bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluating Child Sexual Abuse in the Emergency Department: Clinical and Behavioral Indicators
Authors: Kini Narendra , Brady William J. , Lazoritz Stephen
Published: September 2008

Child sexual abuse is an increasingly common problem. This article reviews the current clinical and behavioral indicators that will aid the emergency physician when evaluating and managing this condition. The most common differential diagnoses are described and a general approach to this diagnosis is suggested. Adopting a multidisciplinary method when evaluating this problem will lessen the anxiety facing the examining physician and provide a better outcome for the child, parents, and community.
Incremental Benefit of Individual American College of Surgeons Trauma Triage Criteria
Authors: Henry Mark C. , Hollander Judd E. , Alicandro Jeanne M. , Cassara Guy , O'Malley Susan , Thode Henry C.
Published: September 2008

Objective: To determine the incremental benefit of individual American College of Surgeons (ACS) trauma triage criteria for prediction of severe injuries after consideration of concurrent physiologic, anatomic, mechanism, or “other” criteria.

Methods: A prospective cross‐sectional study of motor vehicle crash victims transported to any of the 12 hospitals in a suburbadrural county by local ambulance services was performed. Demographic and individual ACS criteria were collected using structured data instruments. EDs provided patient disposition within 24 hours of patient arrival. Medical records were reviewed. Major outcomes were admission, operative interventions (OR), major nonorthopedic operative interventions or death (Maj‐OR), and injury severity score (ISS). To optimize sensitivity and specificity of out‐of‐hospital triage decision rules, receiver operating characteristic (ROC) curves were derived.

Results: Of 1,545 patients, 13% were admitted; 6% had OR; 1% had Maj‐OR; and 3% had ISSs ≥16. For all outcomes, the most useful criteria were physiologic and anatomic. Some additional criteria (crash speed >20 mph, ≥30‐inch vehicle deformity, axle displacement) substantially worsened specificity. with minimal or no improvement in sensitivity. For example, the optimal ROC curve for Maj‐OR was determined by a systolic blood pressure <90 mm Hg, Glasgow Coma Scale (GCS) score 43, respiratory rate (RR) <10 or >29, death of a same‐car occupant, penetrating injury, and/or ≥24‐inch opposite‐side compartment intrusion (sensitivity, 85%; specificity, 87%). An ISS ≥16 was predicted by GCS score <13, RR <10 or >29, penetrating injury, 2 proximal long bone fractures, flail chest, ≥24‐inch opposite‐side compartment intrusion, patient ejection, rollover, and/or age <5 or >55 years (sensitivity, 86%; specificity, 70%).

Conclusion: Physiologic and anatomic trauma triage criteria predicted increased hospital resource utilization and severe injury. On the other hand, when used concurrently with physiologic, anatomic, and “other” criteria, some mechanism criteria worsen specificity with negligible improvement in sensitivity. In particular, crash speed >20 mph and ≥30‐inch vehicle deformity had little predictive value for all outcomes.
Continuous vs Intermittent Nebulized Albuterol for Emergency Management of Asthma
Authors: Khine Hnin , Fuchs Susan M. , Saville Alan L.
Published: September 2008

Objective: To compare the efficacy and safety of continuous nebulized (CN) albuterol therapy with those of intermittent nebulized (IN) albuterol therapy in the ED treatment of children with moderate to severe asthma exacerbations.

Methods: A prospective, randomized, single‐blind study was conducted at a children's hospital ED. Patients aged 2 to 18 years with a moderate to severe asthma exacerbation (asthma score ≥8) were enrolled. Patients were randomized to receive either IN albuterol (0.15 mg/kg/dose every 30 min) or CN albuterol (0.3 mg/kg/ hr) for a maximum of 2 hours. All patients received prednisone at entry. All released patients were evaluated by telephone, 48 hours after the ED visit. Estimates of respiratory therapist (RT) time commitments for the 2 delivery systems were calculated.

Results: There were 35 patients assigned to IN therapy and 35 to CN therapy. Nine of the 35 patients (26%) in the IN group and 8 of the 35 patients (22%) in the CN group were hospitalized (p = NS). Although the durations of ED therapy were comparable in the 2 groups, the time spent by the RTs in delivering asthma therapy was significantly less for the CN group than it was for the IN group (30.3 min vs 51.9 min per patient; p < 0.001). There was no major adverse effect in either study group.

Conclusion: There was no difference in efficacy or safety between CN therapy and IN therapy in the ED management of moderate to severe asthma exacerbations in children. Moreover, CN therapy provided a significant time savings in the delivery of asthma therapy to patients in a busy ED.
High Prevalence of Sexually Transmitted Diseases in Women with Urinary Infections
Authors: Berg Elijah , Benson Don M. , Haraszkiewicz Paula , Grieb Jerry , McDonald Jacqueline
Published: September 2008

Objective: To determine the prevalence and factors associated with unrecognized sexually transmitted diseases (STDs) in women who had pelvic examinations and were subsequently released from the ED with a sole diagnosis of urinary tract infection (UTI).

Methods: A 3‐month retrospective chart review was performed in an urban teaching hospital ED (>70,000 visits/year). Women aged 12–45 years who had pelvic examinations and were released from the ED with a sole diagnosis of UTI were included. Patient complaints, physical findings, and laboratory results were reviewed. Laboratory evaluations included the complete blood count, urinalysis, urine pregnancy test, and cervical cultures for Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas.

