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Open Access Publications from the University of California

Volume 18, Issue 4, 2017

Emergency Department Operations

The Economics of an Admissions Holding Unit

Introduction: With increasing attention to the actual cost of delivering care, return-on-investment calculations take on new significance. Boarded patients in the emergency department (ED) are harmful to clinical care and have significant financial opportunity costs. We hypothesize that investment in an admissions holding unit for admitted ED patients not only captures opportunity cost but also significantly lowers direct cost of care.Methods: This was a three-phase study at a busy urban teaching center with significant walkout rate. We first determined the true cost of maintaining a staffed ED bed for one patient-hour and compared it to alternative settings. The opportunity cost for patients leaving without being seen was then conservatively estimated. Lastly, a convenience sample of admitted patients boarding in the ED was observed continuously from one hour after decision-to-admit until physical departure from the ED to capture a record of every interaction with a nurse or physician.Results: Personnel costs per patient bed-hour were $58.20 for the ED, $24.80 for an inpatient floor, $19.20 for the inpatient observation unit, and $10.40 for an admissions holding area. An eight-bed holding unit operating at practical capacity would free 57.4 hours of bed space in the ED and allow treatment of 20 additional patients. This could yield increased revenues of $27,796 per day and capture opportunity cost of $6.09 million over 219 days, in return for extra staffing costs of $218,650. Analysis of resources used for boarded patients was determined by continuous observation of a convenience sample of ED-boarded patients, which found near-zero interactions with both nursing and physicians during the boarding interval.  Conclusion: Resource expense per ED bed-hour is more than twice that in non-critical care inpatient units. Despite the high cost of available resources, boarded non-critical patients receive virtually no nursing or physician attention. An admissions holding unit is remarkably effective in avoiding the mismatch of the low-needs patients in high-cost care venues. Return on investment is enormous, but this assumes existing clinical space for this unit.

  • 1 supplemental file

Technology in Emergency Care

Ultrasound vs. Computed Tomography for Severity of Hydronephrosis and Its Importance in Renal Colic

Introduction: Supporting an “ultrasound-first” approach to evaluating renal colic in the emergency department (ED) remains important for improving patient care and decreasing healthcare costs. Our primary objective was to compare emergency physician (EP) ultrasound to computed tomography (CT) detection of hydronephrosis severity in patients with suspected renal colic. We calculated test characteristics of hydronephrosis on EP-performed ultrasound for detecting ureteral stones or ureteral stone size >5mm. We then analyzed the association of hydronephrosis on EP-performed ultrasound, stone size >5mm, and proximal stone location with 30-day events.

Methods: This was a prospective observational study of ED patients with suspected renal colic undergoing CT. Subjects had an EP-performed ultrasound evaluating for the severity of hydronephrosis. A chart review and follow-up phone call was performed.

Results: We enrolled 302 subjects who had an EP-performed ultrasound. CT and EP ultrasound results were comparable in detecting severity of hydronephrosis (x2=51.7, p<0.001). Hydronephrosis on EP- performed ultrasound was predictive of a ureteral stone on CT (PPV 88%; LR+ 2.91), but lack of hydronephrosis did not rule it out (NPV 65%). Lack of hydronephrosis on EP-performed ultrasound makes larger stone size >5mm less likely (NPV 89%; LR-0.39). Larger stone size > 5mm was associated with 30-day events (OR 2.30, p=0.03).

Conclusion: Using an ultrasound-first approach to detect hydronephrosis may help physicians identify patients with renal colic. The lack of hydronephrosis on ultrasound makes the presence of a larger ureteral stone less likely. Stone size >5mm may be a useful predictor of 30-day events.


  • 2 supplemental files

Emergency Department Access

Patient Perspectives on Accessing Acute Illness Care

Introduction: Older adults use the emergency department (ED) at high rates, including for illnesses that could be managed by their primary care providers (PCP). Policymakers have implemented barriers and incentives, often financial, to try to modify use patterns but with limited success. This study aims to understand the factors that influence older adults’ decision to obtain acute illness care from the ED rather than from their PCPs.

Methods: We performed a qualitative study using a directed content analysis approach from February to October 2013. Fifteen community-dwelling older adults age≥65 years who presented to the ED of an academic medical center hospital for care and who were discharged home were enrolled. Semi-structured interviews were conducted initially in the ED and subsequently in patients’ homes over the following six weeks. All interviews were audio-recorded, transcribed, verified, and coded. The study team jointly analyzed the data and identified themes that emerged from the interviews.

Results: The average age of study participants was 74 years (standard deviation ±7.2 years); 53% were female; 80% were white. We found five themes that influenced participants’ decisions to obtain acute illness care from the ED: limited availability of PCP-based care, variable interactions with healthcare providers and systems, limited availability of transportation for illness care, desire to avoid burdening friends and family, and previous experiences with illnesses. 

Conclusion: Community-dwelling older adults integrate multiple factors when deciding to obtain care from an ED rather than their PCPs. These factors relate to personal and social considerations, practical issues, and individual perceptions based on previous experiences. If these findings are validated in confirmatory studies, policymakers wishing to modify where older adults receive care should consider person-centered interventions at the system and individual level, such as decision support, telemedicine, improved transport services, enhancing PCPs’ capabilities, and enhancing EDs’ resources to care for older patients.



