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Open Access Publications from the University of California

Volume 18, Issue 6, 2017

Emergency Department Operations

Decreasing Emergency Department Walkout Rate and Boarding Hours by Improving Inpatient Length of Stay

Introduction: Patient progress, the movement of patients through a hospital system from admission todischarge, is a foundational component of operational effectiveness in healthcare institutions. Optimalpatient progress is a key to delivering safe, high-quality and high-value clinical care. The Baystate PatientProgress Initiative (BPPI), a cross-disciplinary, multifaceted quality and process improvement project, waslaunched on March 1, 2014, with the primary goal of optimizing patient progress for adult patients.

Methods: The BPPI was implemented at our system’s tertiary care, academic medical center, a highvolume,high-acuity hospital that serves as a regional referral center for western Massachusetts. TheBPPI was structured as a 24-month initiative with an oversight group that ensured collaborative goalalignment and communication of operational teams. It was organized to address critical aspects ofa patient’s progress through his hospital stay and to create additional inpatient capacity. The specificgoal of the BPPI was to decrease length of stay (LOS) on the inpatient adult Hospital Medicine serviceby optimizing an interdisciplinary plan of care and promoting earlier departure of discharged patients.Concurrently, we measured the effects on emergency department (ED) boarding hours per patient andwalkout rates.

Results: The BPPI engaged over 300 employed clinicians and non-clinicians in the work. We createdincreased inpatient capacity by implementing daily interdisciplinary bedside rounds to proactively addresspatient progress; during the 24 months, this resulted in a sustained rate of discharge orders writtenbefore noon of more than 50% and a decrease in inpatient LOS of 0.30 days (coefficient: -0.014, 95%CI [-0.023, -0.005] P< 0.005). Despite the increase in ED patient volumes and severity of illness overthe same time period, ED boarding hours per patient decreased by approximately 2.1 hours (coefficient:-0.09; 95% CI [-0.15, -0.02] P = 0.007). Concurrently, ED walkout rates decreased by nearly 32% to amonthly mean of 0.4 patients (coefficient: 0.4; 95% CI [-0.7, -0.1] P= 0.01).

Conclusion: The BPPI realized significant gains in patient progress for adult patients by promotingearlier discharges before noon and decreasing overall inpatient LOS. Concurrently, ED boarding hoursper patient and walkout rates decreased.

Injury Prevention and Population Health

Injuries Associated with Hoverboard Use: A Case Series of Emergency Department Patients

Introduction: Since hoverboards became available in 2015, 2.5 million have been sold in theUS. An increasing number of injuries related to their use have been reported, with limited data onassociated injury patterns. We describe a case series of emergency department (ED) visits forhoverboard-related injuries.

Methods: We performed a retrospective chart review on patients presenting to 10 EDs insoutheastern Virginia from December 24, 2015, through June 30, 2016. We used a free-textsearch feature of the electronic medical record to identify patients documented to have the word“hoverboard” in the record. We reported descriptive statistics for patient demographics, types ofinjuries, body injury location, documented helmet use, injury severity score (ISS), length of stay inthe ED, and ED charges.

Results: We identified 83 patients in our study. The average age was 26 years old ( 18 months to 78years). Of these patients, 53% were adults; the majority were female (61.4%) and African American(56.6%). The primary cause of injury was falls (91%), with an average ISS of 5.4 (0-10). The majorityof injuries were contusions (37.3%) and fractures (36.1%). Pediatric patients tended to have morefractures than adults (46.2% vs 27.3%). Though 20% of patients had head injuries, only one patientreported using a helmet. The mean and median ED charges were $2,292.00 (SD $1,363.64) and$1,808.00, respectively. Head injuries resulted in a significantly higher cost when compared to otherinjuries; median cost was $2,846.00.

Conclusion: While the overall ISS was low, more pediatric patients suffered fractures comparedto adults. Documented helmet use was low, yet 20% of our population had head injuries.Further investigation into proper protective gear and training is warranted.

Endemic Infections

Hepatitis A Virus: A novel Identify-Isolate-Inform Tool for Frontline Healthcare Providers

Hepatitis A virus (HAV) is a highly contagious viral illness that can lead to serious morbidity and occasional mortality. Although the overall incidence of HAV has been declining since the introduction of the HAV vaccine, there have been an increasing number of outbreaks within the United States and elsewhere between 2016 and 2017. These outbreaks have had far reaching consequences, with a large number of patients requiring hospitalization and several deaths. Accordingly, HAV is proving to present a renewed public health challenge. Through the use of the “Identify-Isolate-Inform” Tool as adapted for HAV, emergency physicians can become more familiar with the identification and management of patients presenting to the Emergency Department with exposure, infection, or risk of contracting disease. HAV typically presents with a prodrome of fever, nausea/vomiting, and abdominal pain followed by jaundice. Healthcare providers should maintain strict standard precautions for all patients suspected of having HAV infection as well as contact precautions in special cases. Hand hygiene with soap and water should be emphasized and affected patients should be counseled to avoid food preparation and close contact with vulnerable populations. Additionally, Emergency Department providers should offer post-exposure prophylaxis to exposed contacts and encourage vaccination as well as other preventive measures for at-risk individuals. Emergency department personnel should inform local public health departments of any suspected case.

