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Open Access Publications from the University of California

Volume 14, Issue 6, 2013

Injury Outcomes

Does Young Age Merit Increased Emergency Department Trauma Team Response?

Introduction: To determine if increased trauma team response results in alterations in resource use in a population of children<6 years, especially in those least injured. Methods: We conducted a retrospective before and after study of children <6 years sustaining blunt trauma and meeting defined prehospital criteria. We compared hospitalization rates and missed injuries (injuries identified after discharge from the emergency department/hospital) among patients with and without an upgraded trauma team response. We compared the computed tomography (CT) rate and laboratory testing rate among minimally injured patients (Injury Severity Score [ISS] 6). Results: We enrolled 352 patients with 180 (mean age 2.7 ± 1.5 years) in the upgrade cohort and 172 (mean age 2.6 ± 1.5 years) in the no-upgrade cohort. Independent predictors of hospital admission in a regression analysis included: Glasgow Coma Scale <14 (odds ratio [OR]=11.4, 95% confidence interval [CI] 2.3, 56), ISS (OR=1.55, 95% CI 1.33, 1.81), and evaluation by the upgrade trauma team (OR=5.66, 95% CI 3.14, 10.2). In the 275 patients with ISS < 6, CT (relative risk=1.34, 95% CI 1.09, 1.64) and laboratory tests (relative risk=1.71, 95% CI 1.39, 2.11) were more likely to be obtained in the upgrade cohort as compared to the no-upgrade cohort. We identified no cases of a missed diagnosis. Conclusion: Increasing the trauma team response based upon young age results in increased resource use without altering the rate of missed injuries. In hospitals with ED physicians capable of evaluating and treating injured children, increasing ED trauma team resources solely for young age of the patient is not recommended. [West J Emerg Med. 2013;14(6):569–575.]

Emergency Department Visits by Older Adults for Motor Vehicle Collisions: A Five-Year National Study

Introduction: To describe the epidemiology and characteristics of emergency department (ED) visits by older adults for motor vehicle collisions (MVC) in the United States (U.S.).

Methods: We analyzed ED visits for MVCs using data from the 2003–2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Using U.S. Census data, we calculated annual incidence rates of driver or passenger MVC-related ED visits and examined visit characteristics, including triage acuity, tests performed and hospital admission or discharge. We compared older (65+ years) and younger (18-64 years) MVC patients and calculated odds ratios (OR) and 95% confidence intervals (CIs) to measure the strength of associations between age group and various visit characteristics. Multivariable logistic regression was used to identify independent predictors of admissions for MVC-related injuries among older adults.

Results: From 2003–2007, there were an average of 237,000 annual ED visits by older adults for MVCs. The annual ED visit rate for MVCs was 6.4 (95% CI 4.6-8.3) visits per 1,000 for older adults and 16.4 (95% CI 14.0-18.8) visits per 1,000 for younger adults. Compared to younger MVC patients, after adjustment for gender, race and ethnicity, older MVC patients were more likely to have at least one imaging study performed (OR 3.69, 95% CI 1.46-9.36). Older MVC patients were not significantly more likely to arrive by ambulance (OR 1.47; 95% CI 0.76–2.86), have a high triage acuity (OR 1.56; 95% CI 0.77-3.14), or to have a diagnosis of a head, spinal cord or torso injury (OR 0.97; 95% CI 0.42-2.23) as compared to younger MVC patients after adjustment for gender, race and ethnicity. Overall, 14.5% (95% CI 9.8-19.2) of older MVC patients and 6.1% (95% CI 4.8-7.5) of younger MVC patients were admitted to the hospital. There was also a non-statistically significant trend toward hospital admission for older versus younger MVC patients (OR 1.78; 95% CI 0.71-4.43), and admission to the ICU if hospitalized (OR 6.9, 95% CI 0.9-51.9), after adjustment for gender, race, ethnicity, and injury acuity. Markers of injury acuity studied included EMS arrival, high triage acuity category, ED imaging, and diagnosis of a head, spinal cord or internal injury.

