The Emergency Department as a Potential Site for Smoking Cessation Intervention: A Randomized, Controlled Trial

OBJECTIVE: To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program. METHODS: This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two-page "Stop Smoking" pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post-ED visit. Categorical data were analyzed by chi-square and Fisher's exact tests. Rank data were analyzed by Mann-Whitney tests and continuous data by t-tests. All tests were two-tailed with alpha set at 0.05. RESULTS: One hundred fifty-two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow-up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0-4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1]. CONCLUSION: The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.     

Preventive Care in the Emergency Department: Screening and Brief Intervention for Alcohol Problems in the Emergency Department: A Systematic Review

OBJECTIVE: To systematically review the medical literature in order to determine the strength of the recommendation for screening and brief intervention (SBI) for alcohol-related problems in the emergency department (ED) setting. METHODS: The review followed the methodology of systematic reviews and was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. The primary outcome measure was the prevention of mortality and morbidity secondary to alcohol-related illnesses/injuries. The secondary outcome measures included: decreased consumption; fewer ED/outpatient visits and hospitalizations; a decrease in social consequences; and increased referrals for follow-up and/or treatment. Three Medline searches as well as a search of the Cochrane Library were performed. Two team members reviewed the abstracts and selected pertinent articles. References were screened for additional pertinent articles. RESULTS: Twenty-seven articles were identified and reviewed, in addition to the 14 primary articles included in the 1996 U.S. Preventive Services Task Force Report. The study populations were diverse, including inpatient, outpatient, and college settings, with ages ranging from 12 to 70 years. Four studies were ED-based and two included EDs as one of multiple sites. Thirty-nine studies on SBI, 30 randomized controlled and nine cohort, were used to formulate the current recommendation. A positive effect of the intervention was demonstrated in 32 of these studies. CONCLUSIONS: The authors recommend that SBI for alcohol-related problems in the ED be incorporated into clinical practice.     

Preventive Care in the Emergency Department: Should Emergency Departments Conduct Routine HIV Screening? A Systematic Review

OBJECTIVE: To perform a systematic review of the emergency medicine literature to assess the appropriateness of offering routine HIV screening to patients in the emergency department (ED). METHODS: The systematic review was conducted with the aid of a structured template, a companion explanatory guide, and a grading and methodological scoring system based on published criteria for critical appraisal. Two reviewers conducted independent searches using OvidR, PubMed, MD Consult, and Grateful Med. Relevant abstracts were reviewed; those most pertinent to the stated objective were selected for complete evaluation using the structured template. RESULTS: Fifty-two relevant abstracts were reviewed; of these, nine were selected for detailed evaluation. Seven ED-based prospective cross-sectional seroprevalence studies found HIV rates of 2-17%. Highest rates of infection were seen among patients with behavioral risks such as male homosexual activity and intravenous drug use. Two studies demonstrated feasibility of both standard and rapid HIV testing in the ED, with more than half of the patients approached consenting to testing by either method, consistent with voluntary testing acceptance rates described in other settings. Several cost-benefit analyses lend indirect support for HIV screening in the ED. CONCLUSIONS: Multiple ED-based studies meeting the Centers for Disease Control and Prevention Guideline threshold to recommend routine screening, in conjunction with limited feasibility trials and extrapolation from cost-benefit studies, provide evidence to recommend that EDs offer HIV screening to high-risk patients (i.e., those with identifiable risk factors) or high-risk populations (i.e., those where HIV seroprevelance is at least 1%).     

Emergency Department Use by Terminally Ill Patients: A Systematic Review

ContextTerminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear.ObjectiveTo determine the prevalence of TIP visiting the ED.MethodsSystematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle–Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I²).ResultsWe identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries, and none from low-income countries. Most were from 2015. We found that 45% of patients with cancer visited the ED in the last month of life [95% CI 37–54%] and 75% in the last six months of life [95% CI 62–83%]; I² = 100%. Overall, 17% of patients who visited the ED had a terminal illness [95% CI 12–23%]; I² = 98%. Few studies reported terminal nononcologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or nonresuscitation, or other criteria that could be used for grouping.ConclusionsPatients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with nononcologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.     