Disaster Medicine/ Emergency Medical Services

Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction

Introduction: California has led successful regionalized efforts for several time-critical medicalconditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandatedprotocols exist to define regionalization of care. We aimed to study the trends in regionalizationof care for STEMI patients in the state of California and to examine the differences in patientdemographic, hospital, and county trends.

Methods: Using survey responses collected from all California emergency medical services (EMS)agencies, we developed four categories – no, partial, substantial, and complete regionalization– to capture prehospital and inter-hospital components of regionalization in each EMS agency’sjurisdiction between 2005-2014. We linked the survey responses to 2006 California non-publichospital discharge data to study the patient distribution at baseline.

Results: STEMI regionalization-of-care networks steadily developed across California. Only 14%of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population,but over half of these counties, representing 86% of California’s STEMI patient population, reachedcomplete regionalization in 2014. We did not find any dramatic differences in underlying patientcharacteristics based on regionalization status; however, differences in hospital characteristics wererelatively substantial.

Conclusion: Potential barriers to achieving regionalization included competition, hospital ownership,population density, and financial challenges. Minimal differences in patient characteristics canestablish that patient differences unlikely played any role in influencing earlier or later regionalizationand can provide a framework for future analyses evaluating the impact of regionalization on patientoutcomes.


  • 1 supplemental file

Global Health

Poor Access for African Researchers to African Emergency Care Publications: A Cross-sectional Study

Introduction: Based on relative population size and burden of disease, emergency care publicationoutputs from low- and middle-income regions are disproportionately lower than those of high-incomeregions. Ironically, outputs from regions with higher publication rates are often less relevant in the Africancontext. As a result, the dissemination of and access to local research is essential to local researchers,but the cost of this access (actual and cost-wise) remains unknown. The aim of this study was to describeaccess to African emergency care publications in terms of publisher-based access (open access orsubscription) and alternate access (self-archived or author provided), as well as the cost of access.

Methods: We conducted a retrospective, cross-sectional study using all emergency medicinepublications included in Scopus between 2011 and 2015. A sequential search strategy describedaccess to each article, and we calculated mean article charges against the purchasing power parityindex (used to describe out-of-pocket expense).

Results: We included 666 publications from 49 journals, of which 395 (59.3%) were open access. Forsubscription-based articles, 106 (39.1%) were self-archived, 60 (22.1%) were author-provided, and105 (38.8%) were inaccessible. Mean article access cost was $36.44, and mean processing chargewas $2,319.34. Using the purchasing power parity index it was calculated that equivalent out-ofpocketexpenditure for South African, Ghanaian and Tanzanian authors would respectively be $15.77,$10.44 and $13.04 for access, and $1,004.02, $664.36 and $830.27 for processing. Based on this,the corrected cost of a single-unit article access or process charge for South African, Ghanaian andTanzanian authors, respectively, was 2.3, 3.5 and 2.8 times higher than the standard rate.

Conclusion: One in six African emergency care publications are inaccessible outside institutional librarysubscriptions; additionally, the cost of access to publications in low- and middle-income countries appearsprohibitive. Publishers should strongly consider revising pricing for more equitable access for researchersfrom low- and middle-income countries.


  • 2 supplemental files

Critical Care

Team Size and Stretching-Exercise Effects on Simulated Chest Compression Performance and Exertion

Introduction: Investigators conducted a prospective experimental study to evaluate the effectof team size and recovery exercises on individual providers’ compression quality and exertion.Investigators hypothesized that 1) larger teams would perform higher quality compressions withless exertion per provider when compared to smaller teams; and 2) brief stretching and breathingexercises during rest periods would sustain compressor performance and mitigate fatigue.

Methods: In Phase I, a volunteer cohort of pre-clinical medical students performed four minutesof continuous compressions on a Resusci-Anne manikin to gauge the spectrum of compressorperformance in the subject population. Compression rate, depth, and chest recoil weremeasured. In Phase II, the highest-performing Phase I subjects were placed into 2-, 3-, and/or4-compressor teams; 2-compressor teams were assigned either to control group (no recoveryexercises) or intervention group (recovery exercises during rest). All Phase II teams participatedin 20-minute simulations with compressor rotation every two minutes. Investigators recordedcompression quality and real-time heart rate data, and calculated caloric expenditure fromcontact heart rate monitor measurements using validated physiologic formulas.

