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Publisher: John Wiley and Sons   (Total: 1584 journals)

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Showing 1 - 200 of 1584 Journals sorted alphabetically
Abacus     Hybrid Journal   (Followers: 12, SJR: 0.48, h-index: 22)
About Campus     Hybrid Journal   (Followers: 5)
Academic Emergency Medicine     Hybrid Journal   (Followers: 58, SJR: 1.385, h-index: 91)
Accounting & Finance     Hybrid Journal   (Followers: 45, SJR: 0.547, h-index: 30)
ACEP NOW     Free   (Followers: 1)
Acta Anaesthesiologica Scandinavica     Hybrid Journal   (Followers: 51, SJR: 1.02, h-index: 88)
Acta Archaeologica     Hybrid Journal   (Followers: 137, SJR: 0.101, h-index: 9)
Acta Geologica Sinica (English Edition)     Hybrid Journal   (Followers: 3, SJR: 0.552, h-index: 41)
Acta Neurologica Scandinavica     Hybrid Journal   (Followers: 5, SJR: 1.203, h-index: 74)
Acta Obstetricia et Gynecologica Scandinavica     Hybrid Journal   (Followers: 15, SJR: 1.197, h-index: 81)
Acta Ophthalmologica     Hybrid Journal   (Followers: 5, SJR: 0.112, h-index: 1)
Acta Paediatrica     Hybrid Journal   (Followers: 56, SJR: 0.794, h-index: 88)
Acta Physiologica     Hybrid Journal   (Followers: 6, SJR: 1.69, h-index: 88)
Acta Polymerica     Hybrid Journal   (Followers: 9)
Acta Psychiatrica Scandinavica     Hybrid Journal   (Followers: 35, SJR: 2.518, h-index: 113)
Acta Zoologica     Hybrid Journal   (Followers: 6, SJR: 0.459, h-index: 29)
Acute Medicine & Surgery     Hybrid Journal   (Followers: 2)
Addiction     Hybrid Journal   (Followers: 33, 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: 26, SJR: 0.81, h-index: 81)
Advanced Functional Materials     Hybrid Journal   (Followers: 50, SJR: 5.21, h-index: 203)
Advanced Healthcare Materials     Hybrid Journal   (Followers: 13, SJR: 0.232, h-index: 7)
Advanced Materials     Hybrid Journal   (Followers: 249, SJR: 9.021, h-index: 345)
Advanced Materials Interfaces     Hybrid Journal   (Followers: 6, SJR: 1.177, h-index: 10)
Advanced Optical Materials     Hybrid Journal   (Followers: 5, SJR: 2.488, h-index: 21)
Advanced Science     Open Access   (Followers: 5)
Advanced Synthesis & Catalysis     Hybrid Journal   (Followers: 17, SJR: 2.729, h-index: 121)
Advances in Polymer Technology     Hybrid Journal   (Followers: 13, SJR: 0.344, h-index: 31)
Africa Confidential     Hybrid Journal   (Followers: 19)
Africa Research Bulletin: Economic, Financial and Technical Series     Hybrid Journal   (Followers: 12)
Africa Research Bulletin: Political, Social and Cultural Series     Hybrid Journal   (Followers: 9)
African Development Review     Hybrid Journal   (Followers: 35, SJR: 0.275, h-index: 17)
African J. of Ecology     Hybrid Journal   (Followers: 14, SJR: 0.477, h-index: 39)
Aggressive Behavior     Hybrid Journal   (Followers: 15, SJR: 1.391, h-index: 66)
Aging Cell     Open Access   (Followers: 10, SJR: 4.374, h-index: 95)
Agribusiness : an Intl. J.     Hybrid Journal   (Followers: 6, SJR: 0.627, h-index: 14)
Agricultural and Forest Entomology     Hybrid Journal   (Followers: 14, SJR: 0.925, h-index: 43)
Agricultural Economics     Hybrid Journal   (Followers: 44, SJR: 1.099, h-index: 51)
AIChE J.     Hybrid Journal   (Followers: 29, 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: 35, 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: 128, 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: 91, SJR: 2.325, h-index: 51)
American J. of Economics and Sociology     Hybrid Journal   (Followers: 27, SJR: 0.211, h-index: 26)
American J. of Hematology     Hybrid Journal   (Followers: 31, 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: 36, SJR: 1.41, h-index: 88)
American J. of Political Science     Hybrid Journal   (Followers: 252, SJR: 5.101, h-index: 114)
American J. of Primatology     Hybrid Journal   (Followers: 15, SJR: 1.197, h-index: 63)
American J. of Reproductive Immunology     Hybrid Journal   (Followers: 3, SJR: 1.347, h-index: 75)
American J. of Transplantation     Hybrid Journal   (Followers: 16, SJR: 2.792, h-index: 140)
American J. on Addictions     Hybrid Journal   (Followers: 9, SJR: 0.843, h-index: 57)
Anaesthesia     Hybrid Journal   (Followers: 120, 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: 16)
Anatomia, Histologia, Embryologia: J. of Veterinary Medicine Series C     Hybrid Journal   (Followers: 3, SJR: 0.295, h-index: 27)
Anatomical Sciences Education     Hybrid Journal   (Followers: 1, SJR: 0.633, h-index: 24)
Andrologia     Hybrid Journal   (Followers: 2, SJR: 0.528, h-index: 45)
Andrology     Hybrid Journal   (Followers: 2, SJR: 0.979, h-index: 14)
Angewandte Chemie     Hybrid Journal   (Followers: 159)
Angewandte Chemie Intl. Edition     Hybrid Journal   (Followers: 210, 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: 6, SJR: 0.569, h-index: 24)
Annalen der Physik     Hybrid Journal   (Followers: 5, SJR: 1.46, h-index: 40)
Annals of Anthropological Practice     Partially Free   (Followers: 2, SJR: 0.187, h-index: 5)
Annals of Applied Biology     Hybrid Journal   (Followers: 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: 44, 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: 67, SJR: 0.754, h-index: 69)
Applied Organometallic Chemistry     Hybrid Journal   (Followers: 7, SJR: 0.632, h-index: 58)
Applied Psychology     Hybrid Journal   (Followers: 136, SJR: 1.023, h-index: 64)
Applied Psychology: Health and Well-Being     Hybrid Journal   (Followers: 48, SJR: 0.868, h-index: 13)
Applied Stochastic Models in Business and Industry     Hybrid Journal   (Followers: 5, SJR: 0.613, h-index: 24)
Aquaculture Nutrition     Hybrid Journal   (Followers: 14, SJR: 1.025, h-index: 55)
Aquaculture Research     Hybrid Journal   (Followers: 31, SJR: 0.807, h-index: 60)
Aquatic Conservation Marine and Freshwater Ecosystems     Hybrid Journal   (Followers: 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: 25, SJR: 0.261, h-index: 9)
Archiv der Pharmazie     Hybrid Journal   (Followers: 4, SJR: 0.628, h-index: 43)
Archives of Drug Information     Hybrid Journal   (Followers: 4)
Archives of Insect Biochemistry and Physiology     Hybrid Journal   (SJR: 0.768, h-index: 54)
Area     Hybrid Journal   (Followers: 12, SJR: 0.938, h-index: 57)
Art History     Hybrid Journal   (Followers: 215, SJR: 0.153, h-index: 13)
Arthritis & Rheumatology     Hybrid Journal   (Followers: 51, SJR: 1.984, h-index: 20)
Arthritis Care & Research     Hybrid Journal   (Followers: 28, SJR: 2.256, h-index: 114)
Artificial Organs     Hybrid Journal   (Followers: 1, SJR: 0.872, h-index: 60)
ASHE Higher Education Reports     Hybrid Journal   (Followers: 14)
Asia & the Pacific Policy Studies     Open Access   (Followers: 14)
Asia Pacific J. of Human Resources     Hybrid Journal   (Followers: 316, 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: 4, SJR: 0.196, h-index: 12)
Asian J. of Control     Hybrid Journal   (SJR: 0.862, h-index: 34)
Asian J. of Endoscopic Surgery     Hybrid Journal   (SJR: 0.394, h-index: 7)
Asian J. of Organic Chemistry     Hybrid Journal   (Followers: 4, SJR: 1.443, h-index: 19)
Asian J. of Social Psychology     Hybrid Journal   (Followers: 5, SJR: 0.665, h-index: 37)
Asian Politics and Policy     Hybrid Journal   (Followers: 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: 8, SJR: 0.714, h-index: 40)
Australasian J. On Ageing     Hybrid Journal   (Followers: 7, SJR: 0.39, h-index: 22)
Australian & New Zealand J. of Statistics     Hybrid Journal   (Followers: 13, SJR: 0.275, h-index: 28)
Australian Accounting Review     Hybrid Journal   (Followers: 4, SJR: 0.709, h-index: 14)
Australian and New Zealand J. of Family Therapy (ANZJFT)     Hybrid Journal   (Followers: 3, SJR: 0.382, h-index: 12)
Australian and New Zealand J. of Obstetrics and Gynaecology     Hybrid Journal   (Followers: 43, 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: 23, 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: 17, SJR: 0.384, h-index: 30)
Australian J. of Public Administration     Hybrid Journal   (Followers: 388, 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: 66, SJR: 0.59, h-index: 29)
Australian Psychologist     Hybrid Journal   (Followers: 11, SJR: 0.331, h-index: 31)
Australian Veterinary J.     Hybrid Journal   (Followers: 19, SJR: 0.459, h-index: 45)
Autism Research     Hybrid Journal   (Followers: 31, SJR: 2.126, h-index: 39)
Autonomic & Autacoid Pharmacology     Hybrid Journal   (SJR: 0.371, h-index: 29)
Banks in Insurance Report     Hybrid Journal   (Followers: 1)
Basic & Clinical Pharmacology & Toxicology     Hybrid Journal   (Followers: 10, SJR: 0.539, h-index: 70)
Basic and Applied Pathology     Open Access   (Followers: 2, SJR: 0.113, h-index: 4)
Basin Research     Hybrid Journal   (Followers: 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: 9, SJR: 0.297, h-index: 23)
Behavioral Sciences & the Law     Hybrid Journal   (Followers: 23, SJR: 0.736, h-index: 57)
Berichte Zur Wissenschaftsgeschichte     Hybrid Journal   (Followers: 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: 3, SJR: 6.469, h-index: 114)
Biologie in Unserer Zeit (Biuz)     Hybrid Journal   (Followers: 42, SJR: 0.12, h-index: 1)
Biology of the Cell     Full-text available via subscription   (Followers: 9, SJR: 1.812, h-index: 69)
Biomedical Chromatography     Hybrid Journal   (Followers: 6, SJR: 0.572, h-index: 49)
Biometrical J.     Hybrid Journal   (Followers: 5, SJR: 0.784, h-index: 44)
Biometrics     Hybrid Journal   (Followers: 36, SJR: 1.906, h-index: 96)
Biopharmaceutics and Drug Disposition     Hybrid Journal   (Followers: 10, SJR: 0.715, h-index: 44)
Biopolymers     Hybrid Journal   (Followers: 18, SJR: 1.199, h-index: 104)
Biotechnology and Applied Biochemistry     Hybrid Journal   (Followers: 45, SJR: 0.415, h-index: 55)
Biotechnology and Bioengineering     Hybrid Journal   (Followers: 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: 18, SJR: 1.374, h-index: 71)
Bipolar Disorders     Hybrid Journal   (Followers: 10, SJR: 2.592, h-index: 100)
Birth     Hybrid Journal   (Followers: 34, 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]   [58 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  [1584 journals]
  • Changing Systems Through Effective Teams: A Role for Simulation
    • Authors: Elizabeth D. Rosenman; Rosemarie Fernandez, Ambrose H. Wong, Michael Cassara, Dylan D. Cooper, Maybelle Kou, Torrey A. Laack, Ivette Motola, Jessica R. Parsons, Benjamin R. Levine, James A. Grand
      Abstract: Teams are the building blocks of the healthcare system, with growing evidence linking the quality of health care to team effectiveness, and team effectiveness to team training. Simulation has been identified as an effective modality for team training and assessment. Despite this, there are gaps in methodology, measurement, and implementation that prevent maximizing the impact of simulation modalities on team performance. As part of the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes,” we explored the impact of simulation on various aspects of team effectiveness. The consensus process included an extensive literature review, group discussions, and the conference “work-shop” involving emergency medicine physicians, medical educators, and team science experts. The objectives of this work are to: (1) explore the antecedents and processes that support team effectiveness, (2) summarize the current role of simulation in developing and understanding team effectiveness, and (3) identify research targets to further improve team-based training and assessment, with the ultimate goal of improving health care systems.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-20T04:17:57.47012-05:0
      DOI: 10.1111/acem.13260
       
