Who Should Be Estimating a Patient's Weight in the Emergency Department?

Objectives: Medical personnel often need to estimate a patient's weight rapidly and accurately to administer pharmacologic agents whose dosages are based on weight. Inaccurate estimates of weight may result in administration of either subtherapeutic or, in other cases, toxic doses of medications. The hypothesis of this study was that the patient is a more accurate estimator of his or her own weight than the physician or nurse caring for him or her. Methods: This was a prospective study in which adult patients presenting to an urban emergency department (ED) were examined for study eligibility. Patients unable to stand were excluded. The patient, physician, and nurse caring for the patients were independently asked to estimate the patients' weights. The patients were then weighed. Results: A convenience sample of 458 patients were enrolled during a four‐week period. The median measured (actual) weight was 172.5 lb. The best estimate of a patient's weight was made by the patient himself or herself: the median difference between patient estimates and actual weights was 0 lb (interquartile range [IQR] =?5 to 5). The physicians and nurses had larger underestimates: ?5 lb (IQR =?22 to 12) and ?6 lb (IQR =?22 to 10), respectively. Weight was estimated within 10% of actual weight by 90.6% of the patients, 50.4% of the physicians, and 49.6% of the nurses. Conclusions: When a patient is unable to be weighed, the patient's own weight estimate should be used. If neither is possible, the physician or nurse should estimate the patient's weight.     

Is Sonographic Assessment of Fetal Weight Influenced by Formula Selection?

Objective. Several published formulas exist for the determination of estimated fetal weight (EFW), with limited data on their comparative accuracies. The aims of our study were to assess and compare the performance of different EFW formulas in predicting actual birth weight (BW) in an urban population. Methods. Patients with an EFW determined within 7 days of delivery were considered eligible for the study. Fourteen published formulas, derived from populations comparable to ours, were used to recalculate EFWs from the same initial measurements. The accuracy of the EFWs obtained from the different formulas were compared by percentage error methods using bias and precision and Bland‐Altman limits of agreement methods. Sensitivity and specificity for prediction of being small for gestational age (SGA) were calculated. Results. Eighty‐one fetuses were included in the study. Formula C of Hadlock et al [Hadlock C; log₁₀ BW = 1.335 ? 0.0034(abdominal circumference [AC])(femur length [FL]) + 0.0316(biparietal diameter) + 0.0457(AC) + 0.1623(FL); Am J Obstet Gynecol 1985; 151:333–337] had the best performance according to the bias and precision method. Bland‐Altman limits of agreement confirmed these results. Among the formulas, the sensitivity for detection of SGA ranged from 72% to 100%, and specificity was 41% to 88%. Hadlock C had the optimal sensitivity/specificity trade‐off for detection of SGA. Conclusions. Fourteen formulas showed considerable variation of bias and precision in our population as well as a wide range of sensitivities and specificities for SGA. The choice of the appropriate formula for EFW in a given population should be based on objective and explicit criteria. Consideration of bias and precision for the formula in the population being assessed is critical and may affect clinical care.     

Bedside Estimation of Patient Height for Calculating Ideal Body Weight in the Emergency Department

Background: Ideal body weight (IBW), which can be calculated using the variables of true height and sex, is important for drug dosing and ventilator settings. True height often cannot be measured in the emergency department (ED). Objectives: Determine the most accurate method to estimate IBW using true height-based IBW that uses true height estimated by providers or patients compared to true height estimated by a regression formula using measured tibial length, and compare all to the conventional 70 kg male/60 kg female standard IBW. Methods: Prospective, observational, double-blind, convenience sampling of stable adult patients in a tertiary care ED from September 2004 to April 2006. Derivation set (215 patients) had blinded provider and patient true height estimates and tibial length measurements compared to gold-standard standing true height. A validation set (102 patients) then compared the accuracy of IBW using true height calculated from the regression formula vs. IBW using gold-standard true height. Regression formula for men tibial length-IBW (kg) = 25.83 + 1.11 × tibial length; for women tibial length-IBW = 7.90 + 1.20 × tibial length; R² = 0.89, p < 0.001. Inter-rater correlation of tibial length was 0.94. Results: Derivation set: percent within 5 kg of true height-based IBW for men/women = Patient: 91.1%:/85.7%; Physician: 66.1%/45.1%; Nurse: 65.7%/ 47.3%; tibial length: 66.1%/63.7%; and 70 kg male/60 kg female standard 46%/75%. Validation set: tibial length-IBW estimates were within 5 kg of true height-ideal body weight in only 56.2% of men and 42.2% of women. Conclusions: Patient-reported height is the best bedside method to estimate true height to calculate ideal body weight. Physician and nurse estimates of true height are substantially less accurate, as is true height obtained from a regression formula that uses measured tibial length. All methods were more accurate than using the conventional 70 kg male/60 kg female IBW standard.     