Results: Phase I subjects delivered compressions that were 24.9% (IQR1-3: [0.5%-74.1%])correct with a median rate of 112.0 (IQR1-3: [103.5-124.9]) compressions per minute anddepth of 47.2 (IQR1-3: [35.7-55.2]) mm. In their first rotations , all Phase II subjects deliveredcompressions of similar quality and correctness (p=0.09). Bivariate analyses of 2-, 3-, and4-compressor teams’ subject compression characteristics by subsequent rotation did notidentify significant differences within or across teams. On multivariate analyses, only subjects in2-compressor teams exhibited significantly lower compression rat es (control subjects; p<0.01),diminished chest release (intervention subjects; p=0.03), and greater exertion over successiverotations (both control [p≤0.03] and intervention [p≤0.02] subj ects).

Conclusion: During simulated resuscitations, 2-compressor teams exhibited increased levels ofexertion relative to 3- and 4-compressor teams for comparable compression delivery. Stretchingand breathing exercises intended to assist with compressor recovery exhibited mixed effects oncompression performance and subject exertion.

Emergency Department Access

Impact of Superstorm Sandy on Medicare Patients’ Utilization of Hospitals and Emergency Departments

Introduction: National health security requires that healthcare facilities be prepared to provide rapid,effective emergency and trauma care to all patients affected by a catastrophic event. We sought toquantify changes in healthcare utilization patterns for an at-risk Medicare population before, during,and after Superstorm Sandy’s 2012 landfall in New Jersey (NJ).

Methods: This study is a retrospective cohort study of Medicare beneficiaries impacted bySuperstorm Sandy. We compared hospital emergency department (ED) and healthcare facilityinpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20%random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012(N=224,116). Outcome measures were pre-storm discharges (or transfers), average length of stay,service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission.

Results: In the pre-storm week, hospital transfers from skilled nursing facilities (SNF) increased by39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prioryear. In the post-storm week, ED visits increased by 14% statewide; of these additional “surge”patients, 20% were admitted to the hospital. The increase in ED demand was more than double thestatewide average in the most highly impacted coastal regions (35% versus 14%).

Conclusion: Superstorm Sandy impacted both pre- and post-storm patient movement in NewJersey; post-landfall ED surge was associated with overall storm impact, which was greatest incoastal counties. A significant increase in the number and severity of pre-storm transfer patients,in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attentionto the importance of collaborative regional approaches to healthcare in large-scale events.

  • 1 supplemental file

Emergency Department Utilization by Children in the USA, 2010-2011

Introduction: Epidemiological surveillance data for emergency department (ED) visits by children areimperative to guide resource allocation and to develop health policies that advance pediatric emergencycare. However, there are sparse population-based data on patient-level information (e.g., the number ofchildren who present to the emergency department [ED]). In this context, we aimed to investigate boththe patient- and visit-level rates of ED utilization by children.

Methods: This was a retrospective cohort study using population-based multipayer data – state EDdatabases (SEDD) and state inpatient databases (SID) – from six geographically-dispersed U.S. states(California, Florida, Iowa, Nebraska, New York, and Utah) in 2010 and 2011. We identified all childrenaged <18 years who presented to the ED and described the patient-level ED visit rate, visit-level ED visitrate, and proportion of all ED visits made by children. We conducted the analysis using the 2011 SEDDand SID data. We also repeated the analysis using the 2010 data to determine the consistency of theresults across different years.

Results: In 2011, 2.9 million children with a patient identifier presented to EDs in the six U.S. states.At the patient-level, 15 out of every 100 children presented to an ED at least once per year. Of thesechildren, 25% presented to EDs 2-3 times per year with an approximately 1.5-fold variation across thestates (e.g., 19% in Utah vs. 28% in Florida). In addition, 5% presented to EDs ≥4 times per year. At thevisit-level, 6.7 million ED visits were made by children in 2011 – 34 ED visits per 100 children annually.ED visits by children accounted for 22% of all ED visits (including both adults and children), with arelatively small variation across the states (e.g., 20% in New York vs. 24% in Nebraska). Analysis of the2010 data gave similar results for the ED utilization by children.

Conclusion: By using large population-based data, we found a substantial burden of ED visits at bothpatient- and visit-levels. These findings provide a strong foundation for policy makers and professionalorganizations to strengthen emergency care for children.

  • 2 supplemental files

Technology in Emergency Medicine

Characterizing New England Emergency Departments by Telemedicine Use

Introduction: Telemedicine connects emergency departments (ED) with resources necessaryfor patient care; its use has not been characterized nationally, or even regionally. Our primaryobjective was to describe the prevalence of telemedicine use in New England EDs and theclinical applications of use. Secondarily, we aimed to determine if telemedicine use wasassociated with consultant availability and to identify ED characteristics associated withtelemedicine use.

