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Open Access Publications from the University of California

Volume 13, Issue 2, 2012

Injury Prevention and Population Health

Trauma Center-Based Surveillance of Nontraffic Pedestrian Injury among California Children

Introduction: Every year in the United States, thousands of young children are injured by passenger vehicles in driveways or parking areas. Little is known about risk factors, and incidence rates are difficult to estimate because ascertainment using police collision reports or media sources is incomplete. This study used surveillance at trauma centers to identify incidents and parent interviews to obtain detailed information on incidents, vehicles, and children.

Methods: Eight California trauma centers conducted surveillance of nontraffic pedestrian collision injury to children aged 14 years or younger from January 2005 to July 2007. Three of these centers conducted follow-up interviews with family members.

Results: Ninety-four injured children were identified. Nine children (10%) suffered fatal injury. Seventy children (74%) were 4 years old or younger. Family members of 21 victims from this study (23%) completed an interview. Of these 21 interviewed victims, 17 (81%) were male and 13 (62%) were 1 or 2years old. In 13 cases (62%), the child was backed over, and the driver was the mother or father in 11 cases (52%). Fifteen cases (71%) involved a sport utility vehicle, pickup truck, or van. Most collisions occurred in a residential driveway.

Conclusion: Trauma center surveillance can be used for case ascertainment and for collecting information on circumstances of nontraffic pedestrian injuries. Adoption of a specific external cause-of injury code would allow passive surveillance of these injuries. Research is needed to understand the contributions of family, vehicular, and environmental characteristics and injury risk to inform prevention efforts. [West J Emerg Med. 2012;13(2):139–145.]

Violent and Fatal Youth Trauma: Is There a Missed Opportunity?

Introduction: Accidents and assaults (homicides) are the leading causes of death among the youth of the United States, accounting for 53.3% of deaths among children aged 1 to 19 years. Victim recidivism, defined as repeated visits to the emergency department (ED) as a victim of violent trauma, is a significantly growing public health problem. As 5-year mortality rates for recidivism are as high as 20%, it is important to determine whether victims with a history of violent trauma are at increased risk for fatal outcome with their next trauma. We hypothesized that victims of violent trauma who have had 1 prior ED visit for violent trauma will have increased odds of fatal outcome.

Methods: A retrospective chart review was conducted for patients presenting with penetrating trauma to the ED from January 1, 1999 to December 31, 2009. All patients between the ages of 15 to 25 years who presented to the ED for any penetrating trauma were included. Patients with prior presentations for penetrating trauma were compared to those patients who were first-time presenters to determine the odds ratio of fatal outcome.

Results: Overall, 15,395 patients were treated for traumatic presentations. Of these, 1,044 met inclusion criteria. Demographically, 79.4% were Hispanic, 19.4% were African American, and 0.96% were Caucasian. The average age was 21 years, and 98% of the population was male. One hundred and forty-seven (14%) had prior presentations, and 897 (86%) did not. Forty of the 147 patients (27%) with prior presentations had a fatal outcome as compared to 29 patients of the 868 (3%) without prior presentations, with odds ratio of 10.8 (95% confidence interval, 6.4–18.1; Pearson v2, P, 0.001). The 5-year mortality rate for those patients with fatal outcomes was calculated at 16.5%.

Conclusion: Patients who had prior ED visits for penetrating trauma were at greater risk for fatal outcomes compared to those with no prior visits. Therefore, trauma-related ED visits might offer an opportunity for education and intervention. This may help to prevent future fatalities. [West J Emerg Med. 2012;13(2):146–150.]

Alcohol Misuse and Multiple Sexual Partners

Introduction: We examine the association between self-reported alcohol misuse and alcohol use within 2 hours of having sex and the number of sexual partners among a sample of African-Americanand Latino emergency department (ED) patients.

Methods: Cross-sectional data were collected prospectively from a randomized sample of all ED patients during a 5-week period. In face-to-face interviews, subjects were asked to report their alcohol use and number of sexual partners in the past 12 months. Data were analyzed using multiple variable negative binomial regression models, and effect modification was assessed through inclusion of interaction terms.

