Stephen R. Pitts

National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity.

STUDY OBJECTIVE We evaluate recent trends in emergency department (ED) crowding and its potential causes by analyzing ED occupancy, a proxy measure for ED crowding. METHODS We analyzed data from the annual National Hospital Ambulatory Medical Care Surveys from 2001 to 2008. The surveys abstract patient records from a national sample of hospital EDs to generate nationally representative estimates of visits. We used time of ED arrival and length of ED visit to calculate mean and hourly ED occupancy. RESULTS During the 8-year study period, the number of ED visits increased by 1.9% per year (95% confidence interval 1.2% to 2.5%), a rate 60% faster than population growth. Mean occupancy increased even more rapidly, at 3.1% per year (95% confidence interval 2.3% to 3.8%), or 27% during the 8 study years. Among potential factors associated with crowding, the use of advanced imaging increased most, by 140%. But advanced imaging had a smaller effect on the occupancy trend than other more common throughput factors, such as the use of intravenous fluids and blood tests, the performance of any clinical procedure, and the mention of 2 or more medications. Of patient characteristics, Medicare payer status and the age group 45 to 64 years accounted for small disproportionate increases in occupancy. CONCLUSION Despite repeated calls for action, ED crowding is getting worse. Sociodemographic changes account for some of the increase, but practice intensity is the principal factor driving increasing occupancy levels. Although hospital admission generated longer ED stays than any other factor, it did not influence the steep trend in occupancy.

Emergency department hypertension and regression to the mean

STUDY OBJECTIVE To evaluate the importance of regression to the mean in the assessment of asymptomatic hypertension in the emergency department. METHODS This was an historical cohort study of patients in the adult ED of a large urban teaching hospital. THe main outcome was changed in diastolic blood pressure (DBP). Subjects were 195 consecutive hypertensive patients with two sets of vital signs. Patients with specified acute conditions potentially associated with abnormal blood pressure were excluded, as were patients given vasoactive medications. RESULTS A statistical formula was used to predict the average blood pressure for hypertensive patients, using the observed mean and standard deviation of an all-patient sample. Given a threshold of 90 mm Hg, the expected mean DBP for hypertensive patients was 102.7 mm Hg, compared with an observed value of 104.5 mm Hg. Given an observed correlation coefficient of .73 between first and second measurements, a formula for regression to the mean predicted a spontaneous blood pressure decline of 7.2 mn Hg. A mean decline if 11.6 mm Hg was observed. The decline of 4.4 mm Hg more than expected among asymptomatic hypertensives was similar to the spontaneous decline of 3.7 mm Hg observed in the all-patient sample. CONCLUSION Patients who present with asymptomatic hypertension in the ED on average experience a spontaneous decline in blood pressure after they arrive. Most of this effect can be explained by regression to the mean. A small amount of this drop may represent attenuation of an initial alerting reaction.

A Cross-sectional Study of Emergency Department Boarding Practices in the United States

OBJECTIVES The median emergency department (ED) boarding time for admitted patients has been a nationally reportable core measure that now also affects ED accreditation and reimbursement. However, no direct national probability samples of ED boarding data have been available to guide this policy until now. The authors studied new National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items to establish baseline values, to generate hypotheses for future research, and to help improve survey quality in the future. METHODS This was a cross-sectional, multistage, stratified annual analysis of EDs and ED visits from the National Hospital Ambulatory Medical Care Survey public use files from 2007 to 2010, a total of 139,502 visit records. These data represent the only national measure of ED boarding. The main outcome of interest was boarding duration for individual patient visits. Data analyses accounted for complex sampling design. RESULTS The national median boarding time was 79 minutes, with an interquartile range of 36 to 145 minutes. The prevalence of boarding for more than 2 hours among admitted patients was 32% (95% confidence interval [CI] = 30% to 35%). Average ED volume, occupancy, acuity, and hospital admission rates increased abruptly from the second to the third quartile of median boarding duration. The half of hospitals with the longest median boarding times accounted for 73% of ED visits and 79% of ED hospitalizations nationally. Thirty-nine percent of EDs (95% CI = 32% to 46%) reported never holding patients for more than 2 hours, but visit-level analysis at these EDs found that 21% of admissions did in fact stay in the ED over 2 hours. Only 19% of EDs (95% CI = 16% to 22%) used a strategy of moving admitted patients to alternative sites in the hospital during crowded times. CONCLUSIONS In this national survey, ED boarding of admitted patients disproportionately affects hospitals with higher ED volumes, which also see sicker patients who wait longer to be seen, but not hospitals with higher proportions of Medicaid or uninsured visits. This finding implies that, unlike other quality measures, there is a negative volume-outcome relationship for timely hospitalization from the ED.