Conclusion: Although ED visits after MVC for older adults are less common per capita, older adults are more commonly admitted to the hospital and ICU. Older MVC victims require significant ED resources in terms of diagnostic imaging as compared to younger MVC patients. As the U.S. population ages, and as older adults continue to drive, emergency departments (EDs) will have to allocate appropriate resources and develop diagnostic and treatment protocols to care for the increased volume of older adult MVC victims. [West J Emerg Med. 2013;14(6):576–581.]

 

Vital Signs: Emergency Department and Older Adult Motor Vehicle Collisions: Prevention is Paramount

In 2009, the Center for Disease Control and Prevention reported there were 33 million licensed drivers 65 years and older in the U.S. This represents a 23 percent increase from 1999, number that is predicted to double by 2030. Although, motor vehicle collisions (MVC)-related to emergency department (ED) visits for older adults are lower per capita than for younger adults, the older-adults MVCs require more resources, such as additional diagnostic imaging and increased odds of admission. Addressing the specific needs of older-adults could lead to better outcomes yet not enough research currently exists. It is important to continue training emergency physicians to treat the increasing older-patient population, but its also imperative we increase our injury prevention and screening methodology. We review research findings from the article: Emergency Department Visits by Older Adults for Motor Vehicle Collisions: A Five-year national study, with commentary on current recommendation and policies for the growing older-adult driving population. [West J Emerg Med.2013;14(6):582–584.]

Emergency Department Operations

The Impact of Working with Medical Students on Resident Productivity in the Emergency Department

Introduction: Academic emergency departments (ED) strive to balance educational needs of residents and medical students with service requirements that optimize patient care. No study to date has evaluated whether resident precepting of medical students affects residents’ clinical productivity. Understanding the interplay of these variables may allow for ED staffing that maximizes productivity. We sought to determine whether the precepting of medical students impacts resident productivity.Methods: This study was performed at a tertiary care ED with a 70,000 annual patient census. We performed a computer-based (Verinet Systems, Alachua, Fl) retrospective review of patient encounters initiated by second- and third-year emergency medicine residents (PGY2 and PGY3) assigned to medical student precepting shifts and compared these shifts with those of the same residents when not working with students. Data collection over 12 months included shift length from the monthly schedule and number of patients and relative value units (RVUs) from the Verinet System. Patients seen per hour (pt/hr) and relative value unit per hour (RVUs/hr) were calculated. We compared parameters using two-tailed T-tests. The hospital’s institutional review board approved this study.Results: Daily census was 202 on days without medical student rotators and 200 on days with student rotators (P = 0.29). While precepting students, PGY3s saw 1.40 pt/hr versus 1.39 pt/hr without students (P = 0.88) and PGY2s saw 1.28 pt/hr with students compared to 1.28 pt/hr without students (P = 0.94). PGY3s generated 3.97 RVU/hr with students and 4.03 RVU/hr while working independently (P = 0.68) and PGY2s generated 3.82 RVU/hr working with students versus 3.74 RVU/hr without (P = 0.44). There were no productivity differences between resident precepting shifts and regular shifts.Conclusion: In this study, resident productivity was not affected by precepting medical students. [West J Emerg Med.2013;14(6):585–589.]

Predictive Value of Capnography for Suspected Diabetic Ketoacidosis in the Emergency Department

Introduction: Metabolic acidosis confirmed by arterial blood gas (ABG) analysis is one of the diagnostic criteria for diabetic ketoacidosis (DKA). Given the direct relationship between end-tidal carbon dioxide (ETco2), arterial carbon dioxide (PaCO2) and metabolic acidosis, measuring ETco2 may serve as a surrogate for ABG in the assessment of possible DKA. The current study focuses on the predictive value of capnography in diagnosing DKA in patients referring to the emergency department (ED) with increased blood sugar levels and probable diagnosis of DKA.

Methods: In a cross-sectional prospective descriptive-analytic study carried out in an ED, we studied 181 patients older than 18 years old with blood sugar levels of higher than 250 mg/dl and probable DKA. ABG and capnography were obtained from all patients. To determine predictive value, sensitivity, specificity and cut-off points, we developed receiver operating characteristic curves.