Effectiveness of Resident Physicians as Triage Liaison Providers in an Academic Emergency Department

Introduction: Emergency department (ED) crowding is associated with detrimental effects on EDquality of care. Triage liaison providers (TLP) have been used to mitigate the effects of crowding.Prior studies have evaluated attending physicians and advanced practice providers as TLPs, withlimited data evaluating resident physicians as TLPs. This study compares operational performanceoutcomes between resident and attending physicians as TLPs.

Methods: This retrospective cohort study compared aggregate operational performance at anurban, academic ED during pre- and post-TLP periods. The primary outcome was defined ascost-effectiveness based upon return on investment (ROI). Secondary outcomes were defined asdifferences in median ED length of stay (LOS), median door-to-provider (DTP) time, proportion of leftwithout being seen (LWBS), and proportion of “very good” overall patient satisfaction scores.

Results: Annual profit generated for physician-based collections through LWBS capture (afterdeducting respective salary costs) equated to a gain (ROI: 54%) for resident TLPs and a loss(ROI: -31%) for attending TLPs. Accounting for hospital-based collections made both profitable,with gains for resident TLPs (ROI: 317%) and for attending TLPs (ROI: 86%). Median DTP time forresident TLPs was significantly lower (p<0.0001) than attending or historical control. Proportion of “verygood” patient satisfaction scores and LWBS was improved for both resident and attending TLPs overhistorical control. Overall median LOS was not significantly different.

Conclusion: Resident and attending TLPs improved DTP time, patient satisfaction, and LWBSrates. Both resident and attending TLPs are cost effective, with residents having a more favorablefinancial profile.

Treatment Protocol Assessment

Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program

Introduction: Over 300,000 patients in the United States sustain low-trauma fragility hip fracturesannually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal painmanagement reduce morbidity and mortality. Our overall goal was to determine the effects of a GFPon the emergency department (ED) pain management of geriatric fragility hip fractures.

Methods: We performed a retrospective study including patients age ≥65 years with fragility hipfractures two years before and two years after the implementation of the GFP. Outcomes were timeto (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED,and amount of opioid medication administered in the first 24 hours. We used permutation tests toevaluate differences in ED pain management following GFP implementation.

Results: We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period.In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidenceinterval [CI] 45-63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%;p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs.10mg, p<0.001) than patients in the pre-GFP period.

Conclusion: Implementation of a GFP was associated with improved ED pain management forgeriatric patients with fragility hip fractures. Future studies should evaluate the effects of thesechanges in pain management on longer-term outcomes.

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Practice Variability

Physician Variability in Management of Emergency Department Patients with Chest Pain

Introduction: Chest pain is a common emergency department (ED) presentation accounting for 8-10million visits per year in the United States. Physician-level factors such as risk tolerance are predictive ofadmission rates. The recent advent of accelerated diagnostic pathways and ED observation units mayhave an impact in reducing variation in admission rates on the individual physician level.

Methods: We conducted a single-institution retrospective observational study of ED patients with adiagnosis of chest pain as determined by diagnostic code from our hospital administrative database.We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram(ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into twogroups: “admission” (this included observation and inpatients) and “discharged.” We stratified physiciansby age, gender, residency location, and years since medical school. We controlled for patient- andhospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values.

Results: Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to thehospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) weredischarged. Median number of patients per physician was 132 (interquartile range 89-172). Averageadmission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) wereto observation. There was significant variation in the admission rate at the individual physician level withadjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’characteristics, years elapsed since finishing medical school demonstrated a trend towards associationwith a higher admission probability.

Conclusion: There is substantial variation among physicians in the management of patients presentingwith chest pain, with physician experience playing a role.


Patient Safety

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain

Less than half of patients with a chest pain history indicative of acute coronary syndrome havea diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. Thephysician must dissect the ECG for elusive, but perilous, characteristics that are often missed bymachine analysis. ST depression is interpreted and often suggestive of ischemia; however, whenexclusive to leads V1‒V3 with concomitant tall R waves and upright T waves, a posterior infarctionshould first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR shouldraise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECGfindings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographicfindings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precedean inferior myocardial infarction. Similarly, something as ordinary as an upright and tall T wave ora biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, shouldgive pause and merit careful inspection since misinterpretation occurs in 20-40% of misdiagnosedmyocardial infarctions.



Ethical and Legal Issues

Optimizing the Use of a Precious Resource: The Role of Emergency Physicians in a Humanitarian Crisis

Emergency physicians (EP) are uniquely suited to provide care in crises as a result of their broadtraining, ability to work quickly and effectively in high-pressure, austere settings, and their inherentflexibility. While emergency medicine training is helpful to support the needs of crisis-affected anddisplaced populations, it is not in itself sufficient. In this article we review what an EP should carefullyconsider prior to deployment.

Injury Prevention and Population Health

Screening for Victims of Sex Trafficking in the Emergency Department: A Pilot Program

Introduction: Estimates suggest that hundreds of thousands of sex trafficking victims live in theUnited States. Several screening tools for healthcare professionals to identify sex trafficking victimshave been proposed, but the effectiveness of these tools in the emergency department (ED) remainsunclear. Our primary objective in this study was to evaluate the feasibility of a screening survey toidentify adult victims of sex trafficking in the ED. We also compared the sensitivity of emergencyphysician concern and a screening survey for identifying sex trafficking victims in the ED anddetermined the most effective question(s) for identifying adult victims of sex trafficking.

