Etiology and disposition associated with radiology discrepancies on emergency department patients

BackgroundDiagnostic errors made by radiology resident physicians may lead to significant morbidity/mortality and patient dissatisfaction.ObjectiveTo determine the etiology and disposition associated with radiology discrepancies on emergency department (ED) patients.MethodsWe conducted a retrospective electronic chart review of patients presenting to our ED during “off hours” at the Penn State Hershey Medical Center during October 2013–November 2014 and had a radiology discrepancy, defined as a patient discharged from the ED with a diagnostic interpretation disagreement between the initial radiology resident physician read and final radiology attending physician read.Results81,201 images were performed during “off hours”, with 174 radiology discrepancies (0.214%) identified. Most discrepancies were associated with CT scans (62%). The most common final diagnostic interpretations associated with discrepancies were missed fracture (10.9%), incidental findings of mass or cyst (10.3%), gastrointestinal inflammation (6.3%), and pneumonia (5.7%). 10% of radiology discrepancies were instructed to emergently return to the ED. The most common modality associated with ED follow-up was CT scan of the abdomen/pelvis (50%). Of the 17 patients that returned to the ED, 10 had additional diagnostic imaging, 9 received a subspecialist consult, 5 required surgical treatment, 5 required additional medications, and 1 required a medical hospitalization.ConclusionsBased on our sample, discrepancies were a small percentage of images performed during “off hours”, and were associated with CT scans, missed fractures, and non-emergent outpatient follow-up. We suggest that ED and radiology departments work collaboratively to monitor their own rates of discrepancies, and subsequent morbidities and mortalities, to improve patient care.     

PS2-54: The Flow of Tumor Data: A Technical Review of Tumor Data Production, Submission and Use

Background The Virtual Data Warehouse tumor registry enables important multi-site research in cancer prevention, treatment and outcomes, as well as health communications and quality. Ideally, data are collected from hospitals where the tumors are biopsied, staged, and reported to the state. These data can be difficult to obtain for HMOs such as Kaiser Permanente in the Mid-Atlantic States (KPMAS) that do not own their own hospitals. In such cases, the HMO must request tumor data from the state. This process is particularly complex at KPMAS, which represents three independent jurisdictions (Maryland, Virginia and the District of Columbia). Our end goal is to develop a KPMAS tumor registry that integrates data from electronic health record (EHR) systems and state tumor registries. A key intermediate objective was to develop a comprehensive understanding of tumor registry development at more advanced HMORN sites in order to efficiently build the KPMAS tumor registry. Methods We used a multi-pronged approach to develop the technical structure for the KPMAS tumor registry. First, we surveyed other HMORN sites that have previously successfully developed tumor registries. Second, we reached out to existing tumor registry efforts within KPMAS to reduce duplication, capitalize on existing work in this area, and document the workflow: from data capture through state reporting and integration into our electronic health record. Third, we developed relationships with key tumor registry managers in all three KPMAS jurisdictions to identify the processes required for obtaining tumor data corresponding to our members. During this process, we requested both a data dictionary and a set of dummy data from each of the external jurisdictions. Results Using the data dictionaries and dummy data provided by the external tumor registries, we developed a technical solution for housing and managing tumor related information from multiple sources. Key considerations involved integrating data from external sources with data from the EHR and removing duplicate data that results from integrating data from three external agencies that cover a highly mobile geographic area. Conclusions Integrating tumor data from multiple sources involves both technical challenges and requires that a complete understanding of the data meaning.     

The accuracy of point-of-care ultrasound to diagnose long bone fractures in the ED

Objectives

To determine the diagnostic accuracy of emergency physician performed point-of care ultrasound (POCUS) for detecting long bone fractures compared to standard radiography.

Methods

This was a single-blinded, prospective observational study of patients presenting to two emergency departments (ED) with trauma to long bones. The study used a convenience sample of patients seen during the study investigators' scheduled clinical shifts. Patients presenting to the ED with complaints of long bone trauma were included in the study when a study investigator was available in the ED. POCUS examinations of injured long bones were performed using a standard protocol. The investigators documented their interpretation prior to radiographs being performed. After standard radiographs were performed, the final radiology reading by a radiology attending physician was obtained from the medical record.

