bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Continuous Quality Improvement Approach to IL‐372 Documentation Compliance in an Academic Emergency Department, and Its Impact on Dictation Costs, Billing Practices, and Average Patient Length of Stay
Authors: Higgins III George L. , Becker Mary H. 
Published: January 2008

AbstractObjective: To determine whether continuous quality improvement (CQI) methodology could improve and maintain IL‐372 documentation compliance in an academic emergency department (ED). The impact on transcription costs, billing practices, and average patient length of stay was also analyzed. Methods: Baseline IL‐372 compliance data were collected and shared with staff during a multidisciplinary educational session. Faculty dictation became mandatory. Pocket‐sized dictation templates were provided. A Documentation Improvement Committee monitored outcomes. Each month of the study period, a compliance officer reviewed approximately 100 records. The following indicators were monitored: IL‐372 compliance rates, dictation rates, transcription costs, down‐coding rates, percentage of billable records, and average patient length of stay. Individualized results were provided to faculty. Results: During the ten‐month study period, compliance rates increased from 60% to 100% (p‐trend < 0.001), while dictation rates increased from 69% to 100% (p < 0.001). Rates of down‐coding adjustments improved from 54% to 2% (p‐trend < 0.001). The percentage of billable records increased from 65% to 100% (p‐trend < 0.001). Transcription costs increased a modest 16%. The average patient length of stay remained unchanged. Conclusion: The application of CQI methodology, combined with the availability of dictation, resulted in sustained improvement in IL‐372 compliance. This was associated with a parallel increase in dictation rates, although concurrent transcription costs increased only modestly. The percentage of billable records increased, while the number of charts requiring down‐coding decreased, both beneficial outcomes. Average length of stay was not adversely impacted by this added documentation requirement.
Anti—Interleukin‐6 Antibodies Attenuate Inflammation in a Rat Meningitis Model
Authors: Marby David , Lockhart Gregory R. , Raymond Richard , Linakis James G. 
Published: January 2008

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

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

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

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

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

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

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

Abstract Objective: To evaluate the frequency of pericardial effusion in patients presenting to the emergency department (ED) with unexplained, newonset dyspnea. Methods: This prospective observational study took place at an urban community hospital ED with a residency program and an annual census of 65,000 visits. Patients presenting between May 1999 and January 2000 with new‐onset dyspnea were eligible if they lacked any pulmonary, infectious, hematological, traumatic, psychiatric, cardiovascular, or neuromuscular explanation for their dyspnea after ED evaluation. Patients received a focused echocardiogram by certified emergency physicians. Data were recorded on standardized data sheets and studies were taped for review. Effusions were categorized as small when the fluid stripe measured less than 10 mm. Moderate‐sized effusions measured 10 to 15 mm. Large effusions measured more than 15 mm. Results: One hundred three patients were enrolled. Median age was 56 years (IQR 44, 95% CI = 32 to 67). Fourteen patients (13.6%, 95% CI = 8% to 23%) had effusions. Four had large effusions that explained their dyspnea and were admitted to cardiology; two of these effusions were hemorrhagic, and two were viral in origin. Seven patients with small effusions were treated conservatively at home. Three patients had moderate‐sized effusions; all were admitted but treated conservatively. Conclusions: While limited by small numbers, these preliminary data suggest that patients with unexplained dyspnea should be checked for pericardial effusion when bedside ED ultrasound is available.
Emergency Medicine Resident Patient Care Documentation Using a Hand‐held Computerized Device
Authors: Bird Steven B. , Zarum Robert S. , Renzi Francis P. 
Published: January 2008

Abstract Objective: To determine whether emergency medicine (EM) resident documentation of procedures, patient encounters, and patient follow‐ups improved after implementation of a personal digital assistant (PDA) hand‐held recording system. Methods: All first‐year EM residents were provided a PalmV (Palm, Inc., Santa Clara, CA) PDA. A customized patient procedure and encounter program was constructed using Pendragon Forms (Pendragon Software Corporation, Libertyville, IL) and loaded into each PDA. Residents were instructed to enter information on patients who had any of 21 procedures performed or were considered to be clinically unstable. These data were downloaded to the residency coordinator's desktop computer. The mean number of procedures, encounters, and follow‐ups performed per resident were then compared with those of a group of 36 historical controls from the three previous first‐year resident classes who recorded the same information using a handwritten card system. Data from the historical controls were combined and the means of each group were compared by Student's t‐test. Results: Mean documentation of three procedures was significantly increased in the PDA group versus the index card system: conscious sedation 5.8 vs. 0.03 (p < 0.000005), thoracentesis 2.2 vs. 0.0 (p = 0.002), ultrasound 6.3 vs. 0.0 (p = 0.002). The mean numbers of pericardiocenteses and unstable pediatric surgical patient evaluations were significantly decreased in the hand‐held group [from 1.2 to 0.4 (p = 0.03) and from 9.1 to 2.2 (p = 0.02), respectively]. Patient follow‐up documentations were not statistically different between the two groups. Conclusions: Use of a hand‐held PDA was associated with an increase in first‐year EM resident documentation in three of 20 procedures and a decrease in one procedure and the number of unstable surgical pediatric patient resuscitations. The overall time savings in constructing a resident procedure database, as well as the other uses of the PDAs, may make transition to a hand‐held computer‐based procedure log an attractive option for EM residencies.
Utility of an Initial D‐dimer Assay in Screening for Traumatic or Spontaneous Intracranial Hemorrhage
Authors: Hoffmann Mark E. , Ma O. John , Gaddis Gary 
Published: January 2008

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

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

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