The Paradox of the Nested Pediatric Emergency Department

Objectives: Nested pediatric emergency departments (nPEDs) are defined as dedicated treatment areas operating during peak pediatric hours within general emergency departments (EDs). This study examined three staffing models for nPEDs and their impact on pediatric encounters. Methods: Three models were applied to children younger than 37 months presenting to the ED of an urban community hospital over one year. In the nPED, physicians cared only for nPED patients. In the restricted (rPED) model, physicians cared only for pediatric patients presenting outside nPED hours. In the total ED (tED) model, physicians treated all pediatric patients regardless of time. Full-time equivalent pediatric encounters, potential neonatal lumbar punctures, and illness severity were determined for all models. Statistical analysis was performed by analysis of variance and chi-square test. Results: For the 3,389 eligible ED visits, the number of annual patient encounters per full-time equivalent was 1,236 for the nPED, 805 for the tED, and 336 for the rPED (p < 0.001). Physicians practicing only in the nPED treated 3.7 times the number of children younger than 37 months than did physicians in the rPED model and 1.5 times the number than did physicians in the tED model. Spending 10% of total practice hours in the nPED would increase pediatric encounters 26% for rPED physicians, while practicing 25% of time in the nPED would increase pediatric encounters 67% and equate to 45% of nPED encounters. An nPED physician could expect to perform 17 neonatal lumbar punctures, compared with ten for a tED physician and four for an rPED physician (p < 0.001). There was no significant difference in severity of illness for the three models. Conclusions: Physicians practicing in facilities that include an nPED must dedicate some portion of their practice to the nPED to maintain equivalent pediatric encounters.     

Emergency Department Characteristics and Capabilities in Beijing, China

Background

Emergency Departments (EDs) are a critical, yet heterogeneous, part of international emergency care.

Objectives

We sought to describe the characteristics, resources, capabilities, and capacity of EDs in Beijing, China.

Methods

Beijing EDs accessible to the general public 24 h per day/7 days per week were surveyed using the National ED Inventories survey instrument (www.emnet-nedi.org). ED staff were asked about ED characteristics during the calendar year 2008.

Results

Thirty-six EDs participated (88% response rate). All were located in hospitals and were independent hospital departments. Participating EDs saw a median of 80,000 patients (interquartile range 40,000–118,508). The vast majority (91%; 95% confidence interval [CI] 78–98%) had a contiguous layout, with medical and surgical care provided in one area. Most EDs (55%) saw only adults; 39% saw both adults and children, and 6% saw only children. Availability of technological and consultant resource in EDs was high. The typical ED length of stay was between 1 and 6 h in 49% of EDs (95% CI 32–67%), whereas in the other half, patients reportedly remained for over 6 h; 36% (95% CI 21–54%) of respondents considered their ED over capacity.

Conclusions

Beijing EDs have high volume, long length of stay, and frequent reports of EDs being over capacity. To meet its rapidly growing health needs in urban areas, China should consider improving urban ED capacity and training more Emergency Medicine specialists capable of efficiently staffing its crowded EDs.     

