Study objective: Emergency department computerized triage logs might be useful for automated ED surveillance and potentially for early identification of bioterrorism events. We describe a Web-based surveillance progra...
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Study objective: Emergency department computerized triage logs might be useful for automated ED surveillance and potentially for early identification of bioterrorism events. We describe a Web-based surveillance program and its feasibility for surveillance. Methods: A Web-based surveillance program that receives computerized chief complaint data daily from a large academic urban teaching hospital and performs syndromic analysis on these data was developed. On the basis of preset limits, the Web-based surveillance program sends an alert e-mail message when the syndromic analysis reveals an increase in the number of patients in predefined symptom groups. The feasibility of this system was tested by using historical data during an influenza outbreak (December 1999 to January 2000) and applying the anthrax symptom group. Results: The Web-based surveillance program identified the influenza outbreak in the first week. Conclusion: Computerized triage logs might be a feasible method for bioterrorism and influenza surveillance. The Web-based nature of the surveillance program creates the opportunity for other hospitals to contribute data, potentially resulting in an automated network of ED computerized triage log surveillance.
Study objective: This is a pilot study designed to assess the feasibility of a point prevalence study to assess the degree of crowding in hospital emergency departments (EDs). In addition, we sought to measure the deg...
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Study objective: This is a pilot study designed to assess the feasibility of a point prevalence study to assess the degree of crowding in hospital emergency departments (EDs). In addition, we sought to measure the degree of physical crowding and personnel shortage in our sample. Methods: A mail survey was sent to a random sample of 250 EDs chosen from a database compiled by the American College of Emergency Physicians of 5,064 EDs in the United States. In addition to demographic information, respondents were asked to count the patients and staff in their EDs at 7 Pm local time on Monday March 12,, 2001 (index time). Results: The response rate was 36%. At the index time, there was an average of 1.1 patients per treatment space, and 52% of EDs reported more than 1 patient per treatment space. There was also evidence of personnel shortage, with a mean of 4.2 patients per registered nurse and 49% of EDs having each registered nurse caring for more than 4 patients. There was a mean of 9.7 patients per physician. Sixty-eight percent of EDs had each physician caring for more than 6 patients. There was crowding present in all geographic areas and all hospital types (teaching-nonteaching status of the hospital). Consistent with the crowded conditions, 11% of institutions were on ambulance diversion and not accepting new acute patients. Delays in transfer of admitted patients out of the ED contributed to the physical crowding. Twenty-two percent of patients in the ED were already admitted and were awaiting transfer to an inpatient bed;73% of EDs were boarding 2 or more inpatients. The amount of crowding quantified by this point prevalence study was confirmed by the amount of crowding reported for the previous week: 48% of EDs were boarding inpatients during the previous week for a mean of 8.9 hours, 4.2 days per week;31% had been on diversion;59% had been routinely using their halls for patients;38% had been doubling their rooms;and 47% had been using nonclinical space for pa
Study objective: We discuss a prospective case series of patients who present with a severe gamma-hydroxybutyrate intoxication with confirmatory serum and urine gamma-hydroxybutyrate levels. Methods: Patients with a c...
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Study objective: We discuss a prospective case series of patients who present with a severe gamma-hydroxybutyrate intoxication with confirmatory serum and urine gamma-hydroxybutyrate levels. Methods: Patients with a clinical suspicion of gamma-hydroxybutyrate-like drug overdoses and a Glasgow Coma Scale score of 8 or lower were identified from July 1998 through January 1999. Serial serum specimens and a single urine specimen were collected. The levels of gamma-hydroxybutyrate were performed by gas chromatography-mass spectrometry. Results: All 16 suspected severe gamma-hydroxybutyrate overdose patients had significant serum or urine levels of gamma-hydroxybutyrate. Serum levels ranged from 45 to 295 mg/L, with a median of 180 mg/L (interquartile range [IQR] 235 to 118 mg/L). Patients who developed a Glasgow Coma Scale score of 3 had serum levels that ranged from 72 to 300 mg/L, with a median of 193 mg/L (IQR 242 to 124 mg/L). The time of awakening ranged from 30 minutes to 190 minutes, with a median of 120 minutes (IQR 150 to 83 minutes). Quantitative serum gamma-hydroxybutyrate levels did not correlate with the degree of coma or the time to awakening. Urine levels ranged from 432 to 2,407 mg/L, with a median of 1,263 mg/L (IQR 1,550 to 796 mg/L). Mild transitory hypoventilation occurred in 5 of the 16 patients. Conclusion: All of our patients with clinically suspected severe gamma-hydroxybutyrate overdose were confirmed to have significant serum and urine levels of exogenous gamma-hydroxybutyrate. They presented with severe coma that lasted 1 to 2 hours. Transient hypoventilation occurred in one third of these patients.