Emergency Department Resource Use by Supervised Residents vs Attending Physicians Alone

IMPORTANCE Few studies have evaluated the common assumption that graduate medical education is associated with increased resource use. OBJECTIVE To compare resources used in supervised vs attending-only visits in a nationally representative sample of patient visits to US emergency departments (EDs). DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of the National Hospital Ambulatory Medical Care Survey (2010), a probability sample of US EDs and ED visits. EXPOSURES Supervised visits, defined as visits involving both resident and attending physicians. Three ED teaching types were defined by the proportion of sampled visits that were supervised visits: nonteaching ED, minor teaching ED (half or fewer supervised visits), and major teaching ED (more than half supervised visits). MAIN OUTCOMES AND MEASURES Association of supervised visits with hospital admission, advanced imaging (computed tomography, ultrasound, or magnetic resonance imaging), any blood test, and ED length of stay, adjusted for visit acuity, demographic characteristics, payer type, and geographic region. RESULTS Of 29,182 ED visits to the 336 nonpediatric EDs in the sample, 3374 visits were supervised visits. Compared with the 25,808 attending-only visits, supervised visits were significantly associated with more frequent hospital admission (21% vs 14%; adjusted odds ratio [aOR], 1.42; 95% CI, 1.09-1.85), advanced imaging (28% vs 21%; aOR, 1.27; 95% CI, 1.06-1.51), and a longer median ED stay (226 vs 153 minutes; adjusted geometric mean ratio, 1.32; 95% CI, 1.19-1.45), but not with blood testing (53% vs 45%; aOR, 1.18; 95% CI, 0.96-1.46). Of visits to the sample of 121 minor teaching EDs, a weighted estimate of 9% were supervised visits, compared with 82% of visits to the 34 major teaching EDs. Supervised visits in major teaching EDs compared with attending-only visits were not associated with hospital admission (aOR, 1.15; 95% CI, 0.83-1.58), advanced imaging (aOR, 1.21; 95% CI, 0.96-1.53), or any blood test (aOR, 1.02; 95% CI, 0.79-1.33), but had longer ED stays (adjusted geometric mean ratio, 1.32; 95% CI, 1.14-1.53). CONCLUSIONS AND RELEVANCE In a sample of US EDs, supervised visits were associated with a greater likelihood of hospital admission and use of advanced imaging and with longer ED stays. Whether these associations are different in EDs in which more than half of visits are seen by residents requires further investigation.

Supraclavicular subclavian vein catheterization: Modified landmarks for needle insertion

STUDY OBJECTIVE Identification of reliable landmarks for supraclavicular subclavian vein catheterization that requires no patient manipulation and is easily located. PATIENT POPULATION Thirty-five fresh human cadavers. DESIGN AND METHODS Descriptive study of percutaneous guide wire placement into the subclavian vein using as a new landmark the junction of middle and medial thirds of the clavicle. The position of the guide wire was confirmed by palpation of the wire in the subclavian vein during autopsy. RESULTS Successful placement of a guide wire into the subclavian vein occurred in 33 of 35 cadavers (94%) using the new landmark. CONCLUSION The new landmark for supraclavicular subclavian vein catheterization is reliable, requires no patient manipulation, and is as successful as the standard landmarks.

Tricycle injuries presenting to US emergency departments, 2012-2013

OBJECTIVE: To investigate the characteristics of tricycle-related injuries in children presenting to US emergency departments (EDs). METHODS: Data regarding tricycle injuries in children younger than 18 years of age were obtained from the National Electronic Injury Surveillance System for calendar years 2012 and 2013. Data included body regions injured, ED disposition, and demographics. RESULTS: There were an estimated 9340 tricycle-related injuries treated in US EDs from 2012 to 2013. The average age was 3 years. Children 2 years of age had the highest frequency of injuries. Boys accounted for 63.6% of all injuries. Children 1 to 2 years of age represented 51.9% of all injuries. Lacerations were the most common type of injury. Internal organ damage was the most common type of injury in 3- and 5-year-olds. Contusions were the most common type of injury in 1- and 7-year-olds. The head was the most commonly injured region of the body and the most common region to endure internal damage. The elbows were the most commonly fractured body part. The upper extremity was more frequently fractured than the lower extremity. Approximately 2.4% of all injured children were admitted to the hospital. CONCLUSIONS: The upper extremity of children, particularly the elbow, was more frequently fractured than the lower extremity. The head was the most common body part to endure internal damage. By elucidating the characteristics of tricycle-related injuries, preventive measures can be implemented to decrease the incidence of tricycle-related injuries and ED visits.