Validation of the Luscombe weight formula for estimating children's weight

Objective: Several paediatric weight estimation methods have been described for use when direct weight measurement is not possible. A new age‐based weight estimation method has recently been proposed. The Luscombe formula, applicable to children aged 1–10 years, is calculated as (3 × age in years) + 7. Our objective was to externally validate this formula using an existing database. Method: Secondary analysis of a prospective observational cohort study. Data collected included height, age, ethnicity and measured weight. The outcome of interest was agreement between estimated weight using the Luscombe formula and measured weight. Secondary outcome was comparison with performance of Argall, APLS and Best Guess formulae. Accuracy of weight estimation methods was compared using mean difference (bias), 95% limits of agreement, root mean square error and proportion with agreement within 10%. Results: Four hundred and ten children were studied. Median age was 4 years; 54.4% were boys. Mean body mass index was 17 kg/m² and mean measured weight was 21.2 kg. The Luscombe formula had a mean difference of 0.66 kg (95% limits of agreement ?9.9 to +11.3 kg; root mean square error of 5.44 kg). 45.4% of estimates were within 10% of measured weight. The Best Guess and Luscombe formulae performed better than Argall or APLS formulae. Conclusion: The Luscombe formula is among the more accurate age‐based weight estimation formulae. When more accurate methods (e.g. parental estimation or the Broselow tape) are not available, it is an acceptable option for estimating children's weight.     

A Systematic Review of Patient Tracking Systems for Use in the Pediatric Emergency Department

Background

Patient safety is of great importance in the pediatric emergency department (PED). The combination of acutely and critically ill patients and high patient volumes creates a need for systems to support physicians in making accurate and timely diagnoses. Electronic patient tracking systems can potentially improve PED safety by reducing overcrowding and enhancing security.

Objectives

To enhance our understanding of current electronic tracking technologies, how they are implemented in a clinical setting, and resulting effect on patient care outcomes including patient safety.

Methods

Nine databases were searched. Two independent reviewers identified articles that contained reference to patient tracking technologies in pediatrics or emergency medicine. Quantitative studies were assessed independently for methodological strength by two reviewers using an external assessment tool.

Results

Of 2292 initial articles, 22 were deemed relevant. Seventeen were qualitative, and the remaining five quantitative articles were assessed as being methodologically weak. Existing patient tracking systems in the ED included: infant monitoring/abduction prevention; barcode identification; radiofrequency identification (RFID)- or infrared (IR)-based patient tracking. Twenty articles supported the use of tracking technology to enhance patient safety or improve efficiency. One article failed to support the use of IR patient sensors due to study design flaws.

Conclusions

Support exists for the use of barcode-, IR-, and RFID-based patient tracking systems to improve ED patient safety and efficiency. A lack of methodologically strong studies indicates a need for further evidence-based support for the implementation of patient tracking technology in a clinical or research setting.     

Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department

BackgroundPractice variation exists in pain management of children with long bone fractures (LBFs).ObjectiveThe objectives of this study were to describe current pain management in children with LBFs and the factors associated with the undertreatment of pain.MethodsWe retrospectively studied children (aged 0–18 years) with a diagnosis of LBF in a pediatric emergency department (PED) from November 2015 through August 2016. Demographic characteristics and quality measures were noted. We determined the impact of PED crowding using the National Emergency Department Overcrowding Scale.ResultsA total of 905 patients (63% male, 48% African American) were enrolled. Median age was 6 years (interquartile range [IQR] 7 years), 72% had upper extremity injuries, falls were the most common mechanism (74%), and the majority were discharged (77%). Median time to pain score was 6 min (IQR 14 min). Seventy-two percent received analgesia with a median time to order of 63 min and medication receipt of 87 min. Ibuprofen was the analgesia prescribed most commonly. There were no identified factors associated with oligoanalgesia. Nonuse of narcotics was associated with African-American race, public insurance, single fractures, and arrival via private vehicle. Ambulance arrivals, lower extremity fractures, and disaster mode were associated with receiving analgesia within 60 min.ConclusionsIn our study, 28% of children with LBFs did not receive pain medications, especially during normal PED volumes. Additional studies are required to explore triage as a venue for analgesia delivery for LBFs.     

