bluuebunny/crossref_metadata_2025_split huggingface dataset:
Rapid Improvement of Acute Pulmonary Edema with Sublingual Captopril
Authors: Hamilton Richard J. , Carter Wallace A. , Gallagher E. John 
Published: September 2008

ABSTRACTObjective: 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

ABSTRACTObjectives: 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

ABSTRACTObjective: 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

ABSTRACTObjective: 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

ABSTRACTObjective: 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

ABSTRACTObjective: 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

ABSTRACTObjectives: 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

ABSTRACTObjective: 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

ABSTRACTObjective: 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

ABSTRACTObjectives: 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

ABSTRACTObjective: 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.
The Effect of Soft Cervical Collars on Persistent Neck Pain in Patients with Whiplash Injury
Authors: Gennis Paul , Miller Leslie , Gallagher E. John , Giglio James , Carter Wallace , Nathanson Noel 
Published: September 2008

ABSTRACTObjective: To assess the efficacy of soft cervical collars in the early management of whiplash‐injury‐related pain.Methods: A controlled, clinical trial was conducted in an urban ED. Adults with neck pain following automobile crashes indicated their initial degrees of pain on a visual analog scale. Patients with cervical spine fractures or subluxation, focal neurologic deficits, or other major distracting injuries were excluded. Patients were assigned to receive a soft cervical collar or no collar based on their medical record numbers. Pain at ≥ 6 weeks postinjury was coded as none, better, same, or worse, and analyzed as 3 dichotomous outcomes: recovered (pain = none); improved (pain = none or better); and deteriorated (pain = worse).Results: Of 250 patients enrolled, 196 (78%) were available for follow‐up. Of these patients, 104 (53%) were assigned to the soft cervical collar group, and 92 (47%) to the control group. These groups were similar in age, gender, seat position in the car, seat belt use, and initial pain score. Pain persisted at ≥ 6 weeks in 122 (62%) patients. The groups showed no difference in follow‐up pain category (p = 0.59). There was no significant difference between the 2 groups in complete recovery (p = 0.34), improvement (p = 0.34), or deterioration (p = 0.60). The study had a power of 80% to detect an absolute difference of at least 20% in recovery, 17% in improvement, and 7% in deterioration (2–tailed, ex = 0.05).Conclusions: Most patients with whiplash injuries have persistent pain for at least 6 weeks. Soft cervical collars do not influence the duration or degree of persistent pain.