Results: Sixty-two of 181 patients suffered from DKA. We observed significant differences between both groups (DKA and non-DKA) regarding age, pH, blood bicarbonate, PaCO2 and ETco2 values (P≤0.001). Finally, capnography values more than 24.5 mmHg could rule out the DKA diagnosis with a sensitivity and specificity of 0.90.

Conclusion: Capnography values greater than 24.5 mmHg accurately allow the exclusion of DKA in ED patients suspected of that diagnosis. Capnography levels lower that 24.5 mmHg were unable to differentiate between DKA and other disease entities. [West J Emerg Med. 2013;14(6):590–594.]

Does High Body Mass Index Obviate the Need for Oral Contrast for Abdominal-Pelvic Computed Tomography in Emergency Department Patients?

Introduction: High body mass index (BMI) values generally correlate with a large proportion of intra-peritoneal adipose tissue. Because intra-peritoneal infectious and inflammatory conditions manifest with abnormalities of the adipose tissue adjacent to the inflamed organ, it is presumed that with a larger percentage of adipose surrounding a given organ, visualization of the inflammatory changes would be more readily apparent. Do higher BMI values sufficiently enhance the ability of a radiologist to read a computed tomography of the abdomen and pelvis, so that the need for oral contrast to be given is precluded?

Methods: Forty six patients were included in the study: twenty seven females, and nineteen males. They underwent abdominal/pelvic CTs without oral or intravenous contrast in the emergency department. Two board certified radiologists reviewed their CTs, and assessed them for radiographic evidence of intra-abdominal pathology. The patients were then placed into one of four groups based on their body mass index. Kappa analysis was performed on the CT reads for each group to determine whether there was significant inter-rater agreement regarding contrast use for the patient in question.

Results: There was increasingly significant agreement between radiologists, regarding contrast use, as the study subject’s BMI increased. In addition, there was an advancing tendency of the radiologists to state that there was no need for oral or intravenous contrast in patients with higher body mass indices, as the larger quantity of intra-peritoneal adipose allowed greater visualization and inspection of intra-abdominal organs.

Conclusion: Based on the results of this study, it appears that there is a decreasing need for oral contrast in emergency department patients undergoing abdominal/pelvic CT, as a patient’s BMI increases. Specifically, there was statistically significant agreement, between radiologists, regarding contrast use in patients who had a BMI greater than twenty-five. [West J Emerg Med.2013;14(6):595–597.]

Provider Workforce

Mid-level Providers Working in a Low-acuity Area are More Productive than in a High-acuity Area

Introduction: Mid-level providers (MLP) are extensively used in staffing emergency departments (ED). We sought to compare the productivity of MLPs staffing a low-acuity and high-acuity area of a community ED.Methods: This is a retrospective review of MLP productivity at a single center 42,000-volume community ED from July 2009 to September 2010. MLPs staffed day shifts (8AM-6PM or 10AM-10PM) in high- and low-acuity sections of the ED. We used two-tailed T-test to compare patients/hour, relative value units (RVUs)/hour, and RVUs/patient between the 2 MLP groups. Results: We included 49 low-acuity and 55 high-acuity shifts in this study. During the study period, MLPs staffing low-acuity shifts treated a mean of 2.7 patients/hour (confidence interval [CI] +/- 0.23), while those staffing high-acuity shifts treated a mean of 1.56 patients/hour (CI +/- 0.14, P < 0.0001). MLPs staffing low-acuity shifts generated a mean of 4.45 RVUs/hour (CI +/- 0.34) compared to 3.19 RVUs/hour (CI +/-0.29) for those staffing high-acuity shifts (P < 0.0001). MLPs staffing low-acuity shifts generated a mean of 1.68 RVUs/patient (CI +/- 0.06) while those staffing high-acuity shifts generated a mean RVUs/patient of 2.05 (CI +/- 0.09, P < 0.0001). Conclusion: MLPs staffing a low-acuity area treated more patients/hour and generated more RVUs/hour than when staffing a high-acuity area. [West J Emerg Med.2013;14(6):598–601.]