Guardian Availability in Children Evaluated in the Emergency Department for Blunt Head Trauma

Background: Enrolling children in research studies in the emergency department (ED) is typically dependent on the presence of a guardian to provide written informed consent. Objectives: The objectives were to determine the rate of guardian availability during the initial ED evaluation of children with nontrivial blunt head trauma, to identify the reasons why a guardian is unavailable, and to compare clinical factors in patients with and without a guardian present during initial ED evaluation. Methods: This was a prospective study of children (<18 years of age) presenting to a single Level 1 trauma center after nontrivial blunt head trauma over a 10‐month period. Physicians documented patient history and physical examination findings onto a structured data form after initial evaluation. The data form contained data points regarding the presence or absence of the patient’s guardian during the initial ED evaluation. For those children for whom the guardian was not available during the initial ED evaluation, the physicians completing the data forms documented the reasons for the absence. Results: The authors enrolled 602 patients, of whom 271 (45%, 95% confidence interval [CI] = 41% to 49%) did not have a guardian available during the initial ED evaluation. In these 271 patients, 261 had reasons documented for lack of guardian availability, 43 of whom had multiple reasons. The most common of these was that the guardian did not ride in the ambulance (51%). Those patients without a guardian available were more likely to be older (mean age, 11.4 years vs. 7.6 years; p < 0.001), be victims of a motor vehicle collision (MVC; 130/268 [49%] vs. 35/328 [11%]; p < 0.001), have a Glasgow Coma Scale (GCS) score <14 (21/269 [7.8%] vs. 11/331 [3.3%]; p = 0.02), and undergo cranial computed tomography (CT) scanning (224/271 [83%] vs. 213/331 [64%]; p < 0.001). Multivariate analysis identified similar independent risk factors for lack of guardian presence. Conclusions: Nearly one‐half of children with nontrivial blunt head trauma evaluated in the ED may not have a guardian available during their initial ED evaluation. Patients whose guardians are not available at the time of initial ED evaluation are older and have more severe mechanisms of injury and more serious head trauma. ED research studies of pediatric trauma patients that require written informed consent from a guardian at the time of initial ED evaluation and treatment may have difficulty enrolling targeted sample size numbers and will likely be limited by enrollment bias.     

Validation of the Elderly Risk Assessment Index in the Emergency Department

ObjectivesThe Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients.MethodsObservational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated.ResultsThe cohort included 27,397 visits among 18,607 patients. Median age 74 years (66–82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4–16] vs 5 [1–11], p < 0.0001), return visits (11 [5–17] vs 7 [2–13], p < 0.0001); and death within one year (14 [7–20] vs 6 [2–13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02–2.28, p < 0.0001), return within 30 days OR 1.99 (1.85–2.14), and to die within a year, OR 2.69 (2.54–2.85).ConclusionThe ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.     

超声预测巨大胎儿体重公式准确性研究

目的： 求出较为准确的预测巨大胎儿体重公式。方法： 通过超声测量 １４２ 例胎儿头围 （ＨＣ）、腹围（ＡＣ）、股骨径 （ＦＬ） 及胎儿腿部皮下脂肪厚度 （ＦＴＨ）, 根据各生理参数计算出ＨＣ、ＡＣ、ＦＬ、ＦＴＨ 分别与胎儿体重的直线回归方程以及以上４ 参数与胎儿体重的多元线性回归方程, 并进行比较。结果： 应用多元线性回归方程预测巨大胎儿体重较直线回归方程准确。结论：多元线性回归方程考虑到了影响胎儿体重的各个因素,因此其准确性较高。     

Health,Emergency Department Use,and Early Identification of Young Children Exposed to Trauma

Background

Childhood trauma is an important public health problem with financial, physical health, and mental health repercussions. Emergency departments (EDs) are often the first point of contact for many young children affected by emotionally or psychologically traumatic events (e.g., neglect, separation from primary caregiver, maltreatment, witness to domestic violence within the family, natural disasters).

Study Objectives

Describe the prevalence of physical health symptoms, ED use, and health-related problems in young children (birth through 5 years) affected by trauma, and to predict whether or not children experiencing trauma are more likely to be affected by health-related problems.

Methods

Community-based, cross-sectional survey of 208 young children. Traumatic events were assessed by the Traumatic Events Screening Inventory – Parent Report Revised. Child health symptoms and health-related problems were measured using the Caregiver Information Questionnaire, developed by ORC Macro (Atlanta, GA).

Results

Seventy-two percent of children had experienced at least one type of traumatic event. Children exposed to trauma were also experiencing recent health-related events, including visits to the ED (32.2%) and the doctor (76.9%) for physical health symptoms, and recurring physical health problems (40.4%). Children previously exposed to high levels of trauma (four or more types of events) were 2.9 times more likely to report having had recently visited the ED for health purposes.

