bluuebunny/crossref_metadata_2025 huggingface dataset:
Resuscitation Research: Future Directions and Ethical Issues
Authors: Marco Catherine A.
Published: January 2008

Cardiopulmonary resuscitation research is a vital area of research that has made significant contributions to medical care over the last several decades. Abundant information currently exists in the medical literature, as a result of research in the areas of cardiac arrest and outcomes, physiology of cardiac arrest, pharmacologic treatments, mechanical interventions, and societal and ethical issues. Despite numerous clinical trials demonstrating physiologic benefit of various interventions, few interventions have had as much impact on outcomes of cardiac arrest as have improvements in out‐of‐hospital response times and rapid availability of medical treatment. Although abundant information exists regarding physiologic aspects of resuscitation, relatively little information exists about ethical, psychological, and social aspects of resuscitation. In addition to attempts to improve outcomes of cardiac arrest, researchers should also strive to improve the experiences of patients and families involved. These realities provide future strategies and directions for the best use of resuscitation research resources; although physiologic and pharmacologic research will always have significant roles in the improvement of medical care, the rapid delivery of out‐of‐hospital care and ethical issues will be indispensable areas of research focus in the future.
Use, Understanding, and Beliefs about Complementary and Alternative Medicines among Emergency Department Patients
Authors: Weiss Steven J. , Takakuwa Kevin M. , Ernst Amy A.
Published: January 2008

Abstract. Objectives: To describe the extent of complementary and alternative medicine (CAM) use among emergency department (ED) patients, to evaluate patients' understanding of CAMs, and to determine gender differences in beliefs about CAMs. Methods: This study was a convenience sampling of patients seen in an urban ED. Patient demographics were recorded. A questionnaire was administered that assessed patients' knowledge and use of CAMs. Patients were also asked about their beliefs on safety, medication interactions, and conveying information about these substances to their physicians. Results: A total of 350 ED patients were included in the study; 87% had heard of at least one of the CAMs. There was no difference between genders or races concerning knowledge about CAMs. The most commonly known CAMs were ginseng (75%), ginkgo biloba (55%), eucalyptus (58%), and St. John's wort (57%). Forty‐three percent of the responders had used CAMs at some time and 24% were presently using CAMs. The most commonly used CAMs were ginseng (13%), St. John's wort (6%), and ginkgo biloba (9%). All CAMs were considered to be safe by 16% of the patients. Only 67% would tell their doctors they were using CAMs. Females were more likely than males to believe that CAMs do not interact with other medications (15% vs 7%, difference 8%, 95% CI = 2% to 15%). Conclusions: Complementary and alternative medicines are familiar to most patients and used by many of them. Despite this, a large percentage of patients would not tell their physicians about their use of alternative medications. Emergency medicine providers should be aware of the commonly used CAMs, and questions about their use should be routinely included in ED exams.
Predicting Patient Visits to an Urgent Care Clinic Using Calendar Variables
Authors: Batal Holly , Tench Jeff , McMillan Sean , Adams Jill , Mehler Phillip S.
Published: January 2008

Abstract. Objective: To develop a prediction equation for the number of patients seeking urgent care. Methods: In the first phase, daily patient volume from February 1998 to January 1999 was matched with calendar and weather variables, and stepwise linear regression analysis was performed. This model was used to match staffing to patient volume. The effects were measured through patient complaint and “left without being seen” rates. The second phase was undertaken to develop a model to account for the continual yearly increase in patient volume. For this phase daily patient volume from February 1998 to April 2000 was used; the patient volume from May 2000 to July 2000 was used as a validation set. Results: First‐phase prediction equation was: daily patient volume = 66.2 + 11.1 January + 4.56 winter + 47.2 Monday + 37.3 Tuesday + 35.6 Wednesday + 28.2 Thursday + 24.2 Friday + 7.96 Saturday + 10.1 day after a holiday. This equation accounted for 75.2% of daily patient volume (p < 0.01). Inclusion of significant weather variables only minimally improved the predictive ability (r2= 0.786). The second‐phase final model was: daily patient volume = 57.2 + 0.035 Newdate + 52.0 Monday + 44.2 Tuesday + 39.2 Wednesday + 30.2 Thursday + 26.5 Friday + 10.9 Saturday + 12.2 February + 3.9 March, which accounted for 72.7% of the daily variation (p < 0.01). The model predicted the patient volume in the validation set within ±11%. When the first‐phase model was used to predict patient volume and thus staffing, the percentage of patients who left without being seen decreased by 18.5% and the number of patient complaints dropped by 30%. Conclusions: Use of a prediction equation allowed for improved accuracy in staffing patterns with associated improvement in measures of patient satisfaction.
Cost‐Benefit Analysis of Social Work Services in the Emergency Department: A Conceptual Model
Authors: Gordon James A.
Published: January 2008

