The Validity of Emergency Department Triage Blood Pressure Measurements

OBJECTIVE: Automated blood pressure (ABP) devices are ubiquitous at emergency department (ED) triage. Previous studies failed to evaluate ABP devices against accepted reference standards or demonstrate triage readings as accurate reflections of blood pressure (BP). This study evaluated ED triage measurements made using an ABP device and assessed agreement between triage BP and BP taken under recommended conditions. METHODS: A prospective study was conducted at an urban teaching hospital. Patients were enrolled by convenience sampling. Simultaneous automated and manual triage BPs were obtained using one BP cuff with a Y-tube connector. Research assistants were certified in obtaining manual BP as described by the British Hypertension Society (BHS). Patients were placed in a quiet setting, and manual BP was repeated by American Heart Association (AHA) standards. Data analysis was performed using methods described by Bland and Altman. The ABP device was assessed using Association for the Advancement of Medical Instrumentation (AAMI) and BHS criteria. RESULTS: One hundred seventy-one patients were enrolled. Systolic BP (sBP) range was 81 to 218 mm Hg; diastolic BP (dBP) range was 43 to 130 mm Hg. Automated vs. manual sBP difference was 3.8 +/- 11.2 mm Hg (95% confidence interval [CI] = 2.1 to 5.4); dBP difference was 6.6 +/- 9.0 mm Hg (95% CI = -7.9 to -5.2). Manual triage BP vs. AHA standard SBP difference was 11.6 +/- 12.8 mm Hg (95% CI = 9.1 to 14.1); dBP difference was 9.9 +/- 10.4 mm Hg (95% CI = 7.9 to 12.0). The ABP device failed to meet AAMI criteria and received a BHS rating of "D." Poor operator technique and extraneous patient and operator movement appeared to hamper accuracy. CONCLUSIONS: ABP triage measurements show significant discrepancies from a reference standard. Repeat measurements following AHA standards demonstrate significant decreases in the measured blood pressures.     

Pain Scores Improve Analgesic Administration Patterns for Trauma Patients in the Emergency Department

OBJECTIVE: To determine the efficacy of pain scores in improving pain management practices for trauma patients in the emergency department (ED). METHODS: A prospective, observational study of analgesic administration to trauma patients was conducted over a nine-week period following educational intervention and introduction of verbal pain scores (VPSs). All ED nursing and physician staff in an urban Level I trauma center were trained to use the 0-10 VPS. Patients younger than 12 years old, having a Glasgow Coma Scale score (GCS) <8, or requiring intubation were excluded from analysis. Demographics, mechanism of injury, vital signs, pain scores, and analgesic data were extracted from a computerized ED database and patients' records. The staff was blinded to the ongoing study. RESULTS: There were 150 patients studied (183 consecutive trauma patients seen; 33 patients excluded per criteria). Pain scores were documented for 73% of the patients. Overall, 53% (95% confidence interval [CI] = 45% to 61%) of the patients received analgesics in the ED. Of the patients who had pain scores documented, 60% (95% CI = 51% to 69%) received analgesics, whereas 33% (95% CI = 18% to 47%) of the patients without pain scores received analgesics. No patient with a VPS < 4 received analgesics, whereas 72% of patients with a VPS > 4 and 82% with a VPS > 7 received analgesics. Mean time to analgesic administration was 68 minutes (95% CI = 49 to 87). CONCLUSIONS: Pain assessment using VPS increased the likelihood of analgesic administration to trauma patients with higher pain scores in the ED.     

Student reflective groups at a Scottish College of Nursing

In this paper student views on reflective groups, set up as an important element of the new Project 2000 course in a Scottish College of Nursing, are reported. A random sample of 19 students were interviewed. While the reflective groups were very popular with students because they provided support, there was little evidence of a linkage between theory and practice. It was clear that the ambitious objective of stimulating reflection-on-action was not attained. Practice certainly was discussed, but it tended to be dominated by dramatic and emotionally charged aspects of care rather than the more frequent routine concerns. There were, however, indications that the original aim of the reflective groups could be achieved if tutors could establish a common understanding of the purpose of the groups and of reflection, and if the practices on which students reflected consisted less of single day visits where the students saw themselves as non-participant outsiders.     

