Bon S. Ku

Factors associated with use of urban emergency departments by the U.S. homeless population.

Objective. Homeless individuals frequently use emergency departments (EDs), but previous studies have investigated local rather than national ED utilization rates. This study sought to characterize homeless people who visited urban EDs across the U.S. Methods. We analyzed the ED subset of the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED), a nationally representative probability survey of ED visits, using methods appropriate for complex survey samples to compare demographic and clinical characteristics of visits by homeless vs. non-homeless people for survey years 2005 and 2006. Results. Homeless individuals from all age groups made 550,000 ED visits annually (95% confidence interval [CI] 419,000, 682,000), or 72 visits per 100 homeless people in the U.S. per year. Homeless people were older than others who used EDs (mean age of homeless people = 44 years compared with 36 years for others). ED visits by homeless people were independently associated with male gender, Medicaid coverage and lack of insurance, and Western geographic region. Additionally, homeless ED visitors were more likely to have arrived by ambulance, to be seen by a resident or intern, and to be diagnosed with either a psychiatric or substance abuse problem. Compared with others, ED visits by homeless people were four times more likely to occur within three days of a prior ED evaluation, and more than twice as likely to occur within a week of hospitalization. Conclusions. Homeless people who seek care in urban EDs come by ambulance, lack medical insurance, and have psychiatric and substance abuse diagnoses more often than non-homeless people. The high incidence of repeat ED visits and frequent hospital use identifies a pressing need for policy remedies.

Risk factors associated with difficult venous access in adult ED patients

OBJECTIVE The objective was to determine risk factors associated with difficult venous access (DVA) in the emergency department (ED). METHODS This was a prospective, observational study conducted in the ED of an urban tertiary care hospital. Adult patients undergoing intravenous (IV) placement were consecutively enrolled during periods of block enrollment. The primary outcome was DVA, defined as 3 or more IV attempts or use of a method of rescue vascular access to establish IV access. Univariate and multivariate analyses for factors predicting DVA were performed using logistic regression. RESULTS A total of 743 patients were enrolled, of which 88 (11.8%) met the criteria for DVA. In the adjusted analysis, only 3 medical conditions were significantly associated with DVA: diabetes (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.1-2.8), sickle cell disease (OR 3.8, 95% CI 1.5-9.5), and history of IV drug abuse (OR 2.5, 95% CI 1.1-5.7). Notably, age, body mass index, and dialysis were not. Of patients who reported a history of requiring multiple IV attempts in the past for IV access, 14% met criteria for DVA on this visit (OR 7.7 95% CI 3-18). Of the patients who reported a history of IV insertion into the external jugular, ultrasound-guided IV placement, or a central venous catheter for IV access, 26% had DVA on this visit (OR 16.7, 95% CI 6.8-41). CONCLUSIONS Nearly 1 of every 9 to 10 adults in an urban ED had DVA. Diabetes, IV drug abuse, and sickle cell disease were found to be significantly associated with DVA.

The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity

INTRODUCTION Ultrasound-guided peripheral intravenous catheters (USGPIVs) have been observed to have poor durability. The current study sets out to determine whether vessel characteristics (depth, diameter, and location) predict USGPIV longevity. METHODS A secondary analysis was performed on a prospectively gathered database of patients who underwent USGPIV placement in an urban, tertiary care emergency department. All patients in the database had a 20-gauge, 48-mm-long catheter placed under ultrasound guidance. The time and reason for USGPIV removal were extracted by retrospective chart review. A Kaplan-Meier survival analysis was performed. RESULTS After 48 hours from USGPIV placement, 32% (48/151) had failed prematurely, 24% (36/151) had been removed for routine reasons, and 44% (67/151) remained in working condition yielding a survival probability of 0.63 (95% confidence interval [CI], 0.53-0.70). Survival probability was perfect (1.00) when placed in shallow vessels (<0.4 cm), moderate (0.62; 95% CI, 0.51-0.71) for intermediate vessels (0.40-1.19 cm), and poor (0.29; 95% CI, 0.11-0.51) for deep vessels (≥1.2 cm); P < .0001. Intravenous survival probability was higher when placed in the antecubital fossa or forearm locations (0.83; 95% CI, 0.69-0.91) and lower in the brachial region (0.50; 95% CI, 0.38-0.61); P = .0002. The impact of vessel depth and location was significant after 3 hours and 18 hours, respectively. Vessel diameter did not affect USGPIV longevity. CONCLUSION Cannulation of deep and proximal vessels is associated with poor USGPIV survival. Careful selection of target vessels may help improve success of USGPIV placement and durability.

