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Publisher: John Wiley and Sons   (Total: 1577 journals)

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Showing 1 - 200 of 1577 Journals sorted alphabetically
Abacus     Hybrid Journal   (Followers: 12, SJR: 0.48, h-index: 22)
About Campus     Hybrid Journal   (Followers: 5)
Academic Emergency Medicine     Hybrid Journal   (Followers: 64, SJR: 1.385, h-index: 91)
Accounting & Finance     Hybrid Journal   (Followers: 46, SJR: 0.547, h-index: 30)
ACEP NOW     Free   (Followers: 1)
Acta Anaesthesiologica Scandinavica     Hybrid Journal   (Followers: 49, SJR: 1.02, h-index: 88)
Acta Archaeologica     Hybrid Journal   (Followers: 148, 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: 5, 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: 3)
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: 26, SJR: 6.411, h-index: 86)
Advanced Engineering Materials     Hybrid Journal   (Followers: 26, SJR: 0.81, h-index: 81)
Advanced Functional Materials     Hybrid Journal   (Followers: 50, SJR: 5.21, h-index: 203)
Advanced Healthcare Materials     Hybrid Journal   (Followers: 13, SJR: 0.232, h-index: 7)
Advanced Materials     Hybrid Journal   (Followers: 255, 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: 5, 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: 19)
Africa Research Bulletin: Economic, Financial and Technical Series     Hybrid Journal   (Followers: 12)
Africa Research Bulletin: Political, Social and Cultural Series     Hybrid Journal   (Followers: 9)
African Development Review     Hybrid Journal   (Followers: 35, 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: 10, 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: 14, SJR: 0.925, h-index: 43)
Agricultural Economics     Hybrid Journal   (Followers: 45, SJR: 1.099, h-index: 51)
AIChE J.     Hybrid Journal   (Followers: 30, SJR: 1.122, h-index: 120)
Alcoholism and Drug Abuse Weekly     Hybrid Journal   (Followers: 7)
Alcoholism Clinical and Experimental Research     Hybrid Journal   (Followers: 7, SJR: 1.416, h-index: 125)
Alimentary Pharmacology & Therapeutics     Hybrid Journal   (Followers: 34, SJR: 2.833, h-index: 138)
Alimentary Pharmacology & Therapeutics Symposium Series     Hybrid Journal   (Followers: 3)
Allergy     Hybrid Journal   (Followers: 50, SJR: 3.048, h-index: 129)
Alternatives to the High Cost of Litigation     Hybrid Journal   (Followers: 3)
American Anthropologist     Hybrid Journal   (Followers: 135, 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: 89, SJR: 2.325, h-index: 51)
American J. of Economics and Sociology     Hybrid Journal   (Followers: 27, 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: 262, 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: 125, 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: 16)
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: 219)
Angewandte Chemie Intl. Edition     Hybrid Journal   (Followers: 212, SJR: 6.229, h-index: 397)
Animal Conservation     Hybrid Journal   (Followers: 37, SJR: 1.576, h-index: 62)
Animal Genetics     Hybrid Journal   (Followers: 9, 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: 48, 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: 24, 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: 91, SJR: 0.545, h-index: 15)
Antipode     Hybrid Journal   (Followers: 47, 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: 68, SJR: 0.754, h-index: 69)
Applied Organometallic Chemistry     Hybrid Journal   (Followers: 7, SJR: 0.632, h-index: 58)
Applied Psychology     Hybrid Journal   (Followers: 152, SJR: 1.023, h-index: 64)
Applied Psychology: Health and Well-Being     Hybrid Journal   (Followers: 48, 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: 4)
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: 229, SJR: 0.153, h-index: 13)
Arthritis & Rheumatology     Hybrid Journal   (Followers: 51, SJR: 1.984, h-index: 20)
Arthritis Care & Research     Hybrid Journal   (Followers: 27, SJR: 2.256, h-index: 114)
Artificial Organs     Hybrid Journal   (Followers: 1, SJR: 0.872, h-index: 60)
ASHE Higher Education Reports     Hybrid Journal   (Followers: 14)
Asia & the Pacific Policy Studies     Open Access   (Followers: 15)
Asia Pacific J. of Human Resources     Hybrid Journal   (Followers: 312, 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: 4, 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: 13, 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: 7, SJR: 0.39, h-index: 22)
Australian & New Zealand J. of Statistics     Hybrid Journal   (Followers: 13, 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: 44, 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: 27, 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: 401, SJR: 0.418, h-index: 29)
Australian J. of Rural Health     Hybrid Journal   (Followers: 4, SJR: 0.43, h-index: 34)
Australian Occupational Therapy J.     Hybrid Journal   (Followers: 69, SJR: 0.59, h-index: 29)
Australian Psychologist     Hybrid Journal   (Followers: 11, SJR: 0.331, h-index: 31)
Australian Veterinary J.     Hybrid Journal   (Followers: 19, SJR: 0.459, h-index: 45)
Autism Research     Hybrid Journal   (Followers: 31, 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: 10, 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: 3, 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: 187, 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: 19, SJR: 1.374, h-index: 71)
Bipolar Disorders     Hybrid Journal   (Followers: 9, SJR: 2.592, h-index: 100)
Birth     Hybrid Journal   (Followers: 37, 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: 5, 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: 225, SJR: 2.083, h-index: 125)

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Journal Cover Academic Emergency Medicine
  [SJR: 1.385]   [H-I: 91]   [64 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  [1577 journals]
  • Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to
           Intranasal Fentanyl for Analgesia in Children with Suspected Extremity
           Fractures
    • 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
           Factors
    • 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
       
  • Critical Appraisal of Emergency Medicine Educational Research: The Best
           Publications of 2015
    • Authors: Corey R. Heitz; Wendy Coates, Susan E. Farrell, Jonathan Fisher, Amy Miller Juve, Lalena M. Yarris
      Abstract: ObjectiveTo critically appraise the medical education research literature of 2015, and review the highest quality quantitative and qualitative examples.Methods434 EM-related articles were discovered upon a search of ERIC, PsychINFO, PubMED and SCOPUS. These were both quantitative and qualitative in nature. All were screened by two of the authors using previously published exclusion criteria, and the remaining were appraised by all authors using a previously published scoring system. The highest scoring articles were then reviewed.Results61 manuscripts were scored, and 10 quantitative and 2 qualitative papers were the highest scoring and are reviewed and summarized in the article.ConclusionsThis installment in this critical appraisal series reviews twelve of the highest quality EM-related medical education research manuscripts published in 2015.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-31T01:10:48.346937-05:
      DOI: 10.1111/acem.13305
       