Abstract. Objective: To describe an economic model for formal cost‐benefit analysis of emergency department (ED)‐based social services. Methods: The varied monetary costs and benefits associated with ED‐based social work services were projected for three hypothetical levels of ED volume (30,000, 60,000, and 90,000 patients/year). Primary benefits included the prevention of return ED visits, the prevention of “social” hospital admissions, and the protection of doctor and nurse time. The primary cost was salary support for full‐time social work staffing. Sensitivity analysis was performed to account for varying estimates. Results: For a small‐volume ED, total benefits to offset costs ranged from $43,869 to $81,504, yielding a net cost of $99,936 up to $137,571 for full‐time social work coverage. For a moderate‐size ED, total benefits ranged from $87,660 to $162,930, yielding a net cost of only $18,510 on the high end of the sensitivity analysis, and $87,668 on the low end. For a large‐volume ED, total benefits ranged from $131,529 to $247,434, yielding a net cost of $49,911 on the low end of the sensitivity analysis, but a net benefit of $65,994 on the high end. Conclusions: Dedicated social work staffing of EDs may yield net economic benefits, especially in large urban centers. Moderate‐size EDs may almost “break even” in economic terms, and small EDs may realize a net cost, but in either case, the cost of social services can be significantly offset by decreased utilization of hospital and ED services, and by more efficient use of medical staff time.
Anti—Interleukin‐6 Antibodies Attenuate Inflammation in a Rat Meningitis Model
Authors: Marby David , Lockhart Gregory R. , Raymond Richard , Linakis James G.
Published: January 2008

Objectives: Interleukin‐6 (IL‐6) is elevated in the cerebrospinal fluid (CSF) of humans and animals with bacterial meningitis. This study's hypothesis was that anti‐IL‐6 antibodies will attenuate meningeal inflammation in a rat model of bacterial meningitis. Methods: 14 male Sprague‐Dawley rats were inoculated intracisternally (IC) with 0.1 mL of heat‐killed pneumococci. At one hour post‐inoculation, the rats received intraperitoneal doses of either 1.0 mL phosphate‐buffered saline (PBS treatment group, n? 7) or 70 μg anti‐IL‐6 antibodies in 1.0 mL PBS (anti‐IL‐6 antibody treatment group, n? 7). Nine rats (normal group, n? 9) had no inoculation, and four rats (surgical sham group, n? 4) had IC inoculations of saline. At six hours post‐inoculation, all the animals had CSF removed via IC tap. The CSF protein and white blood cell (WBC) count measures were compared using a t‐test. Results: Mean CSF WBC for the anti‐IL‐6 treatment group was 2,458/μL, versus the PBS controls' mean of 9,697/μL (p ? 0.007). Mean CSF protein for the anti‐IL‐6 group was 180 mg/dL, versus 296 mg/dL for the controls (p ? 0.032). The surgical sham and normal animals had normal CSF WBC and protein values. Conclusions: In this rat meningitis model, systemic treatment with anti‐IL‐6 antibodies after the induction of meningitis suppressed both CSF WBC count and CSF protein level, two important indices of meningeal inflammation.
Potassium Repletion Fails to Interfere with Reduction of Serum Lithium by Sodium Polystyrene Sulfonate in Mice
Authors: Linakis James G. , Savitt Daniel L. , Trainor Brian J. , Young James E. , Lacouture Peter G.
Published: January 2008

Objectives: Previous studies have shown that oral sodium polystyrene sulfonate (SPS) lowers serum lithium concentrations after acute and chronic toxic lithium exposures. Because hypokalemia may represent a deterrent to the clinical use of SPS for lithium intoxication, this study was designed to determine whether potassium (K+) repletion interferes with the effect of SPS on serum lithium. Methods: 168 male, CD‐1 mice were given lithium chloride (LiCl) (250 mg/kg) by gavage at time 0. Half of the mice were then given SPS (5 g/kg/dose) and half an equivalent volume of water by gavage at times 20 and 40 minutes. Half of each of these subgroups was then given potassium chloride (KCl) (3 mmol/kg) intraperitoneally and half an equivalent volume of normal saline. The animals were then sacrificed at one, two, four, and eight hours after lithium administration and the sera were analyzed for lithium and K+ by atomic absorption spectrophotometry. The groups were compared with analysis of variance. Results: The SPS lowered both lithium and K+ concentrations (ps ≤ 0.0001). The KCl treatment was associated with transiently increased K+ concentrations (p < 0.0001) and with mildly elevated lithium concentrations when compared with the results of the animals not treated with KCl (p ? 0.0016). The KCl treatment‐associated increase in lithium concentration occurred both in the animals treated with water and in those treated with SPS. Conclusions: Potassium repletion did not interfere with the ability of SPS to lower serum lithium concentration in animals experimentally poisoned with lithium.
Hyperammonemia and Coma without Hepatic Dysfunction Induced by Valproate Therapy
Authors: Barrueto Fermin , Hack Jason B.
Published: January 2008

The authors report a case of a 41‐year‐old mentally disabled man with bipolar disorder who presented to the emergency department with altered mental status. He was found to have a significantly elevated ammonia level (377 μM/L) with no signs of hepatic insufficiency. His coma and hyperammonemia were attributed to his chronic valproate therapy. This patient had the highest serum ammonia level ever reported with a therapeutic valproate level in the absence of any other anticonvulsant therapy, metabolic abnormality, or hepatic dysfunction. The authors discuss this case and review the current literature on hyperammonemia in valproic acid therapy and the use of L‐carnitine in these patients.
Different Management Options for Anaphylactoid Purpura with Intussusception A Case Report
Authors: Li Wen‐Chieh , Ko Sheung‐Fat , Kuo Hsin‐Wei , Huang Song‐Chie , Liang Chi‐Di , Tiao Mao‐Meng
Published: January 2008

