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Emergency department crowding as a health policy issue: Past development, future directions

ANNALS OF EMERGENCY MEDICINE 2002年第4期40卷 388-393页

作者： Richardson, LD Asplin, BR Lowe, RA Mt Sinai Sch Med Dept Emergency Med New York NY 10029 USA Reg Hosp St Paul MN USA HealthPartners Res Fdn St Paul MN USA Oregon Hlth & Sci Univ Dept Emergency Med Portland OR 97201 USA Oregon Hlth & Sci Univ Dept Publ Hlth & Prevent Med Div Med Informat & Outcomes Res Portland OR 97201 USA Univ Penn Leonard Davis Inst Med Econ Philadelphia PA 19104 USA

[Ann Emerg Med. 2002;40:388-393.]

关键词：拥挤急诊室医院/统计学和数值数据急诊室医院/发展趋势卫生政策机构间关系卫生保健组织鉴定联合委员会国家卫生统计中心(美国) 美国人类

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"Between me and the computer": Increased detection of intimate partner violence using a computer questionnaire

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ANNALS OF EMERGENCY MEDICINE 2002年第5期40卷 476-484页

作者： Rhodes, KV Lauderdale, DS He, T Howes, DS Levinson, W Univ Chicago Dept Med Sect Emergency Med Chicago IL 60637 USA Univ Chicago Dept Hlth Studies Chicago IL 60637 USA Univ Chicago Pritzker Sch Med Chicago IL 60637 USA Univ Toronto Dept Med Toronto ON Canada

Study objective: The emergency department is a problem-focused environment in which routine screening for intimate partner violence (IPV) is difficult. We hypothesized that screening for IPV during computer-based health-risk assessment would be acceptable to patients and improve detection. Methods: We performed a descriptive study of IPV data collected during a controlled trial of computer-based health promotion in an urban hospital ED. Patients received computer-generated health advice, and physicians received patient risk summaries. Outcomes were patient disclosure and physician documentation of IPV and associated risks. Results: Two hundred forty-eight patients (69% female, 90% black, mean age 39 years) participated in a clinical trial of computer-based health promotion in the ED. Of 170 women, 53 (33%) disclosed emotional abuse, and 25 (15%) disclosed physical abuse. Of 78 men, 22 (29%) disclosed emotional abuse, and 5 (6%) disclosed physical abuse. Patients were also willing to self-report a history or concern of hurting someone close to them. This was true for 21 (14%) women and 15 (22%) men. Controlling for demographic factors, disclosures of victimization and perpetration were associated with multiple psychosocial risks. Computer screening resulted in chart documentation in 19 of 83 potential cases of IPV compared with I case documented in the group that received usual care. Conclusion: Providing an opportunity for patients to confidentially self-disclose IPV has the potential to supplement current screening efforts and to allow providers to focus on assessment, counseling, and referral for those at risk. However, further measures will be needed to ensure that information gathered through computer screening is adequately addressed during the acute care or follow-up visit.

关键词：计算机机密家庭暴力/预防和控制家庭暴力/统计学和数值数据急诊室医院/统计学和数值数据健康促进普查/方法危险性评估/方法美国/流行病学市区人口成年人女(雌)性人类男(雄)性

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The Canadian CT head rule study for patients with minor head injury: Rationale, objectives, and methodology for phase I (derivation)

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ANNALS OF EMERGENCY MEDICINE 2001年第2期38卷 160-169页

作者： Stiell, IG Lesiuk, H Wells, GA McKnight, RD Brison, R Clement, C Eisenhauer, MA Greenberg, GH MacPhail, I Reardon, M Worthington, J Verbeek, R Rowe, B Cass, D Dreyer, J Holroyd, B Morrison, L Schull, M Laupacis, A Ottawa Hosp Res Inst Ottawa ON Canada Univ Ottawa Div Emergency Med Ottawa ON Canada Univ Ottawa Dept Med Ottawa ON Canada Univ Ottawa Dept Epidemiol & Community Hlth Ottawa ON Canada Univ Ottawa Div Neurosurg Clin Epidemiol Unit Ottawa ON Canada Univ Alberta Div Emergency Med Edmonton AB Canada Queens Univ Dept Emergency Med Kingston ON Canada Univ Toronto Div Emergency Med Toronto ON Canada Univ Western Ontario Div Emergency Med London ON Canada Univ British Columbia Div Emergency Med Vancouver BC V5Z 1M9 Canada

