Zachary F. Meisel

Arriving by Emergency Medical Services Improves Time to Treatment Endpoints for Patients With Severe Sepsis or Septic Shock

OBJECTIVES The objective was to evaluate the effect of arrival to the emergency department (ED) by emergency medical services (EMS) on time to initiation of antibiotics, time to initiation of intravenous fluids (IVF), and in-hospital mortality in patients with severe sepsis and septic shock. METHODS The authors performed an evaluation of prospectively collected registry data of patients with a diagnosis of severe sepsis or septic shock who presented to an urban academic ED during a 2-year period from January 1, 2005, to December 31, 2006. Descriptive and multivariate analytic methods were used to analyze the data. Using unadjusted and adjusted models, out-of-hospital patients who presented to the ED by ambulance (EMS) were compared to control patients who arrived by alternative means (non-EMS). Primary outcomes measured were ED time to initiation of antibiotics, ED time to initiation of IVF, and in-hospital mortality. RESULTS A total of 963 severe sepsis patients were enrolled in the registry. Median time to antibiotics was 116 minutes for EMS (interquartile range [IQR] = 66 to 199) vs. 152 minutes for non-EMS (IQR = 92 to 252, p ≤ 0.001). Median time to initiation of IVF was 34 minutes for EMS (IQR = 10 to 88) and 68 minutes for non-EMS (IQR = 25 to 121, p ≤ 0.001). After adjustment for the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, age, and initial serum lactate level, no significant differences in hospital mortality were seen (adjusted relative risk [aRR] for EMS vs. non EMS = 1.24, 95% confidence interval [CI] = 0.92 to 1.66, p = 0.16). The Cox proportional hazard ratio (HR) comparing EMS to non-EMS care after similar adjustment was HR = 1.27 for IVF (95% CI = 1.10 to 1.47, p = 0.004) and HR = 1.25 for antibiotics (95% CI = 1.08 to 1.44, p = 0.003). CONCLUSIONS Out-of-hospital care was associated with improved in-hospital processes for the care of critically ill patients. Despite shortened ED treatment times for septic patients who arrive by EMS, a mortality benefit could not be demonstrated.

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.

Objective To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome. Design Multicenter pragmatic parallel randomized controlled trial. Setting Six emergency departments in the United States. Participants 898 adults (aged >17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain. Interventions Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events. Results Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P<0.001). There were no major adverse cardiac events due to the intervention. Conclusions Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing. Trial registration ClinicalTrials.gov NCT01969240.

“I Didn't Know the Gun Was Loaded”: An Examination of Two Safety Devices That Can Reduce the Risk of Unintentional Firearm Injuries

Some handguns contain built-in safety devices intended to prevent injuries caused by erroneously believing that a handgun is loaded. A loaded chamber indicator indicates the presence of ammunition in the gun; a magazine safety prevents the gun from being fired when the ammunition magazine is removed, even if one round remains in the firing chamber.In our patent search these devices date back to the turn of the century. But on 1998 pistol models, only 11% contained a loaded chamber indicator and 14% had a magazine safety. In our random-digit-dial telephone survey of U.S. adults, 34.8% of poll respondents (incorrectly) thought that a firearm with its ammunition magazine removed could not be shot, or said that they did not know.Some of the 1100 unintentional gun deaths in the U.S. each year might be prevented if the prevalence of these and other safety devices is increased through legislation, litigation, or voluntary manufacturer action.

Qualitative Research in Emergency Care Part I: Research Principles and Common Applications.

Qualitative methods are increasingly being used in emergency care research. Rigorous qualitative methods can play a critical role in advancing the emergency care research agenda by allowing investigators to generate hypotheses, gain an in-depth understanding of health problems or specific populations, create expert consensus, and develop new intervention and dissemination strategies. This article, Part I of a two-article series, provides an introduction to general principles of applied qualitative health research and examples of its common use in emergency care research, describing study designs and data collection methods most relevant to our field, including observation, individual interviews, and focus groups. In Part II of this series, we will outline the specific steps necessary to conduct a valid and reliable qualitative research project, with a focus on interview-based studies. These elements include building the research team, preparing data collection guides, defining and obtaining an adequate sample, collecting and organizing qualitative data, and coding and analyzing the data. We also discuss potential ethical considerations unique to qualitative research as it relates to emergency care research.

