William E. Baker

Sonographic diagnosis of pneumothorax.

Lung sonography has rapidly emerged as a reliable technique in the evaluation of various thoracic diseases. One important, well-established application is the diagnosis of a pneumothorax. Prompt and accurate diagnosis of a pneumothorax in the management of a critical patient can prevent the progression into a life-threatening situation. Sonographic signs, including ‘lung sliding’, ‘B-lines’ or ‘comet tail artifacts’, ‘A-lines’, and ‘the lung point sign’ can help in the diagnosis of a pneumothorax. Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for the detection of a pneumothorax. Small occult pneumothoraces may be missed on CXR during a busy trauma scenario, and CXR may not always be feasible in critically ill patients. Computed tomography, the gold standard for the detection of pneumothorax, requires patients to be transported out of the clinical area, compromising their hemodynamic stability and delaying the diagnosis. As ultrasound machines have become more portable and easier to use, lung sonography now allows a rapid evaluation of an unstable patient, at the bedside. These advantages combined with the low cost and ease of use, have allowed thoracic sonography to become a useful modality in many clinical settings.

The Effect of an Ambulance Diversion Ban on Emergency Department Length of Stay and Ambulance Turnaround Time

STUDY OBJECTIVEnMassachusetts became the first state in the nation to ban ambulance diversion in 2009. It was feared that the diversion ban would lead to increased emergency department (ED) crowding and ambulance turnaround time. We seek to characterize the effect of a statewide ambulance diversion ban on ED length of stay and ambulance turnaround time at Boston-area EDs.nnnMETHODSnWe conducted a retrospective, pre-post observational analysis of 9 Boston-area hospital EDs before and after the ban. We used ED length of stay as a proxy for ED crowding. We compared hospitals individually and in aggregate to determine any changes in ED length of stay for admitted and discharged patients, ED volume, and turnaround time.nnnRESULTSnNo ED experienced an increase in ED length of stay for admitted or discharged patients or ambulance turnaround time despite an increase in volume for several EDs. There was an overall 3.6% increase in ED volume in our sample, a 10.4-minute decrease in length of stay for admitted patients, and a 2.2-minute decrease in turnaround time. When we compared high- and low-diverting EDs separately, neither saw an increase in length of stay, and both saw a decrease in turnaround time.nnnCONCLUSIONnAfter the first statewide ambulance diversion ban, there was no increase in ED length of stay or ambulance turnaround time at 9 Boston-area EDs. Several hospitals actually experienced improvements in these outcome measures. Our results suggest that the ban did not worsen ED crowding or ambulance availability at Boston-area hospitals.

Evaluation of physician competency and clinical performance in emergency medicine.

This article (1) provides the background history of assessing health care quality; (2) presents an overview of current interest and importance of measuring physician competency and performance, including requirements related to certifying bodies and those integral to pay-for-performance programs; (3) describes some of the current methods of evaluating the practice performance of emergency physicians, including peer review and use of health care quality measures; and (4) discusses the state of the literature as it pertains to health care quality and individual emergency physician performance.

Clinician-performed ultrasound diagnosis of ruptured interstitial pregnancy.

An interstitial pregnancy is a rare type of ectopic pregnancy located within the proximal portion of the fallopian tube in the muscular wall of the uterus. They are more likely to result in significant or fatal hemorrhage because of the increased vascularity. Diagnosis of interstitial pregnancy is challenging but critical to facilitate prompt and appropriate intervention. Ultrasound performed by an emergency physician is commonly used to assess early pregnancy, but little has been published in the emergency medicine literature regarding its use in assessing for presence of interstitial pregnancy. We describe a case of a ruptured interstitial pregnancy diagnosed by emergency ultrasonography in the emergency department and review the literature regarding the sonographic findings of interstitial pregnancies.

Geographic Variation in Use of Ambulance Transport to the Emergency Department

Study objective: Evidence on variability in emergency medical services use is limited. We obtain national evidence on geographic variation in the use of ambulance transport to the emergency department (ED) among Medicare enrollees and assess the role of health status, socioeconomic status, and provider availability. Methods: We used 2010 Medicare claims data for a random sample of 999,999 enrollees aged 66 years and older, and identified ambulance transport and ED use. The main outcome measures were number of ambulance transports to the ED per 100 person‐years (ambulance transport rate) and proportion (percentage) of ED visits by ambulance transport by hospital referral regions. Results: The national ambulance transport rate was 22.2 and the overall proportion of ED visits by ambulance was 36.7%. Relative to hospital referral regions in the lowest rate quartile, those in the highest quartile had a 75% higher ambulance transport rate (incidence rate ratio [IRR] 1.75; 95% confidence interval [CI] 1.69 to 1.81) and a 15.5% higher proportion of ED visits by ambulance (IRR 1.155; 95% CI 1.146 to 1.164). Adjusting for health status, socioeconomic status, and provider availability reduced quartile 1 versus quartile 4 difference in ambulance transport rate by 43% (IRR 1.43; 95% CI 1.38 to 1.48) and proportion of ED visits by ambulance by 7% (IRR 1.145; 95% CI 1.135 to 1.155). Among the 3 covariate domains, health status was associated with the largest variability in ambulance transport rate (30.1%), followed by socioeconomic status (12.8%) and provider availability (2.9%). Conclusion: Geographic variability in ambulance use is large and associated with variation in patient health status and socioeconomic status.

