Esther H. Chen

The association between physician risk tolerance and imaging use in abdominal pain

OBJECTIVE We sought to determine the impact of 3 validated scales of physician risk behavior on imaging use in emergency department (ED) patients with abdominal pain. METHODS We performed a prospective cohort study of nonpregnant ED patients with acute, nontraumatic abdominal pain and then administered 3 instruments (a risk-taking subscale of the Jackson Personality Index, the stress from uncertainty scale, and a malpractice fear scale) to attending physicians who had evaluated these patients and made decisions regarding abdominal imaging. Outcomes were the use of abdominal pelvic computed tomography (CT) and any imaging use (CT, ultrasound, or abdominal plain film). Hierarchical logistic regression was used to determine the effect of risk scales on abdominal imaging use. RESULTS Of 838 patients with acute abdominal pain, 487 (58%) received imaging studies; 395 (47%) received an CT, 111 (13%) ultrasound, and 122 (15%) an abdominal plain film. Both CT and any imaging use were lower among the physicians who were least risk-averse as measured by the risk-taking subscale (highest quartiles vs 3 lower quartiles). In adjusted analysis, probability of CT in the least risk-averse group was 35% (95% confidence interval [CI], 28%-44%) compared to 50% (95% CI, 45%-54%) among more risk-averse physicians, and the probability of any imaging was 53% (95% CI, 44%-61%) compared to 64% (95% CI, 61%-68%). Malpractice fear and stress due to uncertainty were not predictive of imaging use. CONCLUSION Self-reported physician risk-taking behavior predicts the use of imaging in ED patients with abdominal pain, whereas malpractice fear and stress due to uncertainty do not.

Poor Sensitivity of a Modified Alvarado Score in Adults With Suspected Appendicitis

STUDY OBJECTIVE A clinical decision rule that identifies patients at low risk for appendicitis may reduce the reliance on computed tomography (CT) for diagnosis. We seek to prospectively evaluate the accuracy of a low modified Alvarado score in emergency department (ED) patients with suspected appendicitis and compare the score to clinical judgment. We hypothesize that a low modified Alvarado score will have a sufficiently high sensitivity to rule out acute appendicitis. METHODS We performed a prospective observational study of adult patients with suspected appendicitis at 2 academic urban EDs. A low modified Alvarado score was defined as less than 4. The sensitivity and specificity were calculated with 95% confidence interval (CI) for a low modified Alvarado score, and a final diagnosis of appendicitis was confirmed by CT, laparotomy, or 7-day follow-up. RESULTS Two hundred sixty-one patients were included for analysis (mean age 35 years [range 18 to 89 years], 68% female patients, 52% white). Fifty-three patients (20%) had acute appendicitis. The modified Alvarado score test characteristics demonstrated a sensitivity and specificity of 72% (95% CI 58% to 84%) and 54% (95% CI 47% to 61%), respectively. Unstructured clinical judgment that appendicitis was either the most likely or second most likely diagnosis demonstrated a sensitivity and specificity of 93% (95% CI 82% to 98%) and 33% (95% CI 27% to 40%), respectively. CONCLUSION With a sensitivity of 72%, a low modified Alvarado score is less sensitive than clinical judgment in excluding acute appendicitis.

The Impact of Crowding on Time until Abdominal CT Interpretation in Emergency Department Patients with Acute Abdominal Pain

Abstract Objective: We assessed the relationship between emergency department (ED) crowding and delays in care in patients presenting with abdominal pain who receive abdominal computed tomography (CT). Methods: Prospective cohort study of adults who presented over a 1-year period to 2 urban academic EDs with abdominal pain and received CT. Each subject had 3 validated crowding measures assigned at enrollment (ED census, waiting room number, number of admitted patients). These were normalized to quartiles to signify least to most crowded. The Cuzick test was used for trend and log-linear regression and tested the association between ED crowding and time from triage to CT read. The time interval was further decomposed into triage to room, room to CT order, and order to CT read times. The adjusted analysis controlled for age, sex, race, pain score, time of day, triage level, and site. Results:767 patients were enrolled (mean age, 44±17 years; 61% female; 60% black). Median time from triage to CT read was 375 minutes (interquartile range [IQR], 276–497). Individual time intervals included triage to room (46 minutes [IQR, 16–111]), room to CT order (83 minutes [IQR, 38–151]), and order to CT read (203 minutes [IQR, 138–375]). Across waiting room quartiles, triage to CT read was associated with progressively longer times (318 vs 364 vs 414 vs 445 minutes; P < 0.001 for trend). Similar trends were noted for waiting room number and admitted patients (P < 0.001). In multivariable analysis, the association between ED crowding and time from triage to CT read remained significant and consistent across all crowding measures (P < 0.001). When decomposed into time intervals, triage to room time showed the greatest difference (22 vs 38 vs 72 vs 92 minutes; P < 0.001). Conclusion: ED crowding is associated with an approximately 2-hour delay to CT interpretation availability. Attempts to reduce delays in abdominal CTs may include earlier provider evaluation and placement in the queue for scanning.