Variations in Ambulance Use in the United States: the Role of Health Insurance

OBJECTIVES The purpose of this study was to describe the associations between individual health insurance and ambulance utilization using a national sample of patients who receive emergency department (ED) care. METHODS The data source was the National Hospital Ambulatory Medical Care Survey, years 2004 through 2006. Noninstitutionalized patients between ages 18 and 65 years were included. The primary dependent variable was ambulance use. Multivariable logistic regression methods were used to assess the associations between health insurance status and ambulance use and to adjust for confounders. RESULTS A total of 61,013 ED visits were included, representing a national sample of approximately 70 million annual ED visits over 3 years. Ambulance transport was used in 11% of private insurance visits, 16% of Medicaid visits, and 13% of uninsured visits. In the adjusted model, visits by patients with Medicaid (adjusted odds ratio [aOR] = 1.60, 99% confidence interval (CI) = 1.37 to 1.86) and the uninsured (aOR = 1.43, 99% CI = 1.23 to 1.66) were more likely to arrive by ambulance than visits by patients with private insurance. Ambulance use among the uninsured was most pronounced in metropolitan areas. CONCLUSIONS Ambulance use varies by health insurance status. Medicaid coverage and lack of insurance are each independently associated with increased odds of ambulance use, suggesting a disproportionate role for emergency medical services (EMS) in the care of patients with limited financial resources.

Interview-based Qualitative Research in Emergency Care Part II: Data Collection, Analysis and Results Reporting

Qualitative methods are increasingly being used in emergency care research. Rigorous qualitative methods can play a critical role in advancing the emergency care research agenda by allowing investigators to generate hypotheses, gain an in-depth understanding of health problems or specific populations, create expert consensus, and develop new intervention and dissemination strategies. In Part I of this two-article series, we provided an introduction to general principles of applied qualitative health research and examples of its common use in emergency care research, describing study designs and data collection methods most relevant to our field (observation, individual interviews, and focus groups). Here in Part II of this series, we outline the specific steps necessary to conduct a valid and reliable qualitative research project, with a focus on interview-based studies. These elements include building the research team, preparing data collection guides, defining and obtaining an adequate sample, collecting and organizing qualitative data, and coding and analyzing the data. We also discuss potential ethical considerations unique to qualitative research as it relates to emergency care research.

Addressing prehospital patient safety using the science of injury prevention and control

There is inadequate information about the scope andcharacter of adverse events in prehospital care. However, there is ample evidence to suggest that prehospital patient safety hazards are often unique andunderrecognized. We first summarize what is currently understood about prehospital patient safety andidentify the specific aspects of emergency medical services (EMS) care that may make conventional approaches to the evaluation andimprovement of patient safety more difficult. Next we introduce the concept of using injury prevention andcontrol science to analyze prehospital adverse events andto help develop EMS patient safety solutions. Injury prevention andcontrol is a proven public health approach for the study andreduction of both intentional andunintentional injuries. It includes the use of a Haddon phase–factor matrix to identify possible interventions, especially environmental modifications that provide automatic protection. We demonstrate how this method can be used as a complementary approach in efforts to prevent injuries caused by prehospital adverse medical events.

