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1.
Mauro Giordano Tiziana Ciarambino Pietro Castellino Lorenzo Malatino Alessandro Cataliotti Luca Rinaldi Giuseppe Paolisso Luigi Elio Adinolfi 《The American journal of emergency medicine》2017,35(5):749-752
Study objective
We investigated seasonal prevalence of hyponatremia in the emergency department (ED).Design
A cross-sectional study using clinical chart review.Setting
University Hospital ED, with approximately 28 000 patient visits a year.Type of participants
We reviewed 15 049 patients, subdivided in 2 groups: the adult group consisting of 9822 patients aged between 18 and 64 years old and the elderly group consisting of 5227 patients aged over 65 years presenting to the ED between January 1st, 2014 and December 31st, 2015.Intervention
Emergency patients were evaluated for the presence of hyponatremia by clinical chart review.Measurements and main results
Hyponatremia was defined as a serum sodium level < 135 mmol/l. Mean monthly prevalence of hyponatremia was of 3.74 ± 0.5% in the adult group and it was significantly increased to 10.3 ± 0.7% in the elderly group (p < 0.05 vs adults). During the summer, hyponatremia prevalence was of 4.14 ± 0.2% in adult and markedly increased to 12.52 ± 0.7% (zenith) in elderly patients (p < 0.01 vs adult group; p < 0.05 vs other seasons in elderly group). In the elderly group, we reported a significant correlation between weather temperature and hyponatremia prevalence (r: 0.491; p < 0.05).Conclusion
We observed a major influence of climate on the prevalence of hyponatremia in the elderly in the ED. Decline in renal function, salt loss, reduced salt intake and increased water ingestion could all contribute to developing hyponatremia in elderly patients during the summer. These data could be useful for emergency physicians to prevent hot weather-induced hyponatremia in the elderly. 相似文献2.
Matthew J. Binks Rhys S. Holyoak Thomas M. Melhuish Ruan Vlok Elyse Bond Leigh D. White 《The American journal of emergency medicine》2017,35(10):1542-1546
Background
Hypoxemia increases the risk of intubation markedly. Such concerns are multiplied in the emergency department (ED) and during retrieval where patients may be unstable, preparation or preoxygenation time limited and the environment uncontrolled. Apneic oxygenation is a promising means of preventing hypoxemia in this setting.Aim
To test the hypothesis that apnoeic oxygenation reduces the incidence of hypoxemia during endotracheal intubation in the ED and during retrieval.Methods
We undertook a systematic review of six databases for all relevant studies published up to November 2016. Included studies evaluated apneic oxygenation during intubation in the ED and during retrieval. There were no exemptions based on study design. All studies were assessed for level of evidence and risk of bias. The Review Manager 5.3 software was used to perform meta-analysis of the pooled data.Results
Six trials and a total 1822 cases were included for analysis. The study found a significant reduction in the incidence of desaturation (RR = 0.76, p = 0.002) and critical desaturation (RR = 0.51, p = 0.01) when apneic oxygenation was implemented. There was also a significant improvement in first pass intubation success rate (RR = 1.09, p = 0.004).Conclusion
Apneic oxygenation may reduce patient hypoxemia during intubation performed in the ED and during retrieval. It also improves intubation first-pass success rate in this setting. 相似文献3.
Joshua J. Solano Nicole M. Dubosh Philip D. Anderson Richard E. Wolfe Jonathan A. Edlow Shamai A. Grossman 《The American journal of emergency medicine》2017,35(5):753-756
Background
Minimizing and preventing adverse events and medical errors in the emergency department (ED) is an ongoing area of quality improvement. Identifying these events remains challenging.Objective
To investigate the utility of tracking patients transferred to the ICU within 24 h of admission from the ED as a marker of preventable errors and adverse events.Methods
From November 2011 through June 2016, we prospectively collected data for all patients presenting to an urban, tertiary care academic ED. We utilized an automated electronic tracking system to identify ED patients who were admitted to a hospital ward and then transferred to the ICU within 24 h. Reviewers screened for possible error or adverse event and if discovered the case was referred to the departmental Quality Assurance (QA) committee for deliberations and consensus agreement.Results
Of 96,377 ward admissions, 921 (1%) patients were subsequently transferred to the ICU within 24 h of ED presentation. Of these 165 (19%) were then referred to the QA committee for review. Total rate of adverse events regardless of whether or not an error occurred was 2.1%, 19/921 (95% CI 1.4% to 3.0%). Medical error on the part of the ED was 2.2%, 20/921 (95% CI 1.5% to 3.1%) and ED Preventable Error in 1.1%, 10/921 (95% CI 0.6% to 1.8%).Conclusion
Tracking patients admitted to the hospital from the ED who are transferred to the ICU < 24 h after admission may be a valuable marker for adverse events and preventable errors in the ED. 相似文献4.