Derivation of a clinical prediction rule for evaluating patients with abdominal pain and diarrhea

OBJECTIVE The objective of the study was to develop a simple prediction rule to reliably identify abdominal pain patients with diarrhea who may require surgical intervention. METHODS We performed a secondary analysis of a prospective cohort study of adults with acute nontraumatic abdominal pain and diarrhea in an urban emergency department (ED). Structured data collection included 109 historical and 28 physical examination items, laboratory and radiographic results, and final diagnosis. The main outcome was operative intervention. RESULTS One thousand patients were enrolled; 174 patients with diarrhea were included in this analysis. Patients had a mean age of 39 +/- 16 years and were likely to be female (64%) and black (60%). Fifteen (9%) patients received a surgical intervention from the ED. Clinical variables associated with the need for surgical intervention using univariate analysis were age older than 40 years, constant pain, and peritonitis on examination. Using recursive partitioning multivariate analysis, the derived prediction rule included 2 variables: age older than 40 years and constant pain. This rule had a sensitivity of 1.0 (95% confidence interval, 0.78-1.0) and specificity of 0.23 (95% confidence interval, 0.16-0.30). CONCLUSION Patients older than 40 years with constant abdominal pain and diarrhea are likely to have a surgical cause of their symptoms.

Top 10 ideas to improve your bedside teaching in a busy emergency department

Physicians are called upon to teach students, residents, patients and their families in the clinical environment every day as part of clinical care. A fast-paced emergency department offers a unique set of challenges that require the physician to be an effective communicator. We present a top 10 list of ideas selected from the literature for the busy clinician to use on that next shift to improve bedside teaching.

Assessing Systems-based Practice

The conceptual definition of systems-based practice (SBP) does not easily translate into directly observable actions or behaviors that can be easily assessed. At the Academic Emergency Medicine consensus conference on education research in emergency medicine (EM), a breakout group presented a review of the literature on existing assessment tools for SBP, discussed the recommendations for research tool development during breakout sessions, and developed a research agenda based on this discussion.

Complications of percutaneous procedures

Minimally invasive percutaneous procedures are increasingly being performed by both interventional radiologists and noninterventionalists. Patients with postprocedural issues will likely present to the emergency department for evaluation and treatment. This review focuses on the evaluation and management of the complications of common percutaneous procedures.

Diagnosis of a Facial Artery Pseudoaneurysm Using Emergency Bedside Ultrasound

BACKGROUND Pseudoaneurysms of the extracranial arterial system are rare. We report a case of a facial artery pseudoaneurysm initially mistaken for an abscess. With bedside ultrasound performed in the Emergency Department (ED) by the treating physician, the mass was identified as a pseudoaneurysm. OBJECTIVES In this report we review the anatomy of the extracranial arterial system of the head and neck, discuss the pathogenesis and clinical presentation of pseudoaneuryms, and present diagnostic imaging and treatment options for pseudoaneurysms of the face. CASE REPORT A 51-year-old man presented with facial swelling and pain at the site of a laceration that he had sustained 1 month previously. Before incision and drainage, bedside ultrasound was performed in the ED by the treating physician to confirm the presumptive diagnosis of abscess with possible foreign body. The ultrasound revealed the mass to be a pseudoaneurysm. CONCLUSIONS Although pseudoaneurysms of the head and neck are rare, a history of trauma should prompt the consideration of a vascular injury with the need for imaging before drainage procedures of a presumed abscess. To our knowledge, the use of clinician-performed bedside ultrasound to detect facial artery pseudoaneurysms has never been reported.

Research Priorities in the Utilization and Interpretation of Diagnostic Imaging: Education, Assessment, and Competency.

The appropriate selection and accurate interpretation of diagnostic imaging is a crucial skill for emergency practitioners. To date, the majority of the published literature and research on competency assessment comes from the subspecialty of point-of-care ultrasound. A group of radiologists, physicists, and emergency physicians convened at the 2015 Academic Emergency Medicine consensus conference to discuss and prioritize a research agenda related to education, assessment, and competency in ordering and interpreting diagnostic imaging. A set of questions for the continued development of an educational curriculum on diagnostic imaging for trainees and competency assessment using specific assessment methods based on current best practices was delineated. The research priorities were developed through an iterative consensus-driven process using a modified nominal group technique that culminated in an in-person breakout session. The four recommendations are: 1) develop a diagnostic imaging curriculum for emergency medicine (EM) residency training; 2) develop, study, and validate tools to assess competency in diagnostic imaging interpretation; 3) evaluate the role of simulation in education, assessment, and competency measures for diagnostic imaging; 4) study is needed regarding the American College of Radiology Appropriateness Criteria, an evidence-based peer-reviewed resource in determining the use of diagnostic imaging, to maximize its value in EM. In this article, the authors review the supporting reliability and validity evidence and make specific recommendations for future research on the education, competency, and assessment of learning diagnostic imaging.

Abdominal Pain in Special Populations

Evaluation and management of acute abdominal pain in special populations can be challenging for the emergency physician. This article focuses on two specific populations: patients with altered immunologic function and postprocedural patients. Recognition of life-threatening abdominal diseases may be delayed in immunosuppressed patients because of the atypical presentations of these conditions. In postprocedural patients, evaluation of acute abdominal symptoms requires an understanding of the complications of procedures often performed by others. The unique characteristics of abdominal pain in these two populations and, more specifically, which diseases to consider and how to use appropriate testing to detect life-threatening conditions, are discussed.