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Open Access Publications from the University of California

Volume 18, Issue 5, 2017

Emergency Department Operations

Magnetic Resonance Imaging Utilization in an Emergency Department Observation Unit


Emergency Department Observation Units (EDOUs) are a valuable alternative to inpatient admissions for Emergency Department (ED) patients needing extended care. However, while the use of advanced imaging is becoming more common in the ED, there are no studies characterizing the use of magnetic resonance imaging (MRI) examinations in the EDOU.


This Institutional Review Board-approved, retrospective study was performed at a 999-bed quaternary care academic Level 1 adult and pediatric trauma center, with approximately 114,000 ED visits annually and a 32-bed adult EDOU. The EDOU patient database was retrospectively reviewed for all MRI examinations done from October 1st, 2013 to September 30th, 2015. We sought to describe the most frequent uses for MRI during EDOU admissions and reviewed EDOU length of stay (LOS) to determine whether the use of MRI was associated with any change in LOS.


22,840 EDOU admissions were recorded during the two-year study period, and 4,437 (19%) of these patients had a least one MRI examination during their stay. 2,730 (62%) of these studies were of the brain, head, or neck and an additional 1,392 (31%) were of the spine. There was no significant difference between the median LOS of admissions in which an MRI study was performed (17.5 hours) and the median LOS (17.7 hours) of admissions in which an MRI study was not performed [p=0.33].


Neuroimaging makes up the clear majority of MRI examinations from our EDOU, and the use of MRI does not appear to prolong EDOU LOS.  Future work should focus on the appropriateness of these MRI examinations to determine potential resource and cost savings.


Trends and Characteristics of Emergency Department Visits for Fall-Related Injuries in Older Adults, 2003-2010

Introduction: One third of older adults fall each year, and falls are costly to both the patient in terms ofmorbidity and mortality and to the health system. Given that falls are a preventable cause of injury, ourobjective was to understand the characteristics and trends of emergency department (ED) fall-relatedvisits among older adults. We hypothesize that falls among older adults are increasing and examinepotential factors associated with this rise, such as race, ethnicity, gender, insurance and geography.

Methods: We conducted a secondary analysis of data from the National Hospital AmbulatoryMedical Care Survey (NHAMCS) to determine fall trends over time by examining changes in EDvisit rates for falls in the United States between 2003 and 2010, detailing differences by gender,sociodemographic characteristics and geographic region.

Results: Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age≥ 65 increased from 60.4 (95% confidence interval [CI][51.9-68.8]) to 68.8 (95% CI [57.8-79.8]) per1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75-84 yearsincreased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p =0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the Southincreased from 54.4 to 71.1 (p=0.03).

Conclusion: ED visit rates for falls are increasing over time. There is a national movement toincrease falls awareness and prevention. EDs are in a unique position to engage patients on futurefall prevention and should consider ways they can also partake in such initiatives in a manner that isfeasible and appropriate for the ED setting. [West J Emerg Med. 2017;18(5)785-793.]


Prevalence of Intracranial Hemorrhage after Blunt Head Trauma in Patients on Pre-injury Dabigatran

Introduction: Dabigatran etexilate was the first direct-acting oral anticoagulant approved in the UnitedStates. The prevalence of intracranial hemorrhage after blunt head trauma in patients on dabigatranis currently unknown, complicating adequate ability to accurately compare the risks and benefitsof dabigatran to alternative anticoagulants. We aimed to determine the prevalence of intracranialhemorrhage for patients on dabigatran presenting to a Level I trauma center.

Methods: This is a retrospective observational study of adult patients on dabigatran who presented toa Level I trauma center and received cranial computed tomography (CT) following blunt head trauma.Patients who met inclusion criteria underwent manual chart abstraction. Our primary outcome wasintracranial hemorrhage on initial cranial CT.

Results: We included a total of 33 eligible patient visits for analysis. Mean age was 74.8 years (SD11.2, range 55-91). The most common cause of injury was ground-level fall (n = 22, 66.7%). One patient(3.0%, 95% confidence interval [CI] 0.[1-15.8%]) had intracranial hemorrhage on cranial CT. No patients(0%, 95% CI [0-8.7%]) required neurosurgical intervention. One in-hospital death occurred from infection.

Conclusion: To our knowledge, this is the first study to evaluate the prevalence of intracranialhemorrhage after blunt head trauma for patients on dabigatran presenting to the emergency department,including those not admitted. The intracranial hemorrhage prevalence in our study is similar to previousreports for patients on warfarin. Further studies are needed to determine if the prevalence of intracranialhemorrhage seen in our patient population is true for a larger patient population in more diverse clinicalsettings. [West J Emerg Med. 2017;18(5)794–799.]

Provider Workforce

Congratulations, You’re Pregnant! Now About Your Shifts . . . : The State of Maternity Leave Attitudes and Culture in EM

Introduction: Increasing attention has been focused on parental leave, but little is known aboutearly leave and parental experiences for male and female attending physicians. Our goal wasto describe and quantify the parental leave experiences of a nationally representative sample ofemergency physicians (EP).

Methods: We conducted a web-based survey, distributed via emergency medicine professionalorganizations, discussion boards, and listservs, to address study objectives.

