Dizziness Presentations in U.S. Emergency Departments, 1995–2004

Objectives:  The objectives were to describe presentation characteristics and health care utilization information pertaining to dizziness presentations in U.S. emergency departments (EDs) from 1995 through 2004.
Methods:  From the National Hospital Ambulatory Medical Care Survey (NHAMCS), patient visits to EDs for "vertigo-dizziness" were identified. Sample data were weighted to produce nationally representative estimates. Patient characteristics, diagnoses, and health care utilization information were obtained. Trends over time were assessed using weighted least squares regression analysis. Multivariable logistic regression analysis was used to control for the influence of age on the probability of a vertigo-dizziness visit during the study time period.
Results:  Vertigo-dizziness presentations accounted for 2.5% (95% confidence interval [CI] = 2.4% to 2.6%) of all ED presentations during this 10-year period. From 1995 to 2004, the rate of visits for vertigo-dizziness increased by 37% and demonstrated a significant linear trend (p < 0.001). Even after adjusting for age (and other covariates), every increase in year was associated with increased odds of a vertigo-dizziness visit. At each visit, a median of 3.6 diagnostic or screening tests (95% CI = 3.2 to 4.1) were performed. Utilization of many tests increased over time (p < 0.01). The utilization of computerized tomography and magnetic resonance imaging (CT/MRI) increased 169% from 1995 to 2004, which was more than any other test. The rate of central nervous system diagnoses (e.g., cerebrovascular disease or brain tumor) did not increase over time.
Conclusions:  In terms of number of visits and important utilization measures, the impact of dizziness presentations on EDs is substantial and increasing. CT/MRI utilization rates have increased more than any other test.     

On-call Specialists and Higher Level of Care Transfers in California Emergency Departments

Objectives:  To survey California emergency department (ED) medical directors' impressions of on-call specialist availability and higher level of care (HLOC) transfer needs and difficulties and changes since the passage of the Emergency Medicine Treatment and Active Labor Act (EMTALA) final rule in 2003.
Methods:  The authors conducted a survey of all California ED medical directors from February to June 2006 with regard to the composition of the ED on-call panel and need for HLOC transfer. ED demographic data were obtained from the California Office of Statewide Health Planning and Development.
Results:  Overall response rate was 243 of 347 (70%). More than 80% of respondent EDs reported having internal medicine, obstetrics/gynecology (OB/GYN), and pediatrics on call. However, fewer than 60% of EDs reported cardiac surgery, otolaryngology, neurosurgery, plastic surgery, or vascular surgery on call. Specialists were less likely to be on call in rural EDs. On-call coverage was rated worse than 3 years ago for 10 of 16 specialties. Rural EDs were more likely, and trauma centers and teaching hospitals were less likely to transfer at least one patient daily for HLOC. ED medical directors reported that the ability to transfer for HLOC has worsened over the past 3 years for all specialties. Respondents indicated that more than 40% of ear, nose, and throat (ENT), orthopedics, plastic surgery, and mental health HLOC transfers take more than 3 hours.
Conclusions:  This survey of California ED medical directors suggests ED on-call specialist availability and the ability to transfer for HLOC have worsened since the passage of the EMTALA final rule in 2003.     

Availability of Rapid Human Immunodeficiency Virus Testing in Academic Emergency Departments

Objectives:  The Centers for Disease Control and Prevention (CDC) recommends routine human immunodeficiency virus (HIV) screening of emergency department (ED) patients aged 13 to 64 years. The study objectives were to determine the accessibility of rapid HIV testing in academic EDs, to identify factors that influence an ED's adoption of testing, and to describe current HIV testing practices.
Methods:  Online surveys were sent to EDs affiliated with emergency medicine (EM) residency programs ( n  = 128), excluding federal hospitals and facilities in U.S. territories. Eighty percent ( n  = 102) responded. Most e-mail recipients ( n  = 121) were Emergency Medicine Network (EMNet) investigators; remaining contacts were obtained from residency-related Web sites.
Results:  Most academic EDs ( n  = 58; 57%; 95% confidence interval (CI) = 47% to 66%) offer rapid HIV testing. Among this group, 26 (45%) allow providers to order tests without restrictions. Of the other 32 EDs, 100% have policies allowing for rapid HIV testing following occupational exposures, but less than 10% have guidelines for testing in other clinical situations. Forty-seven percent expect to routinely offer HIV testing in the next 2 to 3 years. Only 59% of the EDs that offered rapid tests in any situation could link an HIV-positive patient to subspecialty care. The facility characteristic most important to availability of rapid HIV testing was the presence of on-site HIV counselors.
Conclusions:  Most academic EDs now offer rapid HIV testing (57%), but few use it in situations other than occupational exposure. Less than half of academic EDs expect to implement CDC guidelines regarding routine screening within the next few years. The authors identified facility characteristics (e.g., counseling, ability to refer) that may influence adoption of rapid HIV testing.     