  • Rate-control with beta-blockers versus calcium-channel blockers in the
           emergency setting: predictors of medication class choice and associated
           hospitalization
    • Authors: Clare L Atzema; Peter C Austin
      Abstract: ObjectivesRate-control is an important component of the management of patients with atrial fibrillation (AF). Previous studies of emergency department (ED) rate-control have been limited by relatively small sample sizes. We examined the use of beta-blockers (BB) versus non-dihydropyridine calcium channel blockers (CCB) in ED patients from 24 sites, and the associated hospital admission rates.MethodsIn this pre-planned sub-study, we examined chart data on AF patients who visited one of 24 hospital EDs in Ontario, Canada, between April 2008 and March 2009. We describe the proportion of patients who received either a BB or a CCB, had a heart rate < 110 beats/minute 2 hours later, and any complications. We used hierarchical logistic regression modeling to determine the predictors of BB versus CCB use, and to assess the between-hospital variation in use of BB versus CCB. Solely in patients who had no rhythm control attempts, we examined the difference in the probability of hospital admission after propensity score matching patients by medication class.ResultsOf the 1639 patients who received either a BB (n=429) or a CCB (n=1210), 70.9% of the patients who received a BB had successful rate-control, versus 66.1% for a CCB. Complications were rare (2.4%), and the large majority were hypotension (2.0%). In adjusted analyses, predictors of receiving a BB (compared to a CCB) included already being on a BB, being sent in from a doctor's office, or being seen at a teaching hospital. In contrast, patients with evidence of heart failure, prior use of a CCB, a higher presenting heart rate, a successful pharmacological cardioversion (versus no attempt), or who were seen at the highest AF volume EDs were significantly less likely to receive a BB, compared to a CCB. Systematic between-hospital differences accounted for 8% of the variation in BB versus CCB use. Hospital characteristics accounted for the large majority of that variation: after accounting for patient characteristics the between-hospital variation decreased by a relative 2.8%. By further adjusting for hospital characteristics, it decreased by a relative 74.7%. Among propensity-score matched patients with no rhythm-control attempts, more CCB patients were admitted (51.6%) compared to BB patients (40.0%) (difference of 11.6%; 95% CI, 7.9-16.2).ConclusionsIn this study of 24 EDs, CCBs were used more frequently for rate-control than BBs, and complications were rare and easily managed using both agents. Variation between hospitals in BB versus CCB use was predominantly due to hospital characteristics such as teaching status and AF volumes, rather than different case-mix. Among patients who did not receive attempts at rhythm control, use of a BB for rate control was associated with a lower rate of hospitalization.This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-29T17:55:59.220022-05:
      DOI: 10.1111/acem.13303
       
  • The 2017 Academic Emergency Medicine Consensus Conference: Catalyzing
           System Change through Healthcare Simulation: Systems, Competency, and
           Outcomes
    • 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
           education
    • 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
           Department
    • 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
           use'
    • 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
       
  • Current Status of Gender and Racial/ Ethnic Disparities Among Academic
           Emergency Medicine Physicians
    • Authors: Tracy E. Madsen; Judith A. Linden, Kirsten Rounds, Yu-Hsiang Hsieh, Bernard L. Lopez, Dowin Boatright, Nidhi Garg, Sheryl L Heron, Amy Jameson, Dara Kass, Michelle D. Lall, Ashley M Melendez, James J. Scheulen, Kinjal N. Sethuraman, Lauren M. Westafer, Basmah Safdar
      Abstract: ObjectiveA 2010 survey identified disparities in salaries by gender and underrepresented minorities (URM). With an increase in the EM workforce since, we aimed to 1) Describe the current status of academic EM workforce by gender, race and rank, and 2) Evaluate if disparities still exist in salary or rank by gender.MethodsInformation on demographics, rank, clinical commitment, and base and total annual salary for full-time faculty members in U.S. academic EDs were collected in 2015 via the Academy of Administrators in Academic Emergency Medicine (AAAEM) Salary Survey. Multiple linear regression was used to compare salary by gender while controlling for confounders.ResultsResponse rate was 47% (47/101), yielding data on 1371 full-time faculty; 33% women, 78% white, 4% black, 5% Asian, 3% Asian Indian, 4% other, and 7% unknown race. Comparing white race to nonwhite, 62% vs. 69% were instructor/assistant, 23% vs. 20% were associate, and 15% vs. 10% were full professors. Comparing women to men, 74% vs. 59% were instructor/assistant, 19% vs. 24% were associate, and 7% vs. 17% were full professors. Of 113 Chair/Vice-Chair positions, only 15% were women, and 18% were nonwhite. Women were more often fellowship trained (37% vs. 31%), less often core-faculty (59% vs. 64%), with fewer administrative roles (47% vs. 57%) (all p
      PubDate: 2017-08-05T03:10:24.978257-05:
      DOI: 10.1111/acem.13269
       
  • Re: SAEM Annual Meeting Abstracts
    • PubDate: 2017-08-04T07:35:25.211009-05:
      DOI: 10.1111/acem.13258
       
  • The Emergency Department's Impact on Inpatient Critical Care Resources
    • Authors: Kyle J. Gunnerson
      Abstract: Critical care is an expensive and limited resource in the United States. Estimates from more than a decade ago suggest that over $100 billion a year is spent on critical care services.1 Over the past two decades, the number of patients presenting to the Emergency Department (ED) requiring critical care services has increased at a much higher rate than the growth in overall ED volume.2,3 The proportion of ED patients requiring Intensive Care Unit (ICU) admission has increased 75% over the first decade of the twenty-first century. In addition to the increase in the absolute number of patients requiring critical care admission, the ED length of stay for critically ill patients increased by 60 minutes. This resulted in a total nationwide increase in critical care provided in the ED by more than threefold. This disproportionate increase in critical care time reflects both the increase in critical care volume and the increase in ED boarding of critically ill patients. Data from 2008 reported the median boarding time for a patient waiting in the ED for an ICU bed was more than 5 hours, and 30% of patients waited more than 6 hours for an ICU bed.2,3This article is protected by copyright. All rights reserved.
      PubDate: 2017-08-03T18:23:24.664512-05:
      DOI: 10.1111/acem.13268
       
  • Diagnosis of Subarachnoid Hemorrhage – Time for a Paradigm
           Shift'
    • 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
       
  • The HII Score – A Novel Tool to Assess Impairment from Alcohol in
           Emergency Department Patients
    • Authors: J B Hack; E J Goldlust, D Ferrante, B Zink
      Abstract: BackgroundOver 35 million alcohol impaired (AI) patients are cared for in Emergency Departments (EDs) annually. Emergency physicians are charged with ensuring AI patients’ safety by identifying resolution of alcohol induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients.ObjectiveTo evaluate a novel standardized emergency department assessment of alcohol impairment — Hack's Impairment Index (HII score), in a busy urban Emergency Department.MethodsA retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both “usual” and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2-5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated.Results8074 visits from 3219 unique patients were eligible for study, including 7973 (98.7%) with ethanol levels, 5061 (62.7%) with complete HII scores, and 3646 (45.2%) with HCP assessments. Correlations between HII scores and ethanol levels were poor (Pearson's R2 = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients’ visits.ConclusionsThe HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with HCP evaluations.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-30T06:40:21.365779-05:
      DOI: 10.1111/acem.13266
       
  • Patient and Surrogate Views of Community Consultation for Emergency
           Research
    • 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
       
  • Depression and anxiety among emergency department patients:Utilization and
           barriers to care
    • Authors: Beau Abar; Ashley Holub, Joseph Lee, Vincent DeRienzo, Flavia Nobay
      Abstract: BackgroundAnxiety and depression rates among ED patients are substantially higher than in the general population. Additionally, those with mental health issues often have difficulty accessing care. Unfortunately, issues of anxiety and depression are frequently not addressed in the ED due to competing care priorities. This may lead to increased burden and overcrowding in EDs.ObjectiveThis study related anxiety and depression with ED utilization and perceived barriers to care.MethodsIn order to limit the impact of insurance coverage on ED utilization and access to care, a convenience sample of adults 45-85 years of age in the ED were surveyed. The GAD-7 and PHQ-9 were used to measure anxiety and depression.ResultsA total of 251 subjects were enrolled. Severe anxiety was observed in 10% of patients, while moderately severe or severe depression was observed in 12%. Patients who were both severely anxious and depressed visited the ED nearly twice as often as non-anxious and non-depressed patients. The majority of patients cited at least one moderate barrier to care, and greater anxiety and depression scores were related to greater perceived barriers to care. Perceived barriers to care were> 3 times higher among patients who were both anxious and depressed compared to in patients who were neither depressed nor anxious and twice as high as in those who were either depressed or anxious (p
      PubDate: 2017-07-25T03:10:20.329232-05:
      DOI: 10.1111/acem.13261
       
