Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: This study aims to characterize the population of patients presenting to a pediatric emergency department (ED) for a first complex febrile seizure, and subsequently assess the rate of acute bacterial meningitis (ABM) occurrence in this population. Furthermore, this study seeks to identify whether a specific subset of patients may be atlesser risk for ABM or other serious neurological disease.

Methods: This retrospective cohort study reviewed the charts of patients between the ages of 6 months to 5 years of age admitted to an ED between 2005 and 2010 for a first complex febrile seizure (CFS). The health information department generated a patient list based onadmission and discharge diagnoses, which was screened for patient eligibility. Exclusion criteria included history of a complex febrile seizure, history of an afebrile seizure, trauma, or severe underlying neurological disorder. Data extracted included age, gender, relevant medical history, descriptions of seizure, treatment received, and follow-up data. Patientspresenting with two short febrile seizures within 24 hours were then analyzed separately to assess health outcomes in this population.

Results: There were 193 patients were eligible. Lumbar puncture was performed on 136 subjects; it was significantly more likely to be performed on patients that presented with seizure focality, status epilepticus, or a need for intubation. Fourteen patients were found tohave pleocytosis following white blood cell (WBC) count correction, and 1 was diagnosed with ABM (0.5% [95% confidence interval: 0.0–1.5, n = 193]). Forty-three patients had 2 brief febrile seizures within 24 hours. Of the 43, 17 received lumbar puncture while in the ED. None of these patients were found to have ABM or other serious neurological disease.

Conclusion: ABM is rare in patients presenting with a first complex febrile seizure. Patients presenting only with 2 short febrile seizures within 24 hours may be less likely to have ABM, and may not require lumbar puncture without other clinical symptoms of neurological disease. [West J Emerg Med. 2013;14(3):206–211.]

Introduction: Arterial blood gas and serum lactate (ABG / SL) values have been shown to be markers for occult shock and poor outcome following blunt trauma. However, the utility of ABG / SL in blunt trauma patients who also receive computed tomographies (CT) of the chest, abdomen, and pelvis (CT C&A) remains unknown. Methods: A chart review was performed of all adult blunt trauma patients who received both CT C&A and ABG / SL upon presentation to our emergency department (ED) between January 1, 2007 and December 31, 2007. These patients (n=360) were identified from our institutional trauma registry database. Patients were divided into subgroups based upon whether they had a positive or negative ED evaluation for traumatic injury requiring hospitalization or immediate operative management. The expected course for patients with negative ED evaluations regardless of ABG / SL was discharge home. The primary outcome measure was the proportion of patients with a negative ED evaluation and an abnormal ABG or SL that were admitted to the hospital. Results: 2.9% of patients with a negative ED evaluation and abnormal ABG or SL were admitted. Of these, none were found to have any post-traumatic sequalae. Conclusion: We found that abnormal ABG / SL results do not change management or discharge disposition in patients without clinical or radiographic evidence of traumatic injury on CT C&A. Among patients who receive CT C&A, the routine measurement of arterial blood gas and lactate may be an unnecessary source of additional cost, patient discomfort, and delay in care. [West J Emerg Med. 2013;14(3):212–217.]

Introduction: There are few reports summarizing the effectiveness of oral and intravenous (IV) acetylcysteine. We determined the proportion of acetaminophen poisoned patients who develop hepatotoxicity (serum transaminase > 1000 IU/L) when treated with oral and IV acetylcysteine.

Methods: Studies were double abstracted by trained researchers. We determined the proportions of patients who developed hepatotoxicity for each route using a random effects model. Studies were further stratified by early and late treatment.

Results: We screened 4,416 abstracts; 16 articles, including 5,164 patients, were included in the meta-analysis. The overall rate of hepatotoxicity for the oral and IV routes were 12.6% and 13.2%, respectively. Treatment delays are associated with a higher rate of hepatotoxicity.

Conclusion: Studies report similar rates of hepatotoxicity for oral and IV acetylcysteine, but direct comparisons are lacking. While it is difficult to disentangle the effects of dose and duration from route, our findings suggest that the rates of hepatotoxicity are similar for oral and IV administration. [West J Emerg Med. 2013;14(3):218–226.]