Preventive Care in the Emergency Department A Systematic Literature Review on Emergency Department-based Interventions that Address Smoke Detectors in the Home

OBJECTIVES: To assess the effectiveness of an emergency department (ED)-based strategy to identify and counsel selected patients about the importance of an operational smoke detector in the home and to offer a graded recommendation regarding such a strategy. METHODS: A systematic review was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. Two Medline combined searches were performed using the following terms: emergency medical services and counseling, protective devices and smoke detectors, accidents, home, burns, fires, and residential fires. A free-text search of indexed and nonindexed citations in Emergency Medical Abstracts from 1977 to 1999 and a search of the Cochrane Library were also performed. In addition, reviewers performed independent Medline searches and suggested four additional studies. Studies selected for inclusion in this systematic review were required to meet the following criteria: 1) report ED-based research and 2) address the topic of fire and burn prevention with some pertinent discussion of ED-based interventions. The initial inclusion criteria had restricted studies to those that reported the results of counseling strategies for smoke detectors. The authors later decided to consider, as indirectly relevant, studies that did not investigate counseling strategies. Data from the selected studies were extracted using the template form, and the validity and applicability of the results to emergency practice were assessed. Recommendations were derived following criteria developed by a systematic review of preventive interventions in the ED. RESULTS: Six articles were closely reviewed. Four of the six studies met the inclusion criteria. One other study that did not meet the inclusion criteria was also considered. No study focused specifically on the counseling of ED patients about smoke detectors. CONCLUSIONS: Following the criteria of the graded recommendations used for the parent project. a recommendation cannot be made either for or against an ED-based strategy to counsel patients on the importance of smoke detectors. No studies located in our review directly assessed the effectiveness of such a strategy. Based on the retrospective case series study of the potential opportunity for a home fire safety intervention during an emergency medical services visit and the Safe Block Project study, it may be worthwhile to consider further research on the effectiveness of systems-level/structural interventions, with a targeted focus on strategies that attempt to overcome barriers associated with active interventions.     

Alcohol and Tobacco Use in the Elder Emergency Department Patient: Assessment of Rates and Medical Care Utilization

OBJECTIVES: To determine rates of alcohol and tobacco use among independent elder emergency department (ED) patients and assess the extent of health care use of this population. METHODS: A convenience sample of independent elders (age > or =65 years) in an urban academic ED was enrolled. Patients were excluded if they were medically unstable or had a change in mental status. The Fagerstrom Test for Nicotine Dependence, and the Alcohol Use Disorders Identification Test (AUDIT) scales were used to measure tobacco and alcohol use. Subjects completed questionnaires about their health and use of the health care system. Data were analyzed by using t-tests to compare independent variables. RESULTS: A total of 565 subjects completed the study. Of these, 296 (52.4%) were male and 269 (47.6%) were female; mean age was 77.1 years. Fifty-four (9.5%) were smokers, and 22 (3.9%) were nicotine-dependent by the Fagerstrom test (Fagerstrom+). Alcohol use was reported at least once monthly by 176 (31.2%) and twice monthly by 76 (13.5%) patients; 12 (2.1%) were alcohol-dependent by the AUDIT scale (AUDIT+). Two (0.35%) were both Fagerstrom+ and AUDIT+. Fagerstrom+ subjects visited a physician less often than Fagerstrom- subjects (3.9 vs. 4.6 annual visits, p < 0.0009). AUDIT+ subjects visited a primary care physician less (3.3 vs. 4.2 annual visits, p < 0.007) or "any" physician less (3.9 vs. 4.6 annual visits, p < 0.01) than AUDIT- subjects. AUDIT+ and Fagerstrom+ subjects did not differ from AUDIT- and Fagerstrom- subjects in number of annual ED visits, self-reported general health, physical symptoms (except nervousness, p < 0.004), comorbid illnesses, hospital admissions, and injuries requiring treatment. CONCLUSIONS: Elder ED patients have low rates of nicotine and alcohol dependence. Nicotine- or alcohol-dependent elders use outpatient providers less often than nondependent elders but use EDs at the same rate and report similar health patterns.     