Methods: We enrolled a convenience sample of medically stable female ED patients, age 18-40 years.Patients completed a 14-question survey. Physician concern for sex trafficking was documented priorto informing the physician of the survey results. A “yes” answer to any question or physician concernwas considered a positive screen, and the patient was offered social work consultation. We defined a“true positive” as a patient admission for or social work documentation of sex trafficking. Demographicand clinical information were collected from the electronic medical record.

Results: We enrolled 143 patients, and of those 39 (27%, 95% confidence interval [CI] [20%-35%])screened positive, including 10 (25%, 95% CI [13%-41%]) ultimately identified as victims of sextrafficking. Sensitivity of the screening survey (100%, 95% CI [74%-100%]) was better than physicianconcern (40%, 95% CI [12%-74%]) for identifying victims of sex trafficking, difference 60%, 95% CI[30%-90%]. Physician specificity (91%, 95% CI [85%-95%]), however, was slightly better than thescreening survey (78%, 95% CI [70%-85%]), difference 13%, 95% CI [4%-21%]. All 10 (100%, 95%CI[74%-100%]) “true positive” cases answered “yes” to the screening question regarding abuse.

Conclusion: Identifying adult victims of sex trafficking in the ED is feasible. A screening survey appearsto have greater sensitivity than physician concern, and a single screening question may be sufficient toidentify all adult victims of sex trafficking in the ED

Research Methods

Difference in R01 Grant Funding Among Osteopathic and Allopathic Emergency Physicians over the Last Decade

Introduction: Receiving an R01 grant from the National Institutes of Health (NIH) is regarded as amajor accomplishment for the physician researcher and can be used as a means of scholarly activityfor core faculty in emergency medicine (EM). However, the Accreditation Council for GraduateMedical Education requires that a grant must be obtained for it to count towards a core facultymember’s scholarly activity, while the American Osteopathic Association states that an applicationfor a grant would qualify for scholarly activity whether it is received or not. The aim of the study wasto determine if a medical degree disparity exists between those who successfully receive an EM R01grant and those who do not, and to determine the publication characteristics of those recipients.

Methods: We queried the NIH RePORTER search engine for those physicians who received anR01 grant in EM. Degree designation was then determined for each grant recipient based on aweb-based search involving the recipient’s name and the location where the grant was awarded.The grant recipient was then queried through PubMed central for the total number of publicationspublished in the decade prior to receiving the grant.

Results: We noted a total of 264 R01 grant recipients during the study period; of those who receivedthe award, 78.03% were allopathic physicians. No osteopathic physician had received an R01 grantin EM over the past 10 years. Of those allopathic physicians who received the grant, 44.17% held adual degree. Allopathic physicians had an average of 48.05 publications over the 10 years prior togrant receipt and those with a dual degree had 51.62 publications.

Conclusion: Allopathic physicians comprise the majority of those who have received an R01 grantin EM over the last decade. These physicians typically have numerous prior publications and anadvanced degree.

Prehospital Care

Altitude-Related Change in Endotracheal Tube Cuff Pressures in Helicopter EMS

Introduction: Over-inflation of endotracheal tube (ETT) cuffs has the potential to lead to scarring and stenosis of the trachea.1, 2,3, 4 The air inside an ETT cuff is subject to expansion as atmospheric pressure decreases, as happens with an increase in altitude. Emergency medical services helicopters are not pressurized, thereby providing a good environment for studying the effects of altitude changes ETT cuff pressures. This study aims to explore the relationship between altitude and ETT cuff pressures in a helicopter air-medical transport program.

Methods: ETT cuffs were initially inflated in a nonstandardized manner and then adjusted to a pressure of 25 cmH2O. The pressure was again measured when the helicopter reached maximum altitude. A final pressure was recorded when the helicopter landed at the receiving facility.

Results: We enrolled 60 subjects in the study. The mean for initial tube cuff pressures was 70 cmH2O. Maximum altitude for the program ranged from 1,000-3,000 feet above sea level, with a change in altitude from 800-2,480 feet. Mean cuff pressure at altitude was 36.52 ± 8.56 cmH2O. Despite the significant change in cuff pressure at maximum altitude, there was no relationship found between the maximum altitude and the cuff pressures measured.

Conclusion: Our study failed to demonstrate the expected linear relationship between ETT cuff pressures and the maximum altitude achieved during typical air-medical transportation in our system. At altitudes less than 3,000 feet above sea level, the effect of altitude change on ETT pressure is minimal and does not require a change in practice to saline-filled cuffs.

Emergency Medical Services Professionals’ Attitudes About Community Paramedic Programs

Introduction: The number of community paramedic (CP) programs has expanded to mitigatethe impact of increased patient usage on emergency services. However, it has not beendetermined to what extent emergency medical services (EMS) professionals would be willing toparticipate in this model of care. With this project, we sought to evaluate the perceptions of EMSprofessionals toward the concept of a CP program.

Methods: We used a cross-sectional study method to evaluate the perceptions of participatingEMS professionals with regard to their understanding of and willingness to participate in a CPprogram. Approximately 350 licensed EMS professionals currently working for an EMS servicethat provides coverage to four states (Missouri, Arkansas, Kansas, and Oklahoma) were invitedto participate in an electronic survey regarding their perceptions toward a CP program. Weanalyzed interval data using the Mann-Whitney U test, Kruskal-Wallis one-way analysis ofvariance, and Pearson correlation as appropriate. Multivariate logistic regression was performedto examine the impact of participant characteristics on their willingness to perform CP duties.Statistical significance was established at p ≤ 0.05.