Introduction: Higher-level-of-care (HLOC) transfers to tertiary care hospitals are common. While this has been shown profitable for hospitals, the impact on physicians has not been described. Community medical center call panels continue to erode, in part due to the perception that patients needing transfer are underinsured. Surveys show that the problematic specialties to maintain call panels in community hospitals are neurosurgery, otolaryngology, plastic surgery, orthopedics and ophthalmology. This places greater stress on tertiary care hospitals’ physicians. The objective of this study is to describe the financial consequences to physicians who care for HLOC transfers across specialties and compare these with all patients from each specialty and specialty-specific national reimbursement benchmarks.

Methods: Financial data were obtained for all HLOC transfers to a single tertiary care center from January 2007 through March 2008. Work relative value unit (RVU) and reimbursement were taken from a centralized professional fee billing office. National benchmarks for reimbursement per RVU were calculated from the 2006 Medical Group Management Association (MGMA) Compensation and Production Survey.

Results: In this period 570 patients were transferred, 319 (55.9%) through the emergency department (ED). Reimbursement per RVU varied from a high of $74.93 for neurosurgery to $25.91 for family medicine. Reimbursement to emergency medicine (EM) for HLOC patients was 16% above the average reimbursement per RVU for all ED patients ($50.5 vs. $43.7). Similarly, neurosurgery reimbursement per RVU was 22% above the reimbursement per RVU for all patients ($74.93 vs. $61.27). The remainder of specialties was reimbursed less ($25.91 vs $69.60) per RVU for HLOC patients than for all of their patients at this center. All specialties at this site were reimbursed less for each HLOC patient than national average reimbursement for all patients in each specialty.

Conclusion: Average professional fee reimbursement for HLOC patients was higher for EM and neurosurgery than for all other patients in these specialties at this site, but lower for the rest of the specialties. Compared to the national benchmarks, this site had an overall lower reimbursement per RVU for all specialties, reflecting a poorer patient mix. At this site HLOC transfers patients are financially advantageous for EM and neurosurgery. [West J Emerg Med. 2013;14(3):227–232.]

Tuberculosis (TB) is a known cause of secondary pneumothorax. In areas with endemic TB, complications from the disease, including pneumothorax, are increasing in prevalence. We present the cases of 3 patients (ages 32 years, 17 years, and 3 months) seen in the emergency department at John F. Kennedy Medical Center in Monrovia, Liberia, West Africa. Each presented with shortness of breath and cough, and with some degree of respiratory distress. Airway compromise was present with tracheal or mediastinal deviation. Each patient underwent tube thoracostomy with improvement in pneumothorax and respiratory status. [West J Emerg Med.]

Introduction: We sought to develop and test a computer-based, interactive simulation of a hypothetical pandemic influenza outbreak. Fidelity was enhanced with integrated video and branching decision trees, built upon the 2007 federal planning assumptions. We conducted a before-and-after study of the simulation effectiveness to assess the simulations’ ability to assess participants’ beliefs regarding their own hospitals’ mass casualty incident preparedness.

Methods: Development: Using a Delphi process, we finalized a simulation that serves up a minimum of over 50 key decisions to 6 role-players on networked laptops in a conference area. The simulation played out an 8-week scenario, beginning with pre-incident decisions. Testing: Role-players and trainees (N=155) were facilitated to make decisions during the pandemic. Because decision responses vary, the simulation plays out differently, and a casualty counter quantifies hypothetical losses. The facilitator reviews and critiques key factors for casualty control, including effective communications, working with external organizations, development of internal policies and procedures, maintaining supplies and services, technical infrastructure support, public relations and training. Pre- and post-survey data were compared on trainees.

Results: Post-simulation trainees indicated a greater likelihood of needing to improve their organization in terms of communications, mass casualty incident planning, public information and training. Participants also recognized which key factors required immediate attention at their own home facilities.

Conclusion: The use of a computer-simulation was effective in providing a facilitated environment for determining the perception of preparedness, evaluating general preparedness concepts and introduced participants to critical decisions involved in handling a regional pandemic influenza surge. [West J Emerg Med. 2013;14(3):236–242.]

Introduction:The purpose of this study was to determine if differences could be detected in the presentation patterns and admission rates among frequent emergency department users (FEDU) of an urban emergency department over a 10-year period.

