Neonate With a Swollen Thigh.
Ann Emerg Med. 2016 Nov;68(5):e87-e88
Authors: Dessie A, Constantine E
PMID: 27772691 [PubMed - in process]
Male With Hypertension.
Ann Emerg Med. 2016 Nov;68(5):e85-e86
Authors: Yamanoğlu A, Celebi Yamanoğlu NG, Sogut O
PMID: 27772690 [PubMed - in process]
Young Man With Epigastric Pain.
Ann Emerg Med. 2016 Nov;68(5):e83-e84
Authors: Ha YR, Park SY
PMID: 27772689 [PubMed - in process]
Elderly Male With Mass on Right Thumb.
Ann Emerg Med. 2016 Nov;68(5):e81-e82
Authors: Bernardes Filho F, de Oliveira Alves A
PMID: 27772688 [PubMed - in process]
Ann Emerg Med. 2016 Nov;68(5):646
Authors: Hollander JE, Litt HI
PMID: 27772687 [PubMed - in process]
Mandatory Electronic Prescriptions Are a Hazard to the Health of Emergency Department Patients.
Ann Emerg Med. 2016 Nov;68(5):646-647
Authors: Patel N, Kaban N, Rose J, Steinberg E, Heller M
PMID: 27772686 [PubMed - in process]
Coronary Computed Tomography Angiography for Low-Risk Chest Pain.
Ann Emerg Med. 2016 Nov;68(5):645
Authors: Finnerty NM, Weinstock MB
PMID: 27772685 [PubMed - in process]
Ann Emerg Med. 2016 Nov;68(5):644-645
Authors: Wang RC, Fahimi J
PMID: 27772684 [PubMed - in process]
The Importance of an Accurate Diagnosis for Renal Colic.
Ann Emerg Med. 2016 Nov;68(5):643-644
Authors: Meltzer AC, Michel C
PMID: 27772683 [PubMed - in process]
Aortic Dissection! Or Is It? Sigh.
Ann Emerg Med. 2016 Nov;68(5):640-642
Authors: Grock A, Weinstock MB, Jhun P, Herbert M
PMID: 27772682 [PubMed - in process]
Adolescent Athlete With Sudden Groin Pain.
Ann Emerg Med. 2016 Nov;68(5):639-648
Authors: Cozzi G, Guastalla V, Barbi E
PMID: 27772681 [PubMed - in process]
Child With Sore Throat.
Ann Emerg Med. 2016 Nov;68(5):638-647
Authors: Wawrzyniak M, Eilbert W
PMID: 27772680 [PubMed - in process]
One and Done: Steroids for Adult Asthma: November 2016 Annals of Emergency Medicine Journal Club.
Ann Emerg Med. 2016 Nov;68(5):636-637
Authors: Davis WT, Barrett TW
PMID: 27772679 [PubMed - in process]
Would You Like Fries With That?
Ann Emerg Med. 2016 Nov;68(5):634-635
Authors: Rancour S
PMID: 27772678 [PubMed - in process]
Ann Emerg Med. 2016 Nov;68(5):632-633
Authors: Raymond KA
PMID: 27772677 [PubMed - in process]
Just Listen: You Will Truly Be Amazed at All That You Can Hear.
Ann Emerg Med. 2016 Nov;68(5):631
Authors: Davis JE
PMID: 27772676 [PubMed - in process]
Ann Emerg Med. 2016 Nov;68(5):628-630
Authors: Waxman M
PMID: 27772675 [PubMed - in process]
Geolocalization of Influenza Outbreak Within an Acute Care Population: A Layered-Surveillance Approach.
Ann Emerg Med. 2016 Nov;68(5):618-626
Authors: Kannan VC, Hodgson N, Lau A, Goodin K, Dugas AF, LoVecchio F
STUDY OBJECTIVE: We seek to use a novel layered-surveillance approach to localize influenza clusters within an acute care population. The first layer of this system is a syndromic surveillance screen to guide rapid polymerase chain reaction testing. The second layer is geolocalization and cluster analysis of these patients. We posit that any identified clusters could represent at-risk populations who could serve as high-yield targets for preventive medical interventions.