Results: We analyzed data from 464 respondents; 56% were women. Most experienced childbirthwhile employed as an EP. Fifty-three percent of women and 60% of men reported working in a settingwith a formal maternity leave policy; however, 36% of women and 18% of men reported dissatisfactionwith these policies. Most reported that other group members cover maternity-related shift vacancies;a minority reported that pregnant partners work extra shifts prior to leave. Leave duration andcompensation varied widely, ranging from no compensated leave (18%) to 12 or more weeks at 100%salary (7%). Supportive attitudes were reported during pregnancy (53%) and, to a lesser degree (43%),during leave. Policy improvement suggestions included the development of clear, formal policies;improving leave duration and compensation; adding paternity and adoption leave; providing support forphysicians working extra to cover colleagues’ leave; and addressing breastfeeding issues.

Conclusion: In this national sample of EPs, maternity leave policies varied widely. The duration andcompensation during leave also had significant variation. Participants suggested formalizing policies,increasing leave duration and compensation, adding paternity leave, and changing the coverage forvacancies to relieve burden on physician colleagues. [West J Emerg Med. 2017;18(5)800-810.]

Societal Impact on Emergency Care

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois

Introduction: This study analyzes changes in hospital emergency department (ED) visit ratesbefore and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We comparethe association between population insurance status change and ED visit rate change between a24-month (2012-2013) pre-ACA period and a 24-month post-ACA (2014-2015) period across 88socioeconomically diverse areas of Illinois.

Methods: We used annual American Community Survey estimates for 2012-2015 to obtain insurancestatus changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 IllinoisPublic Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18-64 residents. Over 12million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents ofeach PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. Wethen estimated n=88 correlations between population insurance-status changes and changes in EDvisit rates per 1,000 residents comparing the two years before and after ACA implementation.

Results: The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductionsin uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment.Compared to 2012-2013, 2014-2015 average monthly ED visits by the uninsured dropped 42%,but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increasesin Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollmentwas the only significant correlate of area change in total ED visits and explained a third of variationacross the 88 PUMAs.

Conclusion: ACA implementation in Illinois accelerated existing trends towards greater use of hospitalED care. It remains to be seen whether providing better access to primary and preventive care tothe formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a partof continued, long-term growth. Monitoring ED use at the local level is critical to the success of newhome- and community-based care coordination initiatives. [West J Emerg Med. 2017;18(5)811-820.]

  • 1 supplemental file

Treatment Protocol Assessment

Head CT for Minor Head Injury Presenting to the Emergency Department in the Era of Choosing Wisely

Introduction: The Choosing Wisely campaign currently recommends avoiding computed tomography(CT) of the head in low-risk emergency department (ED) patients with minor head injury, based onvalidated decision rules. However, the degree of adherence to this guideline in clinical practice isunknown. The objective of this study was to evaluate adherence to the Choosing Wisely campaign’srecommendations regarding head CT imaging of patients with minor head injury in the ED.

Methods: We conducted a retrospective cohort study of adult ED patients at a Level I traumacenter. Patients aged ≥ 18 years who presented to the ED with minor head injury were identified viaInternational Classification of Diseases, 9th Revision, Clinical Modification codes. Medical recordabstraction was conducted to determine the presence of clinical symptoms of the NEXUS II criteria,medical resource use, and head CT findings. We used descriptive statistics to characterize the studysample, and proportions were used to quantify guidelines adherence.

Results: A total of 489 subjects met inclusion criteria. ED providers appropriately applied the ChoosingWisely criteria for 75.5% of patients, obtaining head CTs when indicated by the NEXUS II rule (41.5%),and not obtaining head CTs when the NEXUS II criteria were not met (34.0%). However, ED providersobtained non-indicated CTs in 23.1% of patients. Less than 2% of the sample did not receive a headCT when imaging was indicated by NEXUS II.

Conclusion: ED providers in our sample had variable adherence to the Choosing Wisely head-CTrecommendation, especially for patients who did not meet the NEXUS II criteria. [West J EmergMed. 2017;18(5)821-829.]


Emergency Physician-performed Transesophageal Echocardiography in Simulated Cardiac Arrest

Introduction: Transesophageal echocardiography (TEE) is a well-established method of evaluatingcardiac pathology. It has many advantages over transthoracic echocardiography (TTE), including theability to image the heart during active cardiopulmonary resuscitation. This prospective simulation studyaims to evaluate the ability of emergency medicine (EM) residents to learn TEE image acquisitiontechniques and demonstrate those techniques to identify common pathologic causes of cardiac arrest.

Methods: This was a prospective educational cohort study with 40 EM residents from two participatingacademic medical centers who underwent an educational model and testing protocol. All participantswere tested across six cases, including two normals, pericardial tamponade, acute myocardial infarction(MI), ventricular fibrillation (VF), and asystole presented in random order. Primary endpoints were correctidentification of the cardiac pathology, if any, and time to sonographic diagnosis. Calculated endpointsincluded sensitivity, specificity, and positive and negative predictive values for emergency physician (EP)-performed TEE. We calculated a kappa statistic to determine the degree of inter-rater reliability.