Head injuries are among the most common types of trauma seen in North American emergency departments, with an estimated I million cases seen annually. "Minor" head injury (sometimes known as "mild") is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, that is, with a Glasgow Coma Scale Although most patients with minor head score of 13 to 15. injury can be discharged without sequelae after a period of observation, in a small proportion, their neurologic condition deteriorates and requires neurosurgical intervention for intracranial hematoma. The objective of the Canadian CT Head Rule Study is to develop an accurate and reliable decision rule for the use of computed tomography (CT) in patients with minor head injury. Such a decision rule would allow physicians to be more selective in their use of CT without compromising care of patients with minor head injury. This paper describes in detail the rationale, objectives, and methodology for Phase I of the study in which the decision rule was derived.

关键词：加拿大/流行病学颅脑损伤/流行病学颅脑损伤/放射摄影术数据说明统计决策支持技术急诊室医院/统计学和数值数据格拉斯哥昏迷量表前瞻性研究敏感性与特异性体层摄影术 X线计算机青少年成年人老年人人类中年人

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Emergency department analgesia for fracture pain

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ANNALS OF EMERGENCY MEDICINE 2003年第2期42卷 197-205页

作者： Brown, JC Klein, EJ Lewis, CW Johnston, BD Cummings, P Childrens Hosp & Med Ctr Seattle WA 98105 USA Univ Washington Sch Med Dept Pediat Seattle WA 98195 USA Univ Washington Sch Publ Hlth & Community Med Dept Epidemiol Seattle WA 98195 USA

Study objectives: We analyze records of all emergency department (ED) patients with extremity or clavicular fractures to describe analgesic use, compare analgesia between adults and children, and compare analgesia between the subset of these adults and children with documented moderate or severe pain. Among children, we compare treatment between pediatric and nonpediatric facilities. Methods: Analysis of the ED component of the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1997 through 2000 was conducted. The proportion of patients with closed extremity and clavicular fracture that received any analgesic and narcotic analgesic medications was determined for each age category. Survey-adjusted regression analyses compared pain and narcotic medications by age and ED type (pediatric versus other). Analyses were repeated for the subset of patients with moderate or severe pain severity scores. Results: Of 2,828 patients with isolated closed fractures of the extremities or clavicle, 64% received any analgesic and 42% received a narcotic analgesic. Pain severity scores were recorded for 59% of visits overall, 47% of children younger than 4 years, and 34% of children younger than 1 year. Among patients with documented moderate or severe pain, 73% received an analgesic and 54% received a narcotic analgesic. Compared with adults, a lower proportion of children (less than or equal to15 years) received either any analgesic or a narcotic analgesic (P<.001). After adjustment for confounders and survey design, the proportion of patients aged 0 to 3, 4 to 8, 9 to 15, 16 to 29, 30 to 69, and 70 years and older who received any analgesic was 54% (95% confidence interval [CI] 41% to 67%), 63% (95% CI 57% to 68%), 60% (95% CI 57% to 64%), 67% (95% CI 62% to 73%), 68% (95% CI 64% to 72%), and 58% (95% CI 52% to 65%), respectively;the proportion who received a narcotic analgesic was 21% (95% CI 11% to 31%), 30% (95% CI 22% to 37%), 27% (95% CI

关键词：医学科学研究中心年龄因素镇痛/统计学和数值数据锁骨/损伤药物利用急诊室医院/标准急诊室医院/统计学和数值数据四肢/损伤骨折/并发症卫生保健调查医院社区医院儿科线性模型疼痛/诊断疼痛/病因学疼痛/预防和控制疼痛测定疾病严重程度指数美国青少年成年人老年人儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性中年人

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The prevalence of hospital health promotion and disease prevention services: Good news, bad news, and policy implications

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MILBANK QUARTERLY 2000年第1期78卷 115-+页

作者： Olden, PC Clement, DG Univ Scranton Panuska Coll Profess Studies Grad Hlth Adm Program Scranton PA 18510 USA Virginia Commonwealth Univ Richmond VA 23284 USA

In recent years, American health care has shifted toward an emphasis on population health in communities. National data from the American Hospital Association Annual Survey of Hospitals are used to describe the prevalence of 26 services provided by general hospitals that could contribute to health promotion and disease prevention (HPDP). Cross-sectional descriptive analyses, based on national data sources, linked HPDP services to hospital characteristics, and factor analysis identified significant categories of HPDP activities. The results showed that many specific HPDP services are offered by thousands of hospitals, but prevalence, distribution, and availability of the services are uneven across the size and ownership of hospitals and their communities. Policy initiatives could increase the prevalence of hospitals' health promotion and disease prevention services, thereby improving the health status of their communities.