  • Speechless
    • Authors: Nadine T. Himelfarb
      Abstract: Bright blue eyes rimmed with deep sun wrinkles, a crown of mousy brown hair that appeared freshly cut by a four-year old with safety scissors, the patient was thin figured, wearing a flannel, yellowed t-shirt peaking from underneath, and a boxy, heavily stained canvas jacket over the shoulders. Old jeans were cinched at the waist by a crackled leather belt. The dirty right foot which lay bare on the stretcher was then thrust at me. The patient pointed angrily at the exposed foot.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-20T03:40:38.347599-05:
      DOI: 10.1111/acem.13259
       
  • A simulation-based approach to measuring team situational awareness in
           emergency medicine: A multicenter, observational study
    • Authors: Elizabeth D. Rosenman; Aurora J. Dixon, Jessica M. Webb, Sarah Brolliar, Simon J. Golden, Kerin A. Jones, Sachita Shah, James A. Grand, Steve W.J. Kozlowski, Georgia T. Chao, Rosemarie Fernandez
      Abstract: ObjectivesTeam situational awareness (TSA) is critical for effective teamwork and supports dynamic decision-making in unpredictable, time-pressured situations. Simulation provides a platform for developing and assessing TSA; but these efforts are limited by suboptimal measurement approaches. The objective of this study was to develop and evaluate a novel approach to TSA measurement in interprofessional emergency medicine teams.MethodsWe performed a multicenter, prospective, simulation-based observational study to evaluate an approach to TSA measurement. Interprofessional emergency medical teams, consisting of emergency medicine resident physicians, nurses, and medical student, were recruited from the University of Washington (Seattle, WA) and Wayne State University (Detroit, MI). Each team completed a simulated emergency resuscitation scenario. Immediately following the simulation, team members completed a TSA measure, a team perception of shared understanding item, and a team leader effectiveness measure. Subject matter expert reviews and pilot testing of the TSA measure provided evidence of content and response process validity. Simulations were recorded and independently coded for team performance using a previously validated measure. The relationships between the TSA measure other variables (team clinical performance, team perception of shared understanding, team leader effectiveness, and team experience) were explored. The TSA agreement metric was indexed by averaging the pairwise agreement for each dyad on a team, and then averaging across dyads to yield agreement at the team level. For the team perception of shared understanding and team leadership effectiveness measures, individual team member scores were aggregated within a team to create a single team score. We computed descriptive statistics for all outcomes. We calculated Pearson's Product-Moment Correlations to determine bivariate correlations between outcome variables with two-tailed significance testing (p < 0.05).ResultsA total of 123 participants were recruited and formed 3-person teams (n = 41 teams). All teams completed the assessment scenario and post-simulation measures. Team situational awareness agreement ranged from 0.19 to 0.9 and had a mean (SD) of 0.61 (0.17). Team situational awareness correlated with team clinical performance (p
      PubDate: 2017-07-17T08:07:23.008638-05:
      DOI: 10.1111/acem.13257
       