Results: Of the 350 EMS professionals receiving an invitation, 283 (81%) participated. Of thoseparticipants, 165 (70%) indicated that they understood what a CP program entails. One hundredthirty-five (58%) stated they were likely to attend additional e ducation in order to becomea CP, 152 (66%) were willing to perform CP duties, and 175 (75%) felt that their respective communities would be in favor of a local CP program. Using logistic regression with regard towillingness to perform CP duties, we found that females were more willing than males (OR =4.65; p = 0.03) and that those participants without any perceived time on shift to commit to CPduties were less willing than those who believed their work shifts could accommodate additionalduties (OR = 0.20; p < 0.001).

Conclusion: The majority of EMS professionals in this study believe they understand CPprograms and perceive that their communities want them to provide CP-level care. While fewerin number, most are willing to attend additional CP education and/or are willing to perform CP duties.

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Behavioral Health

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

Introduction: The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.

Methods: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors.Results: Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area.Conclusion: The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

Managing Acute Behavioural Disturbances in the Emergency Department Using the Environment, Policies and Practices: A Systematic Review

Introduction: Effective strategies for managing acute behavioural disturbances (ABDs) within emergency departments (EDs) are needed given their rising occurrence and negative impact on safety, psychological wellbeing, and staff turnover. Non-pharmacological interventions for ABD management generally fall into four categories: environmental modifications; policies; practice changes; and education. Our objective was to systematically review the efficacy of strategies for ABD management within EDs that involved changes to environment, architecture, policy and practice.

Methods: We performed systematic searches of CINAHL Plus with Full Text, PsycINFO, MEDLINE, and EMBASE, as well as reference lists of relevant review articles to identify relevant studies published between January 1985 - April 2016. We included studies written in English, which reported management of behavioural disturbances in adults associated with the ED through the use of environmental modifiers (including seclusion, restraint, specialised rooms, architectural changes), policy, and practice-based interventions excepting education-only interventions. Efficacy outcomes of interest included incidence, severity, and duration of ABD, incidence of injuries, staff absenteeism, restraint use, restraint duration, and staff and patient perceptions. Two reviewers independently screened titles and abstracts, and assessed the relevancy and eligibility of studies based on full-text articles. Two authors independently appraised included studies. A narrative synthesis of findings was undertaken.

Results: Studies reporting interventions for managing ABDs within the ED are limited in number and quality. The level of evidence for efficacy is low, requiring caution in conclusions. While there is preliminary evidence for environmental change in the form of specialised behavioural rooms, security upgrades and ED modifications, these are not supported by evidence from controlled studies. Many of these “common sense” environmental changes recommended in many guidelines have been widely implemented in EDs.

Conclusion: There is an unambiguous gap in the literature regarding the efficacy of interventions for ABD management in EDs involving environmental, policy or practice-based changes. With growing demand on EDs, and with increasing numbers of ABDs, identification of robust evidence-based interventions for safe and effective ABD management is vital.

  • 4 supplemental files

Critical Care

Derivation and Validation of The Prehospital Difficult Airway IdentificationTool (PreDAIT): A Predictive Model for Difficult Intubation

Introduction: Endotracheal intubation (ETI) in the prehospital setting poses unique challengeswhere multiple ETI attempts are associated with adverse patient outcomes. Early identificationof difficult ETI cases will allow providers to tailor airway-man agement efforts to minimizecomplications associated with ETI. We sought to derive and validate a prehospital difficult airwayidentification tool based on predictors of difficult ETI in other settings.

Methods: We prospectively collected patient and airway data on all airway attempts from 16Advanced Life Support (ALS) ground emergency medical services (EMS) agencies from January2011 to October 2014. Cases that required more than two ETI attempts and cases where analternative airway strategy (e.g. supraglottic airway) was employed after one unsuccessful ETIattempt were categorized as “difficult.” We used a random allocation sequence to split the datainto derivation and validation subsets. Using backward elimination, factors with a p<0.1 wereincluded in the multivariable regression for the derivation cohort and then tested in the validationcohort. We used this model to determine the area under the curve (AUC), and the sensitivity andspecificity for each cut point in both the derivation and valida tion cohorts.

Results: We collected data on 1,102 cases with 568 in the derivation set (155 difficult cases;27%) and 534 in the validation set (135 difficult cases; 25%). O f the collected variables,five factors were predictive of difficult ETI in the derivation m odel (adjusted odds ratio, 95%confidence interval [CI]): Glasgow coma score [GCS] >3 (2.15, 1. 19-3.88), limited neckmovement (2.24, 1.28-3.93), trismus/jaw clenched (2.24, 1.09-4. 6), inability to palpate thelandmarks of the neck (5.92, 2.77-12.66), and fluid in the airwa y such as blood or emesis (2.25,1.51-3.36). This was the most parsimonious model and exhibited good fit (Hos mer-Lemeshowtest p = 0.167) with an AUC of 0.68 (95% CI [0.64-0.73]). When applied to the validatio n set,the model had an AUC of 0.63 (0.58-0.68) with high specificity for identifying di fficult ETI if >2factors were present (87.7% (95% CI [84.1-90.8])).

Conclusion: We have developed a simple tool using five factors that may aid p rehospitalproviders in the identification of difficult ETI.

