Incidence,clinical presentation,and management of constipation in a pediatric ED

Objectives

The study aimed to assess, in pediatric patients presenting to the emergency department (ED), the incidence of visit to the ED for functional constipation (FC), symptoms, signs of presentation, and management from ED physicians.

Design

This is a retrospective study of hospital records for a period of 1 year at the ED of “Bambino Gesù” Children's Hospital, Rome, Italy. Children younger than 15 years discharged from ED with a diagnosis of FC in the 1-year period were included.

Interventions

We analyzed medical records of 202 patients (<15 years) with FC diagnosis at discharge. Main outcome measures included incidence, demographic characteristics, clinical presentations of FC patients, and ED physicians' interventions.

Results

Two hundred two FC cases were studied in a 12-month study period. Compared with the total number of ED consultations, the incidence of FC was 0.4%. The number of patients 4 years or younger was much higher than patients older than 4 years (P < .0001). Bowel frequency of 3 bowel movements or less per day, acute abdominal pain, and stool retention were found to be significantly more frequent than the other presenting symptoms (P < .0001). The number of patients beginning a therapy after ED discharge was significantly higher compared with that already treated before ED visit (P < .0001). Discharged patients were referred to community pediatricians significantly more frequently than to pediatric gastroenterologists (P = .003).

Conclusions

Emergency department physicians have an important role in the diagnosis and management of FC despite its relatively low incidence. Indeed, ED intervention in many cases leads not only to recognition this disease but also to an approach for therapeutic strategy, avoiding complications of chronic constipation.     

Prospective, 10-year evaluation of the impact of Hispanic ethnicity on pain management practices in the ED

Introduction

Hispanic ethnicity has been reported as an independent risk factor for oligoanalgesia in the emergency department (ED).

Objectives

The objectives are to compare pain management practices in White and Hispanic patients in the ED to determine whether treatment differences exist.

Methods

Prospective analysis of a convenience sample of patients presenting to an urban, academic, tertiary-care ED over the 10-year period from 2000 to 2010. We compared patients with pain-related complaints of any nature, who self-identified their race as White or Hispanic, and evaluated initial morphine administration/dosing, arrival/disposition pain scores, and overall ED satisfaction scores (0-10 scale).

Results

Fifteen thousand sixty patients were enrolled. Eighty-one point 2 percent (n, 12 232) of the patients were White and 11.2% (n, 1680), Hispanic. White and Hispanic patients reported similar pain at presentation (6.7 vs 7.3, P < .001) and discharge/admission (4.6 vs 4.8, P = .14). Hispanic patients were not less likely to receive an analgesic during the ED visit (odds ratio, 1.06; confidence interval, 0.96-1.17; P = .62), nor less likely to receive an opioid analgesic (odds ratio, 0.97; confidence interval, 0.88-1.08; P = .70). Hispanic patients, on average, received similar initial doses of morphine (4.1 vs 4.3 mg, P = .29) and had similar wait times from arrival to initial dose of morphine (82 vs 86 minutes). Overall ED satisfaction scores were the same (8.7 vs 8.7, P = .65).

Conclusion

White and Hispanic patients were similar in rates of initial morphine administration for pain-related complaints. These findings contrast with previous studies reporting lower rates of initial analgesia administration among Hispanic patients in the ED.     

Predicting the hyperglycemic crisis death (PHD) score: a new decision rule for emergency and critical care

Background

We investigated independent mortality predictors of hyperglycemic crises and developed a prediction rule for emergency and critical care physicians to classify patients into mortality risk and disposition groups.

Methods

This study was done in a university-affiliated medical center. Consecutive adult patients (> 18 years old) visiting the emergency department (ED) between January 2004 and December 2010 were enrolled when they met the criteria of a hyperglycemic crisis. Data were separated into derivation and validation sets—the former were used to predict the latter. December 31, 2008, was the cutoff date. Thirty-day mortality was the primary endpoint.