  • Welcome to the real world: Do the conditions of FDA approval devalue high
           sensitivity troponin'
    • Authors: Richard Body; Simon Mahler
      Abstract: In January 2017 the Food and Drug Administration (FDA) approved the first high sensitivity cardiac troponin (hs-cTn) assay for use in the United States: the 5th generation hs-cTnT assay manufactured by Roche Diagnostics. This landmark decision finally enables Americans to benefit from the same improvements in diagnostic technology that the rest of the world has utilized for some six years.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-17T08:07:14.884094-05:
      DOI: 10.1111/acem.13256
       
  • Bacteremia Prediction Model for Community-Acquired Pneumonia: External
           Validation in a Multicenter Retrospective Cohort
    • Authors: Byunghyun Kim; Jungho Choi, Kyuseok Kim, Sujin Jang, Tae Gun Shin, Won Young Kim, Jung-Youn Kim, Yoo Seok Park, Soo Hyun Kim, Hui Jai Lee, Jonghwan Shin, JeSung You, Kyung Su Kim, Sung Phil Chung
      Abstract: ObjectiveMany studies have described constructing a prediction model for bacteremia in community-acquired pneumonia (CAP), but these studies were not validated in external heterogeneous groups. The objective of this study was to test the generalizability of a previous bacteremia prediction model for CAP by external validation.MethodsThis multicenter retrospective cohort analysis was performed in eight tertiary urban hospital emergency departments (ED). We reviewed adult patients who were hospitalized after presentation to the ED with CAP. We categorized the enrolled patients into three groups according to the bacteremia prediction model score and calculated the number of patients with or without a blood culture-positive result. We performed a multivariable analysis to identify significant predictors for bacteremia.ResultsAmong the enrolled 2,001 patients, 1,592 (79.6%), 371 (18.5%), and 38 (1.9%) were stratified to a low, moderate, and high-risk group, respectively, and this proportion was similar with previous study. Each group had a bacteremia-positive rate as follows: 1.2% for the low-risk group, 7.2% for the moderate-risk group, and 31.5% for the high-risk group. The area under the receiver operating characteristic curve for the bacteremia model in the external validation cohort was 0.81, and there was no significant difference with that of the previous internal validation cohort (p = 0.246). Assuming that blood cultures were not performed in the low-risk patients, the sensitivity and specificity of this model were 0.68 and 0.81, respectively. Additionally, the positive predictive value and negative predictive value were 9.54% and 98.87%, respectively. A platelet count less than 130,000 cell/μL, albumin less than 3.3 mg/dL, and C-reactive protein (CRP) greater than 17 mg/dL were identified as significant predictors with a sensitivity and specificity of, 0.70 and 0.83, respectively.ConclusionThe bacteremia prediction model was well validated in the general population and could help physicians make the decision to reduce the number of blood cultures in patients with CAP.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-16T22:20:23.342737-05:
      DOI: 10.1111/acem.13255
       
  • Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in
           the Emergency Department
    • Authors: Brian C. Weiner
      Abstract: In their introduction, Gungor et al described ultrasound as a technique for evaluation of patients with low prior probability of acute appendicitis. This testing protocol for appendicitis is being proposed to challenge and perhaps replace the current standard of care for imaging, CT scanning. Specificity of CT scanning is reported in the range of 92-98% and CT is generally felt to be more accurate than ultrasonography The finding of 95.8% specificity for their method appears competitive and may be arithmetically correct but is seriously flawed.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-11T03:40:26.123869-05:
      DOI: 10.1111/acem.13254
       
  • Conflicts of Interest in Emergency Medicine
    • Authors: Joel Martin Geiderman; Kenneth V. Iserson, Catherine A. Marco, John Jesus, Arvind Venkat
      Abstract: Conflicts of interest are common in the practice of emergency medicine and may be present in the areas of clinical practice, relations with industry, expert witness testimony, medical education, research, and organizations. A conflict of interest occurs when there is dissonance between a primary interest and another interest. The concept of professionalism in medicine places the patient as the primary interest in any interaction with a physician. We contend that patient welfare is the ultimate interest in the entire enterprise of medicine. Recognition and management of potential, real and perceived conflicts of interest are essential to the ethical practice of emergency medicine. This paper discusses how to recognize, address, and manage them.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-08T09:55:32.699239-05:
      DOI: 10.1111/acem.13253
       
  • Broken Bones: The Radiologic Atlas of Fractures and Dislocations, Second
           Edition
    • Authors: Kathleen Cowling; Aron Slear
      Abstract: Broken Bones: The Radiologic Atlas of Fractures and Dislocations, Second Edition is exactly what it's title describes and functions as a quick reference and learning tool on how to identify fractures that are evident on plain radiography. The audience that this text will most likely benefit is a healthcare provider that is tasked with reading and interpreting his or her own plain films. Whether this is an Emergency Medicine physician with or without a radiology department, a radiologist looking for a quick reference, or an orthopedic surgery resident studying fractures in different regions of the body.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-04T03:16:41.213795-05:
      DOI: 10.1111/acem.13251
       