Racial and Ethnic Differences in Emergency Care for Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Objectives:  The objective was to investigate racial and ethnic differences in emergency care for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).
Methods:  The authors performed a prospective multicenter cohort study involving 24 emergency departments (EDs) in 15 U.S. states. Using a standard protocol, consecutive ED patients with AECOPD were interviewed, their charts reviewed, and 2-week telephone follow-ups were completed.
Results:  Among 330 patients, 218 (66%) were white, 84 (25%) were African American, and 28 (8%) were Hispanic. A quarter of the 24 EDs cared for 59% of all minority patients. Compared with white patients, African American and Hispanic patients were more likely to be uninsured or with Medicaid (19, 49, and 52%, respectively; p < 0.001), were less likely to have a primary care provider (93, 81, and 82%, respectively; p = 0.005), and had more frequent ED visits in the past year (medians = 1, 2, and 3, respectively; p = 0.002). In the unadjusted analyses, minority patients were less likely to receive diagnostic procedures, more likely to receive systemic corticosteroids in the ED, less likely to be admitted, and more likely to have a relapse. After adjustment for patient and ED characteristics, these many racial and ethnic differences in quality of care were nearly completely eliminated.
Conclusions:  Despite pronounced racial and ethnic differences in stable COPD, all racial and ethnic groups received comparable quality of emergency care for AECOPD and had similar short-term outcomes.     

Can the Emergency Department Algorithm Detect Changes in Access to Care?

Objectives:  The "emergency department algorithm" (EDA) uses emergency department (ED) diagnoses to assign probabilities that a visit falls into each of four categories: nonemergency, primary care–treatable emergency, preventable emergency needing ED care, and nonpreventable emergency. The EDA's developers report that it can evaluate the medical safety net because patients with worse access to care will use EDs for less urgent conditions. After the Oregon Health Plan (OHP, Oregon's expanded Medicaid program) underwent cutbacks affecting access to care in 2003, the authors tested the ability of the EDA to detect changes in ED use.
Methods:  All visits to 22 Oregon EDs during 2002 were compared with visits during 2004. For each payer category, mean probabilities that ED visits fell into each of the four categories were compared before versus after the OHP cutbacks.
Results:  The largest change in mean probabilities after the cutbacks was 2%. Attempts to enhance the sensitivity of the EDA through other analytic strategies were unsuccessful. By contrast, ED visits by the uninsured increased from 6,682/month in 2002 to 9,058/month in 2004, and the proportion of uninsured visits leading to hospital admission increased by 51%.
Conclusions:  The EDA was less useful in demonstrating changes in access to care than were other, simpler measures. Methodologic concerns with the EDA that may account for this limitation are discussed. Given the widespread adoption of the EDA among health policy researchers, the authors conclude that further refinement of the methodology is needed.     

Distances to Emergency Department and to Primary Care Provider's Office Affect Emergency Department Use in Children

Objectives:  Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children's hospital.
Methods:  This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child's home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children's hospital. The outcome variable was each child's ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations.
Results:  On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP.
Conclusions:  Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.     

