bluuebunny/crossref_metadata_2025 huggingface dataset:
A Comparison of the Bioavailabilities of Oral and Intravenous Ethanol in Healthy Male Volunteers
Authors: Cobaugh Daniel J. , Gibbs Michael , Shapiro David E. , Krenzelok Edward P. , Schneider Sandra M.
Published: January 2008

Abstract. Objectives: Ethanol (EtOH), the antidote for methanol and ethylene glycol, is administered by the oral (PO) and intravenous (IV) routes. Serum concentrations (SCs) of 100 mg/dL or more are targeted for clinical effect. This study was completed to validate the assumption that there are minimal differences in SC achieved between these two routes. Methods: Twenty healthy male volunteers were randomized to receive either PO or IV EtOH. Subjects abstained from EtOH for 48 hours before each phase. After a seven‐day washout period, the subjects crossed over to the other group. Inclusion criteria were no history of medical problems, age between 21 and 40 years, and actual body weight within 10% of ideal weight. Baseline EtOH SCs were obtained before participation in each phase. Two hours after a standard breakfast, the subjects received 700 mg/kg of PO or IV EtOH. PO EtOH was administered as a 20% solution in juice over 10 minutes. IV EtOH, controlled by an infusion pump, was administered as a 10% solution over 30 minutes. Blood was drawn for EtOH SCs at 45, 75, 105, 135, 165, 225, 285, and 345 minutes after start of the dose. Results: All initial EtOH SCs were 0. EtOH SCs were higher after IV administration. Mean peak SC was 103.6 mg/dL after IV administration and 71.3 mg/dL after PO administration (p < 0.0001). Mean time to peak was 46.5 minutes after IV administration and 103.5 minutes after PO administration (p < 0.0001). Total area under the curve was 17,440 min‐mg/dL after IV administration and 13,875 min‐mg/dL after PO administration (p < 0.003). The order of treatments did not affect results (p > 0.1). Conclusion: Significant differences exist between the SCs of EtOH as well as the times to peak SC after PO and IV administrations.
Validation of the Ottawa Ankle Rules in Children with Ankle Injuries
Authors: Plint Amy C. , Bulloch Blake , Osmond Martin H. , Stiell Ian , Dunlap Hal , Reed Martin , Tenenbein Milton , Klassen Terry P.
Published: January 2008

Abstract. Objectives: The Ottawa Ankle Rules (OAR) have been found to be 100% sensitive in adult patients with ankle injuries, and application of the OAR has resulted in a 28% reduction in the number of x‐rays ordered. The objectives of this study were to determine the sensitivity and specificity of the OAR in children and to determine the potential change in x‐ray utilization. Methods: Children, aged 2‐16 years, presenting to the EDs of two children's hospitals, with an ankle injury in the previous 48 hours, were enrolled. All patients were assessed by either staff physicians or fellows. X‐rays were ordered according to standard clinical practice. Prior to reviewing x‐rays, the physical examination was recorded on a standardized form. Positive outcomes (clinically significant) were defined as fractures with fragments ≥3 mm. Patients not x‐rayed and asymptomatic at five to seven days postinjury were considered to have no significant fracture. Results: Six hundred seventy patients were enrolled. The OAR were 100% sensitive (95% CI = 95% to 100%) for significant ankle fractures, with a specificity of 24% (95% CI = 20% to 28%). The OAR were 100% sensitive (95% CI = 82% to 100%) for the midfoot, with a specificity of 36% (95% CI = 29% to 43%). If the OAR had been followed, there would have been a reduction of ankle x‐rays by 16% and foot x‐rays by 29% without missing any clinically significant fracture. However, analysis of the two hospitals showed that if the rules had been applied, one would have a reduction in x‐rays, while the other center would have an increase. Conclusions: This study demonstrates the OAR to be sensitive for detecting clinically significant (≥3 mm) ankle and midfoot fractures in children. The application of these rules may reduce the number of x‐rays ordered. A further study is required to determine the effect of using the OAR in clinical practice.
The Utility of a Dilatation and Evacuation Procedure in Patients with Symptoms Suggestive of Ectopic Pregnancy and Indeterminate Transvaginal Ultrasonography
Authors: Dart Robert , Dart Linda , Mitchell Patricia , O'Rourke Nancy
Published: January 2008