  • Outcomes following possible undiagnosed aneurysmal subarachnoid
           hemorrhage: a contemporary analysis
    • Authors: Dustin G. Mark; Mamata V. Kene, David R. Vinson, Dustin W. Ballard
      Abstract: ObjectivesExisting literature suggests that patients with aneurysmal subarachnoid hemorrhage (aSAH) and “sentinel” aSAH symptoms prompting health care evaluations prior to aSAH diagnosis are at increased risk of unfavorable neurologic outcomes and death. Accordingly these encounters have been presumed to be unrecognized opportunities to diagnose aSAH, and the worse downstream outcomes representative of the added risks of delayed diagnoses. We sought to reinvestigate this paradigm among a contemporary cohort of patients with aSAH.MethodsA case-control cohort was retrospectively assembled among patients diagnosed with aSAH between January 1, 2007 and June 30, 2013 within an integrated healthcare delivery system. Patients with a discrete clinical evaluation for headache or neck pain within 14 days prior to formal aSAH diagnosis were identified as cases, and the remaining patients served as controls. Modified Rankin Scale (mRS) scores at 90 days and 1 year were determined by structured chart review. Multivariable logistic regression controlling for age, gender, ethnicity, presence of intracerebral or intraventricular hemorrhage at diagnosis, and aneurysm size was used to compare adjusted outcomes. Sensitivity analyses were performed using varying definitions of favorable neurologic outcomes, a restricted control subgroup of patients with normal mental status at hospital admission, inclusion of additional cases that were diagnosed outside of the integrated health system, and exclusion of patients without evidence of subarachnoid blood on initial non-contrast cranial computed tomography at the diagnostic encounter (i.e. “CT-negative” SAH).Results450 patients with aSAH were identified, 46 (10%) of whom had clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis (cases). In contrast to prior reports, no differences were observed among cases as compared to control patients in adjusted odds of death or unfavorable neurologic status at 90 days (0.35, 95%CI 0.11-1.15; 0.59, 95%CI 0.22-1.60, respectively) or at 1 year (0.58, 95%CI 0.19-1.73; 0.52, 95%CI 0.18-1.51, respectively). Likewise, neither restricting the analysis to a control subgroup of patients with normal mental status at hospital admission, varying the dichotomous definition of unfavorable neurologic outcome, inclusion of cases diagnosed outside the integrated health system, or exclusion of patients with CT-negative SAH resulted in significant adjusted outcome differences.ConclusionIn a contemporary cohort of patients with aSAH, we observed no statistically significant increase in the adjusted odds of death or unfavorable neurologic outcomes among patients with clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis of aSAH. While these findings cannot exclude a smaller risk difference than previously reported, they can help refine decision analyses and testing threshold determinations for patients with possible aSAH.This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-04T02:55:38.278825-05:
      DOI: 10.1111/acem.13252
       
  • Response to Letter: Diagnostic Value of Bedside Ultrasound in Acute
           Appendicitis in ED: Methodological and Statistical Issues on Diagnostic
           Value
    • Authors: Faruk Gungor; Erkan Goksu, Taylan Kilic
      Abstract: The validity of a diagnostic test can be demonstrated by comparing it to a gold standard test. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), positive and negative likelihood ratios, diagnostic odds ratio, and the area under the ROC curve are the parameters that reflect the discriminative ability of a diagnostic study. Diagnostic accuracy is very sensitive to the characteristics of the study population and it is affected by the prevalence or the spectrum of the disease studied. Therefore, it is important to know how to interpret the diagnostic parameters of the tests studied (3).This article is protected by copyright. All rights reserved.
      PubDate: 2017-07-03T12:32:12.015975-05:
      DOI: 10.1111/acem.13250
       
  • Using Press Ganey Provider Feedback To Improve Patient Satisfaction: A
           Pilot Randomized Controlled Trial
    • Authors: Craig D Newgard; Rongwei Fu, James Heilman, Mary Tanski, O. John Ma, Alan Lines, L. Keith French
      Abstract: Study ObjectiveTo conduct a pilot randomized controlled trial to assess the feasibility, logistics and potential effect of monthly provider funnel plot feedback reports from Press Ganey data and semi-annual face-to-face coaching sessions to improve patient satisfaction scores.MethodsThis was a pilot randomized controlled trial of 25 emergency medicine faculty providers in one urban academic emergency department. We enrolled full-time clinical faculty with at least 12 months of baseline Press Ganey data, who anticipated working in the ED for at least 12 additional months. Providers were randomized into intervention or control groups in a 1:1 ratio. The intervention group had an initial 20-minute meeting to introduce the funnel plot feedback tool and standardized feedback on their baseline Press Ganey scores, then received a monthly email with their individualized funnel plot depicting cumulative Press Ganey scores (compared to their baseline score and the average score of all providers) for 12 months. The primary outcome was the difference in Press Ganey “Doctor-Overall” scores between treatment groups at 12 months. We used a weighted analysis of covariance model to analyze the study groups, accounting for variation in the number of surveys by provider and baseline scores.ResultsOf 37 eligible faculty, we enrolled 25 providers, 13 of whom were randomized to the intervention group and 12 to the control group. During the study period, there were 815 Press Ganey surveys returned, ranging from 4 to 71 surveys per provider. For the standardized overall doctor score over 12 months (primary outcome), there was no difference between the intervention and control groups (difference 1.3 points, 95% confidence interval -2.4 – 5.9, p = .47). Similarly, there was no difference between groups when evaluating the four categories of doctor-specific patient satisfaction scores from the Press Ganey survey (all p> 0.05).ConclusionsIn this pilot trial of monthly provider funnel plot Press Ganey feedback reports, there was no difference in patient satisfaction scores between the intervention and control groups after 12 months. While this study was not powered to detect outcome differences, we demonstrate the feasibility, logistics, and effect sizes that could be used to inform future definitive trials.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-29T14:00:24.136282-05:
      DOI: 10.1111/acem.13248
       
  • Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult
           Open Globe Injuries by Neuroradiology and Ophthalmology
    • Authors: Eric L. Crowell; Vivek A. Koduri, Emilio P. Supsupin, Robert E. Klinglesmith, Alice Z. Chuang, Gene Kim, Laura A. Baker, Robert M. Feldman, Lauren S. Blieden
      Abstract: ObjectiveTo evaluate the sensitivity and specificity of computed tomography (CT) diagnosis of open globes; determine which imaging factors are most predictive of open globe injuries; and evaluate the agreement between neuroradiologist and ophthalmologist readers for diagnosis of open and closed globes.MethodsThis study was a retrospective cohort study. Patients who presented to Memorial Hermann—Texas Medical Center with suspicion for open globes were reviewed. One neuroradiologist and 2 ophthalmologists masked to clinical information reviewed CT images for signs concerning for open globe including change in globe contour, anterior chamber deformation, intraocular air, vitreous hemorrhage, subretinal fluid indicating retinal or choroidal detachment, dislocated or absent lens, intraocular foreign body, and orbital fracture. Using the clinically or surgically confirmed globe status as the true globe status, sensitivity, specificity, and agreement (kappa) were calculated and used to investigate which imaging factors are most predictive of open globe injuries.ResultsOne hundred fourteen patients were included: 35 patients with open globes and 79 patients with closed globes. Specificity was greater than 97% for each reader, and sensitivity ranged from 51 to 77% among readers. The imaging characteristics most consistently used to predict an open globe injury were change in globe contour and vitreous hemorrhage (sensitivity: 43% to 57% and specificity> 98%). The agreement of impression of open globe between the neuroradiologist and ophthalmologists was good and excellent between ophthalmologists.ConclusionsCT imaging is not absolute, and the sensitivity is still inadequate to be fully relied upon. The CT imaging findings most predictive of an open globe injury were change in globe contour and vitreous hemorrhage. Clinical exam or surgical exploration remains the most important component in evaluating for a suspected open globe, with CT imaging as an adjunct.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-29T14:00:21.118048-05:
      DOI: 10.1111/acem.13249
       