Results: The 395 study participants reported an average of 1.4 (standard error=0.11) sexual partners in the past 12 months, 23% reported misusing alcohol, and 28% reported consuming alcohol before sex. There was no statistically significant association between alcohol misuse and the number of sexual partners; however, alcohol before sex was associated with a larger number of sexual partners in the past year. Moreover, among those who misused alcohol, participants who reported alcohol before sex were 3 times more likely to report a higher number of sexual partners (risk ratio=3.2; confidence interval [CI]=1.9–5.6). The association between alcohol use before sex and number of sexual partners is dependent upon whether a person has attributes of harmful drinking over the past 12 months.Overall, alcohol use before sex increases the number of sexual partners, but the magnitude of this effect is significantly increased among alcohol misusers.

Conclusion: Alcohol misusers and those who reported having more than 1 sexual partner were morelikely to cluster in the same group, ie, those who used alcohol before sex. Efforts to reduce the burden of sexually transmitted diseases, including human immunodeficiency virus, and other consequences of risky sexual behavior in the ED population should be cognizant of the interplay of alcohol and risky sexual behaviors. EDs should strive to institute a system for regular screening, brief intervention, and referral of at-risk patients to reduce negative consequences of alcohol misuse, including those of risky sexual behaviors. [West J Emerg Med. 2012;13(2):151–159.]


Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens’ Syndrome and Upright T wave in V1

We present a case of Wellens’ syndrome together with upright T wave in lead V1 in a man presenting with atypical chest pain, and we discuss the significance of its prompt recognition by the emergency physicians who are involved in the evaluation of patients with coronary artery disease in emergency departments. [West J Emerg Med. 2012;13(2):160–162.]

Emergency Department Administration

Time Series Analysis of Emergency Department Length of Stay per 8-Hour Shift

Introduction: The mean emergency department (ED) length of stay (LOS) is considered a measure of crowding. This paper measures the association between LOS and factors that potentially contribute to LOS measured over consecutive shifts in the ED: shift 1 (7:00 AM to 3:00 PM), shift 2 (3:00 PM to 11:00PM), and shift 3 (11:00 PM to 7:00 AM).

Methods: Setting: University, inner-city teaching hospital. Patients: 91,643 adult ED patients between October 12, 2005 and April 30, 2007. Design: For each shift, we measured the numbers of (1) ED nurses on duty, (2) discharges, (3) discharges on the previous shift, (4) resuscitation cases, (5) admissions, (6) intensive care unit (ICU) admissions, and (7) LOS on the previous shift. For each 24-hour period, we measured the (1) number of elective surgical admissions and (2) hospital occupancy. We used autoregressive integrated moving average time series analysis to retrospectively measure the association between LOS and the covariates.

Results: For all 3 shifts, LOS in minutes increased by 1.08 (95% confidence interval 0.68, 1.50) forevery additional 1% increase in hospital occupancy. For every additional admission from the ED, LOS in minutes increased by 3.88 (2.81, 4.95) on shift 1, 2.88 (1.54, 3.14) on shift 2, and 4.91 (2.29, 7.53) onshift 3. LOS in minutes increased 14.27 (2.01, 26.52) when 3 or more patients were admitted to the ICU on shift 1. The numbers of nurses, ED discharges on the previous shift, resuscitation cases, andelective surgical admissions were not associated with LOS on any shift.

Conclusion: Key factors associated with LOS include hospital occupancy and the number of hospital admissions that originate in the ED. This particularly applies to ED patients who are admitted to the ICU. [West J Emerg Med. 2012;13(2):163–168.]