Intussusception is the most common surgical indication of anaphylactoid purpura. About 50% of cases are of the ileo‐ileal type. Surgical intervention, rather than radiologic reduction, is preferable for older children suffering from anaphylactoid purpura with intussusception, where a lead point lesion is often found. The authors report a case of anaphylactoid purpura with intussusception with spontaneous reduction, and postulate that subsequent to relieving bowel‐wall edema using antihistamine and steroid therapy, the ileo‐ileal intussusception may spontaneously reduce.
Emergency Department Overcrowding Following Systematic Hospital Restructuring Trends at Twenty Hospitals over Ten Years
Authors: Schull Michael J. , Szalai John‐Paul , Schwartz Brian , Redelmeier Donald A.
Published: January 2008

Objective: Hospital restructuring often results in fewer inpatient beds, increased ambulatory services, and closures of hospitals or emergency departments (EDs). The authors sought to determine the impact of systematic hospital restructuring on ED overcrowding. Methods: Time series analyses of average monthly overcrowding for EDs in Toronto, Ontario, Canada, from 1991 and 2000 (n ? 20 hospitals, 120 months) were conducted. Autoregression models evaluated the rate of increase of overcrowding before and during systematic restructuring. A secondary analysis included total ED visits, patient age, and sex distribution as covariates. Seasonality was assessed by means of spectral analysis. Results: Severe and moderate overcrowding averaged 3% and 14% of the time each month, respectively, over the whole period. Before restructuring (n ? 74 months), severe and moderate overcrowding averaged 0.5% and 9% per month, respectively; during restructuring (n ? 46 months), the monthly averages were 6% and 23%, respectively. Neither severe nor moderate overcrowding was increasing before restructuring. During restructuring, however, both increased significantly (severe 0.2% per month [p < 0.0001]; moderate 0.5% per month [p < 0.0001]). Similar results were found after controlling for ED utilization. Female gender independently predicted increased overcrowding; older age predicted reduced moderate overcrowding; number of total visits was not a predictor. Spectral analysis revealed significant seasonality in overcrowding. Conclusions: Hospital restructuring was associated with increased ED overcrowding, even after controlling for utilization and patient demographics. Restructuring should proceed slowly to allow time for monitoring of its effects and modification of the process, because the impact of incremental reductions in hospital resources may be magnified as maximum operating capacity is approached.
When the Safety Net Is Unsafe Real‐time Assessment of the Overcrowded Emergency Department
Authors: Reeder Timothy J. , Garrison Herbert G.
Published: January 2008

Although much work has been done evaluating causes for increased demand for emergency department (ED) services, few ways are available to help determine that an individual ED is overcrowded. Four calculations are proposed using real‐time data for accurately diagnosing an ED with potential for failing both as a safety net and as a source for quality health care. The bed ratio (BR) accounts for the number of patients in relation to the available treatment spaces. The BR is obtained by adding the current number of ED patients to the predicted arrivals minus the predicted departures and dividing the result by the total number of treatment spaces. The acuity ratio (AR) measures the relative burden of illness in the ED. The AR is the average triage category of all patients in the ED. The provider ratio (PR) determines the volume of patients that can be evaluated and treated by the physician providers. The PR is found by dividing the arrivals per hour by the sum of the average patients per hour usually disposed for each provider on duty. From these ratios, the demand value (DV) is calculated, which gives an overall measure of current demand. The DV is found by taking the sum of the BR and PR and multiplying by the AR. A DV of more than 7 should initiate a specific assessment of the individual ratios in order to accurately diagnose the problem and institute action. Based on the values, predetermined processes can be instituted to help remedy the overcrowded situation. Trended over time, the ratios can provide the data needed for better resource assessment, planning, and allocation.
Threats to the Health Care Safety Net
Authors: Taylor Todd B.
Published: January 2008

The American health care safety net is threatened due to inadequate funding in the face of increasing demand for services by virtually every segment of our society. The safety net is vital to public safety because it is the sole provider for first‐line emergency care, as well as for routine health care of last resort, through hospital emergency departments (ED), emergency medical services providers (EMS), and public/free clinics. Despite the perceived complexity, the causes and solutions for the current crisis reside in simple economics. During the last two decades health care funding has radically changed, yet the fundamental infrastructure of the safety net has change little. In 1986, the Emergency Medical Treatment and Active Labor Act established federally mandated safety net care that inadvertently encouraged reliance on hospital EDs as the principal safety net resource. At the same time, decreasing health care funding from both private and public sources resulted in declining availability of services necessary to support this shift in demand, including hospital inpatient beds, EDs, EMS providers, on‐call specialists, hospital‐based nurses, and public hospitals/clinics. The result has been ED/hospital crowding and resource shortages that at times limit the ability to provide even true emergency care and threaten the ability of the traditional safety net to protect public health and safety. This paper explores the composition of the American health care safety net, the root causes for its disintegration, and offers short‐ and long‐term solutions. The solutions discussed include restructuring of disproportionate share funding; presumed (deemed) eligibility for Medicaid eligibility; restructuring of funding for emergency care; health care for foreign nationals; the nursing shortage; utilization of a “health care resources commission”; “episodic (periodic)” health care coverage; best practices and health care services coordination; and government and hospital providers' roles. Conclusions: There is a base amount of funding that must be available to the American health care safety net to maintain its infrastructure and provide appropriate growth, research, development, and expansion of services. Fall below this level and the infrastructure will eventually crumble. America must patch the safety net with short‐term funding and repair it with long‐term health care policy and environmental changes.
Incidence of Pericardial Effusion in Patients Presenting to the Emergency Department with Unexplained Dyspnea
Authors: Blaivas Michael
Published: January 2008