Results

One-hundred six patients were enrolled into the study, and 147 long bone POCUS examinations were performed. Forty-two fractures were present by radiographs and the prevalence of fractures was 29%. The sensitivity was 90.2% (4/41, 95% CI: 76.9-97.3) and specificity was 96.1% (4/102, 95% CI: 90.3-98.9). The positive likelihood ratio was 23.0 (95% CI: 8.8-60.5), and the negative likelihood ratio was 0.102 (95% CI: 0.040, 0.258). The positive predictive value was 90.2% (4/41, 95% CI: 76.9-97.3) and the negative predictive value was 96.1% (4/102, 95% CI: 90.3-98.9).

Conclusions

Emergency physicians can accurately evaluate long bone fractures in the ED using POCUS. In particular, long bone fractures can be excluded with a high degree of confidence.     

断层融合技术对鼻骨骨折的诊断价值

目的评价应用冠状位断层融合技术摄片对鼻骨骨折病例的诊断价值。方法对直接鼻骨外伤的病例同摄鼻侧位片及冠状位断层融合技术片,并进行结果对照。结果59例疑似有鼻骨骨折病例鼻侧位片明确诊断24例,占总数40％。冠状位断层融合技术片明确诊断35例,占总数60％。结论冠状位断层融合技术片对鼻骨骨折的影像诊断有较高的实用意义。     

The development of radiology and the Society for Medical Radiology of the DDR

After a retrospective history of radiology since the discovery of x-rays the development of medical radiology and the Society for Medical Radiology of the DRG are described. Cornerstones of these development are the foundation of the Society for Medical Radiology in 1954, the continuous increase of the numbers of examinations until 1974, the significantly increased availability of modern imaging methods since 1985 and the introduction of special training courses for physicians in the fields of diagnostic radiology, radiation therapy and nuclear medicine in 1988. A bibliography was compiled, containing data on the numbers of available devices, costs in medical care and the impact on life expectancy.     

“What Do People Do If They Don't Have Insurance?”: ED‐to‐ED Referrals

Objective

Up to 20% of patients seen in public emergency departments (EDs) have already been seen for the same complaint at another ED, but little is known about the origin or impact of these duplicate ED visits. The goals of this investigation were to explore 1) whether patients making a repeat ED visit are self‐referred or indirectly referred from the other ED and 2) gather the perspective of affected patients on the health, social, and financial consequences of these duplicate ED visits.

Methods

This mixed‐methods study conducted over a 10‐week period during 2016 in a large public hospital ED in Texas prospectively surveyed patients seen in another ED for the same chief complaint. Selected patients presenting with fractures were then enrolled for semistructured qualitative interviews, which were audiotaped, transcribed, and independently coded by two team members until thematic saturation was reached.

Results

A total of 143 patients were identified as being recently seen at another local ED for the same chief complaint prior to presenting to the public hospital; 94% were uninsured and 61% presented with fractures. A total of 27% required admission at the public ED and 95% of those discharged required further outpatient follow‐up. Fifty‐one percent of patients completed a survey and qualitative interviews were conducted with 23 fracture patients. Fifty‐three percent of patients reported that staff at the first hospital told them to go the public hospital ED, and 23% reported referral from a follow‐up physician associated with the first hospital. Seventy‐three percent reported receiving the same tests at both EDs. Interview themes identified multiple health care visits for the same injury, concern about complications, disrespectful treatment at the first ED, delayed care, problems accessing needed follow‐up care without insurance, loss of work, and financial strain.

Conclusions

The majority of patients presenting to a public hospital ED after treatment for the same complaint in another local ED were indirectly referred to the public ED without transferring paperwork or records, incurring duplicate testing and patient anxiety.

     

Care of minor burn injuries: an analysis of burn clinic and emergency room charges

Most burn injuries are minor in nature and can be managed on an outpatient basis. Such patients are usually evaluated and treated in emergency departments (ED) rather than in specialized outpatient burn care facilities. Although many burn centers maintain such facilities for the initial care of these patients, this practice is not commonplace because of conflicting interests of the ED and burn team. We first analyzed the hospital charges for all thermally injured patients admitted for a period of < or = 24 hours between April 1996 and August 1998. This was followed by an independent analysis of the hospital charges for all outpatient visits to the burn clinic and ED during calendar year 1998. Physician charges were not included in the second study. Patients admitted for < or = 24 hours had mean hospital charges of $1185 when initially evaluated in the ED compared with $691 if they were directly admitted to the burn unit (P < 0.001). This difference was largely because of higher charges for medication, laboratory, radiologic studies, and the ED visit charges. In the second study the mean charge for care administered in the ED was $192 compared with $139 for treatment in the outpatient burn clinic (P < 0.0001). Patients treated in the burn clinic had significantly lower radiology and treatment charges but significantly higher pharmacy charges than patients treated in the ED. These data have supported our efforts to develop a walk-in burn treatment center. Such a program should not only result in reduced charges for care, but also enhance patient access to the expertise of the multidisciplinary burn team and help ensure optimal outcomes.     