Insurance Exchange Marketplace: Implications for Emergency Medicine Practice

The Patient Protection and Affordable Care Act of 2010 requires states to establish healthcare insurance exchanges by 2014 to facilitate the purchase of qualified health plans. States are required to establish exchanges for small businesses and individuals. A federally operated exchange will be established, and states failing to participate in any other exchanges will be mandated to join the federal exchange. Policymakers and health economists believe that exchanges will improve healthcare at lower cost by promoting competition among insurers and by reducing burdensome transaction costs. Consumers will no longer be isolated from monthly insurance premium costs. Exchanges will increase the number of patients insured with more cost-conscious managed care and high-deductible plans. These insurance plan models have historically undervalued emergency medical services, while also underinsuring patients and limiting their healthcare system access to the emergency department. This paradoxically increases demand for emergency services while decreasing supply. The continual devaluation of emergency medical services by insurance payers will result in inadequate distribution of resources to emergency care, resulting in further emergency department closures, increases in emergency department crowding, and the demise of acute care services provided to families and communities. [West J Emerg Med. 2012;13(2):169–171.]

Patient and Physician Willingness to Use Personal Health Records in the Emergency Department

Introduction: Patient care in the emergency department (ED) is often complicated by the inability to obtain an accurate prior history even when the patient is able to communicate with the ED staff. Personal health records (PHR) can mitigate the impact of such information gaps. This study assesses ED patients’ willingness to adopt a PHR and the treating physicians’ willingness to use that information.

Methods: This cross-sectional study was answered by 184 patients from 219 (84%) surveys distributed in an academic ED. The patient surveys collected data about demographics, willingness and barriers to adopt a PHR, and the patient’s perceived severity of disease on a 5-point scale. Each patient survey was linked to a treating physician survey of which 210 of 219 (96%) responded.

Results: Of 184 surveys completed, 78% of respondents wanted to have their PHR uploaded onto the Internet, and 83% of providers felt they would access it. Less than 10% wanted a software company, an insurance company, or the government to control their health information, while over 50% wanted a hospital to control that information. The patients for whom these providers would not have used a PHR had a statistically significant lower severity score of illness as determined by the treating physician from those that they would have used a PHR (1.5 vs 2.4, P, 0.01). Fifty-seven percent of physicians would only use a PHR if it took less than 5 minutes to access.

Conclusion: The majority of patients and physicians in the ED are willing to adopt PHRs, especially if the hospital participates. ED physicians are more likely to check the PHRs of more severely ill patients. Speed of access is important to ED physicians. [West J Emerg Med. 2012;13(2):172–175.]

Measuring Emergency Physicians’ Work: Factoring in Clinical Hours, Patients Seen, and Relative Value Units into 1 Metric

Measuring workplace performance is important to emergency department management. If an unreliable model is used, the results will be inaccurate. Use of inaccurate results to make decisions, such as how to distribute the incentive pay, will lead to rewarding the wrong people and will potentially demoralize top performers. This article demonstrates a statistical model to reliably measure the work accomplished, which can then be used as a performance measurement. [West J Emerg Med.2012;13(2):176–180.]


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Physician Assistants Contribution to Emergency Department Productivity

Introduction: The objective of this report is to determine physician assistant (PA) productivity in an academic emergency department (ED) and to determine whether shift length or department census impact productivity.

Methods: A retrospective chart review was conducted at a tertiary ED during June and July of 2007.Productivity was calculated as the mean number of patients seen each hour. Analysis of variance was used to compare the productivity of different length shifts, and linear regression analysis was used to assess the relationship between productivity and department volume.

Results: One hundred sixty PA shifts were included. Shifts ranged from 4 to 13 hours. Mean productivity was 1.16 patients per hour (95% confidence interval [CI] ¼ 1.12–1.20). Physician assistants generated a mean of 2.35 relative value units (RVU) per hour (95% CI¼1.98–2.72). There was no difference in productivity on different shift lengths (P¼0.73). There was no correlation between departmental census and productivity, with an R2 (statistical term for the coefficient of determination) of0.01.

