Ashley F. Sullivan

Randomized controlled trial of vitamin D supplementation for winter‐related atopic dermatitis in Boston: a pilot study

which is much higher than in healthy controls (Table 2). However, the other 57Æ5% of patients with GAE did not have ichthyosis, suggesting that other factors must be studied further. Atopic diathesis is associated with dry skin; however, our results did not show a higher percentage of patients with atopic diathesis in the GAE group (Table 2). In contrast to reports in the literature, the GAE group in our study contained more women than men. The gender difference in sebaceous activity, with a rapid decline of sebaceous activity in older woman, cannot completely explain this, because half of our patients were between 21 and 40 years, and 80% of those were female. The bathing habits of women were similar to those of men (Tables 1 and 2). The significance of these results needs to be studied further.

Vitamin D insufficiency in pregnant and nonpregnant women of childbearing age in the United States

OBJECTIVE We evaluated vitamin D insufficiency in a nationally representative sample of women and assessed the role of vitamin supplementation. STUDY DESIGN We conducted secondary analysis of 928 pregnant and 5173 nonpregnant women aged 13-44 years from the National Health and Nutrition Examination Survey 2001-2006. RESULTS The mean 25-hydroxyvitamin D (25[OH]D) level was 65 nmol/L for pregnant women and 59 nmol/L for nonpregnant women. The prevalence of 25(OH)D<75 nmol/L was 69% and 78%, respectively. Pregnant women in the first trimester had similar 25(OH)D levels as nonpregnant women (55 vs 59 nmol/L), despite a higher proportion taking vitamin D supplementation (61% vs 32%). However, first-trimester women had lower 25(OH)D levels than third-trimester women (80 nmol/L), likely from shorter duration of supplement use. CONCLUSION Adolescent and adult women of childbearing age have a high prevalence of vitamin D insufficiency. Current prenatal multivitamins (400 IU vitamin D) helped to raise serum 25(OH)D levels, but higher doses and longer duration may be required.

Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993–2008

OBJECTIVE The objective was to describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period. METHOD Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950-E959) during 1993-2008. RESULTS Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury [1.50 (95% confidence interval, 1.33-1.67) visits per 1000 US population], and the average annual number for these ED visits more than doubled from 244,000 in 1993-1996 to 538,000 in 2005-2008. During the same time frame, ED visits for these injuries per 1000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82) and blacks (1.14 to 2.10). Visits were most common among ages 15-19, and the number of visits coded as urgent/emergent decreased from 0.95 in 1993-1996 to 0.70 in 2005-2008. CONCLUSIONS ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs.

Access to Emergency Care in the United States

STUDY OBJECTIVE Rapid access to emergency services is essential for emergency care-sensitive conditions such as acute myocardial infarction, stroke, sepsis, and major trauma. We seek to determine US population access to an emergency department (ED). METHODS The National Emergency Department Inventories-USA was used to identify the location, annual visit volume, and teaching status of all EDs in the United States. EDs were categorized as any ED, by patient volume, and by teaching status. Driving distances, driving speeds, and out-of-hospital times were estimated with validated models and adjusted for population density. Access was determined by summing the population that could reach an ED within the specified intervals. RESULTS Overall, 71% of the US population has access to an ED within 30 minutes, and 98% has access within 60 minutes. Access to teaching hospitals was more limited, with 16% having access within 30 minutes and 44% within 60 minutes. Rural states had lower access to all types of EDs. CONCLUSION Although the majority of the US population has access to an ED, there are regional disparities in ED access, especially by rurality. Future efforts should measure the relationship between access to emergency services and outcomes for emergency care-sensitive conditions. The development of a regionalized emergency care delivery system should be explored.

