: 88)
American J. of Political Science     Hybrid Journal   (Followers: 272, 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: 3, SJR: 1.347, h-index: 75)
American J. of Transplantation     Hybrid Journal   (Followers: 17, SJR: 2.792, h-index: 140)
American J. on Addictions     Hybrid Journal   (Followers: 9, SJR: 0.843, h-index: 57)
Anaesthesia     Hybrid Journal   (Followers: 136, 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: 18)
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: 196)
Angewandte Chemie Intl. Edition     Hybrid Journal   (Followers: 219, SJR: 6.229, h-index: 397)
Animal Conservation     Hybrid Journal   (Followers: 39, 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: 47, SJR: 5.584, h-index: 241)
Annals of Noninvasive Electrocardiology     Hybrid Journal   (Followers: 2, SJR: 0.531, h-index: 38)
Annals of Public and Cooperative Economics     Hybrid Journal   (Followers: 9, 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: 13)
Annual Review of Information Science and Technology     Hybrid Journal   (Followers: 14)
Anthropology & Education Quarterly     Hybrid Journal   (Followers: 25, SJR: 0.72, h-index: 31)
Anthropology & Humanism     Hybrid Journal   (Followers: 17, 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: 90, SJR: 0.545, h-index: 15)
Antipode     Hybrid Journal   (Followers: 49, SJR: 2.212, h-index: 69)
Anz J. of Surgery     Hybrid Journal   (Followers: 7, 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: 70, SJR: 0.754, h-index: 69)
Applied Organometallic Chemistry     Hybrid Journal   (Followers: 7, SJR: 0.632, h-index: 58)
Applied Psychology     Hybrid Journal   (Followers: 206, SJR: 1.023, h-index: 64)
Applied Psychology: Health and Well-Being     Hybrid Journal   (Followers: 49, 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: 14, 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: 27, 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: 25, SJR: 0.261, h-index: 9)
Archiv der Pharmazie     Hybrid Journal   (Followers: 4, 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: 12, SJR: 0.938, h-index: 57)
Art History     Hybrid Journal   (Followers: 246, SJR: 0.153, h-index: 13)
Arthritis & Rheumatology     Hybrid Journal   (Followers: 50, SJR: 1.984, h-index: 20)
Arthritis Care & Research     Hybrid Journal   (Followers: 26, 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: 323, 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   (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: 2, 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: 4, 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: 11, SJR: 0.82, h-index: 62)
Australian Dental J.     Hybrid Journal   (Followers: 7, SJR: 0.482, h-index: 46)
Australian Economic History Review     Hybrid Journal   (Followers: 4, SJR: 0.171, h-index: 12)
Australian Economic Papers     Hybrid Journal   (Followers: 29, 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: 14, 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: 408, SJR: 0.418, h-index: 29)
Australian J. of Rural Health     Hybrid Journal   (Followers: 5, SJR: 0.43, h-index: 34)
Australian Occupational Therapy J.     Hybrid Journal   (Followers: 72, SJR: 0.59, h-index: 29)
Australian Psychologist     Hybrid Journal   (Followers: 12, SJR: 0.331, h-index: 31)
Australian Veterinary J.     Hybrid Journal   (Followers: 20, SJR: 0.459, h-index: 45)
Autism Research     Hybrid Journal   (Followers: 36, 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: 24, SJR: 0.736, h-index: 57)
Berichte Zur Wissenschaftsgeschichte     Hybrid Journal   (Followers: 9, 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: 16, SJR: 1.172, h-index: 90)
Biological Reviews     Hybrid Journal   (Followers: 4, SJR: 6.469, h-index: 114)
Biologie in Unserer Zeit (Biuz)     Hybrid Journal   (Followers: 42, 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: 36, 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: 45, SJR: 0.415, h-index: 55)
Biotechnology and Bioengineering     Hybrid Journal   (Followers: 160, 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: 6, 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: 243, SJR: 2.083, h-index: 125)

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Journal Cover Academic Emergency Medicine
  [SJR: 1.385]   [H-I: 91]   [65 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  [1580 journals]
  • 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
  • Disseminating and Sustaining Emergency Department Innovations for Older
           Adults: Good Ideas Deserve Better Policies
    • Authors: Alexander X. Lo; Kevin Biese
      Abstract: Older adults often visit the emergency department (ED) with chief complaints that understate or detract from their true complex health care needs. These needs are frequently missed because addressing them requires a time-consuming effort that is antithetical to the (necessarily) rapid, complaint-specific protocols of the ED. Key ED performance indices (e.g., length of stay; through-put) also create a disincentive against undertaking comprehensive geriatric assessments when not clearly germane to the chief complaint. However, ignoring these complex care issues can contribute to poor health outcomes. These visits often serve as sentinel events in the patient's health trajectory which irreversibly hastens loss of independence. Such encounters will only increase as the population ages.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-27T10:25:19.342338-05:
      DOI: 10.1111/acem.13339
  • Air ambulance delivery and administration of 4-factor prothrombin complex
           concentrate is feasible and decreases time to anticoagulation reversal
    • Authors: Claire Vines; Stephanie J. Tesseneer, Robert D. Cox, Damon A. Darsey, Kristin Carbrey, Michael A. Puskarich
      Abstract: ObjectivesTo evaluate the feasibility, safety, and preliminary efficacy of four-factor prothrombin complex concentrate (4-factor PCC) administration by an air ambulance service prior to or during transfer of patients with warfarin-associated major hemorrhage to a tertiary care center for definitive management (interventional arm) compared to patients receiving 4-factor PCC following transfer by air ambulance or ground without 4-factor PCC treatment (conventional arm).MethodsRetrospective chart review of patients presenting to a large academic medical center. All patients presenting to the emergency department (ED) treated with 4-factor PCC from April 1st 2014 through June 30th 2016 were identified For this study, only transfer patients with an INR>1.5 actively treated with warfarin were included. The primary outcome was the proportion of patients with an INR ≤1.5 upon tertiary care hospital arrival, and the secondary efficacy outcome was difference in time to achievement of INR ≤1.5. Additional safety and efficacy objectives included difference in thromboembolic complications, length of stay, ICU length of stay and in-patient mortality between groups.ResultsOf the 72 included patients, a higher proportion of patients in the interventional group had an INR ≤1.5 on ED arrival (proportion difference 0.82, 95% CI 0.64 to 0.92; p < 0.0001) and significantly reduced time to observed INR ≤1.5 (181 vs 541 minutes; p = 0.001). No differences were observed in thromboembolic complications or patient-centered outcomes with the exception of mortality, which was significantly higher in patients in the interventional group. This group was also observed to have lower Glasgow Coma Scale and higher intubation rates prior to transfer and treatment.ConclusionsDispatch of an air ambulance carrying 4-factor PCC with administration prior to transfer is feasible and leads to more rapid improvement in INR among patients with warfarin-associated major hemorrhage.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-27T10:15:20.889505-05:
      DOI: 10.1111/acem.13338
  • 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
  • Peripheral Intravenous Cannula Insertion and Use in the Emergency
           Department; an Intervention Study
    • Authors: Tracey Hawkins; Jaimi H Greenslade, Jessica Suna, Julian Williams, Matthew Jensen, Maria Donohue, Elizabeth Ho, Christopher Van Hise, Diana Egerton-Warburton, Louise Cullen
      Abstract: ObjectivesTo examine cannulation practice and effectiveness of a multi-modal intervention to reduce peripheral intravenous cannula (PIVC) insertion in emergency department (ED) patients.MethodsA prospective before and after study and cost analysis was conducted at a single tertiary ED in Australia. Data were collected 24 hours a day for two weeks pre- and post-implementation of a multi-modal intervention. PIVC placement and utilization within 24 hours were evaluated in all eligible patients.ResultsA total of 4,173 participants were included in the analysis. PIVCs were placed in 42.1% of patients’ pre-intervention and 32.4% post-intervention, a reduction of 9.8% (95% CI: 6.8 to -12.72%). PIVC usage within 24 hours of admission was 70.5% pre-intervention and 83.4% post-intervention; an increase of 12.9% (95% CI: 8.8-17.0%). Sixty-six patients were observed in the ED for cost analysis. The mean time per PIVC insertion was 15.3 (95% CI: 12.6 - 17.9) minutes. PIVC insertion cost, including staff time and consumables per participant, was A$22.79 (95% CI:A$19.35 - $26.23).ConclusionsThe intervention reduced PIVC placement in the ED and increased the percentage of PIVC placed that were used. This program benefits patients and health services alike, with potential for large cost savings.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-16T17:40:52.796198-05:
      DOI: 10.1111/acem.13335
