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Open Access Publications from the University of California

Volume 13, Issue 5, 2012

Healthcare Utilization

Does Limiting Oral Contrast Decrease Emergency Department Length of Stay ?

Introduction: The purpose of this study was to examine the impact on emergency department (ED) length of stay (LOS) of a new protocol for intravenous (IV)-contrast only abdominal/pelvic computed tomography (ABCT) compared to historical controls.

Methods: This was a retrospective case-controlled study performed at a single academic medical center. Patients ≥ 18 undergoing ABCT imaging for non-traumatic abdominal pain were included in the study. We compared ED LOS between historical controls undergoing ABCT imaging with PO/IV contrast and study patients undergoing an IV-contrast-only protocol. Imaging indications were the same for both groups and included patients with clinical suspicion for appendicitis, diverticulitis, small bowel obstruction, or perforation. We identified all patients from the hospital’s electronic storehouse (imaging code, ordering department, imaging times), and we abstracted ED LOS and disposition from electronic medical records.

Results: Two hundred and eleven patients who underwent PO/IV ABCT prep were compared to 184 patients undergoing IV-contrast only ABCT prep. ED LOS was shorter for patients imaged with the IV-contrast only protocol (4:35 hrs vs. 6:39 hrs, p < 0.0001).

Conclusion: Implementation of an IV-contrast only ABCT prep for select ED patients presenting for evaluation of acute abdominal pain significantly decreased ED LOS. [West J Emerg Med 2012;13(5):383-387.]

Value of Mandatory Screening Studies in Emergency Department Patients Cleared for Physchiatric Admission

Introduction: Laboratory and radiographic studies are often required by psychiatric services prior to admitting emergency patients who are otherwise deemed medically stable. Such testing may represent an unnecessary expense that prolongs emergency department stays without significantly improving care. This study determines the prevalence of such testing and how often it leads to changes in care.

Methods: We prospectively tracked laboratory testing among psychiatric patients presenting to the emergency departments of two academic tertiary care facilities. For each visit we determined whether laboratory or radiographic studies were ordered, and whether the examination was conducted at the request of the emergency physician as part of a medical screening examination or requested by the psychiatry service. We then determined if this testing changed patient disposition.

Results: Our study enrolled 598 patients. Of these, emergency physicians ordered testing as a part of medical screening on 155 patients (25.9%). We found the psychiatry service ordered laboratory or radiographic studies for 191 of 434 patients (44.0%) who emergency physicians determined did not require ancillary testing for medical clearance. Of these 191 patients, only one (0.5%; 95% Confidence Interval: 0.01% - 2.9%) had an abnormal result that led to a change in disposition. Total Medicare reimbursement rates for the additional ancillary testing in this study was $37,682.

Conclusion: Ancillary testing beyond what is required for medical clearance of psychiatric emergency patients rarely alters care. Policies that require panels of testing prior to psychiatric admission are costly and appear to be unnecessary. [West J Emerg Med 2012;13(5):388-393.]

Technology in Emergency Care

Quantitative Brain Electrical Activity in the Initial Screening of Mild Traumatic Brain Injuries

Introduction: The incidence of emergency department (ED) visits for Traumatic Brain Injury (TBI) in the United States exceeds 1,000,000 cases/year with the vast majority classified as mild (mTBI). Using existing computed tomography (CT) decision rules for selecting patients to be referred for CT, such as the New Orleans Criteria (NOC), approximately 70% of those scanned are found to have a negative CT. This study investigates the use of quantified brain electrical activity to assess its possible role in the initial screening of ED mTBI patients as compared to NOC.

Methods: We studied 119 patients who reported to the ED with mTBI and received a CT. Using a hand-held electroencephalogram (EEG) acquisition device, we collected data from frontal leads to determine the likelihood of a positive CT. The brain electrical activity was processed off-line to generate an index (TBI-Index, biomarker). This index was previously derived using an independent population, and the value found to be sensitive for significant brain dysfunction in TBI patients. We compared this performance of the TBI-Index to the NOC for accuracy in prediction of positive CT findings.

Results: Both the brain electrical activity TBI-Index and the NOC had sensitivities, at 94.7% and 92.1% respectively. The specificity of the TBI-Index was more than twice that of NOC, 49.4% and 23.5% respectively. The positive predictive value, negative predictive value and the positive likelihood ratio were better with the TBI-Index. When either the TBI-Index or the NOC are positive (combining both indices) the sensitivity to detect a positive CT increases to 97%.