OPEN ACCESS TO DIABETES CENTER FROM THE EMERGENCY DEPARTMENT REDUCES HOSPITALIZATIONS IN THE SUSEQUENT YEAR

OBJECTIVEnPatients who present to the emergency department (ED) for diabetes without hyperglycemic crisis are at risk of unnecessary hospitalizations and poor outcomes. To address this, the ED Diabetes Rapid-referral Program (EDRP) was designed to provide ED staff with direct booking into the diabetes center. The objective of this study was to determine the effects of the EDRP on hospitalization rate, ED utilization rate, glycemic control, and expenditures.nnnMETHODSnWe conducted a single-center analysis of the EDRP cohort (n = 420) and compared 1-year outcomes to historic controls (n = 791). We also compared EDRP patients who arrived (ARR) to those who did not show (NS). The primary outcome was hospitalization rate over 1 year. Secondary outcomes included ED recidivism rate, hemoglobin A1c (HbA1c), and healthcare expenditures.nnnRESULTSnCompared with controls, the EDRP cohort was less likely to be hospitalized (27.1% vs. 41.5%, P<.001) or return to the ED (52.2% vs. 62.3%, P = .001) at the end of 1 year. Total hospitalizations were also lower in the EDRP (157 ± 19 vs. 267 ± 18 per 1,000 persons per year, P<.001). The EDRP cohort had a greater reduction in HbA1c (-2.66 vs. -2.01%, P<.001), which was more pronounced when ARR patients were compared with NS (-2.71% vs. -1.37%, P<.05). The mean per patient institutional healthcare expenditures were lower by

Disparities in Emergency Department Visits Among Collocated Racial/Ethnic Medicare Enrollees

5,461 compared with controls.nnnCONCLUSIONnEliminating barriers to scheduling diabetes-focused ambulatory care for ED patients was associated with significant reductions in hospitalization rate, ED recidivism rate, HbA1c, and healthcare expenditures in the subsequent year.nnnABBREVIATIONSnARR = arrived ED = emergency department EDRP = emergency department diabetes rapid-referral Program HbA1c = hemoglobin A1c NS = no show.

A critical analysis of unplanned ICU transfer within 48 hours from ED admission as a quality measure

Study objective: We estimate emergency department (ED) use differences across Medicare enrollees of different race/ethnicity who are residing in the same zip codes. Methods: In this retrospective cohort study, we stratified all Medicare fee‐for‐service beneficiaries aged 66 years and older (2006 to 2012) by residence zip code and identified zip codes with racial/ethnic diversity, defined as containing at least 1 enrollee from each of 3 racial/ethnic groups: Hispanics, (non‐Hispanic) blacks, and (non‐Hispanic) whites. Our primary study population consisted of a stratified random sample of approximately equal number of each racial/ethnic group from each zip code with racial/ethnic diversity (N=1,563,631). We identified ED visits, comorbidities, primary‐care‐treatable status, and patient disposition. We characterized socioeconomic status by zip code poverty rate. The main outcome measure was the ratio of ED visit rate (number of visits/100 person‐years) between each minority group and whites. Results: Of 38,423 zip codes nationally, 41% met the racial/ethnic diversity criterion; these zip codes contained 85% of the Medicare fee‐for‐service beneficiaries. Among enrollees from zip codes with racial/ethnic diversity, the ED visit rate among whites was 45.4 (95% confidence interval 45.1 to 45.6), and the ED visit rate ratio was 1.34 (95% confidence interval 1.33 to 1.36) among blacks and 1.23 (95% confidence interval 1.22 to 1.24) among Hispanics. ED visit rate ratios for both minority groups were greater than 1.00 among all subgroups by age, comorbidity, zip code poverty rate, urban/rural area, and primary‐care‐treatable and disposition status. Conclusion: Among Medicare enrollees, blacks and Hispanics had higher ED use rates than whites overall and among subgroups by demographics and socioeconomic status.

Ultrasound-guided hip arthrocentesis in the ED

HYPOTHESISnUnplanned intensive care unit (ICU) transfer (UIT) within 48 hours of emergency department (ED) admission increases morbidity and mortality. We hypothesized that a majority of UITs do not have critical interventions (CrIs) and that CrI is associated with worse outcomes.nnnOBJECTIVEnThe objective of the study is to characterize all UITs (including patients who died before ICU transfer), the proportion with CrI, and the effect of having CrI on mortality.nnnDESIGNnThis is a single-center, retrospective cohort study of UITs within 48 hours from 2008 to 2013 at an urban academic medical center and included patients 18 years or older without advanced directives (ADs). Critical intervention was defined by modified Delphi process. Data included demographics, comorbidities, reasons for UIT, length of stay, CrIs, and mortality. We calculated descriptive statistics with 95% confidence intervals (CIs).nnnRESULTSnA total of 837 (0.76%) of 108 732 floor admissions from the ED had a UIT within 48 hours; 86 admitted patients died before ICU. We excluded 23 ADs, 117 postoperative transfers, 177 planned ICU transfers, and 4 with missing data. Of the 516 remaining, 65% (95% CI, 61%-69%) received a CrI. Unplanned ICU transfer reasons are as follows: 33 medical errors, 90 disease processes not present on arrival, and 393 clinical deteriorations. Mortality was 10.5% (95% CI, 8%-14%), and mean length of stay was 258 hours (95% CI, 233-283) for those with CrI, whereas the mortality was 2.8% (95% CI, 1%-6%) and mean length of stay was 177 hours (95% CI, 157-197) for those without CrI.nnnCONCLUSIONSnUnplanned ICU transfer is rare, and only 65% had a CrI. Those with CrI had increased morbidity and mortality.