Robert W. Derlet

Overcrowding in the nation's emergency departments: complex causes and disturbing effects

Ten years ago, serious overcrowding in emergency departments became a national issue. Although temporary improvement of the problem occurred, the issue of ED overcrowding has now resurfaced and threatens to become worse. Overcrowding is caused by a complex web of interrelated issues described in this article. ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatisfaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence. Solving the problem of overcrowding will not only require a major financial commitment from the federal government and local hospitals, but will also require a cooperation from managed care. Unless the problem is solved in the near future, the general public may no longer be able to rely on EDs for quality and timely emergency care, placing the people of this country at risk.

A decision rule for identifying children at low risk for brain injuries after blunt head trauma

STUDY OBJECTIVE Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries. METHODS We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules. RESULTS Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children < or =2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications. CONCLUSION Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children < or =2 years of age), and headache.

3% NaCl and 7.5% NaCl/dextran 70 in the resuscitation of severely injured patients.

Cardiovascular resuscitation of the severely injured patient in the field remains unsatisfactory because large volumes of intravenous fluid are needed to keep up with ongoing blood losses and because only small volumes of fluid can be given. In the first study reported here, small volumes (less than or equal to 12 mL/kg) of 3% NaCl were given to patients who were having surgery for severe injuries. The 3% NaCl restored blood pressure, pH, and urine output with approximately one half of the cumulative fluid requirement of patients who received isotonic fluids (p less than 0.05). In a second study, 7.5% NaCl/dextran 70, 250 mL, was given in a prospective, randomized, and double-blinded trial to injured patients in the field. Blood pressure in the hypertonic/hyperoncotic group increased 49 mmHg during transport (p less than 0.005); blood pressure in patients given lactated Ringers solution increased 19 mmHg (NS). Survival favored the hypertonic/hyperoncotic group. The 7.5% NaCl/dextran 70 solution appears particularly promising for treatment of injured patients in the field.

Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients

Our study objective was to determine whether simple clinical criteria can be used to safely reduce the number of patients who require cranial computed tomography (CT) scan after sustaining minor head trauma. Awake patients (Glascow Coma Scale = 15) who presented to the emergency department with acute head injury associated with a loss of consciousness were evaluated for clinical predictors of head injury prior to CT scan. The studied risk factors included severe headache, nausea, vomiting, and depressed skull fracture on physical examination. Patients with no risk factors present were compared with patients with one or more risk factors with respect to abnormal CT rate and rate of operative intervention for head injury. Of the 2143 patients entered into the study, 1302 (61%) had no risk factor for head injury, whereas 841 (39%) had one or more risk factors present. A total of 138 (6.4%) of those studied had an abnormal CT scan. This number included 3.7% of those patients with no risk factors vs. 11% in patients with one or more risk factors. The CT scan abnormalities in the no-risk-factor group were not clinically significant. All 5 patients who required operative intervention had at least one of the risk factors present. The use of four simple clinical criteria in minor head trauma patients would allow a 61% reduction in the number of head CT scans performed and still identify all patients who require neurosurgical intervention and the majority of patients with an abnormal CT scan. This method could lead to a large savings in patient charges nationwide. Further studies may be helpful in confirming these findings.

Prospective Identification and Triage of Nonemergency Patients Out of an Emergency Department: A 5-Year Study

STUDY OBJECTIVE To determine whether nonemergency patients can be prospectively identified by triage nurses and safely triaged out of the emergency department without treatment. METHODS All adult patients (16 years or older) who presented to a university ED were provided an evaluation by a triage nurse. For a patients case to be defined as nonemergency, four criteria were required: vital signs within a specific range, presence of 1 of 50 potentially nonemergent chief complaints, absence of key indicators found on screening examination, and absence of chest pain, abdominal pain, any severe pain, and inability to walk. Between July 1988 and July 1993, patients who satisfied these criteria were defined as nonemergency, refused care in the ED, and triaged out of the ED. Patients were referred to off-site clinics. The clinics had agreed to see patients in advance of the study, and the referral lists were frequently updated. Outcome data were obtained by telephone surveys to both triaged individuals and other health care providers. RESULTS In this 5-year study, 176,074 adults presented to the ambulatory triage area in the ED, and 31,165 (18%) were defined as nonemergency, were not treated, and were referred elsewhere. Letters and telephone calls to all referral clinics, eight local EDs, and the coroners office identified no instances of gross mistriage and only a small number of insignificant adverse outcomes. Telephone follow-up to individuals triaged away was successful in 34% of calls and showed that 39% of persons received care elsewhere on the same day, 35% received care within 3 days, and 26% decided not to seek medical care. A group of 1.0% sought care at other hospital EDs for minor complaints. CONCLUSION A subset of patients with nonemergency problems can be prospectively identified and triaged out of the ED without significant adverse outcomes provided there is community support for follow-up care.