Results: Forty EM residents completed both the educational module and testing protocol. This resultedin a total of 80 normal TEE studies and 160 pathologic TEE studies. Our calculations for the abilityto diagnose life-threatening cardiac pathology by EPs in a high-fidelity TEE simulation resulted in asensitivity of 98%, specificity of 99%, positive likelihood ratio of 78.0, and negative likelihood ratio of0.025. The average time to diagnose each objective structured clinical examination case was as follows:normal A in 35 seconds, normal B in 31 seconds, asystole in 13 seconds, tamponade in 14 seconds,acute MI in 22 seconds, and VF in 12 seconds. Inter-rater reliability between participants was extremelyhigh, resulting in a kappa coefficient across all cases of 0.95.

Conclusion: EM residents can rapidly perform TEE studies in a simulated cardiac arrest environmentwith a high degree of precision and accuracy. Performance of TEE studies on human patients in cardiacarrest is the next logical step to determine if our simulation data hold true in clinical practice. [West JEmerg Med. 2017;18(5)830-834.]

Emergency Department Administration

Increased Computed Tomography Utilization in the Emergency Department and Its Association with Hospital Admission

Introduction: Our goal was to investigate trends in computed tomography (CT) utilization in emergency departments (EDs) and its association with hospitalization. Methods: We conducted an analysis of an administrative claims database of U.S. privately insured and Medicare Advantage enrollees. We identified ED visits from 2005 through 2013 and assessed for CT use, associated factors, and hospitalization after CT, along with patient demographics. We used both descriptive methods and regression models adjusted for year, age, sex, race, geographic region, and Hwang comorbidity score to explore associations among CT use, year, demographic characteristics, and hospitalization. Results: We identified 33,144,233 ED visits; 5,901,603 (17.8%) involved CT. Over time, CT use during ED visits increased 59.9%. CT use increased in all age groups but decreased in children since 2010. In propensity-matching analysis, odds of hospitalization increased with age, comorbidities, male sex, and CT use (odds ratio, 2.38). Odds of hospitalization over time decreased more quickly for patients with CT. Conclusion: CT utilization in the ED has increased significantly from 2005 through 2013. For children, CT use after 2010 decreased, indicating caution about CT use. Male sex, older age, and higher number of comorbidities were predictors of CT in the ED. Over time, odds of hospitalization decreased more quickly for patients with CT.

  • 3 supplemental files

Population Health Research Design

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties

Introduction: This study investigated factors that influence emergency medicine (EM) patients’ decisionsto participate in clinical trials and whether the impact of these factors differs from those of other medicalspecialties.

Methods: A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years ofage or older, active patients on the day of the survey, and able to complete the survey without assistance.We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences inparticipants’ responses.

Results: A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factorsbetween EM and one or more of the other specialties. Regardless of a patient’s gender, race, andeducation, the relationship with their doctor was more motivating to patients seen in other specialties thanto EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285-2.389}], ID [OR:3.281,95% CI{2.293-4.695}], and OB/GYN [OR:2.408, 95% CI{1.741-3.330}]). EM’s rankings of “how well theresearch was explained” and whether “the knowledge learned would benefit others” as their top twomotivating factors were similar across other specialties. All nine barriers showed statistically significantdifferences (p≤0.008) between EM and one or more other specialties. Participants from all specialtiesindicated “risk of unknown side effects” as their strongest barrier. Regardless of the patients’ race, “timecommitment” was considered to be more of a barrier to other specialties when compared to EM (FM[OR:1.613, 95% CI{1.218-2.136}], ID [OR:1.340, 95% CI{1.006-1.784}], or OB/GYN [OR:1.901, 95%CI{1.431-2.526}]). Among the six resources assessed that help patients decide whether to participate ina clinical trial, only one scored statistically significantly different for EM (p<0.001). EM patients ranked“having all material provided in my own language” as the most helpful resource.

Conclusion: There are significant differences between EM patients and those of other specialties in thefactors that influence their participation in clinical trials. Providing material in the patient’s own language,explaining the study well, and elucidating how their participation might benefit others in the future mayhelp to improve enrollment in EM-based clinical trials. [West J Emerg Med. 2017;18(5)846-855.]

Patient Safety

Antimicrobial Therapy for Pneumonia in the Emergency Department: The Impact of Clinical Pharmacists on Appropriateness

Introduction: Pneumonia impacts over four million people annually and is the leading cause of infectiousdisease-related hospitalization and mortality in the United States. Appropriate empiric antimicrobialtherapy decreases hospital length of stay and improves mortality. The objective of our study was to testthe hypothesis that the presence of an emergency medicine (EM) clinical pharmacist improves the timingand appropriateness of empiric antimicrobial therapy for community-acquired pneumonia (CAP) andhealthcare-associated pneumonia (HCAP).

Methods: This was a retrospective observational cohort study of all emergency department (ED) patientspresenting to a Midwest 60,000-visit academic ED from July 1, 2008, to March 1, 2016, who presentedto the ED with pneumonia and received antimicrobial therapy. The treatment group consisted of patientswho presented during the hours an EM pharmacist was present in the ED (Monday-Friday, 0900-1800).The control group included patients presenting during the hours when an EM clinical pharmacist was notphysically present in the ED (Monday-Friday, 1800-0900, Saturday/Sunday 0000-2400 day). We definedappropriate empiric antimicrobial therapy using the Infectious Diseases Society of America consensusguidelines on the management of CAP, and management of HCAP.