Results

We enrolled 295 patients who made 330 visits to the ED: derivation set = 235 visits (25 deaths: 10.6%), validation set = 95 visits (10 deaths: 10.5%). We found 6 independent mortality predictors: Absent tachycardia, Hypotension, Anemia, Severe coma, Cancer history, and Infection (AHA.SCI). After assigning weights to each predictor, we developed a Predicting Hyperglycemic crisis Death (PHD) score that stratifies patients into mortality-risk and disposition groups: low (0%) (95% CI, 0-0.02%): treatment in a general ward or the ED; intermediate (24.5%) (95% CI, 14.8-39.9%): the intensive care unit or a general ward; and high (59.5%) (95% CI, 42.2-74.8%): the intensive care unit. The area under the curve for the rule was 0.946 in the derivation set and 0.925 in the validation set.

Conclusions

The PHD score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in adult patients with hyperglycemic crises.     

Violence and abuse faced by junior physicians in the emergency department from patients and their caretakers: a nationwide study from Pakistan

Background

Across the globe, physicians in the emergency department (ED) are subject to violence by patients and visitors. This has been shown to have negative effects on patient care and physician performance.

Study Objectives

This study was conducted to determine the magnitude of the problem in a developing country, to examine the effects of ED violence on physician satisfaction and performance, and to identify underlying etiologies and potential solutions.

Methods and Setting

This nationwide cross-sectional study examined physicians-in-training (n = 675) in the EDs of nine major tertiary care hospitals in Pakistan.

Results

The study reveals a significant problem, with 76.9% of physicians facing verbal (65.0%) or physical (11.9%) abuse from patients or their caretakers in the previous 2 months. Male physicians were more likely than female physicians to be victims of such episodes (p < 0.05), as were physicians who had spent more than 60 h in the ED in the past 2 months (p < 0.0001). Reduced job satisfaction and a decline in the quality of job performance were reported by 40.7% and 44.3% of physicians, respectively. Junior trainee physicians were more likely to report impairment in job performance when compared to their senior colleagues (p = 0.014). Patients’ lack of education, overcrowding in the ED, and lack of coverage by security staff were identified as the major areas that need attention to address the problem.

Conclusion

This study provides further evidence of the global prevalence of the problem, with the first nationwide epidemiological study performed in a developing country.     

Staffing of the ED by non–emergency medicine-trained personnel: the VA experience

Study objective

VA (Veteran's Affairs) emergency departments (EDs) are generally staffed with physicians trained in internal medicine (IM), although recently, a movement has begun toward hiring emergency medicine (EM)-trained staff. At our institution, the ED is staffed by physicians of both specialties. This study examines the frequency of unscheduled return visits to the ED in an effort to compare the quality of emergency care given by physicians trained in IM and EM.

Methods

The record of all visits to a VA hospital ED during a 90-day period were examined, and all those visits resulting in a return ED visit within the 30 subsequent days were noted.

Results

The charts of 2891 consecutive ED patients were examined. The rate of revisits was significantly higher for the IM than for the EM-trained physicians (8.9% vs 5.5%, respectively; P < .001). The IM-trained physicians had a significantly higher rate of admissions upon revisit within 30 days than did the EM-trained physicians (3.5% vs 1.9%, respectively; P = .014). The IM-trained staff had lower initial hospitalization rates than the EM physicians (20% vs 43%, respectively; P < .0001).

Conclusions

The IM-trained physicians were less likely to hospitalize patients, although this can be partially explained by the lower acuity of patients during the hours that they covered. The IM-trained physicians were significantly more likely to have a patient return after discharge and also more likely to have a patient return in need of hospitalization. This may reflect a difference in training for the rapid diagnosis and risk stratification of ED patients.     

The influence of physician seniority on disparities of admit/discharge decision making for ED patients

Objectives

Differences in disposition between emergency physicians (EPs) have been studied in select patient populations but not in general emergency department (ED) patients. After determining whether a difference existed in admit/discharge decision making of EPs for general ED patients, we focus our study in examining the influence of EP seniority on the decision to discharge ED patients.