Conclusion: In the ED, PAs saw 1.16 patients and generated 2.35 RVUs per hour. The length of the shift did not affect productivity. Productivity did not fluctuate significantly with changing departmental volume. [West J Emerg Med. 2012;13(2):181–185.]


Teaching and Clinical Efficiency: Competing Demands

Introduction: Teaching ability and efficiency of clinical operations are important aspects of physician performance. In order to promote excellence in education and clinical efficiency, it would be important to determine physician qualities that contribute to both. We sought to evaluate the relationship between teaching performance and patient throughput times.

Methods: The setting is an urban, academic emergency department with an annual census of 65,000patient visits. Previous analysis of an 18-question emergency medicine faculty survey at this institution identified 5 prevailing domains of faculty instructional performance. The 5 statistically significant domains identified were: Competency and Professionalism, Commitment to Knowledge and Instruction, Inclusion and Interaction, Patient Focus, and Openness and Enthusiasm. We fit a multivariate, random effects model using each of the 5 instructional domains for emergency medicine faculty as independent predictors and throughput time (in minutes) as the continuous outcome. Faculty that were absent for any portion of the research period were excluded as were patient encounters without direct resident involvement.

Results: Two of the 5 instructional domains were found to significantly correlate with a change inpatient treatment times within both datasets. The greater a physician’s Commitment to Knowledge and Instruction, the longer their throughput time, with each interval increase on the domain scale associated with a 7.38-minute increase in throughput time (90% confidence interval [CI]: 1.89 to 12.88 minutes). Conversely, increased Openness and Enthusiasm was associated with a 4.45-minute decrease in throughput (90% CI: 8.83 to 0.07 minutes).

Conclusion: Some aspects of teaching aptitude are associated with increased throughput times (Openness and Enthusiasm), while others are associated with decreased throughput times (Commitment to Knowledge and Instruction). Our findings suggest that a tradeoff may exist between operational and instructional performance. [West J Emerg Med. 2012;13(2):186–193.]



Clinical Practice

Emergency Department Management of Delirium in the Elderly

An increasing number of elderly patients are presenting to the emergency department. Numerous studies have observed that emergency physicians often fail to identify and diagnose delirium in the elderly. These studies also suggest that even when emergency physicians recognized delirium, they still may not have fully appreciated the import of the diagnosis. Delirium is not a normal manifestation of aging and, often, is the only sign of a serious underlying medical condition. This article will review the significance, definition, and principal features of delirium so that emergency physicians may better appreciate, recognize, evaluate, and manage delirium in the elderly. [West J Emerg Med.2012;13(2):194–201.]


Radiation Dose From Medical Imaging: A Primer for Emergency Physicians

Introduction: Medical imaging now accounts for most of the US population’s exposure to ionizing radiation. A substantial proportion of this medical imaging is ordered in the emergency setting. We aim to provide a general overview of radiation dose from medical imaging with a focus on computed tomography, as well as a literature review of recent efforts to decrease unnecessary radiation exposure to patients in the emergency department setting.

Methods: We conducted a literature review through calendar year 2010 for all published articles pertaining to the emergency department and radiation exposure.

Results: The benefits of imaging usually outweigh the risks of eventual radiation-induced cancer in most clinical scenarios encountered by emergency physicians. However, our literature review identified3 specific clinical situations in the general adult population in which the lifetime risks of cancer may outweigh the benefits to the patient: rule out pulmonary embolism, flank pain, and recurrent abdominal pain in inflammatory bowel disease. For these specific clinical scenarios, a physician-patient discussion about such risks and benefits may be warranted.

Conclusion: Emergency physicians, now at the front line of patients’ exposure to ionizing radiation, should have a general understanding of the magnitude of radiation dose from advanced medical imaging procedures and their associated risks. Future areas of research should include the development of protocols and guidelines that limit unnecessary patient radiation exposure. [West J Emerg Med. 2012;13(2):202–210.]



Disaster Preparedness and Population Health


Bilateral Spontaneous Pneumothorax

[West J Emerg Med. 2012;13(2):213–214.]