Supply and Demand of Board-certified Emergency Physicians by U.S. State, 2005

Objectives:  The objective was to estimate the emergency medicine (EM) board-certified emergency physician (EP) workforce supply and demand by U.S. state.
Methods:  The 2005 National Emergency Department Inventories-USA provided annual visit volumes for U.S. emergency departments (EDs). We estimated full-time equivalent (FTE) EP demand at each ED by dividing the actual number of visits by the estimated average EP visit volume (3,548 visits/year) and then summing FTEs by state. Our model assumed that at least one EP should be present 24/7 in each ED. The number of EM board-certified EPs per state was provided by the American Board of Medical Specialties (American Board of Emergency Medicine, American Board of Pediatrics) and the American Osteopathic Board of Emergency Medicine. We used U.S. Census Bureau civilian population estimates to calculate EP population density by state.
Results:  The supply of EM board-certified EPs was 58% of required FTEs to staff all EDs nationally and ranged from 10% in South Dakota to 104% in Hawai'i (i.e., there were more EPs than the estimated need). Texas and Florida had the largest absolute shortages of EM board-certified EPs (2,069 and 1,146, respectively). The number of EM board-certified EPs per 100,000 U.S. civilian population ranged from 3.6 in South Dakota to 13.8 in Washington, DC. States with a higher population density of EM board-certified EPs had higher percent high school graduates and a lower percent rural population and whites.
Conclusions:  The supply and demand of EM board-certified EPs varies by state. Only one state had an adequate supply of EM board-certified EPs to fully staff its EDs.     

Multicenter Study of Limited Health Literacy in Emergency Department Patients

Objectives:  The objective was to evaluate the prevalence of limited health literacy and its association with sociodemographic variables in emergency department (ED) patients.
Methods:  This was a cross-sectional survey in three Boston EDs. The authors enrolled consecutive adult patients during two 24-hour periods at each site. They measured health literacy by the short version of the Test of Functional Health Literacy in Adults (S-TOFHLA). Using multivariate logistic regression, the authors evaluated associations between sociodemographic variables and limited health literacy, as classified by S-TOFHLA scores.
Results:  The authors enrolled 300 patients (77% of eligible). Overall, 75 (25%; 95% confidence interval [CI] = 20% to 30%) of participants had limited health literacy. Limited health literacy was independently associated with older age (compared to 18–44 years, odds ratio [OR] 4.3 [95% CI = 2.0 to 9.2] for 45–64 years and OR 3.4 [95% CI = 1.4 to 8.5] for ≥65 years), less education (compared to high school graduates, OR 2.7 [95% CI = 1.1 to 7.3] for some high school or lower and OR 0.43 [95% CI = 0.21 to 0.88] for some college or higher), and lower income (OR 2.8 [95% CI = 1.2 to 6.6] for ≤$40,000 compared to >$40,000). Although ethnicity, race, and language were associated with limited health literacy in unadjusted analyses, the associations were not significant on multivariate analysis.
Conclusions:  In this sample, one-quarter of ED patients would be expected to have difficulty understanding health materials and following prescribed treatment regimens. Advanced age and low socioeconomic status were independently associated with limited health literacy. The ability of a significant subgroup of ED patients to understand health information, especially during illness or injury, requires further study.     

Distribution of Emergency Departments According to Annual Visit Volume and Urban–Rural Status: Implications for Access and Staffing

Objectives: Ongoing efforts to improve access to emergency care and emergency department (ED) staffing would benefit from a better understanding of the distribution of EDs in the United States by size and location. This article describes the distribution of U.S. ED visit volumes according to ED urban versus rural status. Methods: The authors used the 2007 National Emergency Department Inventories (NEDI)‐USA database to identify all nonfederal U.S. hospitals with EDs and their annual ED visit volumes. One of twelve 2003 Urban Influence Codes was applied to each ED location based on its county. These categories were collapsed into urban counties and three types of rural counties: adjacent to urban, large nonadjacent, and small nonadjacent. The number of emergency physicians (EPs) needed to staff the higher‐volume rural EDs was estimated. Results: Of the 4,874 U.S. EDs in 2007, 58% were in urban counties and 42% in rural counties. Among the 2,038 rural EDs, 56% were adjacent to urban, 15% were large nonadjacent, and 29% were small nonadjacent. Of the 1,503 lower‐volume (< 10,000 visit) EDs, 21% were in urban counties. Of the 3,371 higher‐volume (≥ 10,000 visit) EDs, 25% were in rural counties. Of the 857 higher‐volume rural EDs, 66% were adjacent to urban, 22% were large nonadjacent, and 12% were small nonadjacent. The authors estimate that approximately 5,600 EPs are needed to staff these higher‐volume rural EDs. Conclusions: There are many lower‐volume EDs in urban areas and higher‐volume EDs in rural areas. Most higher‐volume rural EDs are in rural areas adjacent to urban counties. These data challenge popular assumptions regarding ED visit volumes, locations, and staffing needs. ACADEMIC EMERGENCY MEDICINE 2010; 17:1390–1397 © 2010 by the Society for Academic Emergency Medicine     