Methods: This was an IRB approved, retrospective review of all patients who presented to the ED 5 or more times for 3 distinct time periods: “year 0” 11/98-10/99, “year 5” 11/03–10/04, and “year 10” 11/08–10/9. FEDU were grouped into those with 5–9, 10–14, 15–19, and ≥ 20 visits per year. Variables analyzed included number of visits, disposition, and insurance status. We performed comparisons using Kolmogorov-Smirnov and chi-square tests. A P < 0.05 was considered significant.

Results: We found a a 66% increase in FEDU patients over the decade studied, with a significant increase in both the number of FEDU in each visit frequency category over the 3 time periods (P < 0.0001), as well as the total number of visits by each group of FEDU (P < 0.0001). The proportion of FEDU visits for the 5–9 group resulting in admission increased from 25.9% to 29% from year 0 to year 10 (P < 0.001), but not for the other visit groups. In comparing admission rates between FEDU groups, the admission rate for the 5–9 group was significantly higher than the ≥ 20 group for the year 5 time period (P < 0.001) and the year 10 time period (P < 0.001) and showed a similar trend, but not significant, at year 0 (P = 0.052). The overall hospital admission rate for emergency patients over the same time span remained stable at 22-24%. The overall proportion of uninsured FEDU was stable over the decade studied, while the uninsured rate for the overall ED population for the same time periods increased.

Conclusion: The results demonstrate the FEDU population is not a homogeneous group of patients. Increased attention to differences among FEDU groups is necessary in order to plan more effective interventions. [West J Emerg Med. 2013;14(3):243–246.]

The Centers for Disease Control and Prevention (CDC) has published a significant data and trends related to drinking and driving among U.S. high school students. National data from 1991-2011 shows an overall 54% linear decrease (from 22% to 10.3%) in the prevalence of drinking and driving among U.S. high school students aged > 16 years. In 2011, this still represents approximately 950,000 high school students in the age range of 16-19 years. The decrease in drinking and driving among teens is not fully understood, but it is believed to be due to policy developments, enforcement laws, graduated licenses, and economical impacts that have influenced the reduction of alcohol-related fatal crashes among adolescents.^1-5 Most significant to emergency physicians is that even with these restrictions, in 2010, approximately 2,700 teens (ages 16-19) were killed in the United States and about 282,000 were treated and released from EDs for injuries suffered in motor-vehicle accidents.^6,7 In the same year, one in five drivers between the ages of 16-19 were involved in fatal crashes and had positive (>0.00%) blood alcohol concentration (BAC).¹ We present finding from the CDC’s Morbidity and Mortality Weekly Report with commentary on current recommendations and policies for reducing drinking and driving among adolescents. [West J Emerg Med. 2013;14(3):271–274.]

Introduction: To use Colorado’s prescription drug monitoring program (PDMP) to describe the recent opioid prescription history of patients discharged from our emergency department (ED) with a prescription for opioid pain medications.

Methods: Retrospective cohort study of 300 adult ED patients who received an opioid prescription. We abstracted prescription histories for the six months prior to the ED visit from the PDMP, and abstracted clinical and demographic variables from the chart.

Results: There were 5,379 ED visits during the study month, 3,732 of which were discharged. Providers wrote 1,165 prescriptions for opioid analgesics to 1,124/3,732 (30%) of the patients. Median age was 36 years. Thirty-nine percent were male. Patients were 46% Caucasian, 26% African American, 22% Hispanic, 2% Asian and 4% other. These were similar to our overall ED population. There was substantial variability in the number of prescriptions, prescribers and total number of pills. A majority (205/296) of patients had zero or one prescription. The 90th percentile for number of prescriptions was seven, while the 10th percentile was zero. Patients in the highest decile tended to be older, with a higher proportion of Caucasians and females. Patients in the lowest decile resembled the general ED population. The most common diagnoses associated with opioid prescriptions were abdominal pain (11.5%), cold/flu symptoms (9.5%), back pain (5.4%), flank pain (5.0%) and motor vehicle crash (4.7%).

