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Open Access Publications from the University of California

Volume 18, Issue 2, 2017

Emergency Department Operations

Use of Physician-in-Triage Model in the Management of Abdominal Pain in an Emergency Department Observation Unit


With a nationwide increase in Emergency Department (ED) visits it is of paramount importance for hospitals to find efficient ways to manage patient flow.  The purpose of this study is to determine whether there is a significant difference in hospital admission rates, length of stay (LOS), and other demographic factors in two cohorts of patients admitted directly to an emergency department observation unit (EDOU) under an abdominal pain protocol by a physician-in-triage (bypassing the main ED) versus those admitted via the traditional pathway (evaluated and treated in the main ED prior to EDOU admission).


This was a retrospective cohort study of patients admitted to a protocol driven EDOU with a diagnosis of abdominal pain in a single university hospital center ED.    Compiled data was obtained for all patients admitted to the EDOU with a diagnosis of abdominal pain that met EDOU protocol admission criteria. Data for each cohort was then divided into age, gender, payer status, and LOS.  This data was then analyzed to assess any significant differences between the cohorts.


There were 327 total patients eligible for this study (85 physician-in-triage group, 242 traditional ED group).  The total success rate (defined as discharge home) was 90.8% (n=297) and failure rate (defined as admission or transfer) was 9.2% (n= 30).   There were no significant differences observed in success rates between those dispositioned to the EDOU by physicians-in-triage (90.6%) versus via the traditional route (90.5 % p) = 0.98.  There was also a significant difference found between the two groups regarding total LOS with significantly shorter main ED times and EDOU times amongst patients sent to the EDOU by the physician-in- triage group (p<.001).


There were no significant differences in EDOU disposition outcomes in patients admitted to an EDOU by a physician-in-triage or via the traditional route.  Also, there were statistically significant shorter LOSs in patients admitted to the EDOU by triage physicians.   The data from this study supports the implementation of a physician-in-triage model in combination with the EDOU in improving efficiency in the treatment of abdominal pain.     This knowledge may act to cut healthcare costs, and improve patient flow and timely decision making in hospitals with EDOUs.

  • 1 supplemental file

Cross-Continuum Tool Is Associated with Reduced Utilization and Cost for Frequent High-Need Users

Introduction: High-need, high-cost patients can over-utilize acute care services, a pattern of behavior associated with many poor outcomes that disproportionately contributes to increased US healthcare cost. Our objective was to reduce healthcare cost and improve outcomes by optimizing the system of care.  We targeted HNHC patients and identified root causes of frequent healthcare utilization.  We developed a cross-continuum intervention process and a succinct tool called a Complex Care Map (CCM)© that addresses fragmentation in the system and links providers to a comprehensive individualized analysis of the patient story and causes for frequent access to health services.

Methods: Using a pre/post test design, this quality improvement project focused on determining if the interdisciplinary intervention called CCM© had an impact on healthcare utilization and costs for HNHC patients.  Analysis was conducted between November 2012 and December 2015 at Mercy Health Saint Mary’s, a Midwestern urban hospital with greater than 80,000 annual emergency department visits.  Included patients had three or more hospital visits (ED or IP) in the 12 months prior to initiation of a CCM© (n=339).  Individualized CCMs© were created and made available in the Electronic Medical Record (EMR) to all healthcare providers. We compared utilization, cost, social, and healthcare access variables from the EMR and cost accounting system for 12 months before and after CCMs© implementation.  Both descriptive and limited inferential statistics were utilized.


Results: ED mean visits decreased 43% (p<0.001), inpatient mean admissions decreased 44% (p<0.001), outpatient mean visits decreased 17% (p<0.001), CT mean scans decreased 62% (p<0.001), and OBS/IP LOS mean days decreased 41% (p<0.001).  Gross charges decreased 45 % (p<0.001), direct expenses decreased 47% (p<0.001), contribution margin improved by 11% (p=0.002), and operating margin improved by 73% (p<0.001).  Patients with housing increased 14% (p<0.001), those with primary care increased 15% (p<0.001), and those with insurance increased 16% (p<0.001).