Results: Of the 94 women who met study criteria, 53% had proven STDs (19% N. gonorrhoeae 22% C. trachornaris 33% Trichomonas). There was no difference between the patients with positive and negative tests for STDs with regard to complaints, physical findings, and laboratory results (all p > 0.05).

Conclusions: Women undergoing pelvic examinations who are subsequently released, from this urban ED with the diagnosis of UTI have a high (>50%) prevalence of occult STDs. No complaint, physical finding, or laboratory result reviewed was associated with the risk of an STD. Consideration should be given to empirical antibiotic therapy in similar urban populations.
Shock Index as a Marker for Significant Injury in Trauma Patients
Authors: King Randall W. , Plewa Michael C. , Buderer Nancy M. Fenn , Knotts F. Barry
Published: September 2008

Objective: To determine whether the shock index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), is a useful marker for significant injury in trauma patients.

Methods: A retrospective database analysis was used to relate the SI to the clinical measures: death within 24 hours, injury severity score (ISS) ≥16, intensive care unit (ICU) stay ≥1 day, and amount of blood transfused (BT) ≥2 units. Consecutive trauma patients seen at one level I trauma center over a 24‐month period were reviewed; excluded were patients not requiring trauma team consultation, or those with either incomplete records, severe head injury (Glasgow Coma Scale score ≥8), or age 14 years. The SI was calculated from ED admission vital signs. Receiver operating characteristic (ROC) curves were used to find the value of the SI that maximized the sum of sensitivity and specificity for predicting each measure, separately; a separate analysis was done to determine the optimal SI threshold for predicting any of the severity measures.

Results: 1,101 cases met study criteria. The optimal SI values (by ROC analysis) for predicting the severity measures were: 1.10 for death <24 hours, 0.71 for ISS ≥16, 0.77 for ICU ≥1 day, and 0.85 for BT ≥2 units. The optimal SI value (by ROC analysis) for any of the above measures was 0.83; use of this SI cutoff provided a sensitivity of 37% (95% CI 32–42%), a specificity of 83% (95% CI 80–87%). and a negative predictive value of 58% (95% CI 54–61%) for any measure. This SI threshold predicted between 24% fewer cases and 4% more cases of poor outcome than did the optimal thresholds HR and SBP, respectively.

Conclusion: The optimal SI threshold performed similarly to the optimal threshold HR or SBP for prediction of injury severity.
A Multisite Survey of Factors Contributing to Medically Unnecessary Ambulance Transports
Authors: IV Anthony J. Billittier , Moscati Ronald , Janicke David , Lerner E. Brooke , Seymour Jeffrey , Olsson Daniel
Published: September 2008

Objectives: To determine the social and demographic factors associated with medically unnecessary ambulance utilization, and to determine the willingness of patients to use alternate modes of transportation to the ED.

Methods: A multisite prospective survey was conducted of all patients arriving by ambulance to 1 suburban and 4 urban EDs in New York State during a l‐week period.

Results: For 626 patients surveyed, 71 (11.3%) transports were judged medically unnecessary by the receiving emergency physicians using preestablished guidelines. The patient's type of medical insurance and age were significant predictors of unnecessary ambulance transport (stepwise forward logistic regression analysis). Of the 71 patients whose ambulance transports were deemed medically unnecessary, 42 (59%) were Medicaid recipients and 53 (74%) were <40 years of age. The most common reason for using ambulance transport was lack of an alternate mode of transportation (38.5%), although 82% would have been willing to use an alternate mode of transportation if it had been available. Of those who had medically unnecessary ambulance use, 30% indicated that they would not pay for the ambulance service if billed and 50% believed the cost of their ambulance transports was <$100. More than 85% of the patients whose ambulance transports were deemed medically unnecessary were unemployed; and nearly 85% reported a net annual income of <$20,000. While 33% had a primary care provider, only 22% had attempted to contact their doctors before requesting an ambulance.

Conclusions: Patient age 40 years and Medicaid coverage were associated with medically unnecessary ambulance use. Those patients for whom ambulance use was considered medically unnecessary commonly had no alternate means of transportation. Providing alternate means of unscheduled transportation may reduce the incidence of unnecessary ambulance use.
Magnesium Attenuates the Neutrophil Respiratory Burst in Adult Asthmatic Patients
Authors: Cairns Charles B. , Krafi Monica
Published: September 2008

Introduction: IV magnesium (Mg2+) has been proposed as an emergent treatment for acute asthma exacerbations. Recent studies have focused on the effects of Mg2+ on bronchial smooth muscle, yet asthma is primarily an inflammatory disease.

Objective: To assess the effects of Mg2+ on the neutrophil respiratory burst of adult patients with asthma. Methods: A prospective, blind study of volunteer adult asthmatic patients was performed. The patients' polymorphonuclear neutrophils (PMNs) were isolated, purified, and placed into phosphate‐buffered saline with the following test conditions: concentrations of magnesium chloride (MgCl2) added: 0 mmol MgCl2, 1 mmol MgCl2 (low), and 10 mmol MgCl2 (high) both with and without the calcium (Ca) ionophore A23187 (0.1 mmol). PMNs were activated using N‐formyl‐methionyl‐leucyl‐phenylalanine (fMLP) (10 pmol), and the production of superoxide (O‐2) was measured by the spectrophotometric reduction of cytochrome c.