Abstract. Objectives: To ascertain the overall frequency of obtaining chorionic villi (CV) in patients with indeterminate transvaginal ultrasound (US) examinations who have had a dilatation and evacuation (D+E) procedure performed, to determine whether the frequency of obtaining CV is dependent on whether the endometrial cavity is empty at US, and to determine the likelihood of ectopic pregnancy in patients without CV after D+E and with or without an empty endometrial cavity at US. Methods: A retrospective review was made of consecutive ED patients presenting to an urban teaching hospital from August 1991 through August 1997 with abdominal pain or vaginal bleeding and a positive beta‐human chorionic gonatropin (β‐hCG) test. Patients who had a transvaginal US that was read as indeterminate (no extrauterine findings of ectopic pregnancy, and no intrauterine fetal pole or yolk sac) and who had a D+E performed within 48 hours of the ED visit were eligible. US exams were subdivided into two groups, those with empty endometrial cavities and those with endometrial cavities that contained fluid, echogenic material, or sac‐like structures. The presence or absence of CV was based on the official pathology report. Patients were excluded if pathology results were not available. Results: A total of 255 patients met eligibility criteria. Of these, pathology results were not available for five patients. Of the remaining patients, 177 of 250 (70.8%: 95% CI = 64.7% to 76.3%) had CV identified in the pathology specimen. The difference in the frequencies of obtaining CV in those with empty endometrial cavities (35/78; 44.9%: 95% CI = 34% to 56%) vs those without empty endometrial cavities (142/172; 82.6%: 95% CI = 76% to 88%) was significant (p < 0.001). Ectopic pregnancy was diagnosed in 17 of 42 (40.0%) with empty uteri at US and no CV at pathology vs 5 of 26 (19.2%) in whom the uterus was not empty and no CV were obtained (p = 0.07). Conclusion: In symptomatic patients with indeterminate transvaginal ultrasound exams, CV will be identified after D+E in approximately 70% of cases. Although CV were found with increased frequency when the endometrial cavity was not empty, still almost half of the patients with empty uteri had villi identified. Finally, although the frequency of ectopic pregnancy was higher in the patients with empty uteri and no CV at D+E, vs those without an empty uterus and no CV, this difference did not reach statistical significance.
Trends in Emergency Department Utilization, 1988‐1997
Authors: Meggs William J. , Czaplijski Thomas , Benson Nicholas
Published: January 2008

Abstract. Objectives: To study changes in ED utilization over a ten‐year period; and to try to identify factors that affect utilization. Methods: This study was conducted in a university‐affiliated rural tertiary referral center in a stage 1 managed care market, providing primary emergency services to a county of 120,000 and tertiary services to a 29‐county area with 1.2 million people. The year of visit, time of visit, level of care required, length of stay (LOS), and admission status were entered into a computer database for each ED visit. Results: Over the period from 1988 to 1997, the population grew by 18.7%. Over the same time period, the number of ED visits grew 27%. By regression analysis, the number of ED visits was directly related to the size of the service population (correlation coefficient 0.97). During the study period, patient acuity increased, with urgent visits increasing from 45% to 52% while nonurgent visits declined from 55% to 48%. Percentage of patients admitted increased from 14% in 1989 to 20% in 1997. Percentage of patients with LOS exceeding six hours also increased, from 8% in 1989 to 16% in 1997. Conclusions: For the study hospital there was a direct relationship between the ED utilization and population size as well as a historical trend toward increased patient acuity. These trends quantified at one hospital may reflect trends occurring throughout the United States that would affect ED staffing, space, and resource needs.
Why Don't Emergency Department Patients Have Advance Directives?
Authors: Llovera Ingrid , Ward Mary Frances , Ryan James G. , Lesser Martin , Sama Andrew E. , Crough Daniel , Mansfield Mary , Lesser Lenard I.
Published: January 2008

Abstract. Objectives: In 1997 the authors determined that only 27% of their adult ED patients had advance directives (ADs). The purpose of this followup study was to determine the reasons why their adult ED patients do not have ADs. Methods: This prospective study enrolled patients from a convenience sample of representative shifts in the ED selected over a three‐month period. Survey questions included demographic information, whether the patients had a life‐threatening medical problem, whether they had an AD, with whom they had discussed their ADs, and the reasons why they did not have an AD. We excluded those who refused participation or who were incapacitated (i.e., any patient with a condition that precluded him or her from answering the questionnaire himself or herself, such as an altered level of consciousness, dementia, mental retardation, or inability to understand English). Results: Four hundred seventy‐six subjects were enrolled during the study period from an ED census of 816 adult patients. Three hundred forty patients were not included in the study for the following reasons: inability to complete the survey, refusal to participate, or not being approached by the interviewers. Of those enrolled, 77% of the patients did not have an AD (females, 73%; males, 80%). The most frequent reasons given for not having an AD were: 40% never thought about it, 24% preferred family to make the decision, and 23% were procrastinating. Factors jointly predictive of having an AD were older age, having a specialist, having a life‐threatening medical problem, and not being Catholic. Patients who had ADs were discussing their ADs with their primary care physicians (PCPs) only 5% of the time. Conclusion: Many patients, even when they have life‐threatening medical problems, do not have an AD, and several reasons for this have been identified. Few of these ED patients who had ADs had discussed them with their physicians. Further studies should assess whether more physician intervention would increase the percentage of patients who have ADs.
Perceptions of Pediatric Emergency Medicine Fellows and Program Directors about Research Education
Authors: Mason Andrew D. , Biehler Jefry Lloyd , Linares Marc Y.‐R. , Greenberg Barry
Published: January 2008