Results: A total of 406 patients were included in the final analysis (103 treatment patients and 303 controlpatients). During the hours the EM pharmacist was present, patients were significantly more likely toreceive appropriate empiric antimicrobial therapy (58.3% vs. 38.3%; p<0.001). Regardless of pneumoniatype, patients seen while an EM pharmacist was present were significantly more likely to receiveappropriate antimicrobial therapy (CAP, 77.7% vs. 52.9% p=0.008, HCAP, 47.7% vs. 28.8%, p=0.005).There were no significant differences in clinical outcomes.

Conclusion: The presence of an EM clinical pharmacist significantly increases the likelihood ofappropriate empiric antimicrobial therapy for patients presenting to the ED with pneumonia. [West JEmerg Med. 2017;18(5)856-863.]

Availability and Accuracy of EMS Information about Chronic Health and Medications in Cardiac Arrest

Introduction: Field information available to emergency medical services (EMS) about a patient’schronic health conditions or medication therapies could help direct patient care or be used toinvestigate outcome disparities. However, little is known about the field availability or accuracy ofinformation of chronic health conditions or chronic medication treatments in emergent circumstances,especially when the patient cannot serve as an information resource. We evaluated the prehospitalavailability and accuracy of specific chronic health conditions and medication treatments among outof-hospital cardiac arrest (OHCA) patients.

Methods: The investigation was a retrospective cohort study of adult persons suffering ventricularfibrillation OHCA treated by EMS in a large metropolitan county from January 1, 2007, to December31, 2013. The study was designed to determine the availability and accuracy of EMS ascertainmentof selected chronic health conditions and medication treatments. We evaluated chronic healthconditions of “any heart disease,” congestive heart failure (CHF), and diabetes and medicationtreatments of beta blockers and loop diuretics using two distinct sources: 1) EMS report, and 2)hospital record specific to the OHCA event. Because hospital information was considered the goldstandard, we restricted the primary analysis to those who were admitted to hospital.

Results: Of the 1,496 initially eligible patients, 387 could not be resuscitated and were pronounceddead in the field, one patient was left alive at scene due to Physician’s Orders for Life-sustainingTreatment (POLST) orders, 125 expired in the emergency department (n=125), and 983 wereadmitted to hospital. A total of 832 of 1,496 (55.6%) had both sources of data for comparisonand comprised the primary analytic group. Using the hospital record as the gold standard, EMSascertainment had a sensitivity of 0.79 (304/384) and a specificity of 0.88 (218/248) for any priorheart disease; sensitivity 0.45 (47/105) and specificity 0.87 (477/516) for CHF; sensitivity 0.71(143/201) and specificity 0.98 (416/424) for diabetes; sensitivity 0.70 (118/169) and specificity 0.94(273/290) for beta blockers; sensitivity 0.70 (62/89) and specificity 0.97 (358/370) for loop diuretics.

Conclusion: In this cohort of OHCA, information about selected chronic health conditions andmedication treatments based on EMS ascertainment was available for many patients, generallyrevealing moderate sensitivity and greater specificity. [West J Emerg Med. 2017;18(5)864-869.]

  • 2 supplemental files

Health Outcomes

Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions

Introduction: Hospital admissions from the emergency department (ED) now account forapproximately 50% of all admissions. Some patients admitted from the ED may not requireinpatient care if outpatient care could be optimized. However, access to primary care especiallyimmediately after ED discharge is challenging. Studies have not addressed the extent to whichhospital admissions from the ED may be averted with access to rapid (next business day)primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol onavoidance of hospitalizations in a large, urban medical center.

Methods: We conducted a retrospective review of patients referred from the ED to primary care(Weill Cornell Internal Medicine Associates – WCIMA) through a rapid-access-to-primary-careprogram developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals wereclassified as either an avoided admission or not, and classifications were performed by bothemergency physician (EP) and internal medicine physician reviewers. We also collected outcomedata on rapid visit completion, ED revisits, hospitalizations and primary care engagement.

Results: EPs classified 26 (16%) of referrals for rapid primary care fol low-up as avoidedadmissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapidappointment. There were no differences in rates of ED revisits or subsequent hospitalizationsbetween those who attended the rapid follow-up and those who did not attend. Patients whoattended the rapid appointment were significantly more likely to attend at least one subsequentappointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8(18%), P=0.001].

Conclusion: A rapid-ED-to-primary-care-access program may allow EPs to avoid admittingpatients to the hospital without risking ED revisits or subsequent hospitalizations. This protocolhas the potential to save costs over time. A program such as this can also provide a safe andreliable ED discharge option that is also an effective mechanism for engaging patients in primarycare. [West J Emerg Med. 2017;18(5)870-877.]


Pediatric Patients Discharged from the Emergency Department with Abnormal Vital Signs

Introduction: Children often present to the emergency department (ED) with minor conditionssuch as fever and have persistently abnormal vital signs. W e hypothesized that a significantportion of children discharged from the ED would have abnormal vital signs and that thosedischarged with abnormal vital signs would experience very few adverse events.

Methods: We performed a retrospective chart review encompassing a 44-month period of allpediatric patients (aged two months to 17 years) who were discharged from the ED with anabnormal pulse rate, respiratory rate, temperature, or oxygen saturation. We used a local qualityassurance database to identify pre-defined adverse events after discharge in this population.Our primary aim was to determine the proportion of children discharged with abnormal vitalsigns and the frequency and nature of adverse events. Additionally, we performed a subanalysiscomparing the rate of adverse events in children discharged with normal vs. abnormalvital signs, as well as a standardized review of the nature of each adverse event.