Results: Mg2+ reduced activated PMN O‐2 production compared with that for no Mg2+ (1.0 ± 0.1 nmol O‐2/5 ± 105 PMN/min) in both low (‐0.52* ± 0.3 nmol O‐2/5 ± 105 PMN/min) and high (‐0.76* ± 0.3 nmol O‐2/5 ± 105 PMN/min; *p < 0.05) concentrations. The addition of A23187 increased O‐2 production in both the high (0.53* ± 0.02 nmol O‐2/5 ± 105 PMN/min) and the low (1.5* ± 0.6 nmol O‐2/5 ± 105 PMN/ min) Mg2+ groups, with no change in the control group (1.2 ± 0.2 nmol O‐2/105 PMN/min).

Conclusions: In clinically relevant concentrations, Mg2+ attenuates the neutrophil respiratory burst in adult asthmatic patients. Mg2+ appears to affect PMNs by interfering with extracellular Ca2+ influx. Mg2+ may have a beneficial anti‐inflammatory effect in asthmatic individuals.
Reliability of Faculty Clinical Evaluations of Non‐Emergency Medicine Residents during Emergency Department Rotations
Authors: Ryan James G. , Mandel Francine S. , Sama Andrew , Ward Mary E.
Published: September 2008

Objectives: To assess the reliability of faculty evaluations of non‐emergency medicine (non‐EM) residents during clinical ED rotations and to determine the effect that the “leniency” of grading by these evaluators had on the residents' final evaluations.

Methods: A prospective, observational study of the evaluation patterns of EM faculty was performed in an academic ED (50, 000 visits yearly census). Each resident was evaluated on a daily basis by a board‐certified or board‐prepared emergency physician. The evaluation form rated 7 characteristics, but only the rating for overall clinical competence was used for data analysis. If an attending evaluated the same resident more than once, only the first evaluation was used to avoid bias from prior exposure. The scoring patterns of the evaluators, both individually and in groups, were analyzed using 1‐way analysis of variance. Evaluator leniency was estimated using the mean evaluator score across all residents. Since each resident was evaluated by a different combination of evaluators, evaluator leniency for each resident was estimated from the mean leniency of the evaluators who specifically assessed that resident.

Results: During the period of the study, 66 residents rotated through the ED, yielding a total of 401 evaluations. When the scoring patterns of individual evaluators were analyzed, a high degree of variability was found in the mean scores (range 5.23–8.09) and SDs (range 0.45–1.55) across evaluators; p = 0.0001. There was a moderate correlation between the mean overall competence score received by each resident and that resident's evaluators' leniency, r = 0.52; p = 0.0001.

Conclusions: There is significant variability in the scoring patterns of individual evaluators. The evaluators in this study showed large variations in both leniency (as measured by their mean score) and range restriction (as measured by their SD). The differences in evaluator scoring leniency have a moderate correlation with the overall score received by the resident.
A Model for an Integrated Emergency Medicine/Trauma Service
Authors: Hartmann John , Gabram Sheryl , Jacobs Lenworth , Libby Mark
Published: September 2008

Objective: To describe a model for an integrated multidisciplinary trauma service and to compare survival outcomes for patients resuscitated by either emergency medicine (EM) or surgical housestaff assigned to the trauma service.

Methods: A prospective observational study was performed using injured patients evaluated in the trauma room at Hartford Hospital from July 1 through December 31, 1995. Inclusion criteria included an ICD‐9‐CM code of 800 through 959.9 and any of the following: transfer from another hospital, admission to the intensive care unit, hospitalization for ±23 hours, survival probability of ±90%, or Abbreviated Injury Score of ±3. Patients were excluded for burns necessitating transfer to a burn unit for definitive care, and for missing data elements that prevented a patient from being analyzed by the TRISS method. Data elements included mechanism of injury, Injury Severity Score, Revised Trauma Score, probability of survival, age, gender, and whether an EM resident was team leader. Patients in the EM cohort (group 1) were compared with patients for whom a surgical resident was team leader (group 2) for all data elements and for hospital survival. TRISS analysis was performed to evaluate outcomes in comparison with national norms.

Results: After exclusions, 609 patients were left for analysis. There were 141 (30%) resuscitated with an EM resident as team leader. No significant difference was found for matched variables between the groups. Both groups had good comparability with the Major Trauma Outcome Study (MTOS) database baseline, with M scores of 0.949 and 0.942, respectively. Outcomes for both groups also compared favorably with the MTOS norm for survival, with Z scores of 2.38 and 2.35 for groups 1 and 2.

Conclusions: These results suggest that in this model of integrated EW trauma service, equivalent survival outcomes occur whether EM or surgery housestaff act as team leaders.
Burnout and Its Correlates in Emergency Physicians: Four Years' Experience with a Wellness Booth
Authors: Goldberg Richard , Boss R. Wayne , Chan Linda , Goldberg Janet , Mallon William K. , Moradzadeh Doris , Goodman Eric A. , McConkie Mark L.
Published: September 2008

Objective: To measure the degree of burnout among emergency physicians (EPs) and to identify and rank predictive factors.

Methods: Using the Maslach Burnout Inventory as well as a 79‐item questionnaire, a cross‐sectional survey was conducted for physician registrants at the Annual Scientific Assemblies of the American College of Emergency Physicians from 1992 to 1995. Degrees of burnout were stratified into low, moderate, and high ranges. University and stepwise multiple regression analyses were conducted to identify and rank correlates to burnout scores.