Methods

In a 1-year retrospective study, we included a convenience sample of all 18 953 adult nontraumatic ED patients. We reviewed the admit/discharge dispositions at each shift made by 16 EPs. EPs were categorized by seniority to determine whether seniority influenced disposition. Three groups had 5, 4, and 7 EPs each, with >10 years, 5 to 9 years, and <5 years of working experience, respectively.

Results

Patient demographics, triage level, and number of patients per shift did not differ statistically between EPs and each group. The number of discharged patients per shift differed statistically between EPs (P < .001) and each group. The most senior EPs had the lowest discharge rates compared with EPs in intermediate and junior groups. They had lower discharge rates for patients at triage levels 1, 2, and 3 as well as for all patients. However, no difference in unscheduled ED revisit rates was found.

Conclusions

EPs vary in their admit/discharge decision making for general ED patients. More importantly, the most senior EPs were found to have the lowest discharge rates compared with their junior colleagues.     

Diagnostic yield of coronary angiography in patients with acute chest pain: role of noninvasive test

Objectives

This study investigated the diagnostic yield of invasive coronary angiography (CAG) and the impact of noninvasive test (NIV) in patients presented to emergency department (ED) with acute chest pain.

Methods

Patients 50 years or older who visited ED with acute chest pain and underwent CAG were identified retrospectively. Those with ischemic electrocardiogram, elevated cardiac enzyme, known coronary artery disease (CAD), history of cardiac surgery, renal failure, or allergy to radiocontrast were excluded. Diagnostic yields of CAG to detect significant CAD or differentiate the need for revascularization were analyzed according to whether NIV was performed and its result.

Results

Among the total 375 consecutive patients, significant CAD was observed in 244 (65.1%). Diagnostic yields of CAG were higher in patients who underwent NIV before CAG, but the discriminative effect was modest (59.7% vs 70.7% [P = .026] for detection of CAD; 45.0% vs 50.5% [P = .285] for revascularization). Positive results of NIV were significantly associated with the presence of CAD and the need for revascularization, when compared with patients without NIV or patients with negative results (P < .001, respectively).

Conclusion

The diagnostic yield of CAG was only 65% in low- to intermediate-risk ED patients with acute chest pain. Performing of NIV provided only modest improvement in diagnostic yield of CAG. The unexpectedly low diagnostic yield might be attributable to the underuse of NIV and misinterpretation of physicians. We suggest the use of NIV as a gatekeeper to discriminate patients who require CAG and/or revascularization, and for this, better risk stratification and appropriate application of NIV are required.     

Diagnostic performance of initial salivary alpha-amylase activity for acute myocardial infarction in patients with acute chest pain

Background

To rule out acute myocardial infarction (AMI) in chest pain patients constitutes a diagnostic challenge to emergency department (ED) physicians.

Study Objectives

To evaluate the diagnostic value of measuring salivary alpha-amylase (sAA) activity for detecting AMI in patients presenting to the ED with acute chest pain.

Methods

sAA activity was measured in a prospective cohort of 473 consecutive adult patients within 4 h of onset of chest pain. Comparisons were made between patients with a final diagnosis of AMI and those with non-AMI. Univariate analysis and multiple logistic regression model were used to identify independent clinical predictors of AMI.

Results

Initial sAA activity in the AMI group (n = 85; 266 ± 127.6 U/mL) was significantly higher than in the non-AMI group (n = 388; 130 ± 92.8 U/mL, p < 0.001). sAA activity levels were also significantly higher in patients with ST elevation AMI (n = 53) compared to in those with non-ST elevation AMI (n = 32) (300 ± 141.1 vs. 210 ± 74.1 U/mL, p < 0.001). The area under the receiver operating characteristic curve of sAA activity for predicting AMI in patients with acute chest pain was 0.826 (95% confidence interval [CI] 0.782–0.869), with diagnostic odds ratio 10.87 (95% CI 6.16–19.18). With a best cutoff value of 197.7 U/mL, the sAA activity revealed moderate sensitivity and specificity as an independent predictor of AMI (78.8% and 74.5%).