Conclusion: Individualized CCMs© for a select group of patients are associated with decreased healthcare system overutilization and cost of care.

Endemic Infections

Risk of Skin and Soft Tissue Infections among Children Found to be Staphylococcus aureus MRSA USA300 Carriers

The purpose of this study was to examine community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) carriage and infections and determine risk factors associated specifically with MRSA USA300. A case control study was conducted in a pediatric emergency department. Nasal and axillary swabs were collected, and participants were interviewed for risk factors. The primary outcome was the proportion of S. aureus carriers among those presenting with and without a skin and soft tissue infection (SSTI). S. aureus carriers were further categorized into MRSA USA300 carriers or non MRSA USA300 carriers. We found MRSA USA300 carriage rate was higher in children less than 2 years of age, those with an SSTI, children with recent antibiotic use, and those with a family history of SSTI. MRSA USA300 carriers were also more likely to have lower income compared to non MRSA USA300 carriers and no S. aureus carriers. Rates of PVL genes were higher in MRSA carriage isolates with an SSTI, compared to MRSA carriage isolates of patients without an SSTI with an association between MRSA USA300 carriage and presence of PVL in those diagnosed with an abscess.

Injury Prevention and Population Health

Prevalence of Horizontal Violence Among Emergency Attending Physicians, Residents, and Physician Assistants



Horizontal Violence (HV) is malicious behavior perpetrated by healthcare workers against each other. These include bullying, verbal or physical threats, purposeful disruptive behavior, and other malicious behaviors. This pilot study investigates the prevalence of HV among Emergency Department (ED) attending physicians, residents, and mid-level providers (MLPs).



An electronic survey was sent to Emergency Medicine attending physicians (n=67), residents (n=25), and MLPs (n=24) in 3 unique EDs within a single multi-hospital medical system. The survey consisted of 18 questions that asked participants to indicate with what frequency (never, once, a few times, monthly, weekly, or daily) they have witnessed or experienced a particular behavior in the previous 12 months. Seven additional questions aimed to elicit the impact of HV on the participant, the work environment, or the patient care.



Of the 122 survey invitations, 91 were completed yielding a response rate of 74.6%. Of the respondents 64.8% were male and 35.2% were female. Attending physicians represented 41.8%, residents 37.4%, and MLPs 19.8% of respondents. Prevalence of reported behaviors ranged from 1.1% (Q18: physical assault) to 34.1% (Q4: been shouted at). Fourteen of these behaviors were most prevalent in the attending cohort, 6 were most prevalent in the MLP cohort, and 3 of the behaviors were most prevalent in the resident cohort.



The horizontal violence behaviors investigated in this pilot study were similar to data previously published in nursing cohorts. Furthermore, nearly a quarter of participants (22.2%) indicated that HV has affected care for their patients, suggesting further studies are warranted to assess prevalence and the impact HV has on staff and patients.


Twelve Years Since Importance of Cross-Cultural Competency Recognized: Where Are We Now?

Objectives: The objective of this study is to analyze the content and volume of literature that has been written on cultural competency in emergency medicine since its educational imperative was first described by the Institute of Medicine in 2002.

Methods: We conducted a comprehensive literature search through the PUBMED portal in January 2015 to identify all articles and reviews that addressed cultural competency in emergency medicine. Articles were included in the review if cultural competency was described or if its impact on healthcare disparities or curriculum development was described. Two reviewers independently investigated all relevant articles. These articles were then summarized.

Results: Of the 73 abstracts identified in the initial search, only 10 met criteria for inclusion. A common theme found among these 10 articles is that cultural competency in emergency medicine is essential to reducing healthcare disparities and improving patient care. These articles were consistent in their support for cross-cultural educational advancements in the EM curriculum.