  • The Economic Value of Hybrid Single-Photon Emission Computed Tomography
           with Computed Tomography Imaging in Pulmonary Embolism Diagnosis
    • Authors: Lauren K. Toney; Richard D. Kim, Swetha R. Palli
      Abstract: ObjectiveTo quantify the potential economic value of single-photon emission computed tomography (SPECT) with computed tomography (CT; SPECT/CT) versus CT pulmonary angiography (CTPA), ventilation-perfusion (V/Q) planar scintigraphy and V/Q SPECT imaging modalities for diagnosing suspected pulmonary embolism (PE) patients in an emergency setting.MethodsAn Excel-based simulation model was developed to compare SPECT/CT versus the alternate scanning technologies from a payer's perspective. Clinical endpoints (diagnosis, treatment, complications and mortality) and their corresponding cost data (2016 USD) were obtained by performing a best evidence review of the published literature. Studies were pooled and parameters weighted by sample size. Outcomes measured included differences in (1) excess costs (2) total costs and (3) lives lost per annum between SPECT/CT and the other imaging modalities. One-way (±25%) sensitivity and three scenario analyses were performed to gauge the robustness of the results.ResultsFor every 1,000 suspected PE patients undergoing imaging, expected annual economic burden by modality was found to be: 3.2 million (SPECT/CT), 3.8 million (CTPA), 5.8 million (planar) and 3.6 million (SPECT) USD, with a switch to SPECT/CT technology yielding per-patient-per-month cost savings of $51.8 (vs. CTPA), $213.8 (vs. planar), and $36.3 (vs. SPECT) respectively. The model calculated that the incremental number of lives saved with SPECT/CT was 6 (vs. CTPA), and 3 (vs. planar). Utilizing SPECT/CT as the initial imaging modality for workup of acute PE was also expected to save $994,777 (vs. CTPA), $2,852,014 (vs. planar), and $435,038 (vs. SPECT) in ‘potentially avoidable’ excess costs per annum for a payer or health plan.ConclusionCompared to the currently available scanning technologies for diagnosing suspected PE, SPECT/CT appears to confer superior economic value, primarily via improved sensitivity and specificity and low non-diagnostic rates. In turn, the improved diagnostic accuracy accords this modality the lowest ratio of expenses attributable to potentially avoidable complications, misdiagnosis and underdiagnosis.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-26T09:52:40.462267-05:
      DOI: 10.1111/acem.13247
       
  • Systemic Thrombolysis, Catheter-Directed Thrombolysis and Anticoagulation
           for Intermediate-Risk Pulmonary Embolism: A Simulation Modeling Analysis
    • Authors: Christopher Kabrhel; Ayman Ali, Jin Choi, Chin Hur
      Abstract: ObjectivesDecision-making around the use of thrombolysis for patients with intermediate-risk (submassive) PE remains challenging. Studies indicate favorable clinical outcomes with systemic thrombolytics (IV tPA), but the risk of major bleeding and hemorrhagic stroke is a deterrent. Catheter-directed thrombolysis (CDT) may be a preferable strategy, as it has been shown to have a lower risk of bleeding than systemic thrombolysis. However, a three-arm randomized control study comparing IV tPA, CDT, and anticoagulation alone, with long-term follow up, would be costly and is unlikely to be performed. The aim of this study was to use decision modeling to quantitatively estimate the differences between the three strategies.MethodsWe created an individual level state-transition model to simulate long-term outcomes of a hypothetical patient cohort treated with either IV tPA, CDT or anticoagulation alone. Our model incorporated clinical RCT and longitudinal study data to inform patient characteristics and outcomes specific to each study arm. The base case was a 65 year old patient. Additionally, we utilized preliminary data published by the Pulmonary Embolism Response Team (PERT) at the Massachusetts General Hospital. Variance in model inputs was addressed with deterministic and probabilistic sensitivity analyses. Our primary endpoint was quality-adjusted life years (QALYs). Secondary endpoints included total cost and incremental cost-effectiveness ratios (ICER).ResultsCDT (mean, 95% confidence interval) [7.388 (7.381, 7.396) QALYs] resulted in the most long-term utility for eligible patients compared to anticoagulation alone [7.352 (7.345, 7.360) QALYs] or IV tPA [7.343 (7.336, 7.351) QALYs]. Patients receiving CDT had an elevated risk of hemorrhagic stroke in comparison to anticoagulation alone; however, patients treated with anticoagulation alone were more likely to experience recurrent PE associated adverse outcomes. Results were stable with sensitivity analyses varying age and sex. Our probabilistic sensitivity analysis assessing joint variance predicts CDT to be the most effective strategy, when measured by mean QALYs, in 98.4% of runs, while systemic thrombolysis was favored over anticoagulation alone 34.4% of the time. The ICER of CDT compared to anticoagulation was $317,042 per QALY gained.ConclusionIn our model, for those eligible, CDT results in the largest number of QALYs for patients with intermediate-risk PE, although it is relatively expensive and the absolute difference in QALYs between anticoagulation alone and CDT is small. Future studies that provide data on longitudinal quality-of-life outcomes of patients treated for PE and characteristics of CDT would be beneficial to augment model inputs, inform assumptions, and validate results.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-26T05:27:31.989269-05:
      DOI: 10.1111/acem.13242
       
  • Prehospital advanced cardiac life support for out-of-hospital cardiac
           arrest: a cohort study
    • Authors: Alexis Cournoyer; Eric Notebaert, Massimiliano Iseppon, Sylvie Cossette, Luc Londei-Leduc, Yoan Lamarche, Judy Morris, Éric Piette, Raoul Daoust, Jean-Marc Chauny, Catalina Sokoloff, Yiorgos Alexandros Cavayas, Jean Paquet, André Denault
      Abstract: ObjectivesOut-of-hospital advanced cardiac life support (ACLS) has not consistently shown a positive impact on survival. Extracorporeal cardiopulmonary resuscitation (E-CPR) could render prolonged on-site resuscitation (ACLS or basic cardiac life support [BCLS]) undesirable in selected cases. The objectives of this study were to evaluate, in patients suffering from out-of-hospital cardiac arrest (OHCA) and in a subgroup of potential E-CPR candidates, the association between the addition of prehospital ACLS to BCLS and survival to hospital discharge, prehospital return of spontaneous circulation (ROSC) and delay from call to hospital arrival.MethodsThis cohort study targets adult patients treated for OHCA between April 2010 and December 2015 in the city of Montreal, Canada. We defined potential E-CPR candidates using clinical criteria previously described in the literature (65 years of age or younger, initial shockable rhythm, absence of return of spontaneous circulation after 15 minutes of prehospital resuscitation and emergency medical services witnessed collapse or witnessed collapse with bystander cardiopulmonary resuscitation). Associations were evaluated using multivariate regression models.ResultsA total of 7134 patients with OHCA were included, 761 (10.7%) of whom survived to discharge. No independent association between survival to hospital discharge and the addition of prehospital ACLS to BCLS was found in either the entire cohort [adjusted odds ratio (AOR) 1.05 (95% confidence interval 0.84-1.32), p=0.68] or amongst the 246 potential E-CPR candidates [AOR 0.82 (95% confidence interval 0.36-1.84), p=0.63]. The addition of prehospital ACLS to BCLS was associated with a significant increase in the rate of prehospital ROSC in all patients experiencing OHCA (AOR 3.92 [95% CI 3.38-4.55], p
      PubDate: 2017-06-24T04:07:28.384399-05:
      DOI: 10.1111/acem.13246
       
