Amy H. Kaji

Frequent Users of Emergency Department Services: Gaps in Knowledge and a Proposed Research Agenda

Frequent use of emergency department (ED) services is often perceived to be a potentially preventable misuse of resources. The underlying assumption is that similar and more appropriate care can be delivered outside of EDs at a lower cost. To reduce costs and incentivize more appropriate use of services, there have been efforts to design interventions to transition health care utilization of frequent users from EDs to other settings such as outpatient clinics. Many of these efforts have succeeded in smaller trials, but wider use remains elusive for varying reasons. There are also some fundamental problems with the assumption that all or even the majority of frequent ED use is misuse and invoking reasons for that excessive use. These tenuous assumptions become evident when frequent users as a group are compared to less frequent users. Specifically, frequent users tend to have high levels of frequent ED use, have a higher severity of illness, be older, have fewer personal resources, be chronically ill, present for pain-related complaints, and have government insurance (Medicare or Medicaid). Because of the unique characteristics of the population of frequent users, we propose a research agenda that aims to increase the understanding of frequent ED use, by: 1) creating an accepted categorization system for frequent users, 2) predicting which patients are at risk for becoming or remaining frequent users, 3) implementing both ED- and non-ED-based interventions, and 4) conducting qualitative studies of frequent ED users to explore reasons and identify factors that are subject to intervention and explore specific differences among populations by condition, such as mental illness and heart failure.

Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study.

Objective:We hypothesized that laparoscopic cholecystectomy performed within 48 hours of admission for mild gallstone pancreatitis, regardless of resolution of abdominal pain or abnormal laboratory values, would result in a shorter hospital stay. Summary of Background Data:Although there is consensus among surgeons that patients with gallstone pancreatitis should undergo cholecystectomy to prevent recurrence, the precise timing of laparoscopic cholecystectomy for mild disease remains controversial. Methods:Consecutive patients with mild pancreatitis (Ranson score ≤3) were prospectively randomized to either an early laparoscopic cholecystectomy group (within 48 hours of admission) versus a control laparoscopic cholecystectomy group (performed after resolution of abdominal pain and normalizing trend of laboratory enzymes). The primary end point was hospital length of stay. Secondary end point was a composite of rates of conversion to an open procedure, perioperative complications, and need for endoscopic retrograde cholangiography. The study was designed to enroll 100 patients with an interim analysis after 50 patients. Results:At interim analysis, 50 patients were enrolled at a single university-affiliated public hospital. Of them, 25 patients were randomized to the early group and 25 patients to the control group. Patient age ranged from 18 to 74 years with a median duration of symptoms of 2 days upon presentation and a median Ranson score of 1. There were no baseline differences between the groups with regards to demographics, clinical presentation, or the presence of comorbidities. The hospital length of stay was shorter for the early cholecystectomy group (mean: 3.5 [95% CI, 2.7–4.3], median: 3 [IQR, 2–4]) compared with the control group (mean: 5.8 [95% CI, 3.8–7.9], median: 4 [IQR, 4–6] [P = 0.0016]). Six patients from the early group required endoscopic retrograde cholangiography, compared with 4 in the control group (P = 0.72). There was no statistically significant difference in the need for conversion to an open procedure or in perioperative complication rates between the 2 groups. Conclusion:In mild gallstone pancreatitis, laparoscopic cholecystectomy performed within 48 hours of admission, regardless of the resolution of abdominal pain or laboratory abnormalities, results in a shorter hospital length of stay with no apparent impact on the technical difficulty of the procedure or perioperative complication rate.

Predicting Performance on the American Board of Surgery Qualifying and Certifying Examinations: A Multi-institutional Study

BACKGROUND We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents. DESIGN Retrospective review. SETTING Seventeen general surgery training programs in the western United States. PARTICIPANTS Six hundred seven residents who graduated in 2000-2007. MAIN OUTCOME MEASURES First-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research. RESULTS The first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]). CONCLUSIONS Residents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

Early result of ligation of the intersphincteric fistula tract for fistula-in-ano.

PURPOSE: The ligation of the intersphincteric fistula tract is a new surgical procedure without any use of biologic material. The purpose of this study is to present our early results with this novel technique. METHODS: A retrospective review of patients who underwent the procedure for high transsphincteric fistulas was analyzed. The procedure was performed by a single surgeon. Patient and fistula characteristics, complications, and recurrences were reviewed. RESULTS: Twenty-five patients underwent the ligation of intersphincteric fistula tract procedure. All the patients had transsphincteric fistulas that were not suitable for fistulotomy. All patients underwent the procedure on an outpatient basis with a median follow-up of 24 weeks (range, 8–52 wk). Of the 25 patients, 17 (68%) healed completely and did not require any further surgical treatment. Eight of the 25 patients had persistent symptoms: 5 patients had a clear tract with an internal opening, 2 patients had a draining sinus without an identifiable internal opening, and 1 patient presented with an intersphincteric fistula, which was at the site of the intersphincteric groove incision. There were no statistically significant differences in recurrence rates with regard to the presence of a seton at the time of surgery, history of previous operations such as mucosal advancement flap, or seton placement. CONCLUSION: The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe, and it does not require expensive biologic material. Our early data confirm a low recurrence rate with a primary healing rate of 68%.