Lucas Oliveira J. e Silva M. Fernanda Bellolio Elisa M. Smith David J. Daniels Christine M. Lohse Ronna L. Campbell 《The American journal of emergency medicine》2017,35(10):1485-1489
Background
Motor vehicle–related injuries (including off-road) are the leading cause of traumatic brain injury (TBI) and acute traumatic spinal cord injury in the United States.Objectives
To describe motocross-related head and spine injuries of adult patients presenting to an academic emergency department (ED).Methods
We performed an observational cohort study of adult ED patients evaluated for motocross-related injuries from 2010 through 2015. Electronic health records were reviewed and data extracted using a standardized review process.Results
A total of 145 motocross-related ED visits (143 unique patients) were included. Overall, 95.2% of patients were men with a median age of 25 years. Sixty-seven visits (46.2%) were associated with head or spine injuries. Forty-three visits (29.7%) were associated with head injuries, and 46 (31.7%) were associated with spine injuries. Among the 43 head injuries, 36 (83.7%) were concussions. Seven visits (16.3%) were associated with at least 1 head abnormality identified by computed tomography, including skull fracture (n = 2), subdural hematoma (n = 1), subarachnoid hemorrhage (n = 4), intraparenchymal hemorrhage (n = 3), and diffuse axonal injury (n = 3). Among the 46 spine injuries, 32 (69.6%) were acute spinal fractures. Seven patients (4.9%) had clinically significant and persistent neurologic injuries. One patient (0.7%) died, and 3 patients had severe TBIs.Conclusion
Adult patients evaluated in the ED after motocross trauma had high rates of head and spine injuries with considerable morbidity and mortality. Almost half had head or spine injuries (or both), with permanent impairment for nearly 5% and death for 0.7%. 相似文献5.
Joseph B. Miller Richard M. Nowak Brian P. Reed Salvatore DiSomma Prabath Nanayakkara Michele Moyer Scott Millis Harish Kinni Phillip Levy 《The American journal of emergency medicine》2017,35(12):1915-1918
Background
Systemic hemodynamic characteristics of patients with suspected acute ischemic stroke are poorly described. The objective of this study was to identify baseline hemodynamic characteristics of emergency department (ED) patients with suspected acute stroke.Methods
This was a planned analysis of the stroke cohort from a multicenter registry of hemodynamic profiling of ED patients. The registry prospectively collected non-invasive hemodynamic measurements of patients with suspicion for acute stroke within 12 h of symptom onset. K-means cluster analysis identified hemodynamic phenotypes of all suspected stroke patients, and we performed univariate hemodynamic comparisons based on final diagnoses.Results
There were 72 patients with suspected acute stroke, of whom 38 (53%) had a final diagnosis of ischemic stroke, 10 (14%) had hemorrhagic stroke, and 24 (33%) had transient ischemic attack (TIA). Analysis defined three phenotypic clusters based on low or normal cardiac index (CI) and normal or high systemic vascular resistance index (SVRI). Patients with TIA had lower mean CI (2.3 L/min/m2) compared to hemorrhagic or ischemic stroke patients (p < 0.01).Conclusions
The study demonstrates the feasibility of defining hemodynamic phenotypes of ED patients with suspected stroke. 相似文献6.
