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Background: Amidst the opioid epidemic, there has been an increasing focus on opioid utilization in U.S. emergency departments (EDs). Compared with other opioids, little is known about the use of tramadol over the past decade. Tramadol has uncertain efficacy and a concerning adverse effect profile compared with traditional opioids., Objective: Our aim was to describe trends in tramadol use in U.S. EDs between 2007 and 2018., Methods: We analyzed the National Hospital Ambulatory Medical Care Survey from 2007 to 2018 to examine ED visits by patients 18 years or older in which tramadol was administered or prescribed. We examined trends in demographics and resource utilization and compared these trends with those of traditional opioids. Survey-weighted analyses were conducted to provide national-level estimates., Results: Between 2007 and 2018, ED visits in which tramadol was used increased 70.6%, from 1.7% of all ED visits in 2007 to 2.9% in 2018. The largest increases were noted among patients aged 55 through 64 years and 65 years and older. Diagnostic resource utilization increased across the study period. Overall opioid utilization during the study period decreased from 28.4% in 2007 to 17.9% in 2018 (p < 0.001). The use of other specific opioids declined or remained stable between 2007 and 2018., Conclusions: Although the use of traditional opioids decreased from 2007 to 2018, the use of tramadol increased. Increases were largest among older patients, who may be more susceptible to the adverse effects associated with this medication. Further research in the appropriate use of tramadol in the ED setting is warranted., (Copyright © 2022. Published by Elsevier Inc.)

Background: Angioedema (AE) is a clinical syndrome marked by localized swelling of the subcutaneous layer of the skin or the submucosal layer of the respiratory or gastrointestinal tracts. While AE is commonly mediated by histamine (allergic AE), some types result from excessive bradykinin activity, including hereditary AE (HAE), acquired AE, and angiotensin-converting enzyme inhibitor-induced AE. These are less common but important to consider given different treatment requirements and potentially serious outcomes, including death from laryngeal swelling., Objective: This review describes the pathophysiology and clinical features of AE as well as the diagnosis and treatment of AE in the emergency department (ED)., Discussion: Bradykinin-mediated AE does not respond to antihistamines and corticosteroids. By contrast, several targeted, effective therapies are available, including C1-inhibitor (C1-INH) concentrates, which replace the missing protein activity underlying some bradykinin-mediated AE, and medications that directly lessen bradykinin activity (eg, ecallantide and icatibant). Urticaria is generally absent in bradykinin-mediated AE and serves as a primary differentiating factor in the clinical diagnosis. Relevant laboratory assessments may include C1-INH levels, C1-INH function, and C4 complement. Patients with HAE or a family member can communicate their known diagnosis when presenting to the ED, and some may even bring their own medication(s) with them. Patients newly diagnosed with HAE in the ED should be referred for specialized outpatient care upon ED discharge., Conclusions: There is a great need for ED clinicians to be aware of HAE, its differential diagnosis, and appropriate treatment to ensure that patients receive optimal and timely treatment., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Cognitive bias can lead to systematic errors in judgment., Objective: We sought to assess cognitive bias in emergency physicians and compare the results to a sample of nonphysicians., Methods: Selected emergency physicians were invited to take the Rationality Quotient (RQ) test, which measures cognitive biases. Control subjects were nonphysicians selected randomly from individuals who had taken the RQ test contemporaneously. We compared RQ scores overall and by bias and assessed the relationship between self-reported statistical knowledge and familiarity with decision-making biases and RQ scores., Results: Of 150 physicians invited, 95 (63%) completed the RQ test. There was less bias in physicians compared with control subjects (RQ scores were 51.1 for physicians and 43.3 for control subjects, p < 0.001). There was less bias among physicians for both bias blind spot (15 vs. 14.3, p < 0.001) and for representative bias (10.4 vs. 5.2, p < 0.001). Anchoring bias, confirmation bias, projection bias, and attribution error were not significantly different. Emergency physicians with greater self-reported statistical familiarity (either 6 of 7 or 7 of 7 on a Likert scale) had higher RQ scores by 7.7 points (95% confidence interval 3.1-12.3)-i.e., they were less biased. There was no association between self-reported knowledge of decision biases and RQ scores., Conclusion: Cognitive biases were common in this sample of emergency physicians, and physicians demonstrated less bias than control subjects. Variability was mostly attributed to 2 biases: bias blind spot and representative bias., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Common in COPD are acute exacerbations (AE-COPD) that cause acute dyspnea, cough, and bronchospasm. Symptoms of AE-COPD mimic pulmonary embolism (PE)., Methods: We conducted a systematic review of the literature to assess the prevalence of PE in patients admitted to the hospital with a clinical diagnosis of AE-COPD. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we queried PubMed and MEDLINE databases from 1990 to 2017. The search term "prevalence pulmonary embolism, COPD" was used, and Boolean operators were used to combine search terms. Data were extracted from each article, specifically the sample size, study setting, design, and the prevalence of PE., Results: A total of 5 articles were included that demonstrated a prevalence of PE among patients with a clinical diagnosis of AE-COPD that ranged from 3.3-29.1%. Sample sizes varied from 49-197 patients. Studies occurred in both emergency department and inpatient settings, including intensive care units. Among the studies that reported patient characteristics associated with PE in AE-COPD, both obesity and immobility were important., Conclusion: Studies reporting the prevalence of PE during AE-COPD vary considerably in their methods and results. Because of the relatively high prevalence of PE during AE-COPD, it is important for providers to be aware of this linkage between the 2 conditions and to screen patients using clinical gestalt and validated screening tools until more emergency department data are available., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Core laboratory testing may increase length of stay and delay care., Objectives: We compared length of emergency department (ED) care in patients receiving point-of-care testing (POCT) at triage vs. traditional core laboratory testing., Methods: We conducted a prospective, case-controlled trial of adult patients with prespecified conditions requiring laboratory testing and had POCT performed by a nurse after triage for: a basic metabolic panel, troponin I, lactate, INR (i-STAT System), urinalysis (Beckman Coulter Icon), or urine pregnancy test. Study patients were matched with controls based on clinical condition, gender, age, and time to be seen. Groups were compared with Wilcoxon rank-sum or Fisher's exact tests., Results: We matched 52 POCT study patients with 52 controls. Groups were similar in age, gender, clinical condition, time to be seen by a physician (3.3 h, 95% confidence interval [CI] 2.2-4.4, vs. 3.1 h, 95% CI 2.2-4.5 h, in POCT and control patients, respectively; p = 0.84), use of imaging, and disposition. Of 52 study patients, 3 (5.8%, 95% CI 2.0-15.9) were immediately transferred to the critical care area to be urgently seen by an emergency physician. POCT patients had a significantly shorter median (interquartile range [IQR]) ED care time than matched controls (7.6, 95% CI 5.1-9.5 vs. 8.5, 6.2-11.3 h, respectively; p = 0.015). Median [IQR] ED length of stay was similar in study patients and controls (9.6, 95% CI 7.9-14.5 vs. 12.5, 8.2-21.2 h, respectively; p = 0.15)., Conclusions: Among stable adult patients presenting to the ED with one of the prespecified conditions, early POCT at triage, compared with traditional core laboratory testing after evaluation by an ED provider, reduced ED care time by approximately 1 h., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The Segway® Personal Transporter™ (SPT) is used widely as a means of transport for city sightseeing tours, law enforcement, and professionals working in large facilities and factories., Methods: We conducted a systematic review of the literature to assess SPT-related injuries. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, we queried PubMed from 1990 to 2017. The search terms Segway, personal transporter, and injury were used. Only English-language studies were included. Data were extracted from each article, specifically the sample size, study setting, and design, as well as the prevalence of specific injuries., Results: A total of six articles were included that included data on 135 patients. Sample size per study varied from 1 to 41 patients. Studies occurred in both the emergency department and inpatient settings, including medical-surgical wards, and intensive care units. The most commonly reported injuries were orthopedic cases (n = 45), maxillofacial cases (n = 13), neurologic cases (n = 8), and thoracic cases (n = 10)., Conclusions: The SPT is an innovative transportation method; however, its use is associated with a wide range of injuries. Many of these injuries require hospital admission and surgical intervention, incurring significant morbidity and high costs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Emergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS)., Objective: To describe how ED LOS differs among physicians., Methods: We performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOS O/E ); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year., Results: Three hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106-184 min), and the average longest observed LOS was 232 min (range 196-270 min); the average difference was 81 min (range 69-90 min). For LOS O/E , the average lowest LOS O/E was 0.801 (range 0.702-0.887), and the average highest LOS O/E was 1.210 (range 1.186-1.275); the average difference between the lowest LOS O/E and the highest LOS O/E was 0.409 (range 0.305-0.493)., Conclusion: There are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOS O/E for physicians with the lowest LOS O/E at each site averaged approximately 20% less than predicted, and that the LOS O/E for physicians with the highest LOS O/E at each site averaged approximately 20% more than predicted., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Substantial variation exists in rates of emergency department (ED) admission. We examine this variation after accounting for local and community characteristics., Objectives: Elucidate the factors that contribute to admission variation that are amenable to intervention with the goal of reducing variation and health care costs., Methods: We conducted a retrospective cross-sectional study of 1,412,340 patient encounters across 18 sites from 2012-2013. We calculated the adjusted hospital-level admission rates using multivariate logistic regression. We adjusted for patient, provider, hospital, and community factors to compare admission rate variation and determine the influence of these characteristics on admission rates., Results: The average adjusted admission rate was 22.9%, ranging from 16.1% (95% confidence interval [CI] 11.5-22%) to 32% (95% CI 26.0-38.8). There were higher odds of hospital admission with advancing age, male sex (odds ratio [OR] 1.20, 95% CI 1.91-1.21), and patients seen by a physician vs. mid-level provider (OR 2.26, 95% CI 2.23-2.30). There were increased odds of admission with rising ED volume, at academic institutions (OR 2.23, 95% CI 2.20-2.26) and at for-profit hospitals (OR 1.15, 95% CI 1.12-1.18). Admission rates were lower in communities with a higher per capita income, a higher rate of uninsured patients, and in more urban hospitals. In communities with the most primary providers, there were lower odds of admission (OR 0.60, 95% CI 0.57-0.68)., Conclusion: Variation in hospital-level admission rates is associated with a number of local and community characteristics. However, the presence of persistent variation after adjustment suggests there are other unmeasured variables that also affect admission rates that deserve further study, particularly in an era of cost containment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Earlier reports have documented growth of United States emergency department (ED) visits since the early 1990s., Objective: In this report, we describe recent trends in ED utilization and inpatient admissions in Maryland and District of Columbia hospitals from 2011 to 2013., Methods: We analyzed monthly ED visit and inpatient admission volumes from 53 acute care hospitals in Maryland and the District of Columbia from 2011 to 2013. Fixed-effect regression was used to assess the relationship between community-level demographics, hospital insurance mix, urgent care/retail clinic density, and hospitals participating in Maryland's Total Patient Revenue (TPR) pilot-a global payment program-and changes in ED visit and hospital admission volume from 2012 to 2013., Results: Across 53 Maryland and District of Columbia hospitals, ED visits grew 2.8% between 2011 and 2012. From 2012 to 2013, ED visits declined by 3.5%. Admissions declined by 3.3% from 2011 to 2012, then declined again 3.6% from 2012 to 2013. Community demographic or hospital insurance-mix variable and density of urgent care centers were not associated with lower ED visits. Inpatient admissions fell significantly more in hospitals participating in Maryland's TPR global payment pilot program., Conclusions: In 2013, ED visits in fell in Maryland and District of Columbia hospitals, and inpatient admission volumes fell from 2011 to 2013. This is a reversal of decades-long trends in higher health care utilization. These trends were not explained by demographics, insurance, or ED alternatives, however, falling admission rates were more pronounced in Maryland hospitals participating in global payment programs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: There is growing pressure to measure and reduce unnecessary imaging in the emergency department., Objective: We study provider and hospital variation in utilization and diagnostic yield for advanced radiography in diagnosis of pulmonary embolism (PE) and to assess patient- and provider-level factors associated with diagnostic