Emergency Medical Services System Changes Reduce Pediatric Epinephrine Dosing Errors in the Prehospital Setting

OBJECTIVE. The goal was to describe the change in the rate of epinephrine dosing errors in the treatment of pediatric patients in prehospital cardiopulmonary arrest after the Los Angeles County Emergency Medical Services Agency instituted a program in which paramedics were required to use the Broselow tape and to report color zone categories to the base station and base stations were given and instructed formally in the use of the color-coded drug dosing chart. METHODS. An observational analysis of a natural experiment was performed. Children ≤12 years of age who were determined to be in prehospital cardiopulmonary arrest and who received prehospital epinephrine treatment by paramedics, in the periods of 1994 to 1997 and 2003 to 2004, were included in the study. RESULTS. In the 1994 to 1997 cohort, we identified 104 subjects in prehospital cardiopulmonary arrest who received epinephrine with a documented weight and route of administration. Only 29 of 104 subjects in the 1994 to 1997 cohort received the correct dose, whereas 46 of 104 subjects received a first dose within 20% of the correct dose. In the 2003 to 2004 cohort, we identified 41 children ≤12 years of age who were in cardiopulmonary arrest and received prehospital epinephrine treatment but 4 children were excluded, leaving 37 subjects. Twenty-one of 37 subjects received the correct dose, whereas 24 of 37 subjects received a dose within 20%. The odds ratio for obtaining the correct epinephrine dose after the system changes versus before was 3.0, and that for obtaining a dose within 20% of the correct dose was 2.5. CONCLUSIONS. The program seems to have resulted in reduction of the rate of epinephrine dosing errors in the prehospital treatment of children in cardiopulmonary arrest in Los Angeles County.

Assessing Hospital Disaster Preparedness: A Comparison of an On-Site Survey, Directly Observed Drill Performance, and Video Analysis of Teamwork

STUDY OBJECTIVE There is currently no validated method for assessing hospital disaster preparedness. We determine the degree of correlation between the results of 3 methods for assessing hospital disaster preparedness: administration of an on-site survey, drill observation using a structured evaluation tool, and video analysis of team performance in the hospital incident command center. METHODS This was a prospective, observational study conducted during a regional disaster drill, comparing the results from an on-site survey, a structured disaster drill evaluation tool, and a video analysis of teamwork, performed at 6 911-receiving hospitals in Los Angeles County, CA. The on-site survey was conducted separately from the drill and assessed hospital disaster plan structure, vendor agreements, modes of communication, medical and surgical supplies, involvement of law enforcement, mutual aid agreements with other facilities, drills and training, surge capacity, decontamination capability, and pharmaceutical stockpiles. The drill evaluation tool, developed by Johns Hopkins University under contract from the Agency for Healthcare Research and Quality, was used to assess various aspects of drill performance, such as the availability of the hospital disaster plan, the geographic configuration of the incident command center, whether drill participants were identifiable, whether the noise level interfered with effective communication, and how often key information (eg, number of available staffed floor, intensive care, and isolation beds; number of arriving victims; expected triage level of victims; number of potential discharges) was received by the incident command center. Teamwork behaviors in the incident command center were quantitatively assessed, using the MedTeams analysis of the video recordings obtained during the disaster drill. Spearman rank correlations of the results between pair-wise groupings of the 3 assessment methods were calculated. RESULTS The 3 evaluation methods demonstrated qualitatively different results with respect to each hospitals level of disaster preparedness. The Spearman rank correlation coefficient between the results of the on-site survey and the video analysis of teamwork was -0.34; between the results of the on-site survey and the structured drill evaluation tool, 0.15; and between the results of the video analysis and the drill evaluation tool, 0.82. CONCLUSION The disparate results obtained from the 3 methods suggest that each measures distinct aspects of disaster preparedness, and perhaps no single method adequately characterizes overall hospital preparedness.

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Long-term results of ligation of intersphincteric fistula tract (LIFT) for fistula-in-ano.

BACKGROUND: Ligation of intersphincteric fistula tract is a novel surgical technique in the treatment of transsphincteric fistula-in-ano that has been shown to be successful in the short term. Median follow-up in current literature ranges from 5 to 9 months. However, the long-term success rate is unknown. OBJECTIVE: This study describes our long-term results in performing the ligation of intersphincteric fistula tract procedure. DESIGN: This study is a retrospective review. PATIENTS: Thirty-eight patients from August 2008 to October 2011 were evaluated. INTERVENTIONS: All patients underwent the ligation of intersphincteric fistula tract for fistula-in-ano. MAIN OUTCOME MEASURES: Patient and fistula characteristics, primary healing rate, secondary healing rate, previous treatments, and failures were reviewed. RESULTS: The median follow-up was 26 months (range, 3–44 months), and 26 patients (68%) were followed for greater than 12 months. The overall primary healing rate was 61% (23 of 38), and it was 62% (16 of 26) in patients followed for over 12 months. Eighty percent (12/15) of the failures are early failures (persistent symptoms or failure at ⩽6 months), and 20% are late failures (>6 months) with 1 failure occurring 12 months postprocedure. Increase in length of fistula tract was associated with decreased healing (OR 0.55, 95% CI 0.34–0.88, p = 0.01). There were no intraoperative complications and no reported incontinence. CONCLUSION: Our study demonstrates favorable long-term results for the ligation of intersphincteric fistula tract procedure. It appears that long tracts negatively affect healing, and late failures can occur up to 12 months postoperatively. Understanding the type of failure can help guide subsequent treatment to maximize healing success.