Conclusions

High initial sAA activity is an independent predictor of AMI in patients presenting to the ED with chest pain.     

Improved Physician Consult Response Times in an Academic Emergency Department After Implementation of an Institutional Guideline

Background

Physician consultation in the Emergency Department (ED) can account for a significant portion of ED length of stay, which can lead to poor clinical outcomes.

Objective

The purpose of this study was to determine whether an institutional guideline could lead to a reduction in time between consult request and admission decision. This guideline codified a 90-min expected time interval to arrive and complete an admission disposition where the consulting and admitting service were the same in an academic ED with weekly audits and reports to departmental chairs and hospital administrators.

Methods

This was a study of consultation times of patients who presented to an academic ED 6 months before the adoption of an institutional guideline and 6 months after the adoption of the guideline. Data measurement in both periods included the length of time from ED consult order to admission disposition, time of ED discharge, number of ED consultations (single and multiple), ED admissions, and the hospital discharge time of admitted patients.

Results

Physician consult response time decreased from 121 min to 100 min (p < 0.0001), and patients left the ED 18 min earlier (p = 0.0221) after implementation of the consultation guideline despite more ED visits, consultations, and admissions in the post-implementation time period. Patients were discharged from the inpatient setting 50 min later (p < 0.0001) after implementation of the guideline.

Conclusion

An institutional guideline codifying timely ED consultations led to a significant reduction in the time from ED consultation to admission disposition while also allowing patients to leave the ED earlier in a high-occupancy academic medical center. However, the discharge time of admitted hospital patients was later after implementation of the guideline.     

Effects of implementing a rapid admission policy in the ED

Objective

The purpose of this study is to determine the impact of a new rapid admission policy (RAP) on emergency department (ED) length of stay (EDLOS) and time spent on ambulance diversion (AD).

Methods

The RAP, instituted in January 2005, allows attending emergency physicians to send stable patients, requiring admission to the general medicine service, directly to available inpatient beds. The RAP thereby eliminates 2 conventional preadmission practices: having admitting physicians evaluate the patient in the ED and requiring all diagnostic testing to be complete before admission. We compared patient characteristics, percentage of patients leaving without being seen, EDLOS for admitted patients, time on AD, and total adjusted facility charge for a 3-month period after the RAP implementation to the same period of the prior year.

Results

There was a 1.1% increase in census with no difference in patient demographics, acuity, or disposition categories for the 2 periods. The EDLOS decreased on average by 10.1 minutes (95% confidence interval [CI], 3.3-17.0 minutes), resulting in an average of 4.2 hours of extra bed availability per day. Weekly minutes of AD decreased 169 minutes (95% CI, 29-310 minutes). There was also a 3.2% increase (95% CI, 3.1%-3.3%) in adjusted facility charge between these periods in 2005 compared with 2004.

Conclusions

The RAP resulted in a small decrease in the EDLOS, which likely decreased AD time. The resulting small increase in ED volume and higher acuity ambulance patients significantly improved ED revenue. Wider implementation of the policy and more uniform use among emergency physicians may further improve these measures.     

Hospitalist bed management effecting throughput from the emergency department to the intensive care unit

Rationale

Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes.

Objective

To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the “active bed management” (ABM) intervention.

Methods

A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow.

Measurement

Throughput time for patients presenting to the ED requiring ICU admission was analyzed.

Main Results

The ED census was higher during the intervention period as compared with the control period, 17?573 versus 16?148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (±14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant.

Conclusion

Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety.     