  • 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
  • What's Next for Acute Heart Failure Research'
    • Authors: Sean P. Collins; Phillip D. Levy, Gregory J. Fermann, Michael M. Givertz, Jennifer M. Martindale, Peter S. Pang, Alan B. Storrow, Deborah D. Diercks, G. Michael Felker, Gregg C Fonarow, David J Lanfear, Daniel J. Lenihan, JoAnn M. Lindenfeld, W. Frank Peacock, Douglas M. Sawyer, John M. Teerlink, Javed Butler
      Abstract: Each year over one million patients with acute heart failure (AHF) present to a United States emergency department (ED). The vast majority are hospitalized for further management. The length of stay and high post-discharge event rate in this cohort has changed little over the last decade. Therapeutic trials have failed to yield substantive improvement in post-discharge outcomes, subsequently, AHF care has changed little in the last 40 years. Prior research studies have been fragmented as either “inpatient” or “ED-based”. Recognizing the challenges in identification and enrollment of ED patients with AHF, and the lack of robust evidence to guide management, an AHF clinical trials network was developed. This network has demonstrated, through organized collaboration between cardiology and emergency medicine, that many of the hurdles in AHF research can be overcome. The development of a network that supports the collaboration of acute care and HF researchers, combined with the availability of federally funded infrastructure, will facilitate more efficient conduct of both explanatory and pragmatic trials in AHF. Yet many important questions remain, and in this document our group of emergency medicine and cardiology investigators have identified four high priority research areas.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-09T03:31:57.781097-05:
      DOI: 10.1111/acem.13331
  • Clinical vignettes inadequate to assess impact of implicit bias:
           concerning limitations of a systematic review
    • Authors: Elizabeth A. Samuels; Dowin H. Boatright, Leon Sanchez, Sheryl Heron, Aisha T. Liferidge, Taneisha Wilson, Ava Pierce, Alden Landry, Lisa Moreno-Walton, Jeffrey Druck, Joel Moll, Bernard Lopez
      Abstract: We are writing in response to Dehon et al's article “A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making”1 in the August 2017 issue of Academic Emergency Medicine. As members of SAEM's Academy of Diversity and Inclusion in Emergency Medicine, we believe it is imperative to pursue research on the impact of bias and discrimination on clinical practice and healthcare outcomes. While we commend Dr. Dehon and her colleagues for their effort to assess the impact of implicit bias on clinical decision-making, we do not think that the evidence reviewed supports the breadth of their conclusions.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-05T14:35:21.47312-05:0
      DOI: 10.1111/acem.13317
  • 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
  • An Emergency Department Observation Unit is a feasible setting for
           Multidisciplinary Geriatric Assessments in compliance with the Geriatric
           Emergency Department Guidelines
    • Authors: Lauren T. Southerland; Anthony J. Vargas, Lalitha Nagaraj, Tanya R. Gure, Jeffery M. Caterino
      Abstract: BackgroundThe Geriatric Emergency Department Guidelines recommend providing multidisciplinary geriatric assessment in the Emergency Department (ED), but these assessments can be difficult to coordinate and may prolong length of stay. Patients who need longer than a typical ED stay can be placed in an ED Observation Unit (Obs Unit). We investigated the effects of offering multidisciplinary assessments for ED patients in an Obs Unit.MethodsEvaluation by a geriatric hospital consultation team, physical therapist, case manager, and/or pharmacist was made available to all Obs Unit patients. Use of any or all of these ancillary consult services could be requested by the Obs Unit physician. A retrospective chart review of random older adult Obs Unit patients was done to assess rates of consult use and interventions by these consulting teams. All patients ≥ 65 years old in our IRB approved, monthly Obs Unit quality database from October 2015 through March 2017 were included.ResultsOur quality database included 221 older patients over 18 months. The average age was 73.3 years (range 65-96) and 55.2% were women. The average observation length of stay was 14.7 hours (±6.5 hours). The majority (74.3%) were discharged from the Obs Unit and 72 hour ED recidivism was 3.6%. Overall, at least one of the multidisciplinary consultant services were requested in 40.3% of patients (n=89). Additional interventions or services were recommended in 80.0% of patients evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a pharmacist (5 of 5 patients), 38% of those evaluated by case management (27 of 71 patients), and 100% of those evaluated by a geriatrician (8 of 8 patients). Only 5.4% (n=12) of patients were placed in observation specifically for multidisciplinary assessment; these patients had an average length of stay of 12.2 hours and an admission rate of 41.7%.ConclusionsIncorporating elements of multidisciplinary geriatric assessment for older patients is feasible within an observation time frame and resulted in targeted interventions. An Obs Unit is a reasonable setting to offer services in compliance with the Geriatric ED Guidelines.This article is protected by copyright. All rights reserved.
      PubDate: 2017-10-04T01:40:30.705855-05:
      DOI: 10.1111/acem.13328
  • 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
  • Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy
    • Authors: Christopher E. Trethewy; Steven R. Doherty, Julie M. Burrows, Don Clausen
      Abstract: Study ObjectiveA prospective, randomised controlled trial of Rapid Sequence Intubation (RSI) with Cricoid Pressure (CP) within the Emergency Department (ED). The primary aim of the study was to examine the link between ideal CP and the incidence of aspiration.MethodPatients>18 years of age undergoing RSI in the ED of two hospitals in New South Wales, Australia, were randomly assigned to receive Measured CP using weighing scales to target the ideal CP range (3.060kg – 4.075kg) or Control CP where the weighing scales were used, but the CP operator was blinded to the amount of CP applied during the RSI. A data logger recorded all CP delivered during each RSI. Immediately after intubation, tracheal and oesophageal samples were taken and underwent pepsin analysis.ResultsFifty four RSIs were analysed (25 Measured/29 Control). Macroscopic contamination of the larynx at RSI was observed in 14 patients (26%). During induction (0 – 50 seconds), both groups delivered in-range CP. During intubation (51 – 223 seconds), laryngoscopy was associated with a reduction in mean CP below 3.060 kg in both groups. When compared, there was no statistically significant difference between the groups. For eleven patients, pepsin was detected in the oropharyngeal sample, whilst 3 were positive for tracheal pepsin. Seven patients (4 Control / 3 Measured) were treated for clinical aspiration during hospitalisation. As a result of the finding that neither group could maintain ideal range CP during laryngoscopy, the trial was abandoned.ConclusionLaryngoscopy provides a counter force to CP which is negated in order to facilitate tracheal intubation. The concept that a static 3.060 kg- 4.075kg CP could be maintained during laryngoscopy and intubation was rejected by our study. Whether a lower CP range could prevent aspiration during RSI was not explored by this study.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-28T10:45:19.251613-05:
      DOI: 10.1111/acem.13326
  • 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
  • City Memories
    • Authors: Siu Fai Li
      Abstract: A city is not a city to me, It is a place of memories, A tapestry of faces, Souvenirs of residency. The coffee shop on Third, Shuttered and empty, It is Mayuri and Sarah, Whom I miss so dearly.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-27T09:40:19.842055-05:
      DOI: 10.1111/acem.13323
  • 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
  • Health Systems Science
    • Authors: Delphine Huang; Hemal K. Kanzaria
      Abstract: Medical school graduates are required to master basic science and clinical skills in order to deliver compassionate, high-quality, patient-centered care. Increasingly, however, physicians are expected to go beyond caring for an individual patient, and improve the health of communities and populations in a manner that is equitable, efficient, and cost-effective. Unfortunately, the current United States (US) health system is fragmented, complex, and unsustainably costly.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-26T06:09:47.91802-05:0
      DOI: 10.1111/acem.13300
  • Measuring Emergency Department Patient Population Acuity
    • Authors: Maame Yaa A. B. Yiadom; Christopher W Baugh, Tyler W. Barrett, Xulei Liu, Alan B. Storrow, Timothy J. Vogus, Vikram Tiwari, Corey M. Slovis, Stephan Russ, Dandan Liu,