  • 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
       
  • Welcome to the real world: Do the conditions of FDA approval devalue high
           sensitivity troponin'
    • Authors: Richard Body; Simon Mahler
      Abstract: In January 2017 the Food and Drug Administration (FDA) approved the first high sensitivity cardiac troponin (hs-cTn) assay for use in the United States: the 5th generation hs-cTnT assay manufactured by Roche Diagnostics. This landmark decision finally enables Americans to benefit from the same improvements in diagnostic technology that the rest of the world has utilized for some six years.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-17T08:07:14.884094-05:
      DOI: 10.1111/acem.13256
       
  • Bacteremia Prediction Model for Community-Acquired Pneumonia: External
           Validation in a Multicenter Retrospective Cohort
    • Authors: Byunghyun Kim; Jungho Choi, Kyuseok Kim, Sujin Jang, Tae Gun Shin, Won Young Kim, Jung-Youn Kim, Yoo Seok Park, Soo Hyun Kim, Hui Jai Lee, Jonghwan Shin, JeSung You, Kyung Su Kim, Sung Phil Chung
      Abstract: ObjectiveMany studies have described constructing a prediction model for bacteremia in community-acquired pneumonia (CAP), but these studies were not validated in external heterogeneous groups. The objective of this study was to test the generalizability of a previous bacteremia prediction model for CAP by external validation.MethodsThis multicenter retrospective cohort analysis was performed in eight tertiary urban hospital emergency departments (ED). We reviewed adult patients who were hospitalized after presentation to the ED with CAP. We categorized the enrolled patients into three groups according to the bacteremia prediction model score and calculated the number of patients with or without a blood culture-positive result. We performed a multivariable analysis to identify significant predictors for bacteremia.ResultsAmong the enrolled 2,001 patients, 1,592 (79.6%), 371 (18.5%), and 38 (1.9%) were stratified to a low, moderate, and high-risk group, respectively, and this proportion was similar with previous study. Each group had a bacteremia-positive rate as follows: 1.2% for the low-risk group, 7.2% for the moderate-risk group, and 31.5% for the high-risk group. The area under the receiver operating characteristic curve for the bacteremia model in the external validation cohort was 0.81, and there was no significant difference with that of the previous internal validation cohort (p = 0.246). Assuming that blood cultures were not performed in the low-risk patients, the sensitivity and specificity of this model were 0.68 and 0.81, respectively. Additionally, the positive predictive value and negative predictive value were 9.54% and 98.87%, respectively. A platelet count less than 130,000 cell/μL, albumin less than 3.3 mg/dL, and C-reactive protein (CRP) greater than 17 mg/dL were identified as significant predictors with a sensitivity and specificity of, 0.70 and 0.83, respectively.ConclusionThe bacteremia prediction model was well validated in the general population and could help physicians make the decision to reduce the number of blood cultures in patients with CAP.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-16T22:20:23.342737-05:
      DOI: 10.1111/acem.13255
       
  • Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in
           the Emergency Department
    • Authors: Brian C. Weiner
      Abstract: In their introduction, Gungor et al described ultrasound as a technique for evaluation of patients with low prior probability of acute appendicitis. This testing protocol for appendicitis is being proposed to challenge and perhaps replace the current standard of care for imaging, CT scanning. Specificity of CT scanning is reported in the range of 92-98% and CT is generally felt to be more accurate than ultrasonography The finding of 95.8% specificity for their method appears competitive and may be arithmetically correct but is seriously flawed.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-11T03:40:26.123869-05:
      DOI: 10.1111/acem.13254
       
  • 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
       
  • Broken Bones: The Radiologic Atlas of Fractures and Dislocations, Second
           Edition
    • Authors: Kathleen Cowling; Aron Slear
      Abstract: Broken Bones: The Radiologic Atlas of Fractures and Dislocations, Second Edition is exactly what it's title describes and functions as a quick reference and learning tool on how to identify fractures that are evident on plain radiography. The audience that this text will most likely benefit is a healthcare provider that is tasked with reading and interpreting his or her own plain films. Whether this is an Emergency Medicine physician with or without a radiology department, a radiologist looking for a quick reference, or an orthopedic surgery resident studying fractures in different regions of the body.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-04T03:16:41.213795-05:
      DOI: 10.1111/acem.13251
       
  • 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
       
  • Response to Letter: Diagnostic Value of Bedside Ultrasound in Acute
           Appendicitis in ED: Methodological and Statistical Issues on Diagnostic
           Value
    • Authors: Faruk Gungor; Erkan Goksu, Taylan Kilic
      Abstract: The validity of a diagnostic test can be demonstrated by comparing it to a gold standard test. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), positive and negative likelihood ratios, diagnostic odds ratio, and the area under the ROC curve are the parameters that reflect the discriminative ability of a diagnostic study. Diagnostic accuracy is very sensitive to the characteristics of the study population and it is affected by the prevalence or the spectrum of the disease studied. Therefore, it is important to know how to interpret the diagnostic parameters of the tests studied (3).This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-03T12:32:12.015975-05:
      DOI: 10.1111/acem.13250
       
  • Using Press Ganey Provider Feedback To Improve Patient Satisfaction: A
           Pilot Randomized Controlled Trial
    • Authors: Craig D Newgard; Rongwei Fu, James Heilman, Mary Tanski, O. John Ma, Alan Lines, L. Keith French
      Abstract: Study ObjectiveTo conduct a pilot randomized controlled trial to assess the feasibility, logistics and potential effect of monthly provider funnel plot feedback reports from Press Ganey data and semi-annual face-to-face coaching sessions to improve patient satisfaction scores.MethodsThis was a pilot randomized controlled trial of 25 emergency medicine faculty providers in one urban academic emergency department. We enrolled full-time clinical faculty with at least 12 months of baseline Press Ganey data, who anticipated working in the ED for at least 12 additional months. Providers were randomized into intervention or control groups in a 1:1 ratio. The intervention group had an initial 20-minute meeting to introduce the funnel plot feedback tool and standardized feedback on their baseline Press Ganey scores, then received a monthly email with their individualized funnel plot depicting cumulative Press Ganey scores (compared to their baseline score and the average score of all providers) for 12 months. The primary outcome was the difference in Press Ganey “Doctor-Overall” scores between treatment groups at 12 months. We used a weighted analysis of covariance model to analyze the study groups, accounting for variation in the number of surveys by provider and baseline scores.ResultsOf 37 eligible faculty, we enrolled 25 providers, 13 of whom were randomized to the intervention group and 12 to the control group. During the study period, there were 815 Press Ganey surveys returned, ranging from 4 to 71 surveys per provider. For the standardized overall doctor score over 12 months (primary outcome), there was no difference between the intervention and control groups (difference 1.3 points, 95% confidence interval -2.4 – 5.9, p = .47). Similarly, there was no difference between groups when evaluating the four categories of doctor-specific patient satisfaction scores from the Press Ganey survey (all p> 0.05).ConclusionsIn this pilot trial of monthly provider funnel plot Press Ganey feedback reports, there was no difference in patient satisfaction scores between the intervention and control groups after 12 months. While this study was not powered to detect outcome differences, we demonstrate the feasibility, logistics, and effect sizes that could be used to inform future definitive trials.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-29T14:00:24.136282-05:
      DOI: 10.1111/acem.13248
       
  • Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult
           Open Globe Injuries by Neuroradiology and Ophthalmology
    • Authors: Eric L. Crowell; Vivek A. Koduri, Emilio P. Supsupin, Robert E. Klinglesmith, Alice Z. Chuang, Gene Kim, Laura A. Baker, Robert M. Feldman, Lauren S. Blieden
      Abstract: ObjectiveTo evaluate the sensitivity and specificity of computed tomography (CT) diagnosis of open globes; determine which imaging factors are most predictive of open globe injuries; and evaluate the agreement between neuroradiologist and ophthalmologist readers for diagnosis of open and closed globes.MethodsThis study was a retrospective cohort study. Patients who presented to Memorial Hermann—Texas Medical Center with suspicion for open globes were reviewed. One neuroradiologist and 2 ophthalmologists masked to clinical information reviewed CT images for signs concerning for open globe including change in globe contour, anterior chamber deformation, intraocular air, vitreous hemorrhage, subretinal fluid indicating retinal or choroidal detachment, dislocated or absent lens, intraocular foreign body, and orbital fracture. Using the clinically or surgically confirmed globe status as the true globe status, sensitivity, specificity, and agreement (kappa) were calculated and used to investigate which imaging factors are most predictive of open globe injuries.ResultsOne hundred fourteen patients were included: 35 patients with open globes and 79 patients with closed globes. Specificity was greater than 97% for each reader, and sensitivity ranged from 51 to 77% among readers. The imaging characteristics most consistently used to predict an open globe injury were change in globe contour and vitreous hemorrhage (sensitivity: 43% to 57% and specificity> 98%). The agreement of impression of open globe between the neuroradiologist and ophthalmologists was good and excellent between ophthalmologists.ConclusionsCT imaging is not absolute, and the sensitivity is still inadequate to be fully relied upon. The CT imaging findings most predictive of an open globe injury were change in globe contour and vitreous hemorrhage. Clinical exam or surgical exploration remains the most important component in evaluating for a suspected open globe, with CT imaging as an adjunct.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-29T14:00:21.118048-05:
      DOI: 10.1111/acem.13249
       
  • The Economic Value of Hybrid Single-Photon Emission Computed Tomography
           with Computed Tomography Imaging in Pulmonary Embolism Diagnosis
    • Authors: Lauren K. Toney; Richard D. Kim, Swetha R. Palli
      Abstract: ObjectiveTo quantify the potential economic value of single-photon emission computed tomography (SPECT) with computed tomography (CT; SPECT/CT) versus CT pulmonary angiography (CTPA), ventilation-perfusion (V/Q) planar scintigraphy and V/Q SPECT imaging modalities for diagnosing suspected pulmonary embolism (PE) patients in an emergency setting.MethodsAn Excel-based simulation model was developed to compare SPECT/CT versus the alternate scanning technologies from a payer's perspective. Clinical endpoints (diagnosis, treatment, complications and mortality) and their corresponding cost data (2016 USD) were obtained by performing a best evidence review of the published literature. Studies were pooled and parameters weighted by sample size. Outcomes measured included differences in (1) excess costs (2) total costs and (3) lives lost per annum between SPECT/CT and the other imaging modalities. One-way (±25%) sensitivity and three scenario analyses were performed to gauge the robustness of the results.ResultsFor every 1,000 suspected PE patients undergoing imaging, expected annual economic burden by modality was found to be: 3.2 million (SPECT/CT), 3.8 million (CTPA), 5.8 million (planar) and 3.6 million (SPECT) USD, with a switch to SPECT/CT technology yielding per-patient-per-month cost savings of $51.8 (vs. CTPA), $213.8 (vs. planar), and $36.3 (vs. SPECT) respectively. The model calculated that the incremental number of lives saved with SPECT/CT was 6 (vs. CTPA), and 3 (vs. planar). Utilizing SPECT/CT as the initial imaging modality for workup of acute PE was also expected to save $994,777 (vs. CTPA), $2,852,014 (vs. planar), and $435,038 (vs. SPECT) in ‘potentially avoidable’ excess costs per annum for a payer or health plan.ConclusionCompared to the currently available scanning technologies for diagnosing suspected PE, SPECT/CT appears to confer superior economic value, primarily via improved sensitivity and specificity and low non-diagnostic rates. In turn, the improved diagnostic accuracy accords this modality the lowest ratio of expenses attributable to potentially avoidable complications, misdiagnosis and underdiagnosis.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-26T09:52:40.462267-05:
      DOI: 10.1111/acem.13247
       
  • Systemic Thrombolysis, Catheter-Directed Thrombolysis and Anticoagulation
           for Intermediate-Risk Pulmonary Embolism: A Simulation Modeling Analysis
    • Authors: Christopher Kabrhel; Ayman Ali, Jin Choi, Chin Hur
      Abstract: ObjectivesDecision-making around the use of thrombolysis for patients with intermediate-risk (submassive) PE remains challenging. Studies indicate favorable clinical outcomes with systemic thrombolytics (IV tPA), but the risk of major bleeding and hemorrhagic stroke is a deterrent. Catheter-directed thrombolysis (CDT) may be a preferable strategy, as it has been shown to have a lower risk of bleeding than systemic thrombolysis. However, a three-arm randomized control study comparing IV tPA, CDT, and anticoagulation alone, with long-term follow up, would be costly and is unlikely to be performed. The aim of this study was to use decision modeling to quantitatively estimate the differences between the three strategies.MethodsWe created an individual level state-transition model to simulate long-term outcomes of a hypothetical patient cohort treated with either IV tPA, CDT or anticoagulation alone. Our model incorporated clinical RCT and longitudinal study data to inform patient characteristics and outcomes specific to each study arm. The base case was a 65 year old patient. Additionally, we utilized preliminary data published by the Pulmonary Embolism Response Team (PERT) at the Massachusetts General Hospital. Variance in model inputs was addressed with deterministic and probabilistic sensitivity analyses. Our primary endpoint was quality-adjusted life years (QALYs). Secondary endpoints included total cost and incremental cost-effectiveness ratios (ICER).ResultsCDT (mean, 95% confidence interval) [7.388 (7.381, 7.396) QALYs] resulted in the most long-term utility for eligible patients compared to anticoagulation alone [7.352 (7.345, 7.360) QALYs] or IV tPA [7.343 (7.336, 7.351) QALYs]. Patients receiving CDT had an elevated risk of hemorrhagic stroke in comparison to anticoagulation alone; however, patients treated with anticoagulation alone were more likely to experience recurrent PE associated adverse outcomes. Results were stable with sensitivity analyses varying age and sex. Our probabilistic sensitivity analysis assessing joint variance predicts CDT to be the most effective strategy, when measured by mean QALYs, in 98.4% of runs, while systemic thrombolysis was favored over anticoagulation alone 34.4% of the time. The ICER of CDT compared to anticoagulation was $317,042 per QALY gained.ConclusionIn our model, for those eligible, CDT results in the largest number of QALYs for patients with intermediate-risk PE, although it is relatively expensive and the absolute difference in QALYs between anticoagulation alone and CDT is small. Future studies that provide data on longitudinal quality-of-life outcomes of patients treated for PE and characteristics of CDT would be beneficial to augment model inputs, inform assumptions, and validate results.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-26T05:27:31.989269-05:
      DOI: 10.1111/acem.13242
       