Abstract. Pediatric emergency medicine (PEM) fellows who entered training after January 1995 are required to complete three years of fellowship training. Additionally, they are required to receive instruction in related basic sciences and to demonstrate research competence. Objectives: To determine: 1) whether PEM fellows and program directors perceive their programs as providing adequate training in research principles, 2) the manner in which these principles are taught, and 3) the commitment of fellows and program directors to research and research training. Methods: Pediatric emergency medicine fellows who participated in the Fourth Annual PEM Fellows Conference (Miami, Florida, March 1997) were surveyed. The survey was then extended via mail to all PEM fellows and program directors in the United States and Canada. Results: A total of 159 of the 220 fellows (72%) in the United States and Canada returned completed questionnaires. Fifty‐three of 70 PEM fellows (76%) who attended the conference completed questionnaires, and 106 of 167 fellows (63%) who did not attend the conference responded by mail. Fifty‐three of the 63 program directors (84%) returned completed questionnaires. Of 159 responding fellows, 86 (54%), and of 53 responding program directors, 29 (58%) reported that their programs lacked adequate training in one or more of the surveyed research areas. Thirteen program directors (25%) reported no formal research training in their curricula. Programs that included formal research training were perceived to have higher overall quality than programs that failed to offer such formal training. Sixty‐six of 158 responding fellows (42%) anticipated an ongoing commitment to research in their careers. One hundred fourteen of 153 responding fellows (75%) indicated that, if given the option, they would have pursued a two‐year “clinical track” PEM board certification that did not include a research requirement. Conclusions: More than half of surveyed PEM fellows and program directors perceived important deficiencies in research education within their training programs. Further research is necessary in order to evaluate the validity of these perceptions.
Impact of Patient Acuity on Preference for Information and Autonomy in Decision Making
Authors: Davis Mark A. , Hoffman Jerome R. , Hsu John
Published: January 2008

Abstract. Objectives: To test the hypotheses that ED patients desires for medical information and for autonomy in decision making are inversely related to increasing acuity of illness, increasing age, and lower level of formal education. Methods: The authors conducted a prospective study of ED patients who presented for care during seven nonconsecutive 24‐hour periods. Of 804 patients approached, 665 completed a questionnaire that was administered by a trained research assistant. Patients rated their desire for medical information, and for participation in medical decision making, on two 10‐cm visual analog scales. Patient acuity level was determined in routine fashion by trained triage nurses, who were unaware of the nature of this study. Results: Desire for information was uniformly high, and did not vary statistically between triage groups (p = 0.41). The most acutely ill patients (level I) were more likely to be excluded by the research interviewer (p < 0.001). Of included level I patients, desire to participate was not decreased (p < 0.01). Higher level of formal education (p = 0.036) and younger age (p < 0.001) were associated with greater desire for autonomy in decision making. Conclusion: Among ED patients able to participate, higher acuity of illness was not associated with a decreased desire for medical information. Many very acutely ill patients preferred autonomy in medical decision making. Older patients and those with less formal education expressed a lesser desire for decision‐making autonomy.
Emergency Department Characteristics of Male Sexual Assault
Authors: Pesola Gene R. , Westfal Richard E. , Kuffner Carol A.
Published: January 2008

Abstract. Objective: To characterize the nature, frequency, and treatment of male sexual assault encountered by physicians in an ED. A minor objective compared the lengths of time the victim knew the assailant between males and females to determine whether there were differences between male and female victims. Methods: Retrospective review over four years of all male patients with a diagnosis of sexual assault presenting to an urban academic ED in New York City. Demographics, types of injury, assailant/victim information, and treatment of the assault were obtained. Results: Twenty‐seven male sexual assaults (approximately 12% of all sexual assaults) were documented during this time period. Forcible rectal, oral, or both rectal and oral intercourse occurred 14, 4, and 9 times, respectively. Documented physical trauma occurred in nine of 27 visits, with two admissions for head trauma. Five additional patients complained of rectal pain with no independent objective evidence of trauma. Prophylactic treatment with antibiotics for the prevention of Neisseria gonorrhoeae and Chlamydia trachomatis was offered in 26 of 27 episodes and prophylactic HIV protection was given to only two of 21 eligible patients. Documentation of HIV status and HIV counseling occurred only in ten and five visits, respectively. The male‐to‐female odds ratios for whether the assailant was unknown, known less than 24 hours, or known more than 24 hours were 0.43 (95% CI = 0.15 to 1.26), 2.48 (95% CI = 0.94 to 6.53), and 0.92 (95% CI = 0.31 to 2.71), respectively. Conclusions: The percentage of total sexual assaults occurring in males who present to an ED is now more than 10% of all sexual assaults seen in this urban ED. These assaults are associated with a high proportion of patients with documented trauma. Although the treatment of traditional sexually transmitted diseases appears to be covered well, the need for HIV documentation, counseling, and possible HIV prophylaxis should be addressed more aggressively. In comparing the lengths of the relationships between the victim and the assailant, it appears twice as likely that the female victim will not know her assailant compared with the male, and twice as likely that the male victim will know his assailant less than 24 hours compared with the female.
Identification of Intra‐abdominal Injuries in Children Hospitalized Following Blunt Torso Trauma
Authors: Holmes James F. , Sokolove Peter E. , Land Catherine , Kuppermann Nathan
Published: January 2008