Conclusion: Despite the documented importance of cultural competency education in medicine, there appears to be only 10 articles over the past 12 years regarding its development and implementation in emergency medicine. This comprehensive literature review underscores the relative dearth of publications related to cultural competency in emergency medicine. The limited number of article findings is striking when compared to the growth of emergency medicine research over the same time period and can serve as a stimulus for further research in this significant area of EM education.

A Survey of Emergency Medicine Residents’ Use of Educational Podcasts


Emergency medicine (EM) educational podcasts have become increasingly popular. Residents spend a greater percentage of their time listening to podcasts than they do using other educational materials. Despite this popularity, research into podcasting in the EM context is sparse. We aimed to determine EM residents' consumption habits, optimal podcast preferences, and motivation for listening EM podcasts.



The authors created a survey and emailed it to EM residents at all levels of training at twelve residencies across the United States from September 2015 to June of 2016. In addition to demographics, the twenty-question voluntary survey asked questions exploring three domains: habits, attention, and motivation. The authors used descriptive statistics to analyze results.



Of the 605 residents invited to participate, 356 (n= 60.3%) completed the survey. The vast majority listen to podcasts at least once a month (88.8%). Two podcasts were the most popular by a wide margin, with 77.8% and 62.1% regularly listening to Emergency Medicine: Reviews and Perspectives (EM:RAP) and the EMCrit Podcast, respectively. 84.6% reported the ideal length of a podcast was less than 30 minutes. Residents reported their motivation to listen to EM podcasts was to “Keep up with current literature” (88.5%) and “Learn EM core content” (70.2%). 72.2% of residents said podcasts change their clinical practice either “somewhat” or “very much”.



The results of this survey study suggest most residents listen podcasts at least once a month, prefer podcasts less than 30 minutes in length, have several motivations for choosing podcasts, and report that podcasts change their clinical practice.


  • 2 supplemental files

Behavioral Health

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines


Introduction: In the United States, the number of patients presenting to the emergency department for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist.


Objective: A task force of the American Association of Emergency Psychiatry, consisting of physicians from Emergency Medicine, physicians from Psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to emergency departments.


Method: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the emergency department (Part I) and then combined this with expert consensus (Part II).


Results: In part I, terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the emergency department are discussed.

Conclusions: Emergency physicians should work cooperatively with psychiatric receiving facilities in order to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to emergency departments.

Intentional Recreational Abuse of Quetiapine Compared to Other Second-generation Antipsychotics


Introduction: Case reports and poison center data have demonstrated that the second-generation antipsychotic quetiapine is being obtained and utilized for recreational abuse.  The purpose of this study was to describe the relative rates of abuse for different atypical antipsychotics, and compare their demographic and clinical features.

Methods: A 10-year retrospective analysis of the National Poison Data System (NPDS) database was conducted (2003 – 2013).  Trained nurses and pharmacists with specialty training in toxicology prospectively collect all NPDS data at poison control centers around the United States.  The NPDS was queried for all cases of single-substance second-generation antipsychotic exposures coded as “intentional abuse”.  The data provided by the NPDS regarding rates and clinical features of quetiapine abuse and the abuse of all other second-generation antipsychotics were compared and described descriptively.

Results: During the study period, there were 2118 cases of quetiapine abuse and 1379 cases of other second generation antipsychotic abuse identified. Quetiapine abuse was more common than the abuse of other second-generation antipsychotics, compromising 60.7% of all abuse cases during the study period. After quetiapine, the next most frequently abused medications were risperidone (530 cases, 15.2%) and olanzapine (246 cases, 7.0%). For all second-generation antipsychotics including quetiapine, central nervous system clinical effects were most common, including drowsiness, confusion, and agitation. Other serious clinical effects observed with second-generation antipsychotic abuse included hypotension, respiratory depression, and seizures.

