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Publisher: John Wiley and Sons   (Total: 1583 journals)

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Showing 1 - 200 of 1583 Journals sorted alphabetically
Abacus     Hybrid Journal   (Followers: 11, SJR: 0.48, h-index: 22)
About Campus     Hybrid Journal   (Followers: 5)
Academic Emergency Medicine     Hybrid Journal   (Followers: 54, SJR: 1.385, h-index: 91)
Accounting & Finance     Hybrid Journal   (Followers: 43, SJR: 0.547, h-index: 30)
ACEP NOW     Free  
Acta Anaesthesiologica Scandinavica     Hybrid Journal   (Followers: 50, SJR: 1.02, h-index: 88)
Acta Archaeologica     Hybrid Journal   (Followers: 135, 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: 54, SJR: 0.794, h-index: 88)
Acta Physiologica     Hybrid Journal   (Followers: 7, 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: 5, SJR: 0.459, h-index: 29)
Acute Medicine & Surgery     Hybrid Journal   (Followers: 2)
Addiction     Hybrid Journal   (Followers: 32, SJR: 2.086, h-index: 143)
Addiction Biology     Hybrid Journal   (Followers: 12, SJR: 2.091, h-index: 57)
Adultspan J.     Hybrid Journal   (SJR: 0.127, h-index: 4)
Advanced Energy Materials     Hybrid Journal   (Followers: 24, SJR: 6.411, h-index: 86)
Advanced Engineering Materials     Hybrid Journal   (Followers: 24, SJR: 0.81, h-index: 81)
Advanced Functional Materials     Hybrid Journal   (Followers: 48, SJR: 5.21, h-index: 203)
Advanced Healthcare Materials     Hybrid Journal   (Followers: 13, SJR: 0.232, h-index: 7)
Advanced Materials     Hybrid Journal   (Followers: 246, 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: 4, SJR: 2.488, h-index: 21)
Advanced Science     Open Access   (Followers: 4)
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: 32, SJR: 0.275, h-index: 17)
African J. of Ecology     Hybrid Journal   (Followers: 14, SJR: 0.477, h-index: 39)
Aggressive Behavior     Hybrid Journal   (Followers: 15, SJR: 1.391, h-index: 66)
Aging Cell     Open Access   (Followers: 9, 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: 44, SJR: 1.099, h-index: 51)
AIChE J.     Hybrid Journal   (Followers: 28, SJR: 1.122, h-index: 120)
Alcoholism and Drug Abuse Weekly     Hybrid Journal   (Followers: 7)
Alcoholism Clinical and Experimental Research     Hybrid Journal   (Followers: 7, SJR: 1.416, h-index: 125)
Alimentary Pharmacology & Therapeutics     Hybrid Journal   (Followers: 33, SJR: 2.833, h-index: 138)
Alimentary Pharmacology & Therapeutics Symposium Series     Hybrid Journal   (Followers: 3)
Allergy     Hybrid Journal   (Followers: 49, SJR: 3.048, h-index: 129)
Alternatives to the High Cost of Litigation     Hybrid Journal   (Followers: 3)
American Anthropologist     Hybrid Journal   (Followers: 127, SJR: 0.951, h-index: 61)
American Business Law J.     Hybrid Journal   (Followers: 24, SJR: 0.205, h-index: 17)
American Ethnologist     Hybrid Journal   (Followers: 90, SJR: 2.325, h-index: 51)
American J. of Economics and Sociology     Hybrid Journal   (Followers: 28, SJR: 0.211, h-index: 26)
American J. of Hematology     Hybrid Journal   (Followers: 30, 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: 15, SJR: 1.115, h-index: 61)
American J. of Medical Genetics Part B: Neuropsychiatric Genetics     Hybrid Journal   (Followers: 3, SJR: 1.771, h-index: 107)
American J. of Medical Genetics Part C: Seminars in Medical Genetics     Partially Free   (Followers: 5, SJR: 2.315, h-index: 79)
American J. of Orthopsychiatry     Hybrid Journal   (Followers: 4, SJR: 0.756, h-index: 69)
American J. of Physical Anthropology     Hybrid Journal   (Followers: 35, SJR: 1.41, h-index: 88)
American J. of Political Science     Hybrid Journal   (Followers: 237, SJR: 5.101, h-index: 114)
American J. of Primatology     Hybrid Journal   (Followers: 14, 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: 15, SJR: 2.792, h-index: 140)
American J. on Addictions     Hybrid Journal   (Followers: 9, SJR: 0.843, h-index: 57)
Anaesthesia     Hybrid Journal   (Followers: 116, SJR: 1.404, h-index: 88)
Analyses of Social Issues and Public Policy     Hybrid Journal   (Followers: 11, SJR: 0.397, h-index: 18)
Analytic Philosophy     Hybrid Journal   (Followers: 15)
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: 153)
Angewandte Chemie Intl. Edition     Hybrid Journal   (Followers: 204, SJR: 6.229, h-index: 397)
Animal Conservation     Hybrid Journal   (Followers: 34, SJR: 1.576, h-index: 62)
Animal Genetics     Hybrid Journal   (Followers: 8, SJR: 0.957, h-index: 67)
Animal Science J.     Hybrid Journal   (Followers: 5, 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: 8, 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: 42, 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: 12)
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: 16, SJR: 0.137, h-index: 3)
Anthropology News     Hybrid Journal   (Followers: 14)
Anthropology of Consciousness     Hybrid Journal   (Followers: 11, SJR: 0.172, h-index: 5)
Anthropology of Work Review     Hybrid Journal   (Followers: 11, SJR: 0.256, h-index: 5)
Anthropology Today     Hybrid Journal   (Followers: 93, SJR: 0.545, h-index: 15)
Antipode     Hybrid Journal   (Followers: 45, SJR: 2.212, h-index: 69)
Anz J. of Surgery     Hybrid Journal   (Followers: 6, 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: 66, SJR: 0.754, h-index: 69)
Applied Organometallic Chemistry     Hybrid Journal   (Followers: 6, SJR: 0.632, h-index: 58)
Applied Psychology     Hybrid Journal   (Followers: 133, 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: 13, SJR: 1.025, h-index: 55)
Aquaculture Research     Hybrid Journal   (Followers: 31, SJR: 0.807, h-index: 60)
Aquatic Conservation Marine and Freshwater Ecosystems     Hybrid Journal   (Followers: 34, 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: 14, SJR: 0.156, h-index: 2)
Architectural Design     Hybrid Journal   (Followers: 24, 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: 205, SJR: 0.153, h-index: 13)
Arthritis & Rheumatology     Hybrid Journal   (Followers: 48, 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: 13)
Asia & the Pacific Policy Studies     Open Access   (Followers: 15)
Asia Pacific J. of Human Resources     Hybrid Journal   (Followers: 319, SJR: 0.494, h-index: 19)
Asia Pacific Viewpoint     Hybrid Journal   (SJR: 0.616, h-index: 26)
Asia-Pacific J. of Chemical Engineering     Hybrid Journal   (Followers: 7, 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: 3, 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: 3, 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: 13, 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: 12, SJR: 1.095, h-index: 66)
Austral Entomology     Hybrid Journal   (Followers: 10, SJR: 0.524, h-index: 28)
Australasian J. of Dermatology     Hybrid Journal   (Followers: 7, 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: 3, SJR: 0.709, h-index: 14)
Australian and New Zealand J. of Family Therapy (ANZJFT)     Hybrid Journal   (Followers: 3, SJR: 0.382, h-index: 12)
Australian and New Zealand J. of Obstetrics and Gynaecology     Hybrid Journal   (Followers: 42, 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: 6, 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: 22, 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: 13, SJR: 0.203, h-index: 14)
Australian J. of Psychology     Hybrid Journal   (Followers: 16, SJR: 0.384, h-index: 30)
Australian J. of Public Administration     Hybrid Journal   (Followers: 382, 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: 64, 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: 9, 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: 3, 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: 8, SJR: 0.297, h-index: 23)
Behavioral Sciences & the Law     Hybrid Journal   (Followers: 22, 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: 14, SJR: 1.172, h-index: 90)
Biological Reviews     Hybrid Journal   (Followers: 2, SJR: 6.469, h-index: 114)
Biologie in Unserer Zeit (Biuz)     Hybrid Journal   (Followers: 44, SJR: 0.12, h-index: 1)
Biology of the Cell     Full-text available via subscription   (Followers: 9, SJR: 1.812, h-index: 69)
Biomedical Chromatography     Hybrid Journal   (Followers: 6, SJR: 0.572, h-index: 49)
Biometrical J.     Hybrid Journal   (Followers: 5, SJR: 0.784, h-index: 44)
Biometrics     Hybrid Journal   (Followers: 37, SJR: 1.906, h-index: 96)
Biopharmaceutics and Drug Disposition     Hybrid Journal   (Followers: 10, SJR: 0.715, h-index: 44)
Biopolymers     Hybrid Journal   (Followers: 18, SJR: 1.199, h-index: 104)
Biotechnology and Applied Biochemistry     Hybrid Journal   (Followers: 45, SJR: 0.415, h-index: 55)
Biotechnology and Bioengineering     Hybrid Journal   (Followers: 135, SJR: 1.633, h-index: 146)
Biotechnology J.     Hybrid Journal   (Followers: 13, SJR: 1.185, h-index: 51)
Biotechnology Progress     Hybrid Journal   (Followers: 39, SJR: 0.736, h-index: 101)
Biotropica     Hybrid Journal   (Followers: 17, SJR: 1.374, h-index: 71)
Bipolar Disorders     Hybrid Journal   (Followers: 10, SJR: 2.592, h-index: 100)
Birth     Hybrid Journal   (Followers: 33, 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)

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Journal Cover Academic Emergency Medicine
  [SJR: 1.385]   [H-I: 91]   [54 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  [1583 journals]
  • Care Bundles in Emergency Medicine
    • Authors: Kathleen Cowling; Robert Dumas
      Abstract: The ability to make sound clinical decisions in a high stress and often chaotic atmosphere lies at the heart of emergency medicine. This can be a daunting task when one considers the sheer volume of pathology covered under the umbrella of emergency medicine.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-27T23:30:22.310998-05:
      DOI: 10.1111/acem.13234
  • 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
  • Impact of Hospital “Best Practice” Mandates on Prescription Opioid
           Dispensing after an Emergency Department Visit
    • Authors: Benjamin C. Sun; Nicoleta Lupulescu-Mann, Christina J. Charlesworth, Hyunjee Kim, Daniel M. Hartung, Richard A. Deyo, K John McConnell
      Abstract: ObjectiveWashington State mandated seven hospital “best practices” in July 2012, several of which may affect ED opioid prescribing and provide a policy template for addressing the opioid prescription epidemic. We tested the hypothesis that the mandates would reduce opioid dispensing after an ED visit. We further assessed for a selective effect in patients with prior risky or chronic opioid use.MethodsWe performed a retrospective, observational analysis of ED visits by Medicaid fee-for service beneficiaries in Washington State, between July 1, 2011 to June 30, 2013. We used an interrupted time series design to control for temporal trends and patient characteristics. The primary outcome was any opioid dispensing within 3 days after an ED visit. The secondary outcome was total morphine milligram equivalents (MMEs) dispensed within 3 days.ResultsWe analyzed 266,614 ED visits. Mandates were associated with a small reduction in opioid dispensing after an ED visit (-1.5%, 95%CI: -2.8% to -0.15%). The mandates were associated with decreased opioid dispensing in 42,496 ED visits by patients with prior risky opioid use behavior (-4.7%, 95%CI: -7.1% to -2.3%) and in 20,238 visits by patients with chronic opioid use (-3.6%, 95%CI: -5.6% to -1.7%). Mandates were not associated with reductions in MMEs per dispense in the overall cohort or in either subgroup.ConclusionsWashington state “best practice” mandates were associated with small but non-selective reductions in opioid prescribing rates. States should focus on alternative policies to further reduce opioid dispensing in subgroups of high risk and chronic users.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-23T06:30:23.149342-05:
      DOI: 10.1111/acem.13230
  • 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
  • In response—ultrasound assisted lumbar puncture on infants in the
           pediatric emergency department
    • Authors: Samuel H. F. Lam
      Abstract: I read with interest the recently published article on ultrasound assisted pediatric lumbar puncture (UALP) by Gorn and colleagues1. As an advocate of point-of-care ultrasound in the pediatric emergency department setting, I am greatly encouraged by the study results. However, I would suggest clarification on several details of the study, some of which could potentially lead to biased outcomes.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-15T04:00:41.801593-05:
      DOI: 10.1111/acem.13228
  • Don't Label Me: A Qualitative Study of Patients’ Perceptions and
           Experiences of Sedation during Behavioral Emergency in the Emergency
    • Authors: Celene Y L Yap; Jonathan C Knott, David C M Kong, Marie Gerdtz, Kay Stewart, David McD Taylor
      Abstract: ObjectivesBehavioral emergencies are commonly seen in emergency departments. Acutely agitated patients can be difficult to manage and sedation may be required to decrease dangerous behavior and to ensure the safety of both the patient and staff. While the experience of staff caring for this population has been reported, patients’ experiences with their overall management remains unknown. We aimed to describe the perceptions and experiences of patients regarding the use of sedation during acute behavioral emergencies.MethodsFace-to-face semi-structured interviews were conducted with adults aged 18 years or older, who had received parenteral sedative medication for the management of a behavioral emergency and were deemed capable to participate. The participants were asked about their experiences of receiving care in the emergency department during the episode and their perceptions of sedation. All interviews were transcribed verbatim and analyzed thematically.ResultsData saturation was reached after 13 interviews. Two broad themes emerged: trusting relationships; and needs or wants following sedation. A trusting relationship is built through (i) confidence in care; (ii) sedation as an appropriate treatment; (iii) insight into own behavior; and (iv) humane treatment. Four subthemes of needs or wants were identified: (i) empathy; (ii) debrief; (iii) addressing concerns; and (iv) follow up.ConclusionsA trusting relationship was identified as crucial to minimize the negative impact of coercive measures used to manage behavioral emergencies. Participants expressed similar needs to patients presenting with medical problems. This study illustrates their needs for compassionate communication, adequate information about the treatment provided, and follow-up care.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-13T08:25:31.309894-05:
      DOI: 10.1111/acem.13218
  • A 0h/1h protocol for safe early discharge of chest pain patients
    • Authors: Arash Mokhtari; Bertil Lindahl, Alexandru Schiopu, Troels Yndigegn, Ardavan Khoshnood, Patrik Gilje, Ulf Ekelund
      Abstract: ObjectivesGuidelines recommend a 0h/1h high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There is however little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0h/1h hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and ECG for ruling out major adverse cardiac events (MACE) within 30 days.MethodsThis prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians’ assessments of the ECG, and 0 and 1h hs-cTnT were collected. 30-day MACE was defined as acute myocardial infarction, unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular-block, cardiac arrest or death of cardiac or unknown cause.ResultsA total of 1020 patients were included in the final analysis. The combination of an adapted TIMI score ≤1, a non-ischemic ECG, and either a 0h hs-cTnT
      PubDate: 2017-05-13T04:04:44.304624-05:
      DOI: 10.1111/acem.13224
  • 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
    • 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
    • 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
  • Overcoming the Tower of Babel in Medical Science by Finding the
           ‘EQUATOR’: Research Reporting Guidelines
    • Authors: Christopher R. Carpenter; Zachary F. Meisel
      Abstract: You are hosting a journal club on chest pain management in the emergency department (ED) for colleagues and trainees in your department. Interested in understanding the history of cardiac biomarkers to evaluate ED patients with chest pain, you search PubMed using the combination of terms “cardiac biomarker”, “chest pain”, and “emergency department”. Your search nets no studies prior to 2002 which you doubt is accurate, so you take the old-fashioned approach and start flipping through the oldest issues of emergency medicine journals at your local medical school library.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T09:10:40.566122-05:
      DOI: 10.1111/acem.13225
  • 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
  • Accuracy of Physical Exam, Ankle-Brachial Index, and Ultrasonography in
           the Diagnosis of Arterial Injury in Patients with Penetrating Extremity
           Trauma: A Systematic Review and Meta-Analysis
    • Authors: Ian S. deSouza; Roshanak Benabbas, Sean McKee, Bardiya Zangbar, Ashika Jain, Lorenzo Paladino, Leon Boudourakis, Richard Sinert
      Abstract: BackgroundPenetrating Extremity Trauma (PET) may result in arterial injury, a rare but limb- and life-threatening surgical emergency. Accurate and timely diagnosis is vital to enable potential intervention and prevent significant morbidity.ObjectivesUsing a systematic review/meta-analysis approach, we determined the utility of Physical Examination (exam), Ankle-Brachial Index (ABI), and Ultrasonography (US) in the diagnosis of arterial injury in ED patients who have sustained PET. We applied a test-treatment threshold model to determine which evaluations may obviate CT Angiography (CTA).MethodsWe searched PUBMED, EMBASE, and SCOPUS from inception to November 2016 for studies of ED patients with PET. We included studies on adult and pediatric subjects presenting to the ED with PET. We defined the reference standard to include CTA, catheter angiography, or surgical exploration. When low-risk patients did not undergo the reference standard, trials must have specified that patients were observed for at least 24 hours. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate bias and applicability of the included studies. We calculated positive and negative Likelihood Ratios (LR+ and LR-) of exam (“hard” signs of vascular injury), US, and ABI. Using established CTA test characteristics (sensitivity 96.2%, specificity 99.2%) and applying Pauker-Kassirer method, we developed a test-treatment threshold model (testing threshold: 0.14%, treatment threshold: 72.9%).ResultsWe included 8 studies (n=2,161, arterial injury prevalence: 15.5%). Studies had variable quality with most at high risk for partial and double verification bias. Some studies investigated multiple index tests: Exam (hard signs) was investigated in 3 studies (n=1,170), ABI in 5 studies (n=1,040), and US in 4 studies (n=173). Due to high heterogeneity (I2>75%) of the results, we could not calculate LR+ or LR- for hard signs or LR+ for ABI. The weighted prevalence of arterial injury for ABI was 14.3% and LR- was 0.59 (95% CI 0.48-0.71) resulting in a post-test probability of 9% of arterial injury. Ultrasonography (US) had weighted prevalence of 18.9%, LR+ 35.4 (95% CI 8.3-151), and LR- 0.24 (95% CI 0.08-0.72); post-test probabilities for arterial injury were 89% and 5% after a positive or negative US, respectively. The post-test probability of arterial injury with positive US (89%) exceeded the CTA treatment-threshold (72.9%). The post-test probabilities of arterial injury with negative US (5%) and normal ABI (9%) exceeded the CTA testing-threshold (0.14%). Normal exam (no hard or soft signs) with normal ABI had a combined LR- of 0.01 (95% CI 0.0-0.10) resulting in an arterial injury post-test probability of 0%.ConclusionsIn PET patients, a positive US may obviate CTA. In patients with a normal exam (no hard or soft signs) and a normal ABI, arterial injury can be ruled out. However, a normal ABI or negative US cannot independently exclude arterial injury. Due to large study heterogeneity, we cannot make recommendations when hard signs are present or absent or when ABI is abnormal. In these situations, the physician should use clinical judgment to determine the need for further observation, CTA or catheter angiography, or surgical exploration.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T08:59:12.939952-05:
      DOI: 10.1111/acem.13227
  • 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
  • Bystander CPR is Clustered and Associated with Neighborhood Socioeconomic
           Characteristics: A Geospatial Analysis of Kent County, Michigan
    • Authors: Amy Uber; Richard C. Sadler, Todd Chassee, Joshua C. Reynolds
      Abstract: ObjectivesGeographic clustering of bystander CPR is associated with demographic and socioeconomic features of the community where out-of-hospital cardiac arrest (OHCA) occurred, though this association remains largely untested in rural areas. With a significant rural component and relative racial homogeneity, Kent County, Michigan provides a unique setting to externally validate or identify new community features associated with bystander CPR. Using a large, countywide dataset, we tested for geographic clustering of bystander CPR, and its associations with community socioeconomic features.MethodsSecondary analysis of adult OHCA subjects (2010-2015) in the Cardiac Arrest Registry to Enhance Survival (CARES) dataset for Kent County, MI. After linking geocoded OHCA cases to US census data, we used Moran's I test to assess for spatial autocorrelation of population-weighted cardiac arrest rate by census block group. Getis-Ord Gi statistic assessed for spatial clustering of bystander CPR, and mixed-effects hierarchical logistic regression estimated adjusted associations between community features and bystander CPR.ResultsOf 1,592 subjects, 1,465 met inclusion criteria. Geospatial analysis revealed significant clustering of OHCA in more populated/urban areas. Conversely, bystander CPR was less likely in these areas (99% confidence) and more likely in suburban and rural areas (99% confidence). Adjusting for clinical, demographic, and socioeconomic covariates, bystander CPR was associated with public location (OR 1.19; 95%CI 1.03-1.39), initially shockable rhythms (OR 1.48; 95%CI 1.12-1.96), and in urban neighborhoods (OR 0.54; 95%CI 0.38-0.77).ConclusionsOHCA and bystander CPR are geographically clustered in Kent County, MI, but bystander CPR is inversely associated with urban designation. These results offer new insight into bystander CPR patterns in mixed urban and rural regions, and afford the opportunity for targeted community CPR education in areas of low bystander CPR prevalence.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T08:58:29.267829-05:
      DOI: 10.1111/acem.13222
  • 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)
    • 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
  • A Systematic Review of the Impact of Physician Implicit Racial Bias on
           Clinical Decision Making
    • Authors: Erin Dehon; Nicole Weiss, Jonathan Jones, Whitney Faulconer, Elizabeth Hinton, Sarah Sterling
      Abstract: ObjectivesDisparities in diagnosis and treatment of racial minorities exist in the emergency department (ED). A better understanding of how physician implicit (unconscious) bias contributes to these disparities may help identify ways to eliminate such racial disparities. The objective of this systematic review was to examine and summarize the evidence on the association between physician implicit racial bias and clinical decision making.MethodsBased on PRISMA guidelines, a structured electronic literature search of PubMed, CINAHL, Scopus, and PsycINFO databases was conducted. Eligible studies were those that: 1) Included physicians; 2) Included the Implicit Association Test as a measure of implicit bias; 3) Included an assessment of physician clinical decision making; and 4) Were published in peer reviewed journals between 1998 and 2016. Articles were reviewed for inclusion by two independent investigators. Data extraction was performed by one investigator and checked for accuracy by a second investigator. Two investigators independently scored the quality of articles using a modified version of the Downs and Black Checklist.ResultsOf the 1,154 unique articles identified in the initial search, 9 studies (n = 1,910) met inclusion criteria. Three of the 9 studies involved emergency providers including residents, attending physicians, and advanced practice providers. The majority of studies used clinical vignettes to examine clinical decision making. Studies that included EM providers had vignettes relating to treatment of acute myocardial infarction, pain, and pediatric asthma. An implicit preference favoring white people was common across providers, regardless of specialty. Two of the nine studies found evidence of a relationship between implicit bias and clinical decision making; one of these studies included EM providers. This one study found that EM and internal medicine residents who demonstrated an implicit preference for white individuals were more likely to treat white patients and not black patients with thrombolysis for myocardial infarction. Evidence from the two studies reporting a relationship between physician implicit racial bias and decision making was low in quality.ConclusionsThe current literature indicates that although many physicians, regardless of specialty, demonstrate an implicit preference for white people, this bias does not appear to impact their clinical decision making. Further studies on the impact of implicit racial bias on racial disparities in ED treatment are needed.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-04T11:01:04.537457-05:
      DOI: 10.1111/acem.13214
  • Association between Maternal Comorbidities and Emergency Department Use
           among a National Sample of Commercially-insured Pregnant Women
    • Authors: Shayna D. Cunningham; Urania Magriples, Jordan L. Thomas, Katy B. Kozhimannil, Carolina Herrera, Eric Barrette, Fatma M. Shebl, Jeannette R. Ickovics
      Abstract: ObjectivesEvidence suggests that, despite routine engagement with the health system, pregnant women commonly seek emergency care. The objectives of this study were to examine the association between maternal comorbidities and emergency department use among a national sample of commercially-insured pregnant women.MethodsWe conducted a retrospective cohort study using multi-payer medical claims data maintained by the Health Care Cost Institute for women ages 18-44 years with a live singleton birth in 2011 (N=157,786). The association between common maternal comorbidities (e.g., hypertension, gestational diabetes) and emergency department use during pregnancy was examined using multilevel models, while controlling for age, region, and residential ZIP code.ResultsTwenty percent (n=31,413) of pregnant women had ≥1 emergency department visit, (mean=1.52, SD=1.15). Among those who used the emergency department, 29% had ≥2 visits, and 11% had ≥3 visits. Emergency care seekers were significantly more likely to have ≥1 comorbid condition compared to those with no emergency care: 30% versus 21%, respectively (p
      PubDate: 2017-05-04T10:15:59.205385-05:
      DOI: 10.1111/acem.13215
  • Practice Variation and Effects of E-Mail Only Performance Feedback on
           Resource Use in the Emergency Department
    • Authors: Melissa M. Tavarez; Brandon Ayers, Jong H. Jeong, Carmen M. Coombs, Ann Thompson, Robert Hickey
      Abstract: ObjectivesHigher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of electronic mail (e-mail) only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea. Design: We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years (FY). Setting: Single, tertiary-care pediatric emergency department. Participants: We collected admission and ordering practices data on 19 physicians during baseline, intervention and post-intervention periods. Intervention: We provided physicians with quarterly email-based performance reports during the intervention phase. Main Outcomes Measured: We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders and radiology orders.ResultsThere was wide (2-3 fold) practice variation among physicians. Admission rates ranged from 15-30%, laboratory orders from 19-43%, pharmacy orders from 29-57%, and radiology orders from 11-30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between pre-intervention, intervention or post-intervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the pre-intervention and post-intervention periods.ConclusionsPerformance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-04T02:20:25.625012-05:
      DOI: 10.1111/acem.13211
  • 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
      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
  • Keeping up with the kids: Diffusion of Innovation in Pediatric Emergency
           Medicine Among Emergency Physicians
    • Authors: Robert L. Cloutier; Rakesh D. Mistry, Stephen Cico, Chris Merritt, Samuel H. F. Lam, Marc Auerbach, L. Melissa Skaugset, Jean Klig, Meg Wolff, Myto Duong, Jennifer Walthall
      Abstract: With 30,000,000 emergency department (ED) visits annually, children account for nearly one fourth of all ED visits in the United States. Despite these statistics, EDs across the country remain underprepared to care for pediatric patients [1, 2]. Based on published data, only 45% of EDs report having a pediatric quality improvement plan in place, one third of hospitals do not weigh children in kilograms, less than half have disaster plans in place for pediatric patients and more than 15% are missing critical pediatric emergency equipment [1]. These deficiencies may be due in part to the fact that 80% of children are cared for in non-children's hospital EDs of which 39% nationally see fewer than 5 children per day and 69% see fewer than 14 children per day [1]. Pediatric readiness has improved over the last ten years since the 2006 Institute of Medicine (IOM) call for improved pediatric emergency care, however, it is clear that there are still improvements to be made [3]. This paper will address current challenges, novel opportunities for educational innovations, and next steps in the maturity of emergency care for children in all practice settings.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-28T13:31:41.956971-05:
      DOI: 10.1111/acem.13185
  • Emergency Physicians Are Able to Detect Right Ventricular Dilation with
           Good Agreement Compared to Cardiology
    • Authors: Matt A. Rutz; Julie M. Clary, Jeffrey A. Kline, Frances M. Russell
      Abstract: ObjectiveFocused cardiac ultrasound (FOCUS) is a useful tool in evaluating patients presenting to the emergency department (ED) with acute dyspnea. Prior work has shown that right ventricular (RV) dilation is associated with repeat hospitalizations and shorter life expectancy. Traditionally, RV assessment has been evaluated by cardiologist-interpreted comprehensive echocardiography. The primary goal of this study was to determine the interrater reliability between emergency physicians (EPs) and a cardiologist for determining RV dilation on FOCUS performed on ED patients with acute dyspnea.MethodsProspective, observational study at two urban academic EDs; patients were enrolled if they had acute dyspnea and a computed tomographic pulmonary angiogram without acute disease. All patients had an EP-performed FOCUS to assess for RV dilation. RV dilation was defined as an RV to left ventricular ratio greater than 1. FOCUS interpretations were compared to a blinded cardiologist FOCUS interpretation using agreement and kappa statistics.ResultsOf 84 FOCUS examinations performed on 83 patients, 17% had RV dilation. Agreement and kappa, for EP-performed FOCUS for RV dilation were 89% (95% confidence interval [CI] 80-95%) and 0.68 (95% CI 0.48-0.88), respectively.ConclusionsEP sonographers are able to detect RV dilation with good agreement when compared to cardiology. These results support the wider use of EP-performed FOCUS to evaluate for RV dilation in dyspneic ED patients.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-28T09:18:30.887542-05:
      DOI: 10.1111/acem.13210
  • A novel approach to study medical decision-making in the clinical setting:
           The “own-point-of-view” perspective
    • Authors: Thierry Pelaccia; Jacques Tardif, Emmanuel Triby, Bernard Charlin
      Abstract: BackgroundMaking diagnostic and therapeutic decisions is a critical activity among physicians. It relies on the ability of physicians to use cognitive processes and specific knowledge in the context of a clinical reasoning. This ability is a core competency in physicians, especially in the field of emergency medicine where the rate of diagnostic errors is high. Studies that explore medical decision-making in an authentic setting are increasing significantly. They are based on the use of qualitative methods which are applied at two separate times: 1) a video recording of the subject's actual activity in an authentic setting and 2) an interview with the subject, supported by the video recording. Traditionally, activity is recorded from an “external perspective”, i.e. a camera is positioned in the room in which the consultation takes place. This approach has many limits, both technical and with respect to the validity of the data collected.ObjectivesThe article aims at 1) describing how decision-making is currently being studied, especially from a qualitative standpoint, and the reasons why new methods are needed, and 2) reporting how we used an original, innovative approach to study decision-making in the field of emergency medicine and findings from these studies to guide further the use of this method. The method consists in recording the subject's activity from his own-point-of-view, by fixing a microcamera on his temple or the branch of his glasses. An interview is then held on the basis of this recording, so that the subject being interviewed can relive the situation, in order to facilitate the explanation of his reasoning with respect to his decisions and actions.Results and conclusionsWe describe how this method has been used successfully in investigating medical decision-making in emergency medicine. We provide details on how to use it optimally, taking into account the constraints associated with the practice of emergency medicine, and the benefits in the study of clinical reasoning. The ‘own-point-of-view’ video technique is a promising method to study clinical decision-making in emergency medicine. It is a powerful tool to stimulate recall and help physicians make their reasoning explicit, thanks to a greater psychological immersion.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-27T12:03:35.173149-05:
      DOI: 10.1111/acem.13209
  • Koenig and Schultz's Disaster Medicine: Comprehensive Principles and
           Practices, 2nd Edition
    • Authors: Eric C. Silverman; Mary P. Mercer
      Abstract: Disaster medicine has emerged as a critical discipline within emergency medicine in recent years. Mass casualty incidents and large{\hyphen}scale environmental events have shed light on the need for more formalized disaster medicine curricula and structured response plans. Koenig and Schultz’ Disaster Medicine: Comprehensive Principles and Practices, 2nd edition lives up to its title yet again and delivers in{\hyphen}depth, evidence{\hyphen}based recommendations for healthcare providers, educators, and administrators working in disaster management.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-27T12:03:19.890319-05:
      DOI: 10.1111/acem.13208
  • Individual and Neighborhood Characteristics of Children Seeking Emergency
           Department Care for Firearm Injuries Within the PECARN Network
    • Authors: Patrick M. Carter; Lawrence J. Cook, Michelle L. Macy, Mark R. Zonfrillo, Rachel M. Stanley, James M. Chamberlain, Joel A. Fein, Elizabeth R. Alpern, Rebecca Cunningham,
      Abstract: ObjectiveTo describe the characteristics of children seeking emergency care for firearm injuries within the PECARN network, and assess the influence of both individual and neighborhood factors on firearm-related injury risk.MethodsThis was a retrospective, multicenter cross-sectional analysis of children (
      PubDate: 2017-04-19T17:58:48.72929-05:0
      DOI: 10.1111/acem.13200
  • Use of online health information by geriatric and adult ED patients:
           access, understanding and trust
    • Authors: Grant Scott; Danielle M McCarthy, Amer Z Aldeen, Alyssa Czerniak, D.Mark Courtney, Scott M. Dresden
      Abstract: ObjectiveThe objective was to characterize geriatric patients’ use of online health information (OHI) relative to younger adults and assess their comfort with OHI compared to health information (HI) from their physician.MethodsThis was a prospective cross-sectional survey study of adult ED patients. The survey assessed patients’ self-reported use of OHI in the past year and immediately prior to ED visit and analyzed differences across 4 age groups: 18-39, 40-64, 65-74, and 75+. Patients’ ability to access, understand, and trust OHI was assessed using a 7 point Likert scale and compared to parallel questions regarding HI obtained from their doctor. Patient use of OHI was compared across age groups. Comfort with OHI and HI obtained from a doctor was compared across age groups using the Kruskall Wallis test. Comparisons between sources of health information were made within age groups using the Wilcoxan signed rank test.ResultsOf 889 patients who were approached for study inclusion 723 patients (81.3%) completed the survey. The majority of patients had used OHI in the last year in all age groups, but older patients were less likely to have used OHI: age 18-39: 90.3%, 40-64: 85.3%, 65-74: 76.4% and 75+: 50.7%, p
      PubDate: 2017-04-19T17:58:17.490132-05:
      DOI: 10.1111/acem.13207
  • Correspondence - Response to Letter to the Editor — Ultrasound Assisted
           Lumbar Puncture on Infants in the Pediatric Emergency Department
    • Authors: Michael Gorn
      Abstract: We would like to thank our reader for his/her interest in our work and continuing support of point-of-care ultrasound in pediatric emergency medicine. Our study was conducted at a large academic emergency department with pediatrics and emergency medicine residents, nurse practitioners who function at or above the level of a senior resident (PGY-3 and 4), and pediatric emergency fellows who function as attending physicians. As a routine, all initial lumbar puncture (LP) attempts are made by learners.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-17T13:35:25.580708-05:
      DOI: 10.1111/acem.13198
  • Comparing Emergency Department Patients to Inpatients Receiving a
           Pulmonary Embolism Response Team (PERT) Activation
    • Authors: Erin K. Deadmon; Nicholas J. Giordano, Kenneth Rosenfield, Rachel Rosovsky, Blair Alden Parry, Rasha Fahad Al-Bawardy, Yuchiao Chang, Christopher Kabrhel
      Abstract: ObjectivesThe development of Pulmonary Embolism Response Teams (PERTs) has been widely adopted nationally with the goal of providing multidisciplinary care to patients with high-risk PE. Most PERT activations originate from the Emergency Department (ED), while others are from the intensive care unit (ICU) or inpatient floors. It is unclear if ED PERT activations differ from non-ED PERT activation in terms of presentation, management, and outcome.MethodsWe enrolled a consecutive cohort of patients for whom PERT was activated at an urban academic medical center. We compared three groups of PERT activations based on whether the activation originated from the ED, ICU or a non-ICU inpatient floor. We compared these groups in terms of the proportion of PERT activations that occurred during day, evening or weekend hours, and the proportion of confirmed PE. We also compared PE severity, treatment and outcomes across locations. We tested differences using chi-square tests, with a two-tailed p-value
      PubDate: 2017-04-17T13:35:24.627653-05:
      DOI: 10.1111/acem.13199
  • PREDICTing mortality in the emergency department: external validation and
           derivation of a clinical prediction tool
    • Authors: Rajat N. Moman; Caitlin Loprinzi Brauer, Katherine M. Kelsey, Rachel D. Havyer, Christine M. Lohse, M. Fernanda Bellolio
      Abstract: Backgroundhe Choosing Wisely campaign has called for better engagement of palliative and hospice care services for patients in the emergency department (ED). PREDICT is a clinical prediction tool that was derived in an Australian ED cohort. It assesses a patient's risk of mortality at one year to select those who would benefit from advanced care planning. Such goals of care discussion can improve patients’ ability to communicate what they want out of their healthcare and, in cases of end-of-life, potentially reduce the number of futile interventions. Using a cut-off of 13 points, PREDICT had a reported 95.3% specificity, 53.9% sensitivity for one year mortality. We externally validated PREDICT and derived a simpler modified PREDICT tool in order to systematically identify high-risk patients eligible for goals of care discussions and palliative care consultation in the ED.MethodsThis was an observational cohort study of a random sample of 927 patients aged 55+ seen in the ED in 2014. We identified advance healthcare directives (AHD) on file. We summarized diagnostic accuracy of the clinical tool to predict one year mortality using sensitivity, specificity, and area under the curve (AUC). We refined PREDICT using multivariable modeling. We followed reporting guidelines including STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) for cohort studies and Standards for Reporting of Diagnostic Accuracy (STARD).ResultsA total of 927 patients were included, 55.0% were male, 63 (7.0%) were nursing home residents, 389 (42.0%) patients had an AHD in their medical record at the time of ED visit, and 245 (26.4%) were deceased at one year. Of the 780 patients with PREDICT scores
      PubDate: 2017-04-12T02:05:29.002365-05:
      DOI: 10.1111/acem.13197
  • 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
  • Embedded Clinical Decision Support in Electronic Health Record Decreases