      Abstract: BackgroundEmergency department (ED) acuity is the general level of patient illness, urgency for clinical intervention, and intensity of resource use in an ED environment. The relative strength of commonly used measures of ED acuity is not well understood.MethodsWe performed a retrospective cross-sectional analysis of ED-level data to evaluate the relative strength of association between commonly used proxy measures with a full spectrum measure of ED acuity. Common measures included the percentage of patients with Emergency Severity Index (ESI) scores of 1 or 2, case mix index (CMI), academic status, annual ED volume, inpatient admission rate, percentage of Medicare patients, and patients-seen-per-attending-hour. Our reference standard for acuity is the percentage of high acuity charts (PHAC) coded and billed according to the Centers for Medicare and Medicaid Service's Ambulatory Payment Classification (APC) system. High acuity charts included those APC 4, 5 or critical care. PHAC was represented as a fractional response variable. We examined the strength of associations between common acuity measures and PHAC using Spearman's rank correlation coefficients (rs) and regression models including a quasi-binomial generalized linear model and linear regression.ResultsIn our univariate analysis, the percentage of patients ESI 1or 2, CMI, academic status and annual ED volume had statistically significant associations with PHAC. None explained more than 16% of PHAC variation. For regression models including all common acuity measures, academic status was the only variable significantly associated with PHAC.ConclusionESI had the strongest association with PHAC followed by CMI and annual ED volume. Academic status captures variability outside of that explained by ESI, CMI, annual ED volume, percentage Medicare patients, or patients-per-attending-per-hour. All measures combined only explained only 42.6% of PHAC variation.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-23T01:15:20.316168-05:
      DOI: 10.1111/acem.13319
  • Decision Making in Orthopaedic Trauma
    • Authors: Lynne McCullough
      Abstract: The first edition of Decision Making in Orthopaedic Trauma, is a uniquely formatted textbook intended to guide medical students, resident physicians-in-training, and practicing clinicians in the acute management of a comprehensive range of orthopedic emergencies. The authors of the individual algorithms are members of the faculty at the University of California, San Francisco (UCSF) / Zuckerberg San Francisco General (ZSFG) Orthopaedic Trauma Institute. Relying on their extensive professional experience and relevant evidence based publications, they created an easy to access format that provides a quick, simple to use reference for the critical decision points for a variety of traumatic orthopedic conditions. Using an algorithm-based approach, clinicians are guided through critical decision trees to assist decision making in the evaluation and treatment of a wide variety of orthopedic emergencies, from simple fractures through complex life and limb threatening conditions. The text includes 80 chapters, each composed of a 1-page, beautifully styled and easy to follow flow diagram for decision making, followed by a page listing relevant evidence-based references.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-23T01:10:20.803864-05:
      DOI: 10.1111/acem.13318
  • In Reply
    • Authors: Erin Dehon; Nicole Weiss, Sarah A Sterling
      Abstract: We appreciate the comments and concerns raised by members of SAEM‘s Academy of Diversity and Inclusion in Emergency Medicine1 regarding the findings of our article, “A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making.”2 We agree with Samuels et al.1 that there are notable methodological limitations of earlier studies examining the influence of physician implicit bias on clinical decision making that must be considered when interpreting the findings of our systematic review.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-20T10:20:18.575102-05:
      DOI: 10.1111/acem.13316
  • Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to
           Intranasal Fentanyl for Analgesia in Children with Suspected Extremity
    • Authors: Stacy L. Reynolds; Kathleen K. Bryant, Jonathan R. Studnek, Melanie Hogg, Connell Dunn, Megan A. Templin, Charity G. Moore, James R. Young, Katherine Rivera Walker, Michael S. Runyon
      Abstract: ObjectiveWe compared the tolerability and efficacy of intranasal sub-dissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger non-inferiority trial that could investigate the potential opioid sparing effects of intranasal ketamine.MethodsThis randomized controlled trial compared intranasal ketamine 1 mg/kg to intranasal fentanyl 1.5 μg/kg in children 4–17 years old with acute pain from suspected, isolated extremity fractures presenting to an urban level II pediatric trauma center from December 2015 to November 2016. Patients, parents, treating physicians, and outcome assessors were blinded to group allocation. The primary outcome, a tolerability measure, was the frequency of cumulative side effects and adverse events within 60 minutes of drug administration. The secondary outcomes included the difference in mean pain score reduction at 20 minutes, the proportion of patients achieving a clinically significant reduction in pain in 20 minutes, total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the emergency department (ED) stay, and the feasibility of enrolling children presenting to the ED in acute pain into a randomized trial conducted under US regulations. All patients were monitored until 6 hours after their last dose of study drug, or until admission to the hospital ward or operating room.ResultsOf 629 patients screened, 87 received the study drug and 82 had complete data for the primary outcome (41 patients in each group). The median age (interquartile range) was 8 (3) years and 62% were male. Baseline pain scores were similar among patients randomized to receive ketamine (73 ± 26) and fentanyl (69 ± 26) [mean difference (95% CI): 4 (-7 to 15)]. The cumulative number of side effects was 2.2 times higher in the ketamine group, but there were no serious adverse events and no patients in either group required intervention. The most common side effects of ketamine were bad taste in the mouth (37; 90.2%), dizziness (30; 73.2%), and sleepiness (19; 46.3%). The most common side effects of fentanyl were sleepiness (15; 36.6%), bad taste in the mouth (9; 22%), and itchy nose (9; 22%). No patients experienced respiratory side effects. At 20 minutes, the mean pain scale score reduction was 44 ± 36 for ketamine and 35 ± 29 for fentanyl [mean difference: 9 (95% CI: -4 to 23)]. Procedural sedation with ketamine occurred in 28 ketamine patients (65%) and 25 fentanyl patients (57%) prior to completing the study.ConclusionsIntranasal ketamine was associated with more minor side effects than intranasal fentanyl. Pain relief at 20 minutes was similar between groups. Our data support the feasibility of a larger, non-inferiority trial to more rigorously evaluate the safety, efficacy, and potential opioid sparing benefits of intranasal ketamine analgesia for children with acute pain.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-19T07:40:19.5583-05:00
      DOI: 10.1111/acem.13313
  • 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
  • Inter-Observer Agreement in Pediatric Cervical Spine Injury Assessment
           between Prehospital and Emergency Department Providers
    • Authors: Lorin R Browne; Hamilton Schwartz, Fahd A. Ahmad, Michael Wallendorf, Nathan Kuppermann, E. Brooke Lerner, Julie C. Leonard
      Abstract: BackgroundInvestigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions.ObjectiveTo determine the inter-observer agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma.MethodsThis was a planned, sub-study of a four-site, prospective cohort of children
      PubDate: 2017-09-18T03:10:24.74899-05:0
      DOI: 10.1111/acem.13312
  • 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
  • Hot off the Press: Embedded Clinical Decision Support in Electronic Health
           Record Decreases Use of High-cost Imaging in the Emergency Department:
           EmbED study
    • Authors: Corey Heitz; Justin Morgenstern, William K Milne
      Abstract: This longitudinal before/after study of embedded CDRs assessed the effects of clinical decision support on use of common imaging studies. Among high users, rates of CT-brain and CT c-spine were reduced after implementation of embedded clinical decision instruments, while in low users, rates increased. This article summarizes the manuscript and the Skeptics Guide to Emergency Medicine podcast, as well as the ensuing social media/online discussion.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-15T20:40:30.588457-05:
      DOI: 10.1111/acem.13310
  • Improved Survival for Rural Trauma Patients Transported by Helicopter to a
           Verified Trauma Center: A Propensity Score Analysis
    • Authors: Thein Hlaing Zhu; Lisa Hollister, Dazar Opoku, Samuel M Galvagno