yield., Methods: Retrospective chart review of all adult patients presenting to four hospitals from January 2006 through December 2009 who had a computed tomography or ventilation/perfusion scan to evaluate for PE. Demographic data on the providers ordering the scans were collected. Diagnostic yield (positive scans/total scans ordered) was calculated at the hospital and provider level. The study was not designed to assess appropriateness of imaging., Results: There was significant variation in utilization and diagnostic yield at the hospital level (chi-squared, p < 0.05). Diagnostic yield ranged from 4.2% to 8.2%; after adjusting for patient- and provider-level factors; the two hospitals with an emergency medicine residency training program had higher diagnostic yields (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.6-2.5 and OR 1.9, 95% CI 1.5-2.4). There was no significant variation in diagnostic yield among the 90 providers after adjusting for patient, hospital, and provider characteristics. Providers with < 10 years of experience had lower odds of diagnosing a PE than more experienced graduates (OR 0.8, 95% CI 0.6-0.9)., Conclusions: Although we found significant variation in utilization of advanced radiography for PE and diagnostic yield at the hospital level, there was no significant variation at the provider level after adjusting for patient-, hospital-, and provider-level factors., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Records of patients discharged from the Emergency Department (ED) who return within 72 h and are admitted are often reviewed for potential quality issues., Objectives: We explored 72-h return admissions and determined the prevalence and predictors for substandard management on the initial visit or any adverse outcome., Methods: Retrospective review of quality assurance data from 72-h return admissions in three hospitals from 2006-2010 was performed. Any substandard quality on the first visit or change in outcome on the return admission was considered "low quality." Multivariate logistic regression was used to assess the relationship between cases judged as low quality vs. not low quality., Results: Of 741,132 ED visits across 5 years, 3682 (0.5%) were 72-h return admissions. Of those, 192 (5%) were low quality. In 158 (4%) and 8 (0.2%) there were moderate and severe deviations from care standards, respectively. Similarly, in 53 (1%) and 14 (0.4%) there were moderate and severe changes in outcome. In adjusted analysis, there were higher rates of low-quality 72-h return admissions in ambulance arrivals (odds ratio [OR] 1.5, 95% confidence interval (CI) 1.1-2.1); and lower rates in Medicaid patients (OR 0.3, 95% CI 0.2-0.7). There were higher rates in low-quality 72-h return admissions in hospital 1 (OR 3.6, 95% CI 2.2-6.1) and hospital 3 (OR 3.2, 95% CI 2.0-4.7) compared to hospital 2., Conclusions: Poor care on the initial visit or any poor outcome upon returning in 72-h return admissions is relatively rare in the ED. Reporting 72-h return admissions without chart review may not be a good way to measure clinical quality., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The pre-endoscopic Rockall Score (RS) and the Glasgow-Blatchford Scores (GBS) can help risk stratify patients with upper gastrointestinal bleed who are seen in the Emergency Department (ED). The RS and GBS have yet to be validated in a United States patient population for their ability to discriminate which ED patients with upper gastrointestinal bleed do not need endoscopic hemostasis., Objective: We sought to determine whether patients who received a score of zero on either score (the lowest risk) in the ED still required upper endoscopic hemostasis during hospitalization., Methods: Retrospective electronic medical record chart review was performed during a 3-year period (2007-2009) to identify patients with suspected upper gastrointestinal bleed by ED final diagnosis of gastrointestinal hemorrhage and related terms at a single urban academic ED. The RS and GBS were calculated from ED chart abstraction and the hospital records of admitted patients were queried for subsequent endoscopic hemostasis., Results: Six hundred and ninety patients with gastrointestinal bleed were identified and 86% were admitted to the hospital. One hundred and twenty-two patients had an RS equal to zero; 67 (55%; 95% confidence interval [CI] 46-63%) of these patients were admitted to the hospital and 11 (16%; 95% CI 9-27%) received endoscopic hemostasis. Sixty-three patients had a GBS equal to zero; 15 (24%; 95% CI 15-36%) were admitted to the hospital and 2 (13%; 95% CI 4-38%) received endoscopic hemostasis., Conclusions: Some patients who were identified as lowest risk by the GBS or RS still received endoscopic hemostasis during hospital admission. These clinical decision rules may be insufficiently sensitive to predict which patients do not require endoscopic hemostasis., (Copyright © 2013. Published by Elsevier Inc.)