           Use of High Cost Imaging in the Emergency Department: EmbED study
    • Authors: Kelly Bookman; David West, Adit Ginde, Jennifer Wiler, Robert McIntyre, Andrew Hammes, Nichole Carlson, David Steinbruner, Matthew Solley, Richard Zane
      Abstract: ObjectiveEvaluate the impact of evidence-based clinical decision support tools integrated directly into provider workflow in the electronic health record on utilization of CT brain, c-spine and pulmonary embolism (PE).MethodsValidated, well accepted scoring tools for head injury, c-spine injury and pulmonary embolism were embedded into the electronic health record in a manner minimally disruptive to provider workflow. This was a longitudinal, before/after study in 5 emergency departments in a healthcare system with a common electronic health record. Attending ED physicians practicing during the entire study period were included. The main outcome measure was proportion of CTs ordered by provider (total number of CT scans of a given type divided by total patients seen by that provider) in aggregate in the pre- and post-intervention period.ResultsThere were 235,858 total patient visits analyzed in this study with an absolute decrease of 6106 CT scan ordering for the three studies. Across all sites, there was greater than 6% decrease in utilization of CT brain and CT c-spine [(-10%, 95% CI (-13%, -7%); p < 0.001); (-6%, 95% CI (-11%, -1%); p = 0.03) respectively]. The use of CT PE also decreased but was not significant (-2%, 95%CI (-9%, +5%); p = 0.42). For all CT types, high utilizers in the pre-period decreased usage over 14% in the post-period with CT brain (-18%, 95% CI (-22%, -15%), p < 0.001), CT c-spine (-14%, 95% CI (-20%, -8%), p = 0.001) and CT PE (-23%, 95% CI (-31%, -14%), p < 0.001). For all 3 studies, the average utilizers did not change their usage practices. For CT brain, the low utilizers also did not increase usage but for CT c-spine and CT PE usage was increased [(+29%, 95% CI (10%, 52%) p = 0.003); (+46%, 95% CI (26%, 70%), p < 0.001) respectively].ConclusionEmbedded clinical decision support is associated with decreased overall utilization of high cost imaging, especially among higher utilizers. It also affected low utilizers, increasing their usage consistent with improved adherence to guidelines, but this effect did not offset the overall decreased utilization for CT brain or CT c-spine. Thus, integrating CDS into the provider workflow promotes usage of validated tools across providers, which can standardize the delivery of care and improve compliance with evidence-based guidelines.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-09T05:10:26.667242-05:
      DOI: 10.1111/acem.13195
  • Hot off the Press: Prospective and Explicit Clinical Validation of the
           Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative
    • Authors: Corey Heitz; Justin Morgenstern, William K. Milne
      Abstract: This prospective cohort study included patients >50 years old with dyspnea of 1, the OHFRS would increase sensitivity from 71.8% to 91.8% for SAEs, but also increase admission rates. A threshold of >2 had a similar sensitivity, but decreased admissions (57.2% vs 48.3%.) Addition of NT-proBNP levels did not substantially change the results.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-04T12:15:52.577205-05:
      DOI: 10.1111/acem.13192
  • Emergency Department Vital Signs and Outcomes after Discharge
    • Authors: Gelareh Z. Gabayan; Michael K. Gould, Robert E. Weiss, Stephen F Derose, Vicki Y. Chiu, Catherine A. Sarkisian
      Abstract: ObjectiveVital signs are critical markers of illness severity in the Emergency Department (ED). Providers need to understand the abnormal vital signs in older adults that are problematic. We hypothesized that in patients age > 65 years discharged from the ED, there are abnormal vital signs that are associated with an admission to an inpatient bed within 7 days of discharge.MethodsWe conducted a retrospective cohort study using data from a regional integrated health system of members age > 65 years during the years 2009-2010. We used univariate contingency tables to assess the relationship between hospital admission within 7 days of discharge and vital sign (including systolic blood pressure, heart rate, body temperature, and pulse oximetry (Sp02) values measured closest to discharge) using standard thresholds for abnormal and thresholds derived from the study data..ResultsOf 104,025 ED discharges, 4,638 (4.5%) were followed by inpatient admission within 7-days. Vital signs had a greater odds of admission beyond a single cut-off. The vital signs with at least twice the odds of admission were systolic blood pressure < 97 mmHg (OR 2.02, 95% CI 1.57-2.60), heart rate > 101 bpm (OR 2.00 95% CI 1.75-2.29), body temperature >99.2 degrees Fahrenheit (OR 2.14, 95% CI 1.90-2.41), and pulse oximetry < 92 Sp02 (OR 2.04, 95% CI 1.55-2.68). Patients with two vital sign abnormalities per the analysis had the highest odds of admission. A majority of patients discharged with abnormal vital signs per the analysis were not admitted within 7 days of ED discharge.ConclusionWhile we found a majority of patients discharged with abnormal vital signs as defined by the analysis, not to be admitted after discharge, we identified vital signs associated with at least twice the odds of admission.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-04T08:05:42.7132-05:00
      DOI: 10.1111/acem.13194
  • Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic
           Review and Meta-analysis
    • Authors: P. Brian Savino; Scott Reichelderfer, Mary P. Mercer, Ralph Wang, Karl A. Sporer
      Abstract: ObjectivesThe use of video laryngoscopy (VL) for intubation has gained recent popularity. In the prehospital setting, it is unclear if VL increases intubation success rates compared to direct laryngoscopy (DL). We sought to conduct a systematic review and meta-analysis of studies comparing VL to DL in the prehospital setting to determine whether the use of VL increases overall and first-pass endotracheal intubation success rates compared to DL.MethodsA systematic search was performed of the Pubmed, Embase, and SCOPUS databases through May 2016 to include studies comparing overall and first-pass success for VL vs. DL in patients requiring intubation in the prehospital setting. Data were abstracted by two reviewers. A meta-analysis was performed using a random effects model.ResultsOf a potential 472 articles, eight eligible studies were included. Considerable heterogeneity (I2 > 90%) precluded reporting an overall pooled estimate across all studies. When stratified by provider type, the pooled estimate for overall intubation success using VL vs. DL was RR = 0.05 (95% CI 0.01, 0.18) in studies of physicians and RR = 2.28 (95% CI 1.00, 5.20) in non-physicians. For first-pass intubation success the pooled RR estimate for using VL vs. DL was 0.32 (95% CI 0.23, 0.44) and 1.83 (95% CI 1.18, 2.84) among studies using physicians and non-physicians, respectively. There was moderate to significant heterogeneity between studies when stratified by provider.ConclusionsAmong physician intubators with significant DL experience, VL does not increase overall or first-pass success rates and may lead to worsening performance. However, among non-physician intubators with less experience with DL, VL may provide benefit in the prehospital setting.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-01T01:55:46.139124-05:
      DOI: 10.1111/acem.13193
  • D-Dimer Interval Likelihood Ratios for Pulmonary Embolism
    • Authors: Michael A. Kohn; Frederikus A. Klok, Nick Es
      Abstract: ObjectiveTo estimate D-Dimer interval likelihood ratios (iLRs) for diagnosing pulmonary embolism (PE).MethodsThe authors used pooled patient-level data from five PE diagnostic management studies to estimate iLRs for the eight D-Dimer intervals with boundaries 250, 500, 750, 1000, 1500, 2500, and 5000 ng/mL. Logistic regression was used to fit the data so that an interval increase corresponds to increasing the likelihood ratio by a constant factor.ResultsThe iLR for the D-Dimer interval 1000-1499 ng/mL was essentially 1.0 (0.98 with 95% CI 0.82-1.18). In the logistic regression model, the constant between-interval factor was 2.0 (95% CI 1.9 to 2.1). Using these iLR estimates, if the pre-D-Dimer probability of PE is 15%, only a D-Dimer less than 500 ng/mL will result in a post-test probability below 3%; if the pre-test probability is 5%, the threshold for a “negative” D-Dimer is 1000 ng/mL.ConclusionsA decision strategy based on these approximate iLRs agrees with several published strategies.This article is protected by copyright. All rights reserved.
      PubDate: 2017-04-01T01:55:33.257576-05:
      DOI: 10.1111/acem.13191
  • Intravenous versus Non-Intravenous Benzodiazepines for the Abortion of
           Seizures: A Systematic Review and Meta-analysis of Randomized Controlled
    • Authors: Abdussalam Alshehri; Ahmad Abulaban, Rakan Bokhari, Suleiman Kojan, Majid Alsalamah, Mazen Ferwana, Mohammad Hassan Murad
      Abstract: BackgroundThe acquisition of intravenous access in the actively convulsing patient is difficult. This often delays the administration of the intravenous benzodiazepine necessary for seizure abortion. Delays in seizure abortion are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes and increased morbidity.ObjectiveTo assess whether the delay imposed by IV access acquisition is justified by improved outcomes. We compared IV versus non-IV benzodiazepine efficacy in the real world with regards to failure rates (primary outcome), interval to seizure control and observed complications (secondary outcomes).MethodsA systematic review using Medline, Embase and the Cochrane Library. All studies published or in press from the inception of the respective database to July 2016 were included. Only randomized and quasi-randomized controlled trials directly comparing an intra-venous to a non-intravenous (buccal, rectal, intranasal or intramuscular) benzodiazepine were included.ResultsOur search strategy retrieved 2604 citations for review. Total of 11 studies were finally included in qualitative synthesis and 10 in quantitative analysis. Only one was of high quality. For treatment failure, non-IV BDZ was superior to IV BDZ (Odd ratio [OR] = 0.72; 95% confidence interval [CI] = 0.56 to 0.92). However, no significant difference between the two treatments in pediatric subgroup (OR = 1.16; 95% CI = 0.74 to 1.81).Non-IV BDZ was administered faster than IV BDZ and therefore controlled seizures faster (mean difference = 3.41 minutes; 95% CI = 1.69 to 5.13 minutes) despite a longer interval between drug administration and seizure cessation (mean difference = 0.74 minutes; 95% CI = 0.52-0.95 minutes. Respiratory complications requiring intervention were similar between non-IV BDZ and IV BDZ, regardless of administration route (Risk Difference [RD] =0.00; 95% CI = -0.02 to 0.01).ConclusionsNon-IV BDZ, compared to IV BDZ, abort seizures faster and have a superior efficacy and side effect profile. Higher quality studies and further evaluation in different age groups are warranted.This article is protected by copyright. All rights reserved.
      PubDate: 2017-03-25T02:55:28.845256-05:
      DOI: 10.1111/acem.13190
  • Career Development Awards in Emergency Medicine: Resources and Challenges
    • Authors: Bryn E. Mumma; Anna Marie Chang, Bory Kea, Megan L. Ranney,
      Abstract: ObjectivesIn the United States, emergency medicine researchers hold proportionately fewer federal career development awards than researchers in other specialties. Others hypothesize this deficit may partly be attributed to lack of mentors, departmental resources, and qualified applicants. Our objectives were to examine the association between departmental and institutional resources and career development awards and to describe the barriers to conducting research and obtaining grants in emergency medicine.MethodsWe conducted an online, cross-sectional survey study of Vice Chairs for Research and Research Directors at academic emergency departments in the United States in January-February 2016. Participants provided quantitative information regarding their department's demographics, available research resources, number of funded independent investigators, and number of career development awards. They were also asked about the perceived adequacy of departmental and institutional resources and perceived barriers to research and grant success. Data were analyzed using descriptive statistics and multivariable linear regression, as appropriate.ResultsOf 178 eligible participants, 103 (58%) completed the survey. Most departments reported some infrastructure for research and grant submission, including research coordinator(s) (n=75/99; 76%, 95%CI 66-84%), research associates (69/99; 70%, 95%CI 60-79%), and administrative/secretarial research support (79/101; 78%, 95%CI 69-86%). The majority of departments (56/103; 49%, 95%CI 44-64%) had no R01-funded researchers, and only 15 (15%, 95%CI 8-23%) had three or more R01-funded researchers. The most frequently reported challenge to junior faculty applying for grants was low motivation for applying (62/103; 60%, 95%CI 50-70%), followed closely by insufficient mentorship (50/103; 49%, 95%CI 39-59%) and discouragement from low funding rates (50/103; 49%, 95%CI 39-59%). In the multivariable model, only the number of departmental R-level funded researchers was associated with the number of departmental career development awards (coefficient 0.75 95%CI 0.39, 1.11; R2=0.57).ConclusionsWhile more multiple departmental and institutional resources correlated with a greater number of funded career development awards, the single greatest predictor was the number of R-level funded researchers in the department. Low motivation and insufficient mentorship were the most frequently reported barriers to junior faculty applying for career development awards. Further studies are needed to describe junior faculty perspectives on these issues and to explore strategies for overcoming these barriers.This article is protected by copyright. All rights reserved.