Association between multiple IV attempts and perceived pain levels in the emergency department

Purpose Intravenous (IV) access is the most commonly performed procedure in the emergency department (ED). Patients with difficult venous access require multiple needlesticks (MNS) for successful IV cannulation and may experience increased pain with many attempts. Objective To determine the association between number of IV attempts and overall pain experienced by the patient from IV placement. Methods Cross-sectional observational study on consecutive patients undergoing IV placement with a 20-gauge IV in the upper extremity in an urban academic hospital. Exclusion criteria included refusal to participate or fully complete all survey questions. The total number of IV attempts and patient pain scores marked on a standardized visual analog scale was recorded. Mean pain scores of two groups, single needlestick (SNS) and MNS, were compared using Students t-test. Results A total of 760 patients were approached, of whom 31 were excluded, leaving 729 patients in the analysis; 556 with SNS (76%) and 173 with MNS (24%). The mean pain score (95% CI) was 51 mm (46–55 mm) for the MNS group and 25 mm (23–28 mm) for the SNS group, p<0.001. Compared to patients who underwent one IV attempt, patients with two and three attempts had an average 19 mm and 33 mm increase in pain scores, respectively, with the highest average pain associated with five attempts. A total of 58% of MNS patients rated IV placement as the most painful experience while in the ED. Conclusions Patients experience increased pain in association with multiple IV attempts.

Clinician-performed Beside Ultrasound for the Diagnosis of Traumatic Pneumothorax

Introduction: Prior studies have reported conflicting results regarding the utility of ultrasound in the diagnosis of traumatic pneumothorax (PTX) because they have used sonologists with extensive experience. This study evaluates the characteristics of ultrasound for PTX for a large cohort of trauma and emergency physicians. Methods: This was a prospective, observational study on a convenience sample of patients presenting to a trauma center who had a thoracic ultrasound (TUS) evaluation for PTX performed after the Focused Assessment with Sonography for Trauma exam. Sonologists recorded their findings prior to any other diagnostic studies. The results of TUS were compared to one or more of the following: chest computed tomography, escape of air on chest tube insertion, or supine chest radiography followed by clinical observation. Results: There were 549 patients enrolled. The median injury severity score of the patients was 5 (inter-quartile range [IQR] 1–14); 36 different sonologists performed TUS. Forty-seven of the 549 patients had traumatic PTX, for an incidence of 9%. TUS correctly identified 27/47 patients with PTX for a sensitivity of 57% (confidence interval [CI] 42–72%). There were 3 false positive cases of TUS for a specificity of 99% (CI 98%–100%). A “wet” chest radiograph reading done in the trauma bay showed a sensitivity of 40% (CI 23–59) and a specificity of 100% (99–100). Conclusion: In a large heterogenous group of clinicians who typically care for trauma patients, the sonographic evaluation for pneumothorax was as accurate as supine chest radiography. Thoracic ultrasound may be helpful in the initial evaluation of patients with truncal trauma.

Soft Tissue Foreign Body Removal Technique Using Portable Ultrasonography

Retained foreign objects account for as much as 2% of soft tissue injuries sustained in the wilderness. Subcutaneously embedded fragments are often missed during the initial medical evaluation and may result in morbidity secondary to delayed removal. Although the utility of ultrasonography in the emergency department for the detection of retained objects is established, the potential use of point-of-care ultrasound to aid with foreign body removal in the field has not been well described. We present 2 case reports that demonstrate the value of ultrasonography in detecting and successfully removing foreign bodies sustained in the wilderness, and outline a procedural technique that minimizes morbidity and uses equipment available in wilderness medical field kits. We propose that with the advent of portable and handheld ultrasound units, foreign body removal in the field has become feasible and may decrease the morbidity of soft tissue injuries, particularly in austere and wilderness environments with limited access to immediate medical care.

Resuscitation of the pregnant patient: What is the effect of patient positioning on inferior vena cava diameter? ,