Lauren T. Southerland Lauren Slattery Joseph A. Rosenthal Deborah Kegelmeyer Anne Kloos 《The American journal of emergency medicine》2017,35(2):329-332
Objectives
The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls.Methods
Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered.Results
The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n = 23) as at risk for falls, whereas the 4SBT identified 43% (n = 25). Combining triage questions with the 4SBT identified 60.3% (n = 35) as at high risk for falls, as compared with 39.7% (n = 23) with triage questions alone (P < .01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were inpatients unaware that they were at risk for falls (new diagnoses).Conclusions
Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and significantly increases the detection of older adults at risk for falls. 相似文献7.
A pilot mobile integrated healthcare program for frequent utilizers of emergency department services
Vicki A. Nejtek Subhash Aryal Deepika Talari Hao Wang Liam O&#x;Neill 《The American journal of emergency medicine》2017,35(11):1702-1705
Purpose
To examine whether or not a mobile integrated health (MIH) program may improve health-related quality of life while reducing emergency department (ED) transports, ED admissions, and inpatient hospital admissions in frequent utilizers of ED services.Methods
A small retrospective evaluation assessing pre- and post-program quality of life, ED transports, ED admissions, and inpatient hospital admissions was conducted in patients who frequently used the ED for non-emergent or emergent/primary care treatable conditions.Results
Pre- and post-program data available on 64 program completers are reported. Of those with mobility problems (n = 42), 38% improved; those with problems performing usual activities (N = 45), 58% reported improvement; and of those experiencing moderate to extreme pain or discomfort (N = 48), 42% reported no pain or discomfort after program completion. Frequency of ED transports decreased (5.34 ± 6.0 vs. 2.08 ± 3.3; p < 0.000), as did ED admissions (9.66 ± 10.2 vs. 3.30 ± 4.6; p < 0.000), and inpatient hospital admissions (3.11 ± 5.5 vs. 1.38 ± 2.5; p = 0.003).Conclusion
Results suggest that MIH participation is associated with improved quality of life, reduced ED transports, ED admissions, and inpatient hospital admissions. The MIH program may have potential to improve health outcomes in patients who are frequent ED users for non-emergent or emergent/primary care treatable conditions by teaching them how to proactively manage their health and adhere to therapeutic regimens. Programmatic reasons for these improvements may include psychosocial bonding with participants who received in-home care, health coaching, and the MIH team's 24/7 availability that provided immediate healthcare access. 相似文献8.
Rex Pui Kin Lam Wai Lam Yip Chi Keung Wan Matthew Sik Hon Tsui 《The American journal of emergency medicine》2017,35(4):665.e1-665.e4
Background
Chemical restraint is often required to control agitation induced by methamphetamine. Dexmedetomidine is an α-2 adrenergic receptor agonist with sedative, analgesic, and sympatholytic properties. Its use in the emergency department (ED) to control methamphetamine-induced agitation has not been reported.Objective
To report two cases of methamphetamine-induced agitation successfully sedated with dexmedetomidine in the ED.Case Report
The first case was a 42-year-old man with unstable emotion and violent behaviours after smoking methamphetamine. His agitation did not respond to a large cumulative dose of benzodiazepines (10 mg of diazepam and 332 mg of midazolam) administered over 48 h and sedation was achieved with dexmedetomidine. The second case was a 38-year-old methamphetamine user with unstable emotion and recurrent episodes of agitation despite repeated doses of benzodiazepines, whose agitation was controlled with dexmedetomidine infusion.Discussion
In both cases, dexmedetomidine apparently reduced the dose of benzodiazepines needed to achieve adequate sedation. Transient falls in blood pressure and slowing of the heart rate were noted, which resolved either spontaneously or after reducing the infusion rate without requiring drug treatment.Conclusion
Dexmedetomidine can be considered as an adjunct for chemical restraint when standard treatment fails to control the agitation induced by methamphetamine, but patient's hemodynamic state should be monitored closely during administration. Its efficacy and safety in the ED warrant further evaluation with prospective controlled trials. 相似文献9.