Conclusion: The hand-held EEG device with a limited frontal montage is applicable to the ED environment and its performance was superior to that obtained using the New Orleans criteria. This study suggests a possible role for an index of brain function based on EEG to aid in the acute assessment of mTBI patients. [West J Emerg Med. 2012;13(5):394-400.]

Patient Communication

Urine Collection in the Emergency Department: What Really Happens in There?

Introduction: In women with suspected urinary tract infection (UTI), a non-contaminated voided specimen is considered important for valid urinalysis and culture results. We assess whether midstream parted-labia catch (MSPC) instructions were provided by nurses, understood, and performed correctly, according to the patient.

Methods: We conducted a cross-sectional survey of English- and Spanish-speaking female patients submitting voided urine samples for urinalysis for suspected UTI. The survey was conducted in a public teaching hospital emergency department (ED) from June to December 2010, beginning 2 months after development and dissemination of a nursing MSPC instructions protocol. Research assistants administered the survey within 2 hours of urine collection. Nurses were unaware of the study purpose.

Results: Of 129 patients approached, 74 (57%) consented and were included in the analysis. Median age was 35; 44% were Latino. Regarding instructions from nurses, patients reported the following: 45 (61%; 95% CI 50-72%) received any instructions; of whom 37 (82%; 95% CI 71-93%) understood them completely. Sixteen (36%; 95% CI 22-51%) were instructed to collect midstream; and 7 (16%; 95% CI 6-29%) to part the labia. Regardless of receiving or understanding instructions, 33 (45%; 95% CI 33-57%) reported actually collecting midstream, and 11 (15%, 95% CI 8-25%) parting the labia.

Conclusion: In this ED, instructions for MSPC urine collection frequently were not given, despite a nursing protocol, and patients rarely performed the essential steps. An evidence-based approach to urine testing in the ED that considers urine collection technique, is needed. [West J Emerg Med. 2012;13(5):401-405.]

Prehospital Care

Comparison of Prehospital Glucose with or without IV Thiamine

Introduction: Loading of thiamine prior to glucose administration during hypoglycemia to prevent Wernicke’s encephalopathy is routine in the prehospital setting. To date no study has looked at the validity of this therapy.

Methods: We evaluated a retrospective cohort of 242 patients who received intravenous glucose for hypoglycemia comparing those who received thiamine supplementation versus those who did not. Study endpoints were heart rate, blood pressure, Glasgow Coma Scale (GCS), reentry into the 911 system, and emergency department (ED) discharge rates.

Results: There were no significant differences between the thiamine, and without-thiamine groups. All patients were discharged neurologically intact or were alert and oriented when refusing transport to the hospital. None of the 242 patients re-called 911 within the immediate 24-hour period or returned to the ED.

Conclusion: To our knowledge this is the first study in the literature which evaluated the use of thiamine with glucose to prevent Wernicke’s encephalopathy in the prehospital setting. We found that routine administration of thiamine with glucose did not result in differences in respiratory rate, systolic blood pressure, GCS or ED hospital discharge rates. Until further research is done to validate our results emergency medical services leadership should consider whether the routine use of thiamine in the prehospital setting is appropriate for their system. [West J Emerg Med. 2012;13(5):406-409.]

Emergency Department Access

Factors Influencing Emergency Department Preference for Access to Health Care

Introduction: African-Americans are more likely than Caucasians to access healthcare through the emergency department (ED); however, the reasons behind this pattern are unclear. The objective is to investigate the effect of race, insurance, socioeconomic status, and perceived health on the preference for ED use.

Methods: This is a prospective study at a tertiary care ED from June to July 2009. Patients were surveyed to capture demographics, healthcare utilization, and baseline health status. The primary outcome of interest was patient-reported routine place of healthcare. Other outcomes included frequency of ED visits in the previous 6 months, barriers to primary care and patient perception of health using select questions from the Medical Outcomes Study Short Form 36 (SF-36).

Results: Two hundred and ninety-two patients completed the survey of whom 58% were African-American and 44% were uninsured. African-Americans were equally likely to report 3 or more visits to the ED, but more likely to state a preference for the ED for their usual place of care (24% vs. 13%, p < 0.01). No significant differences between groups were found for barriers to primary care, including insurance. African-Americans less often reported comorbidities or hospitalization within the previous 6 months (23% vs. 34%, p = 0.04). On logistic regression modeling, African-Americans were more than 2 times as likely to select the ED as their usual place of healthcare (OR 2.24, 95% CI 1.22 - 4.08).


Conclusion: African-Americans, independent of health insurance, are more likely than Caucasians to designate the ED as their routine place of healthcare. [West J Emerg Med. 2012;13(5):410-415.]