Methods: We analyzed data from the National Emergency Department Inventory-New Englandsurvey, which assessed basic ED characteristics in 2014. The survey queried directors of everyED (n=195) in the six New England states (excluding federal hospitals and college infirmaries).Descriptive statistics characterized ED telemedicine use; multivariable logistic regressionidentified independent predictors of use.

Results: Of the 169 responding EDs (87% response rate), 82 (49%) reported usingtelemedicine. Telemedicine EDs were more likely to be rural (18% of users vs. 7% of nonusers,p=0.03); less likely to be academic (1% of users vs. 11% of non-users, p=0.01); andless likely to have 24/7 access to neurology (p<0.001), neurosurgery (p<0.001), orthopedics(p=0.01), plastic surgery (p=0.01), psychiatry (p<0.001), and hand surgery (p<0.001)consultants. Neuro/stroke (68%), pediatrics (11%), psychiatry (11%), and trauma (10%) were themost commonly reported applications. On multivariable analysis, telemedicine was more likely inrural EDs (odds ratio [OR] 4.39, 95% confidence interval [CI] 1. 30-14.86), and less likely in EDswith 24/7 neurologist availability (OR 0.21, 95% CI [0.09-0.49] ), and annual volume <20,000 (OR0.24, 95% CI [0.08-0.68]).

Conclusion: Telemedicine is commonly used in New England EDs. In 2014, use was morecommon among rural EDs and EDs with limited neurology consultant availability. In contrast,telemedicine use was less common among very low-volume EDs.

  • 3 supplemental ZIPs

Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices

Peripheral intravenous line placement is a common procedure in emergency medicine. Ultrasoundguidance has been demonstrated to improve success rates, as well as decrease complicationsand pain. This paper provides a narrative review of the literature focusing on best practices andtechniques to improve performance with this procedure. We provide an evidence-based discussionof preparation for the procedure, vein and catheter selection, multiple techniques for placement, andline confirmation.

  • 5 supplemental videos

Patient Satisfaction

Heated Ultrasound Gel and Patient Satisfaction with Bedside Ultrasound Studies: The HUGS Trial

Introduction: Our goal was to determine if heated gel for emergency department (ED) bedsideultrasonography improves patient satisfaction compared to room-temperature gel.

Methods: We randomized a convenience sample of ED patients determined by their treating physicianto require a bedside ultrasound (US) study to either heated gel (102.0° F) or room-temperature gel(82.3° F). Investigators performed all US examinations. We informed all subjects that the study entailedinvestigation into various measures to improve patient satisfaction with ED US examinations but didnot inform them of our specific focus on gel temperature. Investigators wore heat-resistant gloves whileperforming the examinations to blind themselves to the gel temperature. After completion of the US,subjects completed a survey including the primary outcome measure of patient satisfaction as measuredon a 100-mm visual analogue scale (VAS). A secondary outcome was patient perceptions of sonographerprofessionalism measured by an ordinal scale (1-5).

Results: We enrolled 124 subjects; 120 completed all outcome measures. Of these, 59 underwentrandomization to US studies with room-temperature gel and 61 underwent randomization to heated USgel. Patient 100-mm VAS satisfaction scores were 83.9 among patients undergoing studies with roomtemperaturegel versus 87.6 among subjects undergoing studies with heated gel (effect size 3.7, 95%confidence interval -1.3-8.6). There were similarly no differences between the two arms with regard topatient perceptions of sonographer professionalism.

Conclusion: The use of heated ultrasound gel appears to have no material impact on the satisfaction ofED patients undergoing bedside ultrasound studies.

The Impact of an Emergency Department Front-End Redesign on Patient-Reported Satisfaction Survey Results

Introduction: For emergency department (ED) patients, delays in care are associated withdecreased satisfaction. Our department focused on implementing a front-end vertical patient flowmodel aimed to decrease delays in care, especially care initiation. The physical space for this newmodel was termed the Flexible Care Area (FCA). The purpose of this study was to quantify theimpact of this intervention on patient satisfaction.

Methods: We conducted a retrospective study of patients discharged from our academic ED over aone-year period (7/1/2013-6/30/2014). Of the 34,083 patients discharged during that period, 14,075were sent a Press-Ganey survey and 2,358 (16.8%) returned the survey. We subsequently comparedthese survey responses with clinical information available through our electronic health record(EHR). Responses from the Press-Ganey surveys were dichotomized as being “Very Good” (VG, thehighest rating) or “Other” (for all other ratings). Data abstracted from the EHR included demographicinformation (age, gender) and operational information (e.g. – emergency severity index, length of stay,whether care was delivered entirely in the FCA, utilization of labs or radiology testing, or administrationof opioid pain medications). We used Fisher’s exact test to calculate statistical differences inproportions, while the Mantel-Haenszel method was used to report odds ratios.