Samantha Dankoff Patricia Li Adam J. Shapiro Terry Varshney Alexander S. Dubrovsky 《The American journal of emergency medicine》2017,35(4):615-622
Objectives
Primary objective was to characterize lung ultrasound findings in children with asthma presenting with respiratory distress to the emergency department (ED). Secondary objectives included correlating these findings with patients' clinical course in the ED.Methods
Eligible patients 2–17 years of age, underwent a lung ultrasound by the study sonographer between November 2014 to December 2015. Positive lung ultrasound was defined as the presence of ≥ 1 of the following findings: ≥ 3 B-lines per intercostal space, consolidation and/or pleural abnormalities. The treating physician remained blinded to ultrasound findings; clinical course was extracted from the medical chart.Results
A total of sixty patients were enrolled in this study. Lung ultrasound was positive in 45% (27/60) of patients: B-line pattern in 38%, consolidation in 30% and pleural line abnormalities in 12%. A positive lung ultrasound correlated with increased utilization of antibiotics (26% vs 0%, p = 0.03), prolonged ED length of stay (30% vs. 9%, p = 0.04) and admission rate (30% vs 0%, p = 0.03). Inter-rater agreement between novice and expert sonographers was excellent with a kappa of 0.92 (95% CI: 0.84–1.00).Conclusions
This study characterized lung ultrasound findings in pediatric patients presenting with acute asthma exacerbations; nearly half of whom had a positive lung ultrasound. Positive lung ultrasounds were associated with increased ED and hospital resource utilization. Future prospective studies are needed to determine the utility and reliability of this tool in clinical practice. 相似文献10.
Peter Pruitt Joshua Penn David Peak Pierre Borczuk 《The American journal of emergency medicine》2017,35(2):255-259
Background
Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources.Objective
Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU).Methods
Retrospective evaluation of patients age ≥ 16, GCS ≥ 13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery.Results
1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure > 2 weeks after discharge.Conclusions
Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit. 相似文献11.
Michael D. April Chase Donaldson Lloyd I. Tannenbaum Tyler Moore Jose Aguirre Alexander Pingree James H. Lantry 《The American journal of emergency medicine》2017,35(10):1474-1479
Background
Our objective was to compare in-hospital mortality among emergency department (ED) patients meeting trial-based criteria for septic shock based upon whether presenting with refractory hypotension (systolic blood pressure < 90 mm Hg after 1 L intravenous fluid bolus) versus hyperlactatemia (initial lactate ≥ 4 mmol/L).Methods
We conducted a retrospective cohort analysis by chart review of ED patients admitted to an intensive care unit with suspected infection during 1 August 2012–28 February 2015. We included all patients with body fluid cultures sampled either during their ED stay without antibiotic administration or within 24 h of antibiotic administration in the ED. We excluded patients not meeting criteria for either refractory hypotension or hyperlactatemia. Trained chart abstractors blinded to the study hypothesis double entered data from each patient's record including demographics, clinical data, treatments, and in-hospital mortality. We compared in-hospital mortality among patients with isolated refractory hypotension, isolated hyperlactatemia, or both. We also calculated odds ratios (ORs) via logistic regression for in-hospital mortality based on presence of refractory hypotension or hyperlactatemia.Results
Of 202 patients included in the analysis, 38 (18.8%) died during hospitalization. Mortality was 10.9% among 101 patients with isolated refractory hypotension, 24.4% among 41 patients with isolated hyperlactatemia, and 28.3% among 60 patients with both (p = 0.01). Logistic regression analyses yielded in-hospital mortality OR for refractory hypotension of 1.3 (95% CI 0.5–3.8) versus OR for hyperlactatemia of 2.9 (95% CI 1.2–7.4).Conclusions
Hyperlactatemia appears associated with higher in-hospital mortality compared to refractory hypotension among ED patients with septic shock. 相似文献12.