Societal Impact on Emergency Care

How Frequently are “Classic” Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department?

Introduction: Drug-seeking behavior (DSB) in the emergency department (ED) is a very common problem, yet there has been little quantitative study to date of such behavior.The goal of this study was to assess the frequency with which drug seeking patients in the ED use classic drug seeking behaviors to obtain prescription medication.

Methods: We performed a retrospective chart review on patients in an ED case management program for DSB. We reviewed all visits by patients in the program that occurred during a 1-year period, and recorded the frequency of the following behaviors: complaining of headache, complaining of back pain, complaining of dental pain, requesting medication by name, requesting a refill of medication, reporting medications as having been lost or stolen, reporting 10/10 pain, reporting greater than 10/10 pain, reporting being out of medication, and requesting medication parenterally. These behaviors were chosen because they are described as “classic” for DSB in the existing literature.

Results: We studied 178 patients from the case management program, who made 2,486 visits in 1 year. The frequency of each behavior was: headache 21.7%, back pain 20.8%, dental pain 1.8%, medication by name 15.2%, requesting refill 7.0%, lost or stolen medication 0.6%, pain 10/10 29.1%, pain greater than 10/10 1.8%, out of medication 9.5%, and requesting parenteral medication 4.3%. Patients averaged 1.1 behaviors per visit.


Conclusion: Drug-seeking patients appear to exhibit “classically” described drug-seeking behaviors with only low to moderate frequency. Reliance on historical features may be inadequate when trying to assess whether or not a patient is drug-seeking. [West J Emerg Med. 2012;13(5):416-421.]

Vital Signs: Prescription Drug Monitoring Programs and Other Interventions to Combat Prescription Opioid Abuse

The Center for Disease Control and Prevention (CDC) has published significant data and trends related to opioid prescription pain relievers (OPR). In 2008, 20,044 deaths were attributed to prescription drug overdose of which 14,800 (73.8%) were due to OPR, an amount greater than the number of overdose deaths from heroin and cocaine combined. The majority of these deaths were unintentional. Between 1999-2008, overdose deaths from OPR increased almost four-fold. Correspondingly, sales of OPR were four times greater in 2010 than in 1999. Most significant to emergency physicians is the estimate that 39% of all opioids prescribed, administered or continued come from the emergency department (ED).  We present findings from the CDC’s Morbidity and Mortality Weekly Report (MMWR) with commentary on current recommendations and policies for curtailing the OPR epidemic.1  [West J Emerg Med. 2012;13(5):422-425.]

In the Soup: Caustic Ingestion from the Improper Consumption of a Self-Heating Soup

We present a caustic ingestion case from the improper preparation of a self-heating soup can. A 54 year old man cut apart a self-heating canister of OnTech® Hillside Tomato soup and consumed the calcium oxide heating material with the soup. He presented to the ED with odynophagia and pharyngeal irritation. A normal chest radiograph, and computed tomography (CT) scan of chest, and several normal laboratory studies were obtained. Emergent esophagogastroduodenoscopy was performed due to worsening symptoms despite narcotic analgesia. This is the first known case of its kind, where a self-heating chemical agent was mixed with food and ingested. [West J Emerg Med. 2012;13(5):426-428.]

Development of a Data Collection Instrument for Violent Patient Encounters against Healthcare Workers

Introduction: Healthcare and social workers have the highest incidence of workplace violence of any industry. Assaults toward healthcare workers account for nearly half of all nonfatal injuries from occupational violence. Our goal was to develop and evaluate an instrument for prospective collection of data relevant to emergency department (ED) violence against healthcare workers.

Methods: Participants at a high-volume tertiary care center were shown 11 vignettes portraying verbal and physical assaults and responded to a survey developed by the research team and piloted by ED personnel addressing the type and severity of violence portrayed. Demographic and employment groups were compared using the independent-samples Mann-Whitney U Test.

Results: There were 193 participants (91 male). We found few statistical differences when comparing occupational and gender groups. Males assigned higher severity scores to acts of verbal violence versus females (mean M,F=3.08, 2.70; p<0.001). While not achieving statistical significance, subgroup analysis revealed that attending physicians rated acts of verbal violence higher than resident physicians, and nurses assigned higher severity scores to acts of sexual, verbal, and physical violence versus their physician counterparts.

Conclusion: This survey instrument is the first tool shown to be accurate and reliable in characterizing acts of violence in the ED across all demographic and employment groups using filmed vignettes of violent acts. Gender and occupation of ED workers does not appear to play a significant role in perception of severity workplace violence. [West J Emerg Med. 2012;13(5):429-433.]

