Lee Wilbur

Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

OBJECTIVES Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. METHODS This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. RESULTS A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. CONCLUSIONS In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury.

HIV Testing in U.S. Emergency Departments: At the Crossroads

C ommon sense principles and compelling evidence support the incorporation of human immunodeficiency virus (HIV) screening in emergency settings. First, early identification of individuals with HIV has been proven to delay disease progression, prevent occurrence of HIV-related complications, and save thousands of individuals from ever getting infected, thereby eliminating opportunities for further propagation of disease in the community. Second, empirical data demonstrate that individuals with unrecognized late-stage HIV come to emergency departments (EDs) at disproportionately higher rates than any other health care venue, and ED patients are highly receptive to agree to HIV screening in this setting. Third, the ever-increasing simplicity of the HIV testing process itself, through opt-out consent and availability of multiple point-of-care rapid assays, creates technically feasible opportunities for implementation of screening in EDs. Thus, one wonders why, as reported by Berg et al. in this issue of Academic Emergency Medicine, fewer than 20% of EDs report performing routine HIV screening. Two aspects of the study by Berg et al. deserve particular attention with regard to enhancing our understanding of evolving HIV screening efforts in U.S. EDs and highlight one key ongoing challenge. First, despite the far-reaching 2006 Centers for Disease Control and Prevention (CDC) guidelines recommending widespread HIV screening across health care settings, the overall rates of HIV screening in EDs reported in the study by Berg et al. remain low (survey conducted in 2009). While methodologic limitations with the survey exist and were appropriately cited by the authors, the rates of screening reported are fairly consistent with those from another large national survey conducted over the same time period. In that study, approximately 22% of EDs were reported to offer ‘‘systematic’’ HIV testing, defined as testing or screening organized at the departmental or institutional level, thereby closely approximating the survey query by Berg et al. that assessed availability of ‘‘routine HIV screening.’’ The second focuses on the factors included in the author’s multivariate analysis that concluded that ‘‘ED directors concern regarding the added costs of HIV preventative service’’ was negatively correlated with HIV screening program availability. This issue is particularly relevant, given the evolving vision within the Division of HIV ⁄ AIDS Prevention at the CDC to encourage EDs to move toward more self-sustained HIV screening programs [personal communication, National Alliance of State and Territorial AIDS Directors (NASTED) Meeting: HIV Testing in Hospital Emergency Departments: Collaborative Strategies for Implementation, Washington DC, April 9, 2010]. Since 2006, both indirect resource support and directed ear-marked funding have resulted in a dramatic rise in the number of EDs that report conducting any HIV testing, with more than 80% doing so as of 2009. Both extramural funding and peer-reviewed publications related to ED-based HIV testing show steady increases annually over the past decade, with annual original research and other publications rising from approximately 50 to over 200 per year (Haukoos, J; as presented at the Annual SAEM meeting in Chicago, June 2012). Still, as described by Berg et al. and others, the majority of U.S. EDs do not operate HIV screening programs, and 90% of those sites are financially supported by external research or program support, principally derived from federal, state, or local government sources. Compounding the challenge of dependency on external support is the lack of experience in seeking or attaining third-party reimbursement for HIV screening costs. Currently, costs of the HIV test kits used across U.S. EDs are principally provided ‘‘free of charge’’ by local or state health departments or federal agencies. Without these public health funds to support HIV testing programs, sustainability remains in doubt. Thus, concerns of the ED directors, as catalogued by Berg et al., seem appropriate. Burke et al. addressed obstacles to HIV testing and report that reimbursement for HIV testing performed in both fee-for-service and managed care insurance programs is critical to support sustainability of HIV testing program in EDs. Suggested interventions for the challenges of reimbursement included, ‘‘increasing provider reimbursement for HIV testing in fee-forservice programs, and reimbursing HIV testing above the capitated rate for managed care programs.’’ Although the Center for Medicare and Medicaid Services issued an advisory to all state Medicaid directors indicating that HIV screening is reimbursable, Medicaid reimbursement remains a state-by-state decision. Thus, it remains unclear in most locales whether either

Is Screening Women for Intimate Partner Violence in the Emergency Department Effective

TUDY SELECTION his systematic review included andomized controlled trials to valuate the effectiveness of ntimate partner violence screening r interventions. Diagnostic ccuracy studies reporting ensitivity, specificity, or other ccuracy measures of screening echniques were eligible; however, he authors included only research onducted in the United States or n similar populations, published in 003 or later. Screening referral ate studies, attitudinal studies, or tudies that lacked valid reference tandards or instruments not useful or intimate partner violence creening were excluded. Reported utcomes were reduced exposure o intimate partner violence, hysical or mental morbidity, or ortality from intimate partner iolence.

Can the San Francisco Syncope Rule predict short-term serious outcomes in patients presenting with syncope?

DATA SOURCES The authors performed a systematic electronic search of MEDLINE, EMBASE, Med-Pilot, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Register of Controlled Trials, ClinicalTrials.gov, and Web of Science from database inception through January 17, 2011. No language restriction was applied. Reference lists and bibliographies of review articles relating to risk stratification in syncope and UpToDate database entries relating to emergency department (ED) management of syncope were also searched.