Derivation andInternal Validation of a Rule to Predict Hospital Admission in Prehospital Patients

Objective. To derive andinternally validate a simple prediction rule, using routinely collected prehospital patient data, that discriminates between hospital admission andemergency department (ED) discharge for adult patients who arrive by ambulance. Methods. We performed a retrospective cohort study of consecutive adult nontrauma patients transported to two separate EDs over two months by a city-run emergency medical services (EMS) system. We tested whether specific prehospital variables could predict hospital admission using chi-square tests, logistic regression, andreceiver-operating characteristic curves. We created a rule to predict the probabilities of hospital admission for individual patients. Results. Of 401 patients, the mean age was 47 years; 60% were black and32% were white; 51% were female; and33% were admitted to an inpatient service after evaluation in the ED. Independent predictors of admission were dyspnea (adjusted odds ratio [OR] 6.8; awarded 3 points), chest pain (OR 5.2; 3 points), anddizziness, weakness, or syncope (OR 3.5; 2 points). Also predictive were age ≥60 years (OR 5.5; 3 points) andthe prehospital identification of a history of diabetes (OR 1.9; 1 point) or cancer (OR 3.9; 2 points). Patients who had a score of 5 or higher had a greater than 69% chance of being admitted to an inpatient unit. Conclusion. Routinely collected EMS patient information can help predict hospital admission for certain ED patients.

What do patients say about emergency departments in online reviews? A qualitative study

Background Patients have adopted web-based tools to report on the quality of their healthcare experiences. We seek to examine online reviews for US emergency departments (EDs) posted on Yelp, a popular consumer ratings website. Methods We conducted a qualitative analysis of unstructured, publicly accessible reviews for hospitals available on http://www.yelp.com. We collected all reviews describing experiences of ED care for a stratified random sample of 100 US hospitals. We analysed the content of the reviews using themes derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) inpatient care survey. We also used modified grounded theory to iteratively code the text of the reviews, identifying additional themes specific to emergency care. The data were double-coded, and discrepancies were evaluated to ensure consensus. Results Of the 1736 total reviews, 573 (33%) described patient experiences involving the ED. The reviews contained several themes assessed by the HCAHPS survey, including communication with nurses, communication with doctors, and pain control. The reviews also contained key themes specific to emergency care: waiting and efficiency; decisions to seek care in the ED; and events following discharge, including administrative difficulties. Conclusions These exploratory findings suggest that online reviews for EDs contain similar themes to survey-based assessments of inpatient hospital care as well as themes specific to emergency care. Consumer rating websites allow patients to provide rapid and public feedback on their experience of medical care. Web-based platforms may offer a novel strategy for assessing patient-centred quality in emergency care.

Influence of sex on the out-of-hospital management of chest pain.

BACKGROUND Sex disparities in the diagnosis and treatment of chest pain or suspected angina have been demonstrated in multiple clinical settings. Out-of-hospital (OOH) care for chest pain is protocol-driven and may be less likely to demonstrate differences between men and women. OBJECTIVES The objectives were to investigate the relationship between sex and the OOH treatment of patients with chest pain. The authors sought to test the hypothesis that OOH care for chest pain patients would differ by sex. METHODS A 1-year retrospective cohort study of 683 emergency medical services (EMS) patients with a complaint of chest pain was conducted. Included were patients taken to any one of three hospitals (all cardiac referral centers) by a single municipal EMS system. Excluded were patients transported by basic life support (BLS) units, those younger than 30 years, and patients with known contraindications to any of the outcome measures. Multivariable regression was used to adjust for potential confounders. The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured. RESULTS A total of 342 women and 341 men were included. Women were less likely than men to receive aspirin (relative risk [RR] = 0.76; 95% confidence interval [CI] = 0.59 to 0.96), nitroglycerin (RR = 0.76; 95% CI = 0.60 to 0.96), or an IV (RR 0.86; 95% CI = 0.77 to 0.96). These differences persisted after adjustment for demographics and emergency department (ED) evaluation for acute coronary syndrome (ACS) as a blunt marker for cardiac risk. Women were also less likely to receive these treatments among the small subgroup of patients who were later diagnosed with acute myocardial infarction (AMI). CONCLUSIONS For OOH patients with chest pain, sex disparities in treatment are significant and do not appear to be explained by differences in patient age, race, or underlying cardiac risk.