The feasibility of Rubidium-82 positron emission tomography stress testing in low-risk chest pain protocol patients.

OBJECTIVE To evaluate the feasibility of dipyridamole-induced reversible ischemia on myocardial perfusion positron emission tomography (PET) imaging using Rubidium-82 (Rb-82 PET) to predict the presence of acute coronary syndrome (ACS) in emergency department (ED) chest pain patients at low risk who were admitted to an observation unit. METHODS Retrospective cross-sectional study of electronic medical records after computerized record retrieval. We matched all ED chest pain visits to a database of all scans read by cardiology between January 1, 2004 and January 1, 2006. A PET scan was performed at the ED physicians discretion after a negative observation unit workup, including serial cardiac biomarkers and ECGs. Data were collected on a standardized abstraction instrument. RESULTS There were 7,691 ED visits for chest pain. Among these patients, 1177 had an Rb-82 PET. Fifty four (4.6%) of these patients had an abnormal or probably abnormal scan. Of these, 28 had catheter-proven significant coronary disease, requiring either revascularization or intensive medical management; 22 patients had ACS by clinical assessment but did not undergo catheterization. Four had no coronary artery disease on catheterization. CONCLUSION In a low-risk chest pain population, cardiac PET imaging had true-positive cardiac catheterization rates which were comparable to prior studies of SPECT sestimibi imaging and coronary CTA imaging. With the rapid dissemination of PET technology, and superior performance compared to current imaging methods, myocardial perfusion PET is a feasible alternative to traditional provocative testing in an ED observation unit.

Prediction of Emergency Department Hospital Admission Based on Natural Language Processing and Neural Networks

OBJECTIVE To describe and compare logistic regression and neural network modeling strategies to predict hospital admission or transfer following initial presentation to Emergency Department (ED) triage with and without the addition of natural language processing elements. METHODS Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a cross-sectional probability sample of United States EDs from 2012 and 2013 survey years, we developed several predictive models with the outcome being admission to the hospital or transfer vs. discharge home. We included patient characteristics immediately available after the patient has presented to the ED and undergone a triage process. We used this information to construct logistic regression (LR) and multilayer neural network models (MLNN) which included natural language processing (NLP) and principal component analysis from the patients reason for visit. Ten-fold cross validation was used to test the predictive capacity of each model and receiver operating curves (AUC) were then calculated for each model. RESULTS Of the 47,200 ED visits from 642 hospitals, 6,335 (13.42%) resulted in hospital admission (or transfer). A total of 48 principal components were extracted by NLP from the reason for visit fields, which explained 75% of the overall variance for hospitalization. In the model including only structured variables, the AUC was 0.824 (95% CI 0.818-0.830) for logistic regression and 0.823 (95% CI 0.817-0.829) for MLNN. Models including only free-text information generated AUC of 0.742 (95% CI 0.731- 0.753) for logistic regression and 0.753 (95% CI 0.742-0.764) for MLNN. When both structured variables and free text variables were included, the AUC reached 0.846 (95% CI 0.839-0.853) for logistic regression and 0.844 (95% CI 0.836-0.852) for MLNN. CONCLUSIONS The predictive accuracy of hospital admission or transfer for patients who presented to ED triage overall was good, and was improved with the inclusion of free text data from a patients reason for visit regardless of modeling approach. Natural language processing and neural networks that incorporate patient-reported outcome free text may increase predictive accuracy for hospital admission.

Neither ondansetron nor metoclopramide reduced nausea and vomiting in the emergency department