Objective: To evaluate the frequency of pericardial effusion in patients presenting to the emergency department (ED) with unexplained, newonset dyspnea. Methods: This prospective observational study took place at an urban community hospital ED with a residency program and an annual census of 65,000 visits. Patients presenting between May 1999 and January 2000 with new‐onset dyspnea were eligible if they lacked any pulmonary, infectious, hematological, traumatic, psychiatric, cardiovascular, or neuromuscular explanation for their dyspnea after ED evaluation. Patients received a focused echocardiogram by certified emergency physicians. Data were recorded on standardized data sheets and studies were taped for review. Effusions were categorized as small when the fluid stripe measured less than 10 mm. Moderate‐sized effusions measured 10 to 15 mm. Large effusions measured more than 15 mm.

Results: One hundred three patients were enrolled. Median age was 56 years (IQR 44, 95% CI = 32 to 67). Fourteen patients (13.6%, 95% CI = 8% to 23%) had effusions. Four had large effusions that explained their dyspnea and were admitted to cardiology; two of these effusions were hemorrhagic, and two were viral in origin. Seven patients with small effusions were treated conservatively at home. Three patients had moderate‐sized effusions; all were admitted but treated conservatively.

Conclusions: While limited by small numbers, these preliminary data suggest that patients with unexplained dyspnea should be checked for pericardial effusion when bedside ED ultrasound is available.
Emergency Medicine Resident Patient Care Documentation Using a Hand‐held Computerized Device
Authors: Bird Steven B. , Zarum Robert S. , Renzi Francis P.
Published: January 2008

Objective: To determine whether emergency medicine (EM) resident documentation of procedures, patient encounters, and patient follow‐ups improved after implementation of a personal digital assistant (PDA) hand‐held recording system.

Methods: All first‐year EM residents were provided a PalmV (Palm, Inc., Santa Clara, CA) PDA. A customized patient procedure and encounter program was constructed using Pendragon Forms (Pendragon Software Corporation, Libertyville, IL) and loaded into each PDA. Residents were instructed to enter information on patients who had any of 21 procedures performed or were considered to be clinically unstable. These data were downloaded to the residency coordinator's desktop computer. The mean number of procedures, encounters, and follow‐ups performed per resident were then compared with those of a group of 36 historical controls from the three previous first‐year resident classes who recorded the same information using a handwritten card system. Data from the historical controls were combined and the means of each group were compared by Student's t‐test.

Results: Mean documentation of three procedures was significantly increased in the PDA group versus the index card system: conscious sedation 5.8 vs. 0.03 (p < 0.000005), thoracentesis 2.2 vs. 0.0 (p = 0.002), ultrasound 6.3 vs. 0.0 (p = 0.002). The mean numbers of pericardiocenteses and unstable pediatric surgical patient evaluations were significantly decreased in the hand‐held group [from 1.2 to 0.4 (p = 0.03) and from 9.1 to 2.2 (p = 0.02), respectively]. Patient follow‐up documentations were not statistically different between the two groups.

Conclusions: Use of a hand‐held PDA was associated with an increase in first‐year EM resident documentation in three of 20 procedures and a decrease in one procedure and the number of unstable surgical pediatric patient resuscitations. The overall time savings in constructing a resident procedure database, as well as the other uses of the PDAs, may make transition to a hand‐held computer‐based procedure log an attractive option for EM residencies.
Utility of an Initial D‐dimer Assay in Screening for Traumatic or Spontaneous Intracranial Hemorrhage
Authors: Hoffmann Mark E. , Ma O. John , Gaddis Gary
Published: January 2008

Objective: To evaluate the sensitivity of a D‐dimer assay as a screening tool for possible traumatic or spontaneous intracranial hemorrhage. If adequately sensitive, the D‐dimer assay may potentially permit omission of a more expensive computed tomography (CT) scan of the head when such hemorrhage is clinically suspected. Methods: Prospective, consecutive, blinded study of patients (age > 16 years) requiring a CT scan of the head for suspected intracranial hemorrhage over a five‐month period at a university, Level I trauma center. All study patients had a serum D‐dimer assay obtained prior to their CT scans. Sensitivity and specificity, with 95% confidence intervals (95% CIs), of the enzyme‐linked immunosorbent assay (ELISA) D‐dimer assay for the detection of intracranial hemorrhage were calculated. Results: Of the 319 patients entered in the study, 25 (7.8%) had a CT scan positive for intracranial hemorrhage. Patients with intracranial hemorrhage were more likely to have a positive D‐dimer assay (chi‐square ? 13.075, p < 0.001). The D‐dimer assay had 21 true‐positive and four false‐negative tests, resulting in a sensitivity of 84.0% (95% CI ? 63.7% to 95.5%) and a specificity of 55.8% (95% CI ? 55.5% to 55.9%). The four false‐negative cases included one small intraparenchymal hemorrhage, one small subarachnoid hemorrhage, one moderate‐sized intraparenchymal hemorrhage with mid‐line shift, and one large subdural hematoma requiring emergent surgery. Conclusions: Due to the catastrophic nature of missing an intracranial hemorrhage in the emergency department, the D‐dimer assay is not adequately sensitive or predictive to use as a screening tool to allow routine omission of head CT scanning.
Epidemiology of Thoracolumbar Spine Injury in Blunt Trauma
Authors: Holmes James F. , Miller Paul Q. , Panacek Edward A. , Lin Steven , Horne Nathanael S. , Mower William R.
Published: January 2008