Results: Of 1, 272 registrants taking the inventory, 60% registered in the moderate to high burnout ranges. Twenty‐one correlates were identified. These were classified broadly in terms of negative perceptions of self, negative practice habits and attitudes, and unhealthy lifestyles. The most highly ranked correlates were: self recognition of burnout, lack of job involvement, negative self‐assessment of productivity, dissatisfaction with career, sleep disturbances, increased number of shifts per month, dissatisfaction with specialty services, intent to leave the practice within 10 years, higher levels of alcohol consumption, and lower levels of exercise. Age and years of practice were not significant predictors of burnout. Projected attrition rates were 7.5% over 5 years and 25% over 10 years.

Conclusions: Elevated levels of burnout exist among a substantial percentage of surveyed EPs. However, there is evidence for a “survivor” category of practitioners for whom burnout either does not develop or is a reversible process. The projected attrition rate over 5 and 10 years appears to be no greater than that of the average medical specialty.
New–onset Atrial Fibrillation: When Is Admission Medically Justified?
Authors: Mulcahy Beth , Coates Wendy C. , Henneman Philip L. , Lewis Roger J.
Published: September 2008

Objective: To determine 1) the percentage of patients with new–onset atrial fibrillation for whom admission is medically justified and 2) whether those patients for whom hospitalization is medically justified can be reliably identified in the ED.

Methods: A retrospective, descriptive cohort analysis was performed using consecutive adult patients with new–onset atrial fibrillation seen in an urban, county hospital ED from 1987 through 1992. Admissions were categorized as medically justified if patients were hypotensive (systolic blood pressure <90 mm Hg), had a diagnosis other than new–onset atrial fibrillation that warranted admission, or had a significant complication during the ED stay or during the subsequent hospitalization. The need for admission was considered to have been apparent during the ED evaluation if the patient fulfilled the above criteria for a medically justified admission while in the ED.

Results: Admission was medically justified for 143 of the 216 patients (66%; 95% CI 60–71%) admitted to our institution. For those patients whose admissions were medically justified, the most common concurrent conditions were congestive heart failure and chest pain suggestive of myocardial ischemia. The need for admission was apparent during the ED evaluation for 140 of the 143 patients (98%; 95% CI 94–100%) whose admissions were categorized as medically justified.

Conclusion: Approximately one third of patients with new–onset atrial fibrillation may not require admission to the hospital. Most patients (98%) for whom admission is medically justified can be reliably identified during the ED evaluation.
Sertraline Overdose
Authors: Lau G. T. , Horowitz B. Zane
Published: September 2008

Objective: To determine the clinical presenting signs and symptoms in presumed overdoses of sertraline, a recently approved antidepressant.

Methods: A prospective study involving five western regional poison control centers was performed to evaluate the clinical manifestations of presumed sertraline ingestions (overdoses). Information about calls pertaining to sertraline ingestions was recorded on a standard data collection form. Data including subject age, sex, amount ingested, coingestants, time interval to evaluation, vital signs, presenting signs and symptoms, ECG abnormalities, treatment given, disposition, and length of stay in the ED were collected over a nine–month period.

Results: Of 42 ingestions reported, two were adverse reactions to normal doses and 40 were overdoses. Stated amounts of sertraline ingested ranged from 50 to 8, 000 mg (mean 1, 579 mg). Mean patient age was 35. 3 years (range 1 to 69 years). Mean interval to presentation was 3. 0 hours. Seventeen of the 40 patients ingested sertraline alone. Of this subgroup, ten had no sign or symptom. The most common abnormalties reported in isolated sertraline overdose were tremor, lethargy, and nausea. Less common findings included agitation, confusion, and vomiting. There was no significant morbidity in this subgroup of presumed isolated sertraline ingestion. Of the 23 patients who ingested other medications along with sertraline, four were asymptomatic. Benzodiazepines and alcohol were the most frequently coingested substances. Lethargy, nausea, dry mouth, and mydriasis were the most common features reported in this group. Treatment included lavage, activated charcoal, and observation. Twelve patients were admitted for 24–hour observation, none had an adverse outcome. Of the patients released from the ED, the mean length of stay was 3. 9 hours.

Conclusion: Sertraline is commonly taken in overdose with other medications or alcohol. The signs and symptoms that develop in association with an overdose of sertraline appear to be minor and of short duration.
The Minimum Clinically Important Difference in Physician–assigned Visual Analog Pain Scores
Authors: Todd Knox H. , Funk Joseph P.
Published: September 2008

Objective: To determine the minimum clinically important difference in physician–assigned visual analog scale (VAS) pain scores.

Methods: Physicians attending emergency medicine didactic conferences were enrolled in this descriptive study. The subjects sequentially reviewed 11 written scenarios describing patients in moderate to severe pain. The subjects rated their perceptions of each patient's pain on a 100–mm VAS, then contrasted this pain with that of the previous patient scenario. For these contrasts, the subjects chose one of five responses: “much less,” “a little less,” “about the same,” “a little more,” or “much more” pain. The minimum clinically important difference was defined as the difference between scores for scenario pairs in which one patient's pain was rated “a little less” or “a little more” severe.