Impact of Ambulance Transportation on Resource Use in the Emergency Department

OBJECTIVE: To determine how ambulance transportation is associated with resource use in the emergency department (ED). METHODS: A retrospective administrative database review of patient visits to a Montreal tertiary care hospital ED in one year (April 2000-March 2001). Measures of resource use included ED length of stay, admission to the hospital, and whether consultations and radiology/imaging tests (excluding plain-film x-rays) were ordered from the ED. RESULTS: During the study period, 39,674 patients made 59,142 visits to the ED. Ambulance transportation was used for 15.6% of these ED visits. Compared with non-ambulance visits, ambulance visits were more likely to be made by older patients (mean age: 68 vs. 47 years), to be made by females (59% vs. 55%), to have a greater triage urgency score (mean on 1-5 scale, with 1 most urgent: 2.7 vs. 3.9), and to occur after office hours, 5 PM to 9 AM (47% vs. 43%). Ambulance visits were also more likely than non-ambulance visits to result in: a longer length of stay (mean: 13.3 hours [95% CI = 13.0 to 13.6] vs. 5.9 [95% CI = 5.8 to 6.0]), hospital admission (40% vs. 10%) (odds ratio [OR]: 5.94 [95% CI = 5.59 to 6.33]), consultations (56% vs. 20%) (OR: 5.15 [95% = 4.86 to 5.45]), and radiology/imaging tests (20% vs. 12%) (OR: 1.93 [95% CI = 1.81 to 2.07]). In multivariate models that adjusted for the effects of age, gender, triage urgency, and temporal factors, ambulance transportation maintained its association with greater resource use. CONCLUSIONS: This preliminary study indicates that patients arriving at the ED by ambulance use significantly more resources than their walk-in counterparts.     

Accuracy of radiographic readings in the emergency department

Objectives

A review of radiology discrepancies of emergency department (ED) radiograph interpretations was undertaken to examine the types of error made by emergency physicians (EPs).

Methods

An ED quality assurance database containing all radiology discrepancies between the EP and radiology from June 1996 to May 2005 was reviewed. The discrepancies were categorized as bone, chest (CXR), and abdomen (AXR) radiographs and examined to identify abnormalities missed by EPs.

Results

During the study period, the ED ordered approximately 151?693 radiographs. Of the total, 4605 studies were identified by radiology as having a total of 5308 abnormalities discordant from the EP interpretation. Three hundred fifty-nine of these abnormalities were not confirmed by the radiologist (false positive). The remainder of the discordant studies represented abnormalities identified by the radiologist and missed by the EP (false negatives). Of these false-negative studies, 1954 bone radiographs (2.4% of bone x-rays ordered) had missed findings with 2050 abnormalities; the most common missed findings were fractures and dislocations. Of the 220 AXRs (3.7% of AXRs ordered) with missed findings, 240 abnormalities were missed; the most common of these was bowel obstruction. Of the 2431 CXRs (3.8% of CXRs ordered), 2659 abnormalities were missed; the most common were air-space disease and pulmonary nodules. The rate of discrepancies potentially needing emergent change in management based solely on a radiographic discrepancy was 85 of 151?693 x-rays (0.056%).

Conclusions

Approximately 3% of radiographs interpreted by EPs are subsequently given a discrepant interpretation by the radiology attending. The most commonly missed findings included fractures, dislocations, air-space disease, and pulmonary nodules. Continuing education should focus on these areas to attempt to further reduce this error rate.     