Conclusion:  Quetiapine abuse is common, and is abused far more often than any other second-generation antipsychotic. Emergency physicians should be aware of the clinical effects that may occur after second-generation antipsychotic abuse.

Health Outcomes

Estimating the Cost of Care for Emergency Department Syncope Patients: Comparison of Three Models

Introduction: We sought to compare three hospital cost estimation models for patients undergoing evaluation for unexplained syncope with hospital cost data. Developing such a model would allow researchers to assess the value of novel clinical algorithms for syncope management.

Methods: Complete health services data, including disposition, testing, and length of stay (LOS), were collected on 67 adult patients (age 60 years and older) who presented to the Emergency Department (ED) with syncope at a single hospital. Patients were excluded if a serious medical condition was identified. Three hospital cost estimation models were created to estimate facility costs: V1, unadjusted Medicare payments for observation and/or hospital admission, V2: modified Medicare payment, prorated by LOS in calendar days, and, V3: modified Medicare payment, prorated by LOS in hours. Total hospital costs included unadjusted Medicare payments for diagnostic testing and estimated facility costs. These estimates were plotted against actual cost data from the hospital finance department. Correlation and regression analyses were performed.

Results: Of the three models, V3 consistently outperformed the others with regard to correlation and goodness of fit. The Pearson correlation coefficient for V3 was 0.88 (95% Confidence Interval 0.81, 0.92) with an R-square value of 0.77 and a linear regression coefficient of 0.87 (95% Confidence Interval 0.76, 0.99).

Conclusion: Using basic health services data, it is possible to accurately estimate hospital costs for older adults undergoing a hospital-based evaluation for unexplained syncope. This methodology could help assess the potential economic impact of implementing novel clinical algorithms for ED syncope. 

  • 2 supplemental files

Serum Lactate Predicts Adverse Outcomes in Emergency Department Patients With and Without Infection



Lactate levels are increasingly used to risk stratify emergency department (ED) patients with and without infection. Whether a serum lactate provides similar prognostic value across diseases is not fully elucidated. This study assesses the prognostic value of serum lactate in ED patients with and without infection to both report and compare relative predictive value across etiologies.


We conducted a prospective, observational study of ED patients displaying abnormal vital signs (AVS) (heart rate ≥130 bpm, respiratory rate ≥24 bpm, shock index ≥1, and/or systolic blood pressure <90 mmHg). The primary outcome, deterioration, was a composite of acute renal failure, non-elective intubation, vasopressor administration or in-hospital mortality.


Of the 1152 patients with AVS who were screened, 488 patients met the current study criteria: 34% deteriorated and 12.5% died. The deterioration rate was 88/342 (26%, 95% CI: 21 – 30%) for lactate < 2.5 mmol/L, 47/90 (52%, 42 – 63%) for lactate 2.5 – 4.0 mmol/L, and 33/46 (72%, 59 – 85%) for lactate >4.0mmol/L. Trended stratified lactate levels were associated with deterioration for both infected (p<0.01) and non-infected (p<0.01) patients. In the logistic regression models, lactate > 4mmol/L was an independent predictor of deterioration for patients with infection (OR 4.8, 95% CI: 1.7 – 14.1) and without infection (OR 4.4, 1.7 – 11.5).


Lactate levels can risk stratify patients with AVS who have increased risk of adverse outcomes regardless of infection status.

  • 1 supplemental file

Technology in Emergency Medicine

Using the Electronic Medical Record to Reduce Unnecessary Ordering of Coagulation Studies for Patients with Chest Pain

Objectives: Our goal was to reduce ordering of coagulation studies in the emergency department (ED) that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR).

Methods: A pre and post quasi-experimental study design was used to evaluate the impact of an EMR-based intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured before and after intervention via detailed review of randomly sampled encounters during two-month periods before and after intervention. Existing orders were classified as clinically indicated or non-value added. Order frequencies were calculated as percentages and differences between groups were assessed by chi-square analysis.