Intravenous contrast alone vs intravenous and oral contrast computed tomography for the diagnosis of appendicitis in adult ED patients

Objective

When the diagnosis of appendicitis is uncertain, computerized tomography (CT) scans are frequently ordered. Oral contrast is often used but is time consuming and of questionable benefit. This study compared CT with intravenous contrast alone (IV) to CT with IV and oral contrast (IVO) in adult patients with suspected appendicitis.

Methods

This is a prospective, randomized study conducted in a community teaching emergency department (ED). Patients with suspected appendicitis were randomized to IV or IVO CT. Scans were read independently by 2 designated study radiologists blinded to the clinical outcome. Surgical pathology was used to confirm appendicitis in patients who went to the operating room (OR). Discharged patients were followed up via telephone. The primary outcome measure was the diagnosis of appendicitis. Secondary measures included time from triage to ED disposition and triage to OR.

Results

Both IV (n = 114) and IVO (n = 113) scans had 100% sensitivity (95% confidence interval [CI], 89.3-100 and 87.4-100, respectively) and negative predictive value (95% CI, 93.7-100 and 93.9-100, respectively) for appendicitis. Specificity of IV and IVO scans was 98.6 and 94.9 (95% CI, 91.6-99.9 and 86.9-98.4, respectively), respectively, with positive predictive values of 97.6 and 89.5 (95% CI, 85.9-99.9 and 74.2-96.6). Median times to ED disposition and OR were 1 hour and 31 minutes (P < .0001) and 1 hour and 10 minutes (P = .089) faster for the IV group, respectively. Patients with negative IV scans were discharged nearly 2 hours faster (P = .001).

Conclusions

Computerized tomography scans with intravenous contrast alone have comparable diagnostic performance to IVO scans for appendicitis in adults. Patients receiving IV scans are discharged from the ED faster than those receiving IVO scans.     

The Effect of Boarders on Emergency Department Process Flow

Background

Emergency department (ED) overcrowding with boarders and waiting times are a significant concern in many countries.

Objective

We aim to show the relationship between boarders in the ED and the percentage time to disposition in under 6 h for our ED patients.

Method

A review was carried out to show the percentage of patients presenting to the ED compliant with a 6-h standard per day compared to the number of attendances, the number of admissions to the hospital, and the number of boarders in the ED per day.

Results

Over the 2-year study period, there was an average 0.37% fall in the ED's rate of compliance per day, with a 6-h standard for each boarder in the ED.

Conclusion

Boarding patients in the ED has a negative effect on compliance with our 6-h standard of time to disposition.     

Resource utilization and health care charges associated with the most frequent ED users

Study objective

Emergency department (ED) visits have continued to rise, and frequent ED users account for up to 8% of all ED visits. Reducing visits by frequent ED users may be one way to help reduce health care costs. We hypothesize that frequent users have unique ED utilization patterns resulting in differences in health care charges.

Methods

We conducted a retrospective review of electronic medical records from an urban community teaching hospital for the year 2012 comparing the top 108 frequent ED users (> 12 visits/year) to a randomly selected group of 108 nonfrequent users (< 4 visits/year). We compared demographic characteristics, distance lived from the hospital, medical and psychiatric history, substance abuse history, diagnostic testing, disposition, and amount charged to the patient for each visit. We compared data using χ² for proportions and t test or Wilcoxon rank sum based on normality of the data.

Results

The top 108 frequent ED users accounted for 1922 visits (2.9%), whereas the 108 nonfrequent users accounted for 150 visits (0.2%), in 2012 (all ED visits n = 65,398). Frequent users were more often unemployed, have public insurance, have mental health conditions, use tobacco, have a greater number of allergies to medications, and live closer to the hospital (P < .01). Disposition and median charge per visit did not differ between frequent and nonfrequent users ($1220 vs $1280). The total charges of the frequent ED users’ visits were $10,465,216.07 versus $1,012,610.21 for nonfrequent users.

Conclusions

Frequent users have unique medical and social characteristics; however, disposition and visit charges did not differ from nonfrequent users.     