Efficacy and Safety of Tranexamic Acid in Prehospital Traumatic Hemorrhagic Shock: Outcomes of the Cal-PAT Study

Introduction: The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess thesafety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-inducedhemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administrationby paramedics within the framework of North American emergency medicine standards and protocols.

Methods: This is an ongoing multi-centered, prospective, observational cohort study with a retrospectivechart-review comparison. Trauma patients identified in the prehospital setting with signs of hemorrhagicshock by first responders were administered one gram of TXA followed by an optional second one-gram doseupon arrival to the hospital, if the patient still met inclusion criteria. Patients administered TXA make up theprehospital intervention group. Control group patients met the same inclusion criteria as TXA candidates andwere matched with the prehospital intervention patients based on mechanism of injury, injury severity score,and age. The primary outcomes were mortality, measured at 24 hours, 48 hours, and 28 days. Secondaryoutcomes measured included the total blood products transfused and any known adverse events associatedwith TXA administration.

Results: We included 128 patients in the prehospital intervention group and 125 in the control group.Although not statistically significant, the prehospital intervention group trended toward a lower 24-hourmortality rate (3.9% vs 7.2% for intervention and control, respectively, p=0.25), 48-hour mortality rate (6.3%vs 7.2% for intervention and control, respectively, p=0.76), and 28-day mortality rate (6.3% vs 10.4% forintervention and control, respectively, p=0.23). There was no significant difference observed in knownadverse events associated with TXA administration in the prehospital intervention group and control group. Areduction in total blood product usage was observed following the administration of TXA (control: 6.95 units;intervention: 4.09 units; p=0.01).

Conclusion: Preliminary evidence from the Cal-PAT study suggests that TXA administration may be safe inthe prehospital setting with no significant change in adverse events observed and an associated decreaseduse of blood products in cases of trauma-induced hemorrhagic shock. Given the current sample size, astatistically significant decrease in mortality was not observed. Additionally, this study demonstrates thatit may be feasible for paramedics to identify and safely administer TXA in the prehospital setting.

Evaluating the Laboratory Risk Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the Emergency Department

Introduction: Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in grossmorbidity and mortality if not treated in its early stages. The Laboratory Risk Indicator for Necrotizing Fasciitis(LRINEC) score is used to distinguish NF from other soft tissue infections such as cellulitis or abscess. Thisstudy analyzed the ability of the LRINEC score to accurately rule out NF in patients who were confirmed tohave cellulitis, as well as the capability to differentiate cellulitis from NF.

Methods: This was a 10-year retrospective chart-review study that included emergency department (ED)patients ≥18 years old with a diagnosis of cellulitis or NF. We calculated a LRINEC score ranging from0-13 for each patient with all pertinent laboratory values. Three categories were developed per the originalLRINEC score guidelines denoting NF risk stratification: high risk (LRINEC score ≥8), moderate risk (LRINECscore 6-7), and low risk (LRINEC score ≤5). All cases missing laboratory values were due to the absence ofa C-reactive protein (CRP) value. Since the score for a negative or positive CRP value for the LRINEC scorewas 0 or 4 respectively, a LRINEC score of 0 or 1 without a CRP value would have placed the patient in the“low risk” group and a LRINEC score of 8 or greater without CRP value would have placed the patient in the“high risk” group. These patients missing CRP values were added to these respective groups.

Results: Among the 948 ED patients with cellulitis, more than one-tenth (10.7%, n=102 of 948) weremoderate or high risk for NF based on LRINEC score. Of the 135 ED patients with a diagnosis of NF, 22patients had valid CRP laboratory values and LRINEC scores were calculated. Among the other 113 patientswithout CRP values, six patients had a LRINEC score ≥ 8, and 19 patients had a LRINEC score ≤ 1. Thus, atotal of 47 patients were further classified based on LRINEC score without a CRP value. More than half of theNF group (63.8%, n=30 of 47) had a low risk based on LRINEC ≤5. Moreover, LRINEC appeared to performbetter in the diabetes population than in the non-diabetes population.

Conclusion: The LRINEC score may not be an accurate tool for NF risk stratification and differentiationbetween cellulitis and NF in the ED setting. This decision instrument demonstrated a high false positive ratewhen determining NF risk stratification in confirmed cases of celulitis and a high false negative rate in casesof confirmed NF.

Index to Predict In-hospital Mortality in Older Adults after Non-traumatic Emergency Department Intubations

Introduction: Our goal was to develop and validate an index to predict in-hospital mortality in olderadults after non-traumatic emergency department (ED) intubations.

Methods: We used Vizient administrative data from hospitalizations of 22,374 adults >75 years whounderwent non-traumatic ED intubation from 2008-2015 at nearly 300 U.S. hospitals to develop andvalidate an index to predict in-hospital mortality. We randomly selected one half of participants for thedevelopment cohort and one half for the validation cohort. Considering 25 potential predictors, wedeveloped a multivariable logistic regression model using least absolute shrinkage and selection operatormethod to determine factors associated with in-hospital mortality. We calculated risk scores using pointsderived from the final model’s beta coefficients. To evaluate calibration and discrimination of the finalmodel, we used Hosmer-Lemeshow chi-square test and receiver-operating characteristic analysis andcompared mortality by risk groups in the development and validation cohorts.