Results: Pre-intervention, 73.8% (76/103) of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76) were non-value added. Post-intervention, 38.5% (40/104) of patients with chest pain had coagulation studies ordered, of which 60% (24/40) were non-value added. There was an absolute reduction of 35.3% (95% CI: 22.7%, 48.0%) in the total ordering of coagulation studies and 26.4% (95% CI: 13.8%, 39.0%) in non-value added order placement.

Conclusion: Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies.

Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam


The Focused Assessment with Sonography in Trauma (FAST) exam is a critical diagnostic test for intraperitoneal free fluid (FF). Current teaching is that fluid accumulates first in Morison’s pouch. The goal of this study was to evaluate the “sub-quadrants” of traditional FAST views to determine the most sensitive areas for FF accumulation.



We analyzed a retrospective cohort of all adult trauma patients who had a recorded FAST exam by emergency medicine (EM) physicians at a Level 1 trauma center from January 2012 – June 2013. Ultrasound fellowship-trained faculty with three EM residents reviewed all FAST exams. Studies were excluded if they were incomplete, of poor image quality, or with incorrect medical record information. Positive studies were assessed for FF localization, comparing the traditional abdominal views and on a sub-quadrant basis: RUQ1 - hepato-diaphragmatic, RUQ2 - Morison’s pouch, RUQ3 - caudal liver edge and superior paracolic gutter, LUQ1 - splenic-diaphragmatic, LUQ2 - spleno-renal, LUQ3 – around inferior pole of kidney, SP1 - bilateral to bladder, SP2 - posterior to bladder, SP3 – posterior to uterus (females).  FAST results were confirmed by chart review of computed tomography (CT) results or operative findings.



Of the included 1008 scans, 48 (4.8%) were positive. The RUQ was the most positive view with 32/48 (66.7%) positive. In the RUQ sub-quadrant analysis, the most positive view was the RUQ3 with 30/32 (93.8%) positive.



The RUQ is most sensitive for FF assessment with the superior paracolic gutter area around the caudal liver edge (RUQ3) being the most positive sub-quadrant within the RUQ.

Who Are the Most Influential Emergency Physicians on Twitter?

Introduction: Twitter has recently gained popularity in emergency medicine (EM). Opinion leaders on Twitter have significant influence on the conversation and content, yet little is known about these opinion leaders. We aimed to describe a methodology to identify the most influential emergency physicians (EPs) on Twitter and present a current list.

Methods: We analyzed 2,234 English language EPs on Twitter from a previously published list of Twitter accounts generated by a snowball sampling technique. Using NodeXL software, we performed a network analysis of these EPs and ranked them on three measures of influence: in-degree centrality, Eigenvector centrality, and betweenness centrality. We analyzed the top 100 users in each of these three measures of influence and compiled a list of users found in the top 100 in all three measures.

Results: Of the 300 total users identified by one of the measures of influence, there were 142 unique users. Of the 142 unique users, 61 users were in the top 100 on all three measures of influence. We identify these 61 users as the most influential EM Twitter users.

Conclusion: We both describe a method for identifying the most influential users and provide a list of the 61 most influential EPs on Twitter as of January 1, 2016. This application of network science to the EM Twitter community can guide future research to better understand the networked global community of EM.

  • 1 supplemental file


Academic Primer Series: Eight Key Papers about Education Theory


Many teachers adopt instructional methods based on assumptions of best practices without attention to or knowledge of supporting education theory.  Familiarity with a variety of theories informs education that is efficient, strategic, and evidence-based. As part of the Academic Life in Emergency Medicine Faculty Incubator Program a list of key education theories for junior faculty was developed.


A list of key papers on theories relevant to medical education was generated using an expert panel, a virtual community of practice synthetic discussion, and a social media call for resources.  A three-round, Delphi-informed voting methodology including novice and expert educators produced a rank order of the top papers.