Impact of Physician Screening in the Emergency Department on Patient Flow

Background

Physician triage is one of many front-end interventions being implemented to improve emergency department (ED) efficiency.

Study Objective

We aim to determine the impact of this intervention on some key components of ED patient flow, including time to physician evaluation, treatment order entry, diagnostic order entry, and disposition time for admitted patients.

Methods

We conducted a 2-year before–after analysis of a physician triage system at an urban tertiary academic center with 90,000 annual visits. The goal of the physician in triage was to arrange safe disposition of straightforward patients as well as to initiate work-ups. All medium-acuity patients arriving during the hours of the intervention were impacted and thus included in the analysis. Our primary outcome was the time to disposition decision. In addition to before–after analysis, comparison was made with high-acuity patients, a group not impacted by this intervention. Patient flow data were extracted from the ED information system. Outcomes were summarized with medians and interquartiles. Multivariable regression analysis was performed to investigate the intervention effect controlling for potential confounding variables.

Results

The median time to disposition decision decreased by 6 min, and the time to physician evaluation, analgesia, antiemetic, antibiotic, and radiology order decreased by 16, 70, 66, 36, and 16 min, respectively. These findings were all statistically significant. Similar results were observed from the multivariable regression models after controlling for potential confounding factors.

Conclusions

Physician triage led to earlier evaluation, physician orders, and a decrease in the time to disposition decision.     

Practice variation in the management for nontraumatic pediatric patients in the ED

Study objective

To improve the management quality and monitoring for common pediatric illnesses in the general emergency department (ED), we examined the effect of physician specialty training on medical resource use and patient outcomes.

Methods

This was a retrospective cohort review of visits by children less than 18 years to the ED of 2 university-affiliated teaching hospitals. Clinical management by 2 groups (emergency physicians [EPs] and pediatricians each working 168 h/wk) was compared with respect to demographics, ED resource use, short-term outcome, disposition, direct ED costs for each visit, and frequency of radiographic and laboratory test use. The effects of medical decision making on resource use was assessed by comparing costs of radiographic studies, laboratory studies, and medication.

Results

Between-group differences in mean patient age, sex, and triage category were insignificant. Compared to pediatricians, EPs used radiographic and laboratory studies more frequently (respectively, 10.1% and 3.8% higher frequency and 90.5% and 7.6% higher cost) and less medication (12.5% lower cost). Patients managed by EPs had longer ED length of stay (LOS), higher admission rates to general wards, and shorter LOS per hospitalization but similar 72-hour revisit rates, needed more frequent referral for medical reasons, and left more frequently against medical advice.

Conclusion

Emergency physicians spent more time and medical resources and admitted patients at a higher rate. Emergency physicians and pediatricians managed critical patients similarly.     

The effect of an observation unit on the rate of ED admission and discharge for pyelonephritis

Objectives

We sought to determine if the opening of an adult emergency department (ED) observation unit (OU) would impact the rate of hospital admission and ED discharges for pyelonephritis.

Methods

A retrospective cohort study was performed with all adult patients from October 2003 through December 2006 in the ED meeting inclusion criteria for pyelonephritis. Clinical, demographic, and laboratory data were recorded. Primary outcomes were rates of admission, ED discharge, and return ED visits before and after the opening of our OU. We compared admission, discharge, and readmission rates using the χ² test.

Results

Nine hundred thirty charts were reviewed with 633 included for analysis. Urine cultures were performed on 420 subjects with 71% being positive. The percentage of patients admitted to a hospital inpatient unit from the ED decreased from 36% to 26% (relative risk [RR], 0.73; P = .01) after opening the OU. The percentage of patients discharged home from the ED decreased from 65% to 51% (RR, 0.76; P < .001). Among OU patients, 29% were admitted to the hospital for further inpatient care. Emergency department recidivism was unchanged by opening the OU (RR, 0.86; P = .68).