Abstract. Objective: To determine the utility of the ED physical examination and laboratory analysis in screening hospitalized pediatric blunt trauma patients for intra‐abdominal injuries (IAIs). Methods: The authors reviewed the records of all patients aged <15 years who sustained blunt traumatic injury and were admitted to a Level 1 trauma center over a four‐year period. Patients were considered high‐risk for IAI if they had any of the following at ED presentation: decreased level of consciousness (GCS < 15), abdominal pain, tenderness on abdominal examination, or gross hematuria. Patients without any of these findings were considered moderate risk for IAI. The authors compared moderate‐risk patients with and without IAIs with regard to physical examination and laboratory findings obtained in the ED. Results: Of 1,040 children with blunt trauma, 559 (54%) were high‐risk and 481 (46%) were moderate‐risk for IAI. 126 (23%) of the high‐risk and 22 (4.6%) of the moderate‐risk patients had IAIs. Among moderate‐risk patients with and without IAIs, those with IAIs were more likely to have abdominal abrasions (5/22 vs 34/459, p = 0.008), an abnormal chest examination (11/22 vs 86/457, p = 0.01), higher mean serum concentrations of aspartate aminotransferase (AST) (604 U/L vs 77 U/L, p < 0.001) and alanine aminotransferase (ALT) (276 U/L vs 39 U/L, p = 0.002), higher mean white blood cell (WBC) counts (16.3 K/mm3 vs 12.8 K/mm3, p < 0.001), and a higher prevalence of >5 RBCs/hpf on urinalysis (7/22 vs 54/427, p = 0.02). There was no significant difference (p > 0.05) between moderate‐risk patients with and without IAIs in initial serum concentrations of amylase, initial hematocrit, drop in hematocrit >5 percentage points in the ED, or initial serum bicarbonate concentrations. Conclusion: In children hospitalized for blunt torso trauma who are at moderate risk for IAI, ED findings of abdominal abrasions, an abnormal chest examination, and microscopic hematuria as well as elevated levels of AST and ALT, and elevated WBC count are associated with IAI.
Prevalence of Smokers and Nicotine‐addicted Patients in a Suburban Emergency Department
Authors: Richman Peter B. , Dinowitz Seth , Nashed Ashraf , Eskin Barnet , Cody Ronald
Published: January 2008

Abstract. Objective: To define the prevalence of smokers and nicotine‐addictedpatients in a suburban, community ED. Methods: This was a prospective survey of consecutive ED patients seen in a suburban ED with an annual patient census of 48,000. Medically stable patients aged 18 years or older were eligible for inclusion. Patients were excluded if they had predominantly psychiatric complaints or were critically ill. Patients were queried about their smoking habits by a closed‐question survey, which included the previously validated Fagerstrom Test for Nicotine Dependence. The study was conducted during a six‐week period, only at times when there were dedicated research associates available to ensure consecutive patient entry. Continuous variables were analyzed by Student's t‐tests. Clinical variables were analyzed by chi‐square tests. All tests were two‐tailed with alpha at 0.05. Results: 1,515 patients comprised the study group. The mean age (±SD) was 45.6 (±18.9) years; 52% were female, 25% were nonwhite, and 47% were college graduates. There were 317 (21%) smokers. Patients having private physicians were less likely to smoke (18% vs 29%, p = 0.001). Of all smokers, 46% were moderately to severely nicotine‐dependent, 69% wanted to quit, and 30% expressed an interest in joining a smoking cessation program. Conclusion: A substantial percentage of ED patients smoke, many of them are nicotine‐addicted, and the majority would like to quit. Randomized, controlled trials are needed to determine whether interventions by physicians in the ED can have an impact on the smoking habits of these patients.
Research Fundamentals VI: Misconduct in Biomedical Research
Authors: Biros Michelle H. , Fish Susan S. , Taggart Pamela
Published: January 2008