Improving Child Protection in the Emergency Department: A Systematic Review of Professional Interventions for Health Care Providers

Objectives: This systematic review evaluated the effectiveness of professional and organizational interventions aimed at improving medical processes, such as documentation or clinical assessments by health care providers, in the care of pediatric emergency department (ED) patients where abuse was suspected. Methods: A search of electronic databases, references, key journals, and conference proceedings was conducted and primary authors were contacted. Studies whose purpose was to evaluate a strategy aimed at improving ED clinical care of suspected abuse were included. Study methodologic quality was assessed by two independent reviewers. One reviewer extracted the data, and a second checked for completeness and accuracy. Results: Six studies met the inclusion criteria: one randomized controlled trial (RCT), one quasi‐RCT, and four observational studies. Study quality ranged from modest (observational studies) to good (trials). Variation in study interventions and outcomes limited between‐study comparisons. The quasi‐RCT supported self‐instructional education kits as a means to improve physician knowledge for both physical abuse (mean ± standard deviation [SD] pretest score = 13.12 ± 2.36; mean ± SD posttest score = 18.16 ± 1.64) and sexual abuse (mean ± SD pretest score = 10.81 ± 3.20; mean ± SD posttest score = 18.45 ± 1.79). Modest‐quality observational studies evaluated reminder systems for physician documentation with similar results across studies. Compared to standard practice, chart checklists paired with an educational program increased physician consideration of nonaccidental burns in burn cases (59% increase), documentation of time of injury (36% increase), and documentation of consistency (53% increase) and compatibility (55% increase) of reported histories. Decisional flow charts for suspected physical abuse also increased documentation of nonaccidental physical injury (69.5% increase; p < 0.0001) and had a similar significant effect as checklists on increasing documentation of history consistency and compatibility (69.5 and 70.0% increases, respectively; p < 0.0001) when compared to standard practice. No improvements were noted in these studies for documentation of consultations or current status with child protective services. The introduction of a specialized team and crisis center to standardize practice had little effect on physician documentation, but did increase documentation of child protective services involvement (22.7% increase; p < 0.005) and discharge status (23.7% increase; p < 0.02). Referral to social services increased in one study following the introduction of a chart checklist (8.6% increase; p = 0.018). A recently conducted multisite RCT did not support observational findings, reporting no significant effect of educational sessions and/or a chart checklist on ED practices. Conclusions: The small number of studies identified in this review highlights the need for future quality studies that address care of a vulnerable clinical population. While moderate‐quality observational studies suggest that education and reminder systems increase clinical knowledge and documentation, these findings are not supported by a multisite randomized trial. The limited theoretical base for conceptualizing change in health care providers and the influence of the ED environment on clinical practice are limitations to this current evidence base. ACADEMIC EMERGENCY MEDICINE 2010; 17:117–125 © 2010 by the Society for Academic Emergency Medicine     

A Survey of the Emergency Department Population and Their Interest in Preventive Health Education

OBJECTIVE: To determine which preventive health information the emergency department (ED) population (patients and visitors) would be most interested in having available to them while they spend time in the waiting area. METHODS: This was a prospective survey of consecutive adults seated in the ED waiting area during a representative week on predetermined shifts. The survey asked them to indicate whether they would be interested in obtaining information about the following preventive health issues: breast cancer, prostate cancer, smoking, obesity, stress reduction, exercise programs, alcohol/drugs, HIV, blood pressure screening, immunizations, referrals to primary care physicians, Pap smears, car safety, smoke detectors, domestic and youth violence, depression, gun safety, and safe sex. RESULTS: Of the 1284 subjects approached, 878 (68%) made up the study group (56% female, mean age = 44 years, 60% white); 406 refused. The information people were most interested in obtaining was the following: 52% of the respondents were interested in referral to stress reduction programs, 51% in information about exercise programs, 42% in blood pressure screening, 40% in information about breast cancer screening, 33% in depression information/screening, 33% in prostate cancer screening, 26% in immunization against pneumococcus, 24% in immunization against tetanus, 26% in smoking cessation programs, and 26% in safe driving information. Women were most interested in breast cancer screening (64%); and men, in prostate cancer screening (55%). CONCLUSIONS: Of the 878 subjects in the study group, 96% were interested in obtaining information about one or more preventive health issues. An opportunity exists to respond to this interest by providing material for public health education in the waiting area of EDs.     