Conclusions

Preventing recurrent trauma or recognizing early trauma exposure is difficult, but essential if long-term negative consequences are to be mitigated or prevented. Within EDs, there are missed opportunities for identification and intervention for trauma-exposed children, as well as great potential for expanding primary and secondary prevention of maltreatment-associated illness, injury, and mortality.     

National Emergency Department Overcrowding Study tool is not useful in an Australian emergency department

Objective: To determine the accuracy and usefulness of the National Emergency Department Overcrowding Study (NEDOCS) tool in an urban hospital ED in Australia by direct comparison with subjective assessment by senior ED staff. Method: A sample of simultaneous subjective and objective data pairs were collected six times a day for a period of 3 weeks. All senior medical staff in the ED answered a brief questionnaire along with the senior charge nurse for the ED. Simultaneously, the senior charge nurse also documented the total number of patients in the ED, the number of patients awaiting admission, the number of patients on ventilators, the longest time waited by an ED patient for ward bed, and the waiting time for the last patient from the Waiting Room placed on a trolley. The objective indicators were entered into a Web‐based NEDOCS tool and transformed scores were compared with the averaged and transformed subjective scores for each sample time. Bland–Altmann and Kappa statistics were used to test the agreement between the objective and subjective measuring methods. Results: The mean difference between the subjective and objective methods was small (3.5 [95% confidence interval ?0.875–7.878] ); however, the 95% limits of agreement was wide (?46.52–53.43). The Kappa statistic used to assess the extent of reproducibility between categorical variables was 0.31 (95% confidence interval 0.17–0.45). Conclusion: The present study suggests that NEDOCS method of processing the objective overcrowding data does not accurately reflect the subjective assessment of the senior staff working at that time in the ED. This might be because the assumptions of the original NEDOCS study are flawed.     

Medication Errors in the Management of Anaphylaxis in a Pediatric Emergency Department

Background

Despite the publication of recent guidelines for anaphylaxis management, many studies show that physicians are still not at ease with the management of anaphylaxis.

Objectives

To evaluate the rate and severity of medication errors before and after implementation of a standard order form for anaphylaxis management.

Methods

A before-and-after study was conducted. All children <18 years of age presenting to a tertiary care pediatric hospital Emergency Department with anaphylaxis between September 2007 and November 2010 were included. Patients were divided into two groups according to intervention (Pre and Post). Intervention consisted of the implementation of a standard order form (SOF) for anaphylaxis management. The post-intervention group was further sub-divided into SOF+ (when the SOF was used) and SOF− (when the SOF was not used).

Results

A total of 96 medical charts were reviewed. There were 31 patients in Pre and 65 in Post (29 in SOF+ and 36 in SOF−). A total of 243 drugs were ordered. Thirty-five percent (85/243) of these orders contained at least one medication error. Fifty-five percent (47/85) were dosage errors. The rate of medication errors was the same between Pre and Post (60% vs. 59%, p = 0.95). However, the rate of dosage errors was significantly reduced when the SOF was used (21% in SOF+ vs. 50% in Pre, p = 0.02 and 21% in SOF+ vs. 50% in SOF−, p = 0.02).

Conclusions

Medication errors in the management of anaphylaxis were frequent. Use of an SOF significantly reduced the rate of dosage errors.     

Clinician‐led design for optimising flow: Seizing the opportunity for a new‐build Australian Emergency Department

A new ED build creates a unique opportunity to improve the way we provide clinical care. Often, the focus is primarily on increasing clinical cubicle numbers but this may have a negligible, or even negative impact on care delivery. Instead, Australian EDs should examine the entire patient journey to inform design, reviewing outdated triage and registration models and maximising physical capacity by introducing advanced split‐flow models that optimise clinical space and provide high‐risk patients faster access to clinical care. Efficient ED patient flow is critical for success and is closely linked with departmental design, but too often this design process is delegated to architects with limited knowledge of ED function and with limited input from emergency clinicians. This relationship between clinicians and architects should remain collaborative but requires re‐alignment. Independent, expert ED‐specific designers can empower and provide valuable support for clinician‐led design teams in their interactions with architects.