M ODIFICATION OF THE L ARYNGEAL T UBE

Background. Approximately 40% of Hennepin County Medical Center's (HCMC's) ambulance runs are for minor medical conditions as defined by billing criteria [“ALS minor,” i.e., no advanced life support (ALS) procedures done in the field]. Current metropolitan guidelines mandate that all such patients must be transported to a hospital unless they refuse this service. It has been proposed that some patients with minor medical conditions could be better served by treatment in the field by paramedics and referred to a clinic or hospital for early follow-up care. It is proposed that this approach would save costs and improve paramedic availability for patients with more serious conditions. Objective. To evaluate the feasibility and safety of implementing such a program by identifying high-volume, low-complexity groupings of cases. Such high-volume, low-complexity cases would serve as the topics for curriculum development for paramedic training in field treatment and referral. Methods. Data were obtained from ambulance run sheets and emergency department (ED) records for all patients transported by the HCMC ambulance service in 1996 who were covered by the Metropolitan Health Plan (MHP) and who were categorized for billing purposes as “ALS minor” transports. The data included demographic information, vital signs, presenting problem, diagnoses in the ED, and procedures, laboratory studies, or x-rays done in the ED. Patients were classified as “potentially treatable” in the field if they were treated and discharged from the ED without undergoing any procedures or diagnostic studies. Patients who required more extensive evaluation in the ED, or who were admitted, were classified as likely too “complex” to be treated at the scene and then referred for early follow-up. The data were analyzed to find the most common presenting problems and the numbers, characteristics, and dispositions of “potentially treatable” and “complex” patients in each group. This information was used to determine what, if any, types of patients could potentially be treated safely and effectively according to this scheme. Results. The study group comprised 1,103 patients, representing 127 different presenting medical problems. There were 523 (47%) “potentially treatable” patients and 580 (53%) “complex” patients. The 127 medical problems were grouped and the 15 most common presenting problem groups were identified. Within these groups there was no single medical problem with high volume. Each of these 15 most common problem groups contained a substantial proportion of “complex” patients, ranging from 24% to 100%. Conclusions. None of the 15 most frequently encountered problem groups consisted of a high enough proportion of “potentially treatable” cases to serve as a high-volume, low-complexity category for paramedic treatment in the field with early follow-up. Without any identified high-volume, low-complexity categories, a treatment and referral program as proposed in this article would require a substantial investment in development of appropriate criteria and in training paramedics to apply the criteria for numerous clinical entities. This would limit any cost saving, and require great care to avoid compromising patient safety accompanied by substantial professional liability exposure.     

Optimizing emergency department care transitions to outpatient settings: A systematic review and meta-analysis

IntroductionSuboptimal transitions from the emergency department (ED) to outpatient settings can result in poor care continuity, and subsequently higher costs to the healthcare system. We aimed to systematically review care transition interventions (CTIs) for adult patients to understand how effective ED-based CTIs are in reducing return visits to the ED and increasing follow-up visits with primary care physicians.MethodsWe searched multiple databases and identified eligible published RCTs of ED-based CTIs affecting outpatient follow-up rates, ED readmission and hospital admission. Two independent authors reviewed titles and abstracts for potential inclusion and selected studies for full review. Study quality was assessed using the Cochrane risk-of-bias tool. ED-based CTIs were classified using a care continuity framework.ResultsOur search generated 28,807 articles; 112 were selected for full-text review. Data were abstracted from 42 articles that met inclusion criteria. Pooling data from 20 studies (n = 8178 patients) found a relative increase in outpatient follow-up with ED-based CTIs compared to routine care (odds ratio 1.79, 95% confidence interval [CI] 1.43, 2.24). However, ED-based CTIs (20 studies, n = 8048 patients) had no significant effect on ED readmissions (odds ratio 1.02, 95% CI 0.87, 1.20]) or hospital admission after ED discharge (13 studies, n = 5742 patients) (odds ratio 0.99, 95% CI 0.86, 1.14) when compared to routine care. Twenty-two studies encompassed CTIs supporting all three functions of care continuity (information, communication and coordination).ConclusionsED-based CTIs do not appear to reduce ED revisit or hospital admission after ED discharge but are effective in increasing follow-up.     

Improving Patient Care in the Diagnostic Imaging Department: The Role of the Nurse Navigator

A trip to the radiology department can be a journey through the frightening unknown for patients. Radiology nurses, strong patient advocates, are not often in a position to provide anticipatory guidance to allay fears and reduce stress. The nurse navigator’s (NN) mandate is to improve care and decrease stress and anxiety for diagnostic imaging patients. By coordinating care, the NN helps patients receive a timely diagnosis and efficient treatment. Using specialized radiology knowledge, the NN provides procedure-specific education tailored to individual patient needs. Patient care is improved as the NN develops strong professional relationships with internal and external stakeholders. Having an in-depth exposure to numerous radiology patients and procedures, the NN possesses a unique perspective on potential system pitfalls. This perspective allows the NN to advocate change on a much wider basis than the frontline radiology nurse may be able to.     