METHODS: This was a prospective observational surveillance study. Patients were screened with a previously derived clinical decision guideline that has a 90% sensitivity and 30% specificity for influenza. Patients received points for the following signs and symptoms within the past 7 days: cough (2 points), headache (1 point), subjective fever (1 point), and documented fever at triage (temperature >38°C [100.4°F]) (1 point). Patients scoring 3 points or higher were indicated for influenza testing. Patients were tested with Xpert Flu (Cepheid, Sunnyvale, CA), a rapid polymerase chain reaction test. Positive results were mapped with ArcGIS (ESRI, Redlands, CA) and analyzed with kernel density estimation to create heat maps.
RESULTS: There were 1,360 patients tested with Xpert Flu with retrievable addresses within the greater Phoenix metro area. One hundred sixty-seven (12%) of them tested positive for influenza A and 23 (2%) tested positive for influenza B. The influenza A virus exhibited a clear cluster pattern within this patient population. The densest cluster was located in an approximately 1-square-mile region southeast of our hospital.
CONCLUSION: Our layered-surveillance approach was effective in localizing a cluster of influenza A outbreak. This region may house a high-yield target population for public health intervention. Further collaborative efforts will be made between our hospital and the Maricopa County Department of Public Health to perform a series of community vaccination events before the next influenza season. We hope these efforts will ultimately serve to reduce the burden of this disease on our patient population, and that this system will serve as a framework for future investigations locating at-risk populations.
PMID: 27772674 [PubMed - in process]
Male With Pain in His Neck.
Ann Emerg Med. 2016 Nov;68(5):545-561
Authors: Gold M, Fenig M
PMID: 27772673 [PubMed - in process]
Young Man With Severe Abdominal Pain.
Ann Emerg Med. 2016 Nov;68(5):544-552
Authors: Lewandowski A, Dorsey S
PMID: 27772672 [PubMed - in process]
Characteristics of and Predictors for Apnea and Clinical Interventions During Procedural Sedation.
Ann Emerg Med. 2016 Nov;68(5):564-573
Authors: Krauss BS, Andolfatto G, Krauss BA, Mieloszyk RJ, Monuteaux MC
STUDY OBJECTIVE: We describe the characteristics of and predictors for apnea and clinical interventions during emergency department (ED) procedural sedation.
METHODS: High-resolution data were collected prospectively, using a convenience sample of ED patients undergoing propofol or ketofol sedation. End tidal CO2 (etco2), respiratory rate, pulse rate, and SpO2 were electronically recorded in 1-second intervals. Procedure times, drug delivery, and interventions were electronically annotated. Kaplan-Meier curves were used to describe the onset of clinical interventions as a function of sedation time. The onset of apnea (15 consecutive seconds with carbon dioxide ≤10 mm Hg) and clinical interventions were estimated with a series of Cox proportional hazards survival models, with time to first apnea or clinical intervention as the dependent variable. Finally, we tested the association between apnea and clinical intervention.
RESULTS: Three hundred twelve patients were analyzed (53% male patients). Apnea was preceded by etco2 less than 30 mm Hg or greater than 50 mm Hg at 30, 60, and 90 seconds before its onset. Clinical interventions were predicted by apnea, SpO2, and propofol use. Increasing age predicted both apnea and interventions. Apnea was not predicted by respiratory rate or SpO2. Apnea occurred in half of the patients and clinical interventions in a quarter of them. Clinical intervention was not predicted by abnormal respiratory rate or abnormal etco2 level. The majority of clinical interventions (85%) were minor, with no cases of assisted ventilation, intubation, or complications.
CONCLUSION: Alterations in etco2 predicted apnea along a specific time course. Alterations in SpO2, apnea, and propofol use predicted clinical interventions. Increasing age predicted both apnea and clinical intervention.
PMID: 27553482 [PubMed - in process]
A Pragmatic Randomized Evaluation of a Nurse-Initiated Protocol to Improve Timeliness of Care in an Urban Emergency Department.
Ann Emerg Med. 2016 Nov;68(5):546-552
Authors: Douma MJ, Drake CA, O'Dochartaigh D, Smith KE
STUDY OBJECTIVE: Emergency department (ED) crowding is a common and complicated problem challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or treatments implemented by nurses before patients are treated by a physician or nurse practitioner have been suggested as a potential strategy to improve patient flow.
METHODS: This is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay.