We describe a method for scheduling shifts in a large academic emergency medicine group. The method starts with a survey of the faculty to assign shift equivalent values to each of the 13 different shifts used during ...
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We describe a method for scheduling shifts in a large academic emergency medicine group. The method starts with a survey of the faculty to assign shift equivalent values to each of the 13 different shifts used during the week. A weekday day shift is assigned a value of 1.0, and the shifts range in value up to 2.1 units. Each faculty member is then assigned a shift allocation for the academic year equally divided among the various shift types. Faculty members can request reallocation of shift types on the basis of the individual shift equivalent values. Once the number of the different shifts are allocated as required by the schedule, a lottery is held whereby individual faculty members choose specific shifts in turn for the upcoming year. The lottery selection is done by the faculty members accessing a common server from their office computers during a specified period. The lottery process continues until all shifts are filled. The creation of shift equivalent values facilitates the initial allocation of shifts and subsequent trades between faculty members.
Study objective: We characterize the use of analgesics among children of different race and ethnicity who had isolated long bone fractures that were treated in emergency departments (EDs) across the United States. Met...
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Study objective: We characterize the use of analgesics among children of different race and ethnicity who had isolated long bone fractures that were treated in emergency departments (EDs) across the United States. Methods: According to ED survey data from the National Hospital Ambulatory Medical Care Survey for 1992 through 1998, patients younger than 19 years and visiting EDs with isolated long bone fractures were identified by International Classification of Diseases, Ninth Revision codes. Analgesic-prescribing rates were examined for children of different racial and ethnic groups. Multivariate logistic regression was used to determine the independent effect of race and ethnicity on analgesic use and on opioid use while other potential confounders were controlled. Results: One thousand thirty records representing approximately 3.9 million children were identified. Seven hundred ninety-two records were of non-Hispanic white patients, 111 were of black patients, and 127 were of Hispanic white patients. No significant difference was noted among the different racial and ethnic groups for receipt of analgesic medications or of opioid analgesic medications. Children with long bone fractures who visited the ED in the South (adjusted odds ratio [OR] 1.91;95% confidence interval [CI] 1.19 to 3.09) and the West (adjusted OR 1.78;95% CI 1.07 to 2.96) received opioid analgesic medications more often than children in the Northeast. Children in the South also received any analgesics more often (adjusted OR 1.61;95% CI 1.01 to 2.56). Conclusion: No difference in analgesic prescription or opioid analgesic prescription was found between black and Hispanic children compared with non-Hispanic white children with long bone fractures in EDs. There are, however, previously unreported regional differences in analgesic administration.
Study objective: Health Care providers in hospital emergency departments rarely take substance abuse histories or assess associated treatment need. This study compares documentation of psychoactive drug-related diagno...
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Study objective: Health Care providers in hospital emergency departments rarely take substance abuse histories or assess associated treatment need. This study compares documentation of psychoactive drug-related diagnoses for adult ED patients in medical records with treatment need assessed through self-report, toxi-cologic screening, and Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria. Methods: A statewide, 2-stage, probability sample survey was conducted in 7 Tennessee general hospital EDs from June 1996 to January 1997. Main outcome measures were the prevalence of diagnosed substance abuse problems, positive bioassay results, denied use, and treatment need. Sensitivity and multivariate analyses, were conducted by using varied case definitions of treatment need. Results: Thirty-one percent (95% confidence interval [CI] 27.3% to 34.7%) of screened ED patients (n=1,330) had positive test results for substance use. Their prevalence of denial of use in the 30 days before the survey ranged from 10% for alcohol (95% CI 5.7% to 14.3%) to 100% for phencyclidine. One percent of all ED patients (n=1,502) had a recorded diagnosis of substance abuse. By contrast, as many as 27% (95% CI 23.3% to 31.8%) were assessed as needing substance abuse treatment on the basis of a comprehensive case definition that accounted, for denial;and positive test results. A sensitivity analysis using other case definitions is also presented. For example, 4% (95% CI 2.8% to 5.3%) of patients met the very strict definition of DSM-IV current drug dependence only. Under the comprehensive case definition, TennCare patients (adjusted odds ratio [OR] 1.63;95% CI 1.30 to 2.05) and Medicare patients (adjusted OR 2.50;95% CI 1.34 to 4.65) showed excess treatment need relative to the privately insured. Excess need was also exhibited by patients reporting I or more prior ED visits in the past year (adjusted OR 1.62;95% CI 1.13 to 2.31) and by patients taking 2 or more hou
作者：
Geiderman, JMCedars Sinai Med Ctr
Dept Emergency Med Ruth & Harry Roman Emergency Dept Los Angeles CA 90048 USA Cedars Sinai Med Ctr
Burns & Allen Res Inst Cedars Sinai Ctr Hlth Care Eth Los Angeles CA 90048 USA
Emergency departments commonly keep files of patients who are suspected of frequently visiting them and fabricating symptoms to obtain prescription drugs, usually opioids, for nontherapeutic purposes. Such files have ...