Results: Death during the index hospitalization occurred in 40% of cases. The final model included sixvariables: history of myocardial infarction, history of cerebrovascular disease, history of metastatic cancer,age, admission diagnosis of sepsis, and admission diagnosis of stroke/ intracranial hemorrhage. Thosewith low-risk scores (<6) had 31% risk of in-hospital mortality while those with high-risk scores (>10) had58% risk of in-hospital mortality. The Hosmer-Lemeshow chi-square of the model was 6.47 (p=0.09), andthe c-statistic was 0.62 in the validation cohort.

Conclusion: The model may be useful in identifying older adults at high risk of death after ED intubation.


Academic Primer Series: Five Key Papers about Study Designs in Medical Education

Introduction: A proper understanding of study design is essential to creating successful studies. This is also important when reading or peer reviewing publications. In this article, we aimed to identify and summarize key papers that would be helpful for faculty members interested in learning more about study design in medical education research.

Methods: The online discussions of the 2016-2017 Academic Life in Emergency Medicine Faculty Incubator program included a robust and vigorous discussion about education study design, which highlighted a number of papers on that topic. We augmented this list of papers with further suggestions by expert mentors. Via this process, we created a list of 29 papers in total on the topic of medical education study design. After gathering these papers, our authorship group engaged in a modified Delphi approach to build consensus on the papers that were most valuable for the understanding of proper study design in medical education.

Results: We selected the top five most highly rated papers on the topic domain of study design as determined by our study group. We subsequently summarized these papers with respect to their relevance to junior faculty members and to faculty developers.

Conclusion: This article summarizes five key papers addressing study design in medical education with discussions and applications for junior faculty members and faculty developers. These papers provide a basis upon which junior faculty members might build for developing and analyzing studies.


A User’s Guide to the ALiEM Emergency Medicine Match Advice Web Series

ALiEM EM Match Advice is a web series hosted on the Academic Life in Emergency Medicinewebsite. The intended audience includes senior medical students seeking a residency inemergency medicine (EM) and the faculty members who advise them. Each episode featuresa panel of three EM program directors who discuss a critical step in the residency applicationprocess. This article serves as a user’s guide to the series, including a timeline for viewingeach episode, brief summaries of the panel discussions, and reflection questions for discussionbetween students and their faculty advisors.

Academic Primer Series: Key Papers About Competency-Based Medical Education

Introduction: Competency-based medical education (CBME) presents a paradigm shift in medicaltraining. This outcome-based education movement has triggered substantive changes across the globe.Since this transition is only beginning, many faculty members may not have experience with CBMEnor a solid foundation in the grounding literature. We identify and summarize key papers to help facultymembers learn more about CBME.

Methods: Based on the online discussions of the 2016-2017 ALiEM Faculty Incubator program, a seriesof papers on the topic of CBME was developed. Augmenting this list with suggestions by a guest expertand by an open call on Twitter for other important papers, we were able to generate a list of 21 papers intotal. Subsequently, we used a modified Delphi study methodology to narrow the list to key papers thatdescribe the importance and significance for educators interested in learning about CBME. To determinethe most impactful papers, the mixed junior and senior faculty authorship group used three-round votingmethodology based upon the Delphi method.

Results: Summaries of the five most highly rated papers on the topic of CBME, as determined by thismodified Delphi approach, are presented in this paper. Major themes include a definition of core CBMEthemes, CBME principles to consider in the design of curricula, a history of the development of the CBMEmovement, and a rationale for changes to accreditation with CBME. The application of the study findingsto junior faculty and faculty developers is discussed.

Conclusion: We present five key papers on CBME that junior faculty members and faculty expertsidentified as essential to faculty development. These papers are a mix of foundational and explanatorypapers that may provide a basis from which junior faculty members may build upon as they help toimplement CBME programs.

Academic Primer Series: Key Papers About Peer Review

Introduction: Peer review, a cornerstone of academia, promotes rigor and relevance in scientificpublishing. As educators are encouraged to adopt a more scholarly approach to medical education,peer review is becoming increasingly important. Junior educators both receive the reviews of theirpeers, and are also asked to participate as reviewers themselves. As such, it is imperative for juniorclinician educators to be well-versed in the art of peer reviewing their colleagues’ work. In thisarticle, our goal was to identify and summarize key papers that may be helpful for faculty membersinterested in learning more about the peer-review process and how to improve their reviewing skills.

Methods: The online discussions of the 2016-17 Academic Life in Emergency Medicine (ALiEM)Faculty Incubator program included a robust discussion about peer review, which highlighted anumber of papers on that topic. We sought to augment this list with further suggestions by guestexperts and by an open call on Twitter for other important papers. Via this process, we created a listof 24 total papers on the topic of peer review. After gathering these papers, our authorship groupengaged in a consensus-building process incorporating Delphi methods to identify the papers thatbest described peer review, and also highlighted important tips for new reviewers.

Results: We found and reviewed 24 papers. In our results section, we present our authorshipgroup’s top five most highly rated papers on the topic of peer review. We also summarize thesepapers with respect to their relevance to junior faculty members and to faculty developers.

Conclusion: We present five key papers on peer review that can be used for faculty development fornovice writers and reviewers. These papers represent a mix of foundational and explanatory papersthat may provide some basis from which junior faculty members might build upon as they both undergothe peer-review process and act as reviewers in turn.