Results: Of 33,185 children discharged during the study period, 5,540 (17%) of thesepatients had at least one abnormal vital sign. There were 24/5,540 (0.43%) adverse eventsin the children with at least one abnormal vital sign vs. 47/27,645 (0.17%) adverse events inthe children with normal vital signs [relative risk = 2.5 (95% confidence interval, 1.6 to 2.4)].However, upon review of each adverse event we found only one case that was related tothe index visit, was potentially preventable by a 23-hour hospital observation, and causedpermanent disability.

Conclusion: In our study population, 17% of the children were discharged with at least oneabnormal vital sign, and there were very few adverse (0.43%) events associated with this practice.Heart rate was the most common abnormal vital sign leading to an adverse event. Severe adverseevents that were potentially related to the abnormal vital sign(s) were exceedingly rare. Additionalresearch is needed in broader populations to better determine the rate of adverse events andpossible methods of avoiding them. [West J Emerg Med. 2017;18(5)878-883.]

  • 1 supplemental file

Behavioral Health

Predictors of Return Visits Among Insured Emergency Department Mental Health and Substance Abuse Patients, 2005-2013

Introduction: Our goal was to describe the pattern and identify risk factors of early-return ED visits orinpatient admissions following an index mental health and substance abuse (MHSA)-related ED visit in theUnited States.

Methods: We performed a retrospective cohort study using Optum Labs Data Warehouse, a nationallyrepresentative database containing administrative claims data on privately insured and MedicareAdvantage enrollees. Authors identified patients presenting to an ED with a primary diagnosis of MHSAbetween 2005 and 2013 who were discharged home. Study inclusion required continuous insuranceenrollment for the 12 months preceding and the 31 days following the index ED visit. During the studyperiod we included only the first ED visit for each patient.

Results: A total of 49,672 (14.2%) had a return visit to the ED or had a hospitalization within 30 daysfollowing discharge. Mean time to the next ED visit or inpatient admission was 11.7 days. An increasedage (age 65+ vs. age <18 years; OR 1.65, 95% CI [1.57 to 1.74]), chronic medical comorbidities (Hwangcomorbidity 5+ vs 0; OR 1.31, 95% CI [1.27 to 1.35]), prior ED and inpatient utilization (4+ visits vs 0 visits;OR 5.59, 95% CI [5.41 to 5.78]) were associated with return visits within 30 days following discharge.

Conclusion: In an analysis of nearly 350,000 ED visits for MHSA, 14.2 % of patients returned to the ED orhospital within 30 days. This study identified a number of factors associated with return visits for acute care.[West J Emerg Med. 2017;18(5)884-893.]

  • 6 supplemental files

Effect Of A “No Superuser Opioid Prescription” Policy On ED Visits And Statewide Opioid Prescription

Introduction: The U.S. opioid epidemic has highlighted the need to identify patients at riskof opioid abuse and overdose. We initiated a novel emergency department- (ED) basedinterventional protocol to transition our superuser patients from the ED to an outpatient chronicpain program. The objective was to evaluate the protocol’s effect on superusers’ annual ED visits.Secondary outcomes included a quantitative evaluation of statewide opioid prescriptions for thesepatients, unique prescribers of controlled substances, and ancillary testing.

Methods: Patients were referred to the program with the following inclusion criteria: ≥ 6 visitsper year to the ED; at least one visit identified by the attendi ng physician as primarily driven byopioid-seeking behavior; and a review by a committee comprising ED administration and casemanagement. Patients were referred to a pain management clinic and informed that they wouldno longer receive opioid prescriptions from visits to the ED for chronic pain complaints. Electronicmedical record (EMR) alerts notified ED providers of the patient’s referral at subsequent visits. Weanalyzed one year of data pre- and post-referral.

Results: A total of 243 patients had one year of data post-referral for analysis. Median annualED visits decreased from 14 to 4 (58% decrease, 95% CI [50 to 66]). We also found statisticallysignificant decreases for these patients’ state prescription drug monitoring program (PDMP) opioidprescriptions (21 to 13), total unique controlled-substance prescribers (11 to 7), computed tomographyimaging (2 to 0), radiographs (5 to 1), electrocardiograms (12 to 4), and labs run (47 to 13).

Conclusion: This program and the EMR-based alerts were successful at decreasing local EDvisits, annual opioid prescriptions, and hospital resource allocation for this population of patients.There is no evidence that these patients diverted their visits to neighboring EDs after beinginformed that they would not receive opioids at this hospital, as opioid prescriptions obtained bythese patients decreased on a statewide level. This implies that individual ED protocols can havesignificant impact on the behavior of patients. [West J Emerg Med. 2017;18(5)894-902.]

Injury Prevention and Population Health

Loaded Questions: Internet Commenters’ Opinions on Physician-Patient Firearm Safety Conversations

Introduction: Medical and public health societies advocate that healthcare providers (HCPs) counselat-risk patients to reduce firearm injury risk. Anonymous online media comments often contain extremeviewpoints and may therefore help in understanding challenges of firearm safety counseling. To helpinform injury prevention efforts, we sought to examine commenters’ stated opinions regarding firearmsafety counseling HCPs.