      Abstract: ObjectivesRecent studies using advanced statistical methods to control for confounders have demonstrated an association between helicopter transport (HT) vs. ground ambulance transport (GT) in terms of improved survival for adult trauma patients. The aim of this study was to apply a methodologically vigorous approach to determine if HT is associated with a survival benefit for when trauma patients are transported to a verified trauma center in a rural setting.MethodsThe ascertainment of trauma patients age ≥15 years (n=469 cases) by HT and (n=580 cases) by GT between 1999 and 2012 was restricted to the scene of injury in a rural area of 10 to 35 miles from the trauma center. The propensity score (PS) was determined using data including demographics, prehospital physiology, intubation, total prehospital time and injury severity. The propensity score matching was performed with different calipers to select a higher percentage of matches of HT compared to GT patients. The outcome of interest was survival to discharge from hospital. Identical logistic regression analysis was done taking into account for each matched design to select an appropriate effect estimate and confidence interval (CI) controlling for initial vital signs in emergency department, the need for urgent surgery, intensive care unit admission and mechanical ventilation.ResultsUnadjusted mortality for HT compared to GT was 7.7% and 5.3% respectively (p> 0.05). The adjusted rates were 4.0% for HT and 7.6% for GT (p < 0.05). In a PS well-matched dataset, HT was associated with a 2.69-fold increase in odds of survival compared to GT patients [adjusted OR (AOR) = 2.69; 95% C.I. = 1.21 to 5.97].ConclusionsIn a rural setting, we demonstrated improved survival associated with HT compared to GT for scene transportation of adult trauma patients to a verified level II trauma center using an advanced methodologic approach, which included adjustment for transport distance. The implication of survival benefit to rural population is discussed. We recommend larger studies with multiple trauma systems need to be repeated using similar study methodology to substantiate our findings.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-12T06:21:51.960636-05:
      DOI: 10.1111/acem.13307
  • Pre-hospital Supraglottic Airway was Associated with Good Neurological
           Outcome in Cardiac Arrest Victims Especially Who Received Prolonged
           Cardiopulmonary Resuscitation
    • Authors: Min Ji Park; Woon Yong Kwon, Kyuseok Kim, Gil Joon Suh, Jonghwan Shin, You Hwan Jo, Kyung Su Kim, Hui Jai Lee, Joonghee Kim, Se Jong Lee, Jeong Yeon Kim, Jun Hwi Cho
      Abstract: IntroductionWe performed this study to investigate the association of pre-hospital supraglottic airway (SGA) on neurological outcome in cardiac arrest victims with adjustment of post-resuscitation variables as well as pre-hospital and resuscitation variables.MethodsThis study was a retrospective study based on a multicenter prospective cohort registry from December 2013 to April 2016. According to the 28-day cerebral performance categories (CPC) scale, patients were divided into good outcome group (CPC 1–2) and poor outcome group (CPC 3–5). We compared the two groups with respect to demographic variables, pre-hospital and in-hospital resuscitation variables, and post-resuscitation variables.Results869 cardiac arrest victims who received in-progress cardiopulmonary resuscitation (CPR) were delivered to the emergency department of three hospitals, and 310 patients were admitted to the intensive care unit. The use of a pre-hospital SGA was independently associated with 28-day good neurological outcome [odds ratio (OR), 7.880; 95% confidence interval (CI), 1.334-46.534; p = 0.023] when post-resuscitation variables were adjusted, although there were no significant association with the acquisition of sustained return of spontaneous circulation (ROSC) [OR, 0.992; 95% CI, 0.591-1.666; p = 0.976]. Furthermore, a pre-hospital SGA was significantly associated with good neurological outcome, especially in patients who received prolonged CPR (low flow time>15 minutes) [OR, 3.411; 95% CI, 1.232-9.449; p = 0.018] rather than in patients with non-prolonged CPR [OR, 4.500; 95% CI, 0.746-27.132; P = 0.101].ConclusionsWhen post-resuscitation variables were adjusted, the pre-hospital SGA was independently associated with 28-day good neurological outcome in cardiac arrest victims.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-12T06:16:05.276392-05:
      DOI: 10.1111/acem.13309
  • 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
  • A Decision Instrument to Identify Isolated Traumatic Subdural Hematomas at
           Low Risk of Neurological Deterioration, Surgical Intervention or
           Radiographic Worsening
    • Authors: Peter Pruitt; Jonathan Van Ornam, Pierre Borczuk
      Abstract: Background and ObjectivesSubdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low-risk for neurological decline, neurosurgical intervention or radiographic worsening.MethodsRetrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and CT-documented isolated SDH presenting to a university affiliated, urban, 100,000-annual-visit ED from 2009-2015. Demographic, historical and physical exam variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT and neurological decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model.Results644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors: SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS < 14 and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1% and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5% and negative likelihood ratio was 0.127.ConclusionSubdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-04T22:53:31.592773-05:
      DOI: 10.1111/acem.13306
  • Patients Visiting Multiple Emergency Departments: Patterns, Costs and Risk
    • Authors: Todd W. Lyons; Karen L Olson, Nathan P. Palmer, Reed Horwitz, Kenneth D Mandl, Andrew M. Fine
      Abstract: ObjectiveWe sought to characterize the population of patients seeking care at multiple EDs and to quantify the proportion of all ED visits and costs accounted for by these patients.MethodsWe performed a retrospective, cohort study of de-identified insurance claims for privately insured patients with ≥ 1 ED visit between 2010 and 2016. We measured the number of EDs visited by each patient and determined the overall proportion of all ED visits and ED costs accounted for by patients who visit multiple EDs. We identified factors associated with visiting multiple EDs.Results8,651,716 patients made 16,390,676 ED visits over the study period, accounting for $26,102,831,740 in ED costs. A significant minority (20.5%) of patients visited more than one ED over the study period. However, these patients accounted for a disproportionate amount of all ED visits (41.4%) and all ED costs (39.2%). A small proportion (0.4%) of patients visited 5 of more EDs but accounted for 2.8% of ED visits and costs. Among patients with two ED visits within 30-days, 32% were to different EDs. Having at least one ED visit for mental health or substance abuse related diagnosis was associated with increased odds of visiting multiple EDs.ConclusionsA substantial minority of patients visit multiple EDs, but account for a disproportionate burden of overall ED utilization and costs. Future work should evaluate the impact of visiting multiple EDs on care utilization and outcomes and explore systems for improving access to patient records across care centers.This article is protected by copyright. All rights reserved.
      PubDate: 2017-09-01T02:30:32.634467-05:
      DOI: 10.1111/acem.13304
  • 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
  • “What do people do if they don't have insurance'”: ED to
           ED Referrals
    • Authors: Laura N Medford-Davis; Siddharth Prasad, Karin V Rhodes
      Abstract: ObjectiveUp to 20% of patients seen in public emergency departments (EDs) have already been seen for the same complaint at another ED, but little is known about the origin or impact of these duplicate ED visits. The goals of this investigation were to explore (1) whether patients making a repeat ED visit are self-referred or indirectly referred from the other ED; and (2) gather the perspective of affected patients on the health, social, and financial consequences of these duplicate ED visits.MethodsThis mixed-methods study conducted over a 10-week period during 2016 in a large public hospital ED in Texas prospectively surveyed patients seen in another ED for the same chief complaint. Selected patients presenting with fractures were then enrolled for semi-structured qualitative interviews, which were audiotaped, transcribed, and independently coded by two team members until thematic saturation was reached.Results143 patients were identified as being recently seen at another local ED for the same chief complaint prior to presenting to the public hospital; 94% were uninsured and 61% presented with fractures. 27% required admission at the public ED and 95% of those discharged required further outpatient follow-up. 51 patients completed a survey and qualitative interviews were conducted with 23 fracture patients. 53% of patients reported that staff at the first hospital told them to go the public hospital ED, and 23% reported referral from a follow-up physician associated with the first hospital. 73% reported receiving the same tests at both EDs. Interview themes identified multiple healthcare visits for the same injury, concern about complications, disrespectful treatment at the first ED, delayed care, problems accessing needed follow-up care without insurance, loss of work, and financial strain.ConclusionsThe majority of patients presenting to a public hospital ED after treatment for the same complaint in another local ED were indirectly referred to the public ED without transferring paperwork or records, incurring duplicate testing and patient anxiety.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-28T08:50:22.344042-05:
      DOI: 10.1111/acem.13301
  • Identifying Emergency Department Patients at Low Risk for a Variceal
           Source of Upper Gastrointestinal Hemorrhage
    • Authors: Lauren R. Klein; Joel Money, Kaveesh Maharaj, Aaron Robinson, Tarissa Lai, Brian E. Driver