Prospective Multicenter Study of Children With Bronchiolitis Requiring Mechanical Ventilation

OBJECTIVE: To identify factors associated with continuous positive airway pressure (CPAP) and/or intubation for children with bronchiolitis. METHODS: We performed a 16-center, prospective cohort study of hospitalized children aged <2 years with bronchiolitis. For 3 consecutive years from November 1 until March 31, beginning in 2007, researchers collected clinical data and a nasopharyngeal aspirate from study participants. We oversampled children from the ICU. Samples of nasopharyngeal aspirate were tested by polymerase chain reaction for 18 pathogens. RESULTS: There were 161 children who required CPAP and/or intubation. The median age of the overall cohort was 4 months; 59% were male; 61% white, 24% black, and 36% Hispanic. In the multivariable model predicting CPAP/intubation, the significant factors were: age <2 months (odds ratio [OR] 4.3; 95% confidence interval [CI] 1.7–11.5), maternal smoking during pregnancy (OR 1.4; 95% CI 1.1–1.9), birth weight <5 pounds (OR 1.7; 95% CI 1.0–2.6), breathing difficulty began <1 day before admission (OR 1.6; 95% CI 1.2–2.1), presence of apnea (OR 4.8; 95% CI 2.5–8.5), inadequate oral intake (OR 2.5; 95% CI 1.3–4.3), severe retractions (OR 11.1; 95% CI 2.4–33.0), and room air oxygen saturation <85% (OR 3.3; 95% CI 2.0–4.8). The optimism-corrected c-statistic for the final model was 0.80. CONCLUSIONS: In this multicenter study of children hospitalized with bronchiolitis, we identified several demographic, historical, and clinical factors that predicted the use of CPAP and/or intubation, including children born to mothers who smoked during pregnancy. We also identified a novel subgroup of children who required mechanical respiratory support <1 day after respiratory symptoms began.

National Study of the Emergency Physician Workforce, 2008

STUDY OBJECTIVE We describe the characteristics of the US emergency physician workforce. METHODS We performed a cross-sectional analysis of the 2008 American Medical Association Physician Masterfile, which includes data on all physicians who have ever obtained a medical license in at least 1 US state. We included all physicians who designated emergency medicine as their primary or secondary specialty. RESULTS There were 39,061 clinically active emergency physicians, of which 57% were emergency medicine board certified and 69% were emergency medicine trained or emergency medicine board certified. Family medicine (31%) and internal medicine (23%) were the most common backgrounds for non-emergency medicine-trained/emergency medicine board certified emergency physicians, and most (75%) graduated from residency greater than or equal to 20 years ago. Nearly all (98%) emergency physicians who graduated within the past 5 years were emergency medicine trained or emergency medicine board certified. Rural emergency physicians were much less likely than urban emergency physicians to have emergency medicine training (31% versus 57%), emergency medicine board certified (43% versus 59%), and to have graduated in the past 5 years (8% versus 19%). The density of all emergency physicians per 100,000 population was highest in New England (16.0) and in urban areas (14.5). The lowest emergency physician densities were in West South Central (10.2) and rural areas (10.3). Density of emergency medicine-trained or emergency medicine board certified emergency physicians was 10.3 in urban, 5.3 in large rural, and 2.5 in small rural areas. CONCLUSION Although newer emergency physicians are almost all emergency medicine trained or emergency medicine board certified, many non-emergency medicine-trained/emergency medicine board certified emergency physicians still provide clinical coverage of EDs. Demand for all emergency physicians will likely continue for several decades and the shortage may even increase in rural areas.