Factors Associated With General Surgery Residents’ Desire to Leave Residency Programs: A Multi-institutional Study

IMPORTANCE General surgical residency continues to experience attrition. To date, work hour amendments have not changed the annual rate of attrition. OBJECTIVE To determine how often categorical general surgery residents seriously consider leaving residency. DESIGN, SETTING, AND PARTICIPANTS At 13 residency programs, an anonymous survey of 371 categorical general surgery residents and 10-year attrition rates for each program. Responses from those who seriously considered leaving surgical residency were compared with those who did not. MAIN OUTCOMES AND MEASURES Factors associated with the desire to leave residency. RESULTS The survey response rate was 77.6%. Overall, 58.0% seriously considered leaving training. The most frequent reasons for wanting to leave were sleep deprivation on a specific rotation (50.0%), an undesirable future lifestyle (47.0%), and excessive work hours on a specific rotation (41.4%). Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). On univariate analysis, older age, female sex, postgraduate year, training in a university program, the presence of a faculty mentor, and lack of Alpha Omega Alpha status were associated with serious thoughts of leaving surgical residency. On multivariate analysis, only female sex was significantly associated with serious thoughts of leaving residency (odds ratio, 1.2; 95% CI, 1.1-1.3; P = .003). Eighty-six respondents were from historically high-attrition programs, and 202 respondents were from historically low-attrition programs (27.8% vs 8.4% 10-year attrition rate, P = .04). Residents from high-attrition programs were more likely to seriously consider leaving residency (odds ratio, 1.8; 95% CI, 1.0-3.0; P = .03). CONCLUSIONS AND RELEVANCE A majority of categorical general surgery residents seriously consider leaving residency. Female residents are more likely to consider leaving. Thoughts of leaving seem to be associated with work conditions on specific rotations rather than with overall work hours and are more prevalent among programs with historically high attrition rates.

Detection of undiagnosed diabetes and prediabetic states in high-risk emergency department patients.

BACKGROUND Diabetes is often not diagnosed until complications appear, and one-third of those with diabetes may be undiagnosed. Prediabetes and diabetes are conditions in which early detection would be appropriate, because the duration of hyperglycemia is a predictor of adverse outcomes, and there are effective interventions to prevent disease progression and to reduce complications. OBJECTIVES The objectives were to determine the prevalence of diabetes mellitus and prediabetes in emergency department (ED) patients with an elevated random glucose or risk factors for diabetes but without previously diagnosed diabetes and to identify which at-risk ED patients should be considered for referral for confirmatory diagnostic testing. METHODS This two-part study was composed of a prospective 2-year cohort study, and a 1-week cross-sectional survey substudy, set in an urban ED in Los Angeles County, California. A convenience sample was enrolled of 528 ED patients without previously diagnosed diabetes with either 1) a random serum glucose > or = 140 mg/dL regardless of the time of last food intake or a random serum glucose > or = 126 mg/dL if more than 2 hours since last food intake or 2) at least two predefined diabetes risk factors. Measurements included presence of diabetes risk factors, ED glucose, cortisol, insulin and glycosylated hemoglobin (HbA(1c)), and 2-hour oral glucose tolerance test results, administered at 6-week follow-up. RESULTS Glycemic status was confirmed at follow-up in 256 (48%) of the 528 patients. Twenty-seven (11%) were found to have diabetes, 141 (55%) had prediabetes, and 88 (34%) had normal results. Age, ED glucose, HbA(1c), cortisol, and random serum glucose > or = 140 mg/dL were associated with both diabetes and prediabetes on univariate analysis. A random serum glucose > or = 126 mg/dL after 2 hours of fasting was associated with diabetes but not prediabetes; ED cortisol, insulin, age > or = 45 years, race, and calculated body mass index (BMI) were associated with prediabetes but not diabetes. In multivariable models, among factors measurable in the ED, the only independent predictor of diabetes was ED glucose, while ED glucose, age > or = 45 years, and symptoms of polyuria and polydipsia were independent predictors of prediabetes. All at-risk subjects with a random ED blood glucose > 155 mg/dL had either prediabetes or diabetes on follow-up testing. CONCLUSIONS A substantial fraction of this urban ED study population was at risk for undiagnosed diabetes and prediabetes, and among the at-risk patients referred for follow-up, the majority demonstrated diabetes or prediabetes. Notably, all patients with two risk factors and a random serum glucose > 155 mg/dL were later diagnosed with prediabetes or diabetes. Consideration should be given to referring ED patients with risk factors and a random glucose > 155 mg/dL for follow-up testing.