关键词：美国医院协会社区卫生服务/组织和管理卫生政策健康促进/方法医院/统计学和数值数据预防卫生服务/统计学和数值数据美国人类

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Reproducibility of increased blood pressure during an emergency department or urgent care visit

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ANNALS OF EMERGENCY MEDICINE 2003年第4期41卷 507-512页

作者： Backer, HD Decker, L Ackerson, L Kaiser Permanente Med Ctr Emergency Dept Hayward CA USA Kaiser Permanente Med Ctr Dept Emergency Med Hayward CA USA Kaiser Permanente Med Ctr Dept Internal Med Hayward CA USA So Calif Permanente Med Grp Div Res Oakland CA USA

Study objective: We determine the reproducibility of increased blood pressure measurements among adults in the emergency department or minor injury clinic. Methods: The study was conducted at Kaiser Permanente Medical Center in Hayward, CA, a large, group-model health maintenance organization providing capitated insurance coverage. All patients were included in the study who had no current diagnosis of hypertension but had increased blood pressure on their presentation to the ED or minor injury clinic during the 2-month study period. The staff was asked to repeat the blood pressure later during the index visit and provide these patients with written instructions to return for additional repeat measures. We compared blood pressures taken in the ED to measurements before and after the ED visit. Results: Four hundred seven patients were included in the study. Of the initial elevated blood pressures, 211 (51.8%) were stage 1 elevation, 147 (36.1%) were stage 2, and 49 (12.0%) were stage 3 by criteria of the Joint National Committee on Hypertension. Sixty-five percent of patients had repeat measures in the clinic during our 5-month follow-up period, despite active outreach and reminders. Seventy percent of those who had repeat blood pressure documented had at least 1 increased blood pressure after their ED visit. The proportion of patients with at least 1 abnormal blood pressure on subsequent measurement increased with increasing stage of initial blood pressure (64.4% for stage 1, 77.1% for stage 2, 97.1% for stage 3), but was similar for patients with and without pain as a chief complaint and was similar for patients seen in the ED compared with patients seen in urgent care. Compared with blood pressures taken during the ED visit, matched blood pressures taken before or after showed no statistically significant differences. Conclusion: Increased blood pressure is common among emergency or urgent care patients without a history of current hypertension, and most of these

关键词：血压测定/方法血压测定/标准加利福尼亚队列研究混杂因素(流行病学) 急症急诊室医院/统计学和数值数据健康维护组织高血压/分类高血压/诊断普查试验预期值转诊和会诊疾病严重程度指数伤病员分拣女(雌)性人类男(雄)性中年人

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Management of coronary risk factors by registered nurses versus usual care in patients with unstable angina pectoris (A Chest Pain Evaluation in The Emergency room [CHEER] substudy)

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第2期86卷 133-138页

作者： Allison, TG Farkouh, ME Smars, PA Evans, RW Squires, RW Gabriel, SE Kopecky, SL Gibbons, RJ Reeder, GS Mayo Clin & Mayo Fdn Div Cardiovasc Dis & Internal Med Rochester MN 55905 USA Mt Sinai Med Ctr Cardiovasc Inst New York NY 10029 USA Mayo Clin & Mayo Fdn Div Emergency Med Serv & Internal Med Rochester MN 55905 USA Mayo Clin & Mayo Fdn Div Hlth Serv Res & Internal Med Rochester MN 55905 USA