Results: There were 230 comparisons by 23 health professionals. Of these, 64 were judged “a little less,” and 56 “a little more,” painful. These 120 comparisons, with their pain score differences, were used to determine the minimum clinically important difference. Pain judged to be “a little less” or “a little more” severe was associated with a mean difference in VAS scores of 18 mm (95% CI 16–20 mm), corresponding to a decrement of 23% (95% CI 20–26%) from the more painful scenario.

Conclusions: Pain research outcomes involving a <18–mm difference, or a 23% decrement in physician–assigned VAS pain scores, although statistically significant, may have little clinical importance.
Serial Electrocardiograms for Chest Pain Patients with Initial Nondiagnostic Electrocardiograms: Implications for Thrombolytic Therapy
Authors: Silber Steven H. , Leo Paul J. , Katapadi Manmohan
Published: September 2008

Objectives: To determine the proportion of acute myocardial infarction (AMI) patients without ST–segment elevation who subsequently develop ST–segment elevation during their hospital courses; and to compare demographics and presenting features of AMI patient subgroups: those with initial ST–segment elevation, those with in–hospital ST–segment elevation, and those with no ST–segment elevation.

Methods: A retrospective cohort analysis of admitted chest pain patients who had a hospital discharge diagnosis of AM1 was performed. Each chart was examined for initial ECG interpretation, serial ECG analysis, patient age, gender, cardiac risk factors, in‐hospital survival, time between sequential ECGs, and number of ECGs performed within the first 48 hours of hospital admission.

Results: Of the 114 charts reviewed, 20 patients had ECGs meeting thrombolytic criteria on arrival. Of the 94 AM1 patients who had nondiagnostic ECGs on arrival, 19 (20%) subsequently developed ECG changes meeting thrombolytic criteria. Seven patients developed these changes within eight hours of the initial ECG, four from eight to 12 hours after, two from 12 to 24 hours after, and six more than 24 hours after. Most patients who had documented AMIs did not develop ECG criteria for thrombolytic therapy during their hospitalizations. Male gender and smoking history were more commonly associated with late ST‐segment elevation for those presenting with nondiagnostic ECGs. All the patients who had late diagnostic ECG changes survived to hospital discharge. Serial ECGs were performed more frequently in the group who had initially diagnostic ECGs and least frequently in the group who did not develop ST‐segment elevation during their hospitalizations.

Conclusions: Most patients with AM1 do not meet ECG criteria for the administration of thrombolytic therapy. A significant minority (20%) of the admitted chest pain patients with subsequently confirmed AMIs developed ECG criteria for thrombolytics during their hospitalizations. Further attention to such patients who have delayed ST‐segment elevation is warranted. A standardized in‐hospital serial ECG protocol should be considered to identify admitted patients who develop criteria for thrombolytic or other coronary revascularization therapy.
Mycobacterial Sepsis Following Intravesical Instillation of Bacillus Calmette–Guérin
Authors: Garyfallou Garyfallos T.
Published: September 2008

Intravesical bacillus Calmette–Guerin (BCG) administration for bladder cancer may lead to BCG dissemination in the compromised host. A case of a 63–year–old man with shock secondary to BCG sepsis is reported. The recognition and treatment of disseminated BCG infection are discussed. In addition to standard therapy for urosepsis, early therapy with steroids and coverage with antitubercular medications should be initiated for patients with this condition. In general, the author recommends that all febrile patients who have received BCG immunotherapy within three years, and who have no obvious source for their fever, have acid–fast bacilli blood cultures done for Mycobacterium bovis, and that these patients be admitted to the hospital for further evaluation.
Emergency Physician Terminations: Doing It Right
Authors: Zun Leslie S.
Published: September 2008

Emergency physicians (EPs), like other specialists in medicine, can be terminated from their positions. Little has been written about the process of physician termination. It is important that this process be well thought–out and performed in a professional manner to ensure that there is no undue damage to the physician or to the institution. The institution must be aware of the effects of terminations on its ability to recruit and retain EPs. To properly terminate a physician employee, the physician manager must use the appropriate termination rationale, ensure appropriate performance evaluations, provide for remediation, understand the psychology of termination, and address the alternatives to termination prior to the termination. Indeed, the hiring process itself must address the grounds on which termination may occur. Successful terminations are performed by planning the process, reviewing the file and the contract, arranging the meeting, examining the termination process, and considering the legal implications and due process issues.
Rapid Improvement of Acute Pulmonary Edema with Sublingual Captopril
Authors: Hamilton Richard J. , Carter Wallace A. , Gallagher E. John
Published: September 2008

Objective: To test the hypothesis that sublingual captopril produces a more rapid improvement of acute pulmonary edema (APE) than does placebo, when added to a standard regimen of O2, nitrates, morphine, and furosemide.

Methods: Prospective, randomized, double‐blind, placebo‐controlled clinical trial in an urban teaching hospital ED. Adults brought to the ED with APE were given captopril or placebo sublingually Every 5 minutes a clinical APE distress score (APEX) was obtained.

Results: Over the first 40 minutes of treatment, the mean APEXs were significantly better for the patients given captopril [p < 0. 001, F = 14. 5, one‐way (repeated‐measures) analysis of variance (ANOVA)]. At 30 minutes, the patients given captopril had a mean APEX improvement of 43% (i. e., to 57% of initial distress); the group given the current standard regimen plus placebo improved only 25% (i. e., to 75% of initial distress; p = 0. 03, multiway ANOVA). In addition, there was less respiratory failure necessitating mechanical ventilation in the captopril patients (9%) vs the placebo patients (20%), which did not achieve significance (p = 0. 10, Fisher's exact test).