Conclusion: Substantial variability exists in the opioid prescription histories of ED patients, but a majority received zero or one prescription in the preceding six months. The top decile of patients averaged more than two prescriptions per month over the six months prior to ED visit, written by more than 6 different prescribers. There was a trend toward these patients being older, Caucasian and female. [West J Emerg Med. 2013;14(3):247–252.]

Introduction: To determine the prevalence of hunger and food insecurity among patients presenting to the emergency department (ED) over 3 consecutive years.

Methods: This was a cross-sectional study of patients presenting to the ED at Hennepin County Medical Center, and urban, Level I trauma center. We prospectively screened adult (age >18) patients presenting to the ED during randomized daily 8-hour periods between June 1 and August 31, 2007 and 2008, and randomized every-other-day periods between June 1 and August 31, 2009. We excluded patients with high acuity complaints, altered mental status, prisoners, those who did not speak Spanish or English, or those considered to be vulnerable. Consenting participants completed a brief demographic survey. The main outcome measures included age, gender, ethnicity, employment, housing status, insurance, access to food, and having to make choices between buying food and buying medicine. All responses were self reported.

Results: 26,211 patients presented during the study; 15,732 (60%) were eligible, 8,044 (51%) were enrolled, and 7,852 (98%) were included in the analysis. The rate of patients reporting hunger significantly increased over the 3-year period [20.3% in 2007, 27.8% in 2008, and 38.3% in 2009 (P < 0.001)]. The rate of patients reporting ever having to choose between food and medicine also increased [20.0% in 2007, 18.5% in 2008, and 22.6% in 2009 (P = 0.006)].

Conclusion: A significant proportion of our ED patients experience food insecurity and hunger. Hunger and food insecurity have become more prevalent among patients seen in this urban county ED over the past 3 years. Emergency physicians should be aware of the increasing number of patients who must choose between obtaining food and their prescribed medications, and should consider the contribution of hunger and food insecurity to the development of health conditions for which ED treatment is sought. [West J Emerg Med. 2013;14(3):253–262.]

Introduction: Visits to settings such as emergency departments (EDs) may present a “teachable moment” in that a patient may be more open to feedback and suggestions regarding their risky alcohol and illicit drug-use behaviors. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an ’opportunistic’ public health approach that targets low-risk users, in addition to those already dependent on alcohol and/or drugs. SBIRT programs provide patients with comprehensive screening and assessments, and deliver interventions of appropriate intensity to reduce risks related to alcohol and drug use. Methods: This study used a single group pre-post test design to assess the effect of the California SBIRT service program (i.e., CASBIRT) on 6 substance-use outcomes (past-month prevalence and number of days of binge drinking, illegal drug use, and marijuana use). Trained bilingual/bicultural Health Educators attempted to screen all adult patients in 12 EDs/trauma centers (regardless of the reason for the patient’s visit) using a short instrument, and then delivered a brief motivational intervention matched to the patient’s risk level. A total of 2,436 randomly selected patients who screened positive for alcohol and/or drug use consented to be in a 6-month telephone follow-up interview. Because of the high loss to follow-up rate, we used an intention-to-treat approach for the data analysis. Results: Results of generalized linear mixed models showed modest reductions in all 6 drug- and alcohol-use outcomes. Men (versus women), those at relatively higher risk status (versus lower risk), and those with only one substance of misuse (versus both alcohol and illicit drug misuse) tended to show more positive change. Conclusion: These results suggest that SBIRT services provided in acute care settings are associated with modest changes in self-reported recent alcohol and illicit drug use. [West J Emerg Med. 2013;14(3):263–270.]