Methods: Qualitative descriptive analysis of online comments posted following news items (in May-June, 2016) about a peer-reviewed publication addressing when and how HCPs should counsel patientsregarding firearms.

Results: Among 871 comments posted by 522 individuals, most (57%) were generally negative towardfirearm discussions, 17% were positive, and 26% were neutral/unclear. Two major categories andmultiple themes emerged. “Areas of agreement” included that discussions may be valuable (1) whenaddressing risk of harm to self or others, (2) in pediatric injury prevention, and (3) as general safetyeducation (without direct questioning), and that (4) HCPs lack gun safety and cultural knowledge. “Areasof tension” included whether (1) firearms are a public health issue, (2) counseling is effective preventionpractice, (3) suicide could/should be prevented, and (4) firearm safety counseling is within HCPs’ purview.

Conclusion: Among this set of commenters with likely extreme viewpoints, opinions were generallynegative toward firearm safety conversations, but with some support in specific situations. Providingeducation, counseling, or materials without asking about firearm ownership was encouraged. Engagingfirearm advocates when developing materials may enhance the acceptability of prevention activities.[West J Emerg Med. 2017;18(5)903-912.]

Using Geospatial Mapping to Determine the Impact of All-Terrain Vehicle Crashes on Both Rural and Urban Communities

Introduction: Deaths and injuries from all-terrain vehicle (ATV) crashes result in approximately700 deaths each year and more than 100,000 emergency department (ED) visits. Commonmisconceptions about ATV crashes are a significant barrier to injury prevention efforts, as is the lackof key information about where and how crashes occur. The purpose of this study was to determineATV crash patterns within a state, and to compare and contrast characteristics of these crashes as afunction of crash-site rurality.

Methods: We performed descriptive, comparative, and regression analyses using a statewide off-roadvehicle crash and injury database (2002-2013). Comparisons were performed by rurality as defined usingthe Rural Urban Commuting Area (RUCA) coding system, and we used geographic information system(GIS) software to map crash patterns at the zip code and county levels.

Results: ATV crashes occurred throughout the state; 46% occurred in urban and 54% in rural zip codeareas. Comparisons of rider and crash characteristics by rurality showed similarities by sex, age, seatingposition, on vs. off the road, and crash mechanism. Conversely, helmet use was significantly loweramong victims of isolated rural crashes as compared to other victims (p=0.004). Crashes in isolatedrural and small rural areas accounted for only 39% of all crashes but resulted in 62% of fatalities. In bothrural and urban areas, less than one-quarter of roadway injuries were traffic related. Relative crash ratesvaried by county, and unique patterns were observed for crashes involving youth and roadway riders.During the study period, 10% and 50% of all crashes occurred in 2% and 20% of the state’s counties,respectively.

Conclusion: This study suggests that ATV crashes are a public health concern for both rural and urbancommunities. However, isolated rural ATV crash victims were less likely to be helmeted, and rural victimswere over-represented among fatalities. Traffic was not the major factor in roadway crashes in eitherrural or urban areas. Unique crash patterns for different riding populations suggest that injury preventionexperts and public policy makers should consider the potential impact of geographical location whendeveloping injury prevention interventions. [West J Emerg Med. 2017;18(5)913-922.]

Pediatric Exposures to Topical Benzocaine Preparations Reported to a Statewide Poison Control System

Introduction: Topical benzocaine is a local anesthetic commonly used to relieve pain caused byteething, periodontal irritation, burns, wounds, and insect bites. Oral preparations may containbenzocaine concentrations ranging from 7.5% to 20%. Pediatric exposure to such large concentrationsmay result in methemoglobinemia and secondarily cause anemia, cyanosis, and hypoxia.

Methods: This is a retrospective study of exposures reported to a statewide poison controlsystem. The electronic health records were queried for pediatric exposures to topical benzocainetreated at a healthcare facility from 2004 to 2014. Cases of benzocaine exposure were reviewedfor demographic and clinical information, and descriptive statistical analysis was performed.

Results: The query resulted in 157 cases; 58 were excluded due to co-ingestants, or miscodingof non-benzocaine exposures. Children four years of age and younger represented the majorityof cases (93%) with a median age of 1 year. There were 88 cases of accidental/ exploratoryexposure, while 6 cases resulted from therapeutic application or error, 4 cases from adversereactions, and 1 case from an unknown cause. Asymptomatic children accounted for 75.5%of cases, but major clinical effects were observed in 5 patients. Those with serious effectswere exposed to a range of benzocaine concentrations (7.5-20%), with 4 cases reportingmethemoglobin levels between 20.2%-55%. Methylene blue was administered in 4 of the casesexhibiting major effects.

Conclusion: The majority of exposures were accidental ingestions by young children. Most exposuresresulted in minor to no effects. However, some patients required treatment with methylene blue andadmission to a critical care unit. Therapeutic application by parents or caregivers may lead to adverseeffects from these commonly available products. [West J Emerg Med.2017;18(5)923–927.]

Technology in Emergency Medicine

What Did You Google? Describing Online Health Information Search Patterns of ED patients and Their Relationship with Final Diagnoses

Introduction: Emergency department (ED) patients’ Internet search terms prior to arrival have notbeen well characterized. The objective of this analysis was to characterize the Internet search termspatients used prior to ED arrival and their relationship to final diagnoses.

