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Objectives The problem of emergency department (ED) crowding is well recognized; however, little data exist on the sustainability of potential solutions, including physician triage and screening. The authors hypothesized that a physician triage screening program (Supplemented Triage and Rapid Treatment [START]) sustainably improves standard ED performance metrics. Methods This retrospective, observational, before-and-after study compared performance measures over 4 years in a tertiary care urban academic medical center with approximately 90,000 annual ED visits. Patients seen between December 2006 and November 2010 were included. Outcome measures included length of stay (LOS) for ED patients, percentage of patients who left without completing assessment (LWCA), percentage of patients treated and dispositioned by START without using monitored beds, and door-to-room time. Descriptive statistics were used. Results Median LOS for START patients was 56 minutes/patient lower when comparing 2010 to 2007 (p

Objectives The study purpose was to determine the optimal use of lumbar puncture (LP) red blood cell (RBC) counts to identify subarachnoid hemorrhage (SAH) when some blood remains in the final tube. Methods A case series was performed at a tertiary emergency department (ED). Records of 4,496 consecutive adult patients billed for LPs between 2001 and 2009 were reviewed. Inclusion criteria were headache (HA), final tube RBCs ≥ 5, and neurovascular imaging within 2 weeks of the visit. Demographics, relevant history and physical examination components, LP results, and neuroimaging findings were recorded for 280 patients. True-positive (TP) and true-negative (TN) SAH were strictly defined. Primary outcomes were the areas under the receiver operating characteristic curves (AUC) for final tube RBC count, differential RBC count between the final and initial tubes, and absolute differential RBC count between the final and initial tubes divided by the mean RBC count of the two tubes (also called the percent change in RBC count). Results There were 26 TP and 196 TN results; 58 patients were neither. The TP group consisted of 19 patients with visible or possible SAH on imaging (17 on noncontrast head computed tomography [CT; 12 definite and five possible] and two on magnetic resonance imaging), six with xanthochromia and a vascular lesion (aneurysm or arteriovenous malformation [AVM] > 2 mm), and one with xanthochromia and polymerase chain reaction (PCR)-positive meningitis. As a test for SAH, final tube RBC AUC was 0.85 (95% confidence interval [CI] = 0.80 to 0.91). Interval likelihood ratios (LRs) for final tube RBC count were LR 0 (95% CI = 0 to 0.3) for RBCs 10,000. Differential RBC count was not associated with SAH, with AUC 0.45 (95% CI = 0.31 to 0.60). However, the percent change in RBC count between the final and initial tubes had an AUC 0.84 (95% CI = 0.78 to 0.90), and the optimal test threshold for SAH was 0.63, with positive LR 3.6 (95% CI = 2.7 to 4.7) and negative LR 0.10 (95% CI = 0.03 to 0.4) for percent change 63%, respectively. This test added additional independent information to the final tube RBC count based on improved logistic regression model fit and discriminatory ability as measured by the LR test and c statistic, respectively. Conclusions Final LP tube RBC count and the percent change in RBC count, but not the simple differential count between the final and initial tubes, were associated with SAH. In this sample, there were no patients with SAH who had RBCs 10,000 increased the odds of SAH by a factor of 6.