John P. Haran Eric Wilsterman Tyler Zeoli Francesca L. Beaudoin Jennifer Tjia Patricia L. Hibberd 《The American journal of emergency medicine》2017,35(2):249-254
Objective
Current Infectious Disease Society of America (IDSA) guidelines for the management of purulent skin or soft tissue infections do not account for patient age in treatment recommendations. The study objective was to determine if age was associated with outpatient treatment failure for purulent skin infection after adjusting for IDSA treatment guidelines.Methods
We conducted a multicenter retrospective study of adult patients treated for a purulent skin infection and discharged home from four emergency departments between April and September 2014. Patients were followed for one month to assess for treatment failure (defined as need for a change in antibiotics, surgical intervention, or hospitalization). We used multivariable logistic regression to examine the role of patient age on treatment failure adjusting for demographic variables (gender, race), comorbidities and severity of infection.Results
A total of 467 patients met inclusion criteria (mean age 37.9 years [SD 14.0], 48.2% of whom were women). Overall, 12.4% failed initial therapy. Patients 65 years and older (n = 35) were almost 4 times more likely to fail initial ED therapy in follow-up compared with younger patients (adjusted Odds Ratio (OR) 3.87, 95% Confidence Interval (CI) 1.24–12.10). After adjustment, for every 10 years of advancing age there was a 43% increased odds of failing initial treatment (OR 1.43 95% CI 1.09–1.88).Conclusion
Elderly patients with purulent skin infections, whose providers followed the 2014 IDSA guidelines, were more likely to fail initial treatment than younger patients. This study suggests that there is a need to re-evaluate treatment guidelines in elderly patients. 相似文献13.
Samir Haydar Matthew Spanier Patricia Weems Samantha Wood Tania Strout 《The American journal of emergency medicine》2017,35(11):1730-1733
Objectives
The Quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score has been shown to accurately predict mortality in septic patients and is part of recently proposed diagnostic criteria for sepsis. We sought to ascertain the sensitive of the score in diagnosing sepsis, as well as the diagnostic timeliness of the score when compared to traditional systemic inflammatory response syndrome (SIRS) criteria in a population of emergency department (ED) patients treated in the ED, admitted, and subsequently discharged with a diagnosis of sepsis.Methods
Electronic health records of 200 patients who were treated for suspected sepsis in our ED and ultimately discharged from our hospital with a diagnosis of sepsis were randomly selected for review from a population of adult ED patients (N = 1880). Data extracted included the presence of SIRS criteria and the qSOFA score as well as time required to meet said criteria.Results
In this cohort, 94.5% met SIRS criteria while in the ED whereas only 58.3% met qSOFA. The mean time from arrival to SIRS documentation was 47.1 min (95% CI: 36.5–57.8) compared to 84.0 min (95% CI: 62.2–105.8) for qSOFA. The median ED “door” to positive SIRS criteria was 12 min and 29 min for qSOFA.Conclusions
Although qSOFA may be valuable in predicting sepsis-related mortality, it performed poorly as a screening tool for identifying sepsis in the ED. As the time to meet qSOFA criteria was significantly longer than for SIRS, relying on qSOFA alone may delay initiation of evidence-based interventions known to improve sepsis-related outcomes. 相似文献14.
Xi Zhang Nicole Rowan Bethann Mangel Pflugeisen Sanjin Alajbegovic 《The American journal of emergency medicine》2017,35(4):594-598
Background
Antibiotics are overprescribed for abnormal urine tests including asymptomatic bacteriuria (AB), contributing to rising antimicrobial resistance rates. Pharmacists reviewed urine cultures daily from emergency department (ED) encounters to assess antibiotic appropriateness. We studied antibiotic prescribing practices and assessed compliance to national guidelines, correlations with urine analysis (UA) components, and opportunities for antimicrobial stewardship in the ED.Methods
This quality improvement project (QIP) was a prospective cohort study at a community hospital ED, with data collected from finalized urine cultures resulting October 30, 2014 through January 5, 2015. Analyses were conducted using Chi-squared and Fisher Exact tests and stepwise multiple logistic regression.Results
Urine cultures from 457 encounters were reviewed, of which 136 met the inclusion criteria as non-pregnant and asymptomatic for urinary tract infection (UTI). 43% of 136 patients were treated with antibiotics, for a total of 426 antibiotic days. Pharmacist interventions for these patients resulted in 122/426 (29%) of potential antibiotic days saved. Factors found to significantly increase the odds of antibiotic prescribing in asymptomatic patients included presence of leukocyte esterase (OR = 4.5, 95% CI: 1.2–17.2; p = 0.03) or nitrites (OR = 10.8, 95% CI: 1.7–68.1; p = 0.01) in the urine and age ≥ 75 (OR = 3.5, 95% CI: 1.2-9.6, p = 0.02).Discussion
Pharmacist intervention in discontinuing or modifying antibiotics for asymptomatic patients with urine cultures reduced unnecessary antibiotic exposure and was a first step in antimicrobial stewardship efforts in the ED. Future work includes limiting urine tests and subsequent antibiotic therapy for non-pregnant asymptomatic patients. 相似文献15.