Background: Boarding of admitted patients in the Emergency Department (ED) is common and is associated with poor patient outcomes., Objectives: We sought to estimate the magnitude of and trends for ED boarding in the US., Methods: We used the 2003-2005 National Hospital Ambulatory Medical Care Survey to estimate the time patients spent boarding in EDs in the US. We used fixed and imputed times required to evaluate, treat, and decide to admit each patient using the number of medications and diagnostic tests received. We calculated the absolute and relative patient-care hours spent boarding in US EDs over the 3-year period., Results: Total patient-hours spent in US EDs increased from 209 million to 217 million between 2003 and 2005. Overall admission rates decreased between 2003 and 2005 (13.9% in 2003, 12.3% in 2005), whereas intensive care unit admission rates increased (1.3% in 2003, 2.0% in 2005). Mean ED length of stay decreased (5.4 h in 2003, 4.6 h in 2005). The proportion of patient-hours accounted for by ED boarding decreased over the study period (11.3-17.1% in 2003, 5.9-15.3% in 2004, and 2.8-12.0% 2005)., Conclusions: Boarding of admitted patients in the ED accounts for a substantial portion of ED patient-care hours. Overall boarding time decreased over the 3 years., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Early recognition of elevated lactate levels may hasten the detection of time-sensitive illness. We studied a method to measure lactate levels in septic patients using a point-of-care (POC) device at Emergency Department triage. A convenience sample of adult patients with sepsis was enrolled. Consenting patients received a fingertip lactate measurement using a POC device. Treating clinicians were blinded to study and POC test results. Whole blood lactate levels were drawn at the discretion of the treating physician. A total of 238 patients were eligible; 154 (65%) consented, 5 left without treatment after consenting. Of the remaining 149, 44 (30%) patients received both POC and whole blood lactates. Median time from triage to POC lactate result was 21 min (interquartile range [IQR] 14-25). Median time from triage to whole blood lactate result was 172 min (IQR 119-256). The time difference between POC test result and whole blood lactate result was 151 min (IQR 101-247). Triage POC fingertip lactate is a feasible method for reducing time to identification of lactate levels in patients with sepsis. Larger studies are needed to determine the ability of POC lactate measurement to aid in the risk stratification of septic patients., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Emergency Medicine (EM) residency graduates are trained to perform Emergency Medicine bedside ultrasound (EMBU). However, the degree to which they use this skill in their practice after graduation is unknown., Objectives: We sought to test the amount and type of usage of EMBU among recent residency graduates, and how usage and barriers vary among various types of EM practice settings., Methods: Graduates from 14 EM residency programs in 2003-2005 were surveyed on their current practice setting and use of EMBU., Results: There were 252 (73%) graduates who completed the survey. Of the 73% of respondents reporting access to EMBU, 98% had used it within the past 3 months. Access to EMBU was higher in academic (97%) vs. community teaching (79%) vs. community non-teaching settings (62%) (p < 0.001), and in Emergency Departments (EDs) where yearly census exceeded 60,000 visits (87% vs. 65%, p < 0.001). Physicians in academic settings reported "high use" of EMBU more frequently than those in community settings for most modalities. FAST (focused assessment by sonography in trauma) was the most common high-use application and the most useful in practice. The greatest impediment to EMBU use was "not enough time" (61%)., Conclusions: Ultrasound usage among recent EM residency graduates is significantly higher in teaching than in community settings and in high-volume EDs. Its use is more widespread than in previous reports in all types of practice. There is a wide range of utilization of ultrasound in the various applications in emergency practice, with the evaluation of trauma being the most common., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Emergency Department (ED) crowding is a common problem in the United States and around the world. Process reengineering methods can be used to understand factors that contribute to crowding and provide tools to help alleviate crowding by improving service quality and patient flow. In this article, we describe the ED as a service business and then discuss specific methods to improve the ED quality and flow. Methods discussed include demand management, critical pathways, process-mapping, Emergency Severity Index triage, bedside registration, Lean and Six Sigma management methods, statistical forecasting, queuing systems, discrete event simulation modeling and balanced scorecards. The purpose of this review is to serve as a background for emergency physicians and managers interested in applying process reengineering methods to improving ED flow, reducing waiting times, and maximizing patient satisfaction. Finally, we present a position statement on behalf of the American Academy of Emergency Medicine addressing these issues., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Measurement of time to first antibiotic dose (TFAD) in the emergency department (ED) in community-acquired pneumonia (CAP) has been controversial., Objective: To evaluate original articles reporting outcomes in CAP patients before and after TFAD measurement and assess whether it increases antibiotic overuse in non-CAP conditions., Methods: We performed searches using PubMed, addressing two questions: 1) Is the measurement of TFAD associated with improved outcomes in CAP? and 2) Is the measurement of TFAD associated with antibiotic overuse or interventions that could result in overuse in non-CAP conditions? Two independent reviewers assessed studies addressing these questions., Results: Eight studies were identified. All were Grade C or D and of "Adequate" quality: two studies supported TFAD by showing improved outcomes (improved survival in one study and no survival difference but shorter hospital length-of-stay in the second) in CAP patients after the implementation of TFAD; one neutral article reported no difference in survival with improved TFAD timing; five studies opposed TFAD either by showing increases in antibiotic overuse in non-CAP patients, or suggesting that TFAD measurement would promote antibiotic misuse., Conclusion: Given inconsistent evidence to demonstrate that improving TFAD in CAP improves outcomes or that TFAD is associated with antibiotic overuse, a Class C indication has been assigned (not acceptable/not appropriate) for ED TFAD measurement. The American Academy of Emergency Medicine recommends that measurement of TFAD in CAP be discontinued.