  • Prehospital advanced cardiac life support for out-of-hospital cardiac
           arrest: a cohort study
    • Authors: Alexis Cournoyer; Eric Notebaert, Massimiliano Iseppon, Sylvie Cossette, Luc Londei-Leduc, Yoan Lamarche, Judy Morris, Éric Piette, Raoul Daoust, Jean-Marc Chauny, Catalina Sokoloff, Yiorgos Alexandros Cavayas, Jean Paquet, André Denault
      Abstract: ObjectivesOut-of-hospital advanced cardiac life support (ACLS) has not consistently shown a positive impact on survival. Extracorporeal cardiopulmonary resuscitation (E-CPR) could render prolonged on-site resuscitation (ACLS or basic cardiac life support [BCLS]) undesirable in selected cases. The objectives of this study were to evaluate, in patients suffering from out-of-hospital cardiac arrest (OHCA) and in a subgroup of potential E-CPR candidates, the association between the addition of prehospital ACLS to BCLS and survival to hospital discharge, prehospital return of spontaneous circulation (ROSC) and delay from call to hospital arrival.MethodsThis cohort study targets adult patients treated for OHCA between April 2010 and December 2015 in the city of Montreal, Canada. We defined potential E-CPR candidates using clinical criteria previously described in the literature (65 years of age or younger, initial shockable rhythm, absence of return of spontaneous circulation after 15 minutes of prehospital resuscitation and emergency medical services witnessed collapse or witnessed collapse with bystander cardiopulmonary resuscitation). Associations were evaluated using multivariate regression models.ResultsA total of 7134 patients with OHCA were included, 761 (10.7%) of whom survived to discharge. No independent association between survival to hospital discharge and the addition of prehospital ACLS to BCLS was found in either the entire cohort [adjusted odds ratio (AOR) 1.05 (95% confidence interval 0.84-1.32), p=0.68] or amongst the 246 potential E-CPR candidates [AOR 0.82 (95% confidence interval 0.36-1.84), p=0.63]. The addition of prehospital ACLS to BCLS was associated with a significant increase in the rate of prehospital ROSC in all patients experiencing OHCA (AOR 3.92 [95% CI 3.38-4.55], p
      PubDate: 2017-06-24T04:07:28.384399-05:
      DOI: 10.1111/acem.13246
       
  • 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
       
  • The Association of Health Literacy with Preventable ED Visits: A
           Cross-Sectional Study
    • Authors: Meenakshi P. Balakrishnan; Jill Boylston Herndon, Jingnan Zhang, Thomas Payton, Jonathan Shuster, Donna L. Carden
      Abstract: BackgroundPolicy-makers argue that emergency department (ED) visits for conditions preventable with high-quality outpatient care contribute to waste in the healthcare system. However, access to ambulatory care is uneven, especially for vulnerable populations like minorities, the poor and those with limited health literacy. The impact of limited health literacy on ED visits that are preventable with timely, high-quality ambulatory care is unknown.ObjectiveTo determine the association of health literacy and preventable ED visits.MethodsWe conducted an observational cross-sectional study of potentially preventable ED visits (outcome) among adults (≥18 years old) in an ED serving an urban community. We assessed health literacy (predictor) through structured interviews with the Rapid Estimate of Adult Literacy in Medicine (REALM). We recorded age, sex, race, employment, payer, marital and health status, and number of comorbidities through structured interviews or electronic record review. We identified potentially preventable ED visits in the two years prior to the index ED visit by applying Agency for Healthcare Research and Quality technical specifications to identify ambulatory care sensitive conditions using ED discharge diagnoses in hospital administrative data. We used Poisson regression to evaluate the number of preventable ED visits among patients with limited (REALM < 61), versus adequate (REALM ≥ 61), health literacy after adjusting for covariates.ResultsOf 1,201 participants, 709 (59%) were female, 370 (31%) were African American, mean age was 41.6 years, and 394 (33%) had limited health literacy. Out of 4,444 total ED visits, 423 (9.5%) were potentially preventable. Of these, 260 (61%) resulted in hospital admission and 163 (39%) were treat-and-release. After adjusting for covariates, patients with limited literacy had 2.3 (95% CI 1.7-3.1) times the number of potentially preventable ED visits resulting in hospital admission compared to individuals with adequate health literacy, 1.4 (95%CI 1.0-2.0) times the number of treat-and-release visits, and 1.9 (95% CI 1.5-2.4) times the number of total preventable ED visits.ConclusionsOur results suggest that the ED may be an important site to deploy universal literacy-sensitive precautions and to test literacy-sensitive interventions with the goal of reducing the burden of potentially preventable ED visits on patients and the healthcare system.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-24T04:02:27.060238-05:
      DOI: 10.1111/acem.13244
       
  • 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
       
  • Society for Academic Emergency Medicine Statement on Plagiarism
    • Authors: Shellie L. Asher; Kenneth V. Iserson, Lisa H. Merck
      Abstract: The integrity of the research enterprise is of the utmost importance for the advancement of safe and effective medical practice for patients and for maintaining the public trust in health care. Academic societies and editors of journals are key participants in guarding scientific integrity. Avoiding and preventing plagiarism helps to preserve the scientific integrity of professional presentations and publications. The Society for Academic Emergency Medicine (SAEM) Ethics Committee discusses current issues in scientific publishing integrity and provides a guideline to avoid plagiarism in SAEM presentations and publications.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-19T09:12:25.97211-05:0
      DOI: 10.1111/acem.13241
       
  • Comparing the No Objective Testing rule to the HEART pathway
    • Authors: Jaimi Greenslade; Louise Cullen
      Abstract: We read with great interest the article by Stopyra and colleagues1 comparing the no objective testing (NOT) rule and the HEART pathway using a cohort of 141 patients. The two rules, developed to risk stratify patients presenting to the emergency department (ED) with acute chest pain, were 100% sensitive for identifying major adverse cardiac events (MACE) at 30 days. The HEART pathway identified a more sizeable portion of low-risk patients who could be discharged without additional cardiac testing.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-13T03:10:21.157336-05:
      DOI: 10.1111/acem.13240
       
  • Response to the Letter to the Editor
    • Authors: Jason P. Stopyra; Chadwick D. Miller, Simon A. Mahler
      Abstract: We appreciate the insights and concerns raised in the above letter to the editor. The authors have thoughtfully highlighted some important distinctions between the original derivation of NOTR and our validation study.1,2 Specifically, the original NOTR derivation included cardiac death, acute myocardial infarction (MI), unstable angina (UA), and “urgent and emergent” revascularization in a composite safety endpoint (and did not include “elective” coronary revascularizations). Our study included death, MI, and any coronary revascularization events, but did not include UA.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-13T02:55:20.988234-05:
      DOI: 10.1111/acem.13239
       
  • Hot Off the Press: Point-of-care ultrasound for non-angulated distal
           forearm fractures in children
    • Authors: Justin Morgenstern; Corey Heitz, William K Milne
      Abstract: This prospective, cross-sectional diagnostic study examined the performance of point of care ultrasound (POCUS) in the diagnosis of suspected non-angulated forearm fractures in pediatric patients aged 4-17 years, using x-rays as the gold standard. The test characteristics reported are a sensitivity of 94.7% (95% CI 89.7-99.8%), a specificity of 93.5% (95% CI 88.6-98.5%), a positive likelihood ratio of 14.6, and a negative likelihood ratio of 0.6.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-07T09:50:32.007454-05:
      DOI: 10.1111/acem.13238
       
  • The Plight of Veterans
    • Authors: Nancy Lutwak
      Abstract: As I listen to the sounds of the VA emergency department I realize the plight of many veterans istragic and some have lived through hard times not commonly recognized. There are so many headlines about veteran suicides, homelessness, post-traumatic stress disorder and injuries from explosive devices.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-05T00:35:22.260523-05:
      DOI: 10.1111/acem.13237
       
  • Bedside Ultrasound in Acute Appendicitis in the Emergency Department:
           Methodological and statistical issues on diagnostic value
    • Authors: Fatemeh Koohi; Siamak Sabour
      Abstract: We were interested to read the recent paper by Gungor F and colleagues published in May issue of the Acad Emerg Med 2017.1 The aim of the authors was to evaluate diagnostic value of point-of-care US (POCUS) in clinical decision making of emergency physicians (EPs) for acute appendicitis (AA) in the emergency department (ED).1 A total of 264 patients were included into a prospective observational clinical study and based on their results 169 (64%) had a diagnosis of AA.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-26T05:55:20.97453-05:0
      DOI: 10.1111/acem.13232
       