Introduction: Emergency medicine residents use simulation training for many reasons, such as gaining experience with critically ill patients and becoming familiar with disease processes. Residents frequently criticize simulation training using current high-fidelity mannequins due to the poor quality of physical exam findings present, such as auscultatory findings, as it may lead them down an alternate diagnostic or therapeutic pathway. Recently wireless remote programmed stethoscopes (simulation stethoscopes) have been developed that allow wireless transmission of any sound to a stethoscope receiver, which improves the fidelity of a physical examination and the simulation case. Methods: Following institutional review committee approval, 14 PGY1-3 emergency medicine residents were assessed during 2 simulation-based cases using pre-defined scoring anchors on multiple actions, such as communication skills and treatment decisions (Appendix 1). Each case involved a patient presenting with dyspnea requiring management based off physical examination findings. One case was a patient with exacerbation of heart failure, while the other was a patient with a tension pneumothorax. Each resident was randomized into a case associated with the simulation stethoscope. Following the cases residents were asked to fill out an evaluation questionnaire. Results: Residents perceived the most realistic physical exam findings on those associated with the case using the simulation stethoscope (13/14, 93%). Residents also preferred the simulation stethoscope as an adjunct to the case (13/14, 93%), and they rated the simulation stethoscope case to have significantly more realistic auscultatory findings (4.4/5 vs. 3.0/5 difference of means 1.4, P = 0.0007). Average scores of residents were significantly better in the simulation stethoscope-associated case (2.5/3 vs. 2.3/3 difference of means 0.2, P = 0.04). There was no considerable difference in the total time taken per case.Conclusion: A simulation stethoscope may be a useful adjunct to current emergency medicine simulation-based training. Residents both preferred the use of the simulation stethoscope and perceived physical exam findings to be more realistic, leading to improved fidelity. Potential sources of bias include the small population, narrow scoring range, and the lack of blinding. Further research, focusing on use for resident assessment and clinical significance with a larger population and blinding of graders, is needed. [West J Emerg Med. 2013;14(3):275–277.]

Introduction: In emergency department (ED) patients with upper abdominal pain, management includes ruling out serious diseases and providing symptomatic relief. One of the major causes of upper abdominal pain is an ulcer caused by Helicobacter pylori (H. pylori), which can be treated and cured with antibiotics. We sought to estimate the prevalence of H. pylori infection in symptomatic patients using a convenience sample at a single urban academic ED and demonstrate the feasibility of ED-based testing. Methods: We prospectively enrolled patients with a chief complaint of pain or discomfort in the upper abdomen for 1 year from February 2011 until February 2012 at a single academic urban ED. Enrolled subjects were tested for H. pylori using a rapid point of care 13C Urea Breath Test (UBT) [Exalenz Bioscience]. We compared patient characteristics between those who tested positive versus negative for the disease.Results: A total of 205 patients with upper abdominal pain were tested over 12 months, and 24% (95% confidence interval: 19% to 30%) tested positive for H. pylori.  Black subjects were more likely to test positive than white subjects (28% v. 6%, P < 0.001). Other factors, such as age and sex, were not different between the 2 groups.Conclusion: In our ED, H. pylori infection was present in 1 in 4 patients with epigastric pain, and testing with a UBT was feasible. Further study is needed to determine the risk factors associated with infection, the prevalence of H. pylori in other EDs, the effect of the test on ED length of stay and the cost-effectiveness of an ED-based test-and-treat strategy. [West J Emerg Med. 2013;14(3):278–282.]

Introduction: The Masimo Radical-7 Pulse CO-Oximeter is a medical device recently approved by the US Food and Drug Administration that performs noninvasive oximetry and estimated venous or arterial hemoglobin measurements. A portable, noninvasive device that rapidly measures hemoglobin concentration could be useful in both austere and modern hospital settings. The objective of this study is to determine the degree of variation between the device’s estimated hemoglobin measurement and the actual venous hemoglobin concentration in undifferentiated emergency department (ED) patients.

Methods: We conducted a prospective, observational, cross-sectional study of adult patients presenting to the ED. The subjects consisted of a convenience sample of adult ED patients who required a complete blood count as part of their care in the ED. A simultaneous probe hemoglobin was obtained and recorded.

Results: Bias between probe and laboratory hemoglobin measurements was _0.5 (95% confidence interval,_0.8 to_0.1) but this was not statistically significant from 0 (t 0.05,124¼0.20, P . 0.5). The limits of agreement were _4.7 and 3.8, beyond the clinically relevant standard of equivalency of 6 1 g/dL.

Conclusion: These data suggest that noninvasive hemoglobin determination is not sufficiently accurate for emergency department use. [West J Emerg Med. 2013;14(3):283–286.]

Introduction: Emergency department (ED) studies often require follow-up with subjects to assess outcomes and adverse events. Our objective was to identify baseline subject characteristics associated with successful contact at 3 time points after the index ED visit within a sample of cigarette smokers.