Smoking Habits of Emergency Department Patients: An Opportunity for Disease Prevention

Objective: To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients.
Methods: A questionnaire was administered prospectively to all non-critical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients.
Results: The study patients were mostly young (mean age = 35 ± 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36–0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46–0.64) of these patients were current smokers.
Conclusions: The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.     

Ultrasound for the Diagnosis and Management of Suspected Urolithiasis in the Emergency Department

Background

This review provides practicing emergency physicians updated information regarding point-of-care ultrasound (POCUS) imaging of patients with suspected urolithiasis.

A Systematic Review of Emergency Department Interventions for College Drinkers

Background

Alcohol use in college-age individuals is associated with increased injury risk. Many college drinkers end up in the emergency department (ED) as a result of their drinking, providing a unique opportunity to intervene.

Objective

This systematic review evaluates the existing evidence for the use of brief ED interventions for alcohol use in the college-age population.

Methods

A systematic search of on-line databases was conducted. Articles were limited to those in English published since 1990. Studies were included if they specifically studied 18- to 20-year-old alcohol users, if they were performed in an ED or acute care setting, and if an intervention regarding alcohol use was attempted.

Results

There were 400 studies identified; 60 abstracts were reviewed, 18 full-text articles were evaluated, and 7 met the inclusion criteria for review. Eligible studies focused on alcohol use only, except for one study that addressed alcohol and other drug use. All examined changes in alcohol intake patterns as a primary outcome, and most also looked for reductions in alcohol-related harm. Each found reductions in alcohol intake patterns or reductions in alcohol-related harm in the intervention group, although some between-group differences were not statistically significant reductions.

Conclusion

Seven studies were identified that measured the outcomes of ED interventions for alcohol use in the college-age population. The studied interventions showed promise but had variable success. More research is needed to establish short- and long-term efficacy, specifically in high-risk underage college students.     

Systematic Review of Emergency Physician–performed Ultrasonography for Lower-Extremity Deep Vein Thrombosis

Objectives:  The authors performed a systematic review to evaluate published literature on diagnostic performance of emergency physician–performed ultrasonography (EPPU) for the diagnosis and exclusion of deep venous thrombosis (DVT).
Methods:  Structured search criteria were used to query MEDLINE and EMBASE, followed by a hand search of published bibliographies. Relevance and inclusion criteria required prospective investigation of emergency department (ED) outpatients with suspected DVT; diagnostic evaluations had to consist of EPPU followed by criterion standard (radiology-performed) imaging. Two authors independently extracted data from included studies; study quality was assessed utilizing a validated tool for quality assessment of diagnostic accuracy studies (QUADAS). Pooled data were analyzed using an unweighted summary receiver-operating-characteristic (SROC) curve; sensitivity and specificity were estimated using a random effects model.
Results:  The initial search yielded 1,162 publications. Relevance screening and selection yielded six articles including 936 patients. Four of the six studies reported adequate blinding but a number of other methodologic flaws were identified. A random effects model yielded an overall sensitivity of 0.95 (95% confidence interval [CI] = 0.87 to 0.99) and specificity of 0.96 (95% CI = 0.87 to 0.99).
Conclusions:  Systematic review of six studies suggests that EPPU may be accurate for the diagnosis of DVT compared with radiology-performed ultrasound (US). However, given the methodologic limitations identified among the primary studies, the estimates of diagnostic test performance may be overly optimistic. Further research into EPPU for suspected DVT is needed before it can be adopted into routine clinical practice.     