  • Undetectable concentrations of an FDA-approved high-sensitivity cardiac
           Troponin T assay to rule out acute myocardial infarction at emergency
           department arrival
    • Authors: Andrew D McRae; Grant Innes, Michelle Graham, Eddy Lang, James E Andruchow, Yunqi Ji, Shabnam Vatanpour, Tasnima Abedin, Hong Yang, Danielle A Southern, Dongmei Wang, Isolde Seiden-Long, Lawrence DeKoning, Peter Kavsak
      Abstract: BackgroundThe objective of this study was to quantify the sensitivity of very low concentrations of high-sensitivity cardiac troponin T (hsTnT) at ED arrival for acute myocardial infarction (AMI) in a large cohort of chest pain patients evaluated in real-world clinical practice.MethodsThis retrospective study included consecutive ED patients with suspected cardiac chest pain evaluated in four urban EDs were, excluding those with ST-elevation AMI, cardiac arrest or abnormal kidney function. The primary outcomes were AMI at 7-, 30- and 90 days. Secondary outcomes included major adverse cardiac events (MACE: all-cause mortality, AMI and revascularization) and the individual MACE components. Test characteristics were calculated for hsTnT values from 3-200ng/L.Results7130 patients met inclusion criteria. AMI incidence at 7-, 30- and 90 days was 5.8%, 6.0% and 6.2%. When the hsTnT assay was performed at ED arrival, the limit of blank of the assay (3ng/L) ruled out 7-day AMI in 15.5% of patients with 100% sensitivity and negative predictive value. The limit of detection of the assay (5ng/L) ruled out AMI in 33.6% of patients with 99.8% sensitivity and 99.95% negative predictive value for 7-day AMI. The limit of quantification (the FDA-approved cutoff for lower the reportable limit) of 6ng/L ruled out AMI in 42.2% of patients with 99.8% sensitivity and 99.95% negative predictive value. The sensitivity of the cutoffs of
      PubDate: 2017-05-19T09:41:36.740462-05:
      DOI: 10.1111/acem.13229
       
  • Utilization of a Sobering Center for Acute Alcohol Intoxication
    • Authors: Shannon Smith-Bernardin; Adam Carrico, Wendy Max, Susan Chapman
      Abstract: ObjectiveTo describe the population utilizing a sobering center for public alcohol intoxication, and compare between single-visit users, repeat users, and high users.MethodsWe conducted a secondary analysis of 1,271 adults cared for in the Sobering Center from July 2014 to June 2015. We divided the population into three groups: single-use (1 visit), repeat users (2-5 visits) and high (6+) users, and evaluated demographics, lifetime health diagnoses utilizing the Elixhauser Comorbidity Index, rates of public service utilization including ambulance and emergency department, and related costs.ResultsThe population was primarily male, middle-aged, and ethnically diverse. As compared to single-visit users (n=869), repeat (n=287) and high users (n=115) were older, were more likely to be currently homeless, and had spent more time homeless. Repeat and high users had significantly higher rates of hypertension, liver disease, diabetes, depression, psychoses, and drug abuse diagnoses as compared to single-visit users. In addition to sobering visits, utilization of ambulance and ED and related costs were significantly greater for the high users compared to repeat and single-visit users.ConclusionsFrom an overall heterogeneous population, more frequent utilizers of the Sobering Center, both high and repeat users as compared to low users, had significantly greater prevalence of chronic disorders, service utilization, and homelessness. Findings indicate that a sobering center can have a prominent role in the care for those with acute alcohol intoxication, particularly those individuals with chronic public intoxication who are likewise homeless. Further longitudinal research could offer important insights as to the population served over time, investigating changes in utilization and efforts towards health and housing stabilization.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T10:45:39.726812-05:
      DOI: 10.1111/acem.13219
       
  • The Epidemiology of Emergency Department Trauma Discharges in the United
           States
    • Authors: Charles J. DiMaggio; Jacob B. Avraham, David C. Lee, Spiros G. Frangos, Stephen P. Wall
      Abstract: ObjectiveInjury related morbidity and mortality is an important emergency medicine and public health challenge in the United States (US). Here we describe the epidemiology of traumatic injury presenting to US emergency departments, define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries.MethodsWe conducted a secondary retrospective, repeated cross-sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all-payer emergency department survey database in the US. Main outcomes and measures were survey-adjusted counts, proportions, means, and rates with associated standard errors, and 95% confidence intervals. We plotted annual age-stratified emergency department discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level 1 or 2 trauma center care with injury fatality using a multi-variable survey-adjusted logistic regression analysis that controlled for age, gender, injury severity, comorbid diagnoses, and teaching hospital status.ResultsThere were 181,194,431 (standard error, se = 4234) traumatic injury discharges from US emergency departments between 2006 and 2012. There was an average year-to-year decrease of 143 (95% CI -184.3, -68.5) visits per 100,000 US population during the study period. The all-age, all-cause case-fatality rate for traumatic injuries across US emergency departments during the study period was 0.17% (se = 0.001). The case-fatality rate for the most severely injured averaged 4.8% (se = 0.001), and severely injured patients were nearly four times as likely to be seen in Level 1 or 2 trauma centers (relative risk = 3.9 (95% CI 3.7, 4.1)). The unadjusted risk ratio, based on group counts, for the association of Level 1 or 2 trauma centers with mortality was RR = 4.9 (95% CI 4.5, 5.3), however, after accounting for gender, age, injury severity and comorbidities, Level 1 or 2 trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 (0.79, 1.18)).There were notable changes at the extremes of age in types and causes of emergency department discharges for traumatic injury between 2009 and 2012. Age-stratified rates of diagnoses of traumatic brain injury increased 29.5% (se = 2.6) for adults older than 85, and increased 44.9% (se = 1.3) for children younger than 18. Firearm related injuries increased 31.7% (se = 0.2) in children five years and younger. The total inflation-adjusted cost of emergency department injury care in the US between 2006 and 2012 was $99.75 billion (se = 0.03).ConclusionsEmergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the US. Level 1 or 2 trauma centers remain a bulwark against the tide of severe trauma in the US. But, the types and causes of traumatic injury in the US are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm-related trauma presenting increased challenges.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T09:20:29.237659-05:
      DOI: 10.1111/acem.13223
       
  • Validation of the No Objective Testing Rule and Comparison to the HEART
           Pathway
    • Authors: Jason P. Stopyra; Chadwick D. Miller, Brian C. Hiestand, Cedric W. Lefebvre, Bret A. Nicks, David M. Cline, Kim L. Askew, Robert F. Riley, Gregory B. Russell, James W. Hoekstra, Simon A. Mahler
      Abstract: BackgroundThe No Objective Testing Rule (NOTR) is a decision aid designed to safely identify Emergency Department (ED) patients with chest pain who do not require objective testing for coronary artery disease.ObjectivesTo validate the NOTR in a cohort of US ED patients with acute chest pain and compare its performance to the HEART Pathway.MethodsA secondary analysis of 282 participants enrolled in the HEART Pathway Randomized Controlled Trial was conducted. Each patient was classified as low-risk or at- risk by the NOTR. Sensitivity for major adverse cardiac events (MACE) at 30 days was calculated in the entire study population. NOTR and HEART Pathways were compared among patients randomized to the HEART Pathway in the parent trial using McNemar's test and the net reclassification index (NRI).ResultsMACE occurred in 22/282 (7.8%) participants, including no deaths, 16/282 (5.6%) with MI, and 6/282 (2.1%) with coronary revascularization without MI. NOTR was 100% (95% CI 84.6-100%) sensitive for MACE and identified 78/282 patients (27.7%, 95% CI 22.5-33.3%) as low-risk. In the HEART Pathway arm (n=141), both NOTR and HEART Pathway identified all patients with MACE as at-risk. Compared to NOTR, the HEART Pathway was able to correctly reclassify 27 patients without MACE as low-risk, yielding a NRI of 20.8% (95% CI 11.3-30.2%).ConclusionsWithin a US cohort of ED patients with chest pain, the NOTR and HEART Pathway were 100% sensitive for MACE at 30 days. However, the HEART Pathway identified more patients suitable for early discharge than the NOTR.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T09:20:24.612215-05:
      DOI: 10.1111/acem.13221
       