      Abstract: BackgroundAssessing the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides therapy, but can be difficult to determine on clinical grounds. The objective of this study was to determine if there are easily ascertainable clinical and laboratory findings that can identify a patient as low risk for a variceal source of hemorrhage.MethodsThis was a retrospective cohort study of adult ED patients with UGIB between January 2008 and December 2014 who had upper endoscopy performed during hospitalization. Clinical and laboratory data were abstracted from the medical record. The source of the UGIB was defined as variceal or nonvariceal based on endoscopic reports. Binary recursive partitioning was utilized to create a clinical decision rule. The rule was internally validated and test characteristics were calculated with 1,000 bootstrap replications.Results719 patients were identified; mean age was 55 years old and 61% were male. There were 71 (10%) patients with a variceal UGIB identified on endoscopy. Binary recursive partitioning yielded a two-step decision rule (platelet count greater than 200,000/uL, and an INR less than 1.3), which identified patients who were low risk for a variceal source of hemorrhage. For the bootstrapped samples, the rule performed with 97% sensitivity (95% confidence interval [CI] 91-100%) and 49% specificity (95% CI 44- 53%).ConclusionAlthough this derivation study must be externally validated before widespread use, patients presenting to the ED with an acute UGIB with platelets of greater than 200,000/uL and an INR less than 1.3 may be at very low risk for a variceal source of their upper gastrointestinal hemorrhage.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-22T06:33:53.777759-05:
      DOI: 10.1111/acem.13297
  • Patient Navigation for Patients Frequently Visiting the Emergency
           Department: A Randomized, Controlled Trial
    • Authors: David Seaberg; Stanton Elseroad, Michael Dumas, Sudave Mendiratta, Jessica Whittle, Cheryl Hyatte, Jan Keys
      Abstract: BackgroundED super-utilizers (patients with 5 or more visits/year) comprise only 5% of the patients seen yet comprise 25% of total ED visits. Though the reasons for this are multifactorial, the cost to the patient and the community is exceedingly high. The cost is not just monetary; care of these patients is inappropriately fragmented and their presence in the ED may contribute to overcrowding affecting the community's emergency readiness. Previous studies using staff trained to help patients navigate their care options have had conflicting results.ObjectivesTo determine whether a trained Patient Navigator (PN) can reduce ED use and costs in super-utilizers over a one year period.MethodsSuper-utilizers were enrolled in a prospective randomized controlled clinical trial. Patients were randomized into the treatment arm and met with a PN who reviewed their diagnosis, associated care plan and identified proper primary care services and community resources for follow-up. The remaining control group was provided standard care. Both groups were given a follow-up call and survey by the PN within 7 days of their visit who assessed primary care follow-up and patient satisfaction using a 4 point Likert scale. After twelve months, the patients’ return ED visits and ED costs were compared to the year prior and primary care compliance and satisfaction were measured using Student-T tests with Bonferroni correction or Mann-Whitney U tests.Results282 patients were enrolled (148 in navigation treatment group, 134 controls). Patients were similarly matched in age, race, gender, insurance and chief complaints. Overall ED visits decreased during the 12 month study period, compared to the 12 months prior to enrollment (2249 visits prior to 2050 visits during study period, -8.8%). There was a greater decrease in ED visits from the pre-enrollment year to post-enrollment year in the treatment group (1148 visits to 996 visits, -13.2%) compared to the control group (1101 visits to 1054 visits, -4.3%)(p
      PubDate: 2017-08-21T02:11:09.589075-05:
      DOI: 10.1111/acem.13280
  • 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
  • Prospective Validation of a Clinical Score for Males Presenting with an
           Acute Scrotum
    • Authors: Lillian C. Frohlich; Niloufar Paydar-Darian, Bartley G. Cilento, Lois K. Lee
      Abstract: ObjectiveTo validate the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score among pediatric emergency medicine providers for the evaluation of pediatric males presenting with testicular pain and swelling (acute scrotum).MethodsWe conducted a prospective cohort study of males 3 months to 18 years old presenting with an acute scrotum. History and physical examination findings, including components of the TWIST score (hard testicle, absent cremasteric reflex, nausea/vomiting, and high riding testicle) as well as diagnostic results (ultrasound, urine, sexually transmitted infection (STI) testing) were recorded. Testicular torsion was confirmed by surgical exploration. Frequencies of patient characteristics, TWIST components, and tests were calculated. We performed the kappa statistic for inter-rater reliability and calculated the test characteristics and receiver operator curves for the TWIST score (range 0-7).ResultsDuring the study period 258 males were enrolled in the study; 19 (7.4%) had testicular torsion. The mean age was 9.8 years (± 0.3 years). The high-risk TWIST score of 7 had 100% specificity (95% confidence interval (CI) 98%, 100%) with 100% positive predictive value (95% CI 40%, 100%) for testicular torsion. The area under the curve was 0.82. The kappa statistic for the overall TWIST score was fair at 0.39.ConclusionsIn this prospective validation of the TWIST score among pediatric emergency providers, the high-risk score demonstrated strong test characteristics for testicular torsion. The TWIST score could be used as part of a standardized approach for evaluation of the pediatric acute scrotum to provide more efficient and effective care.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-20T06:20:20.347631-05:
      DOI: 10.1111/acem.13295
  • Pediatric Emergency Department Utilization and Reliance by Insurance
           Coverage in the United States
    • Authors: Lauren E. Schlichting; Michelle L. Rogers, Annie Gjelsvik, James G. Linakis, Patrick M. Vivier
      Abstract: ObjectivesFor many children, the Emergency Department (ED) serves as the main destination for health care, whether it be for emergent or non-urgent reasons. Through examination of repeat utilization and ED reliance, in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care.MethodsNationally representative data from the 2010-2014 Medical Expenditure Panel Survey (MEPS) were used to examine the annual ED utilization of children age 0-17 years by insurance coverage. Overall utilization, repeat utilization (≥2 ED visits), and ED reliance (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High ED reliance was defined as having>33% of outpatient visits in a year being ED visits.ResultsA total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a one-year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR]: 1.55; 95% confidence interval [CI]: 1.40-1.73) than children with private insurance, whereas uninsured children were less likely (aOR: 0.64; 95% CI: 0.51-0.81). Children age three and under were significantly more likely to visit the ED than children age 15-17, whereas female children and Hispanic and non-Hispanic other race children were significantly less likely to visit the ED than male children and non-Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a one-year period. Children with public insurance were more likely to have two or more visits to the ED (aOR: 1.53; 95% CI: 1.19-1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR: 1.70; 95% CI: 1.47-1.97) and uninsured children (aOR: 1.90; 95% CI: 1.49-2.42) were more likely to be reliant on the ED than children with private insurance.ConclusionsHealth insurance coverage was associated with overall ED utilization, repeat ED utilization, and ED reliance. Demographic characteristics, including gender, age, income, and race/ethnicity were important predictors of ED utilization and reliance.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-18T00:45:21.733665-05:
      DOI: 10.1111/acem.13281
  • Change in Care Transition Practice for Patients with Non-Specific Chest
           Pain after ED Evaluation 2006-2012
    • Authors: Maame Yaa A. B. Yiadom; Cathy A. Jenkins, Christopher W. Baugh, Sean P. Collins, Monisha C. Bhatia, Robert S. Dittus, Alan B. Storrow
      Abstract: ObjectivesFrom 2005-2010 healthcare financing shifts in the United States may have affected care transition practices for emergency department (ED) patients with non-specific chest pain (CP) after ED evaluation. Despite being less acutely ill than those with myocardial infarction, these patients’ management can be challenging. The risk of missing acute coronary syndrome is considerable enough to often warrant admission. Diagnostic advances and reimbursement limitations on the use of inpatient admission are encouraging the use of alternative ED care transition practices. In the setting of these health care changes, we hypothesized there is a decline in inpatient admission rates for patients with non-specific CP after ED evaluation.MethodsWe retrospectively used the Nationwide ED Sample (NEDS) to quantify total and annual inpatient hospital admission rates from 2006-2012 for patients with a final ED diagnosis of non-specific CP. We assessed the change in admission rates over time, and stratified by facility characteristics including: safety-net hospital status, US geographic region, urban/teaching status, trauma-level designation, and hospital funding status.ResultsThe admission rate for all patients with a final ED diagnosis of non-specific CP declined from 19.2% in 2006 to 11.3% in 2012. Variability across regions was observed, while metropolitan teaching hospitals and trauma centers reflected lower admission rates.ConclusionThere was a 41.1% decline in inpatient-hospital admission for patients with non-specific CP after ED evaluation. This reduction is temporally associated with national policy changes affecting reimbursement for inpatient admissions.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-18T00:40:23.495617-05:
      DOI: 10.1111/acem.13279
  • The pediatric submersion score predicts children at low risk for injury
           following submersions
    • Authors: Rohit P. Shenoi; Sachin Allahabadi, Daniel M. Rubalcava, Elizabeth A. Camp
      Abstract: IntroductionPediatric submersion victims often require admission. We wanted to identify a cohort of children at low risk for submersion-related injury who can be safely discharged from the emergency department (ED) after a period of observation.MethodsThis was a single-center retrospective derivation/validation cross-sectional study of children (0-18 years) who presented post-submersion to a tertiary-care, children's hospital ED from 2008-2015. We reviewed demographics, comorbidities, prehospital and ED course. Primary outcome was safe discharge at 8 hours’ post-submersion: Normal mentation and vital signs. To identify potential scoring factors, any p-value ≤0.25 was included in binary logistic regression; p-values
      PubDate: 2017-08-18T00:35:22.577145-05:
      DOI: 10.1111/acem.13278
  • Patient and System Factors Related to Missed Opportunities for Screening
           in an EMR-driven, Opt-out HIV Screening Program in the Emergency
    • Authors: Janet Lin; Sara Baghikar, Cammeo Mauntel-Medici, Sara Heinert, Daven Patel
      Abstract: ObjectiveEmergency Departments (EDs) have implemented HIV screening using a variety of strategies. This study investigates how specific patient and health system factors in the ED impact who is and is not screened in a combined targeted and non-targeted, EMR-driven, opt-out, HIV screening program.MethodsThis was a retrospective, cross sectional study of ED visits where patients were determined eligible for HIV screening by an EMR algorithm between 11/18/2014 and 7/15/2015. The HIV screening workflow included three sequential events, all of which were required to get screened for HIV at the ED visit. The events were having a blood draw, being informed of the HIV screening policy by an ED nurse at the point of blood draw, and the patient consenting to the HIV test. Each event represented a dichotomous outcome and its association with six patient factors (age, gender, race/ethnicity, marital status, preferred language, and Emergency Severity Index (ESI)) and two health system factors (ED crowding and program phase) was investigated using multivariable modeling.ResultsA total of 15,918 ED visits were analyzed. Blood was drawn in 8,388 of 15,918 visits (53%). Of 8,388 visits where blood was drawn, there were 5,947 (71%) visits where ED nurses documented informing patients of the HIV screening policy. Of those visits, patient consent to the HIV test was documented at 3,815 (64%) visits. Patients between 13-19 years of age were significantly less likely to have blood drawn, to be informed of the screening policy, and to consent to the HIV test compared to other age groups. Both ED crowding and a patient's ESI were associated with decreased odds of having a blood draw and being informed of HIV screening by an ED nurse, but showed no association with patients consenting to the HIV test.ConclusionMany patients, particularly adolescents and young adults, are missed in ED HIV screening programs that require blood draw and depend on providers to obtain consent for testing. To ensure these patients are reached, future ED screening programs should strive to develop innovative workflows that allow for blood draws for HIV screening only and streamline the processes of obtaining informed consent and ordering tests for all eligible patients.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-18T00:30:37.236956-05:
      DOI: 10.1111/acem.13277
  • Ketamine or Ketofol: Do we have enough evidence to know which one to
    • Authors: James Miner
      Abstract: Ketamine and propofol are both commonly used emergency department (ED) procedural sedation agents. Their concurrent administration, often referred to as “ketofol”, is widely used for procedural sedation. A simple google search can lead to a lot of opinions on why we should use propofol, ketamine, or ketofol in a given situation for moderate or deep procedural sedation in the ED, but finding evidence that supports differences these opinions assume is much harder to come by.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-12T08:45:22.429668-05:
      DOI: 10.1111/acem.13276
  • 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
  • Emergency Department Provider Perspectives on Benzodiazepine-Opioid
           Co-Prescribing: A Qualitative Study
    • Authors: Howard S. Kim; Danielle M. McCarthy, Jason A. Hoppe, D. Mark Courtney, Bruce L. Lambert
      Abstract: ObjectiveBenzodiazepines and opioids are prescribed simultaneously (i.e. “co-prescribed”) in many clinical settings, despite guidelines advising against this practice and mounting evidence that concomitant use of both medications increases overdose risk. This study sought to characterize the contexts in which benzodiazepine-opioid co-prescribing occurs and providers’ reasons for co-prescribing.MethodsWe conducted focus groups with ED providers (resident and attending physicians, advanced practice providers, and pharmacists) from three hospitals using semi-structured interviews to elicit perspectives on benzodiazepine-opioid co-prescribing. Discussions were audio-recorded and transcribed. We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach, aiming to identify priority categories that describe the phenomenon of benzodiazepine-opioid co-prescribing.ResultsParticipants acknowledged co-prescribing rarely and reluctantly, and often provided specific discharge instructions when co-prescribing. The decision to co-prescribe is multifactorial, often isolated to specific clinical and situational contexts (e.g. low back pain, failed solitary opioid therapy) and strongly influenced by a provider's beliefs about the efficacy of combination therapy. The decision to co-prescribe is further influenced by a self-imposed pressure to escalate care or avoid hospital admission. When considering potential interventions to reduce the incidence of co-prescribing, participants opposed computerized alerts but were supportive of a pharmacist-assisted intervention. Many providers found the process of participating in peer discussions on prescribing habits to be beneficial.ConclusionsIn this qualitative study of ED providers, we found that benzodiazepine-opioid co-prescribing occurs in specific clinical and situational contexts, such as the treatment of low back pain or failed solitary opioid therapy. The decision to co-prescribe is strongly influenced by a provider's beliefs and by self-imposed pressure to escalate care or avoid admission.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-09T01:50:36.656752-05:
      DOI: 10.1111/acem.13273
  • Maintenance of Oxygenation during Rapid Sequence Intubation in the
           Emergency Department
    • Authors: John C. Sakles
      Abstract: Rapid sequence intubation (RSI) is the most common method of airway control in the emergency department (ED).1,2 Administration of an anesthetic agent and a neuromuscular blocking agent (NMBA) optimizes conditions for tracheal intubation and is thought to minimize the risk of aspiration.3-10 Evidence suggests that RSI improves first pass success and reduces complications in the critically ill.11-14This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-09T01:50:19.073509-05:
      DOI: 10.1111/acem.13271
  • Predicting Short-Term Risk of Arrhythmia among Patients with Syncope: The
           Canadian Syncope Arrhythmia Risk Score
    • Authors: Venkatesh Thiruganasambandamoorthy; Ian G. Stiell, Marco L. A. Sivilotti, Brian H. Rowe, Muhammad Mukarram, Kirtana Arcot, Kenneth Kwong, Andrew D. McRae, George A. Wells, Monica Taljaard
      Abstract: BackgroundSyncope can be caused by serious occult arrhythmias not evident during initial emergency department (ED) evaluation. We sought to develop a risk-tool for predicting 30-day arrhythmia or death after ED disposition.MethodsWe conducted a multicenter prospective cohort study at six tertiary-care EDs and included adults (≥16 years) with syncope. We collected standardized variables from clinical evaluation, and investigations including ECG and troponin at index presentation. Adjudicated outcomes included death or arrhythmias including procedural interventions for arrhythmia within 30-days. We used multivariable logistic regression to derive the prediction model and bootstrapping for interval validation to estimate shrinkage and optimism.Results5,010 patients (mean age 53.4 years, 54.8% females, and 9.5% hospitalized) were enrolled with 106 (2.1%) patients suffering 30-day arrhythmia/death after ED disposition. We examined 39 variables and eight were included in the final model: lack of vasovagal predisposition, heart disease, any ED systolic blood pressure 180mmHg, troponin (>99%ile), QRS duration>130msec, QTc interval>480msec and ED diagnosis of cardiac/vasovagal syncope [optimism corrected c-statistic 0.90 (95% CI 0.87 - 0.93); Hosmer-Lemeshow p=0.08]. The Canadian Syncope Arrhythmia Risk Score had a risk ranging from 0.2% to 74.5% for scores of –2 to 8. At a threshold score of ≥0, the sensitivity was 97.1% (95%CI 91.6%,99.4%) and specificity was 53.4% (95%CI 52.0%,54.9%).ConclusionsThe Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at-risk for arrhythmias and aid in acute management decisions. . Once validated, the score can identify low-risk patients who will require no further investigations.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-09T01:46:00.794182-05:
      DOI: 10.1111/acem.13275
  • EmergeNcy Department use of Apneic Oxygenation versus usual care during
           rapid sequence intubation: A randomized controlled trial (The ENDAO Trial)
    • Authors: Nicholas Caputo; Ben Azan, Rui Domingues, Lee Donner, Mark Fenig, Douglas Fields, Robert Fraser, Karlene Hosford, Richard Iuorio, Marc Kanter, Moira McCarty, Thomas Parry, Andaleeb Raja, Mary Ryan, Blaine Williams, Hemlata Sharma, Daniel Singer, Chris Shields, Sandra Scott, Jason R. West,
      Abstract: ObjectivesDesaturation leading to hypoxemia may occur during rapid sequence intubation (RSI). Apneic oxygenation (AO) was developed to prevent the occurrence of oxygen desaturation during the apnea period. The purpose of this study was to determine if the application of AO increases the average lowest oxygen saturation during RSI when compared to usual care (UC) in the emergency setting.MethodsA randomized controlled trial was conducted at an academic, urban, level 1 trauma center. All patients requiring intubation were included. Exclusion criteria were patients in cardiac or traumatic arrest or if pre-oxygenation was not performed. An observer, blinded to study outcomes and who was not involved in the procedure recorded all times, while all saturations were recorded in real time by monitors on a secured server. Two hundred patients were allocated to receive apneic oxygenation (n=100) or usual care (n=100) by pre-determined randomization in a 1:1 ratio.ResultsTwo-hundred and six patients were enrolled. There was no difference in lowest mean oxygen saturation between the two groups (92, 95% CI 91 to 93 in AO vs. 93, 95% CI 92 to 94 in UC, p=0.11).ConclusionThere was no difference in lowest mean oxygen saturation between the two groups. The application of AO during RSI did not prevent desaturation of patients in this study population.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-09T01:45:20.359201-05:
      DOI: 10.1111/acem.13274
  • Pulmonary Embolism Testing among Emergency Department Patients who are
           Pulmonary Embolism Rule-out Criteria Negative
    • Authors: Ian Buchanan; Troy Teeples, Margaret Carlson, Jacob Steenblik, Joseph Bledsoe, Troy Madsen
      Abstract: IntroductionPrevious studies have demonstrated that rates of pulmonary embolism (PE) testing have increased without a concomitant decrease in PE related mortality. The Pulmonary Embolism Rule-out Criteria (PERC) intend to reduce testing for PE in the emergency department (ED) by identifying low-risk patients (“PERC-negative”) who do not require d-dimer, computed tomography pulmonary angiogram (CTPA), or ventilation/perfusion (VQ) scan for PE. This study assesses PE testing rates among PERC-negative patients presenting to an urban academic ED.MethodsWe prospectively enrolled a convenience sample of ED patients with chest pain and/or shortness of breath presenting between June 2010 and December 2015. We recorded baseline variables at the time of ED presentation, information on testing performed in the ED, and the diagnosis of acute PE during the ED visit. We classified patients as PERC-positive or PERC-negative utilizing baseline variables and clinical characteristics.ResultsOf the 3024 study patients, 54.8% (95% confidence interval: 53-56.5) were female and the mean age was 51.7 years (51.1-52.3). 17.5% (16.2-18.9) of study patients were PERC negative and 33.7% (32-35.4) of all patients underwent testing for PE. 25.5% (22-29.4) of PERC-negative patients had PE testing compared to 35.4% (33.6-37.3) of PERC-positive patients (p < 0.001). 7.2% (5.3-9.7) of PERC-negative patients had advanced imaging without a d-dimer compared to 19.2% (17.8-20.8) of PERC-positive patients (p
      PubDate: 2017-08-08T08:25:19.236214-05:
      DOI: 10.1111/acem.13270
  • Diagnosis of Subarachnoid Hemorrhage – Time for a Paradigm
    • Authors: Nicole M. Dubosh; Jonathan A. Edlow
      Abstract: The second edition of Thomas Kuhn's “Structure of Scientific Revolutions” that captivated one of us in college was published in 1970.1 In the book, Kuhn argues that progress in science is made not by the step-by-step building of incremental ideas or experiments, but by paradigm shifts – whole new ways of looking at phenomena using novel tools (the telescope for Galileo) or concepts (a heliotropic, rather than a geotropic solar system for Copernicus). Our current paradigm about misdiagnosis of patients with aneurysmal subarachnoid hemorrhage (SAH) is that patients who were misdiagnosed on a first visit to a physician who are then correctly diagnosed on a subsequent visit have worse outcomes than patients who are correctly diagnosed in the first place. Now, new data challenge this time-honored concept.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-02T10:10:25.224959-05:
      DOI: 10.1111/acem.13267
  • Patient and Surrogate Views of Community Consultation for Emergency
    • Authors: Alexandra E. Fehr; Victoria M. Scicluna, Rebecca D. Pentz, Adrianne N. Haggins, Neal W. Dickert
      Abstract: ObjectivePre-trial community consultation (CC) is required for emergency research conducted under an exception from informed consent (EFIC) in the United States. CC remains controversial and challenging, and minimal data exist regarding the views of individuals enrolled in EFIC trials on this process. It is important to know whether participants perceive CC to be meaningful and, if so, whom they believe should be consulted.MethodsWe conducted a secondary analysis of data from two studies interviewing patients and surrogates of two recent EFIC trials (PEER-RAMPART and PEER-ProTECT). These interviews included similar open- and closed-ended questions regarding participants’ views of the importance of CC, the rationale for their responses, and their views regarding which populations should be included in consultation efforts. A template analytic strategy was used for qualitative analysis of textual data, and descriptive statistics were tabulated to characterize demographic data and instances of major themes.Results90% of participants perceived CC to be valuable. Participants’ reasons for finding CC valuable clustered in 2 categories: 1) as a method of informing the public about the trial to be conducted; and 2) as a way of obtaining input and feedback from the community. Participants cited the medical community (43%) and individuals with a connection to the study condition (41%) as the most important groups to involve in consultation efforts; only 5% suggested consulting the general public in the area where the research will be conducted.ConclusionParticipants in EFIC trials and their decision-makers generally valued CC as a method of informing and seeking input from the community. Participants felt that the most appropriate groups to consult were the medical community and individuals with connections to the condition under study. Consultation efforts focused on these two groups, rather than the general public, may be more efficient and more meaningful to individuals involved in EFIC trials. These findings also reinforce the importance of the distinction between public disclosure and CC.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-30T06:35:20.517498-05:
      DOI: 10.1111/acem.13265
  • Comparing Direct and Video Laryngoscopy for Prehospital Intubation: Can
           Meta-Analysis Provide an Exact Solution'
    • Authors: Hui-Xian Li; Fu-Shan Xue, Gui-Zhen Yang, Ya-Yang Liu
      Abstract: The recent systemic review and meta-analysis by Savino et al.1 comparing performance of video versus direct laryngoscopy for prehospital intubation was of great interested to us. They conclude that among physician intubators with significant direct laryngoscopy (DL) experience, video laryngoscopy (VL) does not increase overall or first-pass success rate and may lead to worsening performance. However, among non-physician intubators with less experience with DL, VL may provide benefit in the prehospital setting. In a meta-analysis, the results from many studies are mathematically synthesized by complex statistical methods to evaluate the diversity among results and to estimate a common pooled effect with increased precision.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-28T02:45:52.775559-05:
      DOI: 10.1111/acem.13263
  • In Reply: Comparing Direct and Video Laryngoscopy for Prehospital
           Intubation: Can Meta-Analysis Provide and Exact Solution'
    • Authors: P. Brian Savino; Scott Reichelderfer, Mary P. Mercer, Karl A. Sporer, Ralph C. Wang
      Abstract: We thank the authors for this letter and appreciate the opportunity to respond to the comments and clarify our position. We agree with the authors in a number of their specific comments, and will attempt to address each of them. The first comment refers to the difference in video laryngoscopy devices and how “… pooling of results from studies evaluating performance of different VLs for prehospital intubation may lead to intrinsic inconsistencies in the primary endpoints.”This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-28T02:40:23.734378-05:
      DOI: 10.1111/acem.13262
  • 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
  • Speechless
    • Authors: Nadine T. Himelfarb