Results: Of the returned surveys, 62% rated overall care for the visit as VG. However, fewerpatients reported their care as VG if they were seen in FCA (53.4% versus 63.2%, p=0.027). Patientsseen in FCA were less likely to have advanced imaging performed (12% versus 23.8%, p=0.001) orlabs drawn (24.8% vs. 59.1%, p=0.001). Length of stay (FCA mean 159 ±103.5 minutes versus non-FCA 223 ±117 minutes) and acuity were lower for FCA patients than non-FCA patients (p=0.001).There was no statistically significant difference between patient-reported ratings of physicians ornurses when comparing patients seen in FCA vs. those not seen in FCA.

Conclusion: Patients seen through the FCA reported a lower overall rating of care comparedto patients not seen in the FCA. This occurred despite a shorter overall length of stay for thesepatients, suggesting that other factors have a meaningful impact on patient satisfaction.

Population Health Research Design

Understanding the Intention-to-treat Principle in Randomized Controlled Trials

Clinicians, institutions, and policy makers use results from randomized controlled trials to makedecisions regarding therapeutic interventions for their patients and populations. Knowing the effectthe intervention has on patients in clinical trials is critical for making both individual patient as well aspopulation-based decisions. However, patients in clinical trials do not always adhere to the protocol.Excluding patients from the analysis who violated the research protocol (did not get their intendedtreatment) can have significant implications that impact the results and analysis of a study.

Intention-to-treat analysis is a method for analyzing results in a prospective randomized studywhere all participants who are randomized are included in the statistical analysis and analyzedaccording to the group they were originally assigned, regardless of what treatment (if any) theyreceived. This method allows the investigator (or consumer of the medical literature) to draw accurate(unbiased) conclusions regarding the effectiveness of an intervention. This method preserves thebenefits of randomization, which cannot be assumed when using other methods of analysis.

The risk of bias is increased whenever treatment groups are not analyzed according to the groupto which they were originally assigned. If an intervention is truly effective (truth), an intention-to-treatanalysis will provide an unbiased estimate of the efficacy of the intervention at the level of adherencein the study. This article will review the “intention-to-treat” principle and its converse, “per-protocol”analysis, and illustrate how using the wrong method of analysis can lead to a significantly biasedassessment of the effectiveness of an intervention.

Sex as a Biological Variable in Emergency Medicine Research and Clinical Practice: A Brief Narrative Review

The National Institutes of Health recently highlighted the significant role of sex as a biologicalvariable (SABV) in research design, outcome and reproducibility, mandating that this variable beaccounted for in all its funded research studies. This move has resulted in a rapidly increasing bodyof literature on SABV with important implications for changing the clinical practice of emergencymedicine (EM). Translation of this new knowledge to the bedside requires an understanding ofhow sex-based research will ultimately impact patient care. We use three case-based scenarios inacute myocardial infarction, acute ischemic stroke and important considerations in pharmacologictherapy administration to highlight available data on SABV in evidence-based research to providethe EM community with an important foundation for future integration of patient sex in the delivery ofemergency care as gaps in research are filled.

  • 1 supplemental file

Patient Safety

Knowledge Translation of the PERC Rule for Suspected Pulmonary Embolism: A Blueprint for Reducing the Number of CT Pulmonary Angiograms

Introduction: Computerized decision support decreases the number of computed tomography pulmonary angiograms (CTPA) for pulmonary embolism (PE) ordered in emergency departments, but it is not always well accepted by emergency physicians. We studied a department-endorsed, evidence-based clinical protocol that included the PE rule-out criteria (PERC) rule, multi-modal education using principles of knowledge translation (KT), and clinical decision support embedded in our order entry system, to decrease the number of unnecessary CTPA ordered. Methods: We performed a historically controlled observational before-after study for one year pre- and post-implementation of a departmentally-endorsed protocol. We included patients > 18 in whom providers suspected PE and who did not have a contraindication to CTPA. Providers entered clinical information into a diagnostic pathway via computerized order entry. Prior to protocol implementation, we provided education to ordering providers. The primary outcome measure was the number of CTPA ordered per 1,000 visits one year before vs. after implementation. Results: CTPA declined from 1,033 scans for 98,028 annual visits (10.53 per 1,000 patient visits (95% CI [9.9-11.2]) to 892 scans for 101,172 annual visits (8.81 per 1,000 patient visits (95% CI [8.3-9.4]) p<0.001. The absolute reduction in PACT ordered was 1.72 per 1,000 visits (a 16% reduction). Patient characteristics were similar for both periods.Conclusion: Knowledge translation clinical decision support using the PERC rule significantly reduced the number of CTPA ordered.