Conclusion: In APE, the addition of sublingual captopril to the standard regimen of O2, nitrates, morphine, and furosemide produces more rapid clinical improvement than does the standard regimen alone.
Pediatric Trauma: Enabling Factors, Social Situations, and Outcome
Authors: Hartzog Timothy H. , Timerding Beverly L. , Alson Roy L
Published: September 2008

Objectives: 1) To determine, for severely injured pediatric patients, which enabling factors and social situations are associated with the most severe and costly injuries; 2) to determine which subsets of patients are affected by particular enabling factors; and 3) to determine which enabling factors are associated with death.

Methods: Retrospective chart review of patients included in a pediatric trauma registry at a level I trauma center, plus review of medical examiner reports for deaths declared at the scene for one year. Abstracted data included age, gender, enabling factors (e. g., abuse/assault, neglect, endangerment, and nonuse of safety measures), mechanisms of injury, Injury Severity Scale (ISS) score, length of stay, need for intensive care unit (ICU) care, and expense.

Results: Records were reviewed for 336 identified children. There was a 2: 1 male‐to‐female ratio; 9. 5% died, 3. 5% at the scene. Active endangerment or neglect was associated with death (p = 0. 0004). However, the nonuse of safety devices was more common and resulted in a higher absolute number of deaths. Similarly, while inadvertent gunshot wounds, intentional injury, and environmental mishaps were more commonly lethal, motor vehicle crashes (MVCs) were more common and claimed the most lives. Cost was highest for the patients aged 14–16 years, in part reflecting the larger number of MVCs.

Conclusion: The severity of pediatric trauma is largely influenced by the mechanism of injury. Our data highlight the importance of enabling factors for such injuries overall and as a function of age group (reflecting developmental status). While injury prevention education for caregivers is necessary, the incorporation of passive safety measures also is vital for decreasing injuries and their severity.
Analysis of Hispanic Motor Vehicle Trauma Victims in Illinois, 1991–1992
Authors: Lee Patricia , Orsay Elizabeth , Lumpkin John , Ramakrishman V. , Callahan Edward
Published: September 2008

Objective: 1) To develop a profile of Hispanic motor vehicle trauma victims in Illinois, 2) to ascertain whether differences exist between Hispanic and general‐Illinois‐population motor vehicle trauma victims, and 3) to identify potential target areas for future injury intervention programs.

Methods: A retrospective analysis of Illinois motor vehicle trauma patients admitted from July 1991 to June 1992 was made. Participants were motor vehicle trauma victims (drivers and passengers) who presented to one of 73 level I or level II trauma centers throughout Illinois and were entered into the Illinois Trauma Registry (ITR) from July 1, 1991 through June 30, 1992.

Results: Of the 12, 299 motor vehicle trauma victims in the ITR, 771 (6. 3%) were Hispanic, 8, 979 (73. 0%) were white, 1, 115 (9. 1%) were black, and 1, 434 (11. 6%) were other. When compared with the other racial groups, the group of Hispanic victims were younger (25. 2 vs 33. 2 years), had higher male predominance (72. 8% vs 60. 9%), and had the lowest rate of safety equipment/occupant restraint use (21. 7% vs 34. 7%). A high alcohol use rate (30. 7%) and high mean serum ethanol levels (44 mmol/L; 0. 2 mg%) were noted. When contrasted with other racial/ethnic groups, the Hispanic victims had lower Injury Severity Scale scores (p < 0. 001), but mean hospital charges tended to be higher, with fewer alternative sources of payment (p < 0. 001).

Conclusion: Using age‐adjusted data from the ITR, Hispanic motor vehicle trauma victim features differ significantly from those of other racial groups. Effective health maintenance and injury prevention strategies should address the basis for these differences.
Domestic Violence: Diurnal Mismatch between Need and Availability of Services
Authors: Birnbaum Adrienne , Calderon Yvette , Gennis Paul , Rao Rama , Gallagher E. John
Published: September 2008

Objective: To determine whether a diurnal discordance exists between need and availability of services for victims of domestic violence.

Methods: A consecutive sample of women presenting to a municipal hospital ED with physical injuries suspected to be related to domestic violence were entered into a registry. Date and time of presentation and perceived need for services information were collected from all patients who answered affirmatively a screening question for domestic violence and whose conditions did not preclude administration of the data collection instrument. The Social Service Departments of all of the 53 911–receiving hospitals in New York City were contacted to ascertain availability of social services for victims of domestic violence by time of day.

Results: Twenty‐eight of 32 (88%; 95% CI: 71%, 97%) victims of domestic violence presented to the ED during hours other than weekday 9 am to 5 pm. Of these, 63% desired counseling, 32% lacked a safe place to go, and 82% had children. Of those who had children, 48% were concerned for the children's safety. In hospital social services were universally available weekday daytime (9 AM to 5 pm) but were available in only 11 % of hospitals (95% CI: 4%, 23%) at other times.