This study examined whether nurses could manage coronary risk factors in patients with unstable angina more effectively than physicians practicing usual care. Three hundred twenty-six patients were randomized in the emergency room to a 6-month program of risk factor management by a registered nurse versus participation in usual care. The nurse intervention consisted of a 30-minute counseling visit at 6 to 10 days after the chest pain episode and a second 30-minute session 1 month later. Multiple risk factors were assessed and addressed: smoking, blood lipids, blood pressure, blood glucose, physical inactivity, weight, psychological stress, and social isolation. Compared with usual care, nurse intervention patients significantly reduced both triglycerides (-29 +/- 8 vs 5 +/- 6 mg/dl;p <0.0004) and weight (-0.9 +/- 3.3 vs +0.1 +/- 2.1 kg;p = 0.0071), and had corresponding improvements in self-reported diet compliance and exercise (+34 +/- 106 vs +9 +/- 98 minutes, p = 0.0491). No significant differences between groups were observed in terms of 6-month changes in total, high-density lipoprotein, or low-density lipoprotein cholesterol, blood pressure, fasting blood glucose, percent body fat or waist-hip ratio, or psychological distress scores. The 6-month rate of recurrent events (cardiac death, out-of-hospital cardiac arrest, myocardial infarction) and/or revascularizations (coronary artery bypass surgery or coronary angioplasty) was lower in the nurse intervention group (1% vs 9%;p = 0.002). We conclude that a nurse-delivered risk factor intervention program for patients with chest pain is feasible and more effective than usual care in terms of fostering lifestyle changes that may lower coronary risk. (C)2000 by Excerpta Medico, inc.

关键词：心绞痛不稳定型/血液心绞痛不稳定型/流行病学心绞痛不稳定型/治疗临床工作能力/统计学和数值数据咨询急症护理/标准急诊室医院/标准急诊室医院/统计学和数值数据生活方式医务人员医院/标准明尼苏达/流行病学危险因素老年人女(雌)性人类男(雄)性中年人

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Evaluation of the pediatric risk of admission score in a pediatric emergency department

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ANNALS OF EMERGENCY MEDICINE 2003年第5期41卷 630-638页

作者： Gravel, J Gouin, S Amre, D Bergeron, S Lacroix, J Univ Montreal Hop St Justine Dept Pediat Div Emergency Med Montreal PQ H3T 1C5 Canada Univ Montreal Hop St Justine Dept Pediat Res Inst Montreal PQ H3T 1C5 Canada Univ Montreal Hop St Justine Dept Pediat Div Intens Care Montreal PQ H3T 1C5 Canada

Study objectives: The pediatric risk of admission (PRISA) score was developed to predict the risk for hospitalization for pediatric emergency department patients. We sought to evaluate prospectively the predictive value of the PRISA score with respect to the risk for hospitalization in a pediatric ED. Methods: A prospective cohort study was conducted in a pediatric tertiary center ED. From November 1, 2000, to October 31, 2001, 3 periods of 8 hours each were randomly chosen monthly. During these periods, all patients triaged to the ED were evaluated. Data collection was performed by an investigator uninvolved in the patients' treatment. Data were recorded before the decision regarding hospitalization was made. Odds ratios for the risk of hospitalization related to individual criteria and PRISA scores were calculated. Discrimination and calibration of the score were assessed. Results: During the study periods, 1,930 patients were evaluated. Among these, 203 hospitalizations were observed, and the PRISA score predicted 235. The goodness-of-fit test demonstrated that the score had good predictive ability (chi(2) =28.15;P=38). Receiver operating characteristic curve analysis confirmed the latter findings (area under the curve 0.79 [95% confidence interval 0.72 to 0.86]). Some individual criteria of the score did not significantly predict risk for admission. Conclusion: The PRISA score is a good predictor of the risk for hospitalization in a pediatric ED. It seems more accurate for the sicker patients. Some variables of the score could be deleted or modified to optimize its accuracy.

关键词：卡方分布急诊室医院/统计学和数值数据住院/统计学和数值数据医院儿科/统计学和数值数据 Logistic模型病人入院/统计学和数值数据试验预期值前瞻性研究魁北克 ROC曲线危险性评估疾病严重程度指数青少年成年人儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性

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Direct access day case oral surgery

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BRITISH DENTAL JOURNAL 2000年第8期188卷 452-456页

作者： Joshi, A Doyle, L Worthington, HV Rood, JP Manchester Royal Infirm Dept Oral & Maxillofacial Surg Manchester M13 9WL Lancs England Univ Manchester Dent Hosp Dept Dent Med & Surg Manchester M15 6FH Lancs England GKT Sch Dent London SE5 9RW England