      PubDate: 2017-03-25T01:25:48.473873-05:
      DOI: 10.1111/acem.13189
  • Sports Medicine for the Emergency Physician: A Practical Handbook. Edited
           by Anna L. Waterbrook, MD, FACEP, CAQ-SM. New York: Cambridge University
           Press, 2016; 427 + ix pp; $89.99 (softcover).
    • Authors: Michael D. Burg
      PubDate: 2017-03-22T05:57:02.915386-05:
      DOI: 10.1111/acem.13176
  • 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
  • Telephone Call Follow-up: A Missed Educational Opportunity
    • Authors: Justin N. Hall
      Abstract: He was a previously healthy middle-aged male who recently experienced his first emergency department visit, one he recounted may be his last. As I listened attentively at the end of the phone line, I cringed as he described in vivid detail his recent experience. He presented with sudden-onset back pain after a lifting injury at work. He asked to remain in a stretcher as his pain was less in the supine position.3This article is protected by copyright. All rights reserved.
      PubDate: 2017-03-10T17:50:30.901692-05:
      DOI: 10.1111/acem.13187
  • Cost-effectiveness analysis appraisal and application: an emergency
           medicine perspective
    • Authors: Michael D. April; Brian P. Murray
      Abstract: Cost-effectiveness is an important goal for emergency care delivery. The many diagnostic, treatment, and disposition decisions made in the emergency department (ED) have a significant impact upon healthcare resource utilization. Cost-effectiveness analysis (CEA) is an analytic tool to optimize these resource allocation decisions through the systematic comparison of costs and effects of alternative healthcare decisions. Yet few emergency medicine leaders and policy-makers have any formal training in CEA methodology. This paper provides an introduction to the interpretation and use of CEA with a focus on application to emergency medicine problems and settings. It applies a previously-published CEA to the hypothetical case of a patient presenting to the ED with chest pain who requires risk stratification. This paper uses a widely-cited checklist to appraise the CEA. This checklist serves as a vehicle for presenting basic CEA terminology and concepts. General topics of focus include measurement of costs and outcomes, incremental analysis, and sensitivity analysis. Integrated throughout the paper are recommendations for good CEA practice with emphasis on the guidelines published by the United States Panel on Cost-Effectiveness in Health and Medicine. Unique challenges for emergency medicine CEAs discussed include the projection of long-term outcomes from emergent interventions, costing ED services, and applying study results to diverse patient populations across various ED settings. The discussion also includes an overview of the limitations inherent in applying CEA results to clinical practice to include the lack of incorporation of non-cost considerations in CEA (e.g., ethics). After reading this article, emergency medicine leaders and researchers will have an enhanced understanding of the basics of CEA critical appraisal and application. The paper concludes with an overview of economic evaluation resources for readers interested in conducting ED-based economic evaluation studies.This article is protected by copyright. All rights reserved.
      PubDate: 2017-03-10T17:50:30.14067-05:0
      DOI: 10.1111/acem.13186
  • Acute Coronary Syndrome Screening and Diagnostic Practice Variation
    • Authors: Maame Yaa A. B Maya Yiadom; Xulei Liu, Conor M. McWade, Dandan Liu, Alan B. Storrow,
      Abstract: BackgroundIn the absence of the existing acute coronary syndrome guidelines directing the clinical practice implementation of ED screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice.MethodsThis is a cross-sectional clinical practice epidemiology study with the emergency department (ED) as the unit of analysis characterizing variability in the acute coronary syndrome (ACS) evaluation across 62 diverse EDs. We explored 3 domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early ECG to diagnose STEMI, 2) non-uniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of NSTEMI, and 3) variation in the use of non-invasive testing (NIVT) to identify obstructive CAD or detect inducible ischemia.ResultsWe found 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk-stratify before troponin testing. For the diagnosis of non-infarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in-hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first line NIVT (42%).ConclusionOur results suggest highly variable ACS screening and clinical practice.This article is protected by copyright. All rights reserved.
      PubDate: 2017-03-06T02:30:27.552502-05:
      DOI: 10.1111/acem.13184
  • Identifying low-risk patients for early discharge from emergency
           department without using subjective descriptions of chest pain: Insights
           from Providing Rapid Out of hospital Acute Cardiovascular Treatment
           (PROACT) 3 and 4 trials
    • Authors: Nariman Sepehrvand; Yinggan Zheng, Paul W. Armstrong, Robert C. Welsh, Justin A. Ezekowitz
      Abstract: BackgroundSeveral accelerated diagnostic protocols (ADP) have been developed to allow emergency department (ED) physicians to identify appropriate patients for safe early discharge after presentation with symptom of chest pain. Most ADPs require chest pain to be described and modify the algorithm based on the subjective chest pain characteristics. We investigated the performance of 3 established major ADPs simplified by eliminating the need for chest pain as a descriptor.MethodsWe pooled patients from PROACT-3 and 4 trials, in which patients presenting to emergency medical services (EMS) with chest pain or dyspnea were enrolled. The simplified Vancouver Chest Pain Rule (sVCPR), the simplified Emergency Department Assessment of Chest Pain Score (sEDACS) ADP and the Accelerated Diagnostic protocol to Assess Patients with chest pain using contemporary Troponins as the only biomarker (ADAPT-ADP) were compared using the sensitivity, specificity, and positive and negative predictive values (NPV). The primary outcome of interest was 30-day major adverse cardiac events (MACE); the diagnosis of ACS occurring within 30 days after ED presentation was also explored.Results1081 patients were included (median age 67 years, 53% male, median GRACE score 113) of which, 222 ACS diagnosis and 150 cardiac events occurred within 30 days after index ED presentation. The sVCPR, sEDACS≥3, and ADAPT-ADP, respectively, identified 9.7%, 13.3% and 4.1% of patients as low risk with a sensitivity and NPV of 100% for the primary outcome of 30-day MACE. The sEDACS-ADP identified 24.2% of patients as low risk with a cut-point score of 4 (sensitivity of 98.0% and NPV of 98.8%). The sVCPR, sEDACS≥3 and ADAPT-ADP, respectively, had a NPV of 98.1%, 95.8% and 93.3% in identifying patients at higher risk of ACS diagnosis within 30 days after index ED visit.ConclusionThe diagnostic protocols performed well without their chest pain characteristics component. Further studies are suggested to explore the performance of ADPs when these simplified ADPs are combined with high-sensitive troponin assays.This article is protected by copyright. All rights reserved.
      PubDate: 2017-03-06T02:15:35.402533-05:
      DOI: 10.1111/acem.13183
  • Is It Okay To Ask: Transgender Patient Perspectives on Sexual Orientation
           and Gender Identity Collection in Healthcare
    • Authors: Allysha C. Maragh-Bass; Maya Torain, Rachel Adler, Anju Ranjit, Eric Schneider, Ryan Shields, Lisa M. Kodadek, Claire Snyder, Danielle German, Susan Peterson, Jeremiah Schuur, Brandyn Lau, Adil H. Haider
      Abstract: ObjectiveThe National Academy of Medicine and Joint Commission recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare to address LGBT health disparities. We explored transgender patient-reported views on the importance of SO/GI collection, their willingness to disclose, and their perceived facilitators of SO/GI collection in primary care and Emergency Department (ED) settings.MethodsWe recruited a national sample of self-identified transgender patients. Participants completed demographic questions, survey questions, and free response comments regarding their views of SO/GI collection. Data were analyzed using descriptive statistics; inductive content analysis was conducted with open-ended responses.ResultsPatients mostly self-identified as Male gender (54.5%), White (58.4%), and sexual orientation other than Heterosexual, or LGB (33.7%; N=101). Patients felt it was more important for primary care providers to know their GI than SO (89.1% vs. 57%; p
      PubDate: 2017-02-24T18:30:35.24233-05:0
      DOI: 10.1111/acem.13182
  • Diagnostic Accuracy of History, Physical Exam, Laboratory Tests and
           Point-of-Care-Ultrasound for Pediatric Acute Appendicitis in the Emergency
           Department: A Systematic Review and Meta-Analysis
    • Authors: Roshanak Benabbas; Mark Hanna, Jay Shah, Richard Sinert
      Abstract: BackgroundAcute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children.ObjectivesTo determine the utility of history, physical exam, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department-Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies specifically, CT scan, MRI and Radiology Department Ultrasound (RUS).MethodsWe searched PUBMED, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative Likelihood Ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying Pauker-Kassirer method we developed a test-treatment threshold model.ResultsTwenty-one studies were included encompassing 8,605 patients with AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of “undifferentiated abdominal pain” and abdominal pain “suspected of AA”. In patients with “undifferentiated abdominal pain” history of “pain migration to RLQ” (LR+ 4.81, 95% CI 4.81-6.44) and presence of “cough/hop pain” in the physical exam (LR+ 7.64, 95% CI 5.94-9.83) were most strongly associated with AA. In patients “suspected of AA” none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical exam finding most strongly associated with AA (LR+ 3.52, 95% CI 2.65-4.68). Among different PAS cutoff points PAS≥ 9 (LR+ 5.26, 95% CI 3.34-8.29) was most associated with AA. None of the history, physical exam, lab tests findings or PAS alone could rule in or rule out AA in patients with “undifferentiated abdominal pain” or those “suspected of AA”. Emergency Department Point-of-Care Ultrasound (ED-POCUS) had LR+ 9.24 (95% CI 6.24-13.28) and LR- 0.17 (95% CI 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA.ConclusionPresence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical exam. Once AA is suspected, no single history, physical exam, lab finding or score attained on PAS can eliminate the need for imaging studies. Test characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-18T15:10:23.740447-05:
      DOI: 10.1111/acem.13181
  • MRI vs. Ultrasound as the initial imaging modality for pediatric and young
           adult patients with suspected appendicitis
    • Authors: Daniel Imler; Christine Keller, Shyam Sivasankar, Nancy Ewen Wang, Shreyas Vasanawala, Matias Bruzoni, James Quinn
      Abstract: BackgroundWhile ultrasound (US), given its lack of ionizing radiation is currently the recommended initial imaging study of choice for the diagnosis of appendicitis in pediatric and young adult patients, it does have significant shortcomings. US is time intensive, operator dependent, and results in frequent inconclusive studies, thus necessitating further imaging, and admission for observation or repeat clinical visits. A rapid focused Magnetic Resonance Imaging (MRI) for appendicitis has been shown to have definitive sensitivity and specificity, similar to Computed tomography (CT) but without radiation and offers a potential alternative to US.ObjectiveIn this single-center prospective cohort study, we sought to determine the difference in total length of stay and charges between rapid MRI and US as the initial imaging modality in pediatric and young adult patients presenting to the Emergency Department (ED) with suspected appendicitis. We hypothesized that rapid MRI would be more efficient and cost effective than US as the initial imaging modality in the ED diagnosis of appendicitis.MethodsA prospective randomized cohort study of consecutive patients was conducted in patients 2-30 years of age in an academic ED with access to both rapid MRI and US imaging modalities 24/7. Prior to the start of the study, the days of the week were randomized to either rapid MRI or US as the initial imaging modality. Physicians evaluated patients with suspected appendicitis per their usual manner. If the physician decided to obtain radiologic imaging, the pre-determined imaging modality for the day of the week was used. All decisions regarding other diagnostic testing and/or further imaging were left to the physician's discretion. Time intervals (min) between triage, order placement, start of imaging, end of imaging, image result and disposition (discharge vs. admission), as well as total charges (diagnostic testing, imaging and repeat ED visits) were recorded.ResultsOver a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45/82 (55%) of patients were in the US first group; and 37/82 (45%) patients were in the rapid MRI first group. There were no differences in patient demographics or clinical characteristics between the groups and no cases of missed appendicitis in either group. 11/45 (24%) of US first patients had inconclusive studies, resulting in follow-up rapid MRI and 5 return ED visits contrasted with no inconclusive studies or return visits (p< 0.05) in the rapid MRI group. The rapid MRI compared to US group was associated with longer ED length of stay (mean difference 100 min; 95% CI 35-169) and increased ED charges (mean difference $4,887; 95% CI $1,821 - $8,513).ConclusionsIn the diagnosis of appendicitis, US first imaging is more time efficient and less costly than rapid MRI despite inconclusive studies after US imaging. Unless the process of obtaining a rapid MRI becomes more efficient and less expensive, US should be the first line imaging modality for appendicitis in patients 2-30 years of age.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-16T15:00:30.053438-05:
      DOI: 10.1111/acem.13180
  • Emergency Department Initiated Home Oxygen for Bronchiolitis: A
