Douglas W. Lowery-North

Measuring social contacts in the emergency department.

Background Infectious individuals in an emergency department (ED) bring substantial risks of cross infection. Data about the complex social and spatial structure of interpersonal contacts in the ED will aid construction of biologically plausible transmission risk models that can guide cross infection control. Methods and Findings We sought to determine the number and duration of contacts among patients and staff in a large, busy ED. This prospective study was conducted between 1 July 2009 and 30 June 2010. Two 12-hour shifts per week were randomly selected for study. The study was conducted in the ED of an urban hospital. There were 81 shifts in the planned random sample of 104 (78%) with usable contact data, during which there were 9183 patient encounters. Of these, 6062 (66%) were approached to participate, of which 4732 (78%) agreed. Over the course of the year, 88 staff members participated (84%). A radiofrequency identification (RFID) system was installed and the ED divided into 89 distinct zones structured so copresence of two individuals in any zone implied a very high probability of contact <1 meter apart in space. During study observation periods, patients and staff were given RFID tags to wear. Contact events were recorded. These were further broken down with respect to the nature of the contacts, i.e., patient with patient, patient with staff, and staff with staff. 293,171 contact events were recorded, with a median of 22 contact events and 9 contacts with distinct individuals per participant per shift. Staff-staff interactions were more numerous and longer than patient-patient or patient-staff interactions. Conclusions We used RFID to quantify contacts between patients and staff in a busy ED. These results are useful for studies of the spread of infections. By understanding contact patterns most important in potential transmission, more effective prevention strategies may be implemented.

Informed consent for computed tomography

Computed tomography (CT) accounts for a large quantity of patient exposure to ionizing radiation. Ionizing radiation is listed by the World Health Organization as a carcinogen [1,2]. Over the last thirty years in the United States, the rate of CT use in medical imaging has increased from 2.3 million to more than 60 million scans/y [3-5]. Between 2000 and 2006, Broder [6] reported a 4-fold increase in utilization within US emergency departments (EDs). For example, abdominal CT delivers a dose of 3.5 to 25 mSv, or 1 to 8 years of background radiation [1,2,6-25]. Ionizing radiation from this routine test is conservatively estimated to induce cancer in 1 per 5000-10 000 patients [8,10,26-28]. Increased utilization of CT leads to higher patient exposure to radiation and subsequent risk of cancer development. In 1957, Paul G. Gebhard first articulated the idea of informed consent, the duty of the physician to disclose all risks and benefits of a medical procedure to the patient. This is routinely practiced before surgical procedures and even the use of intravenous medications, such as CT contrast. However, it is not current standard of care to obtain informed consent for CT imaging [29]. This may be due to the fact that radiation from CT causes no immediately tangible effect or visible scar. However, like surgery, radiation leaves a biologic mark on the patient. Development of cancer may not occur until decades later. To explain this risk to patients, our team designed a 1-page Informed Consent for Computerized Tomography form. The consent defines the risks, benefits, and alternatives to CT imaging. We then conducted a survey to study the effect of informed consent on patient understanding of medical radiation. The consent is written at an eighth-grade reading level and describes radiation dose from chest x-ray, abdominal CT, and background radiation [7,10,26-28]. The consent was reviewed and approved by hospital legal, medical records, and quality/ safety teams. As a quality initiative, the study was exempted from evaluation by the institutional review board. To quantify the educational value of the consent, a 5-question survey was administered to evaluate patient understanding of medical radiation. Patients who presented to the ED waiting room during study times were asked to complete the survey, regardless of chief complaint. Critically ill patients or those who demonstrated language barriers were excluded. Group I (50 patients) completed the survey in May 2010. Fifty additional patients (group II) participated in June 2010. Group II reviewed the consent and then completed the survey. Patients were also asked if they prefer to know the risks and benefits of CT. Differences between groups were measured with Fisher exact tests using OpenEpi (Open

Written Informed Consent for Computed Tomography of the Abdomen/Pelvis is Associated with Decreased CT Utilization in Low-Risk Emergency Department Patients