Untreated Hypertension and the Emergency Department: A Chance to Intervene?

Objectives:  Untreated hypertension (HTN) is a major public health problem. Screening for untreated HTN in the emergency department (ED) may lead to appropriate treatment of more patients. The authors investigated the accuracy of identifying HTN in the ED, the proportion of ED patients with untreated HTN, patient characteristics predicting untreated HTN, and provider documentation of untreated HTN.
Methods:  The authors performed a retrospective cross-sectional study on a random sample of 2,061 adults treated at an urban academic ED. The validity of six candidate definitions of HTN in the ED was assessed in a subsample using outpatient clinic records as the reference standard. "Untreated HTN" was HTN without a HTN medication listed in the ED history. "Documentation of untreated HTN was documentation of HTN as a visit problem, specific referral for HTN, or ED discharge with a HTN" information sheet or a HTN medication. Multivariable logistic regression was used to determine associations.
Results:  The preferred definition of HTN in the ED had sensitivity of 86% (95% confidence interval [CI] = 80% to 90%), specificity of 78% (95% CI = 69% to 85%), and accuracy of 83% (95% CI = 78% to 87%). Of the 42% (95% CI = 40% to 44%) of ED patients with HTN, 43% (95% CI = 39% to 46%) had untreated HTN. Patients who were younger and male, without primary care physicians, with fewer prior ED visits, and without cardiovascular comorbidities, had higher odds of untreated HTN. Of those with untreated HTN, 8% (95% CI = 5% to 11%) had their untreated HTN documented.
Conclusions:  Untreated HTN was common in the ED but rarely documented. Providers can use ED blood pressures along with patient characteristics to identify those with untreated HTN for referral to primary care.     

The Six-item Screener to Detect Cognitive Impairment in Older Emergency Department Patients

Background:  Cognitive impairment due to delirium or dementia is common in older emergency department (ED) patients. To prevent errors, emergency physicians (EPs) should use brief, sensitive tests to evaluate older patient's mental status. Prior studies have shown that the Six-Item Screener (SIS) meets these criteria.
Objectives:  The goal was to verify the performance of the SIS in a large, multicenter sample of older ED patients.
Methods:  A prospective, cross-sectional study was conducted in three urban academic medical center EDs. English-speaking ED patients ≥65 years old were enrolled. Patients who received medications that could affect cognition, were too ill, were unable to cooperate, were previously enrolled, or refused to participate were excluded. Patients were administered either the SIS or the Mini-Mental State Examination (MMSE), followed by the other test 30 minutes later. An MMSE of 23 or less was the criterion standard for cognitive impairment; the SIS cutoff was 4 or less for cognitive impairment. Standard operator characteristics of diagnostic tests were calculated with 95% confidence intervals (CIs), and a receiver operating characteristic curve was plotted.
Results:  The authors enrolled 352 subjects; 111 were cognitively impaired by MMSE (32%, 95% CI = 27% to 37%). The SIS was 63% sensitive (95% CI = 53% to 72%) and 81% specific (95% CI = 75% to 85%). The area under the receiver operating characteristic curve was 0.77 (95% CI = 0.72 to 0.83).
Conclusions:  The sensitivity of the SIS was lower than in prior studies. The reasons for this lower sensitivity are unclear. Further study is needed to clarify the ideal brief mental status test for ED use.     