Implementation of a Successful Incentive-Based Ultrasound Credentialing Program for Emergency Physicians

Introducion: With the rapid expansion of emergency ultrasound, resident education in ultrasound has become more clearly developed and broadly integrated. However, there still exists a lack of guidance in the training of physicians already in practice to become competent in this valuable skill. We sought to employ a step-wise, goal-directed, incentive-based credentialing program to educate emergency physicians in the use of emergency ultrasound.  Successful completion of this program was the primary outcome.

Methods: The goal was for the physicians to gain competency in 8 basic ultrasound examinations types: aorta, Focused Assessment with Sonography in Trauma (FAST), cardiac, renal, biliary, transabdominal pelvic, transvaginal pelvic, and deep venous thrombosis (DVT). We separated the 2.5 year training program into 4 distinct blocks, with each block focusing on 2 of the ultrasound examination types. Each block consisted of didactic and hands-on sessions with the goal of the physician completing 25 technically-adequate studies of each examination type. There was a financial incentive associated with completion of these requirements.

Results: A total of 31 physicians participated in the training program. Only one physician, who retired prior to the end of the 2.5 year period, did not successfully complete the program. All have applied for and received hospital privileging in emergency ultrasound and incorporated it into their daily practice.

Conclusion: We found that a step-wise, incentive-based ultrasound training program with a combination of didactics and ample hands-on teaching was successful in the training of physicians already in practice. [West J Emerg Med.2013;14(6):602–608.]

A Survey of Graduating Emergency Medicine Residents’ Experience with Cricothyrotomy

Introduction: The Emergency Medicine (EM) Residency Review Committee stipulates that residents perform 3 cricothyrotomies in training but does not distinguish between those done on patients or via other training methods. This study was designed to determine how many cricothyrotomies residents have performed on living patients, the breadth and prevalence of alternative methods of instruction, and residents’ degree of comfort with performing the procedure unassisted. Methods: We utilized a web-based tool to survey EM residents nearing graduation and gathered data regarding the number of cricothyrotomies performed on living and deceased patients, animals, and models/simulators. Residents indicating experience with the procedure were asked additional questions as to the indication, supervision, and outcome of their most recent cricothyrotomy. We also collected data regarding experience with rescue airway devices, observation of cricothyrotomy, and comfort (“0-10” scale with “10” representing complete confidence) regarding the procedure. Results: Of 296 residents surveyed, 22.0% performed a cricothyrotomy on a living patient, and 51.6% had witnessed at least one performed. Those who completed a single cricothyrotomy reported a significantly greater level of confidence, 6.3 (95% confidence interval [CI] 5.7-7.0), than those who did none, 4.4 (95% CI 4.1-4.7), p<<0.001. Most respondents, 68.1%, had used the recently deceased to practice the technique, and those who had done so more than once reported higher confidence, 5.5 (95% 5.1-5.9), than those who had never done so, 4.1 (95% CI 3.7-4.5), p<<0.001. Residents who practiced cricothyrotomy on both simulators and the recently deceased expressed more confidence, 5.4 (95% CI 5.0-5.8), than those who used only simulators, 4.0 (95% CI 3.6-4.5), p<<0.001. Neither utilization of models, simulators, or animals, nor observance of others’ performance of the procedure independently affected reported confidence among residents. Conclusion: While prevalence of cricothyrotomy and reported comfort with the procedure remain low, performing the procedure on living or deceased patients increased residents’ confidence in undertaking an unassisted cricothyrotomy upon graduation in the population surveyed. There is evidence to show that multiple methods of instruction may yield the highest benefit, but further study is needed. [West J Emerg Med. 2013;14(6):654–661.]