A Sepsis-related Diagnosis Impacts Interventions and Predicts Outcomes for Emergency Patients with Severe Sepsis

Introduction: Many patients meeting criteria for severe sepsis are not given a sepsis-relateddiagnosis by emergency physicians (EP). This study 1) compares emergency department (ED)interventions and in-hospital outcomes among patients with severe sepsis, based on the presenceor absence of sepsis-related diagnosis, and 2) assesses how adverse outcomes relate to three-hoursepsis bundle completion among patients fulfilling severe sepsis criteria but not given a sepsisrelateddiagnosis.

Methods: We performed a retrospective cohort study using patients meeting criteria for severesepsis at two urban, academic tertiary care centers from March 2015 through May 2015. Weincluded all ED patients with the following: 1) the 1992 Consensus definition of severe sepsis,including two or more systemic inflammatory response syndrome criteria and evidence of organdysfunction; or 2) physician diagnosis of severe sepsis or septic shock. We excluded patientstransferred to or from another hospital and those <18 years old. Patients with an EP-assignedsepsis diagnosis created the “Physician Diagnosis” group; the remaining patients composed the“Consensus Criteria” group. The primary outcome was in-hospital mortality. Secondary outcomesincluded completed elements of the current three-hour sepsis bundle; non-elective intubation;vasopressor administration; intensive care unit (ICU) admission from the ED; and transfer to theICU in < 24 hours. We compared proportions of each outcome between groups using the chi-squaretest, and we also performed a stratified analysis using chi square to assess the association betweenfailure to complete the three-hour bundle and adverse outcomes in each group.

Results: Of 418 patients identified with severe sepsis we excluded 54, leaving 364 patients foranalysis: 121 “Physician Diagnosis” and 243 “Consensus Criteria.” The “Physician Diagnosis” grouphad a higher in-hospital mortality (12.4% vs 3.3%, P < 0.01) and compliance with the three-hour sepsisbundle (52.1% vs 20.2%, P < 0.01) compared with the “Consensus Criteria” group. An incompletethree-hour sepsis bundle was not associated with a higher incidence of death, intubation, vasopressoruse, ICU admission or transfer to the ICU in <24 hours in patients without a sepsis diagnosis.

Conclusion: “Physician Diagnosis” patients more frequently received sepsis-specific interventionsand had a higher incidence of mortality. “Consensus Criteria” patients had infrequent adverseoutcomes regardless of three-hour bundle compliance. EPs’ sepsis diagnoses reflect riskstratificationbeyond the severe sepsis criteria.

GLASS Clinical Decision Rule Applied to Thoracolumbar Spinal Fractures in Patients Involved in Motor Vehicle Crashes

Introduction: There are established and validated clinical decision tools for cervical spineclearance. Almost all the rules include spinal tenderness on exam as an indication for imaging. Ourgoal was to apply GLASS, a previously derived clinical decision tool for cervical spine clearance, tothoracolumbar injuries. GLass intact Assures Safe Spine (GLASS) is a simple, objective method toevaluate those patients involved in motor vehicle collisions and determine which are at low risk forthoracolumbar injuries.

Methods: We performed a retrospective cohort study using the National Accident Sampling System-Crashworthiness Data System (NASS-CDS) over an 11-year period (1998-2008). Sampled occupantcases selected in this study included patients age 16-60 who were belt-restrained, front- seatoccupants involved in a crash with no airbag deployment, and no glass damage prior to the crash.

Results: We evaluated 14,191 occupants involved in motor vehicle collisions in this analysis.GLASS had a sensitivity of 94.4% (95% CI [86.3-98.4%]), specificity of 54.1% (95% CI [53.2-54.9%]), and negative predictive value of 99.9% (95% CI [99.8-99.9%]) for thoracic injuries, and asensitivity of 90.3% (95% CI [82.8-95.2%]), specificity of 54.2% (95% CI [53.3-54.9%]), and negativepredictive value of 99.9% (95% CI [99.7-99.9%]) for lumbar injuries.

Conclusion: The GLASS rule represents the possibility of a novel, more-objective thoracolumbarspine clearance tool. Prospective evaluation would be required to further evaluate the validity of thisclinical decision rule.


ALiEM Blog and Podcast Watch: Toxicology

Introduction: The WestJEM Blog and Podcast Watch presents high-quality open-access educationalblogs and podcasts in emergency medicine based on the ongoing Academic Life in Emergency Medicine(ALiEM) Approved Instructional Resources (AIR) and AIR-Professional (Pro) series. Both series criticallyappraise open-access educational blogs and podcasts in EM using an objective scoring instrument. Thisinstallment of the blog and podcast watch series curated and scored relevant posts in the specific topic oftoxicology emergencies from the AIR-Pro Series.