Informed Consent for Research: Current Practices in Academic Emergency Medicine

Background:  The emergency department (ED) environment presents unique barriers to the process of obtaining informed consent for research.
Objectives:  The objective was to identify commonalities and differences in informed consent practices for research employed in academic EDs.
Methods:  Between July 1, 2006, and June 30, 2007, an online survey was sent to the research directors of 142 academic emergency medicine (EM) residency training programs identified through the Accreditation Council for Graduate Medical Education (ACGME).
Results:  Seventy-one (50%) responded. The average number of simultaneous clinical ED-based research projects reported was 7.3 (95% confidence interval [CI] = 5.53 to 9.07). Almost half (49.3%) of respondents reported that EM residents are responsible for obtaining consent. Twenty-nine (41.4%) participating institutions do not require documentation of an individual resident's knowledge of the specific research protocol and consent procedure before he or she is allowed to obtain consent from research subjects.
Conclusions:  It is common practice in academic EDs for clinical investigators to rely on on-duty health care personnel to obtain research informed consent from potential research subjects. This practice raises questions regarding the sufficiency of the information received by research subjects, and further study is needed to determine the compliance of this consent process with federal guidelines.     

Injuries in Youth Football: National Emergency Department Visits during 2001–2005 for Young and Adolescent Players

Objectives:  Limited research exists describing youth football injuries, and many of these are confined to specific regions or communities. The authors describe U.S. pediatric football injury patterns receiving emergency department (ED) evaluation and compare injury patterns between the younger and older youth football participants.
Methods:  A retrospective analysis of ED data on football injuries was performed using the National Electronic Injury Surveillance System–All Injury Program. Injury risk estimates were calculated over a 5-year period (2001–2005) using participation data from the National Sporting Goods Association. Injury types are described for young (7–11 years) and adolescent (12–17 years) male football participants.
Results:  There were an estimated total of 1,060,823 visits to U.S. EDs for males with football-related injuries. The most common diagnoses in the younger group (7–11 years) were fracture/dislocation (29%), sprain/strain (27%), and contusion (27%). In the older group (ages 12–17 years), diagnoses included sprain/strain (31%), fracture/dislocation (29%), and contusion (23%). Older participants had a significantly higher injury risk of injury over the 5-year study period: 11.0 (95% confidence interval [CI] = 9.2 to 12.8) versus 6.1 (95% CI = 4.8 to 7.3) per 1,000 participants/year. Older participants had a higher injury risk across all categories, with the greatest disparity being with traumatic brain injury (TBI), 0.8 (95% CI = 0.6 to 1.0) versus 0.3 (95% CI = 0.2 to 0.4) per 1,000 participants/year.
Conclusions:  National youth football injury patterns are similar to those previously reported in community and cohort studies. Older participants have a significantly higher injury risk, especially with TBI.     

Relapse after Emergency Department Discharge for Acute Asthma

Objectives:  The objectives were to determine patient and treatment-response factors associated with relapse after emergency department (ED) treatment for acute asthma.
Methods:  Subjects aged 18–55 years who were treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview and telephone contact 2 weeks later.
Results:  Of 695 enrolled patients, 604 (86.9%) were discharged from the ED; follow-up was available in 529 (87.5%); 63% were female and the median age was 29 years. Most patients were discharged on oral (70.8%) and inhaled (60.1%) corticosteroids (CS); 2-week treatment adherences were 93.3 and 80.9%, respectively. Relapse occurred in 9.2% at 1 week (95% confidence interval [CI] = 7.1% to 12.0%) and 13.9% (95% CI = 11% to 17%) at 2 weeks. In multivariable modeling, factors associated with relapse were ethnicity (risk ratio [RR] white = 0.66; 95% CI = 0.52 to 0.83); female gender (RR = 1.57; 95% CI = 1.14 to 2.09); any ED visits in the past 2 years (RR = 1.47; 95% CI = 1.18 to 1.80); ever admitted for asthma treatment (RR = 1.83; 95% CI = 1.09 to 2.84); use of combined inhaled CS plus long-acting β₂-agonists (RR = 1.39; 95% CI = 1.07 to 1.78) and of oral CS (RR = 1.35; 95% CI = 1.12 to 1.59) at the time of ED presentation.
Conclusions:  Ethnicity (white), female gender, prior ED visits and admissions for asthma, and recent treatments (especially oral CS) were associated with asthma relapse, which remains relatively common. Future research is required to target this high-risk group.     