Conclusion: Approximately nine of ten victims of domestic violence presented to the ED during hours when only about one hospital in ten can provide the special services these patients require. A marked diurnal mismatch appears to exist between availability of domestic violence services in New York City and the need for these services as measured by a representative sample drawn from an ED population.
Continuous Quality Improvement Reduces Length of Stay for Fast‐track Patients in an Emergency Department
Authors: Fernandes Christopher M. B. , Christenson James M. , Price Ann
Published: September 2008

Objective: To demonstrate how continuous quality improvement (CQI) can identify rational and effective means to reduce length of stay for minor illness/injury in an ED.

Methods: A CQI team documented the process of fast‐track (FT) patient flow and prioritized the causes of delay. In Phase I, two solutions were implemented. In this Phase II of the study, three changes were implemented, including expansion of the FT area, realignment to provide a full‐time FT nurse, and a detailed, stricter triage classification. The outcome was assessed by examining the interval from presentation to release from the ED (length of stay; LOS). Differences were ascertained by analysis of variance for consecutive FT patients not requiring radiography, ECG, or blood testing. Intervals from three pre‐Phase II intervention 48‐hour periods and one post‐Phase II intervention 48‐hour period were analyzed.

Results: Before the Phase I changes, the mean ± SD LOS was 92 ± 46 min. After the Phase I changes, the LOS was 67 ± 31 min. After the Phase II changes, this was reduced to 57 ± 34 min (p < 0. 05).

Conclusion: The formal application of CQI techniques in the ED can change patient flow and reduce LOS for FT patients.
Inability to Follow up ED Patients by Telephone: There Must Be 50 Ways to Leave Your Number
Authors: Adams Stephen L. , Thompson David A.
Published: September 2008

Objective: To determine the ability to complete follow‐up home telephone calls to ED patients.

Methods: A retrospective review of the ability to reach 4, 741 patients called during a posttreatment patient satisfaction survey of visits to a suburban community hospital ED.

Results: Only 54. 9% of all patients called could be contacted after three or fewer phone calls. Of the 2, 139 (45. 1%) who could not be reached, there was no answer for 1, 260 (58. 9%), despite three telephone calls to a number currently in service. A significant minority (21. 1%) had given nonworking numbers. Another 12. 4% indicated that no one by the name of the patient lived at the number called, and 2. 9% of the respondents alleged that the patient was deceased.

Conclusions: Almost half of the patients who present to the ED and supply home telephone numbers give telephone numbers at which they cannot be reached in follow‐up. Using telephone follow‐up alone to reach patients seen in the ED may be an unreliable method of communication.
A Prospective Study of In‐line Skating: Observational Series and Survey of Active In‐line Skaters—Injuries, Protective Equipment, and Training
Authors: Adams Stephen L. , Wyte Collette D. , Paradise Mark S. , del Castillo Jorge
Published: September 2008

Objectives: 1) To assess the relationship between types of injuries incurred and training and protective equipment worn by adults injured while in–line skating; 2) to observe the type and amount of protective equipment worn by in–line skaters while skating; and 3) to survey active in–line skaters about formal training, protective equipment, and history of injuries incurred, and the effect of such injuries on the protective equipment subsequently worn.

Methods: A prospective study of consecutive adult patients presenting to the ED for evaluation of in–line skating injuries; a consecutive–series observational study of active in–line skaters to assess protective equipment worn; and a survey of selected active in–line skaters. Eighty–five adult patients were included who presented with a history of injury related to in–line skating to the EDs of an urban academic medical center, a suburban academic–affiliated hospital, and a community hospital. Four hundred eleven active in–line skaters on the Chicago lakefront were observed for protective equipment worn, 91 of whom participated in the survey.

Results: Of those presenting to the ED with injuries, only 15% indicated that they had received formal inline skating instruction. Of the ED patients, 50% wore no protective equipment; overall, 6% wore a helmet; 44%, wrist protection; 23%, knee protection; and 19%, elbow protection. Only 2% wore all of the above equipment. The primary mechanism of injury reported was a loss of balance (58%); others included collision with objects (25%), collision with bicycles (11%), and collision with cars (5%). Fractures or dislocations occurred in 48% of the patients; 6% had head injuries necessitating CT scans. Those who wore no protective gear were more likely to require hospital admission (p < 0.05). Of the 411 in–line skaters observed, 157 (38%) wore no protective equipment. Compared with the injured group presenting to the ED, fewer observed participants were without protection (p < 0.(35). Among those surveyed, prior injury was not associated with the subsequent use of protective gear.

Conclusion: Patients who present to the ED for evaluation of in–line skating injuries have a high incidence of fractures/dislocations. Few injured or surveyed in–line skaters had formal training. Use of protective equipment by injured skaters was associated with a decreased likelihood of hospitalization. Observed in–line skaters more commonly wore protective gear than did those who presented to the ED with injuries.
The Impact of Health Maintenance Organization Care Authorization Policy on an Emergency Department before California's New Managed Care Law
Authors: Derlet Robert W.
Published: September 2008

Objective: To examine the effect on patient care of HMO–mandated calls for authorisation prior to ED evaluation. The study examined this phenomenon prior to implementation of a California law that discourages such calls.

Methods: Concurrent data were collected for patients who presented to the ED and who had authorization calls made to their HMOs prior to their ED evaluations during the period September through December 1994. Data collected included: 1) the number of authorization calls made, 2) the frequency that ED care was deemed unnecessary by the HMO, 3) the outcomes of patients denied authorization, and 4) the time and personnel involved in completing calls. Follow–up phone calls were made to patients who left the ED after the HMO denied authorization for payment.