Chemical restraint for the agitated patient in the emergency department : Lorazepam versus droperidol

Patients presenting to the emergency department with acute agitation frequently require physical and chemical restraint. To determine the efficacy of lorazepam vs. droperidol, we conducted a prospective, randomized study of violently agitated patients requiring chemical restraint. Patients were randomized to receive either lorazepam or droperidol i.v. A six-point sedation scale was used. Sedation scores were recorded at time 0, 5, 10, 15, 30, and 60 min. Vital signs were compared at time 0 and at 60 min. Repeat dosages of each drug could be given at 30 min. Toxicology screen, ethanol and creatinine phosphokinase levels were obtained. A total of 202 patients were evaluated. One hundred patients received lorazepam and 102 patients received droperidol. Agitation was attributed to methamphetamine toxicity in 146 patients (72%), cocaine toxicity in 28 (14%), psychiatric illness in 20 (10%), and ethanol withdrawal in 8 (4%). Ethanol intoxication was present in 98 patients (49%). Both drugs had similar sedation profiles at 5 min. Patients receiving droperidol had significantly lower sedation scores at times 10, 15, 30, and 60 than lorazepam. More repeat doses of lorazepam were given (40) than droperidol (8) at 30 min. We conclude that droperidol produces a more rapid and better sedation than lorazepam at the doses used in this study in agitated patients requiring chemical restraint. Lorazepam is more likely to require repeat dosing than droperidol. Methamphetamine toxicity was present in the majority of patients in this study.

Amphetamine toxicity: Experience with 127 cases

We present a retrospective study of 127 cases of amphetamine toxicity in an emergency department (ED). The most common presenting symptoms seen were agitation, hallucinations, suicidal behavior, and chest pain. Toxicologic analysis showed amphetamines are generally not mixed with other stimulants. The vast majority of patients did not require pharmacologic treatment in the ED. Thirteen patients (10%) required admission to the hospital. Toxic medical effects of amphetamine-related compounds seen in our patients are discussed.

Superiority of activated charcoal alone compared with ipecac and activated charcoal in the treatment of acute toxic ingestions

A prospective, randomized clinical trial compared the clinical effectiveness of syrup of ipecac and activated charcoal to that of activated charcoal alone in the treatment of acute toxic ingestions. Two hundred adult patients with mild to moderate oral overdoses were entered into the trial. Patients receiving only activated charcoal were discharged from the emergency department in significantly (P less than or equal to .05) less time than those receiving both syrup of ipecac and activated charcoal (6.0 +/- 0.3 vs 6.8 +/- 0.2 hours, respectively). The percentage of patients requiring nonpsychiatric hospitalizations was not significantly different between the two groups (11.2% vs 14.0%, respectively). For the hospitalized patients, the length of time spent in the ICU and in the hospital was not statistically different between the two groups. A complication rate of 5.4% was found with the ipecac and activated charcoal treatment compared with a 0.9% complication rate in the activated charcoal group (P less than or equal to .05). Three episodes of aspiration pneumonitis occurred after administration of ipecac and activated charcoal, while no episodes of aspiration were noted after treatment with only activated charcoal. Together, these data are consistent with the recommendation that ED treatment with activated charcoal alone be the gastrointestinal decontamination procedure of choice for the routine mildly-to-moderately orally poisoned adult patient.

Refusing Care to Patients Who Present to an Emergency Department

In July 1988, our emergency department adopted a policy of refusing to treat patients in the ED if they failed to have what was considered an emergency condition. Screening examinations were performed by triage nurses to determine whether patients were eligible to be seen in the ED. Patients whose vital signs fell within specific categories and who had one of 50 minor chief complaints were refused care in the ED and referred to off-site clinics. The referral of these patients out of the ED after a screening examination falls within the scope of legislation governing ED care and transfer (federal COBRA, Cal SB-12, and Title 22) as determined by the University of California legal counsel. In the first six months of this new triage system, 4,186 patients were referred from the ED; this represented 19% of total ambulatory patients who presented to the triage area. Of the 4,186 patients refused care, 84% were referred to off-site nonuniversity clinics, and 15% were referred to a university-affiliated faculty-staffed clinic. Follow-up letters and telephone calls to their clinics identified no patients who needed retriage to an ED, and only 54 patients (1.3%) complained about their referral out of the ED. Only 42 patients returned to the ED within 48 hours of initial triage, and none had a deterioration of their condition. In conclusion, a selective triage system may be used to effectively decompress an ED, although further study is needed to identify potential rare adverse outcomes.

Emergency department presentation of cocaine intoxication.

All patients who presented to the emergency department as a result of cocaine intoxication during a one-year period were reviewed retrospectively. One hundred thirty-seven cases were reviewed. Patients presented with a wide variety of chief complaints including altered mental status (40%), chest pain (21%), syncope (19%), suicide attempt (13%), palpitations (12%), and seizures (12%), as well as numerous other complaints. There was only one death. Few patients required treatment within the ED; sixteen required hospitalization.