Judith Brillman

Management of Observation Units

Abstract [American College of Emergency Physicians: Management of observation units. Ann Emerg Med June 1995;25:823-830.]

Safe at Home? Domestic Violence and Other Homicides Among Women in New Mexico

STUDY OBJECTIVE To define the contribution of domestic violence (DV) to homicides in women in New Mexico and to examine differences in ethnicity, mechanism, previous documented injuries, incidence of sexual assault, and use of alcohol or illicit drugs between DV- and non-DV-related homicides. METHODS We carried out a retrospective analysis of reports of the state office of the medical investigator (OMI) reports from all female homicides from 1990 to 1993 in New Mexico. A homicide was defined as being related to DV if the perpetrator was a current or former male intimate partner. The chi-squared and Mann-Whitney tests were used to analyze data. RESULTS The OMI investigated 134 homicides in women for an overall fatality rate of 4.3 per 100,000. A male intimate partner was the perpetrator in 62 cases (46%). The rate of DV homicide among American Indians (4.9 per 100,000) was significantly higher than that among Hispanics (1.7) and non-Hispanic whites (1.8)(RR=2.8; 95% confidence interval (CI), 1.5 to 5.1). Firearms were almost two times as likely to be used in DV homicides as in non-DV homicides (RR=1.8; 95% CI, 1.2 to 2.6). Evidence of old injuries was found more often in DV homicide cases (35.5%) than in non-DV cases (83%) (RR=4.3; 95% CI, 1.8 to 9.8). The presence of alcohol or other drugs was higher among non-DV homicide victims (69%) than DV homicide victims (54.3%) (P=.03). CONCLUSION American Indian women are at particularly high risk of homicide, including DV homicide. Firearms were overrepresented in DV homicides, suggesting that removing firearms from the homes of previous DV perpetrators would be a useful public health strategy. Alcohol or illicit drugs were found in approximately two thirds of New Mexico women who were victims of homicide. The high prevalence of history of previous injuries among DV homicide victims indicates that early identification of DV victims in the emergency department and other health care settings is an important point of intervention.

INFECTIOUS DISEASE EMERGENCIES IN DISASTERS

This article discusses the relationship between disasters and infections. Infections that are reviewed include those resulting from (1) a breakdown of the usual mechanisms of infection control, (2) the introduction or emergence of pathogens, and (3) the movement of populations into new areas. Components of infectious-disease surveillance and disaster teams are detailed.

Does a physician visual assessment change triage

A prospective comparative trial was conducted to determine the effect of a physicians visual assessment of emergency patients on triage categorization and ability at triage to predict admission. The setting was a university, county, referral center and residency training site. Participants were a consecutive sample of emergency department patients presenting between the times of 0700 and 2300 hours for 5 weeks. All patients were assigned a triage category by an emergency nurse (RN) who saw the patient and by an emergency physician (EP) who had the option of performing a visual assessment. Triage categorization was compared for interobserver agreement (Kappa [kappa] statistic) and by ability to predict admission (MacNemars test). A total of 3,949 patients was entered. The patients that physicians visually assessed were triaged by nurses as more ill (P < .001). For triage categories visualized by the EP compared with RN categorization, interobserver agreement was 59.8%, kappa = .21. For triage categories not visualized by EP compared with RN categorization, interobserver agreement was 67.9%, kappa = .45 (P < .001). Sensitivity of EPs to predict admission is as follows: all RN triage, 41.3; not seen by EP, 54.9; seen by EP, 69.3. Specificity is as follows: all RN triage, 93.7; not seen by EP, 88.5, seen by EP, 83.9. When physician visual assessment was done, agreement between physicians and nurses decreased by more than half. Physicians who included visual assessment in patient triage were less likely to agree with RN categorization. A visual assessment by the physician improved the sensitivity for predicting admission with an only small cost in specificity.

Observation unit impact on ED admission for asthma

The hypothesis that the use of an observation unit (OU) in the emergency department (ED) results in monetary savings by lowering the hospital admission rate for asthma was studied in a retrospective comparative cohort at an urban university county hospital. All acute asthmatic patients seen in the ED during a 22-month period were included. Preobservation patients were seen before the OU opened (n = 834); postobservation patients were treated afterward (n = 390). Postobservation patients in the experimental group meeting standard criteria were admitted to the OU. Fishers exact test and the binomial distribution were used to analyze proportions of patients admitted. Median charges were compared with the Mann-Whitney test. The difference between groups in hospital admission rate was only 2.7% and was not significant (P = .25). However, 5.3% less patients were admitted directly to the hospital (P = .01), and 6.7% less patients were discharged directly from the ED (P = .005). The OU produced no demonstrable cost savings. The use of an OU for asthmatic patients results in lower initial discharge rates from the ED and does not reduce eventual hospital admission appreciably.