  • Randomized Controlled Double-Blind Trial Comparing Haloperidol Combined
           with Conventional Therapy to Conventional Therapy Alone in Patients with
           Symptomatic Gastroparesis
    • Authors: Carlos J. Roldan; Kimberly A. Chambers, Linda Paniagua, Sonali Patel, Marylou Cardenas-Turanzas, Yashwant Chathampally
      Abstract: ObjectiveGastroparesis is a debilitating condition that causes nausea, vomiting, and abdominal pain. Management includes analgesics and antiemetics, but symptoms are often refractory. Haloperidol has been utilized in the palliative care setting for similar symptoms. The study objective was to determine whether haloperidol as an adjunct to conventional therapy would improve symptoms in gastroparesis patients presenting to the emergency department.Methods and trial designThis was a randomized, double-blind, placebo-controlled trial of adult emergency department patients with acute exacerbation of previously diagnosed gastroparesis. The treatment group received 5 mg haloperidol plus conventional therapy (determined by the treating physician). The control group received a placebo plus conventional therapy. The severity of each subject's abdominal pain and nausea were assessed before intervention and every 15 minutes thereafter for 1 hour using a 10-point scale for pain and a 5-point scale for nausea. Primary outcomes were decreased pain and nausea 1 hour after treatment.Results and Adverse EffectsOf the 33 study patients, 15 were randomized to receive haloperidol. Before treatment, the mean intensity of pain was 8.5 in the haloperidol group and 8.28 in the placebo group; mean pretreatment nausea scores were 4.53 and 4.11, respectively. One hour after therapy, the mean pain and nausea scores in the haloperidol group were 3.13 and 1.83 compared to 7.17 and 3.39 in the placebo group. The reduction in mean pain intensity therapy was 5.37 in the haloperidol group (p ≤0.001) compared to 1.11 in the placebo group (p =0 .11). The reduction in mean nausea score was 2.70 in the haloperidol group (p ≤ 0.001) and 0.72 in the placebo group (p = 0.05). Therefore, the reductions in symptom scores were statistically significant in the haloperidol group but not in the placebo group. No adverse events were reported.ConclusionsHaloperidol as an adjunctive therapy is superior to placebo for acute gastroparesis symptoms.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-24T04:07:26.499841-05:
      DOI: 10.1111/acem.13245
       
  • The Association of Health Literacy with Preventable ED Visits: A
           Cross-Sectional Study
    • Authors: Meenakshi P. Balakrishnan; Jill Boylston Herndon, Jingnan Zhang, Thomas Payton, Jonathan Shuster, Donna L. Carden
      Abstract: BackgroundPolicy-makers argue that emergency department (ED) visits for conditions preventable with high-quality outpatient care contribute to waste in the healthcare system. However, access to ambulatory care is uneven, especially for vulnerable populations like minorities, the poor and those with limited health literacy. The impact of limited health literacy on ED visits that are preventable with timely, high-quality ambulatory care is unknown.ObjectiveTo determine the association of health literacy and preventable ED visits.MethodsWe conducted an observational cross-sectional study of potentially preventable ED visits (outcome) among adults (≥18 years old) in an ED serving an urban community. We assessed health literacy (predictor) through structured interviews with the Rapid Estimate of Adult Literacy in Medicine (REALM). We recorded age, sex, race, employment, payer, marital and health status, and number of comorbidities through structured interviews or electronic record review. We identified potentially preventable ED visits in the two years prior to the index ED visit by applying Agency for Healthcare Research and Quality technical specifications to identify ambulatory care sensitive conditions using ED discharge diagnoses in hospital administrative data. We used Poisson regression to evaluate the number of preventable ED visits among patients with limited (REALM < 61), versus adequate (REALM ≥ 61), health literacy after adjusting for covariates.ResultsOf 1,201 participants, 709 (59%) were female, 370 (31%) were African American, mean age was 41.6 years, and 394 (33%) had limited health literacy. Out of 4,444 total ED visits, 423 (9.5%) were potentially preventable. Of these, 260 (61%) resulted in hospital admission and 163 (39%) were treat-and-release. After adjusting for covariates, patients with limited literacy had 2.3 (95% CI 1.7-3.1) times the number of potentially preventable ED visits resulting in hospital admission compared to individuals with adequate health literacy, 1.4 (95%CI 1.0-2.0) times the number of treat-and-release visits, and 1.9 (95% CI 1.5-2.4) times the number of total preventable ED visits.ConclusionsOur results suggest that the ED may be an important site to deploy universal literacy-sensitive precautions and to test literacy-sensitive interventions with the goal of reducing the burden of potentially preventable ED visits on patients and the healthcare system.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-24T04:02:27.060238-05:
      DOI: 10.1111/acem.13244
       
  • Neurology Concepts: Young Women and Ischemic Stroke: Evaluation and
           Management in the Emergency Department
    • Authors: Bernard P. Chang; Charles Wira, Joseph Miller, Murtaza Akhter, Bradley E. Barth, Joshua Willey, Lauren Nentwich, Tracy Madsen
      Abstract: ObjectiveIschemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g. premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting.MethodsA panel of 6 board certified emergency physicians, 1 with fellowship training in stroke and 1 with training in sex and gender based medicine, along with 1 vascular neurologist were co-authors involved in the paper. Each author used various search strategies (e.g PubMed, Psycinfo, and Google Scholar) for primary research, and review articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authorsResultsEstimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g. tPA) in both pregnant and nonpregnant individuals.ConclusionUnique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-24T03:57:29.544015-05:
      DOI: 10.1111/acem.13243
       
  • Society for Academic Emergency Medicine Statement on Plagiarism
    • Authors: Shellie L. Asher; Kenneth V. Iserson, Lisa H. Merck
      Abstract: The integrity of the research enterprise is of the utmost importance for the advancement of safe and effective medical practice for patients and for maintaining the public trust in health care. Academic societies and editors of journals are key participants in guarding scientific integrity. Avoiding and preventing plagiarism helps to preserve the scientific integrity of professional presentations and publications. The Society for Academic Emergency Medicine (SAEM) Ethics Committee discusses current issues in scientific publishing integrity and provides a guideline to avoid plagiarism in SAEM presentations and publications.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-19T09:12:25.97211-05:0
      DOI: 10.1111/acem.13241
       
  • Adherence to Standards for Reporting Diagnostic Accuracy in Emergency
           Medicine Research
    • Authors: Lucas Gallo; Nadia Hua, Mathew Mercuri, Angela Silveira, Andrew Worster
      Abstract: BackgroundDiagnostic tests are used frequently in the emergency department (ED) to guide clinical decision-making and, hence, influence clinical outcomes. The Standards for Reporting of Diagnostic Accuracy (STARD) criteria was developed to ensure diagnostic test studies are performed and reported to best inform clinical decision making in the ED.ObjectiveTo determine the extent to which diagnostic studies published in emergency medicine journals adhered to STARD 2003 criteria.MethodsDiagnostic studies published in 8 MEDLINE-listed, peer-reviewed, emergency medicine journals over a 5-year period were reviewed for compliance to STARD criteriaResults12649 articles were screened and 114 studies were included in our study. 20% of these were randomly selected for assessment using STARD 2003 criteria. Adherence to STARD 2003 reporting standards for each criteria ranged from 8.7% adherence (criteria: reporting adverse events from performing index test or reference standard) to 100% (multiple criteria).ConclusionJust over half of STARD criteria are reported in more than 80% studies. As poorly reported studies may negatively impact their clinical usefulness, it is essential that studies of diagnostic test accuracy be performed and reported adequately. Future studies should assess whether studies have improved compliance with the STARD 2015 criteria amendment.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-16T08:25:18.637383-05:
      DOI: 10.1111/acem.13233
       