Methods: The AIR-Pro Series is a continuously building curriculum covering a new subject area everytwo months. For each area, eight EM chief residents identify 3-5 advanced clinical questions. and FOAMSearcher to search blogs and podcasts, relevant posts are scored byeight reviewers from the AIR-Pro editorial board, which is comprised of EM faculty and chief residentsat various institutions across North America. The scoring instrument contains five measurementoutcomes based on seven-point Likert scales: recency, accuracy, educational utility, evidence based,and references. The AIR-Pro label is awarded to posts with a score of ≥28 (out of 35) points. An“honorable mention” label is awarded if board members collectively felt that the blogs were valuableand the scores were > 25.

Results: A total of 31 blog posts and podcasts were included. Key educational pearls from the six highqualityAIR-Pro posts and four honorable mentions are summarized.

Conclusion: The WestJEM ALiEM Blog and Podcast Watch series is based on the AIR and AIR-ProSeries, which attempts to identify high-quality educational content on open-access blogs and podcasts.This series provides an expert-based, crowdsourced approach towards critically appraising educationalsocial media content for EM clinicians. This installment focuses on toxicology emergencies.

Characteristics of Emergency Medicine Residency Programs in Colombia

Introduction: Emergency medicine (EM) is in different stages of development around the world.Colombia has made significant strides in EM development in the last two decades and recognized it as amedical specialty in 2005. The country now has seven EM residency programs: three in the capital city ofBogotá, two in Medellin, one in Manizales, and one in Cali. The seven residency programs are in differentstages of maturity, with the oldest founded 20 years ago and two founded in the last two years. Theobjective of this study was to characterize these seven residency programs.

Methods: We conducted semi-structured interviews with faculty and residents from all the existingprograms in 2013-2016. Topics included program characteristics and curricula.

Results: Colombian EM residencies are three-year programs, with the exception of one four-yearprogram. Programs accept 3-10 applicants yearly. Only one program has free tuition and the rest chargetuition. The number of EM faculty ranges from 2-15. EM rotation requirements range from 11-33% oftotal clinical time. One program does not have a pediatric rotation. The other programs require 1-2months of pediatrics or pediatric EM. Critical care requirements range from 4-7 months. Other commonrotations include anesthesia, general surgery, internal medicine, obstetrics, gynecology, orthopedics,ophthalmology, radiology, toxicology, psychiatry, neurology, cardiology, pulmonology, and trauma. Allprograms offer 4-6 hours of protected didactic time each week. Some programs require AdvancedCardiac Life Support, Pediatric Advanced Life Support and Advanced Trauma Life Support, with someprograms providing these trainings in-house or subsidizing the cost. Most programs require one researchproject for graduation. Resident evaluations consist of written tests and oral exams several times per year.Point-of-care ultrasound training is provided in four of the seven programs.

Conclusion: As emergency medicine continues to develop in Colombia, more residency programsare expected to emerge. Faculty development and sustainability of academic pursuits will be criticallyimportant. In the long term, the specialty will need to move toward certifying board exams andprofessional development through a national EM organization to promote standardization acrossprograms.

ALiEM Blog and Podcast Watch: Procedures in Emergency Medicine

Introduction: The WestJEM Blog and Podcast Watch presents high-quality, open-accesseducational blogs and podcasts in emergency medicine (EM) based on the ongoing Academic Lifein EM (ALiEM) Approved Instructional Resources (AIR) and AIR-Professional series. Both seriescritically appraise resources using an objective scoring rubric. This installment of the Blog andPodcast Watch highlights the topic of procedure emergencies from the AIR Series.

Methods: The AIR Series is a continuously building curriculum that follows the Council ofEmergency Medicine Residency Directors’ (CORD) annual testing schedule. For each module,relevant content is collected from the top 50 Social Media Index sites published within the previous12 months, and scored by eight AIR board members using five equally weighted measurementoutcomes: Best Evidence in Emergency Medicine (BEEM) score, accuracy, educational utility,evidence based, and references. Resources scoring ≥30 out of 35 available points receive an AIRlabel. Resources scoring 27-29 receive an “honorable mention” label if the executive board agreesthat the post is accurate and educationally valuable.

Results: A total of 85 blog posts and podcasts were evaluated in June 2016. This report summarizeskey educational pearls from the three AIR posts and the 10 Honorable Mentions.

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


Behavioral Health

Emergency Department Attending Physician Variation in Opioid Prescribing in Low Acuity Back Pain

Introduction: Despite treatment guidelines suggesting alternatives, as well as evidence of a lackof benefit and evidence of poor long-term outcomes, opioid analgesics are commonly prescribedfor back pain from the emergency department (ED). Variability in opioid prescribing suggests a lackof consensus and an opportunity to standardize and improve care. We evaluated the variation inattending emergency physician (EP) opioid prescribing for patients with uncomplicated, low acuityback pain (LABP).