Abstract. The goal of medical research is the acquisition and application of new knowledge for the benefit of individual patients and society as a whole. Achieving this goal requires excellence in scientific methodology, honesty in data collection and interpretation, and realistic assessment of the implications of the findings. Underlying all steps in the acquisition of new knowledge is the absolute need for application of the highest ethical standards for research. Occasionally, ethical principles of research are breached because of lack of understanding or the carelessness of researchers. However, researchers have the obligation to know and apply basic principles of research ethics in order to avoid, prevent, or recognize deviations from ethical scientific behavior. When intentional violations of the principles of ethical research occur, the impact to the scientific and lay community can be profound. Misconduct can be prevented if the ethical principles of research are understood and consistently applied. This paper describes the sources and detection of misconduct in the production of science in order to provide emergency researchers with the knowledge needed to prevent misconduct from occurring at all.
Evaluation of Biphasic Transthoracic Defibrillation in an Animal Model of Prolonged Ventricular Fibrillation
Authors: Scheatzle Mark D. , Menegazzi James J. , Allen Todd L. , Durham S. Bryan
Published: January 2008

Abstract. Objectives: To determine whether a biphasic defibrillation waveform (BDW) would produce a superior rate of converting prolonged ventricular fibrillation (VF) into a perfusing rhythm and delay the occurrence of asystole and/or pulseless electrical activity (PEA) during the resuscitation attempt, when compared with a monophasic defibrillation waveform (MDW). Methods: The authors performed a prospective, randomized, blinded experiment using an established swine model of prolonged VF. Thirty‐four mixed‐breed domestic swine (mean mass 22.9 kg) were sedated (ketamine/xylazine), anesthetized (isoflurane), and intubated. Aortic and femoral venous catheters were placed. ECG was monitored continuously. The animals were shocked into VF (3‐s, 100‐mA, 60‐Hz shock), and were untreated for 8 minutes. Advanced Cardiac Life Support (ACLS) began with 1 minute of standardized (Thumper) chest compressions and ventilation. The animals were randomized to treatment with either BDW or MDW. Standard ACLS protocols were followed. The energy sequence was 2.5 J/kg first, 3.5 J/kg second, and 4.5 J/kg for all subsequent shocks. Outcome variables were time to event of asystole/PEA, return of spontaneous circulation (ROSC), and one‐hour survival. Data were analyzed with two‐tailed Fisher's exact test and Kaplan‐Meier survival plots (alpha = 0.05). Results: ROSC occurred more frequently in the BDW group (7/17) compared with the MDW group (1/17); p = 0.04. Survival analysis showed that the BDW significantly delayed the occurrence of asystole/PEA during the resuscitation attempt when compared with the MDW; log‐ranked p = 0.02. One‐hour survival rates (5/17 BDW and 1/17 MDW, p = 0.17) did not differ. Conclusions: BDW resulted in a superior rate of ROSC and delay in the occurrence of asystole/PEA during the resuscitation attempt when compared with MDW.
Emergency Department Observation of Poisoned Patients: How Long Is Necessary?
Authors: Hollander Judd E. , McCracken Glen , Johnson Scott , Valentine Sharon M. , Shih Richard D.
Published: January 2008

Abstract. Objective: To compare the emergency physician disposition decisions after observation periods of two, four, and six hours in a single cohort of ED patients with acute intentional ingestion to determine the accuracy of disposition decisions at two and four hours relative to the six‐hour period of observation. Methods: This was a prospective observational study at two university hospital EDs. Study participants were patients with potentially toxic oral ingestions occurring less than six hours prior to ED presentation. Patients with isolated recreational drug or ethanol use were excluded. Structured data forms were completed at presentation, and two, four, and six hours later. Data included signs and symptoms consistent with toxic ingestion, physical examination, laboratory determinations, medications ingested, treatment, and suicide risk. At two and four hours, physicians were asked to determine whether they thought the patient was safe for medical clearance. These patients continued to be observed for six hours. The main outcome was whether patients initially thought to be appropriate for early medical clearance were ultimately cleared at six hours. Results: There were 260 patients enrolled: 28 were immediately admitted to the hospital and 17 were immediately discharged; 215 entered ED observation. Patients had a mean age of 24 years; 55% were female; 50% were suicidal; 17% had toxidromes. Of the 215 observed patients, 106 (49%) were deemed safe for early medical clearance at two hours. All 106 were ultimately cleared at six hours (100%, 95% CI = 97% to 100%). Of the 109 not safe for early medical clearance at two hours, 61 (56%) were deemed safe for early medical clearance at four hours; all 61 were subsequently discharged at six hours (100%; 95% CI = 95% to 100%). Overall, 167 of 215 (77%) observed overdose patients were deemed safe for early medical clearance after two or four hours of observation. All 167 were ultimately cleared at six hours (100%; 95% CI = 98.2% to 100%). Conclusions: A large subset of overdose patients who are medically cleared after six hours of observation can be identified within two to four hours of presentation. No patient who was believed to be safe for medical clearance at either two or four hours had a complication within the six‐hour time period (95% CI = 0% to 1.8%). These data suggest that asymptomatic patients with selected acute intentional ingestions can be released from medical observation in less than six hours.
The Clinical Utility of the Rectal—Skin Temperature Difference in the Assessment of Young Infants
Authors: Grover Geeta , Berkowitz Carol D. , Lewis Roger J.
Published: January 2008