Interprofessional Education and Collaboration: A Call to Action for Emergency Medicine

In the resident portfolio piece “Go Team!,” Drs. Bucher and Veysman shine a spotlight on the need for training in interprofessional education and collaborative practice. My fellow colleagues, we are being called to act. The time is now. Our institutions, our communities, our trainees, our nation, and most of all, our patients need us. “Why,” you ask? First, a challenge to the reader. Imagine a health professional separate from your own discipline. If you are a physician, imagine a nurse as an example. Now, describe to that person your understanding of his or her training and scope of practice, the values and ethics of his or her profession, and his or her education, to effectively communicate with your profession in the context of patient care. How well did you do? If only we could ask your hypothetical colleague! For the purposes of this commentary, I assume you were less than perfect. Now I ask you to reflect on a recent conflict between health professionals representing separate disciplines that you witnessed, caused, or resolved in your clinical setting. What was the root cause of that conflict? The answer . . . communication, lack of understanding of separate perspectives, lack of respect of the other’s opinion . . . or all of the above? Did this conflict have the potential to affect patient safety, patient satisfaction, and/or provider morale? These brief examples highlight our own lack of understanding of the other members of the health care team. Dr. Butcher, almost as if he knows many of our own experiences, emphasizes this beautifully when he writes: “When I started my residency, I did not realize just how vital, experienced, and capable our nurses are.” Colleagues, this phenomenon is prevalent, it is a function of our training, and it must change. Interprofessional education (IPE) occurs when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes. The core content of IPE and its methods for education lead to necessary knowledge, skills, and attitudes to produce a collaborative practice-ready workforce to address the health needs of the patients we serve. The health needs facing our nation are vast and include an aging population with increased disease complexity, widening health disparities, suboptimal health literacy, high prevalence of medical error despite a renewed focus on patient safety, and the yet-to-be-determined effects of the Affordable Care Act. With the exception of a few examples, our education and health care systems operate within separate profession-specific silos. We are educated separately, for the most part, yet are paradoxically expected to function efficiently as a team when we assemble together to diagnose, treat, and educate our patients. This fragmentation stifles our ability to truly reach the triple aim goal articulated by the Institute for Health care Improvement (IHI). They charge that the method to optimize our health care education and delivery system is to: 1) improve the care of the patient, 2) improve the health of the population, and 3) decrease the cost of care. How well do you think we can meet that goal and address the needs of our patients using our current fragmented system of education and health care delivery? I assert that emergency medicine is the specialty best prepared to lead this reform. Why? Our keen perspective represents an asset to the health and education reform in our country. We appreciate the direct effects of collaborative practice on patient outcomes when it succeeds and when it fails. We create solutions when resources are limited. We innovate when others are tradition-dependent. We appreciate the continuum of education from undergraduate medical education to practice. And we understand, use, and teach evidence-based methodologies. A recent systematic review on the effect of IPE on professional practice and health care outcomes found that IPE produced positive outcomes in the following areas: diabetes care, collaborative team behavior in operating rooms, management of care delivered in cases of domestic violence, emergency department culture and patient satisfaction, collaborative team behavior, and reduction of clinical error rates for emergency department teams. Based on the growing body of evidence to support IPE across all health disciplines, it is now a required accreditation standard for multiple health disciplines as well as our own emergency medicine milestones. Now that we know “why” this is critical for our specialty to engage in IPE, let us discuss “how.” In May 2011, the Interprofessional Education Collaborative (IPEC) released the “Core Competencies for Interprofessional Collaborative Practice.” This joint effort, sponsored by the national organizations for allopathic medicine, osteopathic medicine, nursing, dentistry, public health, and pharmacy, used best-practices methodology to establish four IPE competency domains: 1) roles

Can Intra-articular Lidocaine Supplant the Need for Procedural Sedation for Reduction of Acute Anterior Shoulder Dislocation?

DATA SOURCES The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 1), MEDLINE (1950 to March 2010), EMBASE (1980 to March 2010), Current Controlled Trials metaRegister of Clinical Trials (March 2010), and OpenSIGLE (System for Information on Grey Literature in Europe—March 2010). Additional studies were sought by searching review articles and textbooks, references cited in primary sources, and raw data from published trials (sought by personal communication).

Can Emergency Physicians Safely Increase the Proportion of Patients With Community-Acquired Pneumonia Who Are Treated in the Outpatient Setting?

DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment were performed independently by 2 investigators. The primary outcome was the proportion of patients treated as outpatients in the intervention groups compared with the control groups. Secondary outcomes were safety measures, including mortality and hospital readmission. A fixed-effects model was used to pool results, which were reported as odds ratios with 95% confidence intervals.

How accurately do pneumonia severity scores predict mortality in patients with community-acquired pneumonia?

Of 402 studies screened, 23 were included for analysis (N 22,753). The mortality rate was 7.4% for the pooled population. Sixteen studies included the Pneumonia Severity Index score, 12 the CURB-65 (Confusion, Uremia 19, Respiratory Rate 30, Blood Pressure 90 systolic or 60 diastolic, and Age 65), 10 the CRB-65, and 5 the CURB score. Sensitivity and specificity were calculated by dichotomizing each severity score (Pneumonia Severity Index score 3, CURB-65 score 2, CRB-65 or CURB score 1), with low scores indicating low risk for death. Quality assessment revealed s large potential for bias because learly described methods for measurng mortality were unavailable in 9 of he included studies and data about inerventions to treat pneumonia were ften lacking. I values for the reported esults ranged from 59% to 98%.