Michael A. Downes James K. Balshaw Tracy M. Muscat Nicole Ritchie Geoffrey K. Isbister 《The American journal of emergency medicine》2017,35(5):764-768
Objectives
This was a before and after study which sought to assess the impact of opening an ED short stay unit (ESSU) on the ED performance of poisoned patients.Methods
Data was collected from two groups of adult patients presenting to an ED with a tertiary referral inpatient Toxicology unit from the 2009 and 2012 calendar years, to assess the impact of the ESSU. The toxicology unit clinical database and hospital electronic medical records were interrogated for demographic, clinical and hospital flow details of presentations. The primary outcome was ED length of stay (LOS). Other outcomes included proportion of patients remaining in ED for their admission, 28 day re-presentations and hospital LOS.Results
During 2009, 795 patients met inclusion criteria, and during 2012, 762. The median LOS in ED was reduced from 8.5 h (IQR: 4.7–14 h) to 2.7 h (IQR: 1.6–4.6; p < 0.0001). The proportion of patients remaining in ED for their entire hospital stay was reduced from 515/795 (65%) to 56/762 (7.3%) [Absolute difference: 57%; 95% CI: 53 to 62%; p < 0.0001]. Total hospital LOS increased from 14.5 h (IQR: 8.4–21.8 h) to 16.7 h (IQR: 11.5–23; p < 0.0001), but there was a decrease in re-presentations with self-poisoning within 28 days from 6.9% in 2009 to 4.5% in 2012 (p < 0.038). There was no difference between disposition destination or toxins causing exposure between the two groups.Conclusions
The ESSU led to a significant improvement in ED performance of poisoned patients. It also potentially assisted in reducing ED overcrowding. 相似文献16.
Tomer Begaz David Elashoff Tristan R. Grogan David Talan Breena R. Taira 《The American journal of emergency medicine》2017,35(10):1426-1429
Study objectives
To compare diagnostic test ordering practices of NPs with those of physicians in the role of Provider in Triage (PIT).Methods
This was a secondary analysis of data from a prospective RCT of waiting room diagnostic testing, where 770 patients had diagnostic studies ordered from the waiting room. The primary outcome was the number of test categories ordered by provider type. Other outcomes included total tests ordered by the end of ED stay, and time in an ED bed. We compared variables between groups using t-test and chi-square, constructed logistic regression models for individual test categories, and univariate and multivariate negative binomial models.Results
Physicians ordered significantly more diagnostic test categories than NPs (1.75 vs. 1.54, p < 0.001). By the end of their ED stay, there was no significant difference in total test categories ordered between provider type: physician 2.67 vs. NP 2.53 (p = 0.08), using a nonbinomial model, incidence rate ratio (IRR) 1.07 (0.98–1.17). Patient time in an ED bed was not significantly different between physicians and NPs (NP 244 min, SD = 133, Physicians 248 min, SD = 152) difference 4 min (? 24.3–16.1) p = 0.688.Conclusion
NPs in the PIT role ordered slightly less diagnostic tests than attending physicians. This slight difference did not affect time spent in an ED bed. By the end of the ED stay, there was no significant difference in total test categories ordered between provider types. PIT staffing with NPs does not appear to be associated with excess test ordering or prolonged ED patient stays. 相似文献17.