Abstract. Objective: Previous studies have suggested that the degree of difference between rectal temperature and peripheral skin temperature [rectal—skin temperature difference (RSTD)] is predictive of serious illness in young infants. The authors sought to determine the clinical utility of the RSTD in the outpatient evaluation of infants up to 2 months of age for serious infectious illness (SII). Methods: Simultaneous rectal and skin (anterior mid—lower leg) temperatures were recorded for all infants ≤2 months of age seen in the ED over a one‐year period. The physician's clinical assessment, rectal temperature, skin temperature, laboratory results, and final diagnoses were also recorded. The RSTD (rectal temperature — skin temperature) was calculated for each infant. Final diagnoses were recorded and classified as SII or nonserious illness (NSI). Mean RSTD for each group was calculated and data were analyzed by the Wilcoxon rank sum test and multivariate regression model. Results: A total of 601 infants [mean age of 28 days (range 2‐65 days)] were enrolled. Nine percent (57 of 601) of infants had SII. Forty percent (23 of 57) of infants with SII were febrile, and 60% (34 of 57) were afebrile. The mean RSTD of febrile infants with SII was 5.8 ± 1.7°C (range 3.2‐9.7°C) and 5.3 ± 1.4°C (range 3.0‐7.6°C) for febrile infants with NSI. The mean RSTD of afebrile infants with SII was 4.8 ± 1.8°C (range 2‐12.5°C) and 4.4 ± 1.5°C (range 0.04‐10.9°C) for afebrile infants with NSI. The RSTD was not associated with SII in either febrile or afebrile infants (p > 0.05, Wilcoxon rank sum test). A multivariate logistic regression model of age, rectal temperature, and RSTD suggested an independent association of rectal temperature with SII (p < 0.0001), but none between age or RSTD and SII (p > 0.05). Conclusion: Once the rectal temperature is known, the RSTD is not a clinically useful test in the evaluation of young infants for serious infectious illness.
Now That We Have the Utstein Style, Are We Using It?
Authors: Cone David C. , Jaslow David S. , Brabson Thomas A.
Published: January 2008

Abstract. Objectives: To examine the extent to which the Utstein style has been used for out‐of‐hospital cardiac arrest (OOHCA) research since its publication in 1991. The style was developed in an effort to standardize OOHCA research and reporting. Methods: To locate all OOHCA research papers published between 1992 and 1997, all issues of six emergency medicine/emergency medical services (EM/EMS) journals were examined manually, and papers from other journals were located using computerized searches. All located articles were examined by the first author to determine whether use of the Utstein style was indicated and if so, whether it had actually been used. When either of these was uncertain, all three authors reviewed the paper, and a consensus was reached. The Pearson chi‐square test was used to compare rates of use from U.S. and non‐U.S. institutions, and from the EM/EMS and non‐EM/EMS literature, with significance set at p < 0.05. Results: All 143 OOHCA research articles identified by the search were examined. The Utstein style was found to be not applicable to 41 (29%), and these were eliminated. The Utstein style was indicated for the remaining 102 studies. Of these, 41 (40%) used the Utstein style, and 61 (60%) did not. There was no difference in rates between papers from sites in the United States (18/48, 38%) and elsewhere (23/54, 43%), or between papers from the EM/EMS literature (17/44, 39%) and non‐EM/EMS literature (25/59, 42%). Despite an upward trend in the use of the Utstein style seen from 1992 to 1994, use leveled off from 1994 to 1997, and has not exceeded 60% in any given calendar year studied. Conclusions: Six years after the release of the Utstein style for OOHCA research, fewer than 60% of OOHCA research articles actually use the style.
Setting the Educational Agenda and Curriculum for Error Prevention in Emergency Medicine
Authors: Croskerry Pat , Wears Robert L. , Binder Louis S.
Published: January 2008

