Robert Shesser

Routine HIV Screening in the Emergency Department Using the New US Centers for Disease Control and Prevention Guidelines Results From a High-Prevalence Area

Background:In 2006, the US Centers for Disease Control and Prevention (CDC) released new recommendations for routine HIV testing. Among these were recommendations that emergency departments (EDs) offer routine opt-out HIV screening to their patients. We established a screening program implementing these recommendations at an urban university hospital ED in Washington, DC. We report the results of this program. Methods:During a 3-month period, ED patients being treated for a wide range of conditions were approached by trained HIV screeners and offered point-of-care rapid HIV testing. Patients with positive results were referred to hospital or community resources for confirmatory testing and treatment. Results:During the program period, 14,986 patients were treated in the ED and 4151 (27.6%) were offered HIV screening. The mean patient age was 37.5 years; 48.5% were black, 39.0% were non-Hispanic white, 4.1% were Hispanic, 1.7% were Asian, and 6.7% responded as being other race. A total of 56.1% were female, and most lived within the Washington, DC metropolitan area. Of the patients offered HIV screening, 2476 (59.7%) accepted the test. Of the 26 patients with a preliminary positive screen, 13 were lost to follow-up, 9 were confirmed positive by Western blot, and 4 were confirmed negative by Western blot. Eight of the 9 patients with confirmed HIV infection were successfully linked to follow-up care. Conclusions:The implementation of the CDC recommendations establishing routine opt-out HIV screening programs in EDs is feasible. Further efforts to establish routine ED HIV testing are therefore warranted.

Pneumomediastinum and pneumothorax after inhaling alkaloidal cocaine

Barotrauma related to drug ingestion is an uncommon entity. We present the cases of two young women who sustained barotrauma associated with the use of alkaloidal cocaine.

Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients.

STUDY OBJECTIVE We examine the central venous catheter placement rate during the implementation of an ultrasound-guided peripheral intravenous access program. METHODS We conducted a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED. RESULTS During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients. CONCLUSION The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.

Double-Blind, Multicenter Trial to Compare the Efficacy of Intramuscular Dihydroergotamine Plus Hydroxyzine Versus Intramuscular Meperidine Plus Hydroxyzine for the Emergency Department Treatment of Acute Migraine Headache☆☆☆★★★

STUDY OBJECTIVE To evaluate intramuscular dihydroergotamine in direct comparison with opioid analgesia in the treatment of acute migraine headache. METHODS This was a prospective, multicenter, double-blind trial performed in the emergency departments of 11 general hospitals in the United States. One hundred seventy-one patients between the ages of 18 and 60 years who presented to the ED with acute migraine headache were enrolled. Patients were randomly assigned to receive either 1 mg dihydroergotamine (DHE) or 1.5 mg/kg meperidine (MEP) by intramuscular injection. The anti-nauseant hydroxyzine (H) was coadministered in both treatment groups. RESULTS One hundred fifty-six patients were evaluable. Treatment groups were comparable in sample size, demographics, and baseline measurements of headache pain. Reduction of headache pain as measured on a 100-mm visual analog scale was 41+/-33 mm (53.5% reduction) for the DHE group, and 45+/-30 mm (55.7% reduction) for the MEP group at 60 minutes after treatment (difference=2.2%; 95% confidence interval [CI] -10%, 14.5%; P=.81). Reduction in the severity of nausea and improvement in functional ability were similar between treatment groups. Central nervous system adverse events were less common in the DHE group (DHE 23.5% versus MEP 37.6%, difference-14.1%: 95% CI -28%, 0%). In particular, dizziness was reported less commonly with DHE than MEP (2% versus 15%, difference=-13%: 95% CI -21%, -5%). CONCLUSION In this prospective, double-blind trial of a convenience sample of ED patients randomly assigned to one of two treatment regimens, DHE and MEP were comparable therapies for acute migraine. The use of DHE avoids several problems associated with opioid analgesia, including dizziness.

Surveillance of construction worker injuries through an urban emergency department

To learn more about the causes of nonfatal construction worker injuries, and to identify injury cases for further work-site investigations or prevention programs, an emergency department-based surveillance program was established. Construction workers with work-related injuries or illnesses were identified by reviewing the medical records of all patients treated at the George Washington University Emergency Department between November 1, 1990 and November 31, 1992. Information regarding the worker, the injury, and the injury circumstances were abstracted from medical records. Information was obtained on 592 injured construction workers from numerous trades. Lacerations were the most commonly treated injuries among these workers, followed by strains and sprains, contusions, and eye injuries. Injuries were most commonly caused by sharp objects (n = 155, 26%), falls (n = 106, 18%), and falling objects (n = 70, 12%). Thirty-five percent of injuries were to the hands, wrists, or fingers. Among the twenty-eight injuries severe enough to require hospital admission, eighteen (64%) were caused by falls. Laborers and Hispanic workers were overrepresented among these severe cases. Emergency Department records were a useful surveillance tool for the initial identification and description of work-related injuries. Although E codes were not that useful for formulating prevention strategies, detailed review of injury circumstances from Emergency Department records was valuable and has helped to establish priorities for prevention activities.