  • 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
       
  • Why do people choose Emergency and Urgent care services' A rapid
           review utilizing a systematic literature search and narrative synthesis
    • Authors: Joanne E Coster; Janette K Turner, Daniel Bradbury, Anna Cantrell
      Abstract: ObjectivesRising demand for emergency and urgent care services are well documented, as are the consequences, for example, ED crowding, increased costs, pressure on services and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions and behavioural changes relating to how people choose to access health services. The aim of this systematic mapping review is to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care.MethodsSystematic searches were conducted across MEDLINE (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost. Peer reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services, and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework based narrative synthesis.ResultsThirty-eight studies were identified that met the inclusion criteria. Most studies were set in the UK (39.4%) or the USA (34.2%)and reported results relating to ED (68.4%).Thirty-nine percent of studies utilised qualitative or mixed research designs Our thematic analysis identified 6 broad themes which summarised reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety and the value of reassurance from emergency based services; views of family, friends or healthcare professionals; convenience (location, not having to make appointment and opening hours); individual patient factors (e.g. cost); perceived need for EMS or hospital care, treatment or investigations.ConclusionsWe identified 6 distinct reasons explaining why patients choose to access emergency and urgent care services: Limited access to or confidence in primary care, patient perceived urgency, convenience, views of family, friends or other health professionals and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T08:58:55.500374-05:
      DOI: 10.1111/acem.13220
       
  • Risk of Intracranial Hemorrhage in Ground Level Fall with Antiplatelet or
           Anticoagulant Agents
    • Authors: Michael Ganetsky; Gregory Lopez, Tara Coreanu, Victor Novack, Steven Horng, Nathan I. Shapiro, Kenneth A. Bauer
      Abstract: ObjectivesAnticoagulant and antiplatelet medications are known to increase the risk and severity of traumatic intracranial hemorrhage (tICH), even with minor head trauma. Most studies on bleeding propensity with head trauma are retrospective, based on trauma registries, or include heterogeneous mechanisms of injury. The goal of this study was to determine the rate of tICH from only a common low-acuity mechanism of injury, that of a ground level fall, in patients taking one or more of the following antiplatelet or anticoagulant medications: aspirin, warfarin, prasugrel, ticagrelor, dabigatran, rivaroxaban, apixaban or enoxaparin.MethodsThis was a prospective cohort study conducted at a level 1 tertiary care trauma center of consecutive patients meeting the inclusion criteria of: a ground level fall with head trauma as affirmed by the treating clinician, a CT head obtained, and taking and one of the above antiplatelet or anticoagulants. Patients were identified prospectively through electronic screening with confirmatory chart review. ED charts were abstracted without subsequent knowledge of the hospital course. Patients transferred with a known abnormal CT head were excluded. Primary outcome was rate of tICH on initial CT head. Rates with 95% confidence intervals were compared.ResultsOver 30 months, we enrolled 939 subjects. The average age was 79.2 years and 44.6% were male. There were a total of 33 patients with tICH (3.5%, 95% CI 2.5%-4.9%). Antiplatelets had a rate of tICH of 4.3% (3.0 - 6.2%) compared to anticoagulants with a rate of 1.7% (0.4 - 4.5%). Aspirin without other agents had an tICH rate of 4.6% (3.2 - 6.6%); of these, 81.5% were taking low dose 81mg. Two patients received a craniotomy (1 taking aspirin, 1 taking warfarin). There were 4 deaths (3 taking aspirin, 1 taking warfarin). Most (72.7%) subjects with tICH were discharged home or to a rehabilitation facility. There were no tICH in 31 subjects taking a DOAC. Confidence intervals were overlapping for the groups.ConclusionThere is a low incidence of clinically significant tICH with a ground level fall in head trauma in patients taking an anticoagulant or antiplatelet medication. There was no statistical difference in rate of tICH between antiplatelet and anticoagulants, which is unanticipated and counter-intuitive as most literature and teaching suggests a higher rate with anticoagulants. A larger data set is needed to determine if small differences between the groups exist.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-05T08:15:30.940616-05:
      DOI: 10.1111/acem.13217
       
  • Global Emergency Medicine: A review of the literature from 2016
    • Authors: Torben K. Becker; Bhakti Hansoti, Susan Bartels, Alison Schroth Hayward, Braden J. Hexom, Kevin M. Lunney, Regan H. Marsh, Maxwell Osei-Ampofo, Indi Trehan, Julia Chang, Adam C. Levine,
      Abstract: ObjectivesThe Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners.MethodsThis year 13,890 articles written in four languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles.ResultsA total of 716 articles met our inclusion criteria and underwent full review. Fifty-nine percent were categorized as emergency care in resource-limited settings, 17% as emergency medicine development, and 24% as disaster and humanitarian response. Nineteen articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed Cohen's Kappa of 0.441.ConclusionsIn 2016, the total number of articles identified by our search continued to increase. The proportion of articles in each of the three categories remained stable. Studies and reviews with a focus on infectious diseases, pediatrics, and the use of ultrasound in resource-limited settings represented the majority of articles selected for final review.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-05T05:31:15.990806-05:
      DOI: 10.1111/acem.13216
       
  • Efficacy of intravenous cobinamide versus hydroxocobalamin or saline for
           treatment of severe hydrogen sulfide toxicity in a swine (Sus Scrofa)
           model
    • Authors: Vikhyat S. Bebarta; Normalynn Garrett, Matthew Brenner, Sari Mahon, Joseph K. Maddry, Susan Boudreau, Maria Castaneda, Gerard Boss
      Abstract: BackgroundHydrogen sulfide (H2S) is a potentially deadly gas that naturally occurs in petroleum and natural gas. The Occupational Health and Safety Administration cites H2S as a leading cause of workplace gas inhalation deaths. Mass casualties of H2S toxicity may be caused by exposure from industrial accidents or release from oil field sites. H2S is also an attractive terrorism tool because of its high toxicity and ease with which it can be produced. Several potential antidotes have been proposed for hydrogen sulfide poisoning but none have been completely successful.ObjectiveTo compare treatment response assessed by the time to spontaneous ventilation among groups of swine with acute H2S induced apnea treated with intravenous (IV) cobinamide (4mg/kg in 0.8 ml of 225mM solution), IV hydroxocobalamin (4mg/kg in 5 ml saline), or saline alone.MethodsTwenty-four swine (45-55 kg) were anesthetized, intubated, and instrumented with continuous femoral and pulmonary artery pressure monitoring. After stabilization, anesthesia was adjusted such that animals would spontaneous ventilate with an FIO2 of 0.21. Sodium hydrosulfide (NaHS; concentration of 8 mg/ml) was begun at 1 mg/kg/min until apnea was confirmed for 20 seconds by capnography. This infusion rate was sustained for 1.5 minutes post apnea, and then decreased to a maintenance rate for the remainder of the study to replicate sustained clinical exposure. Animals were randomly assigned to receive cobinamide (4 mg/kg), hydroxocobalamin (4 mg/kg) or saline and monitored for 60 minutes beginning one-minute post apnea. G* power analysis using the Z test determined that equal group sizes of 8 animals were needed to achieve a power of 80% in detecting a 50% difference in return to spontaneous ventilations at α=0.05.ResultsThere were no significant differences in baseline variables. Moreover, there were no significant differences in the mg/kg dose of NaHS (5.6 mg/kg; p=0.45) required to produce apnea. Whereas all of the cobinamide treated animals survived (8/8), none of the control (0/8) or hydroxocobalamin (0/8) treated animals survived. Mean time to spontaneous ventilation in the cobinamide treated animals was 3.2(±1.1) minutes.ConclusionsCobinamide successfully rescued the severely NaHS-poisoned swine from apnea in the absence of assisted ventilation.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-04T11:01:10.415887-05:
      DOI: 10.1111/acem.13213
       