Objective: To evaluate the prevalence, distribution, and demographics of thoracolumbar (TL) spine injuries following blunt trauma. Methods: Prospective, cross‐sectional study of a consecutive sample of all blunt trauma patients presenting initially to the emergency department (ED) of a Level 1 trauma center and undergoing thoracic and/or lumbar spine radiography from August 1997 to November 1998. The age, sex, and mechanism of injury of each patient as well as location and type of spine injury were recorded for those patients with vertebral fractures, dislocations, or subluxations. Results: Two thousand four hundred four blunt trauma patients were enrolled. Vertebral injuries were identified in 152 individuals (6.3%, 95% CI ? 5.4% to 7.4%). Two hundred sixty distinct anatomic levels of injury were identified in these 152 individuals. Of these 260 injuries, 42 (16.2%) occurred at L1, 38 (14.6%) at L2, 29 (11.1%) at L3, and 27 (10.4%) at T12, making these the most commonly injured vertebrae. Injuries were most common (34 patients) in those aged 30‐39 years and were least common (12 patients) in those under 18 years. Compression fractures (52%) were the most common injury in the thoracic spine, while transverse process fractures (48%) were the most common injuries in the lumbar spine. Conclusions: The prevalence of TL injuries in ED blunt trauma patients undergoing TL radiographs is 6.3%. The most commonly injured area of the TL spine is the thoracolumbar junction.
The Impact of Changes in HCFA Documentation Requirements on Academic Emergency Medicine Results of a Physician Survey
Authors: McLean Samuel A. , Feldman James A.
Published: January 2008

Background: The Health Care Financing Administration (HCFA) has dramatically increased documentation and procedural supervision required by faculty in academic emergency departments (EDs). Objectives: To determine academic emergency medicine (EM) physicians' perceptions of the impact of HCFA documentation requirements (HDR) on teaching time, clinical efficiency, and job satisfaction. Methods: An observational cross‐sectional study was done using a survey of New England academic EM faculty from September to December 1999. E‐mail surveys were followed by hard copy to nonresponders. Teaching time, clinical efficiency, and job satisfaction were rated on a five‐point Likert scale. Yes/no questions about other possible benefits of HCFA regulations were asked. Frequency (95% CI) and chi‐square analyses were performed. Results: One hundred seventy‐four of 233 (75%) responded. Eighty‐nine percent (95% CI ? 84% to 93%) of the respondents thought teaching time was somewhat or markedly decreased by changes in HDR (somewhat 46%, markedly 43%). Seventy‐nine percent (95% CI ? 73% to 85%) believed clinical efficiency was somewhat or markedly decreased by changes in HDR (somewhat 49%, markedly 30%). Eighty percent (95% CI ? 73% to 86%) reported somewhat or markedly decreased job satisfaction due to changes in HDR (somewhat 56%, markedly 24%). Twenty‐one percent (95% CI ? 15% to 27%) believed changes in HDR had improved patient care by requiring increased patient supervision. Forty‐eight percent (95% CI ? 40% to 56%) thought that changes in documentation requirements had decreased medicolegal risk by improving patient documentation. Conclusions: Most academic EM physicians in New England perceive that HDR have decreased clinical efficiency, teaching time, and job satisfaction. These findings suggest that changes in HDR may have a substantial impact on many different aspects of emergency care provided in academic settings.
Using Conjoint Analysis to Assess Patients' Preferences When Visiting Emergency Departments in Hong Kong
Authors: Leung Gabriel M. , Chan Sarah S. C. , Chau Patsy Y. K. , Chua Shui Ching
Published: January 2008

Objectives: To explore factors related to emergency department (ED) attendances in Hong Kong, the authors piloted the application of conjoint analysis in eliciting patient preferences regarding ED visits. Methods: The study recruited 390 semi‐urgent or non‐urgent patients from a targeted convenience sample of three large EDs. Respondents were asked to rank eight scenarios structured to explore the relative importances of three key attributes—self‐perceived illness severity, waiting time, and consultation fee—that may result in an ED visit. Results: Seventy‐eight percent of the respondents would consider visiting a parallel clinic instead of the ED for semiurgent and non‐urgent conditions. The relative importances attached to illness severity, waiting time, and consultation fee were 47.8%, 33.6%, and 18.7%, respectively. Conclusions: This study demonstrated that Hong Kong patients are receptive to the concept of parallel clinics, and illustrated that conjoint analysis is a rigorous survey technique for eliciting the views of patients on health care services in the ED setting.
Bench to Bedside Resuscitation from Prolonged Ventricular Fibrillation
Authors: Angelos Mark G. , Menegazzi James J. , Callaway Clifton W.
Published: January 2008