A Survey of Oregon Emergency Physicians to Assess Mandatory Reporting Knowledge and Reporting Patterns Regarding Intoxicated Drivers in the State of Oregon

Objectives: To assess emergency physician reporting patterns in Oregon before and after the passage of a mandatory intoxicated driving reporting law. Methods: A one‐page survey was mailed to 504 emergency physicians in Oregon in April 2004. Data on reporting frequency were collected using a four‐point ordinal scale regarding motor vehicle crash–involved drivers (MIDs) and intoxicated persons attempting to drive away from the emergency department (DAEDs). Paired observations were assessed for a stated increase in reporting activity following passage of the law using the Wilcoxon signed‐rank test. Associations of postlaw reporting and demographic and knowledge factors were sought using Spearman rank correlation analysis. Results: Of the 504 surveys mailed, 298 (59%) were adequate for analysis. Many respondents (57%) were already aware of the law. Most (92%) agreed that physicians should be mandated to report some crimes. MIDs were always reported by 18% of physicians before the law and by 47% afterward, whereas DAEDs were always reported by 56% of physicians before the law and by 69% afterward. Emergency medicine–trained physicians, higher emergency department census, and increased years of experience were associated with a significantly higher increase in reporting pattern after passage of the law for both MIDs and DAEDs. Conclusions: Although 44% of responding emergency physicians in Oregon were unaware of a mandated reporting law for intoxicated drivers presenting to the ED, most physicians stated an increase in their reporting practice.     

战伤喷剂杀菌效果及影响因素的试验观察

为了研究战伤喷剂杀菌效果及其影响因素,采用悬液定量杀菌试验进行了观察。结果,季铵盐活性物170mg/L喷剂分别作用5min,对金黄色葡萄球菌和大肠杆菌平均杀灭率为99.99%;用850mg/L该喷剂对白色念珠菌作用5min,平均杀灭率为99.99%。该喷剂在54℃放置14d,其杀菌效果无明显降低。受有机物和作用温度等因素对其杀菌效果影响不明显。以该喷剂原液作皮肤喷雾消毒,对自然菌平均除菌率为89.13%。结论,该战伤喷剂可有效杀灭细菌繁殖体和真菌,性能稳定。     

逆转录病毒介导转导的人粒-巨噬系集落刺激因子基因在哺乳动物细胞中的表达(英文)

利用多聚酶链反应(PCR)方法,从活化的人外周血单个核细胞中克隆了人粒-巨噬系集落刺激因子(GM-CSF)的cDNA。DNA序列测定证实此片段为完整的GM-CSF cDNA。应用DNA重组技术,将此cDNA重组于逆转录病毒载体pDORneo上,以Lipofectin介导转染病毒包装细胞PA317,用NIH3T3细胞测定病毒滴度。选取高滴度病毒上清感染中国仓鼠卵巢(CHO)细胞,经G418筛选获抗性克隆,PCR方法鉴定重组载体整合于CHO细胞的基因组DNA中。用CFU-GM集落形成实验检测GM-CSF活性,证实转染后的CHO细胞有GM-CSF的稳定、高效表达。     

Characterizing Emergency Department Discussions about Depression

Background: The reality of emergency health care in the United States today requires new approaches to mental health in the emergency department (ED). Major depression is a disabling condition that disproportionately affects women.
Objectives: To characterize ED provider–patient discussions about depression.
Methods: This was a secondary analysis of a database of audiotaped ED visits with women patients collected during a clinical trial of computer screening for domestic violence and other psychosocial risks. Nonemergent female patients, ages 18–65 years, were enrolled from two socioeconomically diverse academic EDs. All audio files with two or more relevant comments were identified as "significant depression discussions" and independently coded using a structured coding form.
Results: Of 871 audiorecorded ED visits, 70 (8%) included discussions containing any reference to depression and 20 (2%) constituted significant depression discussions. Qualitative analysis of the 20 significant discussions found that 16 (80%) required less than 90 seconds to complete. Ten included less than optimal provider communication characteristics. Despite the brevity or quality of the communication, 15 of the 20 yielded high patient satisfaction with their ED treatment.
Conclusions: ED providers rarely addressed depression. Qualitative analysis of significant patient–provider interactions regarding depression found that screening for depression in the ED can be accomplished with minimal expenditure of provider time and effort. Attention to psychosocial risk factors has the potential to improve the quality of ED care and patient satisfaction.     