Michael D. Perloff Nimesh S. Patel Carlos S. Kase Anuja U. Oza Barbara Voetsch Jose R. Romero 《The American journal of emergency medicine》2017,35(11):1724-1729
Objective
To evaluate occurrence of cerebellar stroke in Emergency Department (ED) presentations of isolated dizziness (dizziness with a normal exam and negative neurological review of systems).Methods
A 5-year retrospective study of ED patients presenting with a chief complaint of “dizziness or vertigo”, without other symptoms or signs in narrative history or on exam to suggest a central nervous system lesion, and work-up included a brain MRI within 48 h. Patients with symptoms commonly peripheral in etiology (nystagmus, tinnitus, gait instability, etc.) were included in the study. Patient demographics, stroke risk factors, and gait assessments were recorded.Results
One hundred and thirty-six patients, who had a brain MRI for isolated dizziness, were included. There was a low correlation of gait assessment between ED physician and Neurologist (49 patients, Spearman's correlation r2 = 0.17). Based on MRI DWI sequence, 3.7% (5/136 patients) had acute cerebellar strokes, limited to or including, the medial posterior inferior cerebellar artery vascular territory. In the 5 cerebellar stroke patients, mean age, body mass index (BMI), hemoglobin A1c, gender distribution, and prevalence of hypertension were similar to the non-cerebellar stroke patient group. Mean LDL/HDL ratio was 3.63 ± 0.80 and smoking prevalence was 80% in the cerebellar stroke group compared to 2.43 ± 0.79 and 22% (respectively, p values < 0.01) in the non-cerebellar stroke group.Conclusions
Though there was preselection bias for stroke risk factors, our study suggests an important proportion of cerebellar stroke among ED patients with isolated dizziness, considering how common this complaint is. 相似文献18.
Jonathan G. Rogg Robert Huckman Michael Lev Ali Raja Yuchiao Chang Benjamin A. White 《The American journal of emergency medicine》2017,35(10):1510-1513
Study objectives
Facing increased utilization and subsequent capacity and budget constraints, ED's must better understand bottlenecks and their effect on process flow to improve process efficiency. The primary objective of this study was to identify bottlenecks in obtaining a head CT and investigate patient waiting time based on those bottlenecks.Methods
This observational study included all patients undergoing a head CT between July 1, 2013 and June 30, 2014 at a large, urban academic ED with over 100,000 visits per year.The primary study outcome was total cycle time, defined as the elapsed time between patient arrival and head CT preliminary report, divided into four components of workflow.Results
8312 patients who had a head CT were included in this study. The median cycle time from patient arrival to head CT preliminary report was 3 h and 13 min with 39 min of waiting time resulting from bottlenecks. In the 4-step model (time from patient arrival to head CT order, time from head CT order to head CT scheduled, time from head CT scheduled to head CT completed, and time from head CT completed to head CT preliminary report), each process was the bottleneck 30%, < 1%, 27%, and 42% of the time, respectively.Conclusion
Demand capacity mismatch in head CT scanning has a significant impact on patient waiting times. This study suggests opportunities to improve wait times through future research to understand the causes of delays in CT ordering, CT completion and timeliness of radiology reports. 相似文献19.
Gary X. Wang Sandeep S. Hedgire Thang Q. Le Jonathan D. Sonis Brian J. Yun Michael H. Lev Ali S. Raja Anand M. Prabhakar 《The American journal of emergency medicine》2017,35(4):527-530
Background
Aortic dissection is typically evaluated with computed tomography angiography (CTA). However, the feasibility of using magnetic resonance angiography (MRA) in the ED is unclear. This study examined the indications and outcomes of MRA in suspected aortic dissection evaluation in the ED.Methods
An IRB approved review identified patients who underwent MRA in the ED for acute thoracic aortic dissection from January 2010 to June 2016. Demographics, clinical assessment, CTA contraindications, outcomes, and ED disposition were analyzed.Results
50 MRAs were ordered for suspected thoracic aortic dissection. 21 (42%) for iodinated contrast allergy, 21 (42%) for renal insufficiency, 2 (4%) due to both, 2 (4%) to spare ionizing radiation, 2 (4%) for further work-up after CTA, and 2 (4%) due to prior contrast enhanced CT within 24 h. Median ED arrival to MRA completion time was 311 min. 42 studies were fully diagnostic; 7 were limited. One patient could not tolerate the examination. 49 MRAs were completed: 2 (4%) patients had acute dissection on MRA and 47 (96%) had negative exams. 17 (35%) received gadolinium. 18 (37%) patients were discharged home from the ED with a median length of stay of 643 min. 2 (4%) were admitted for acute dissection seen on MRA and 29 (59%) for further evaluation.Conclusion
MRA has a clear role in the evaluation for acute thoracic aortic dissection in the ED in patients with contraindications to CTA, and can guide management and facilitate safe discharge to home. 相似文献20.