Setting standards for improved syndromic surveillance

Clearly, there is a need for data at multiple levels and many locations. Investigations of possible cases and outbreaks must occur locally, and local data must be available as generated to healthcare providers and emergency responders. At the same time, regional, national and international authorities need aggregated data to understand the scope of an outbreak and to assist in the response. Thus, in comparison to a system in which data is sent to a central facility for aggregation and redistributed to local areas, we argue that a distributed system is much more appropriate and resilient to a bioterrorism event. The distributed data system can provide information to local responders for their immediate action and reduce demand on a central system and data unavailability over wide area networks while providing raw data immediately to centralized reviewers.

Hantavirus pulmonary syndrome: Recognition and emergency department management

Hantavirus infection with respiratory involvement is a new clinical entity. The respiratory and cardiovascular abnormalities associated with hantavirus infection define the hantavirus pulmonary syndrome (HPS). We present two cases of HPS and discuss the presentation, epidemiology, emergency department management, and differential diagnosis. Treatment of HPS involves intensive care monitoring, airway management, and cardiovascular support. Because human hantavirus infection with respiratory involvement has been recognized recently in all geographic regions of the United States, it is important for emergency physicians to recognize this syndromes characteristic symptoms and laboratory abnormalities. The fulminant clinical course of HPS and its 65% mortality rate underscore the importance of early recognition if potentially life-saving interventions are to be initiated.

Hantavirus: Emergency department respsonse to a disaster from an emerging pathogen

In May 1993, the appearance of critically ill patients with unexplained respiratory distress was noted in the Four Corners area formed by New Mexico, Arizona, and Colorado. This epidemic was ultimately linked to a hantavirus, an emerging pathogen. The impact on the emergency department of a new infectious disease with respiratory distress is described. A model is proposed to manage infectious disease disasters. Emerging infections that are important to emergency physicians are discussed. Recommendations that focus on disaster management and prevention of the spread of an unknown pathogen are developed.

Low Prevalence of Chlamydia trachomatis by Urinary Ligase Chain Reaction in Women Patients in the Emergency Department

UNLABELLED Recent studies suggest that women with acute urethral syndrome or abdominal pain, presenting to emergency departments (EDs), have a high prevalence of Chlamydia trachomatis. OBJECTIVES To estimate the prevalence of C. trachomatis in women presenting to an ED and to see whether those with dysuria or abdominal pain have a higher prevalence of C. trachomatis. METHODS The authors conducted a prospective cross-sectional study of C. trachomatis in the urine of women aged 18 to 50 years who had a urinalysis performed at a university/county ED from February through May 1998. Urine specimens were labeled for the presence of symptoms and analyzed for C. trachomatis by ligase chain reaction (LCR). Polymerase chain reaction (PCR) testing of cervical swabs for C. trachomatis was done for usual clinical indications. Difference in proportions of positive LCR tests among patients was tested with Fishers exact test. Agreement between PCR and LCR was measured using Cohens kappa statistic. RESULTS Of 397 women whose urine was tested, 280 had symptoms of dysuria, abdominal pain, or both, and 117 had no symptoms. The overall prevalence of C. trachomatis by LCR was 3.8% (95% CI = 2.1% to 6.2%); and the combined PCR-LCR prevalence was 4.3% (95% CI = 2.5% to 6.8%). The presence of symptoms was not associated with a positive LCR test for C. trachomatis (p = 0.26, power = 0.8, alpha = 0.05, difference 3% vs. 12%). In the 172 patients who had both a PCR cervical swab and urine LCR, agreement was excellent (kappa = 0.67, 95% CI = 0.45 to 0.90). CONCLUSIONS This ED had a surprisingly low prevalence of C. trachomatis. Women with symptoms were not more likely to test positive than those without.

Symptomatology of HIV-Related Illness and Community-Acquired Illness in an HIV-Infected Emergency Department Population

STUDY HYPOTHESIS Community-acquired infections and non-AIDS-related illnesses are a significant proportion of the final diagnoses in HIV-infected patients presenting to an emergency department. We hypothesized that emergency physicians over-diagnose opportunistic infections in the HIV-infected patient. We also hypothesized that the absolute CD4 lymphocyte level could be used to stratify patients by likelihood of HIV related disease. METHODS We retrospectively reviewed ED logbooks and medical records to find all ED patients with self-reported HIV seropositivity during a 19-month period. Age, sex, insurance status, chief complaint(s), ED assessment, and disposition were recorded from the ED logs; absolute CD4 lymphocyte counts, risk factors, and final diagnoses were recorded from the medical records. HIV-related disease was evaluated with the use of established Centers for Disease Control and Prevention criteria. Data were evaluated with the use of the chi 2 test, the chi 2 test for trend, and kappa-proportions. RESULTS Analysis of 344 ED visits demonstrated that decreasing absolute CD4 lymphocyte counts were associated with increasing incidence of HIV-related disease (P < .001), even when noninfectious causes were excluded. Only 34% of visits were related to HIV-associated illness. Emergency physicians exhibited high sensitivity (72.9%) and specificity (95.5%) in diagnosing HIV-related disease and conducted appropriate visit disposition. CONCLUSION ED visits by HIV-infected individuals are often not made for reasons of opportunistic infection, and the absolute CD4 lymphocyte count is inversely related to HIV-related disease.