RESULTS: Protocols decreased the median time to acetaminophen for patients presenting with pain or fever by 186 minutes (95% confidence interval [CI] 76 to 296 minutes) and the median time to troponin for patients presenting with suspected ischemic chest pain by 79 minutes (95% CI 21 to 179 minutes). Median ED length of stay was reduced by 224 minutes (95% CI -19 to 467 minutes) by implementing a suspected fractured hip protocol. A vaginal bleeding during pregnancy protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438 minutes).
CONCLUSION: Targeting specific patient groups with carefully written protocols can result in improved time to test or medication and, in some cases, reduce ED length of stay. A cooperative and collaborative interdisciplinary group is essential to success.
PMID: 27480203 [PubMed - in process]
Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial.
Ann Emerg Med. 2016 Nov;68(5):574-582.e1
Authors: Ferguson I, Bell A, Treston G, New L, Ding M, Holdgate A
STUDY OBJECTIVE: We determine whether emergency physician-provided deep sedation with 1:1 ketofol versus propofol results in fewer adverse respiratory events requiring physician intervention when used for procedural sedation and analgesia.
METHODS: Consenting patients requiring deep sedation were randomized to receive either ketofol or propofol in a double-blind fashion according to a weight-based dosing schedule. The primary outcome was the occurrence of a respiratory adverse event (desaturation, apnea, or hypoventilation) requiring an intervention by the sedating physician. Secondary outcomes included hypotension and patient satisfaction.
RESULTS: Five hundred seventy-three patients were enrolled and randomized, 292 in the propofol group and 281 in the ketofol group. Five percent in the propofol group and 3% in the ketofol group met the primary outcome, an absolute difference of 2% (95% confidence interval [CI] -2% to 5%). Patients receiving propofol were more likely to become hypotensive (8 versus 1%; difference 7%; 95% CI 4% to 10%). Patient satisfaction was very high in both groups (10/10; interquartile range 10 to 10/10), and although the ketofol group was more likely to experience severe emergence delirium (5% versus 2%; difference 3%; 95% CI 0.4% to 6%), they had lower pain scores at 30 minutes postprocedure. Other secondary outcomes were similar between groups.
CONCLUSION: Ketofol and propofol resulted in a similar incidence of adverse respiratory events requiring the intervention of the sedating physician. Although propofol resulted in more hypotension, the clinical relevance of this is questionable, and both agents are associated with high levels of patient satisfaction.
PMID: 27460905 [PubMed - in process]
Effect of Vapocoolant on Pain During Peripheral Intravenous Cannulation.
Ann Emerg Med. 2016 Nov;68(5):586-588
Authors: Gottlieb M, Hunter B
PMID: 27374950 [PubMed - in process]
Managing Initial Mechanical Ventilation in the Emergency Department.
Ann Emerg Med. 2016 Nov;68(5):614-617
Authors: Weingart SD
PMID: 27289336 [PubMed - in process]
Auricular Acupuncture in Emergency Department Treatment of Acute Pain.
Ann Emerg Med. 2016 Nov;68(5):583-585
Authors: Tsai SL, Fox LM, Murakami M, Tsung JW
The National Institutes of Health and the World Health Organization note that acupuncture is a safe and effective treatment for pain. Nonopioid treatment options for moderate to severe acute pain in the emergency department (ED) are limited. Additional strategies for managing acute pain in the ED are needed. Auricular Battlefield Acupuncture has been described as a simple, safe, rapid, and effective analgesic option to opioid medications in managing acute pain. We describe 4 cases in which emergency physicians with brief training performed this auricular acupuncture protocol to treat patients with acute pain in EDs when opioid analgesia was not an acceptable option.
PMID: 27287548 [PubMed - in process]
Prescription Drug Monitoring Programs: Ethical Issues in the Emergency Department.
Ann Emerg Med. 2016 Nov;68(5):589-598
Authors: Marco CA, Venkat A, Baker EF, Jesus JE, Geiderman JM, ACEP Ethics Committee
Prescription drug monitoring programs are statewide databases available to clinicians to track prescriptions of controlled medications. These programs may provide valuable information to assess the history and use of controlled substances and contribute to clinical decisionmaking in the emergency department (ED). The widespread availability of the programs raises important ethical issues about beneficence, nonmaleficence, respect for persons, justice, confidentiality, veracity, and physician autonomy. In this article, we review the ethical issues surrounding prescription drug monitoring programs and how those issues might be addressed to ensure the proper application of this tool in the ED. Clinical decisionmaking in regard to the appropriate use of opioids and other controlled substances is complex and should take into account all relevant clinical factors, including age, sex, clinical condition, medical history, medication history and potential drug-drug interactions, history of addiction or diversion, and disease state.