      Abstract: Bright blue eyes rimmed with deep sun wrinkles, a crown of mousy brown hair that appeared freshly cut by a four-year old with safety scissors, the patient was thin figured, wearing a flannel, yellowed t-shirt peaking from underneath, and a boxy, heavily stained canvas jacket over the shoulders. Old jeans were cinched at the waist by a crackled leather belt. The dirty right foot which lay bare on the stretcher was then thrust at me. The patient pointed angrily at the exposed foot.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-20T03:40:38.347599-05:
      DOI: 10.1111/acem.13259
  • 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
  • Conflicts of Interest in Emergency Medicine
    • Authors: Joel Martin Geiderman; Kenneth V. Iserson, Catherine A. Marco, John Jesus, Arvind Venkat
      Abstract: Conflicts of interest are common in the practice of emergency medicine and may be present in the areas of clinical practice, relations with industry, expert witness testimony, medical education, research, and organizations. A conflict of interest occurs when there is dissonance between a primary interest and another interest. The concept of professionalism in medicine places the patient as the primary interest in any interaction with a physician. We contend that patient welfare is the ultimate interest in the entire enterprise of medicine. Recognition and management of potential, real and perceived conflicts of interest are essential to the ethical practice of emergency medicine. This paper discusses how to recognize, address, and manage them.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-08T09:55:32.699239-05:
      DOI: 10.1111/acem.13253
  • Outcomes following possible undiagnosed aneurysmal subarachnoid
           hemorrhage: a contemporary analysis
    • Authors: Dustin G. Mark; Mamata V. Kene, David R. Vinson, Dustin W. Ballard
      Abstract: ObjectivesExisting literature suggests that patients with aneurysmal subarachnoid hemorrhage (aSAH) and “sentinel” aSAH symptoms prompting health care evaluations prior to aSAH diagnosis are at increased risk of unfavorable neurologic outcomes and death. Accordingly these encounters have been presumed to be unrecognized opportunities to diagnose aSAH, and the worse downstream outcomes representative of the added risks of delayed diagnoses. We sought to reinvestigate this paradigm among a contemporary cohort of patients with aSAH.MethodsA case-control cohort was retrospectively assembled among patients diagnosed with aSAH between January 1, 2007 and June 30, 2013 within an integrated healthcare delivery system. Patients with a discrete clinical evaluation for headache or neck pain within 14 days prior to formal aSAH diagnosis were identified as cases, and the remaining patients served as controls. Modified Rankin Scale (mRS) scores at 90 days and 1 year were determined by structured chart review. Multivariable logistic regression controlling for age, gender, ethnicity, presence of intracerebral or intraventricular hemorrhage at diagnosis, and aneurysm size was used to compare adjusted outcomes. Sensitivity analyses were performed using varying definitions of favorable neurologic outcomes, a restricted control subgroup of patients with normal mental status at hospital admission, inclusion of additional cases that were diagnosed outside of the integrated health system, and exclusion of patients without evidence of subarachnoid blood on initial non-contrast cranial computed tomography at the diagnostic encounter (i.e. “CT-negative” SAH).Results450 patients with aSAH were identified, 46 (10%) of whom had clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis (cases). In contrast to prior reports, no differences were observed among cases as compared to control patients in adjusted odds of death or unfavorable neurologic status at 90 days (0.35, 95%CI 0.11-1.15; 0.59, 95%CI 0.22-1.60, respectively) or at 1 year (0.58, 95%CI 0.19-1.73; 0.52, 95%CI 0.18-1.51, respectively). Likewise, neither restricting the analysis to a control subgroup of patients with normal mental status at hospital admission, varying the dichotomous definition of unfavorable neurologic outcome, inclusion of cases diagnosed outside the integrated health system, or exclusion of patients with CT-negative SAH resulted in significant adjusted outcome differences.ConclusionIn a contemporary cohort of patients with aSAH, we observed no statistically significant increase in the adjusted odds of death or unfavorable neurologic outcomes among patients with clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis of aSAH. While these findings cannot exclude a smaller risk difference than previously reported, they can help refine decision analyses and testing threshold determinations for patients with possible aSAH.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-04T02:55:38.278825-05:
      DOI: 10.1111/acem.13252
  • Randomized Controlled Double-Blind Trial Comparing Haloperidol Combined
           with Conventional Therapy to Conventional Therapy Alone in Patients with
           Symptomatic Gastroparesis
    • Authors: Carlos J. Roldan; Kimberly A. Chambers, Linda Paniagua, Sonali Patel, Marylou Cardenas-Turanzas, Yashwant Chathampally
      Abstract: ObjectiveGastroparesis is a debilitating condition that causes nausea, vomiting, and abdominal pain. Management includes analgesics and antiemetics, but symptoms are often refractory. Haloperidol has been utilized in the palliative care setting for similar symptoms. The study objective was to determine whether haloperidol as an adjunct to conventional therapy would improve symptoms in gastroparesis patients presenting to the emergency department.Methods and trial designThis was a randomized, double-blind, placebo-controlled trial of adult emergency department patients with acute exacerbation of previously diagnosed gastroparesis. The treatment group received 5 mg haloperidol plus conventional therapy (determined by the treating physician). The control group received a placebo plus conventional therapy. The severity of each subject's abdominal pain and nausea were assessed before intervention and every 15 minutes thereafter for 1 hour using a 10-point scale for pain and a 5-point scale for nausea. Primary outcomes were decreased pain and nausea 1 hour after treatment.Results and Adverse EffectsOf the 33 study patients, 15 were randomized to receive haloperidol. Before treatment, the mean intensity of pain was 8.5 in the haloperidol group and 8.28 in the placebo group; mean pretreatment nausea scores were 4.53 and 4.11, respectively. One hour after therapy, the mean pain and nausea scores in the haloperidol group were 3.13 and 1.83 compared to 7.17 and 3.39 in the placebo group. The reduction in mean pain intensity therapy was 5.37 in the haloperidol group (p ≤0.001) compared to 1.11 in the placebo group (p =0 .11). The reduction in mean nausea score was 2.70 in the haloperidol group (p ≤ 0.001) and 0.72 in the placebo group (p = 0.05). Therefore, the reductions in symptom scores were statistically significant in the haloperidol group but not in the placebo group. No adverse events were reported.ConclusionsHaloperidol as an adjunctive therapy is superior to placebo for acute gastroparesis symptoms.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-24T04:07:26.499841-05:
      DOI: 10.1111/acem.13245
  • Neurology Concepts: Young Women and Ischemic Stroke: Evaluation and
           Management in the Emergency Department
    • Authors: Bernard P. Chang; Charles Wira, Joseph Miller, Murtaza Akhter, Bradley E. Barth, Joshua Willey, Lauren Nentwich, Tracy Madsen
      Abstract: ObjectiveIschemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g. premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting.MethodsA panel of 6 board certified emergency physicians, 1 with fellowship training in stroke and 1 with training in sex and gender based medicine, along with 1 vascular neurologist were co-authors involved in the paper. Each author used various search strategies (e.g PubMed, Psycinfo, and Google Scholar) for primary research, and review articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authorsResultsEstimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g. tPA) in both pregnant and nonpregnant individuals.ConclusionUnique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-24T03:57:29.544015-05:
      DOI: 10.1111/acem.13243
  • Adverse events with ketamine versus ketofol for procedural sedation on
           adults: a double-blinded, randomized controlled trial
    • Authors: Fabien Lemoel; Julie Contenti, Didier Giolito, Mathieu Boiffier, Jocelyn Rapp, Jacques Istria, Marc Fournier, François-Xavier Ageron, Jacques Levraut
      Abstract: ObjectivesThe goal of our study was to compare the frequency and severity of recovery reactions between ketamine and ketamine-propofol 1:1 admixture (“ketofol”).MethodsWe performed a multicentric, randomized, double-blinded trial in which adult patients received emergency procedural sedations with ketamine or ketofol. Our primary outcome was the proportion of unpleasant recovery reactions. Other outcomes were frequency of interventions required by these recovery reactions, rates of respiratory or hemodynamic events, emesis, and satisfaction of patients as well as providers.ResultsOne hundred and fifty-two patients completed the study, 76 in each arm. Compared with ketamine, ketofol determined a 22% reduction in recovery reactions incidence (p
      PubDate: 2017-05-11T08:59:14.128879-05:
      DOI: 10.1111/acem.13226
  • Issue Information
    • Pages: 1301 - 1305
      PubDate: 2017-11-10T10:51:04.403634-05:
      DOI: 10.1111/acem.13096
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