Can I Send This Patient with Stroke Home? Strategies Managing Transient Ischemic Attack and Minor Stroke in the Emergency Department

Background

While transient ischemic attack and minor stroke (TIAMS) are common conditions evaluated in the emergency department (ED), there is controversy regarding the most effective and efficient strategies for managing them in the ED. Some patients are discharged after evaluation in the ED and cared for in the outpatient setting, while others remain in an observation unit without being admitted or discharged, and others experience prolonged and potentially costly inpatient admissions.

Comparison of bedside ultrasound and panorex radiography in the diagnosis of a dental abscess in the ED

Objective

The purpose of the study was to compare bedside ultrasound (US) and panorex radiography in the diagnosis of a dental abscess in emergency department (ED).

Methods

A retrospective review of ED records of adult patients with atraumatic facial pain, swelling, and toothache who received a panorex x-ray and bedside US was performed. Medical records were reviewed for ED evaluation and disposition. Sensitivity and specificity of US and panorex x-ray were calculated to determine the clinical utility of the 2 tests.

Results

A total of 19 patients were identified. No periapical abscess was reported on panorex x-rays in 7 (37%) of 19 patients. Ultrasound agreed with panorex x-rays in 6 (86%) of 7 cases. One case where US disagreed with x-rays was evaluated by dentistry consultants; and incision and drainage were performed, confirming the presence of an abscess. An x-ray diagnosis of periapical abscess was made in 12 (63%) of 19 patients. Ultrasound agreed with panorex x-ray in 10 (83%) of 12 cases. In 1 of the 2 cases where US disagreed with panorex x-rays, x-ray abnormalities were reported on the nonsymptomatic side. The other patient was given antibiotics and recommended outpatient follow-up. Follow-up information was not available to further confirm the presence of an abscess. Assuming that the patient who was lost to follow-up had dental abscess, the sensitivity and specificity of US in diagnosing a dental abscess were 92% and 100%, respectively.

Conclusions

Bedside US is nonionizing, is readily available, and can provide an alternative to panorex x-rays in the evaluation of a dental abscess in ED.     

Creating a circle of trust

Radiology nurses functioning in the many areas of the radiology department strive to connect with their patients on many levels, often within a very short time. Creating a “circle of trust” for each patient supports both patient and nurse satisfaction in care received and delivered. Nurses begin their interaction with either the outpatient or inpatient through an initial review of their orders, indications, and important demographic variables that must be addressed during their diagnostic study or therapeutic intervention. Once registered nurses coordinate the radiology care for the patient, the registered nurse for the first department where the patient will be cared for first will initiate a transport request for the radiology transport team to bring the patient to the central patient holding area. As soon as the nurse is notified that the patient has arrived in the holding area, the patient is greeted by the registered nurse. The nurse verifies that the orders continue to be active and then escorts the patient to the first area of care. Each nurse, using his or her expertise, accompanies each patient through the entire stay in the department from entry to exit.Registered nurses are assigned to each of the radiology department areas: magnetic resonance imaging, interventional radiology, ultrasonography, diagnostic radiology, computed tomography, and nuclear medicine. Radiology requisitions are reviewed by the registered nurse to determine studies that require a nursing presence to facilitate and support care and treatment. Each radiology study or interventional procedure requisition generated for a patient during the stay identifies every radiology department area where the patient will need care from radiology personnel. For example, a patient with orders for computed tomography of the thorax for pulmonary embolism and also scheduled for an ultrasound duplex study of the lower extremities will have both studies printed on both requisitions to alert staff that this patient has several studies to be coordinated. The registered nurses in both areas work together to coordinate the care of this patient. Considerations to be included in the coordination effort include all patient data, inpatient or outpatient status, available recovery suite times if applicable, procedure times, possible imaging issues if one study is completed before another (often related contrast clearance times), technologist availability, and availability of physician staff.The nurse for the area where the patient is first scheduled will remain with the patient until all radiology studies/procedures are completed for the day. All registered nursing staff have expertise in each area in the department, although they might not be the primary nurse responsible in a specific area. For example, in interventional radiology, the registered nurse would remain with the patient through all procedures or studies. After any postprocedure observation, the nurse brings the patient to the central holding area where he or she is then transported to a room or to transportation home. Every attempt is made to have the nurse who cared for the patient follow up with the patient within the next 24 hours.The outcome measures for this innovation that was developed in a shared leadership format indicate tremendous improvement in patient self-identified satisfaction with time spent in the radiology department. Additionally, the radiology nurses express an increase in their job satisfaction, often stating that they “really feel as if I've made a difference.”     