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Emergency departments commonly keep files of patients who are suspected of frequently visiting them and fabricating symptoms to obtain prescription drugs, usually opioids, for nontherapeutic purposes. Such files have previously been given names such as "frequent flyer file," "repeater log," "kook-book," "problem patient file," "atient alert list," or "special needs file." Little has been written about the ethical, legal, and regulatory considerations that should be taken into account when establishing, maintaining, and using such files. This article explores these issues. The term "habitual patient files" is proposed because it is descriptive without being judgmental.
Study objective: The main objective of this study was to determine the sensitivity and specificity of the Ottawa Knee Rules when they were applied to children. The secondary objective was to determine post hoc whether...
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Study objective: The main objective of this study was to determine the sensitivity and specificity of the Ottawa Knee Rules when they were applied to children. The secondary objective was to determine post hoc whether use of the rules would reduce the number of knee radiographs ordered. Methods: This prospective, multicenter validation study included children aged 2 to 16 years who presented to the emergency department with a knee injury sustained in the preceding 7 days. Children were assessed for the variables comprising the Ottawa Knee Rules, and physicians ordered radiographs at their discretion. A positive outcome was defined as any fracture. A negative outcome was defined as children who did not have a fracture on radiograph or, if no radiograph was obtained, were asymptomatic after 14 days. Results: A total of 750 children were enrolled. The mean age was 11.8+/-3.1 years, and 443 (58.7%) were male patients. Seventy children had fractures. Radiography was performed for 670 children, whereas 80 children had only a structured telephone interview. The Ottawa Knee Rules were 100% sensitive (95% confidence interval [CI] 94.9% to 100%), with a specificity of 42.8% (95% CI 39.1% to 46.5%). Only 460 children would have required a radiograph if radiographs had been performed according to the Ottawa Knee Rules, which would have resulted in an absolute reduction of 209 (31.2%) radiographs. Conclusion: The Ottawa Knee Rules are valid in children and have the potential to decrease the use of radiography in children with knee injuries.
Study objective: This study assesses the relationship between substance abuse comorbidity and emergency department use among patients with psychiatric disorders in a large academic medical center. Methods: Data were o...
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Study objective: This study assesses the relationship between substance abuse comorbidity and emergency department use among patients with psychiatric disorders in a large academic medical center. Methods: Data were obtained from an administrative database including every patient visit to the ED of a large, academically affiliated county hospital from January 1994 through June 1998. This study focuses on 12,212 patients who were given a diagnosis of a primary psychiatric disorder in the ED. Diagnoses, assigned during ED visits, were made according to the Diagnostic and Statistical Manual of Mental Disorders III-R or IV. Results: Primary psychiatric patients with substance use comorbidity had a significantly higher mean number of ED visits across the span of the study (mean 5.2;SD 7.4) than primary psychiatric patients without substance use comorbidity (mean 2.8;SD 3.9). In multiple logistic regression analyses predicting several categorizations of heavier use of the ED (either 4+, 8+, 12+, 16+, or 20+ visits over the span of the study), psychiatric patients with a comorbid substance use disorder had adjusted odds ratios of 2.8 to 4.9 (reference group was defined as patients with a psychiatric disorder but no substance use disorder;models controlled for age, race, and sex). Conclusion: Substance use comorbidity among patients presenting to an ED with a psychiatric disorder is associated with substantially increased ED service use. Improved detection, referral, and treatment of substance use disorders in this population could result in decreased ED use and improved patient outcomes.
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