STUDY OBJECTIVE Patients in the third trimester of pregnancy presenting to the emergency department (ED) with hypotension are routinely placed in the left lateral tilt (LLT) position to relieve inferior vena cava (IVC) compression from the gravid uterus thereby increasing venous return. However, the relationship between patient position and proximal intrahepatic IVC filling has never assessed directly. This study set out to determine the effect of LLT position on intrahepatic IVC diameter in third trimester patients under real-time visualization with ultrasound. METHODS This prospective observational study on the labor and delivery floor of a large urban academic teaching hospital enrolled patients between 30 and 42 weeks estimated gestational age from August 2011 to March 2012. Patients were placed in three different positions: supine, LLT, and right lateral tilt (RLT). After the patient was in each position for at least 3 min, IVC ultrasound using the intercostal window was performed by one of three study sonologists. Maternal and fetal hemodynamics were also monitored and recorded in each position. RESULTS A total of 26 patients were enrolled with one excluded from data analysis due to inability to obtain IVC measurements. The median IVC maximum diameter was 1.26 cm (95% confidence interval [CI] 1.13-1.55) in LLT compared to 1.13 cm (95% CI 0.89-1.41) in supine, p=0.01. When comparing each individual patients LLT to supine measurement, LLT lead to an increase in maximum IVC diameter in 76% (19/25) of patients with the average LLT measurement 29% (95% confidence interval 10-48%) larger. Six patients had the largest maximum IVC measurement in the supine position. No patients experienced any hemodynamic instability or distress during the study. CONCLUSION IVC ultrasound is feasible in late pregnancy and demonstrates an increase in diameter with LLT positioning. However, a quarter of patients had a decrease in IVC diameter with tilting and, instead, had the largest IVC diameter in the supine position suggesting that uterine compression of the IVC may not occur universally. IVC assessment at the bedside may be a useful adjunct in determining optimal positioning for resuscitation of third trimester patients.

How Multidimensional Health Locus of Control predicts utilization of emergency and inpatient hospital services

Health locus of control may be an important predictor of health care utilization. We analyzed associations between health locus of control and frequency of emergency department visits and hospital admissions, and investigated self-rated health as a potential mediator. Overall, 863 patients in an urban emergency department completed the Multidimensional Health Locus of Control instrument, and self-reported emergency department use and hospital admissions in the last year. We found small but significant associations between Multidimensional Health Locus of Control and utilization, all of which were mediated by self-rated health. We conclude that interventions to shift health locus of control may change patients’ perceptions of their own health, thereby impacting utilization.

Confirmatory factor analysis and invariance testing between Blacks and Whites of the Multidimensional Health Locus of Control scale

The factor structure of the Multidimensional Health Locus of Control scale remains in question. Additionally, research on health belief differences between Black and White respondents suggests that the Multidimensional Health Locus of Control scale may not be invariant. We reviewed the literature regarding the latent variable structure of the Multidimensional Health Locus of Control scale, used confirmatory factor analysis to confirm the three-factor structure of the Multidimensional Health Locus of Control, and analyzed between-group differences in the Multidimensional Health Locus of Control structure and means across Black and White respondents. Our results indicate differences in means and structure, indicating more research is needed to inform decisions regarding whether and how to deploy the Multidimensional Health Locus of Control appropriately.

Effect of the Sphere Standards on the incidence of communicable and infectious diseases in a returnee camp in South Sudan

Abstract Background The Sphere Standards are primarily focused on factors that acutely affect survival instead of guiding long-term development in displaced populations and have gained consensus in more than 200 aid organisations. However, research was not available to back up every Standard and in those cases the Standards were based on expert or consensus opinion. Therefore, research to validate or refine the Standards will be of benefit to the humanitarian community and the people they serve. Methods A retrospective study was done at a UN High Commissioner for Refugees camp for returnees from Sudan to South Sudan before and after an intervention to introduce the Sphere Standards for water, sanitation, and hygiene (WASH). Data were collected from May 17, 2012, to July 31, 2012. The daily proportion of the camp diagnosed with a communicable or infectious disease was calculated by comparing the daily camp population to the daily counts from the camps medical clinic. A χ 2 analysis was done to compare the weekly disease proportions before and after the camp met the Sphere Standards for WASH. Findings The camp clinic recorded 12 655 consultations. The weekly prevalences of the camp population diagnosed with diarrhoea, an upper respiratory tract infection, or a lower respiratory tract infection in the week before the camp met the Sphere Standards were 0·67%, 0·59%, and 0·34%, respectively. 2 weeks afterwards, they were 0·99%, 1·68%, and 0·57%, respectively. In the fourth week the prevalences for all three decreased (0·82%, 1·48%, and 0·39%, respectively). This pattern was statistically significant for all age groups and also for subgroup analysis on returnees younger than 5 years. Percentages for the diseases tracked ranged from 0·14% to 1·68% with p Interpretation Factors such as the massive influx of returnees to the camp and the introduction of local pathogens into the returnee camp population probably muted the initial effects of improved WASH on the camp. These results suggest that achievement and maintainence of the Sphere Standards will have a significant, although possibly delayed, effect on the incidence of communicable and infectious diseases during a complex humanitarian emergency. Funding None.