Emergency Department Management and Follow-up of Children with Bicycle Spoke Injuries

Background

Evidence for a standard x-ray study and cast immobilization in emergency department (ED) management and follow-up of children with bicycle spoke injury (BSI) is absent.

Objective

To describe the injury pattern and outpatient follow-up and care of ED patients with BSI. In addition, patient characteristics predicting the presence of a fracture and long-term follow-up were assessed.

Methods

This was a retrospective study including BSI patients < 9 years of age. Kruskal-Wallis test was used to compare groups with a fracture, soft tissue injury, and mild skin abrasion. Multivariable logistic regression analysis was used to identify independent predictors of a fracture and long-term outpatient follow-up.

Results

Twenty-three percent of 141 included patients had a fracture, with a median (interquartile range) follow-up of 27 (23–40) days. For soft tissue injury and mild abrasions this was 9 (6–14) and 7 (5–9) days, respectively (p < 0.001). No clinical variables could predict a fracture. Fifty-six (40%) patients required no further care after the first outpatient visit at ∼1 week. Triage category yellow and swelling were independent predictors for more than one outpatient visit, besides presence of fracture. Corrected odds ratios (95% confidence interval) were 2.42 (0.99–5.88) and 4.76 (1.38–16.39), respectively. Only 12% of 141 patients had none of these predictors at ED presentation.

Conclusions

A quarter of ED patients with BSI have a fracture with no clinical signs that could predict the presence of a fracture, justifying a standard x-ray study in ED management. Only 12% of ED patients with BSI have no fracture and no signs that predict long-term follow-up. In this group, further studies are warranted to investigate the benefit of cast immobilization for fractures and soft tissue injury.     

Ins and outs of suprapubic catheters--a clinician's experience

In today's evolving health care field, outpatient procedures are becoming more commonplace. Many patients with suprapubic catheters are now being seen in outpatient or home care settings. Addressing the educational needs of patients, family members, and nursing staff is now more important than ever for successful patient suprapubic catheter management. A basic understanding of how these catheters are initially placed is essential for proper care and avoidance of possible complications. This review of initial placement of suprapubic catheters and post-insertion care is based on one clinician's experience and practice at a local hospital in Pennsylvania.     

Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services

ObjectivesRoutine emergency department (ED) HIV or HCV screening may inadvertently capture patients already diagnosed but does not specifically prioritize identification of this group. Our objective was to preliminarily estimate the volume of this distinct group in our ED population through a pilot electronic health record (EHR) build that identified all patients with indications of HIV or HCV in their EHR at time of ED presentation.MethodsCross-sectional study of an urban, academic ED's HIV/HCV program for previously diagnosed patients August 2017–July 2018. Prevention program staff, alerted by the EHR, reviewed records and interviewed patients to determine if confirmatory testing or linkage to care was needed. Primary outcome was total proportion of ED patients for whom the EHR generated an alert. Secondary outcome was the proportion of patients assessed by program staff who required confirmatory testing or linkage to HIV/HCV medical care.ResultsThere were 65,374 ED encounters with 5238 (8.0%, 95% CI: 7.8%–8.2%) EHR alerts. Of these, 3741 were assessed by program staff, with 798 (21%, 95% CI: 20%–23%) requiring HIV/HCV confirmatory testing or linkage to care services, 163 (20%) for HIV, 551 (69%) for HCV, and 84 (11%) for both HIV and HCV services.ConclusionsPatients with existing indication of HIV or HCV infection in need of confirmatory testing or linkage to care were common in this ED. EDs should prioritize identifying this population, outside of routine screening, and intervene similarly regardless of whether the patient is newly or previously diagnosed.     

Noninvasive evaluation of peripheral vascular disease: recent advances and future implications

Noninvasive diagnostic techniques have become a recognized adjunct in screening and follow-up of patients with peripheral arterial, venous, and cerebrovascular diseases. These techniques provide physiologic information at little or no risk to patients. Although primarily of diagnostic intent, these studies are also expanding our knowledge base about the natural history of peripheral vascular diseases and the efficacy of various interventions. Advances in radiology have complemented but not replaced the need for the noninvasive peripheral vascular laboratory. It is incumbent upon all physicians to appreciate the diagnostic value and recognize the limitations of these noninvasive techniques. Intelligent use of these modalities may enhance patient care without significantly increasing health care costs. Further prospective studies of the cost benefit or effectiveness of these techniques are indicated.