Methods: We collected data via survey; participants listed Internet search terms used. Terms wereclassified into categories: symptom, specific diagnosis, treatment options, anatomy questions,processes of care/physicians, or “other.” We categorized each discharge diagnosis as either symptombasedor formal diagnosis. The relationship between the search term and final diagnosis was assignedto one of four categories of search/diagnosis combinations (symptom search/symptom diagnosis,symptom search/formal diagnosis, diagnosis search/symptom diagnosis, diagnosis search/formaldiagnosis), representing different “trajectories.”

Results: We approached 889 patients; 723 (81.3%) participated. Of these, 177 (24.5%) used theInternet prior to ED presentation; however, seven had incomplete data (N=170). Mean age was 47years (standard deviation 18.2); 58.6% were female and 65.7% white. We found that 61.7% searchedsymptoms and 40.6% searched a specific diagnosis. Most patients received discharge diagnoses ofequal specificity as their search terms (34% flat trajectory-symptoms and 34% flat trajectory-diagnosis).Ten percent searched for a diagnosis by name but received a symptom-based discharge diagnosiswith less specificity. In contrast, 22% searched for a symptom and received a detailed diagnosis.Among those who searched for a diagnosis by name (n=69) only 29% received the diagnosis that theyhad searched.

Conclusion: The majority of patients used symptoms as the basis of their pre-ED presentation Internetsearch. When patients did search for specific diagnoses, only a minority searched for the diagnosisthey eventually received. [West J Emerg Med. 2017;18(5)928-936.]

Diagnostic Accuracy of Ultrasound for Identifying Shoulder Dislocations and Reductions: A Systematic Review of the Literature

Introduction: Patients with shoulder dislocations commonly present to the emergency department.Ultrasound has the potential to save time, radiation exposure, healthcare costs, and possibleneed for re-sedation. We conducted this systematic review to compare the diagnostic accuracy ofultrasound compared with plain radiography in the assessment of shoulder dislocations.

Methods: We searched PubMed, Scopus, the Cochrane Database of Systematic Reviews,and the Cochrane Central Register of Controlled Trials for relevant trials. Primary data and testcharacteristics were obtained for all included studies. We used QUADAS-2 to assess study quality.Meta-analysis was not performed due to significant heterogeneity.

Results: Four studies met our inclusion criteria, comprising 531 assessments with 202 dislocations.Most studies had a sensitivity of 100% for identifying dislocations. One study demonstrated asensitivity of 54%, and another had only one dislocation that was misidentified. All studies were100% specific for detecting dislocation.

Conclusion: Ultrasound may be considered as an alternative diagnostic method for the detectionof shoulder dislocation and reduction, but further studies are necessary before routine use. [West JEmerg Med. 2017;18(5)937-942.]

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Impact of Internally Developed Electronic Prescription on Prescribing Errors at Discharge from the Emergency Department

Introduction: Medication errors are common, with studies reporting at least one error perpatient encounter. At hospital discharge, medication errors vary from 15%-38%. However,studies assessing the effect of an internally developed electronic (E)-prescription systemat discharge from an emergency department (ED) are comparatively minimal. Additionally,commercially available electronic solutions are cost-prohibitive in many resource-limitedsettings. We assessed the impact of introducing an internally developed, low-cost E-prescriptionsystem, with a list of commonly prescribed medications, on prescription error rates at dischargefrom the ED, compared to handwritten prescriptions.

Methods: We conducted a pre- and post-intervention study comparing error rates in a randomlyselected sample of discharge prescriptions (handwritten versus electronic) five months pre andfour months post the introduction of the E-prescription. The internally developed, E-prescriptionsystem included a list of 166 commonly prescribed medications with the generic name, strength,dose, frequency and duration. We included a total of 2,883 prescriptions in this study: 1,475 inthe pre-intervention phase were handwritten (HW) and 1,408 in the post-intervention phase wereelectronic. We calculated rates of 14 different errors and compared them between the pre- andpost-intervention period.

Results: Overall, E-prescriptions included fewer prescription errors as compared to HWprescriptions.Specifically, E-prescriptions reduced missing dose (11.3% to 4.3%, p <0.0001),missing frequency (3.5% to 2.2%, p=0.04), missing strength errors (32.4% to 10.2%, p <0.0001)and legibility (0.7% to 0.2%, p=0.005). E-prescriptions, however, were associated with a significantincrease in duplication errors, specifically with home medication (1.7% to 3%, p=0.02).

Conclusion: A basic, internally developed E-prescription system, featuring commonly usedmedications, effectively reduced medication errors in a low-resource setting where the costs ofsophisticated commercial electronic solutions are prohibitive. [West J Emerg Med. 2017;18(5)943-950.]


Critical Care

Sepsis Definitions: The Search for Gold and What CMS Got Wrong

On October 1, 2015, the United States Centers for Medicare and Medicaid Services (CMS) issued acore measure addressing the care of septic patients. These core measures are controversial amonghealthcare providers. This article will address that there is no gold standard definition for sepsis, severesepsis or septic shock and the CMS-assigned definitions for severe sepsis and septic shock arepremature and inconsistent with evidence-based definitions. [West J Emerg Med. 2017;18(5)951-956.]