  • Comparing the No Objective Testing rule to the HEART pathway
    • Authors: Jaimi Greenslade; Louise Cullen
      Abstract: We read with great interest the article by Stopyra and colleagues1 comparing the no objective testing (NOT) rule and the HEART pathway using a cohort of 141 patients. The two rules, developed to risk stratify patients presenting to the emergency department (ED) with acute chest pain, were 100% sensitive for identifying major adverse cardiac events (MACE) at 30 days. The HEART pathway identified a more sizeable portion of low-risk patients who could be discharged without additional cardiac testing.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-13T03:10:21.157336-05:
      DOI: 10.1111/acem.13240
       
  • Response to the Letter to the Editor
    • Authors: Jason P. Stopyra; Chadwick D. Miller, Simon A. Mahler
      Abstract: We appreciate the insights and concerns raised in the above letter to the editor. The authors have thoughtfully highlighted some important distinctions between the original derivation of NOTR and our validation study.1,2 Specifically, the original NOTR derivation included cardiac death, acute myocardial infarction (MI), unstable angina (UA), and “urgent and emergent” revascularization in a composite safety endpoint (and did not include “elective” coronary revascularizations). Our study included death, MI, and any coronary revascularization events, but did not include UA.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-13T02:55:20.988234-05:
      DOI: 10.1111/acem.13239
       
  • Hot Off the Press: Point-of-care ultrasound for non-angulated distal
           forearm fractures in children
    • Authors: Justin Morgenstern; Corey Heitz, William K Milne
      Abstract: This prospective, cross-sectional diagnostic study examined the performance of point of care ultrasound (POCUS) in the diagnosis of suspected non-angulated forearm fractures in pediatric patients aged 4-17 years, using x-rays as the gold standard. The test characteristics reported are a sensitivity of 94.7% (95% CI 89.7-99.8%), a specificity of 93.5% (95% CI 88.6-98.5%), a positive likelihood ratio of 14.6, and a negative likelihood ratio of 0.6.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-07T09:50:32.007454-05:
      DOI: 10.1111/acem.13238
       
  • Improving Care of Transgender Patients
    • Authors: Nancy Lutwak
      Abstract: The recent publication, Is It Okay To Ask: Transgender Patient Perspectives on Sexual Orientation and Gender Identity Collection in Healthcare, is significant in its discussion of circumstances affecting willingness of transgender patients to disclose gender identity and sexual orientation as well as the participants’ focus on the need for improved LGBT education for medical staff. The authors also emphasize the importance of safe environments in primary care settings and emergency departments where providers may pose questions regarding intimate issues1.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-05T22:43:10.302196-05:
      DOI: 10.1111/acem.13236
       
  • The Plight of Veterans
    • Authors: Nancy Lutwak
      Abstract: As I listen to the sounds of the VA emergency department I realize the plight of many veterans istragic and some have lived through hard times not commonly recognized. There are so many headlines about veteran suicides, homelessness, post-traumatic stress disorder and injuries from explosive devices.This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-05T00:35:22.260523-05:
      DOI: 10.1111/acem.13237
       
  • Starry Aims to Overcome Knowledge Translation Inertia: The Standards for
           Reporting Implementation Studies (StaRI) Guidelines
    • Authors: Christopher R. Carpenter; Hilary Pinnock
      Abstract: In 2007, Academic Emergency Medicine hosted a Consensus Conference on “Knowledge Translation in Emergency Medicine” with the objective of identifying high-yield research priorities for the concept of moving from evidence to action.1 Patients often fail to receive care that aligns with quality indicators, and the Institute of Medicine has estimated that on average 17 years pass before just 14% of effective interventions reach the bedside.2-4 Equally important is the concept that de-implementing wasteful, inefficient, or outdated clinical approaches frequently require more time and effort than is available, so the trajectory of bedside decision-making often yields to the status quo.5This article is protected by copyright. All rights reserved.
      PubDate: 2017-06-02T10:16:46.968646-05:
      DOI: 10.1111/acem.13235
       
  • 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
           Department
    • 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
           States
    • Authors: Charles J. DiMaggio; Jacob B. Avraham, David C. Lee, Spiros G. Frangos, Stephen P. Wall
      Abstract: ObjectiveInjury related morbidity and mortality is an important emergency medicine and public health challenge in the United States (US). Here we describe the epidemiology of traumatic injury presenting to US emergency departments, define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries.MethodsWe conducted a secondary retrospective, repeated cross-sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all-payer emergency department survey database in the US. Main outcomes and measures were survey-adjusted counts, proportions, means, and rates with associated standard errors, and 95% confidence intervals. We plotted annual age-stratified emergency department discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level 1 or 2 trauma center care with injury fatality using a multi-variable survey-adjusted logistic regression analysis that controlled for age, gender, injury severity, comorbid diagnoses, and teaching hospital status.ResultsThere were 181,194,431 (standard error, se = 4234) traumatic injury discharges from US emergency departments between 2006 and 2012. There was an average year-to-year decrease of 143 (95% CI -184.3, -68.5) visits per 100,000 US population during the study period. The all-age, all-cause case-fatality rate for traumatic injuries across US emergency departments during the study period was 0.17% (se = 0.001). The case-fatality rate for the most severely injured averaged 4.8% (se = 0.001), and severely injured patients were nearly four times as likely to be seen in Level 1 or 2 trauma centers (relative risk = 3.9 (95% CI 3.7, 4.1)). The unadjusted risk ratio, based on group counts, for the association of Level 1 or 2 trauma centers with mortality was RR = 4.9 (95% CI 4.5, 5.3), however, after accounting for gender, age, injury severity and comorbidities, Level 1 or 2 trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 (0.79, 1.18)).There were notable changes at the extremes of age in types and causes of emergency department discharges for traumatic injury between 2009 and 2012. Age-stratified rates of diagnoses of traumatic brain injury increased 29.5% (se = 2.6) for adults older than 85, and increased 44.9% (se = 1.3) for children younger than 18. Firearm related injuries increased 31.7% (se = 0.2) in children five years and younger. The total inflation-adjusted cost of emergency department injury care in the US between 2006 and 2012 was $99.75 billion (se = 0.03).ConclusionsEmergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the US. Level 1 or 2 trauma centers remain a bulwark against the tide of severe trauma in the US. But, the types and causes of traumatic injury in the US are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm-related trauma presenting increased challenges.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T09:20:29.237659-05:
      DOI: 10.1111/acem.13223
       
  • Validation of the No Objective Testing Rule and Comparison to the HEART
           Pathway
    • Authors: Jason P. Stopyra; Chadwick D. Miller, Brian C. Hiestand, Cedric W. Lefebvre, Bret A. Nicks, David M. Cline, Kim L. Askew, Robert F. Riley, Gregory B. Russell, James W. Hoekstra, Simon A. Mahler
      Abstract: BackgroundThe No Objective Testing Rule (NOTR) is a decision aid designed to safely identify Emergency Department (ED) patients with chest pain who do not require objective testing for coronary artery disease.ObjectivesTo validate the NOTR in a cohort of US ED patients with acute chest pain and compare its performance to the HEART Pathway.MethodsA secondary analysis of 282 participants enrolled in the HEART Pathway Randomized Controlled Trial was conducted. Each patient was classified as low-risk or at- risk by the NOTR. Sensitivity for major adverse cardiac events (MACE) at 30 days was calculated in the entire study population. NOTR and HEART Pathways were compared among patients randomized to the HEART Pathway in the parent trial using McNemar's test and the net reclassification index (NRI).ResultsMACE occurred in 22/282 (7.8%) participants, including no deaths, 16/282 (5.6%) with MI, and 6/282 (2.1%) with coronary revascularization without MI. NOTR was 100% (95% CI 84.6-100%) sensitive for MACE and identified 78/282 patients (27.7%, 95% CI 22.5-33.3%) as low-risk. In the HEART Pathway arm (n=141), both NOTR and HEART Pathway identified all patients with MACE as at-risk. Compared to NOTR, the HEART Pathway was able to correctly reclassify 27 patients without MACE as low-risk, yielding a NRI of 20.8% (95% CI 11.3-30.2%).ConclusionsWithin a US cohort of ED patients with chest pain, the NOTR and HEART Pathway were 100% sensitive for MACE at 30 days. However, the HEART Pathway identified more patients suitable for early discharge than the NOTR.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-11T09:20:24.612215-05:
      DOI: 10.1111/acem.13221
       