Conclusions

The creation of an OU appears to influence admission decisions of ED physicians. We found that the creation of an OU significantly reduced hospital admissions for pyelonephritis but also significantly reduced ED discharges to home for pyelonephritis at our institution.     

Emergency physicians do not use more resources to evaluate obese patients with acute abdominal pain

Objective

We hypothesized that emergency physicians would use more resources to evaluate acute abdominal pain in obese patients as compared with that in nonobese patients.

Methods

We conducted a secondary analysis of a prospective cohort of adults with acute abdominal pain. Collected data included self-reported height and weight, demographics, medical history, laboratory and x-ray results, and final diagnosis. We followed the patients until they obtained their final diagnosis or for up to 21 days. Patients were grouped according to their body mass index (BMI): nonobese (BMI < 30 kg/m²), obese (BMI = 30-40 kg/m²), and morbidly obese (BMI > 40 mg/m²). The main outcome measure was laboratory and radiographic testing. χ² Tests and analysis of variance were used as appropriate.

Results

Of the 971 patients (mean age, 41 years; 62% black; 65% female), 665 (68%) were nonobese, 246 (25%) were obese, and 60 (6%) were morbidly obese. In comparing nonobese patients with obese patients, we found no difference in laboratory or radiographic testing (3.20 vs 3.21 tests; mean difference, 0.004; 95% confidence interval [CI], −0.26 to 0.27), physicians' pre–computed tomographic scan confidence level in their diagnosis (6.17 vs 6.04, mean difference, −0.13; 95% CI, −0.76 to 0.49), and emergency department (ED) length of stay (LOS; 7.40 vs 7.57 hours; mean difference, −0.17; 95% CI, −0.49 to 0.83). In comparing all 3 groups, we found no difference in diagnostic testing, ED LOS, surgical intervention (10% vs 5% vs 9%, P = .2), disposition, and final diagnosis (P > .05).

Conclusions

Physicians do not use more resources to identify the etiology of acute abdominal pain in obese patients as compared with that in nonobese patients. Furthermore, ED LOS, likelihood of surgical intervention, physicians' confidence level in their preimaging diagnosis, and final diagnosis do not appear to be influenced by BMI.     

Improving patient flow in acute coronary syndromes in the face of hospital crowding

Background

The current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease.

Objective

To measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS.

Methods

Primary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post- availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death.

Results

In the post-implementation period there was a 30% (95% confidence interval [CI] 36–44%) reduction in admissions to telemetry with a 33% (95% CI 26–39%) reduction in ED LOS and a 20% (95% CI 7–34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p = 0.001).

Conclusion

The focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS.     

Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations

Background

Video laryngoscopy has, in recent years, become more available to emergency physicians. However, little research has been conducted to compare their success to conventional direct laryngoscopy.

Objectives

To compare the success rates of GlideScope^® (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) with direct laryngoscopy (DL) for emergency department (ED) intubations.

Methods

This was a 24-month retrospective observational study of all patients intubated in a single academic ED with a level I trauma center. Structured data forms were completed after each intubation and entered into a continuous quality improvement database. All patients intubated in the ED with either the GlideScope^® standard, Cobalt, Ranger, or traditional Macintosh or Miller laryngoscopes were included. All patients intubated before arrival were excluded. Primary analysis evaluated overall and first-attempt success rates, operator experience level, performance characteristics of GVL, complications, and reasons for failure.

Results

There were 943 patients intubated during the study period; 120 were excluded due to alternative management strategies. DL was used in 583 (62%) patients, and GVL in 360 (38%). GVL had higher first-attempt success (75%, p = 0.03); DL had a higher success rate when more than one attempt was required (57%, p = 0.003). The devices had statistically equivalent overall success rates. GVL had fewer esophageal intubations (n = 1) than DL (n = 18); p = 0.005.

Conclusion

The two techniques performed equivalently overall, however, GVL had a higher overall success rate, and lower number of esophageal complications. In the setting of ED intubations, GVL offers an excellent option to maximize first-attempt success for airway management.