Emergency Department Access

National Study of Non-Urgent Emergency Department Visits and Associated Resource Utilization

Introduction: Reducing non-urgent emergency department (ED) visits has been targeted as a method to produce cost savings. To better describe these visits, we sought to compare resource utilization of ED visits characterized as non-urgent at triage to immediate, emergent, or urgent (IEU) visits.Methods: We performed a retrospective, cross-sectional analysis of the 2006-2009 National Hospital Ambulatory Medical Care Survey. Urgency of visits was categorized using the assigned 5-level triage acuity score. We analyzed resource utilization, including diagnostic testing, treatment, and hospitalization within each acuity categorization.Results: From 2006-2009, 10.1% (95% confidence interval [CI], 9.2-11.2) of United States ED visits were categorized as non-urgent. Most (87.8% [95%CI, 86.3-89.2]) non-urgent visits had some diagnostic testing or treatment in the ED. Imaging was common in non-urgent visits (29.8% [95%CI, 27.8-31.8]), although not as frequent as for IEU visits (52.9% [95%CI, 51.6-54.2]). Similarly, procedures were performed less frequently for non-urgent (34.1% [95%CI, 31.8-36.4]) compared to IEU visits (56.3% [95%CI, 53.5-59.0]). Medication administration was similar between the 2 groups (80.6% [95%CI, 79.5-81.7] vs. 76.3% [95% CI, 74.7-77.8], respectively). The rate of hospital admission was 4.0% (95%CI, 3.3-4.8) vs. 19.8% (95%CI, 18.4-21.3) for IEU visits, with admission to a critical care setting for 0.5% of non-urgent visits (95%CI, 0.3-0.6) vs. 3.4% (95%CI, 3.1-3.8) of IEU visits.Conclusions: For most non-urgent ED visits, some diagnostic or therapeutic intervention was performed. Relatively low, but notable proportions of non-urgent ED visits were admitted to the hospital, sometimes to a critical care setting. These data call into question non-urgent ED visits being categorized as “unnecessary,” particularly in the setting of limited access to timely primary care for acute illness or injury. [West J Emerg Med.609-616.]

Healthcare Utilization

New Drugs and Devices from 2011 – 2012 That Might Change Your Practice

To be honest, I thought this would be a lost cause.  Even after skipping a New Drugs and Devices essay in 2012, I figured that I would have to search long and hard to find ten new things that emergency practitioners needed to know about.  Although there were no true blockbuster medications for emergency physicians, I nonetheless found ten medicines that we probably should know, along with a new device that may change the way we work up patients with palpitations, and a clever new delivery system for subcutaneous epinephrine. [West J Emerg Med. 2013;14(6):619–628.]

 

Effectiveness of a Drill-assisted Intraosseous Catheter versus Manual Intraosseous Catheter by Resident Physicians in a Swine Model

Introduction: Our objective was to compare the effectiveness, speed, and complication rate of the traditional manually placed intraosseous (IO) catheter to a mechanical drill-assisted IO catheter by emergency medicine (EM) resident physicians in a training environment. Methods: Twenty-one EM residents participated in a randomized prospective crossover experiment placing 2 intraosseous needles (Cook® Intraosseous Needle, Cook Medical, Bloomington, IN; and EZ-IO® Infusion System, Vidacare, San Antonio, TX). IO needles were placed in anesthetized mixed breed swine (mass range: 25 kg to 27.2 kg). The order of IO placement and puncture location (proximal tibia or distal femur) were randomly assigned. IO placement time was recorded from skin puncture until the operator felt they had achieved successful placement. We used 3 verification criteria: aspiration of marrow blood, easy infusion of 10 mL saline mixed with methylene blue, and lack of stained soft tissue extravasation. Successful placement was defined as meeting 2 out of the 3 predetermined criteria. We surveyed participants regarding previous IO experience, device preferences, and comfort levels using multiple choice, Likert scale, and visual analog scale (VAS) questions. IO completion times, VAS, and mean Likert scales were compared using Student’s t-test and success rates were compared using Fisher’s exact test with p<0.05 considered significant.Results: Drill-assisted IO needle placement was faster than manually placed IO needle placement (3.66 vs. 33.57 seconds; p=0.01). Success rates were 100% with the drill-assisted IO needle and 76.2% with the manual IO needle (p=0.04). The most common complication of the manual IO insertion was a bent needle (33.3% of attempts). Participants surveyed preferred the drill-assisted IO insertion more than the manual IO insertion (p<0.0001) and felt the drill-assisted IO was easier to place (p<0.0001).Conclusion: In an experimental swine model, drill-assisted IO needle placement was faster and had less failures than manual IO needle placement by inexperienced resident physicians. EM resident physician participants preferred the drill-assisted IO needle. [West J Emerg Med.2013;14(6):629–632.]