Question In adults in the emergency department (ED) with undifferentiated nausea and vomiting, what are the relative efficacies of ondansetron and metoclopramide? Methods Design Randomized placebo-controlled trial. Australian Clinical Trials Registry ACTRN 12609000549224. Allocation {Concealed}*. Blinding Blinded (patients, clinicians, {data collectors, and outcome assessors}*). Follow-up period Median 35 minutes. Setting 2 EDs in Australia. Patients 270 adults 18 years of age (median age 42 y, 66% women) who presented to the ED with nausea or vomiting and had IV antiemetic medication recommended by the attending physician. Exclusion criteria included use of antiemetic medication in the past 8 hours or IV fluids during the ED episode of care, hemodynamic instability or primary diagnosis requiring time-critical treatment, pregnancy or lactation, nausea or vomiting related to motion or vertigo, or current treatment with chemotherapy or radiotherapy. Intervention IV metoclopramide, 20 mg (n =88 included in analyses), ondansetron, 4 mg (n =87 included in analyses), or placebo (n =83 included in analyses). Outcomes Change in nausea severity measured on a 100-mm visual analogue scale (VAS). Secondary outcomes included change in nausea severity measured on a numeric scale (ranging from 0 [no nausea] to 10 [worst nausea imaginable]) and by an adjectival scale (a lot less,a little less,the same,a little more, and a lot more), change in the number of self-reported vomiting episodes, and use of rescue medication. 80 patients per group were needed to detect a VAS score reduction 30 mm ( =0.05). Patient follow-up 96% (modified intention-to-treat analysis of patients with both baseline and follow-up nausea VAS severity measurements). Main results Ondansetron, metoclopramide, and placebo did not differ for reduction in nausea severity measured by VAS (Table), numeric scale (median reduction 2 vs 2 vs 1), or adjectival descriptions (72% vs 78% vs 64% indicated symptoms improved a lot or a little); or for reduction in number of vomiting episodes (median reduction 0 vs 0 vs 0). The metoclopramide group used less rescue medication than the placebo group (relative risk reduction [RRR] 51%, 95% CI 16 to 71) and the ondansetron group (RRR 48%, CI 12 to 70). Conclusion In adults presenting to the emergency department with undifferentiated nausea and vomiting, neither ondansetron nor metoclopramide reduced severity of nausea. Reduction in nausea severity with ondansetron vs metoclopramide vs placebo for undifferentiated nausea and vomiting in the emergency department Mean VAS score reduction (mm) (95% CI) at a median 35 min Ondansetron Metoclopramide Placebo 27 (22 to 33) 28 (22 to 34) 23 (16 to 30) VAS = visual analogue scale; CI defined in Glossary. VAS was a 100-mm scale; greater reduction in score equals greater reduction in nausea. Commentary The trial by Egerton-Warburton and colleagues found no difference between metoclopramide and ondansetron for nausea in the ED and, surprisingly, no difference between either drug and placebo. The study was rigorously compliant with the Consolidated Standards of Reporting Trials guidelines and was powered to detect a clinically significant difference in VAS score reductions. Should this alter our practice in the ED? It would be a great leap to base such a major practice change on the results. First, these antiemetics have a benefit in selected patients with severe nausea from single causes, such as cancer chemotherapy (1), unlike the grab-bag of causes in the ED. Second, it is possible to move the goal posts after a study. Unsavory examples of this would be studies that report favorable subgroups that had not been chosen a priori (2). Another way to hedge your bets is to look beyond the negative primary outcome at secondary endpoints. In this case (Table 3 of the article), neither antiemetic had persuasive evidence of benefit over placebo, except for 1 of the 5 outcomesuse of rescue medication (defined as a single dose of ondansetron, 8 mg, if no response to the unidentified study drug). This secondary outcome was more favorable for metoclopramide (but not ondansetron) over placebo, with an NNT of 6 (CI 4 to 21). Of course, with multiple hypotheses it would be good form to reduce the P value threshold or, equivalently, increase confidence interval coverage. This post hoc emphasis on rescue drugs does have a justification in the critical appraisal armamentarium: Equality of treatment after randomization should be reported. The lower use of rescue drugs with metoclopramide is indirect evidence of benefit, like increased use of steroids in the placebo groups of bronchodilator trials for asthma (3).

Homelessness and Emergency Medicine: A Review of the Literature

OBJECTIVES We aimed to synthesize the available evidence on the demographics, prevalence, clinical characteristics, and evidence-based management of homeless persons in the emergency department (ED). Where appropriate, we highlight knowledge gaps and suggest directions for future research. METHODS We conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990, and December 31, 2016. We supplemented this search by cross-referencing bibliographies of the retrieved publications. Peer-reviewed studies written in English and conducted in the United States that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature. RESULTS Twenty-eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) prevalence and sociodemographic characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3) clinical characteristics of homeless ED visits, and 4) medical education and evidence-based management of homeless ED patients. CONCLUSION Homelessness may be underrecognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease-oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence-based treatment strategies in caring for this vulnerable population.