Public Health Considerations in Knowledge Translation in the Emergency Department

Effective preventive and screening interventions have not been widely adopted in emergency departments (EDs). Barriers to knowledge translation of these initiatives include lack of knowledge of current evidence, perceived lack of efficacy, and resource availability. To address this challenge, the Academic Emergency Medicine 2007 Consensus Conference, “Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake,” convened a public health focus group. The question this group addressed was “What are the unique contextual elements that need to be addressed to bring proven preventive and other public health initiatives into the ED setting?” Public health experts communicated via the Internet beforehand and at a breakout session during the conference to reach consensus on this topic, using published evidence and expert opinion. Recommendations include 1) to integrate proven public health interventions into the emergency medicine core curriculum, 2) to configure clinical information systems to facilitate public health interventions, and 3) to use ancillary ED personnel to enhance delivery of public health interventions and to obtain successful funding for these initiatives. Because additional research in this area is needed, a research agenda for this important topic was also developed. The ED provides medical care to a unique population, many with increased needs for preventive care. Because these individuals may have limited access to screening and preventive interventions, wider adoption of these initiatives may improve the health of this vulnerable population.     

Predicting Smoking Stage of Change among Emergency Department Patients and Visitors

Objectives: Little is known about whether emergency department (ED) patients or those who accompany them (visitors) are interested in smoking cessation. The authors hypothesized that several variables would be associated with stage of change, including nicotine dependence, self‐efficacy, presence of a smoking‐related illness, and anticipated cessation‐related health improvement. Methods: For two 24‐hour periods, consecutive patients and visitors aged 18 years and older presenting to four Boston EDs were interviewed. The authors assessed a range of smoking‐related constructs. Exclusion criteria included severe illness, cognitive insufficiency, and acute distress. Results: One thousand ten subjects were screened (56% patients, 44% visitors). Two hundred thirty‐seven (23%) subjects were current smokers, with 57% being in precontemplation, 31% in contemplation, and 12% in preparation stages. When ordinal regression was used, the variables most strongly associated with stage of change were as follows: self‐efficacy (odds ratio [OR] = 5.1; p < 0.001), anticipated cessation‐related health improvement (OR = 2.7; p = 0.02), and having a smoking‐related health problem (OR = 1.9; p = 0.08). Conclusions: Because many disenfranchised Americans use the ED as a regular source of health care, increased attention to smoking in the ED setting holds tremendous public health potential. This study's results reinforce the validity of the stage‐of‐change model within the ED setting. Developers of ED‐initiated interventions will have to consider the heterogeneity in stage of change when designing their treatments.     

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.     

Hemophilia and von Willebrand Disease: A Review of Emergency Department Management

BackgroundHemophilia and von Willebrand disease (VWD) are the most common congenital coagulation factor deficiencies. Patients with these disorders who experience bleeding complications are often initially managed in the emergency department (ED).Objective of the ReviewThis review will focus on the emergency department management of patients with these disorders and provide an update on current treatment options.DiscussionThe mainstay of management is initial stabilization, control of bleeding when possible, and administration of specific factors. Early coordination of care with hematology is critical.ConclusionsEmergency medicine providers must have an understanding of the pathophysiology, clinical presentation, and management strategies in order to optimally care for these complex patients.     

Learning from Patient Safety Incidents in the Emergency Department: A Systematic Review

BackgroundPatient safety incidents are commonly observed in critical and high demanding care settings, including the emergency department. There is a need to understand what causes patient safety incidents in emergency departments and determine the implications for excellence in practice.ObjectiveOur aim was to systematically review the international literature on patient safety incidents in emergency departments and determine what can be learned from reported incidents to inform and improve practice.DiscussionPatient safety incidents in emergency departments have a number of recognized contributing factors. These can be used as groundwork for the development of effective tools to systematically identify incident risk. Participation in efforts to diminish risk and improve patient safety through appropriate incident reporting is critical for removing barriers to safe care.ConclusionsThis review enhances our awareness of contributing factors to patient safety incidents within emergency departments and encourages researchers from different disciplines to investigate the causes of practice errors and formulate safety improvement strategies.