PMID: 27181079 [PubMed - in process]
Law Enforcement and Emergency Medicine: An Ethical Analysis.
Ann Emerg Med. 2016 Nov;68(5):599-607
Authors: Baker EF, Moskop JC, Geiderman JM, Iserson KV, Marco CA, Derse AR, ACEP Ethics Committee
Emergency physicians frequently interact with law enforcement officers and patients in their custody. As always, the emergency physician's primary professional responsibility is to promote patient welfare, and his or her first duty is to the patient. Emergency physicians should treat criminals, suspects, and prisoners with the same respect and attention they afford other patients while ensuring the safety of staff, visitors, and other patients. Respect for patient privacy and protection of confidentiality are of paramount importance to the patient-physician relationship. Simultaneously, emergency physicians should attempt to accommodate law enforcement personnel in a professional manner, enlisting their aid when necessary. Often this relates to the emergency physician's socially imposed duties, governed by state laws, to report infectious diseases, suspicion of abuse or neglect, and threats of harm. It is the emergency physician's duty to maintain patient confidentiality while complying with Health Insurance Portability and Accountability Act regulations and state law.
PMID: 27157455 [PubMed - in process]
"I'm Just a Patient": Fear and Uncertainty as Drivers of Emergency Department Use in Patients With Chronic Disease.
Ann Emerg Med. 2016 Nov;68(5):536-543
Authors: Rising KL, Hudgins A, Reigle M, Hollander JE, Carr BG
STUDY OBJECTIVE: Despite focus during the past decade about the need to design a more patient-centered US health care system, patients have been minimally engaged to define what they want from it. Our objective is to engage patients to identify individual-defined priority outcomes on discharge from the emergency department (ED) and individually tailored interventions to help achieve their outcomes.
METHODS: We used qualitative semistructured interviews with patients with diabetes mellitus or cardiovascular disease who were being discharged from 2 EDs. Questions focused on reasons for seeking ED care, expectations about ED visits, and goals and needs for the days after ED discharge. Themes were identified with a modified grounded theory approach.
RESULTS: Forty patients participated. Patients identified uncertainty about the significance of their symptoms and fear as a result of this uncertainty as primary drivers for their ED visit. Their primary expectation about the visit was receiving a diagnosis and reassurance. The most prominent postdischarge need was answers about the cause of their symptoms and what to expect. Patients were concerned about ability to access follow-up services because of lack of time to navigate the system, transportation, and priority scheduling needs. Suggestions for improvement focused on contacting patients (physically or virtually) once they were home and offering them expedited outpatient evaluations. Primary limitations included enrollment of patients within a single health system and only those with certain chronic conditions, both potentially limiting generalizability.
CONCLUSION: Many patients have ongoing needs that are often not addressed during ED discharge. These needs are based on ongoing uncertainty about the cause of their symptoms and what to expect, and result in feelings of fear. Work is needed to develop approaches to alleviate patient fear and uncertainty and to equip providers with the capabilities and resources needed to adequately address these needs.
PMID: 27156123 [PubMed - in process]
Do Peripheral Thermometers Accurately Correlate to Core Body Temperature?
Ann Emerg Med. 2016 Nov;68(5):562-563
Authors: Hernandez JM, Upadhye S
PMID: 27130799 [PubMed - in process]
Pilot Study of Kano "Attractive Quality" Techniques to Identify Change in Emergency Department Patient Experience.
Ann Emerg Med. 2016 Nov;68(5):553-561
Authors: Bellamkonda VR, Kumar R, Scanlan-Hanson LN, Hess JJ, Hellmich TR, Bellamkonda E, Campbell RL, Hess EP, Nestler DM
STUDY OBJECTIVE: We describe the use of the Kano Attractive Quality analytic tool to improve an identified patient experience gap in perceived compassion by emergency department (ED) providers.
METHODS: In phase 1, point-of-service surveying assessed baseline patient perception of ED provider compassion. Phase 2 deployed Kano surveys to predict the effect of 4 proposed interventions on patient perception. Finally, phase 3 compared patients receiving standard care versus the Kano-identified intervention to assess the actual effect on patient experience.