Ventricular fibrillation (VF) remains the most common cardiac arrest heart rhythm. Defibrillation is the primary treatment and is very effective if delivered early within a few minutes of onset of VF. However, successful treatment of VF becomes increasingly more difficult when the duration of VF exceeds 4 minutes. Classically, successful cardiac arrest resuscitation has been thought of as simply achieving restoration of spontaneous circulation (ROSC). However, this traditional approach fails to consider the high early post—cardiac arrest mortality and morbidity and ignores the reperfusion injuries, which are manifest in the heart and brain. More recently, resuscitation from cardiac arrest has been divided into two phases; phase I, achieving ROSC, and phase II, treatment of reperfusion injury. The focus in both phases of resuscitation remains the heart and brain, as prolonged VF remains primarily a two‐organ disease. These two organs are most sensitive to oxygen and substrate deprivation and account for the vast majority of early post‐resuscitation mortality and morbidity. This review focuses first on the initial resuscitation (achieving ROSC) and then on the reperfusion issues affecting the heart and brain.
Preventive Care in the Emergency Department A Systematic Literature Review on Emergency Department‐based Interventions that Address Smoke Detectors in the Home
Authors: Cortes Leslie Maas , Hargarten Stephen W.
Published: January 2008

Objectives: To assess the effectiveness of an emergency department (ED)‐based strategy to identify and counsel selected patients about the importance of an operational smoke detector in the home and to offer a graded recommendation regarding such a strategy. Methods: A systematic review was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. Two Medline combined searches were performed using the following terms: emergency medical services and counseling, protective devices and smoke detectors, accidents, home, burns, fires, and residential fires. A free‐text search of indexed and nonindexed citations in Emergency Medical Abstracts from 1977 to 1999 and a search of the Cochrane Library were also performed. In addition, reviewers performed independent Medline searches and suggested four additional studies. Studies selected for inclusion in this systematic review were required to meet the following criteria: 1) report ED‐based research and 2) address the topic of fire and burn prevention with some pertinent discussion of ED‐based interventions. The initial inclusion criteria had restricted studies to those that reported the results of counseling strategies for smoke detectors. The authors later decided to consider, as indirectly relevant, studies that did not investigate counseling strategies. Data from the selected studies were extracted using the template form, and the validity and applicability of the results to emergency practice were assessed. Recommendations were derived following criteria developed by a systematic review of preventive interventions in the ED. Results: Six articles were closely reviewed. Four of the six studies met the inclusion criteria. One other study that did not meet the inclusion criteria was also considered. No study focused specifically on the counseling of ED patients about smoke detectors. Conclusions: Following the criteria of the graded recommendations used for the parent project. a recommendation cannot be made either for or against an ED‐based strategy to counsel patients on the importance of smoke detectors. No studies located in our review directly assessed the effectiveness of such a strategy. Based on the retrospective case series study of the potential opportunity for a home fire safety intervention during an emergency medical services visit and the Safe Block Project study, it may be worthwhile to consider further research on the effectiveness of systems‐level/structural interventions, with a targeted focus on strategies that attempt to overcome barriers associated with active interventions.
Triage Nurse Application of the Ottawa Knee Rule
Authors: Szucs Paul A. , Richman Peter B. , Mandell Mark
Published: January 2008

Abstract. Objective: To determine interobserver agreement between triage registered nurses (RNs) and emergency physicians (EPs) regarding indication for knee radiographs by applying the Ottawa knee rule (OKR) and individual components of the rule. Methods: This was a prospective, observational study in a suburban, teaching emergency department. The study enrolled a convenience sample of patients aged >17 years with traumatic knee injuries less than one week old. Patients with prior knee surgery or distracting conditions were excluded. Before study initiation, the RNs and EPs were in‐serviced in the OKR. Nurses and EPs independently examined each patient for OKR criteria, blinded to the other's assessment. Knee radiographs were ordered at the discretion of the EP and were interpreted by board‐certified radiologists. All patients received follow‐up with a structured telephone interview to identify any undetected fractures. Kappa was calculated for each component and the overall application of the OKR to assess interobserver agreement. Results: Ninety‐six patients were enrolled. The mean age was 39.6 ± 18.7 years; 50% were male. Eight patients (8%) had knee fractures. Interobserver agreements between the RNs and EPs for individual components of the OKR were: age ≥55 years (κ= 0.97); inability to weight bear (κ= 0.51); inability to bend knee to 90 degrees (κ= 0.52); fibular head tenderness (κ= 0.45); and isolated patellar tenderness (κ= 0.40). The EPs and RNs agreed with OKR criteria for x‐ray 71% of the time (κ= 0.41). Conclusions: The only criterion that resulted in almost perfect agreement between the RNs and EPs was patient age; agreement for the other four criteria and the overall decision to order x‐rays was moderate.
Meta‐analysis of the Risk of Torsades de Pointes in Patients Treated with Intravenous Racemic Sotalol
Authors: Marill Keith A. , Runge Tim
Published: January 2008