Early triage of patients presenting to the emergency department (ED) with the chief complaint of chest pain suggestive of acute coronary syndrome (ACS) remains a diagnostic challenge. Elements of the chest pain history are associated with increased or decreased likelihoods of ACS.1 Sensitive troponin assays and initial electrocardiogram (ECG) provide important information in the initial decision.2–4 However, clinical history, a single set of cardiac biomarkers, and the initial ECG alone or in combination cannot identify the group of patients who can be safely discharged without further diagnostic testing. The percentage of patients who present to the ED with ACS and are inappropriately discharged is low (around 2%).5 However, discharged subjects have a two to three times increased risk of dying.5 Therefore, the standard of care for subjects with acute chest pain typically includes serial ECG and cardiac biomarkers followed by a stress test with or without imaging.6–9 The standard work-up decreases the risk of diagnostic errors. However, the complete “rule-out myocardial infarction” protocol is time-consuming and costly. Clinical risk scores (e.g., Thrombolysis in Myocardial Infarction [TIMI],10 Goldman,11 and Sanchis12) and triage algorithms are available to predict adverse cardiac events and facilitate the triage decision.10–14 However, the performance of these tools is not optimal.15 Risk scores used for the prediction of future cardiovascular events (e.g., Framingham Risk Score) and risk factors for coronary artery disease (CAD) have only limited value for the confirmation or exclusion of ACS in the ED.16,17 Coronary computed tomography angiography (CTA) permits detection of coronary stenosis and atherosclerotic plaque with high sensitivity, specificity, and negative predictive value.18–22 In patients who present to the ED with acute chest pain, exclusion of a significant coronary stenosis and plaque by coronary CTA has a high negative predictive value for ACS.23–32 In contrast, patients with a significant coronary stenosis detected by computed tomography (CT) have a high likelihood of ACS. However, there is a significant proportion of patients in whom coronary atherosclerotic plaque is present, without significant stenosis. In the Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial, we observed approximately one-third (113 of 368) of patients with nonobstructive plaque.28 The quantitative assessment of coronary plaque and the combination of coronary plaque burden with clinical risk scores could possibly improve the accuracy for the diagnosis as well as the exclusion of ACS. We determined the association of four dichotomized (low- vs. intermediate- to high-risk categories) clinical risk scores and of the coronary atherosclerotic plaque burden as detected by CT with the outcome of ACS in patients who presented to the ED with the chief complaint of chest pain and inconclusive initial evaluation (negative cardiac biomarkers, nondiagnostic ECG changes), and no history of CAD. We hypothesized that the combination of risk scores and plaque burden improves the discriminatory capacity for the diagnosis of ACS.

OBJECTIVES There is limited information on the financial implications of an emergency department ultrasound (ED US) program. The authors sought to perform a fiscal analysis of an integrated ED US program. METHODS A retrospective review of billing data was performed for fiscal year (FY) 2007 for an urban academic ED with an ED US program. The ED had an annual census of 80,000 visits and 1,101 ED trauma activations. The ED is a core teaching site for a 4-year emergency medicine (EM) residency, has 35 faculty members, and has 24-hour availability of all radiology services including formal US. ED US is utilized as part of evaluation of all trauma activations and for ED procedures. As actual billing charges and reimbursement rates are institution-specific and proprietary information, relative value units (RVUs) and reimbursement based on the Centers for Medicare & Medicaid Services (CMS) 2007 fee schedule (adjusted for fixed diagnosis-related group [DRG] payments and bad debt) was used to determine revenue generated from ED US. To estimate potential volume, assumptions were made on improvement in documentation rate for diagnostic scans (current documentation rates based on billed volume versus diagnostic studies in diagnostic image database), with no improvements assumed for procedural ED US. Expenses consist of three components-capital costs, training costs, and ongoing operational costs-and were determined by institutional experience. Training costs were considered sunken expenses by this institution and were thus not included in the original return on investment (ROI) calculation, although for this article a second ROI calculation was done with training cost estimates included. For the purposes of analysis, certain key assumptions were made. We utilized a collection rate of 45% and hospitalization rates (used to adjust for fixed DRG payments) of 33% for all diagnostic scans, 100% for vascular access, and 10% for needle placement. An optimal documentation rate of 95% was used to estimate potential revenue. RESULTS In FY 2007, 486 limited echo exams of abdomen (current procedural terminology [CPT] 76705) and 480 limited echo cardiac exams were performed (CPT 93308) while there were 78 exams for US-guided vascular access (CPT 76937) and 36 US-guided needle placements when performing paracentesis, thoracentesis, or location of abscess for drainage (CPT 76492). Applying the 2007 CMS fee schedule and above assumptions, the revenue generated was 578 RVUs and $35,541 ($12,934 in professional physician fees and $22,607 in facility fees). Assuming optimal documentation rates for diagnostic ED US scans, ED US could have generated 1,487 RVUs and $94,593 ($33,953 in professional physician fees and $60,640 in facility fees). Program expenses include an initial capital expense (estimated at $120,000 for two US machines) and ongoing operational costs ($68,640 per year to cover image quality assurance review, continuing education, and program maintenance). Based on current revenue, there would be an annual operating loss, and thus an ROI cannot be calculated. However, if potential revenue is achieved, the annual operating income will be $22,846 per year with an ROI of 4.9 years to break even with initial investment. CONCLUSIONS Determining an ROI is a required procedure for any business plan for establishing an ED US program. Our analysis demonstrates that an ED US program that captures charges for trauma and procedural US and achieves the potential billing volume breaks even in less than 5 years, at which point it would generate a positive margin.