           Prospective Study of Community Follow-up, Caregiver Satisfaction and
    • Authors: Julia Fuzak Freeman; Sara Deakyne, Lalit Bajaj
      Abstract: ObjectiveRetrospective studies performed have shown home oxygen to be a safe alternative to hospitalization for some patients with bronchiolitis living at high altitudes. We aimed to prospectively describe adverse events, follow-up, duration of home oxygen, factors associated with failure, and caregiver preferences.MethodsThis was a prospective observational study of hypoxemic bronchiolitis patients ages 3-18months who were discharged from a tertiary care pediatric emergency department on home oxygen over 3 winters (2011-2014). Caregivers were contacted on post-discharge days ~3, 7, 14 and 28 while on oxygen. Caregivers not reached by phone were sent a survey and PCPs were contacted. Records of admitted subjects were reviewed. Outcome measures included: Hospital readmission, positive pressure ventilation (noninvasive or intubation), outpatient follow-up, duration of home oxygen therapy, and caregiver satisfaction.Results274 patients were enrolled. 48 (17.5%) were admitted and 225(82.1%) were discharged on oxygen. The median age was 8 months. 18 subjects were lost to follow-up. 196 (87.1%) were successfully treated with outpatient oxygen, and 11 (4.9%) failed outpatient therapy and were hospitalized. Only 1 hospitalized patient required invasive ventilation. The median duration of home oxygen was 7 days. Child noncompliance was the most common problem (reported by14%). The median caregiver comfort level with home oxygen was 9/10. 88% of caregivers would again choose home oxygen over admission.ConclusionsThis study confirms that outpatient oxygen therapy can reduce hospitalizations due to bronchiolitis in a relatively high-altitude setting, with low failure and complication rates. Caregivers are comfortable with home oxygen and prefer it to hospitalization.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-16T14:55:21.904288-05:
      DOI: 10.1111/acem.13179
  • Book Title: Managing Obstetrics Emergencies and Trauma: The MOET Course
    • Authors: Aaron Lawrence; Emily McLaren
      Abstract: Managing Obstetrics Emergencies and Trauma: The MOET Course Manual is an evidence-based text that serves as the foundation for the MOET course. This course dates as far back as 2001 in the United Kingdom and is now taught in six countries. The structure of Managing Obstetrics Emergencies and Trauma (MOET) is similar to that of ATLS and includes a practical classroom component.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-15T23:15:30.937875-05:
      DOI: 10.1111/acem.13178
  • Ketamine as an Adjunct to Opioids for Acute Pain in the Emergency
           Department: A randomized controlled trial
    • Authors: Karen J Bowers; Kelly B McAllister, Meredith Ray, Corey Heitz
      Abstract: ObjectivesThis study had five objectives: 1) to measure and compare total opioid use and number of opioid doses in patients treated with opioids versus ketamine in conjunction with opioids. 2) To measure pain scores up to 2 hours after presentation in the ED patient with pain, comparing standard opioid pain control to ketamine in conjunction with opioids. 3) To compare patient satisfaction with pain control using opioids alone versus ketamine in conjunction with opioids. 4) To monitor and compare side effects in patients treated with opioids versus ketamine in conjunction with opioids. 5) To identify effect variation between different subgroups of patients, with the purpose of focusing future research.We hypothesized that low-dose ketamine, compared to placebo, as an adjunctive treatment to opioids would result in better pain control over 2 hours and greater patient satisfaction with pain control; further, this protocol will result in a lower opioid dosage over 2 hours.MethodsThis was a randomized, double-blinded, placebo-controlled trial at a single academic emergency department evaluating the use of ketamine versus placebo in conjunction with opioids for moderate to severe pain. Subjects with a continued high level of pain after an initial dose of opioid analgesia were randomized to receive either 0.1 mg/kg of ketamine or placebo prior to protocol-based dosing of additional opioid analgesia, if required. Over 120 minutes, subjects were assessed for pain level (0-10), satisfaction with pain control (0-4), side effects, sedation level and need for additional pain medication. Total opioid dose, including the initial dose, was compared between groups.ResultsSixty-three subjects were randomized to the placebo group and 53 to the ketamine group. No significant differences were found in demographics between the groups. Patients receiving ketamine reported lower pain scores over 120 minutes than patients receiving placebo (p = 0.015). Total opioid dose was lower in the ketamine group (9.95 mg, SD 4.83) compared to placebo (12.81 mg, SD 6.81), p = 0.02. Satisfaction did not differ between groups. Fewer patients in the ketamine group required additional opioid doses. More patients reported light-headedness and dizziness in the ketamine group.ConclusionsKetamine, as an adjunct to opioid therapy, was more effective at reducing pain over 120 minutes and resulted in a lower total opioid dose as well as fewer repeat doses of analgesia. More side effects were reported in the ketamine group (51% vs 19%), but the side effect profile appears tolerable.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-08T06:01:03.246938-05:
      DOI: 10.1111/acem.13172
  • Emergency Department triage of traumatic head injury using brain
           electrical activity biomarkers: a multisite prospective observational
           validation trial
    • Authors: Daniel Hanley; Leslie S. Prichep, Jeffrey Bazarian, J. Stephen Huff, Rosanne Naunheim, John Garrett, Elizabeth Jones, David Wright, John O'Neill, Neeraj Badjatia, Dheeraj Gandhi, Kenneth C. Curley, Richard Chiacchierini, Brian O'Neil, Dallas C. Hack
      Abstract: ObjectivesA brain electrical activity biomarker for identifying traumatic brain injury (TBI) in Emergency Department (ED) patients presenting with high GCS after sustaining a head injury has shown promise for objective, rapid, triage. The main objective of this study was to prospectively evaluate the efficacy of an automated classification algorithm to determine the likelihood of being CT positive, in high functioning TBI patients in the acute state.MethodsAdult patients admitted to the ED for evaluation within 72 hours of sustaining a closed head injury with GCS 12-15were candidates for study. 720 patients (18-85 years) meeting inclusion/exclusion criteria were enrolled in this observational, prospective validation trial, at 11 US Emergency Departments. Glasgow Coma Scale was 15 in 97%, with the first and third quartile being 15 (IQR=0) in the study population at the time of the evaluation. Standard clinical evaluations were conducted and 5-10 minutes of EEG was acquired from frontal and frontal-temporal scalp locations. Using an a priori derived EEG based classification algorithm developed on an independent population and applied to this validation population prospectively, the likelihood of each subject being CT+ was determined, and performance metrics were computed relative to adjudicated CT findings.ResultsSensitivity of the binary classifier (CT+ or CT-) was 92.3% (87.8%, 95.5%) for detection of any intracranial injury visible on CT (CT+), with specificity of 51·6% (48.1%, 55.1%) and negative predictive value of 96.0% (93.2%, 97.9%). Using ternary classification (CT+, Equivocal, CT-) demonstrated enhanced sensitivity to traumatic hematomas (≥1cc of blood), 98.6% (92.6%, 100.0%) and negative predictive value of 98.2% (95.5%, 99.5%).ConclusionsUsing an EEG-based biomarker high accuracy of predicting the likelihood of being CT+ was obtained, with high NPV and sensitivity to any traumatic bleeding and to hematomas. Specificity was significantly higher than standard CT decision rules. The short time to acquire results and the ease of use in the ED environment suggests that EEG based classifier algorithms have potential to impact triage and clinical management of head injured patients.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-08T06:01:00.188847-05:
      DOI: 10.1111/acem.13175
  • Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in
           the Emergency Department
    • Authors: Faruk Gungor; Taylan Kilic, Kamil Can Akyol, Gizem Ayaz, Umut Cengiz Cakir, Mehmet Akcimen, Cenker Eken
      Abstract: ObjectiveEarly and accurate diagnosis of acute appendicitis (AA) with ultrasound can minimize the morbidity and mortality of the patients. In this regard, ultrasound can help to the emergency physicians (EPs) in the diagnosing process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point of care ultrasound (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency department (ED).MethodsThe study sample consisted of patients aged>18 years that presented to the ED with an abdominal pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and then with radiology-performed ultrasound (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty values (MDCVs) for AA were determined with visual analogue scale (VAS) scores (0 not present, 100 certainly present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of appendectomy specimens, or clinical follow results. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared.ResultsA total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The sensitivity, specificity, PLR, and NLR of ultrasound examinations were 92.3% (95% CI; 87.2-95.8%), 95.8% (89.5-98.8%), 21.9 (8.4-57.2) and 0.08 (0.05-0.1) for POCUS, and 76.9% (69.8-83%), 97.8% (84.9-99.7%), 36.4 (9.25-144.3) and 0.24 (0.18-0.31) for RADUS, respectively. Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (IQR: 50-65) and 95 (IQR: 20-98), respectively (p=0.000).ConclusionPOCUS, when performed in ED for the diagnosis of AA, has high sensitivity and specificity, and had a positive impact on the clinical decision making of EPs.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-07T12:05:24.610069-05:
      DOI: 10.1111/acem.13169
  • Response to letter to the editor
    • Authors: Catherine Varner
      Abstract: We kindly thank the journal for the opportunity to respond to the recent comments made regarding our manuscript entitled, “Cognitive rest and graduated return to usual activities versus usual care for mild traumatic brain injury: a randomized controlled trial of emergency department discharge instructions.”This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-07T10:10:36.788549-05:
      DOI: 10.1111/acem.13170
  • Mild Traumatic Brain Injury: Is Something Missing when Comparing Cognitive
           Rest and Graduated Return to Usual Activities Versus Usual Care'
    • Authors: Vaitsa Giannouli
      Abstract: I read with great interest the article by Varner et al.1 which aims to determine in a simple, concise, and neat way if mild traumatic brain injury (MTBI) patients randomized to graduated return to usual activity discharge instructions have a decrease in their Post Concussion Symptom Score (PCSS) two weeks after MTBI, compared to patients who receive usual care MTBI discharge instructions.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-07T10:10:35.79141-05:0
      DOI: 10.1111/acem.13171
  • Utility Of Serum Biomarkers In The Diagnosis and Stratification Of Mild
           Traumatic Brain Injury
    • Authors: Lawrence M. Lewis; Derek Schloemann, Linda Papa, Robert Fucetola, Jeffrey Bazarian, Miranda Lindburg, Robert Welch
      Abstract: ObjectiveTo compare test characteristics of a single serum concentration of glial fibrillary acidic protein (GFAP), S-100β, and ubiquitin carboxyl terminal hydrolase L1 (UCH-L1), obtained within 6 hours of head injury, to diagnose mild traumatic brain injury (mTBI) in head-injured subjects.MethodsAdults aged 18-80 who presented to one of seven EDs with a blunt closed head injury, underwent head CT within 4 hours of injury, and had blood drawn for biomarker analysis within 6 hours of injury were eligible. Subjects were considered to have mTBI if they had an initial GCS> 13 and met one or more of the following criteria: loss of consciousness (LOC), post-traumatic amnesia (PTA), or confusion. Subjects with mTBI and an abnormal head CT were categorized as complicated mTBI; those with a normal CT were categorized as uncomplicated mTBI; and subjects with a GCS=15, no LOC, no PTA, and no confusion were considered to not have a mTBI. Biomarker concentration measurements for GFAP and UCH-L1 were performed using an ELISA assay. S-100β concentration was determined using an electrochemiluminescence immunoassay.Median biomarker concentration for each group was compared using the Kruskal Wallis Test. Logistic regression was used to determine area under the receiver-operating curve (AUC) for each of the three biomarkers. Sensitivity, specificity, negative and positive predictive values, and negative and positive likelihood ratios (LR) for the three biomarkers to differentiate between complicated mTBI, uncomplicated mTBI, and no mTBI were calculated.Results247 subjects were enrolled and had adequate clinical and biomarker information for analysis. 188 met criteria for mTBI, with 34 (18.1%) having an acute abnormality on CT (complicated mTBI). The mean age of the study population was 45.8 (SD 17.3) years, and 59.9% were male. Median serum concentrations for all biomarkers were significantly different between groups, lowest in the no mTBI group, and progressively increasing in the uncomplicated and complicated mTBI groups (p
      PubDate: 2017-02-07T10:05:34.232802-05:
      DOI: 10.1111/acem.13174
  • A Novel Emergency Department-Based Community Notification Method for
           Clinical Research Without Consent
    • Authors: Gerald F. O'Malley; Patricia Giraldo, Kenneth Deitch, Elizabeth Andrea Aguilera, Sorin Cadar, Claudia Lares, Rika Nagakuni O'Malley, Nino Oqroshidze, Manisha Verma, Carl Chudnofsky
      Abstract: Providing and receiving informed consent to critically ill or moribund subjects is ethically and practically challenging.1 Historically the concept of autonomy requires research subjects to receive and provide informed consent prior to participating in clinical research. The nature of resuscitation research prevents two-way communication and ethical informed consent. In 1996 the FDA released a set of guidelines allowing for exception from informed consent (EFIC) for emergency research, provided certain requirements are met (21 CF 50.24). The guidelines were updated in April 20132 and are reproduced in Table 1.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-07T10:05:27.11651-05:0