Abstract. Objective: Intravenous (IV) racemic sotalol is useful for the treatment of multiple tachydysrhythmias. The authors hypothesized that the risk of torsades de pointes (TdP) in patients treated with a single IV infusion of sotalol is lower than the 2‐4% risk associated with chronic oral sotalol therapy. Methods: A MEDLINE search under the subject heading “sotalol” was made of all publications involving humans written in English or German from 1966 to October 1, 2000. A meta‐analysis of all original reports including patients who were given a single infusion of at least 1.5 mg/kg or 100 mg of IV sotalol over 30 minutes or less was performed. Potential variables predictive of TdP were assessed. The primary outcome was the observation of TdP associated with IV sotalol infusion. Secondary measurements included hypotension, bradycardia, and worsening of congestive heart failure. All excluded studies and case reports were also examined for evidence of TdP associated with IV sotalol treatment. Results: The search included 1,005 publications. There were 37 reports in which 962 patients received IV sotalol and met the inclusion criteria. There was one report of self‐terminating TdP lasting 10 seconds among the 962 patients included in the study. There was no report of TdP associated with only IV racemic sotalol administration in any of the excluded studies. If it is assumed that the risk of TdP is homogeneous in the population of patients treated with IV sotalol, then based on the 962 included patients, the rate of TdP is 0.1% (95% CI = 0.003% to 0.6%). Conclusions: The overall risk of TdP in patients treated with a single infusion of IV sotalol is low compared with that in patients given chronic oral sotalol therapy.
Selected Tricyclic Antidepressant Ingestions Involving Children 6 Years Old or Less
Authors: McFee Robin B. , Caraccio Thomas R. , Mofenson Howard C.
Published: January 2008

Abstract. Objective: According to the annual report of the American Association of Poison Control Centers, tricyclic antidepressant (TCA) ingestions accounted for 15,708 exposures in 1998, of which 70% (all age groups) were treated at health care facilities (HCFs), with an estimated 2,022 children less than 6 years of age exposed. The study objective was to evaluate the manifestations, referral patterns, HCF management, and medical outcomes in pediatric patients 6 years old or less with TCA ingestions reported to a regional poison control center. Methods: All TCA (amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline) ingestions from January 1, 1993, to December 31, 1997, involving patients aged 6 years or less managed by the poison control center were evaluated for dose, symptoms, treatments, disposition, and outcome. Results: Forty‐four of 48 patients (92%) were asymptomatic. All were single‐drug exposures. Forty‐three patients (90%) ingested a TCA dose that was less than the normally prescribed pediatric dose (5 mg/kg). Of the five children ingesting >5 mg/kg (range 5‐9.4 mg/kg), only one (5.3 mg/kg) was mildly symptomatic (drowsy) prior to admission. Thirty‐one of the 48 (65%) were sent to the emergency department (dose range 0.59‐9.4 mg/kg). Fourteen of the 31 were admitted for 12‐24‐hour observation and none subsequently developed symptoms. Twenty‐three (74%) received activated charcoal (AC). There was no difference in outcome between the children who did and did not receive AC. Conclusions: No case of significant toxicity occurred in the children who experienced unintentional TCA ingestions in this study population. None of the children in the study had toxicity at doses <5 mg/kg. Further study is necessary to develop clinical guidelines for the appropriate referral of unintentional ingestions of TCA involving children.
Graduate Medical Education Downsizing: Perceived Effects of Participating in the HCFA Demonstration Project in New York State
Authors: Spillance Linda L. , Jagoda Andy , Hare Marc A. , Swoboda Thomas K. , Calderon Yvette , Quintana Eileen C.
Published: January 2008

Abstract. Objective: Financial support for graduate medical education (GME) is shrinking nationally as Medicare cuts GME funds. Thirty‐nine hospitals in New York State (NYS) voluntarily participated in a Health Care Financing Administration demonstration project (HCFADP)—the goal of which was to reduce total residency training positions by 4‐5%/year over a five‐year period, while increasing primary care positions. The objective of this study was to determine the effect of downsizing on emergency department (ED) staffing and emergency medicine (EM) residency training. Methods: Structured interviews and surveys of NYS program directors (PDs) were conducted in October—December 1999. Simple frequencies are reported. Results: One hundred percent of 17 PDs completed the interviews and seven of 12 participants in the HCFADP returned surveys. Twelve of 17 programs participated in HCFADP and two programs downsized outside HCFADP. Seven of 12 participants lost EM positions. Six of 12 programs were forced to exclude outside residents from rotating in their ED, leading to a need for one participating program and one non‐participating program to find alternative sites for trauma. Five of 12 institutions provided resident staffing data, reporting a reduction in ED resident coverage in year 1 of the project of 9‐40%. Programs compensated by increasing the number of shifts worked (4/12), increasing shift length (1/12), decreasing pediatric ED shifts (1/12), decreasing elective or research time (2/12), and decreasing off‐service rotations (4/12). Six departments hired physician assistants or nurse practitioners, two hired faculty, and two hired resident moonlighters. Six of 12 programs withdrew from HCFADP and returned to previous resident numbers. Eight of 12 PDs thought that they had decreased time for clinical teaching. Conclusions: A 4‐5% reduction in residency positions was associated with a marked reduction in ED resident staffing and EM residency curriculum changes.
Pediatric Emergency Assessment Tool (PEAT): A Risk‐adjustment Measure for Pediatric Emergency Patients
Authors: Gorelick Marc H. , Lee Chistopher , Cronan Kathleen , Kost Susanne , Palmer Kathleen
Published: January 2008