Academic Primer Series: Key Papers About Teaching with Technology

Introduction: Modern learners have immediate, unlimited access to a wide variety of onlineresources. To appeal to this current generation of learners, educators must embrace the useof technology. However, educators must balance newer, novel technologies with traditionalmethods to achieve the best learning outcomes. Therefore, we aimed to review several papersuseful for faculty members wishing to incorporate technology into instructional design.

Methods: We identified a broad list of papers relevant to teaching and lea rning with technologywithin the online discussions of the Academic Life in Emergency Medicine (ALiEM) FacultyIncubator. This list was augmented with suggestions by a guest expert (BT) and an open callon Twitter (tagged with the #meded and #FOAMed hashtags) yielding 24 papers. We thenconducted a modified three-round Delphi process within the autho rship group, including juniorand senior faculty members, to identify the most impactful papers.

Results: We pared the list of 24 papers to five that were most highly rate d. Two were researchpapers and three were commentaries or editorials. The authorship group reviewed andsummarized these papers with specific consideration to their val ue to junior educators andfaculty developers.

Conclusion: This is a key reading list for junior faculty members and faculty developersinterested in teaching with technology. The commentary contextualizes the importance of thesepapers for medical educators, to optimize use of technology in their teaching or incorporate intofaculty development.

Health Outcomes

Pain Perception in Latino vs. Caucasian and Male vs. Female Patients: Is There Really a Difference?

Introduction: Pain is a common emergency department (ED) complaint. It is important tounderstand the differences in pain perception among different ethnic and demographic populations.

Methods: We applied a standardized painful stimulus to Caucasian and Latino adult patients todetermine whether the level of pain reported differed depending on ethnicity (N=100; 50 Caucasian[C], 50 Latino [L] patients) and gender (N=100; 59 female, 41 male). Patients had an initial painscore of 0 or 1. A blood pressure cuff was inflated 20 mm HG above the patient’s systolic bloodpressure and held for three minutes. Pain scores, using both a 10-cm visual analog scale (VAS) anda five-point Likert scale, were taken at the point of maximal stimulus (2 minutes 50 seconds afterinflation), and at one- and two-minute intervals post deflation.

Results: There was a statistically significant difference between the Likert scale scores of Caucasianand Latino patients at 2min 50sec (mean rank: 4.35 [C] vs. 5.75 [L], p<0.01), but not on the VAS(mean value: 2.94 [C] vs. 3.46 [L], p=0.255). Women had a higher perception of pain than males at2min 50sec on the VAS (mean value: 3.86 [F] vs. 2.24 [M], p<0.0001), and the Likert scale (meanrank: 5.63 [F] vs. 4.21 [M], p<0.01).

Conclusion: Latinos and women report greater pain with a standardized pain stimulus as comparedto Caucasians and men.

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

Introduction: Older, chronically ill patients with limited health literacy are often under-engagedin managing their health and turn to the emergency department (ED) for healthcare needs. Wetested the impact of an ED-initiated coaching intervention on patient engagement and follow-updoctor visits in this high-risk population. We also explored patients’ care-seeking decisions.

Methods: We conducted a mixed-methods study including a randomized controlled trial andin-depth interviews in two EDs in northern Florida. Participants were chronically ill older EDpatients with limited health literacy and Medicare as a payer source. Patients were assignedto an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitativeinterviews (n=9) explored patients’ reasons for ED use. We assessed average between-groupdifferences in patient engagement over time with the Patient Activation Measure (PAM) tool,using logistic regression and a difference-in-difference approach. Between-group differences infollow-up doctor visits were determined. We analyzed qualitative data using open coding andthematic analysis.

Results: PAM scores fell in both groups after the ED visit but fell signi ficantly more in “usualcare” (average decline -4.64) than “intervention” participants (average decline -2.77) (β=1.87,p=0.043). There were no between-group differences in doctor visits. Patients described wellinformedreasons for ED visits including onset and severity of symptoms, lack of timely provideraccess, and immediate and comprehensive ED care.

Conclusion: The coaching intervention significantly reduced declines in pati ent engagementobserved after usual post-ED care. Patients reported well-informed reasons for ED use andwill likely continue to make ED visits unless strategies, such as ED-initiated coaching, areimplemented to help vulnerable patients better manage their health and healthcare.

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Utility of the History and Physical Examination in the Detection of Acute Coronary Syndromes in Emergency Department Patients

Chest pain accounts for approximately 6% of all emergency department (ED) visits and is the mostcommon reason for emergency hospital admission. One of the most serious diagnoses emergencyphysicians must consider is acute coronary syndrome (ACS). This is both common and serious,as ischemic heart disease remains the single biggest cause of death in the western world. Thehistory and physical examination are cornerstones of our diagnostic approach in this patient group.Their importance is emphasized in guidelines, but there is little evidence to support their supposedassociation. The purpose of this article was to summarize the findings of recent investigationsregarding the ability of various components of the history and physical examination to identify whichpatients presenting to the ED with chest pain require further investigation for possible ACS.

Previous studies have consistently identified a number of factors that increase the probabilityof ACS. These include radiation of the pain, aggravation of the pain by exertion, vomiting, anddiaphoresis. Traditional cardiac risk factors identified by the Framingham Heart Study are of limiteddiagnostic utility in the ED. Clinician gestalt has very low predictive ability, even in patients with anon-diagnostic electrocardiogram (ECG), and gestalt does not seem to be enhanced appreciably byclinical experience. The history and physical alone are unable to reduce a patient’s risk of ACS to agenerally acceptable level (<1%).