Appropriateness of Bolus Antihypertensive Therapy for Elevated Blood Pressure in the Emergency Department

Introduction: While moderate to severely elevated blood pressure (BP) is present in nearly halfof all emergency department (ED) patients, the incidence of true hypertensive emergencies inED patients is low. Administration of bolus intravenous (IV) antihypertensive treatment to lowerBP in patients without a true hypertensive emergency is a wasteful practice that is discouragedby hypertension experts; however, anecdotal evidence suggests this occurs with relatively highfrequency. Accordingly, we sought to assess the frequency of inappropriate IV antihypertensivetreatment in ED patients with elevated BP absent a hypertensive emergency.

Methods: We performed a retrospective cohort study from a single, urban, teaching hospital.Using pharmacy records, we identified patients age 18-89 who rec eived IV antihypertensivetreatment in the ED. We defined treatment as inappropriate if documented suspicion for anindicated cardiovascular condition or acute end-organ injury was lacking. Data abstractionincluded adverse events and 30-day readmission rates, and analysis was primarily descriptive.

Results: We included a total of 357 patients over an 18-month period. The mean age was 55;51% were male and 93% black, and 127 (36.4%) were considered inappropriately treated.Overall, labetalol (61%) was the most commonly used medication, followed by enalaprilat(18%), hydralazine (18%), and metoprolol (3%). There were no significant differences betweenappropriate and inappropriate BP treatment groups in terms of clinical characteristics oradverse events. Hypotension or bradycardia occurred in three (2%) patients in the inappropriatetreatment cohort and in two (1%) patients in the appropriately treated cohort. Survival todischarge and 30-day ED revisit rates were equivalent.

Conclusion: More than one in three patients who were given IV bolus antihypertensive treatmentin the ED received such therapy inappropriately by our definitio n, suggesting that significantresources could perhaps be saved through education of providers and development of clearlydefined BP treatment protocols. [West J Emerg Med. 2017;18(5)957-962.]

Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?

Introduction: The electrocardiogram (ECG) is often used to identify which hyperkalemic patients are atrisk for adverse events. However, there is a paucity of evidence to support this practice. This studyanalyzes the association between specific hyperkalemic ECG abnormalities and the development ofshort-term adverse events in patients with severe hyperkalemia.

Methods: We collected records of all adult patients with potassium (K+) ≥6.5 mEq/L in the hospitallaboratory database from August 15, 2010, through January 30, 2015. A chart review identified patientdemographics, concurrent laboratory values, ECG within one hour of K+ measurement, treatments andoccurrence of adverse events within six hours of ECG. We defined adverse events as symptomaticbradycardia, ventricular tachycardia, ventricular fibrillation, cardiopulmonary resuscitation (CPR) and/ordeath. Two emergency physicians blinded to study objective independently examined each ECG forrate, rhythm, peaked T wave, PR interval duration and QRS complex duration. Relative risk wascalculated to determine the association between specific hyperkalemic ECG abnormalities and shorttermadverse events.

Results: We included a total of 188 patients with severe hyperkalemia in the final study group. Adverseevents occurred within six hours in 28 patients (15%): symptomatic bradycardia (n=22), death (n=4),ventricular tachycardia (n=2) and CPR (n=2). All adverse events occurred prior to treatment with calciumand all but one occurred prior to K+-lowering intervention. All patients who had a short-term adverse eventhad a preceding ECG that demonstrated at least one hyperkalemic abnormality (100%, 95% confidenceinterval [CI] [85.7-100%]). An increased likelihood of short-term adverse event was found forhyperkalemic patients whose ECG demonstrated QRS prolongation (relative risk [RR] 4.74, 95% CI[2.01-11.15]), bradycardia (HR<50) (RR 12.29, 95%CI [6.69-22.57]), and/or junctional rhythm (RR 7.46,95%CI 5.28-11.13). There was no statistically significant correlation between peaked T waves andshort-term adverse events (RR 0.77, 95% CI [0.35-1.70]).

Conclusion: Our findings support the use of the ECG to risk stratify patients with severehyperkalemia for short-term adverse events. [West J Emerg Med. 2017;18(5)963-971.]

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Duration of Mechanical Ventilation in the Emergency Department

Introduction: Due to hospital crowding, mechanically ventilated patients are increasinglyspending hours boarding in emergency departments (ED) before intensive care unit (ICU)admission. This study aims to evaluate the association between time ventilated in the ED and inhospitalmortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS).

Methods: This was a multi-center, prospective, observational study of patients ventilated in theED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. Allconsecutive adult patients on invasive mechanical ventilation were eligible for enrollment. Weperformed a Cox regression to assess for a mortality effect for mechanically ventilated patientswith each hour of increasing LOS in the ED and multivariable regression analyses to assessfor independently significant contributors to in-hospital mortal ity. Our primary outcome was inhospitalmortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. Wefurther commented on use of lung protective ventilation and frequency of ventilator changesmade in this cohort.

Results: We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental statuswithout respiratory pathology was the most common reason for intubation, followed by traumaand respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time ofmechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer totalduration of intubation. However, adjusted multivariable regression analysis demonstrated onlyolder age and admission to the neurosciences ICU as independently associated with increasedmortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours hadchanges made to their ventilator.

Conclusion: In a prospective observational study of patients mechanically ventilated in the ED,there was a significant mortality benefit to expedited transfer o f patients into an appropriate ICUsetting. [West J Emerg Med. 2017;18(5)972-979.]

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