Abstract. Objective: To develop a multivariable model predicting the level of care required by pediatric patients for use as a risk‐adjustment tool in the evaluation of emergency medical services for children. Methods: A random 10% sample of records of all visits over a 12‐month period to a suburban, university‐affiliated pediatric emergency department (PED) was selected and abstracted. The outcome variable, level of care received, was categorized in three levels: routine care only (R); diagnostic or therapeutic procedures performed in the ED but patient not admitted (EDT); and admission to hospital (ADM). Predictor variables included information routinely elicited and recorded at the time of triage. Using multinomial logistic regression, a predictive model was derived from a subset of 70% of the selected visits, and was validated in the remaining 30%. Results: The total sample included 2,287 visits. The overall rate of each outcome was R‐37%, EDT‐53%, and ADM‐10%. The final regression model included the following predictors significantly associated with the outcome: age, past medical history, temperature, abnormal respiratory rate or pulse oximetry in triage, chief complaint, and triage level (model likelihood ratio chi‐square, 14 df = 332, p < 0.00001, R2= 0.14). The number of outcomes was well predicted by the model in both subsamples. Analysis of variance showed a significant association between Pediatric Emergency Assessment Tool (PEAT) score (weighted sum of the predicted probabilities of EDT and ADM) and both ED charges and time spent in the ED (p < 0.001). Conclusions: A model based on easily and routinely measured variables can accurately predict the level of care rendered in the PED. The predicted probabilities from such a model correlate well with other outcomes of care and may be useful in adjusting for differences in risk when evaluating quality of care.
Epidemiology and Hospital Course of Rattlesnake Envenomations Cared for at a Tertiary Referral Center in Central Arizona
Authors: Tanen David A. , Ruha Anne‐Michelle , Graeme Kimberlie A. , Curry Steven C.
Published: January 2008

Abstract. Objective: To describe the demographics and primary inpatient treatment of victims of rattle‐snake bites (RSBs) referred to a teritiary referral poison treatment center in central Arizona, and to compare the frequency of local tissue complications and hematologic toxicity during hospitalization in children with those for adults. Methods: This was a chart review of patients diagnosed as having RSB by a toxicology service between July 1994 and April 2000. Data collected included: age, sex, date, bite location, time to and length of hospitalization, time to and amount of antivenin, serial hematologic studies, and inpatient complications. Results: Of 241 patients admitted, 236 charts met inclusion criteria. The majority of RSB victims were male (81%). Children (≤13 years) represented 22%. Most RSBs (78%) occurred between April and September. Mean time (±SEM) to presentation was 1.7 ± 0.2 hours. Antivenin was administered to 77% of patients, with an average (±SEM) of 28.5 ± 0.9 vials administered. Hematologic abnormalities included: coagulopathy (60%), hypofibrinogenemia (49%), and thrombocytopenia (33%). No statistically significant difference in the above parameters was detected between upper‐ and lower‐extremity envenomations, or between children and adults. Immediate antivenin reactions occurred in 36% of patients. Hemorrhagic bullae formation occurred in 22%, occurring most frequently in upper extremities. Operative procedures were required in 3.4% of patients. Hospitalization averaged 2.5 ± 0.1 days. There was no fatality. Conclusions: In Arizona, RSB victims were typically adult males with upper‐extremity bites. Hematologic abnormalities were common. Local tissue complications were more common with upper‐extremity envenomations. No statistically significant difference was detected in frequency of hematologic disorders or local tissue complications when children were compared with adults.
Emergency Department Evaluation of Chest Pain Using Exercise Stress Echocardiography
Authors: Buchsbaum Michael S. , Marshall Erik S. , Levine Brian J. , Bennett Martin A. , DiSabatino Angela , O'Connor Robert E. , Jasani Neil B.
Published: January 2008

Abstract. Objective: Patients with a low risk of coronary artery disease (CAD) presenting to the emergency department (ED) with chest pain pose a diagnostic dilemma because a small percentage will suffer an acute myocardial infarction (MI) and sudden death. The authors conducted this study to determine whether exercise stress echocardiography (ESE) could be used to further support the safe discharge of these low‐risk patients. Methods: A convenience sample of patients ≥30 years of age without a prior cardiac history who presented to an academic community hospital with chest pain, normal initial creatine kinase, and electrocardiography without ischemic changes underwent ESE within 6 ± 1.7 hours (mean ± SD). Abnormal ESE was defined as regional wall motion abnormality at rest or after exercise. The ED disposition and three‐ and six‐month follow‐up for cardiac events were recorded. This was a prospective observational cohort study. Results: Of a total of 149 eligible patients, 145 completed the study. The mean age (±SD) was 47 ± 9 years; 56% were male. No adverse events were noted during ESE. Seven patients (5%) had abnormal ESE (2 with rest wall motion abnormalities and 5 with exercise‐induced wall motion abnormalities). Five of the seven underwent cardiac catheterization; three had CAD. All patients received telephone follow‐up at three months and six months. Of the 138 patients with a normal ESE, all were free of cardiac events at three months. One patient had a non‐Q‐wave MI at six months (negative predictive value = 99.3%, 95% CI = 97.8% to 100%). Conclusions: Exercise stress echocardiography can be used to evaluate low‐risk chest pain patients in the ED. Patients with a normal ESE may be considered for discharge with minimal risk of sequelae.