Introduction The increasing rate of patient exposure to radiation from computerized tomography (CT) raises questions about appropriateness of utilization. There is no current standard to employ informed consent for CT (ICCT). Our study assessed the relationship between informed consent and CT utilization in emergency department (ED) patients. Methods An observational multiphase before-after cohort study was completed from 4/2010–5/2011. We assessed CT utilization before and after (Time I/Time II) the implementation of an informed consent protocol. Adult patients were included if they presented with symptoms of abdominal/pelvic pathology or completed ED CT. We excluded patients with pregnancy, trauma, or altered mental status. Data on history, exam, diagnostics, and disposition were collected via standard abstraction tool. We generated a multivariate logistic model via stepwise regression, to assess CT utilization across risk groups. Logistic models, stratified by risk, were generated to include study phase and a propensity score that controlled for potential confounders of CT utilization. Results 7,684 patients met inclusion criteria. In PHASE 2, there was a 24% (95% CI [10–36%]) reduction in CT utilization in the low-risk patient group (p<0.002). ICCT did not affect CT utilization in the high-risk group (p=0.16). In low-risk patients, the propensity score was significant (p<0.001). There were no adverse events reported during the study period. Conclusion The implementation of ICCT was associated with reduced CT utilization in low-risk ED patients. ICCT has the potential to increase informed, shared decision making with patients, as well as to reduce the risks and cost associated with CT.

Commercial Products That Convey Personal Health Information in Emergencies

OBJECTIVE Describe commercially available products and services designed to convey personal health information in emergencies. METHODS The search engine Google®, supplemented by print ads, was used to identify companies and organizations that offer relevant products and services to the general market. Disease-specific, health system, and health plan-specific offerings were excluded. Vendor web sites were the primary sources of information, supplemented by telephone and e-mail queries to sales representatives. Perfect inter-rater agreement was achieved. RESULTS Thirty-nine unique vendors were identified. Eight sell engraved jewelry. Three offer an embossed card or pamphlet. Twelve supply USB drives with various features. Eleven support password-protected web sites. Five maintain national call centers. Available media differed markedly with respect to capacity and accessibility. Quoted prices ranged from a one-time expenditure of

Contact networks in the emergency department: Effects of time, environment, patient characteristics, and staff role

3.50 to an annual fee of

The Risk of Cross Infection in the Emergency Department: A Simulation Study

200. Associated features and annual fees varied widely. CONCLUSION A wide range of products and services exist to help patients convey personal health information. Health care providers should be familiar with their features, so they can access the information in a disaster or emergency.

Methods for the treatment of a traumatic central nervous system injury

Abstract Emergency departments play a critical role in the public health system, particularly in times of pandemic. Infectious patients presenting to emergency departments bring a risk of cross-infection to other patients and staff through close proximity interactions or contacts. To understand factors associated with cross-infection risk, we measured close proximity interactions of emergency department staff and patients by radiofrequency identification in a working emergency department. The number of contacts (degree) is not related to patient demographic characteristics. However, the amount of time in close proximity (weighted degree) of patients with ED personnel did differ, with black patients having approximately 15min more contact with staff than non-white patients. Patients arriving by EMS had fewer contacts with other patients than patients arriving by other means. There are differences in the number of contacts based on staff role and arrival mode. When crowding is low, providers have the most contact time with patients, while administrative staff have the least. However, when crowding is high, this differential is reversed. The effect of arrival mode is modified by the extent of crowding. When crowding is low, patients arriving by EMS had longer contact with administrative staff, compared to patients arriving by other means. However, when crowding is high, patients arriving by EMS had less contact with administrative staff compared to patients arriving by other means. Our findings should help designers of emergency care focus on higher risk situations for transmission of dangerous pathogens in an emergency department. For instance, the effects of arrival and crowding should be considered as targets for engineering or architectural interventions that could artificially increase social distances.

Dosage regimen for the treatment of a traumatic brain injury with progesterone

OBJECTIVES The risk of cross infection in a busy emergency department (ED) is a serious public health concern, especially in times of pandemic threats. We simulated cross infections due to respiratory diseases spread by large droplets using empirical data on contacts (ie, close-proximity interactions of ≤1m) in an ED to quantify risks due to contact and to examine factors with differential risks associated with them. DESIGN Prospective study. PARTICIPANTS Health workers (HCWs) and patients. SETTING A busy ED. METHODS Data on contacts between participants were collected over 6 months by observing two 12-hour shifts per week using a radiofrequency identification proximity detection system. We simulated cross infection due to a novel agent across these contacts to determine risks associated with HCW role, chief complaint category, arrival mode, and ED disposition status. RESULTS Cross-infection risk between HCWs was substantially greater than between patients or between patients and HCWs. Providers had the least risk, followed by nurses, and nonpatient care staff had the most risk. There were no differences by patient chief complaint category. We detected differential risk patterns by arrival mode and by HCW role. Although no differential risk was associated with ED disposition status, 0.1 infections were expected per shift among patients admitted to hospital. CONCLUSION These simulations demonstrate that, on average, 11 patients who were infected in the ED will be admitted to the hospital over the course of an 8-week local influenza outbreak. These patients are a source of further cross-infection risk once in the hospital. Infect Control Hosp Epidemiol 2018;39:688–693