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Intramedullary Spinal Neurocysticercosis Presenting as Brown-Sequard Syndrome

Cysticercosis is an emerging disease in the United States. Neurocysticercosis may rarely cause disease within the spinal cord, but the occurrence of such pathology can produce debilitating symptoms for patients. We present the second report in the literature of intramedullary spinal neurocysticercosis presenting with a Brown-Sequard syndrome. [West J Emerg Med. 2012;13(5):434–436.]

Injury Outcomes

Occult Pneumothoraces in Acute Trauma Patients

Introduction: Many traumatic pneumothoraces (PTX) are not seen on initial chest radiograph (CR) (occult PTX) but are detected only on computed tomography (CT). Although CR remains the first tool for detecting PTX, most trauma patients with significant thoracoabdominal injuries will receive both CT and CR. The primary objective of this study was to retrospectively determine the effectiveness of CR for detecting PTX in trauma patients. Our hypotheses were that CR is a sensitive indicator of PTX on CT, that chest pain and shortness of breath are good predictors of PTX on CR, and that we could determine other predictors of PTX on CR.

Methods: All trauma patients presenting to our Level I trauma center with a CT-diagnosed PTX over a 2-year period who had both a CR and a chest CT were included. The CT reading was considered the gold standard for PTX diagnosis. Electronic medical records were searched using key words for diagnoses, symptoms, demographics, and radiologic results. We recorded the official radiologist readings for both CR and CT (positive or negative) and the size of the PTX on CT (large, moderate, small, or tiny). The outcome variable was dichotomized based on presence or absence of PTX detected on CR. Descriptive statistics and v2 tests were used for univariate analysis. A regressionanalysis was performed to determine characteristics predictive of a PTX on CR, and 1 variable was added to the model for every 10 positive CRs. With equal-size groups, this study has the power of 80% to detect a 10% absolute difference in single predictors of PTX on CR with 45 subjects in each group.

Results: There were 134 CT-documented PTXs included in the study. Mean age was 42, and 74% were men. For 66 (49%) patients, PTX was detected on CR (sensitivity¼50%). The CR detected 30% of small PTX, 35% of moderate PTX, and 33% of large PTX. Comparing patients with and without PTX on CR, there were no significant differences in shortness of breath or chest pain. There no relationships between PTX detected on CR and age, gender, penetrating versus blunt injury, bilaterality of the PTX, or presence of lung contusion or hemothorax on CT. After adjusting for all significant variables, predictor of a PTX detected on CR was air in the tissue on CR (adjusted odds ratio [OR]¼3.8) and PTX size (compared to a tiny PTX, adjusted OR¼2.0 for a small PTX, 7.5 for a moderate PTX, and 51 for a large PTX). Chest tubes were used in 89% of patients with PTX on CR and 44% of patients with PTX only on CT (difference 45%; 95% confidence interval 30, 58).

Conclusion: Factors associated with PTX on CR included air in the soft tissue on CR and size of the PTX. Even when PTX is not apparent on CR, 44% of these PTXs received placement of a chest tube. [West J Emerg Med. 2012;13(5):437–443.]

Disaster Preparedness

Hospital-Based Coalition to Improve Regional Surge Capacity

Introduction: Surge capacity for optimization of access to hospital beds is a limiting factor in response to catastrophic events. Medical facilities, communication tools, manpower, and resource reserves exist to respond to these events. However, these factors may not be optimally functioning to generate an effective and efficient surge response. The objective was to improve the function of these factors.

Methods: Regional healthcare facilities and supporting local emergency response agencies developed a coalition (the Healthcare Facilities Partnership of South Central Pennsylvania; HCFPSCPA) to increase regional surge capacity and emergency preparedness for healthcare facilities. The coalition focused on 6 objectives: (1) increase awareness of capabilities and assets, (2) develop and pilot test advanced planning and exercising of plans in the region, (3) augment written medical mutual aid agreements, (4) develop and strengthen partnership relationships, (5) ensure National Incident Management System compliance, and (6) develop and test a plan for effective utilization of volunteer healthcare professionals.

Results: In comparison to baseline measurements, the coalition improved existing areas covered under all 6 objectives documented during a 24-month evaluation period. Enhanced communicationsbetween the hospital coalition, and real-time exercises, were used to provide evidence of improved preparedness for putative mass casualty incidents.

Conclusion: The HCFP-SCPA successfully increased preparedness and surge capacity through a partnership of regional healthcare facilities and emergency response agencies. [West J Emerg Med. 2012;13(5):445–452.]