Emergency department crowding and risk of preventable medical errors

The objective of the study is to determine the association between emergency department (ED) crowding and preventable medical errors (PME). This was a retrospective cohort study of 533 ED patients enrolled in the National ED Safety Study (NEDSS) in four Massachusetts EDs. Individual patients’ average exposure to ED crowding during their ED visit was compared with the occurrence of a PME (yes/no) for the three diagnostic categories in NEDSS: acute myocardial infarction, asthma exacerbation, and dislocation requiring procedural sedation. To accommodate site-to-site differences in available administrative data, ED crowding was measured using one of three previously validated crowding metrics (ED Work Index, ED Workscore, and ED Occupancy). At each site, the continuous measure was placed into site-specific quartiles, and these quartiles then were combined across sites. We found that 46 (8.6%; 95% confidence interval, 6.4–11.3%) of the 533 patients experienced a PME. For those seen during higher levels of ED crowding (quartile 4 vs. quartile 1), the occurrence of PMEs was more than twofold higher, both on unadjusted analysis and adjusting for two potential confounders (diagnosis, site). The association appeared non-linear, with most PMEs occurring at the highest crowding level. We identified a direct association between high levels of ED crowding and risk of preventable medical errors. Further study is needed to determine the generalizability of these results. Should such research confirm our findings, we would suggest that mitigating ED crowding may reduce the occurrence of preventable medical errors.

Quality of care for acute asthma in 63 US emergency departments

BACKGROUND Little is known about the quality of acute asthma care in the emergency department (ED). OBJECTIVES We sought to determine the concordance of ED management of acute asthma with National Institutes of Health asthma guidelines, to identify ED characteristics predictive of higher guideline concordance, and to assess whether guideline concordance was associated with hospital admission. METHODS We conducted a retrospective chart review study of acute asthma as part of the National Emergency Department Safety Study. Using a principal diagnosis of asthma, we identified ED visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at the patient and ED level. These scores ranged from 0 to 100, with 100 indicating perfect concordance. RESULTS The cohort consisted of 4,053 subjects; their median age was 34 years, and 64% were women. The overall patient guideline concordance score was 67 (interquartile range, 63-83), and the ED concordance score was 71 (SD, 7). Multivariable analysis showed southern EDs were associated with lower ED concordance scores (beta-coefficient, -8.2; 95% CI, -13.8 to -2.7) compared with northeastern EDs. After adjustment for the severity on ED presentation, patients who received all recommended treatments had a 46% reduction in the risk of hospital admission compared with others. CONCLUSIONS Concordance with treatment recommendations in the National Institutes of Health asthma guidelines was moderate. Significant variations in ED quality of asthma care were found, and geographic differences existed. Greater concordance with guideline-recommended treatments might reduce hospitalizations.

Increasing Critical Care Admissions From U.S. Emergency Departments, 2001–2009

Objectives:Little is known about how recent system-wide increases in demand for critical care have affected U.S. emergency departments (EDs). This study describes changes in the amount of critical care provided in U.S. EDs between 2001 and 2009. Design:Analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2001–2009. Setting:National multistage probability sample of U.S. ED data. U.S. ED capacity was estimated using the National Emergency Department Inventory-United States. Patients:ED patients admitted a critical care unit. Interventions:None. Measurements:Annual hours of ED-based critical care and annual number critical care ED visits. Clinical characteristics, demographics, insurance status, setting, geographic region, and ED length of stay for critically ill ED patients. Main Results:Annual critical care unit admissions from U.S. EDs increased by 79% from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical care unit admission increased from 0.9% to 1.6% (ptrend < 0.001). Between 2001 and 2009, the median ED length of stay for critically ill patients increased from 185 to 245 minutes (+ 60 min; ptrend < 0.02). For the aggregated years 2001–2009, ED length of stay for critical care visits was longer among black patients (12.6% longer) and Hispanic patients (14.8% longer) than among white patients, and one third of all critical care ED visits had an ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend < 0.001). The average daily amount of critical care provided in U.S. EDs tripled from 1.8 to 5.6 hours per ED per day. Conclusions:The amount of critical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay. Increased critical care burden will further stress an already overcapacity U.S. emergency care system.

Suicide Prevention in an Emergency Department Population: The ED-SAFE Study

Importance Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped. Objective To determine whether an ED-initiated intervention reduces subsequent suicidal behavior. Design, Setting, and Participants This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013. Interventions Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk. Main Outcomes and Measures The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed. Results A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99). Conclusions and Relevance Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.