Thirty-four unique papers were identified. Eleven papers described general theories, while 23 papers focused on a specific theory. The top three ranked general education theories and top five ranked specific education theory papers are summarized. The relevance of each paper for junior faculty and faculty developers is also presented.


This paper presents a reading list of key papers for junior faculty in medical education roles. Three papers about general education theories and five papers about specific educational theories are identified and annotated. These papers may help provide foundational knowledge in education theory to inform junior faculty teaching practice.

Academic Primer Series: Five Key Papers about Team Collaboration Relevant to Emergency Medicine


Team collaboration is an essential part of success both within academics and the clinical environment. Often, team collaboration is not taught during medical school or even residency and must be learned during one’s postgraduate career. In this article, we aim to summarize five key papers about team collaboration for early career clinician educators.


We conducted a consensus building process amongst the writing team to generate a list of key papers that describe the importance or significance of team collaboration, seeking input from social media sources. The authors then used a three-round voting methodology akin to a Delphi study to determine the most important papers from the general list.


The five most important papers on the topic of team collaboration, as determined by this mixed group of junior faculty members and faculty developers, is presented in this paper. For each included publication, a summary was provided along with its relevance to junior faculty members and faculty developers.


Five key papers about team collaboration are presented in this paper. These papers provide a foundational background to help junior faculty members with collaborating in teams both clinically and academically. This list may also inform senior faculty and faculty developers about the needs of junior faculty members.

Blog and Podcast Watch: Cutaneous Emergencies

Introduction: The Academic Life in Emergency Medicine (ALiEM) Blog and Podcast Watch presents high quality open access educational blogs and podcasts in emergency medicine (EM) based on the ongoing ALiEM Approved Instructional Resources (AIR) and AIR-Professional series. Both series critically appraise resources using an objective scoring rubric. This installment of the Blog and Podcast Watch highlights the topic of cutaneous emergencies from the AIR series.


Methods: The AIR series is a continuously building curriculum which follows the Council of Emergency Medicine Residency Director’s (CORD) annual testing schedule. For each module, relevant content is collected from the top 50 Social Media Index sites published within the previous 12 months and scored by 8 board members using 5 equally weighted measurement outcomes: Best Evidence in Emergency Medicine (BEEM) score, accuracy, educational utility, evidence based, and references. Resources scoring ≥30 out of 35 available points receive an AIR label. Resources scoring 27-29 receive an Honorable Mention label, if the editorial board agrees that the post is accurate and educationally valuable.


Results: A total of 35 blog posts and podcasts were evaluated. None scored ≥30 points necessary for the AIR label, although 4 Honorable Mention posts were identified. Key educational pearls from these Honorable Mention posts are summarized.


Conclusion: The WestJEM ALiEM Blog and Podcast Watch series is based on the AIR and AIR-Pro series, which attempts to identify high quality educational content on open-access blogs and podcasts. This series provides an expert-based, post-publication curation of educational social media content for EM clinicians with this installment focusing on cutaneous emergencies.

Academic Primer Series: Five Key Papers for Consulting Clinician Educators


Clinician educators are often asked to perform consultations for colleagues.  Invitations to consult and advise others on local problems can help foster great collaborations between centres, and  allows for an exchange of ideas between programs.  In this article, the authors identify and summarize several key papers to  assist emerging clinician educators with the consultation process.


A consensus building process was used to generate a list of key papers that describe the importance and significance of educational consulting, informed by social media sources. A three-round voting methodology, akin to a Delphi study, determinedthe most impactful papers from the larger list.



Summaries of the five most highly rated papers on education consultation are presented in this paper.  These papers were determined by a mixed group of junior and senior faculty members, who have summarized these papers with respect to their relevance for their peer groups.


Five key papers on the educational consultation process are presented in this paper. These papers offer  background and perspective to help junior faculty gain a grasp of consultation processes.