      DOI: 10.1111/acem.13173
  • Prevalence of Brain Injuries and Recurrence of Seizures in Children with
           Post Traumatic Seizures
    • Authors: Mohamed K. Badawy; Peter S Dayan, Michael G Tunik, Frances M Nadel, Kathleen A Lillis, Michelle Miskin, Dominic A Borgialli, Michael C Bachman, Shireen M Atabaki, John D Hoyle, James F Holmes, Nathan Kuppermann,
      Abstract: ObjectivesComputed tomography (CT) is often used in the emergency department (ED) evaluation of children with post-traumatic seizures (PTS); however, the frequency of traumatic brain injuries (TBI) and short-term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBI on CT and short-term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED.MethodsThis was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 emergency departments (ED) in the Pediatric Emergency Care Applied Research Network (PECARN). We evaluated children
      PubDate: 2017-02-07T10:00:27.508386-05:
      DOI: 10.1111/acem.13168
  • When I Get Like That Put A Gun To My Head
    • Authors: Nancy Lutwak; Curt Dill
      Abstract: Yesterday a 95 year old man with prostate carcinoma and widespread bone metastases was brought to the emergency department because of blood in his urine after he pulled on his foley. At triage he was febrile and hypotensive, moaning incoherently which was not a change in mental status. Despite IV fluid hydration and pressors his blood pressure remained low.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-07T01:20:58.444103-05:
      DOI: 10.1111/acem.13166
  • Emergency Physician Knowledge, Attitudes and Behavior regarding ACEP's
           Choosing Wisely Recommendations: A Survey Study
    • Authors: Michelle P. Lin; Thomas Nguyen, Marc A. Probst, Lynne D. Richardson, Jeremiah D. Schuur
      Abstract: ObjectiveIn 2013, the American College of Emergency Physicians joined the Choosing Wisely campaign; however, its impact on emergency physician behavior is unknown. We assessed knowledge, attitudes and self-reported behaviors regarding the Choosing Wisely recommendations.MethodsWe performed a cross-sectional survey of emergency physicians at a national meeting. We approached 819 physicians; 765 (93.4%) completed the survey.ResultsAs a result of the Choosing Wisely campaign, most respondents (64.5%) felt more comfortable discussing low-value services with patients; 54.5% reported reducing utilization; and 52.5% were aware of local efforts to promote the campaign. A majority (62.9%) of respondents were able to identify at least 4 out of 5 recommendations. The most prevalent low-value practices were computed tomography (CT) brain for minor head injury (29.9%) and antibiotics for acute sinusitis (26.9%). Few respondents reported performing lumbar radiograph for non-traumatic low back pain (7.8%) and Foley catheter for patients who can void (5.6%). Respondents reported patient/family expectations as the most important reason for ordering antibiotics for sinusitis (68%) and imaging for low back pain (56.8%). However, concern for serious diagnosis was the most important reason for performing CT chest for patients with normal D-dimer (49.7%) and CT abdomen for recurrent uncomplicated renal colic (42.5%). A minority (3.8% to 26.7%) of respondents identified malpractice risk as the primary reason for performing low-value services.ConclusionsDespite familiarity with Choosing Wisely, many emergency physicians report performing low-value services. Primary reasons for low-value services differ: antibiotic prescribing was driven by patient/family expectations, while concern for serious diagnosis influenced advanced diagnostic imaging. Greater efforts are needed to promote effective dissemination and implementation; such efforts may be targeted based on differing reasons for low-value services.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-06T00:50:28.893898-05:
      DOI: 10.1111/acem.13167
  • Development of a patient-centered outcome measure for emergency department
           asthma patients
    • Authors: Margaret E Samuels-Kalow; Karin V Rhodes, Mira Henien, Emily Hardy, Thomas Moore, Felicia Wong, Carlos A. Camargo, Carolyn T. Rizzo, Cynthia Mollen
      Abstract: BackgroundMeasuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize over-testing and over-treatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care.ObjectiveTo identify concepts for inclusion in a patient-reported outcome measure for ED care, and assess differences in potential concepts by health literacy.Design/MethodsA three-phase qualitative study was completed using freelisting and semi-structured interviewing for concept identification, member checking for concept ranking and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2.ResultsPhase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic / literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access and asthma knowledge were identified as the most important components of the definition of post-ED discharge success. Phase 3 resulted in 5 questions for the proposed measure.ConclusionsA step-wise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The 4 key concepts identified for inclusion: symptom improvement, medication access, correct medication use and asthma knowledge are not measured by existing quality metrics.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-01T09:15:36.905869-05:
      DOI: 10.1111/acem.13165
  • Feasibility of Informed Consent for CT in Acute Trauma Patients
    • Authors: Nicole Moore; Nadia Zuabi, Bhavesh Patel, Mark I. Langdorf, Robert M. Rodriguez
      Abstract: Background/ObjectiveComputed tomography (CT) is common for trauma victims, but is usually done without informing patients of potential risks or obtaining informed consent. The objective of this study was to determine the feasibility of two elements (time and normal level of alertness) necessary for informed consent for CT in adult trauma patients.MethodsWe conducted this prospective observational, two-phase cohort study at two urban, Level 1 trauma centers. In the first phase, we determined the median time needed to obtain informed consent for CT by performing sham consent on 11 injured patients at each site. In the second phase, we observed all adult trauma activation cases that presented during specified time blocks and recorded Glasgow Coma Scale (GCS) scores and the time available for consent (TAC) for CT—defined as the time between the end of the secondary trauma survey and when the patient left the resuscitation room to go to CT. We defined, a priori, feasible consent cases as those in which the patient had a GCS of 15 and a TAC> the median sham consent time at that site.ResultsThe median times for sham CT consent at the two sites were 3:36 and 2:09 minutes:seconds (range 1:12 - 4:54). Of the 729 trauma patients enrolled during phase two, 646 (89%) had a CT scan, and of these 646 patients, 461 (71.4% [95% CI 67.8 – 74.7%]) met feasible consent criteria. Of the 185 patients who failed to meet feasible consent criteria, 171 (92.4%) had a GCS < 15, 1 (0.5%) had a TAC < the sham consent time, and 13 (7.0%) had both.ConclusionWe found that informed consent for CT was likely feasible in over two-thirds of acute, adult trauma patients.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-01T05:06:50.226416-05:
      DOI: 10.1111/acem.13164
  • Toward Precision Diagnostics
    • Authors: Christian Rose; Robert M. Rodriguez
      Abstract: In January 2015 President Obama announced funding for the Precision Medicine Initiative, a multifaceted program that seeks to develop an individualized approach to disease prevention and treatment. Accounting for individual variability, precision medicine aims to deliver “the right treatment at the right dose to the right patient at the right time”, embracing human variation and its drivers: inheritance, exposures, lifestyle, and life experience.1,2 Beyond treatment innovations, full realization of the benefits of precision medicine and individualized health care will require refinements to diagnostic practice – the medical history, physical examination, and diagnostic tests. Within the framework of this comprehensive initiative, we seek to advance the concept of precision diagnostics, and more specifically, precision emergency department (ED) diagnostic testing.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-01T04:21:43.424325-05:
      DOI: 10.1111/acem.13163
  • A systematic review of instruments to identify mental health and substance
           use problems among children in the emergency department
    • Authors: Amanda S. Newton; Amir Soleimani, Scott W. Kirkland, Rebecca J. Gokiert
      Abstract: ObjectiveSpecialized instruments to screen and diagnose mental health problems in children and adolescents are not yet standard components of clinical assessments in emergency departments (EDs). We conducted a systematic review to investigate the psychometric properties, accuracy, and performance metrics of instruments used in the ED to identify pediatric mental health and substance use problems.MethodsWe searched seven electronic databases and the grey literature for psychometric validation studies, diagnostic studies, and cohort studies that assessed any instrument to screen for or diagnose mental illness, emotional or behavioral problems, or substance use disorders. Studies had to include children and adolescents with mental health presentations or positive screens for substance use. Two reviewers independently screened studies for relevance and quality. Diagnostic study quality was assessed with the four QUADAS-2 domains. Psychometric study quality was assessed with published criteria for instrument reliability, validity, and usability. We present a descriptive analysis of the reported psychometric properties and diagnostic performance of instruments for each study.ResultsOf the 4832 references screened, 14 met inclusion criteria. Included studies evaluate 18 instruments for identifying suicide risk (6 studies), alcohol use disorders (6 studies), mood disorders (1 study), and ED decision-making (need for assessment, admission; 1 study). Nine studies include a psychometric focus but quality varies, with no studies fully meeting criteria for reliability, validity, and usability. Seven studies examined diagnostic performance of an instrument, but no study has a low risk of bias for all QUADAS-2 domains. The HEADS-ED instrument has good inter-rater reliability (r=0.785) for identifying general mental health problems and modest evidence for ruling in patients requiring hospital admission (positive likelihood ratio, LR+=6.30). Internal consistency (reliability) varies for instruments to screen for suicide risk (α=0.46-0.97), and no instruments have both high sensitivity and high specificity. The Ask Suicide-Screening Questionnaire (ASQ) is highly sensitive (98%) and has strong evidence for ruling out risk (negative likelihood ratio, LR−=0.04). Among screening instruments for alcohol use disorders, internal consistency is high for the consumption subscale of the Alcohol Use Disorders Identification Test (α=0.83-0.88) and the Adolescent Drinking Index (α=0.92). Both instruments also had sound internal validity. Diagnostically, however, a two-item instrument based on DSM-IV criteria is the most accurate in identifying patients with a disorder (area under the curve: 0.89) and has modest evidence for ruling in and out risk (LR+=8.80, LR−=0.13).ConclusionsFrom available evidence, we recommend that ED clinicians use (a) the HEADS-ED to rule in ED admission among pediatric patients with visits for mental health care, (b) the ASQ to rule out suicide risk among pediatric patients with any visit type, and (c) the DSM-IV two-item instrument to rule in/rule out alcohol use disorders among pediatric patients currently using alcohol. These instruments require minimal to no training or time commitment. We also recommend that clinicians become familiar with each instrument's psychometric properties to understand the quality of the evidence base. In this review, however, we identify methodological limitations in the evidence base. To develop a robust evidence base, additional research is necessary.This article is protected by copyright. All rights reserved.
      PubDate: 2017-02-01T02:45:41.629381-05:
      DOI: 10.1111/acem.13162
  • 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
  • The Impact of a Soiled Airway on Intubation Success in the Emergency
           Department when using the GlideScope or the Direct Laryngoscope
    • Authors: John C. Sakles; G Judson Corn, Patrick Hollinger, Brittany Arcaris, Asad E. Patanwala, Jarrod M. Mosier
      Abstract: BackgroundTo determine the impact of a soiled airway on first pass success when using the GlideScope video laryngoscope or the direct laryngoscope for intubation in the emergency department.MethodsData were prospectively collected on all patients intubated in an academic emergency department from July 1, 2007 to June 30, 2016. Patients ≥18 years of age, who underwent rapid sequence intubation with the GlideScope or the direct laryngoscope were included in the analysis. Data were stratified by device used (GlideScope or direct laryngoscope). The primary outcome was first pass success. Patients were categorized as those without blood or vomitus (CLEAN) and those with blood or vomitus (SOILED) in their airway. Multivariate regression models were developed to control for confounders.ResultsWhen using the GlideScope the first pass success was lower in the SOILED group (249/306; 81.4%) than the in CLEAN group (586/644; 91.0%) (difference 9.6%; 95% CI: 4.7 to 14.5). Similarly, when using the direct laryngoscope, the first pass success was lower in the SOILED group (186/284; 65.5%) than in the CLEAN group (569/751; 75.8%) (difference 10.3%; 95% CI: 4.0 to 16.6). The SOILED airway was associated with a decreased first pass success in both the GlideScope cohort (aOR 0.4; 95% CI: 0.3 to 0.6) and the direct laryngoscope cohort (aOR 0.6; 95% CI: 0.5 to 0.8).ConclusionSoiling of the airway was associated with a reduced first pass success during emergency intubation and this reduction occurred to a similar degree whether using either the GlideScope or the direct laryngoscope.This article is protected by copyright. All rights reserved.
