Status of emergency department ultrasound

Objective : To determine present attitudes to and usage of ultrasound in Australasian emergency medicine. Methods : A questionnaire was devised, field tested and sent, with Australasian College for Emergency Medicine permission, for anonymous completion by the director of emergency medicine training of each emergency department in Australia and New Zealand accredited for advanced training. Results : The overall response rate was 84% (66/79). The data were tabulated and cross‐tabulated comparing major trauma centres, base hospitals, urban hospitals and teaching hospitals. In hours, X‐ray department ultrasound was readily available, but bedside ultrasound was much less available both in and out of hours. There were marked variations in opinion as to whether bedside ultrasound was essential in clinical conditions such as trauma, abdominal or kidney pain. Computed tomography was always preferred to ultrasound. While there was little teaching of either the theoretical or practical aspects of ultrasound to emergency medicine trainees, 75% of respondents believed that ultrasound should not be undertaken only by full‐time ultrasonographers. Conclusions : The survey clearly demonstrated that while bedside or urgent ultrasound is not generally readily available, especially out of hours, the modality is considered to be important by the majority of respondents, and does not require full‐time radiographers. It is clear that formal teaching of ultrasound to trainees is infrequent.     

Sledding Injuries in Patients Presenting to the Emergency Department in a Northern City

OBJECTIVES: Sledding is a common recreational activity in northern communities. The objective of this study was to examine the frequency and nature of sledding injuries (SIs) in patients presenting to emergency departments (EDs). METHODS: The data were derived from a cohort of patients treated at all five EDs in an urban Canadian health region over a two-year period. Following chart review, consenting patients were interviewed by telephone about their sledding activities and the circumstances surrounding the injury. RESULTS: Three hundred twenty-eight patients were correctly coded as having SIs, with 212 patients (65%) reached during the follow-up survey. The median age of those with SIs was 12 years (IQR = 8, 21), and 206 (59%) were male. Injury rates peaked in the 10--14-year age group (87/100,000) for boys and in the 5--9-year age group (75/100,000) for girls. Most patients stated they were drivers (75%), fewer than half were thrown from the sled (42%), and fewer than half (44%) were sledding on community-designated sledding hills at the time of injury. Injuries to the lower extremity (32%), upper extremity (31%), and head (13%) were most common. Thirty-seven (11%) patients with SIs were admitted to hospital vs 4% of patients with other sports/recreation injuries (p < 0.05). CONCLUSIONS: Sledding injuries are common and potentially serious wintertime injuries in northern communities, involving primarily younger patients, with a large pre-adolescent group. However, older sledders (>20 years) have poorer outcomes (hospitalization, lost time from work/school) than their younger counterparts. The SIs treated in the ED appear to lead to hospitalization more frequently than other types of sport/recreation injury, and injury prevention strategies appear warranted.     

When the Safety Net Is Unsafe Real-time Assessment of the Overcrowded Emergency Department

Although much work has been done evaluating causes for increased demand for emergency department (ED) services, few ways are available to help determine that an individual ED is overcrowded. Four calculations are proposed using real-time data for accurately diagnosing an ED with potential for failing both as a safety net and as a source for quality health care. The bed ratio (BR) accounts for the number of patients in relation to the available treatment spaces. The BR is obtained by adding the current number of ED patients to the predicted arrivals minus the predicted departures and dividing the result by the total number of treatment spaces. The acuity ratio (AR) measures the relative burden of illness in the ED. The AR is the average triage category of all patients in the ED. The provider ratio (PR) determines the volume of patients that can be evaluated and treated by the physician providers. The PR is found by dividing the arrivals per hour by the sum of the average patients per hour usually disposed for each provider on duty. From these ratios, the demand value (DV) is calculated, which gives an overall measure of current demand. The DV is found by taking the sum of the BR and PR and multiplying by the AR. A DV of more than 7 should initiate a specific assessment of the individual ratios in order to accurately diagnose the problem and institute action. Based on the values, predetermined processes can be instituted to help remedy the overcrowded situation. Trended over time, the ratios can provide the data needed for better resource assessment, planning, and allocation.     

Rationing and the Role of the Emergency Department as Society's Safety Net

Emergency medicine has an integral role in the establishment of universal access to health care for all persons living in the United States. Currently, emergency departments provide the only unfunded mandate available to millions of American residents who otherwise have no access to health care coverage. Any effort to establish universal care must accept health care rationing as a basic principle, and establish a minimum standard of benefits to which all human beings are entitled in this country. People and employers should be allowed to purchase additional care based on their willingness and ability to pay, but under no circumstances should anyone be denied a basic package of health care benefits. Emergency care must be part of those basic benefits. Emergency medicine charges should be structured so that they are not unduly onerous to society, and should reflect true expenses, including marginal costs for nonurgent care. Emergency physicians (EPs) and hospital administrations should recognize their critical role in serving society in roles that are not strictly medical, and allocate resources to benefit the general population in the greatest way. This role will be expanded to include preventive care, to provide for basic pharmacologic coverage as needed, and to provide necessary immunizations when traditional primary care has failed. We have a moral obligation to recognize that resources are limited and to allocate them so as to benefit the greatest number of patients in the greatest way. As members of the medical profession best equipped to assume such a task, it is incumbent upon EPs to act as advocates to the public to enable us to fulfill this mission.     

Impact of Ambulance Diversion Policies in Urban, Suburban, and Rural Areas of Central Maryland

As a method to control patient flow to overburdened hospitals, effective emergency medical services (EMS) systems provide policies for ambulance diversion. The Maryland state EMS system supports two types of alert for general hospital use: red alert, aimed at limiting the delivery of patients who may require intensive care unit (ICU) admission, and yellow alert, aimed at preventing further overload of already overtaxed emergency departments (EDs). OBJECTIVE: To examine the effect of those alert policies in different geographical environments, urban, suburban, and rural. METHODS: Alert data for 23 hospitals in Central Maryland and ambulance arrival data for approximately 138,000 ambulance calls during calendar year 1996 were combined and analyzed. The impacts of diversion practices in the geographic areas were compared. RESULTS: Red alert reduced volume in all patient acuity levels in all geographic areas by a statistically significant 0.4 patient/hr. Yellow alert diverted low-acuity patients at the rate of 0.13 patient/hr (p<0.001) in urban areas and at the rate of 0.16 patient/hr (p<0.001) in suburban areas, but had minimal impact in the flow of patients in the rural environment. CONCLUSIONS: The ED diversion policy has some limited effect in preventing further patient volume in urban and suburban areas, but has virtually no impact in rural areas. However, an ICU diversion policy diverts patients of all acuities uniformly and inordinately diverts patients not likely to require ICU admissions while having only minimal impact on patients who do require ICU resources. The impact of red alert is uniform in all geographic areas. The impact and efficacy of ambulance diversion policies should be evaluated to ensure they are having the intended effect. While perhaps initially effective, the impact of alert policies may change over time.