Ethical and Legal Issues

Integrated Model of Palliative Care in the Emergency Department

An integrated model of palliative care in the emergency department (ED) of an inner city academic teaching center utilized existing hospital resources to reduce hospital length of stay (LOS) and reduce overall cost. Benefits related to resuscitation rates, intensity of care, and patient satisfactionare attributed to the ED-based palliative team’s ability to provide real time consults, and utilize InterQual criteria to admit to a less costly level of care or transfer directly to home or hospice. [West J Emerg Med.14(6):633–636.]   

Diagnostic Acumen

Needle Decompression in Appalachia Do Obese Patients Need Longer Needles?

Introduction: Needle decompression of a tension pneumothorax can be a lifesaving procedure. It requires an adequate needle length to reach the chest wall to rapidly remove air. With adult obesity exceeding one third of the United States population in 2010, we sought to evaluate the proper catheter length that may result in a successful needle decompression procedure. Advance Trauma Life Support (ATLS) currently recommends a 51 millimeter (mm) needle, while the needles stocked in our emergency department are 46 mm. Given the obesity rates of our patient population, we hypothesize these needles would not have a tolerable success rate of 90%. Methods: We retrospectively reviewed 91 patient records that had computed tomography of the chest and measured the chest wall depth at the second intercostal space bilaterally. Results: We found that 46 mm needles would only be successful in 52.7% of our patient population, yet the ATLS recommended length of 51 mm has a success rate of 64.8%. Therefore, using a 64 mm needle would be successful in 79% percent of our patient population. Conclusion: Use of longer length needles for needle thoracostomy is essential given the extent of the nation’s adult obesity population. [West J Emerg Med. 2013;14(6):650-652.]

Uncommon Etiology of Chest Pain: Pulmonary Sequestration

Chest pain is a common presenting symptom in the emergency department. After ruling out emergent causes, emergency physicians need to identify and manage less commonly encountered conditions. Pulmonary sequestration (PS) is a rare congenital condition involving pulmonary parenchyma. In PS, a portion of non-functional lung tissue receives systemic blood supply from an anomalous artery. While most individuals with PS present in early life with symptoms of difficulty feeding, cyanosis, and dyspnea, some present later with recurrent pneumonia, hemoptysis, or productive cough. In this report, we present a case of PS in an adult with acute onset pleuritic chest pain. [West J Emerg Med. 2013;14(6):638–639.]

Total Collapse of the Heart

[West J Emerg Med. 2013;14(6):640.]

Sedative Dosing Of Propofol For Treatment Of Migraine Headache In The Emergency Department: A Case Series

Introduction: Migraine headaches requiring an emergency department visit due to failed outpatient rescue therapy present a significant challenge in terms of length of stay (LOS) and financial costs. Propofol therapy may be effective at pain reduction and reduce that length of stay given its pharmacokinetic properties as a short acting intravenous sedative anesthetic and pharmacodynamics on GABA mediated chloride flux.Methods: Case series of 4 patients presenting to an urban academic medical center with migraine headache failing outpatient therapy. Each patient was given a sedation dose (1 mg/kg) of propofol under standard procedural sedation precautions.Results: Each of the 4 patients experienced dramatic reductions or complete resolution of headache severity. LOS for 3 of the 4 patients was 50% less than the average LOS for patients with similar chief complaints to our emergency department. 1 patient required further treatment with standard therapy but had a significant reduction in pain and a shorter LOS. There were no episodes of hypotension, hypoxia, or apnea during the sedations.Conclusion: In this small case series, sedation dose propofol appears to be effective and safe for the treatment of refractory migraines, and may result in a reduced LOS. [West J Emerg Med. 2013;14(6):646-649.]

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