Objective To compare the effectiveness of direct access referrals with standard letter referrals, and also assess the impact of the direct access system on the primary care provider, secondary sector and from the patients perspective. Design Surgical and anaesthetic guidelines were agreed and 12 general dental practitioners were recruited to participate in the study. Each practitioner was given 100 envelopes which contained randomly allocated 50 direct and 50 standard referrals. For direct referrals, GDPs completed a pre-operative assessment and obtained an operation date by telephone from the day case unit while the patient was in the surgery. The clinical history sheet was fared to the day unit and the radiographs posted. The only contact the patient had with the hospital was on the day of surgery. Standard referral patients were referred in the traditional way with a referral letter being sent to an out-patient clinic. Evaluation of the effectiveness of the direct referral system versus standard letter method were made via completion of questionnaires by the patients, dental practitioners, hospital clinicians, day case anaesthetist and co-ordinator. Setting The study was carried out over 2 years commencing in 1997 at the Oral Surgery Day Case Unit at Manchester Royal Infirmary. Results A greater number of direct access referrals (409;90%) were treated in comparison with (312;75%) standard referrals IP < 0.001). Eighty nine per cent of direct access records were adequate pre-operatively. More than 70% of dentists and hospital clinicians preferred the direct access referral method. Sixty-three per cent of standard letter patients were satisfied with their mode of referral compared with 87% of direct access patients. Conclusions Given appropriate guidelines dental practitioners are able to refer directly to oral surgery day case operation lists. This has proved to be the favoured method of referral for dental practitioners, the secondary sector and patients.

关键词：门诊外科手术/统计学和数值数据医务工作者的态度牙科医院/统计学和数值数据开业医生牙科/组织和管理开业医生牙科/统计学和数值数据口腔外科手术/统计学和数值数据病人满意度随机分配转诊和会诊/组织和管理转诊和会诊/统计学和数值数据外科口腔/组织和管理青少年成年人人类中年人

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Important factors for the 10-year mortality rate in patients with acute chest pain or other symptoms consistent with acute myocardial infarction with particular emphasis on the influence of age

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AMERICAN HEART JOURNAL 2001年第4期142卷 624-632页

作者： Herlitz, J Karlson, BW Lindqvist, J Sjölin, M Sahlgrens Univ Hosp Div Cardiol S-41345 Gothenburg Sweden

Objective Our purpose was to describe the mortality rate and mode of death over 10 years and factors associated with death among patients admitted to the emergency department with acute chest pain or other symptoms consistent with acute myocardial infarction (AMI). Methods All patients who come to the emergency department of Sahlgrenska University Hospital in Goteborg, Sweden, with acute chest pain or other symptoms consistent with AMI during a 21-month period were studied. Results In all, 5362 patients were registered, for whom information on 10-year mortality was available in 5158 (96.2%). In all, there were 2126 deaths (41.2%). Fifty-two percent of patients were less than or equal to 65 years old. Independent predictors of death registered on admission to hospital during the subsequent 10 years were age (relative risk 1.08, 95% Cl 1.07-1.09), male sex (1.38, 1.25-1.52), initial degree of suspicion of AMI (1.13, 1.06-1.19), a pathologic initial electrocardiogram (1.76, 1.56-1.98), symptoms of congestive heart failure (1.66, 1.39-1.98), "other" nonspecific symptoms (1.22, 1.07-1.39), a history of diabetes mellitus (1.65, 1.44-1.88), a history of congestive heart failure (1.42, 1.26-1.60), a history of previous myocardial infarction (1.26, 1.12-1.40), and a history of hypertension (1.14, 1.03-1.26). For all these predictors there was a strong interaction with age, thus a much more marked influence on outcome among patients less than or equal to 65 years old than among patients > 65 years old. When the above risk indicators were simultaneously considered, development of AMI during the first 3 days after hospital admission was still an independent predictor of death (1.63, 1.43-1.86). Conclusion For patients admitted to the emergency department with acute chest pain or other symptoms consistent with AMI, several predictors based on clinical history and clinical presentation are related to the 10-year prognosis. They are more strongly associated with outcome among pati

关键词：急性病年龄因素死亡原因胸痛/诊断胸痛/流行病学胸痛/死亡率脑电描记术/统计学和数值数据急诊室医院/统计学和数值数据住院/统计学和数值数据高血压/诊断高血压/流行病学心肌梗死/诊断心肌梗死/流行病学心肌梗死/死亡率预后危险性别因素瑞典/流行病学老年人女(雌)性人类男(雄)性中年人

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