Systematic Bias Introduced by the Informed Consent Process in a Diagnostic Research Study

Objectives:  To determine population characteristics, outcomes, and reasons for unsuccessful enrollment among potential study subjects approached for written, informed consent in a minimal-risk emergency department (ED) study. The authors hypothesized that the prevalence of venous thromboembolism (VTE) would be lower among study participants and that medical acuity and refusal to provide a blood sample would be the most common reasons for nonparticipation.
Methods:  The authors requested prospective, written, informed consent for a blood sample and follow-up from consecutive ED patients undergoing evaluation for pulmonary embolism (PE) and recorded spontaneously stated reasons for refusal. VTE was diagnosed or excluded using a combination of D-dimer testing and selective computed tomography (CT) angiography of the chest with venography of the lower extremities. The primary outcome was defined by the number of CT scans positive for VTE among ED patients evaluated for PE.
Results:  Over 16 weeks, 260 of 287 (91%, 95% confidence interval [CI] = 87 to 94%) eligible patients were approached and consent was obtained from 183 patients (64%, 95% CI = 58% to 69%). The prevalence of VTE was 6% among participants and 13% among nonparticipants (95% CI [of the difference] = 1% to 15%). The proportions of African Americans, uninsured, and Medicaid patients were significantly higher among nonparticipants. No significant differences were found in the proportions of nonparticipants who disliked or distrusted research or desired financial reimbursement, compared to those not enrolled due to medical acuity or refused a blood sample.
Conclusions:  These data implicate the written, informed consent process as a significant source of bias on estimated disease prevalence.     

Computers and Connectivity in Illinois Emergency Departments

Although the Internet has been described as "ubiquitous," little is known about the extent to which physicians have access to the Internet while providing clinical care. OBJECTIVE: To assess the extent of Internet connectivity within the clinical area of every ED within the state of Illinois. METHODS: This was a prospective observational study. Each Illinois ED listed in a published directory was called by telephone, and a responsible party was identified to provide information regarding the type and size of the ED, patient demographics, the types of personal computers (PCs) available in the ED (if any), the types of operating systems used, the availability of access to the World Wide Web (Web), and the highest speed at which an Internet connection could be established. Responses regarding the presence and types of PCs and the types of operating systems used were assessed using one-factor chi-square. Univariate and multivariate predictors of the type of PC used, the presence or absence of Web access, and the highest speed of Internet access were evaluated using optimal discriminant analysis and nonlinear classification tree analysis, respectively. RESULTS: One hundred ninety-eight of the 199 EDs in the state of Illinois (99.5%) completed the survey. Of the responding EDs, 50.5% had PCs, but only 17.6% had Web access. When Web access was available, it was most often available through a high-speed Internet connection that was faster than a dial-up modem. Most departments (68.1%) with PCs used the Windows 95 or Windows 98 operating systems. A majority (62.5%) used the Netscape browser exclusively. Larger EDs (more than six ED beds) in rural or suburban areas were more likely to have a PC compared with smaller EDs (six or fewer beds). Large EDs (more than 12 ED beds) in private tertiary care or academic hospitals were most likely to have Web access. CONCLUSIONS: Although half of Illinois EDs have PCs, only one in six has access to the Internet; thus, most emergency physicians do not have ready access to the Web from the site where they deliver clinical care.     

Comparison of Nebulized Epinephrine to Albuterol in Bronchiolitis

Objectives:  To compare the effect of nebulized racemic epinephrine to nebulized racemic albuterol on successful discharge from the emergency department (ED).
Methods:  Children up to their 18th month of life presenting to two teaching hospital EDs with a clinical diagnosis of bronchiolitis who were ill enough to warrant treatment but did not need immediate intubation were eligible for this double-blind randomized controlled trial (RCT). Patients received either three doses of racemic albuterol or one dose of racemic epinephrine plus two saline nebulizers. Disposition was decided 2 hours after the first nebulizer. Successful discharge was defined as not requiring additional bronchodilators in the ED after study drug administration and not subsequently admitted within 72 hours. Adjusted relative risks (aRR) were estimated using the modified Poisson regression with successful discharge as the dependent variable and study drug and severity of illness as exposures. Secondary analysis was performed for patients aged less than 12 months and first presentation.
Results:  The authors analyzed 703 patients; 352 patients were given albuterol and 351 epinephrine. A total of 173 in the albuterol group and 160 in the epinephrine group were successfully discharged (crude RR = 1.08, 95% confidence interval [CI] = 0.92 to 1.26). When adjusted for severity of illness, patients who received albuterol were significantly more likely than patients receiving epinephrine to be successfully discharged (aRR = 1.18, 95% CI = 1.02 to 1.36). This was also true among those with first presentation and in those less than 12 months of age.
Conclusions:  In children up to the 18th month of life, ED treatment of bronchiolitis with nebulized racemic albuterol led to more successful discharges than nebulized epinephrine.     