Results: The total ED census was 19,935 patient visits for the four–month period. Authorization calls were made for 4,642 (23%) of the ED visits. There were 545 patients (12%) in this group who had authorization denied and only 29 (5%) chose to remain in the ED for continued evaluation. The total time required to complete a call ranged from 20 minutes to 2.6 hours. Authorization calls and denials caused the following problems: 1) patients for whom calls were made were subject to delays in ED care; 2) at least seven patients referred to HMO clinics were referred back to the ED because the patient was too sick to receive clinic care; 3) patients were inconsistently asked to sign an against–medical–advice form when they chose to leave with unstable conditions; and 4) high–risk patients denied authorization included patients with final diagnoses of ectopic pregnancy, acute myocardial infarction, pulmonary embolus, respiratory failure, and sepsis.

Conclusions: Calls for payment authorization prior to ED patient evaluation delay patient care and place some patients' health and safety in jeopardy.
Evaluation of Resident Performance and Intensive Bedside Teaching during Direct Observation
Authors: Cydulka Rita K. , Emerman Charles L. , Jouriles Nicholas J.
Published: September 2008

Objective: To describe the experience of a residency program in emergency medicine with an intensive observational evaluation of resident performance in the ED.

Methods: Each resident was directly observed and evaluated during a clinical shift four times each academic year: once by each residency codirector and twice by the resident's faculty advisor. The faculty members performed this evaluation outside of “clinical staffing time,” shadowing the resident for several hours in the ED during the resident's assigned shift. The resident and assigned faculty member discussed the patients' histories and physical examination findings and developed treatment plans together. Prior to initiation of the observation, the faculty were provided with guidelines for the evaluation of specific skills. Immediate feedback of strengths and deficiencies was provided to the resident.

Results: Subjective evaluations by faculty suggest that new insights into resident clinical strengths and weaknesses were determined using this approach. Objective scoring of resident performance demonstrated heterogeneity of skills between residents as well as inconsistency of skills for specific residents.

Conclusions: The program provided the faculty with protected teaching time, an opportunity to share clinical pearls, and unique insights into resident performance that are not obvious during standard clinical interactions.
Is Handwashing Teachable?: Failure to Improve Handwashing Behavior in an Urban Emergency Department
Authors: Dorsey Steven T. , Cydulka Rita K. , Emerman Charles L.
Published: September 2008

Objectives: To assess handwashing frequency according to CDC recommendations; and to test a simple intervention to increase handwashing compliance, designed for the unique setting of the ED.

Methods: A prospective, observational, before–and–after study design with a convenience sampling technique was used to assess handwashing compliance in the ED of a 742–bed urban, university–affiliated medical center with 65,000 visits annually. Emergency physicians (EPs), registered nurses (RNs), and nurse practitioners (NPs) were informed that their patient encounters were being monitored, but the nature of the study was kept confidential. A single observer evaluated individual EPs, RNs, and NPs in one–, two–, or three–hour blocks, recording compliance with CDC handwashing recommendations. After two weeks, brightly colored signs with CDC recommendations for handwashing were posted at all sinks and a copy of a related publication on handwashing by medical personnel was distributed to all staff. Handwashing behaviors were again observed.

Results: A total of 252 situations requiring handwashing were observed, 132 pre–intervention and 120 postintervention. Total handwashing, handwashing by each staff designation, and handwashing in each CDC recommendation category—‐except handwashing between contacts with different patients—‐all showed tendencies toward improvement, though none was significant (p > 0.05). Both the NPs and the RNs demonstrated significantly higher adherence to recommended handwashing between patients after the intervention than did the EPs (85% vs 71% vs 31%, p < 0.01 and p < 0.05, respectively).

Conclusion: Despite a trend in improvement of compliance with CDC recommendations, handwashing among ED personnel remained unacceptably low.
Level I Trauma Certification and Emergency Medicine Resident Major Trauma Experience
Authors: Howell John M. , Savitt Daniel , Cline David , Chisholm Carey D. , Kleinschmidt Kurt
Published: September 2008

Objective: American College of Surgeons (ACS) and Residency Review Committee for Emergency Medicine (RRC–EM) guidelines conflict regarding the role of emergency physicians in directing major trauma resuscitations. This article describes the impact of ACS level I trauma certification on emergency medicine (EM) resident trauma experience.

Methods: A written survey and a follow–up letter were sent to all 101 EM program directors as of August 16, 1994. The survey addressed demographics and trauma experience at hospitals designated by the RRC–EM as primary training sites.

Results: There were 95 (94%) survey respondents. Estimates of the percentage of trauma resuscitations directed by EM residents were significantly lower at level I centers (52% X 27%, 95% CI 45–59%) than they were at non–level I centers (70% X 30%, 95% CI 58–82%) (p < 0.01). There was no significant difference in trauma census between level I and non–level I centers. Of 14 respondents who said they were cited by the RRC–EM for inadequate trauma experience, ten (71%) were in ACS level I trauma centers (p = 1.0). Twelve of the 14 respondents cited for inadequate trauma experience were in either the Northeast or the Midwest.

Conclusions: EM residents direct a smaller percentage of major trauma resuscitations at ACS level I hospitals than they do at non–level I facilities. This finding is not offset by an increased trauma census at level I facilities and may be more pronounced in the Northeast and the Midwest.