Abstract. Graduate and postgraduate medical education currently teaches safety in patient care by instilling a deep sense of personal responsibility in student practitioners. To increase safety, medical education will have to begin to introduce new concepts from the “safety sciences,” without losing the advantages that the values of commitment and responsibility have gained. There are two related educational goals. First, we in emergency medicine (EM) must develop a group of safety‐educated practitioners who can understand and implement safe practice innovations in their clinical settings, and will be instrumental in changing our professional culture. Second, EM must develop a group of teachers and researchers who can begin to deeply understand how safety is maintained in emergency care, develop solutions that will work in emergency department settings, and pass on those insights and innovations. The specifics of what should be taught are outlined briefly. Work is currently ongoing to identify more specifically the core content that should be included in educational programs on patient safety in emergency care. Finally, careful attention will have to be paid to the way in which these principles are taught. It seems unlikely that a series of readings and didactic lectures alone will be effective. The analysis of meaningful cases, perhaps supplemented by high‐fidelity simulation, seems to hold promise for more successful education in patient safety.
Promoting Patient Safety and Preventing Medical Error in Emergency Departments
Authors: Schenkel Stephen
Published: January 2008

Abstract. An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system‐level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.
The Cognitive Imperative Thinking about How We Think
Authors: Croskerry Pat
Published: January 2008

Abstract. There are three domains of expertise required for consistently effective performance in emergency medicine (EM): procedural, affective, and cognitive. Most of the activity is performed in the cognitive domain. Studies in the cognitive sciences have focused on a number of common and predictable biases in the thinking process, many of which are relevant to the practice of EM. It is important to understand these biases and how they might influence clinical decision‐making behavior. Among the specialities, EM provides a unique clinical milieu of inconstancy, uncertainty, variety, and complexity. Injury and illness are seen within narrow time windows, often under pressured ambient conditions. These operating characteristics force practitioners to adopt a distinctive blend of thinking strategies. Principal among them is the use of heuristics, a form of abbreviated thinking that often leads to successful outcomes but that occasionally may result in error. A number of opportunities exist to overcome interdisciplinary, linguistic, and other historical obstacles to develop a sound approach to understanding how we think in EM. This will lead to a better awareness of our cognitive processes, an improved capacity to teach effectively about cognitive strategies, and, ultimately, the minimization or avoidance of clinical error.
The Feedback Sanction
Authors: Croskerry Pat
Published: January 2008

Abstract. The emergency department (ED) is a complex environment. Its equilibrium, or homeostasis, is critically dependent on the continuous action of feedback processes. For any system to function efficiently, it needs to know the outcomes of specific actions in a consistent, reliable, and expeditious way. Historical attitudes and the unique operating characteristics of the ED have combined to impose sanctions on the proper provision of feedback. The following features have been identified as obstructive to optimal feedback operation: incomplete awareness of the significance of the problem, excessive time and work pressures, case infrequency, deficiencies in specialty follow‐up, communication failures, deficient reporting systems for near‐misses, error, and adverse events, biases in case review processes, shift changeover times, and shiftwork. The result is that clinicians, nurses, and trainees are working in conditions that are suboptimal for the provision of safe care, as well as for learning and job fulfillment. Good feedback is a necessary condition for well‐calibrated performance by individuals, and is integral to effective team function. More needs to be known about outcomes for feedback to work efficiently. The critical role of feedback in other aspects of ED function, such as education and human factors engineering, should be emphasized. The current interest in medical error and evolving attitudes toward a new culture of patient safety provide a unique opportunity to examine feedback and the critical role it plays in ED function.
Inadvertent Administration of Sufentanil Instead of Fentanyl during Sedation/Analgesia in a Community Hospital Emergency Department A Report of Two Cases
Authors: Chisholm Carey D. , Klanduch Frank
Published: January 2008

Abstract. The authors report two cases of inadvertent administration of sufentanil instead of fentanyl during patient sedation/analgesia in a community hospital emergency department (ED). Both cases resulted in reversible adverse drug events (ADEs) to the respective patients. In tracing the steps involved in the cause of these errors, the authors discovered several components common to identified pathways that result in ADEs. These include similarities in product packaging appearance and names of these two medications, along with nursing unfamiliarity with the medications. Medication “sound‐alikes” and “look‐alikes” continue to be a source of potential error in the ED.
Incident Monitoring in Emergency Departments An Australian Model
Authors: Vinen John
Published: January 2008

Abstract. The specialty‐based study of incidents, adverse events, and errors in medicine has largely occurred in anesthesia and to a lesser extent in intensive care and psychiatry. Few studies have specifically addressed the problem in emergency medicine (EM). Because of the significant risks, the resulting adverse outcome, and the high degree of preventability of errors occurring in the emergency department (ED), it is essential that an incident monitoring system be part of the ED's risk management program. The combination of time pressure, uncertainty, complexity, and workload means the ED is a high‐risk environment. The delivery of high‐quality emergency care is dependent on having an effective patient processing system in place and, because EM is a “systems‐dependent” specialty, the environment lends itself to improvements to the system (re‐engineering) to improve the safety of the environment given that the majority of errors in the ED are probably the result of failures of the system. This paper describes an existing incident monitoring system that has recently been adopted by six EDs in Australia. It was developed as a result of a similar successful program in anesthesia, and funded by the Federal Department of Health of Australia. Incorporating incident monitoring and analysis to identify causative factors of incidents and the subsequent implementation of corrective strategies as part of the ED risk management program may result in improvement in the quality of care through a reduction in the frequency of incidents.
Evaluation of Error in Medicine Application of a Public Health Model
Authors: Brasel Karen J. , Layde Peter M. , Hargarten Stephen
Published: January 2008