  • 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)
           model
    • Authors: Vikhyat S. Bebarta; Normalynn Garrett, Matthew Brenner, Sari Mahon, Joseph K. Maddry, Susan Boudreau, Maria Castaneda, Gerard Boss
      Abstract: BackgroundHydrogen sulfide (H2S) is a potentially deadly gas that naturally occurs in petroleum and natural gas. The Occupational Health and Safety Administration cites H2S as a leading cause of workplace gas inhalation deaths. Mass casualties of H2S toxicity may be caused by exposure from industrial accidents or release from oil field sites. H2S is also an attractive terrorism tool because of its high toxicity and ease with which it can be produced. Several potential antidotes have been proposed for hydrogen sulfide poisoning but none have been completely successful.ObjectiveTo compare treatment response assessed by the time to spontaneous ventilation among groups of swine with acute H2S induced apnea treated with intravenous (IV) cobinamide (4mg/kg in 0.8 ml of 225mM solution), IV hydroxocobalamin (4mg/kg in 5 ml saline), or saline alone.MethodsTwenty-four swine (45-55 kg) were anesthetized, intubated, and instrumented with continuous femoral and pulmonary artery pressure monitoring. After stabilization, anesthesia was adjusted such that animals would spontaneous ventilate with an FIO2 of 0.21. Sodium hydrosulfide (NaHS; concentration of 8 mg/ml) was begun at 1 mg/kg/min until apnea was confirmed for 20 seconds by capnography. This infusion rate was sustained for 1.5 minutes post apnea, and then decreased to a maintenance rate for the remainder of the study to replicate sustained clinical exposure. Animals were randomly assigned to receive cobinamide (4 mg/kg), hydroxocobalamin (4 mg/kg) or saline and monitored for 60 minutes beginning one-minute post apnea. G* power analysis using the Z test determined that equal group sizes of 8 animals were needed to achieve a power of 80% in detecting a 50% difference in return to spontaneous ventilations at α=0.05.ResultsThere were no significant differences in baseline variables. Moreover, there were no significant differences in the mg/kg dose of NaHS (5.6 mg/kg; p=0.45) required to produce apnea. Whereas all of the cobinamide treated animals survived (8/8), none of the control (0/8) or hydroxocobalamin (0/8) treated animals survived. Mean time to spontaneous ventilation in the cobinamide treated animals was 3.2(±1.1) minutes.ConclusionsCobinamide successfully rescued the severely NaHS-poisoned swine from apnea in the absence of assisted ventilation.This article is protected by copyright. All rights reserved.
      PubDate: 2017-05-04T11:01:10.415887-05:
      DOI: 10.1111/acem.13213
       
  • 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
       
  • 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
       
  • 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
       
  • 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
       
  • Emergency Department Initiated Home Oxygen for Bronchiolitis: A
           Prospective Study of Community Follow-up, Caregiver Satisfaction and
           Outcomes
    • 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
       
  • A Quality Improvement Initiative to Decrease the Rate of Solitary Blood
           Cultures in the Emergency Department
    • Authors: Joseph Choi; Sahand Ensafi, Lucas Brien Chartier, Oliver Van Praet
      Abstract: ObjectivesBest practice guidelines recommend that at least two sets of blood cultures (BCs) be sent when blood cultures are required. However, high rates of solitary BCs are still common in the emergency department (ED). The aim of this study was to evaluate the efficacy of different quality improvement initiatives aimed at reducing the rate of solitary blood cultures being sent to the lab on patients ultimately discharged from our ED.MethodsThis was a multi-centre, multi-phase, prospective study evaluating a comprehensive education-based intervention and a second intervention that combined a computerized forcing function along with a brief education-based intervention. The results were analyzed using segmented regression analysis, as well as statistical process control charts.ResultsThe baseline rate of solitary sets of BCs was 41.1%. The education intervention reduced this rate to 30.3%. The introduction of a forcing function with a brief educational intervention further reduced the rate to 11.6%. This represents an absolute reduction of 29.5% from baseline (relative reduction of 71.8%). According to segmental regression analyses, the education intervention alone did not produce a statistically significant change when factoring possible background time-related trends (P = 0.071). However, the forcing function produced a statistically significant improvement (P < 0.0005), which was maintained for 6 months.ConclusionThe combination of a brief education-based intervention and a computerized forcing function was more effective than education alone in reducing solitary BC collection in our ED in this time series study. Forcing functions can be a powerful tool in modifying behaviours and processes in the clinical setting.This article is protected by copyright. All rights reserved.
      PubDate: 2017-01-20T20:50:34.440395-05:
      DOI: 10.1111/acem.13161
       
  • Issue Information
    • Pages: 781 - 784
      PubDate: 2017-07-11T08:36:18.080224-05:
      DOI: 10.1111/acem.13092
       
  • 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
      First page: 785
      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
       
  • 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
      First page: 796
      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
       
  • 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,
      First page: 803
      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
       
  • 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
      First page: 814
      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
      First page: 822
      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
       
  • D-Dimer Interval Likelihood Ratios for Pulmonary Embolism
    • Authors: Michael A. Kohn; Frederikus A. Klok, Nick Es
      First page: 832
      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
       
  • 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
      First page: 839
      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
       
  • 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
      First page: 846
      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
       
  • Career Development Awards in Emergency Medicine: Resources and Challenges
    • Authors: Bryn E. Mumma; Anna Marie Chang, Bory Kea, Megan L. Ranney,
      First page: 855
      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
       
  • Hot off the Press: Prospective and Explicit Clinical Validation of the
           Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative
           NT-proBNP
    • Authors: Corey Heitz; Justin Morgenstern, William K. Milne
      First page: 864
      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 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
      First page: 867
      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
       
  • Intravenous versus Non-Intravenous Benzodiazepines for the Abortion of
           Seizures: A Systematic Review and Meta-analysis of Randomized Controlled
           Trials
    • Authors: Abdussalam Alshehri; Ahmad Abulaban, Rakan Bokhari, Suleiman Kojan, Majid Alsalamah, Mazen Ferwana, Mohammad Hassan Murad
      First page: 875
      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
       
  • Correspondence - Response to Letter to the Editor — Ultrasound Assisted
           Lumbar Puncture on Infants in the Pediatric Emergency Department
    • Authors: Michael Gorn
      First page: 885
      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
       
  • 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
      First page: 887
      PubDate: 2017-03-22T05:57:02.915386-05:
      DOI: 10.1111/acem.13176
       
  • Koenig and Schultz's Disaster Medicine: Comprehensive Principles and
           Practices, 2nd Edition
    • Authors: Eric C. Silverman; Mary P. Mercer
      First page: 888
      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
       
 
 
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