Safety of immediate treadmill testing in selected emergency department patients with chest pain: A preliminary report

To determine the feasibility and safety of an immediate, symptom-limited, treadmill test on selected emergency department (ED) patients, a convenience sample of 28 patients underwent an exercise treadmill test (ETT) within the first several hours after hospital arrival using the modified Bruce protocol. Patients were included in the study if they presented with otherwise unexplained chest pain consistent with (but not characteristic for) angina pectoris and had a normal electrocardiogram. A negative ETT was seen in 23 of 28 patients, and five of 28 patients had a positive ETT. No patients had serial enzyme or electrocardiogram evolution suggestive of myocardial ischemia, and all patients with a negative ETT were discharged after a full inpatient evaluation designed to rule out unstable coronary disease. At a mean follow-up period of 6.1 months there has been no cardiac morbidity or mortality in the patients with negative ETTs. It was concluded that early ETTS of selected ED patients with chest pain is safe, and an exercise test administered during the ED visit which is negative can preclude unnecessary hospitalization.

The effectiveness of an organized emergency department follow-up system

Half the patients discharged home from our emergency department with the diagnoses of acute infection, cervicolumbar strain, bronchospasm, allergic reaction, headache, syncope, vaginal hemorrhage, and undiagnosed chest/abdominal pain were randomly assigned to receive a follow-up telephone call two to three days after their visit. Patients in the follow-up call group were telephoned by an ED nurse who questioned them about changes in their clinical status and clarified the aftercare and referral instructions received during the ED visit. Seven days after the visit, a questionnaire that rated patient satisfaction about six aspects of the ED visit was sent to those patients who had been contacted successfully (study group), and to a diagnosis-matched group of patients (control) who did not receive a follow-up call. A nurse was able to reach 144 of the 297 patients assigned to the study group. Significant referral and aftercare interventions were made in 53 (37%) cases including three patients who were instructed to return to the ED. Questionnaires were returned by 83 of 144 (49%) of the study group and by 94 of 262 (35%) of the control group. Male study group patients consistently rated five of six aspects of their visit higher than did the male controls. No difference was observed in questionnaire ratings between the female study and control groups. We conclude that male patients reached by a follow-up telephone call have a more positive perception of their ED visit. A follow-up call also can be useful for reinforcing aftercare instructions, follow-up referrals, and problem-patient identification.

Emergency Department Physician-Level and Hospital-Level Variation in Admission Rates

STUDY OBJECTIVE We explore the variation in physician- and hospital-level admission rates in a group of emergency physicians in a single health system. METHODS This was a cross-sectional study that used retrospective data during various periods (2005 to 2010) to determine the variation in admission rates among emergency physicians from 3 emergency departments (EDs) within the same health system. Patients who left without being seen or left against medical advice, patients treated in fast-track departments, patients with primary psychiatric complaints, and those younger than 18 years were excluded, as were physicians with fewer than 500 ED encounters during the study period. Emergency physician-level and hospital-level admission rates were estimated with hierarchic logistic regression, which adjusted for patient age, sex, race, chief complaint, arrival mode, and arrival day and time. RESULTS A total of 389,120 ED visits were included in the analysis, and patients were treated by 89 attending emergency physicians. After adjusting for patient and clinical characteristics, the hospital-level admission rate varied from 27% to 41%. At the physician level, admission rates varied from 21% to 49%. CONCLUSION There was 2.3-fold variation in emergency physician adjusted admission rates and 1.7-fold variation at the hospital level. In the new era of cost containment, wide variation in this common, costly decision requires further exploration.

The chest pain emergency department and the outpatient chest pain evaluation center: revolution or evolution?

STUDY OBJECTIVE To define the chest pain emergency department and the outpatient chest pain evaluation center, and to critically analyze the costs and benefits of modifying or replacing the current system of hospital-based evaluation of chest pain patients with these new systems. DATA SOURCES Peer-reviewed articles, published letters, book chapters, national health statistics, and personal communications were used. Sources were limited to those describing experiences in the United States. STUDY SELECTION Relevant sources from the United States were reviewed. DATA SYNTHESIS The widespread adoption of the chest pain ED as currently configured would result in increased health care expenditures of between

Methemoglobinemia from isobutyl nitrite preparations

389 million and