RESULTS: In phase 1, 193 of 200 surveys (97%) were completed, showing a baseline median score of 4 out of 5 (interquartile range [IQR] 3 to 5), with top box percentage of 33% for patients' perception of receiving compassionate care. In phase 2, 158 of 180 surveys (88%) using Kano-formatted questions were completed, and the data predicted that increasing shared decisionmaking would cause the greatest improvement in the patient experience. Finally, in phase 3, 45 of 49 surveys (92%) were returned and demonstrated a significant improvement in perceived concern and sensitivity, 5 (IQR 5 to 5) versus 4 (IQR 3 to 5) with a difference of 1 (95% CI 0.1-1.9) and a top box rating of 79% versus 35% with a difference of 44% (95% CI 12-66) by patients who received dedicated shared decisionmaking interventions versus those receiving standard of care.
CONCLUSION: Kano analysis is likely predictive of change in patient experience. Kano methods may prove as useful in changing management of the health care industry as it has been in other industries.
PMID: 27125817 [PubMed - in process]
A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma.
Ann Emerg Med. 2016 Nov;68(5):608-613
Authors: Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ
STUDY OBJECTIVE: Oral dexamethasone demonstrates bioavailability similar to that of oral prednisone but has a longer half-life. We evaluate whether a single dose of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral prednisone in treatment of adults with mild to moderate asthma exacerbations to prevent relapse defined as an unscheduled return visit for additional treatment for persistent or worsening asthma within 14 days.
METHODS: Adult emergency department patients (aged 18 to 55 years) were randomized to receive either a single dose of 12 mg of oral dexamethasone with 4 days of placebo or a 5-day course of oral prednisone 60 mg a day. Outcomes including relapse were assessed by a follow-up telephone interview at 2 weeks.
RESULTS: One hundred seventy-three dexamethasone and 203 prednisone subjects completed the study regimen and telephone follow-up. The dexamethasone group by a small margin surpassed the preset 8% difference between groups for noninferiority in relapse rates within 14 days (12.1% versus 9.8%; difference 2.3%; 95% confidence interval -4.1% to 8.6%). Subjects in the 2 groups had similar rates of hospitalization for their relapse visit (dexamethasone 3.4% versus prednisone 2.9%; difference 0.5%; 95% confidence interval -4.1% to 3.1%). Adverse effect rates were generally the same in the 2 groups.
CONCLUSION: A single dose of oral dexamethasone did not demonstrate noninferiority to prednisone for 5 days by a very small margin for treatment of adults with mild to moderate asthma exacerbations. Enhanced compliance and convenience may support the use of dexamethasone regardless.
PMID: 27117874 [PubMed - in process]
Same Physician, Different Location, Different Patient Satisfaction Scores.
Ann Emerg Med. 2016 Nov;68(5):531-535
Authors: Bendesky BS, Hunter K, Kirchhoff MA, Jones CW
STUDY OBJECTIVE: We assess whether patient satisfaction scores differ for individual emergency physicians according to the clinical setting in which patients are treated.
METHODS: We obtained Press Ganey satisfaction survey results from June 2013 to August 2014 for patients treated in either an urban hospital emergency department (ED) or 2 affiliated suburban urgent care centers. The same physicians work in all 3 facilities. Physicians with available survey results from at least 10 patients in both settings were included. Survey scores range from 1 (very poor) to 5 (very good). Survey questions directly assessed physicians' courtesy, ability to keep patients informed about their treatment, concern for patient comfort, listening ability, and the overall care at the facility. We calculated differences in mean urgent care and ED scores for individual physicians, along with the mean of these differences. Our primary outcome was the mean difference between urgent care and ED score with respect to physician courtesy.
RESULTS: Seventeen physicians met inclusion criteria. For all 17 physicians, the point estimate for the mean urgent care courtesy score was higher than the point estimate for the mean ED courtesy score. The mean difference in courtesy scores between urgent care and the ED was 0.35 (95% confidence interval 0.22 to 0.49). ED scores were also consistently lower than urgent care scores for keeping patients informed about their treatment, concern for patient comfort, listening ability, and overall care rating.
CONCLUSION: Although these results are limited by small sample size, we found that physicians consistently received lower satisfaction ratings from ED patients than from urgent care patients. This challenges the validity of using satisfaction scores to compare providers in different practice settings.
PMID: 26875063 [PubMed - in process]