Abstract. A case of a chest tube placed on the wrong side during a trauma resuscitation in the emergency department is presented as an example of medical injury. Two traditional models, the legal model and the managerial model, are described and their application to medical injury discussed. A new public health model is then applied to the case example as a more effective way to address medical injury. The public health model addresses the injury event rather than the error itself using Haddon's matrix as a framework. Pre‐event, event, and post‐event phases are examined to find the weakest link, where intervention has the highest likelihood of successfully preventing future injuries.
An Objective Analysis of Process Errors in Trauma Resuscitations
Authors: Clarke John R. , Spejewski Beverly , Gertner Abigail S. , Webber Bonnie L. , Hayward Catherine Z. , Santora Thomas A. , Wagner David K. , Baker Christopher C. , Champion Howard R. , Fabian Timothy C. , Lewis Frank R. , Moore Ernest E. , Weigelt John A. , Eastman A. Brent , Blank‐Reid Cynthia
Published: January 2008

Abstract. Objective: A computer‐based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome. Methods: A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection. Results: Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2.4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5.1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning. Conclusions: Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.
The Benefit of Houseofficer Education on Proper Medication Dose Calculation and Ordering
Authors: Nelson Lewis S. , Gordon Peter E. , Simmons Marc D. , Goldberg William L. , Howland Mary Ann , Hoffman Robert S.
Published: January 2008

Abstract. Objectives: Drug dosing errors commonly cause morbidity and mortality. This prospective controlled study was performed to determine: 1) residents' understanding of drug dose calculations and ordering; and 2) the short‐term effect of a brief educational intervention on the skills required to properly calculate dosages and order medications. Methods: The study was conducted at an urban public hospital with a four‐year emergency medicine (EM) residency program. The EM residents served as the study group and were unaware of the study design. A written, eight‐question test (T1) with clinical situations and factual questions was administered. Immediately following the test, correct answers were discussed for 30 minutes. Key concepts were emphasized. Six weeks later, a repeat test (T2a) with a similar format was administered to the study group. The same test (T2b) was simultaneously administered to a control group, residents of similar training who did not take T1, in order to determine test equivalency (T1 vs T2). Tests were graded using explicit criteria by a single investigator blinded to the order of administration. Results: Twenty residents completed both tests T1 and T2a. Their mean scores were 48% and 70%, respectively (p < 0.001, paired t‐test). The control group of ten residents had a mean score of 49% (T2b), similar to the study group's scores on T1 (T1 vs T2b, p = 0.40, unpaired t‐test). Conclusion: Emergency medicine residents require specific training in calculating and executing drug ordering. A brief educational intervention significantly improved short‐term performance when retested six weeks later. Long‐term retention is unknown.
Emergency Medicine Resident Errors Identification and Educational Utilization
Authors: Hobgood Cherri D. , MA O. John , Swart Gary L.
Published: January 2008

Abstract. Objectives: To evaluate the error management systems emergency medicine residency directors (EMRDs) use to identify and report clinical errors made by emergency medicine residents and their satisfaction with error‐based teaching as an educational tool. Methods: All 112 EMRDs listed by the Accreditation Council for Graduate Medical Education in 1996 were sent a 15‐item survey. Five areas of error evaluation and management were assessed: 1) systems for tracking and reporting clinical errors; 2) resident participation in the systems; 3) resident remediation; 4) EMRD‐perceived satisfaction with current error‐reporting mechanisms, their educational value, and their ability to identify and prevent errors; and 5) EMRDs' perceptions of faculty and resident satisfaction with the systems. Results: The response rate was 86%. All EMRDs indicated that methods are in place to track and report errors at their institutions. These include morbidity and mortality conference (94%), quality assurance case review conference (76%), and continuous quality improvement audits (60%). A majority of programs (58%) present resident cases anonymously in order to enhance teaching (39%), to avoid embarrassment (28%), and to avoid individual blame (24%). While mandated resident remediation is not required at 48% of the programs, 24% require lectures, 17% require written reports, and 6% require extra clinical shifts. The EMRDs rated the educational value of morbidity and mortality conference as outstanding (11%) or excellent (53%), and rated their systems for identifying key resident errors as outstanding (0%), excellent (14%), or good (47%). Conclusions: All emergency medicine residency programs have systems to track and report resident errors. Resident participation varies widely, as does resident remediation processes. Most EMRDs are satisfied with their systems but few EMRDs rate them as excellent in the detection or prevention of clinical errors.