Methods: This study is a secondary analysis of a prospective cohort. We recruited current adult smokers at 10 U.S. EDs and collected baseline demographics, smoking profile, substance abuse, health conditions, and contact information. Site investigators attempted contact at 2 weeks, 3 months, and 6 months to assess smoking prevalence and quit attempts. Subjects were paid $20 for successful follow-up at each time point. We analyzed data using logistic and Poisson regressions.

Results: Of 375 recruited subjects, 270 (72%) were contacted at 2 weeks, 245 (65%) at 3 months, and 217 (58%) at 6 months. Overall, 175 (47%) were contacted at 3 of 3, 71 (19%) at 2 of 3, 62 (17%) at 1 of 3, and 66 (18%) at 0 of 3 time points. At 6 months, predictors of successful contact were: older age (adjusted odds ratio [AOR] 1.2 [95%CI, 0.99–1.5] per ↑10 years); female sex (AOR 1.7 [95%CI, 1.04–2.8]); non-Hispanic black (AOR 2.3 [95%CI, 1.2–4.5]) vs Hispanic; private insurance (AOR 2.0 [95%CI, 1.03–3.8]) and Medicare (AOR 5.7 [95%CI, 1.5–22]) vs no insurance; and no recreational drug use (AOR 3.2 [95%CI; 1.6–6.3]). The characteristics independently predictive of the total number of successful contacts were: age (incidence rate ratio [IRR] 1.06 [95%CI, 1.00–1.13] per ↑10 years); female sex (IRR 1.18 [95%CI, 1.01–1.40]); and no recreational drug use (IRR 1.37 [95%CI, 1.07–1.74]). Variables related to smoking cessation (e.g., cigarette packs-years, readiness to quit smoking) and amount of contact information provided were not associated with successful contact.

Conclusions: Successful contact 2 weeks after the ED visit was 72% but decreased to 58% by 6 months, despite modest financial incentives. Older, female, and non-drug abusing participants were the most likely to be contacted. Strategies to optimize longitudinal follow-up rates, with limited sacrifice of generalizability, remain an important challenge for ED-based research. This is particularly true for studies on substance abusers and other difficult-to-reach populations. [West J Emerg Med. 2013;14(3):287–295.]

Introduction: Very few studies exist on the use of diltiazem in the prehospital setting. Some practitioners believe this medication is prone to causing hypotension in this setting. Our goals were to determine whether the prehospital administration of diltiazem induced hypotension and to evaluate the efficacy of the drug.

Methods: Our two-tiered system is located in a suburban region of New Jersey with advanced life support (ALS) care provided by fly-car units. The ALS units do not transport patients, and all of them are hospital based. The ALS providers are employed by the hospital system. In New Jersey, all ALS care requires online medical control, including the administration of diltiazem. We retrospectively reviewed patient care records for those who were believed to be in rapid atrial fibrillation and were given diltiazem in a suburban emergeny medical services system over a 22-month period. We examined the differences between heart rate (HR) and blood pressure (BP) on the initial evaluation and on arrival to the emergency department (ED). A hypotensive response was defined as a final systolic BP (SBP) less than 90 mmHg and a drop in SBP of at least 10 mmHg. Diltiazem was considered effective if the ED HR was ,100 beats per minute (bpm) or if it decreased [1]20%.

Results: During the study period, 26,979 patients were transported. Of these patients, 2,488 had a documented rhythm of atrial fibrillation or atrial flutter. Of the 320 patients who received diltiazem, 42 patient encounters were excluded for incomplete data, yielding 278 patients for analysis. The average initial SBP was 139 mmHg and the average diastolic BP was 84 mmHg. The average diltiazem dosage was 16.7 mg. Two patients became hypotensive. The average initial HR was 154 bpm. On arrival to the ED, 33% of the patients had an HR , 100 bpm and 69% had a drop in HR [1] 20%. The overall efficacy of prehospital diltiazem was 73%.

Conclusion: In the prehospital setting, diltiazem is associated with a very low rate of hypotension and appears to be effective in decreasing HR adequately. Prospective studies are needed to confirm these findings. [West J Emerg Med. 2013;14(3):296–300.]

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