Computer-aided analysis of 64- and 320-slice coronary computed tomography angiography: a comparison with expert human interpretation

Routine use of CCTA to triage Emergency Department (ED) chest pain can reduce ED length of stay while providing accurate diagnoses. We evaluated the effectiveness of using Computer Aided Diagnosis in the triage of low to intermediate risk emergency chest pain patients with Coronary Computed Tomographic Angiography (CCTA). Using 64 and 320 slice CT scanners, we compared the diagnostic capability of computer aided diagnosis to human readers in 923 ED patients with chest pain. We calculated sensitivity, specificity, Positive Predictive Value and Negative Predictive Value for cases performed on each scanner. We calculated the area under the Receiver Operator Curve (ROC) comparing results for the two scanners to Computer Aided Diagnosis performance as compared to the human reader. We examined index and 30 Day outcomes by diagnosis for each scanner and the human reader. 60% of cases could be triaged by the computer. Sensitivity was approximately 85% for both scanners, with specificity at 50.6% for the 64 slice and at 56.5% for the 320 slice scanner (per person measures). The NPV was 97.8 and 97.1 for the 64 and 320 slice scanners, respectively. Results for the four major vessels were similar with negative predictive values ranging from 97 to 100%. The ROC for Computer Aided Diagnosis for the 64 and 320 Slice Scanners, using the human reader as the gold standard was 0.6794 and 0.7097 respectively. The index and 30 day outcomes were consistent for the human reader and Computer Aided Diagnosis interpretation. Although Computer Aided Diagnosis with CCTA cannot serve completely as a substitute for human reading, it offers excellent potential as a triage tool in busy EDs.     

Derivation of a Triage Algorithm for Chest Radiography of Community-acquired Pneumonia Patients in the Emergency Department

Background:  Community-acquired pneumonia (CAP) accounts for 1.5 million emergency department (ED) patient visits in the United States each year.
Objectives:  To derive an algorithm for the ED triage setting that facilitates rapid and accurate ordering of chest radiography (CXR) for CAP.
Methods:  The authors conducted an ED-based retrospective matched case–control study using 100 radiographic confirmed CAP cases and 100 radiographic confirmed influenzalike illness (ILI) controls. Sensitivities and specificities of characteristics assessed in the triage setting were measured to discriminate CAP from ILI. The authors then used classification tree analysis to derive an algorithm that maximizes sensitivity and specificity for detecting patients with CAP in the ED triage setting.
Results:  Temperature greater than 100.4°F (likelihood ratio = 4.39, 95% confidence interval [CI] = 2.04 to 9.45), heart rate greater than 110 beats/minute (likelihood ratio = 3.59, 95% CI = 1.82 to 7.10), and pulse oximetry less than 96% (likelihood ratio = 2.36, 95% CI = 1.32 to 4.20) were the strongest predictors of CAP. However, no single characteristic was adequately sensitive and specific to accurately discriminate CAP from ILI. A three-step algorithm (using optimum cut points for elevated temperature, tachycardia, and hypoxemia on room air pulse oximetry) was derived that is 70.8% sensitive (95% CI = 60.7% to 79.7%) and 79.1% specific (95% CI = 69.3% to 86.9%).
Conclusions:  No single characteristic adequately discriminates CAP from ILI, but a derived clinical algorithm may detect most radiographic confirmed CAP patients in the triage setting. Prospective assessment of this algorithm will be needed to determine its effects on the care of ED patients with suspected pneumonia.