Trends in Charges and Payments for Nonhospitalized Emergency Department Pediatric Visits, 1996–2003

Objectives:  To compare charges and payments for outpatient pediatric emergency visits across payer groups to provide information on reimbursement trends.
Methods:  Total charges and payments for emergency department (ED) visits Medicaid/State Children's Health Insurance Program (SCHIP), privately insured, and uninsured pediatric patients from 1996 to 2003 using data from the Medical Expenditure Panel Survey. Average charges per visit and average payments per visit were also tracked, using regression analysis to adjust for changes in patient characteristics.
Results:  While charges for pediatric ED visits rose over time, payments did not keep pace. This led to a decrease in reimbursement rates from 63% in 1996 to 48% in 2003. For all years, Medicaid/SCHIP visits had the lowest reimbursement rates, reaching 35% in 2003. The proportion of visits from children insured by Medicaid/SCHIP also increased over the period examined. In 2003, after adjustment, charges were $792 per visit from children covered by Medicaid/SCHIP, $913 for visits from uninsured children, and $952 for visits from privately insured children.
Conclusions:  Reimbursements for outpatient ED visits in the pediatric population have decreased from the period of 1996 to 2003 in all payer groups: public (Medicaid/SCHIP), private, and the uninsured. Medicaid/SCHIP has consistently paid less per visit than the privately insured and the uninsured. Further research on the effects of these declining reimbursements on the financial viability of ED services for children is warranted.     

Derivation of Clinical Prediction Rules to Identify Children with Fractures after Twisting Injuries of the Ankle

OBJECTIVE: The authors sought to derive maximally sensitive prediction rules for identifying children with significant fractures after acute twisting injuries to the ankle. METHODS: The authors prospectively enrolled a convenience sample of patients younger than 18 years of age who presented to the pediatric emergency department of an urban, tertiary care center after sustaining acute twisting injuries of the ankle. The ankle was defined in two regions: the malleolar zone and the midfoot zone. Clinical findings were documented on standardized data collection sheets by faculty physicians before completion of ankle and/or foot radiograph series. Significant fracture was defined a priori as any fracture other than an avulsion < or =3 mm. The authors conducted binary recursive partitioning with cross-validation to develop models to predict fracture. RESULTS: Data from 717 enrolled patients with a median age of 12.9 years were analyzed. Significant malleolar zone and midfoot zone fractures were diagnosed in 81 of 682 (11.9%) and 10 of 173 (5.8%) patients for whom ankle and foot radiographs were obtained. Recursive partitioning identified patients at low risk for malleolar zone fracture if 1) they had no bone tenderness at either malleolus or the region just proximal to the fibula malleolus or 2) they had bone tenderness at either malleolus but were able to walk four steps in the emergency department and had no swelling at either malleolus. The two-part malleolar zone rule had a sensitivity of 100% and specificity of 19.1% on the learning data and 95.1% (95% confidence interval [95% CI] = 87.8% to 98.6%) and 20.0% (95% CI = 16.8% to 23.4%) on the test data. Tenderness either at the proximal fifth metatarsal or cuboid identified midfoot zone fractures with a sensitivity of 100% and specificity of 31.9% on the learning data and 90.0% (95% CI = 55.4% to 99.7%) and 35.0% (95% CI = 27.7% to 42.8%) on the test sample. CONCLUSIONS: A set of sensitive prediction rules was developed to identify children with significant fractures after twisting injuries to the ankle. External validation and refinement of the rules will be needed before recommendation of widespread use.     

The Minor Injury Scale

Objective: To develop an injury scoring system suitable for non–life–threatening injuries.
Methods: A prospective cohort study was conducted using a representative sample of 1,396 injured adults to identify the outcomes of a range of injuries. Data were collected between March 12, 1992, and March 11,1993, in the Australian Capital Territory, a geographically circumscribed urban community of 296,000 people served by two hospital EDs. Outcomes included "injury–related health status immediately following injury occurrence" and "accumulated health loss over the period of recovery." The injury–related health status of each subject at the time of the injury occurrence was measured using the Health Consequences of Injury Questionnaire (HCIQ), which records this outcome as a value on a unitary scale. Injuries were then stratified by injury type, as identified by the Abbreviated Injury Scale numerical identifiers. The median health index value for each type of injury was designated the injury severity score for that injury type. The "accumulated health loss over time until recovery" for each injury was calculated from repeated administrations of the HCIQ over a six–month follow–up period, and the median outcome value for each injury type was designated the injury morbidity score for that injury.
Results: Injury severity scores for 46 types of minor injury and injury morbidity scores for 39 types of minor injury were tabulated to form the Minor Injury Scale.
Conclusion: This new injury scoring system provides a means of categorizing minor injury according to properties relevant to a public health approach to injury control. Expansion of the number of injury types scored requires further work, as does the testing of the results obtained to confirm the predictive power of the scales.