      PubDate: 2017-01-20T20:45:32.957592-05:
      DOI: 10.1111/acem.13160
  • Global Health and Emergency Care: Defining Clinical Research Priorities
    • Authors: Bhakti Hansoti; Adam R. Aluisio, Meagan A. Barry, Kevin Davey, Brian A. Lentz, Payal Modi, Jennifer A. Newberry, Melissa H. Patel, Tricia A. Smith, Alexandra M. Vinograd, Adam C. Levine,
      Abstract: ObjectivesDespite recent strides in the development of Global Emergency Medicine (EM), the field continues to lag in applying a scientific approach to identifying critical knowledge gaps and advancing evidence-based solutions to clinical and public health problems seen in emergency departments worldwide. Here, progress on the Global EM research agenda created at the 2013 Academic Emergency Medicine Global Health and Emergency Care Consensus Conference is evaluated and critical areas for future development in emergency care research internationally are identified.MethodsA retrospective review of all studies compiled in the Global Emergency Medicine Literature Review (GEMLR) database from 2013 through 2015 was conducted. Articles were categorized and analyzed using descriptive quantitative measures and structured data matrices. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting then further conceptualized and defined Global EM research priorities utilizing consensus-based decision making.ResultsResearch trends in Global EM research published between 2013 and 2015 show a predominance of observational studies relative to interventional or descriptive studies, with the majority of research conducted in the inpatient setting in comparison to the emergency department or pre-hospital setting. Studies on communicable diseases and injury were the most prevalent, with a relative dearth of research on chronic non-communicable diseases. The Global Emergency Medicine Think Tank Clinical Research Working Group identified conceptual frameworks to define high-impact research priorities, including the traditional approach of using global burden of disease to define priorities and the impact of EM on individual clinical care and public health opportunities. EM research is also described through a population lens approach, including gender, pediatrics, and migrant & refugee health.ConclusionsDespite recent strides in Global EM research and a proliferation of scholarly output in the field, further work is required to advocate for and inform research priorities in Global EM. The priorities outlined in this paper aim to guide future research in the field, with the goal of advancing the development of EM worldwide.This article is protected by copyright. All rights reserved.
      PubDate: 2017-01-19T17:00:26.61816-05:0
      DOI: 10.1111/acem.13158
  • Sex and Gender in Acute Care Medicine
    • Authors: Therese G. Mead; Lauren Kershnar
      Abstract: Sex and Gender in Acute Care Medicine is an evidence-based textbook that draws the reader's attention to the underappreciated sex and gender based differences in acute medical care and the gender bias that historically exists in medical research. In a tour through the major disciplines of acute care medicine the authors provide a sex and gender focused perspective on the presentation, management and pathophysiology of key medical conditions in an evidence-based format. The reader may find some of the many disparities discussed surprising and others well known from clinical practice. The editors are leaders in this new field, and this textbook is the first to provide a comprehensive review of sex and gender focused acute medical care. This soft cover is a valuable stimulus for the researcher and a quick-read resource for the practicing physician that has the potential to positively impact patient care in the emergency department.This article is protected by copyright. All rights reserved.
      PubDate: 2017-01-04T09:30:39.151243-05:
      DOI: 10.1111/acem.13157
  • Issue Information
    • Pages: 507 - 510
      PubDate: 2017-05-11T14:33:20.587691-05:
      DOI: 10.1111/acem.13090
  • Hot Off the Press: Which Febrile Children With Sickle Cell Disease Need a
           Chest X-Ray'
    • Authors: Justin Morgenstern; Corey Heitz, William K Milne
      Abstract: This retrospective chart review examined the rate of acute chest syndrome (ACS) in febrile children (aged 3 months to 21 years) with sickle cell disease and used recursive partitioning to determine which clinical factors were predictive of a diagnosis of ACS. Over the course of 2 years, 697 children made 1837 visits to one of two pediatric emergency departments. ACS was diagnosed in 185 (10%) of the visits.This article is protected by copyright. All rights reserved.
      PubDate: 2016-12-23T00:00:42.166293-05:
      DOI: 10.1111/acem.13154
  • Risk, benefit, and cost thresholds for emergency department testing: a
           cross sectional, scenario based study
    • Authors: Arjun Prasad Meka; Jonathan Douglas Porath, Rahul Iyengar, Chelsea Morrow, Angela Fagerlin, William J. Meurer
      Abstract: IntroductionWhile diagnostic testing is common in the emergency department, the value of some testing is questionable. The purpose of this study was to assess how varying levels of benefit, risk, and costs influenced an individual's desire to have diagnostic testing.MethodsA survey through Amazon Mechanical Turk presented hypothetical clinical situations: low risk chest pain and minor traumatic brain injury. Each scenario included three given variables (benefit, risk, and cost), that was independently randomly varied over four possible values (0.1%, 1%, 5%, 10% for benefit and risk and $0, $100, $500, and $1000 for the individual's personal cost for receiving the test). Benefit was defined as the probability of finding the target disease (traumatic intracranial hemorrhage or acute coronary syndrome).Results1000 unique respondents completed the survey. With an increased benefit from 0.1% to 10%, the percent of respondents who accepted a diagnostic test went from 28.4% to 53.1%. [OR: 3.42 (2.57-4.54)] As risk increased from 0.1% to 10%, this number decreased from 52.5% to 28.5%. [OR: 0.33 (0.25-0.44)] Increasing cost from $0 to $1000 had the greatest change of those accepting the test from 61.1% to 21.4%, respectively. [OR: 0.15 (0.11-0.2)]ConclusionsThe desire for testing was strongly sensitive to the benefits, risks and costs. Many participants wanted a test when there was no added cost, regardless of benefit or risk levels, but far fewer elected to receive the test as cost increased incrementally. This suggests that out of pocket costs may deter patients from undergoing diagnostic testing with low potential benefit.This article is protected by copyright. All rights reserved.
      PubDate: 2016-12-17T10:24:22.549199-05:
      DOI: 10.1111/acem.13148
  • H1-antihistamines reduce progression to anaphylaxis among emergency
           department patients with allergic reactions
    • Authors: T. Kawano; F.X. Scheuermeyer, K. Gibo, R. Stenstrom, B Rowe, E. Grafstein, B. Grunau
      Abstract: ObjectivesH1-antihistamines (H1a) can be used to treat ED patients with allergic reactions; however, this is inconsistently done, likely as there is no evidence that this therapy has an impact on serious outcomes. Among emergency department (ED) patients initially presenting with allergic reactions, we investigated whether H1a were associated with lower rates of progression to anaphylaxis.MethodsThis was a retrospective cohort study conducted at two urban Canadian EDs from April 1, 2007 to March 31, 2012. We included consecutive adult patients with allergic reactions while excluding those presenting with anaphylaxis, according to pre-specified criteria. The primary outcome was the proportion of patients who subsequently developed anaphylaxis during medical care, either by emergency medical services (EMS) or in the ED. A pre-specified subgroup analysis excluded patients who received H1a prior to EMS or ED contact. We compared those who received H1a and those who did not, and used multivariable regression and propensity score adjustment techniques to compare outcomes.ResultsOf 2,376 overall patients included, 1,880 (79.1%) were managed with H1a. Of the latter group, 36 / 1,880 (1.9%) developed anaphylaxis, compared to 17 / 496 (3.4%) in the non-H1a-treated group (adjusted odds ratio [AOR] 0.34, 95% CI 0.17 to 0.70; number needed to treat [NNT] to benefit 44.74, 95% CI 35.36 to 99.67). In the subgroup analysis of 1,717 patients who did not receive H1a prior to EMS or ED contact, a similar association was observed (AOR 0.26, 95% CI 0.10 to 0.50; NNT to benefit 38.20, 95% CI 32.58 to 55.24).ConclusionsAmong ED patient with allergic reactions, H1a administration was associated with a lower likelihood of progression to anaphylaxis. These data indicate that early H1a treatment in the ED or prehospital setting may decrease progression to anaphylaxis.This article is protected by copyright. All rights reserved.
      PubDate: 2016-12-15T05:21:28.26013-05:0
      DOI: 10.1111/acem.13147
  • Point-of-care ultrasound for non-angulated distal forearm fractures in
           children: test performance characteristics and patient-centered outcomes
    • Authors: Naveen Poonai; Frank Myslik, Gary Joubert, Josiah Fan, Amita Misir, Victor Istasy, Melanie Columbus, Robert Soegtrop, Alex Goldfarb, Drew Thompson, Alexander Sasha Dubrovsky
      Abstract: ObjectivesDistal forearm fractures are the most common fracture type in children. Point-of-care-ultrasound (POCUS) is increasingly being used and preliminary studies suggest it offers an accurate approach to diagnosis. However, outcomes such as pain, satisfaction, and procedure duration have not been explored but may be salient to the widespread acceptance of this technology by caregivers and children. Our objectives were to examine the test performance characteristics of POCUS for non-angulated distal forearm injuries in children and compare POCUS to x-ray with respect to pain, caregiver satisfaction, and procedure duration.MethodsWe conducted a cross-sectional study involving children aged 4-17 years with a suspected non-angulated distal forearm fracture. Participants underwent both x-ray and POCUS assessment. The primary outcome was sensitivity between POCUS and x-ray, the reference standard. Secondary outcomes included self-reported pain using the Faces Pain Scale - Revised, caregiver satisfaction using a five-item Likert scale, and procedure duration.ResultsPOCUS was performed in 169 children of whom 76 were diagnosed with a fracture including 61 buckle fractures. Sensitivity of POCUS for distal forearm fractures was 94.7% [95% CI: 89.7, 99.8] and specificity was 93.5% [95% CI: 88.6, 98.5]. POCUS was associated with a significantly lower median (IQR) pain score compared to x-ray: 1 (0, 2) versus 2 (1, 3), respectively [median difference: 0.5; 95% CI: 0.5, 1; p
      PubDate: 2016-12-15T05:16:43.884888-05:
      DOI: 10.1111/acem.13146
  • Nonmydriatic Fundoscopic Imaging Using the Pan Optic iExaminer System in
           the Pediatric Emergency Department
    • Authors: Lindsay M. Day; Serena X. Wang, Craig J. Huang
      Abstract: ObjectivesThe primary objective of this study was to determine the percentage of clinically adequate (CA) fundoscopic images that could be obtained using the Pan Optic iExaminer system to perform nonmydriatic fundoscopic imaging in the pediatric emergency department. Secondary objectives were to identify target age groups in which this technology is best utilized, and evaluate the overall ease of use in this setting.MethodsChildren 18 years of age or less who presented to the pediatric emergency department with a non-eye related chief complaint were enrolled and stratified by age group (0-2 years, 2-6 years and 6-18 years). Each enrolled patient underwent a bilateral eye examination using the Pan Optic iExaminer system. Images were submitted for review to a pediatric ophthalmologist and were graded based on clarity and field of view. Ease of use was defined as 80% of patients having at least 1 image of quality to be considered “clinically adequate (CA)” for obtaining a full view of the optic nerve, examination time for both eyes 15 minutes or less, and 3 attempts or less for each eye.ResultsOverall, 91.06% (95% CI 86.01-96.1) of children ages 2-18 years had at least 1 CA image obtained. 16.39% (95% CI 7.10-25.68) of children 0-2 years, 85.25% (95% CI 76.35-94.15) of children 2-6 years, 96.77% (95% CI 92.38-101.17) of 6-18 years had at least 1 CA image. The median total examination time was 3 minutes 24 seconds (IQR 2 minutes 27 seconds, 4 minutes 49 seconds).ConclusionFundoscopic images were consistently obtained using the Pan Optic iExaminer system in the pediatric emergency department particularly in children 2-18 years of age. Clinically adequate images were obtained in children less than 2 years old, but less consistently.This article is protected by copyright. All rights reserved.
      PubDate: 2016-11-01T09:40:33.324955-05:
      DOI: 10.1111/acem.13128
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