Methods: This retrospective study evaluated the provider-specific proportion of LABP patientsdischarged from an urban academic ED over a seven-month period with a prescription for opioids.LABP was strictly defined as (1) back pain chief complaint, (2) discharged from ED with nointerventions, and (3) predefined discharge diagnosis of back pain. We excluded providers if theyhad less than 25 LABP patients in the study period. The primary outcome was the physician-specificproportion of LABP patients discharged with an opioid analgesic prescription. We performed adescriptive analysis and then risk standardized prescribing proportion by adjusting for patient andclinical characteristics using hierarchical logistic regression.

Results: During the seven-month study period, 23 EPs treated and discharged at least 25 LABPpatients and were included. Eight (34.8%) were female, and six (26.1%) were junior attendings (< 5years after residency graduation). There were 943 LABP patients included in the analysis. Providerspecificproportions ranged from 3.7% to 88.1% (mean 58.4% [SD +/- 22.2]), and we found a 22-foldvariation in prescribing proportions. There was a six-fold variation in the adjusted, risk-standardizedprescribing proportion with a range from 12.0% to 78.2% [mean 50.4% (SD +/-16.4)].

Conclusion: We found large variability in opioid prescribing practices for LABP that persistedafter adjustment for patient and clinical characteristics. Our findings support the need to furtherstandardize and improve adherence to treatment guidelines and evidence suggesting alternatives toopioids.

Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review

Introduction: Alcohol use disorders (AUD) place a significant burden on individuals and society. Theemergency department (ED) offers a unique opportunity to address AUD with brief screening tools andearly intervention. We undertook a systematic review of the effectiveness of ED brief interventions forpatients identified through screening who are at risk for AUD, and the effectiveness of these interventionsat reducing alcohol intake and preventing alcohol-related injuries.

Methods: We conducted systematic electronic database searches to include randomized controlled trialsof AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Twoauthors graded and abstracted data from each included paper.

Results: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD.Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a controlintervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significantdifferences between control and intervention groups in their main alcohol-outcome criteria of number ofdrink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumptionin both the control and intervention groups; of those, seven studies did not identify a significant interventioneffect for the main outcome criteria, but nine observed some significant differences between BI and controlconditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking anddriving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g.reduction in driving while intoxicated).

Conclusion: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction inalcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury),and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the EDappears to have a short-term effect in reducing at-risk drinking.


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Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace

Introduction: Violence against healthcare workers in the medical setting is common and associatedwith both physical and psychological adversity. The objective of this study was to identify featuresassociated with assailants to allow early identification of patients at risk for committing an assault inthe healthcare setting.

Methods: We used the hospital database for reporting assaults to identify cases from July 2011through June 2013. Medical records were reviewed for the assailant’s (patient’s) past medical andsocial history, primary medical complaints, ED diagnoses, medications prescribed, presence ofan involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, andfrequency of visits to same hospital requesting prescription for pain medications. We selectedmatched controls at random for comparison. The primary outcome measure(s) reported are featuresof patients committing an assault while undergoing medical or psychiatric treatment within themedical center.

Results: We identified 92 novel visits associated with an assault. History of an involuntarypsychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED ona prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (orconsideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history ofillicit drug use in 33%. Compared with matched controls, all these factors were significantly different.

Conclusion: Patients with obvious risk factors for assault, such as history of assault, psychosis, andinvoluntary psychiatric holds, have a substantially greater chance of committing an assault in thehealthcare setting. These risk factors can easily be identified and greater security attention given tothe patient.

Involuntary Psychiatric Holds in Preadolescent Children

Introduction: Little is known about the use of involuntary psychiatric holds in preadolescentchildren. The primary objective was to characterize patients under the age of 10 years on involuntarypsychiatric holds.

Methods: This was a two-year retrospective study from April 2013 – April 2015 in one urbanpediatric emergency department (ED). Subjects were all children under the age of 10 years whowere on an involuntary psychiatric hold at any point during their ED visit. We collected demographicdata including age, gender, ethnicity and details about living situation, child protective servicesinvolvement and prior mental health treatment, as well as ED disposition.

Results: There were 308 visits by 265 patients in a two-year period. Ninety percent of involuntarypsychiatric holds were initiated in the prehospital setting. The following were common characteristics:male (75%), in custody of child protective services (23%), child protective services involvement(42%), and a prior psychiatric hospitalization (32%). Fifty-six percent of visits resulted in dischargefrom the ED, 42% in transfer to a psychiatric hospital and 1% in admission to the pediatric medicalward. Median length of stay was 4.7 hours for discharged patients and 11.7 hours for patientstransferred to psychiatric hospitals.

Conclusion: To our knowledge, this study presents the first characterization of preadolescentchildren on involuntary psychiatric holds. Ideally, mental health screening and services could beinitiated in children with similar high-risk characteristics before escalation results in placement ofan involuntary psychiatric hold. Furthermore, given that many patients were discharged from theED, the current pattern of utilization of involuntary psychiatric holds in young children should bereconsidered.