  • Searching for Staircases: Strengthening the Connections Between the
           Emergency Department and the Intensive Care Unit
    • Authors: James M Walter; James J Walter
      Abstract: On a fall day in Chicago, a middle-aged man stepped out of a northbound train, appeared to choke, and collapsed. Paramedics arrived within minutes and administered several rounds of defibrillation and intravenous epinephrine. The patient was rapidly transported to an academic medical center, resuscitated in the Emergency Department (ED), and was soon surrounded by a multidisciplinary team of doctors, nurses, and respiratory therapists in the Intensive Care Unit (ICU).This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-12T02:00:25.447705-05:
      DOI: 10.1111/acem.13196
       
  • Characteristics of Short Stay Critical Care Admissions from Emergency
           Departments in Maryland
    • Authors: Obiora O. Chidi; Sarah M. Perman, Adit A. Ginde
      Abstract: ObjectivesCritical care is an expensive and limited resource, and short stay critical care admissions may be treated in alternate, less costly settings. This study objective was to determine the proportion of critical care admissions with a short critical care length of stay and identify the clinical characteristics and diagnoses associated with high and low rates of short stay critical care admissions.MethodsSecondary analysis of the 2011 Maryland State Inpatient Database. The study included adult ED visits admitted to a critical care unit. We compared clinical data and discharge diagnoses for short (≤1 day) versus longer (≥2 days) stay critical care admissions.ResultsA total of 30,212 critical care admissions were eligible, of which 11,494 (38.0%) were short stay. There were significant differences in age, insurance, and co-morbidities between the short stay and the longer stay critical care admissions. Of short stay critical care admissions, 3,404 (29.6%) also had a 1 day overall hospital length of stay. The diagnoses with the highest proportion of short stay critical care admissions were nonspecific chest pain (87.9%), syncope (70.6%), and transient cerebral ischemia (67.6%) and the lowest proportion were respiratory failure (17.9%), sepsis (19.4%), and aspiration pneumonitis (19.8%).ConclusionsOver one-third of critical care admissions were short stay. Alternate strategies to manage these patients, including ED-based critical care units or other venues of inpatient care may be more cost-efficient for selected patients.This article is protected by copyright. All rights reserved.
      PubDate: 2017-03-21T09:45:43.298289-05:
      DOI: 10.1111/acem.13188
       
  • A Quality Improvement Initiative to Decrease the Rate of Solitary Blood
           Cultures in the Emergency Department
    • Authors: Joseph Choi; Sahand Ensafi, Lucas Brien Chartier, Oliver Van Praet
      Abstract: ObjectivesBest practice guidelines recommend that at least two sets of blood cultures (BCs) be sent when blood cultures are required. However, high rates of solitary BCs are still common in the emergency department (ED). The aim of this study was to evaluate the efficacy of different quality improvement initiatives aimed at reducing the rate of solitary blood cultures being sent to the lab on patients ultimately discharged from our ED.MethodsThis was a multi-centre, multi-phase, prospective study evaluating a comprehensive education-based intervention and a second intervention that combined a computerized forcing function along with a brief education-based intervention. The results were analyzed using segmented regression analysis, as well as statistical process control charts.ResultsThe baseline rate of solitary sets of BCs was 41.1%. The education intervention reduced this rate to 30.3%. The introduction of a forcing function with a brief educational intervention further reduced the rate to 11.6%. This represents an absolute reduction of 29.5% from baseline (relative reduction of 71.8%). According to segmental regression analyses, the education intervention alone did not produce a statistically significant change when factoring possible background time-related trends (P = 0.071). However, the forcing function produced a statistically significant improvement (P < 0.0005), which was maintained for 6 months.ConclusionThe combination of a brief education-based intervention and a computerized forcing function was more effective than education alone in reducing solitary BC collection in our ED in this time series study. Forcing functions can be a powerful tool in modifying behaviours and processes in the clinical setting.This article is protected by copyright. All rights reserved.
      PubDate: 2017-01-20T20:50:34.440395-05:
      DOI: 10.1111/acem.13161
       
  • Issue Information
    • Pages: 1037 - 1041
      PubDate: 2017-09-10T17:56:35.051907-05:
      DOI: 10.1111/acem.13094
       
  • Accuracy of Point of Care Ultrasonography for Diagnosing Acute
           Appendicitis: A Systematic Review and Meta-Analysis
    • Authors: Matthew J. Fields; Joshua Davis, Carl Alsup, Amanda Bates, Arthur Au, Srikar Adhikari, Isaac Farrell
      First page: 1124
      Abstract: IntroductionThe use of ultrasonography to diagnose appendicitis has become increasingly common over recent years and is well-established. More recently, point of care ultrasonography (POCUS) has also been studied for the diagnosis of appendicitis, which may also prove a valuable diagnostic tool. The purpose of this study is through systematic review and meta-analysis to identify the test characteristics of POCUS, specifically ultrasonography performed by a non-radiologist physician, in accurately diagnosing acute appendicitis in patients of any age.MethodsWe conducted a thorough and systematic literature search of English language articles published on point of care, physician-performed transabdominal ultrasonography used for the diagnosis of acute appendicitis from 1980 to May, 2015 using OVID® Medline, In-Process, and Other Non-indexed Citations; and SCOPUS. Studies were selected and subsequently independently abstracted by 2 trained reviewers. A random effects pooled analysis was used to construct a hierarchical summary receiver-operator characteristic curve, and a meta-regression was performed. Quality of studies was assessed using the QUADAS-2 tool.ResultsOur search yielded 5,792 unique studies and we included 21 of these in our final review. Prevalence of disease in this study was 29.8%, (range, 6.4%-75.4%). The sensitivity and specificity for POCUS in diagnosing appendicitis was 91% (95%CI, 83%-96%) and 97% (95%CI, 91%-99%), respectively. The positive and negative predictive values were 91% and 94%, respectively. Studies performed by emergency physicians had slightly lower test charcteristics (sensitivity=80%, specificity=92%). There was significant heterogeneity between studies (I2=99%, 95%CI, 99-100%) and the quality of the reported studies was moderate, mostly due to unclear reporting of blinding of physicians and timing of scanning and patient enrollment. Several of the studies were performed by a single operator, and the education and training of the operators was variably reported.ConclusionPOCUS has a relatively high sensitivity and specificity for diagnosing acute appendicitis, though the data presented is limited by the quality of the original studies and large confidence intervals. In the hands of an experienced operator, POCUS is an appropriate initial imaging modality for diagnosing appendicitis. Based on our results, it is premature to utilize POCUS as a standalone test or to rule out appendicitis.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-02T11:05:18.705546-05:
      DOI: 10.1111/acem.13212
       
 
 
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