Ultimately, our review of the evidence clearly demonstrates that “atypical” symptoms cannot rule out ACS,while “typical” symptoms cannot rule it in. Therefore, if a patient has symptoms that are compatible withACS and an alternative cause cannot be identified, clinicians must strongly consider the need for furtherinvestigation with ECG and troponin measurement.

Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment

Introduction: The study objective was to explore emergency physicians’ (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization.

Methods: We provided a five-question survey to 52 EPs, gauging previous experience referring patients to home-based healthcare, patient selection, and motivators and challenges when considering home-based options as an alternative to admission. In addition, we conducted three focus groups and four interviews.

Results: Of participating EPs, 92% completed the survey, 38% reported ordering home-based healthcare from the ED as an alternative to admission, 90% ranked cellulitis among the top three medical conditions for home-based healthcare, 90% ranked “reduce unnecessary hospitalizations and observation stays” among their top three perceived motivators for using home-based care, and 77% ranked “no existing process in place to refer to home-based care” among their top three perceived barriers. Focus group and interview themes included the need for alternatives to admission; the longer-term benefits of home-based healthcare; the need for streamlined transition processes; and the need for highly qualified home-care staff capable of responding the same day or within 24 hours.

Conclusion: The study found that EPs are receptive to referring patients for home-based healthcare following ED treatment and believe people with certain diagnoses are likely to benefit, with the dominant barrier being the absence of an efficient referral process.

Replacement of Dislodged Gastrostomy Tubes After Stoma Dilation in the Pediatric Emergency Department

Introduction: A dislodged gastrostomy tube (GT) is a common complaint that requires evaluationin the pediatric emergency department (ED) and, on occasion, will require stoma dilation tosuccessfully replace the GT. The objective of this study was to describe the frequency that stomadilation is required, the success rate of replacement, complications encountered, and the techniquesused to confirm placement of the GT after dilation.

Methods: We conducted a retrospective medical record review of children 0-18 years whopresented to the pediatric ED from February 2013 through February 2015 with a dislodged GT thatrequired stoma dilation by pediatric emergency physicians with serially increasing Foley cathetersizes prior to successful placement of the GT.

Results: We reviewed a total of 302 encounters in 215 patients, with 97 (32%) of the encountersrequiring stoma dilation prior to replacing a GT. The median amount of dilation was 2 Frenchbetween the initial Foley catheter size and the final GT size. There was a single complication ofa mal-positioned balloon that was identified at the index visit. No delayed complications wereencountered. We performed confirmation of placement in all patients. The two most commonforms of confirmation were aspiration of gastric contents (56/97 [58%]) followed by contrastradiograph in 39 (40%).

Conclusion: The practice of serial dilation of a gastrostomy stoma site to allow successfulreplacement of a gastrostomy tube in pediatric patients who present to the ED with a dislodgedgastrostomy tube is generally successful and without increased complication. All patients received atleast one form of confirmation for appropriate GT placement with the most common being aspirationof gastric contents.

A Comparison of Urolithiasis in the Presence and Absence of Microscopic Hematuria in the Emergency Department

Introduction: Urolithiasis is a common medical condition that accounts for a large number of emergency department (ED) visits each year and contributes significantly to annual healthcare costs. Urinalysis is an important screening test for patients presenting with symptoms suspicious for urolithiasis. At present there is a paucity of medical literature examining the characteristics of ureteral stones in patients who have microscopic hematuria on urinalysis versus those who do not. The purpose of this study was to examine mean ureteral stone size and its relationship to the incidence of clinically significant hydronephrosis in patients with and without microscopic hematuria.

Methods: This is a retrospective chart review of patient visits to a single, tertiary academic medical center ED between July 1, 2008, and August 1, 2013, of patients who underwent non-contrast computed tomography of the abdomen and pelvis and urinalysis. For patient visits meeting inclusion criteria, we compared mean stone size and the rate of moderate-to-severe hydronephrosis found on imaging in patients with and without microscopic hematuria on urinalysis.

Results: Out of a total of 2,370 patient visits 393 (16.6%) met inclusion criteria. Of those, 321 (82%) had microscopic hematuria present on urinalysis. Patient visits without microscopic hematuria had a higher rate of moderate-to-severe hydronephrosis (42%), when compared to patients with microscopic hematuria present (25%, p=.005). Mean ureteral stone size among patient visits without microscopic hematuria was 5.7 mm; it was 4.7 mm for those patients with microscopic hematuria (p=.09). For ureteral stones 5 mm or larger, the incidence of moderate-to-severe hydronephrosis was 49%, whereas for ureteral calculi less than 5 mm in size, the incidence of moderate-to-severe hydronephrosis was 14% (p < 0.0001).

Conclusion: Patients visiting the ED with single-stone ureterolithiasis without microscopic hematuria on urinalysis could be at increased risk of having moderate-to-severe hydronephrosis compared to similar patients presenting with microscopic hematuria on urinalysis. Although the presence of hematuria on urinalysis is a moderately sensitive screening test for urolithiasis, these results suggest patients without hematuria tend to have more clinically significant ureteral calculi, making their detection more important. Clinicians should maintain a high index of suspicion for urolithiasis, even in the absence of hematuria, since ureteral stones in these patients were found to be associated with a higher incidence of obstructive uropathy.