Background: Pulmonary embolism (PE) remains one of the most challenging diagnoses in emergency medicine. The Pulmonary Embolism Rule-out Criteria (PERC) score, a decision aid to reliably distinguish low-risk from very low-risk PE patients, has been derived and validated., Clinical Question: Can a subset of patients with sufficiently low risk for PE be identified who require no diagnostic testing?, Evidence Review: The PERC score derivation and validation trials were located using PubMed and Web of Science. A critical appraisal of this research is presented., Results: One single-center and another multi-center validation trial both confirmed that the eight-item PERC score identified a very low-risk subset of patients in whom PE was clinically contemplated with a negative likelihood ratio 0.17 (95% confidence interval 0.11-0.25) in the larger trial. If applied, the rule would have identified 20% of potential PE patients as very low risk., Conclusion: The PERC score provides clinicians with an easily remembered, validated clinical decision rule that allows physicians to forego diagnostic testing for pulmonary embolus in a very low-risk population.

In the early part of chemical terrorism or hazardous materials events, protective actions and patient care require empirical decisions because reliable and accurate information may not be readily available. It has become increasingly important to identify reliable information resources that are the most likely to be accessed for information during these events. We sought to identify information resources that volunteer Emergency Medical Services (EMS) providers would use during a suspected chemical exposure. Survey questionnaires were completed by 116 of 151 (76.8%) suburban and rural EMS providers. In the past 12 months, most participants used medical journals and textbooks (59.5%), internet sites (57.8%), and poison centers (55.2%) as information resources. For two hypothetical scenarios involving chemical exposures, poison centers were most frequently chosen as likely contacts for information regarding the identity of the agent (case 1: 52.6%, case 2: 48.3%), treatment (74.1%, 64.7%, respectively), and antidote (59.5%, 49.1%, respectively). Fire department hazardous materials team tied with poison centers as the highest for chemical agent in the second scenario (48.3%) and was ranked highest both for decontamination (75.0%, 64.7%, respectively) and personal protection (56.9%, 45.7%, respectively). Poison centers were selected as the best resource for timely information (70.7%), availability (69.0%), and ease of contact (72.4%), and second highest for knowledge of chemical agents (44.0%), after CHEMTREC (56.9%). Finally, poison centers and CHEMTREC received the highest overall ratings (28.4% and 26.7%, respectively). Poison centers are viewed as an important information resource by EMS providers and may be the most commonly sought resource for various information needs during a suspected chemical exposure.

We sought to improve resident chart documentation in an academic emergency department using an incentive. A stipend for educational expenses was offered to residents for documenting charts above specific threshold Evaluation & Management (E&M) levels. Comparisons were made with historical levels. Twenty-two residents participated over 4 months (70% received the stipend). Documentation levels increased significantly from 2.86 and 3.04 during historical controls to 3.31 during the study period (p < 0.05). Fifty-six percent of charts were documented at 99284 or 99285 during the study period compared to 39% and 23% in the control periods (p < 0.05). Three months after the plan (with no incentives), documentation continued to improve, with 59% documented at 99284 or 99285. Mean collection per patient was $48.05 for the study period and $42.36 and $35.86 for the historical periods (p < 0.05). Implementation of a resident incentive program to enhance chart documentation may considerably improve documentation and resident education in proper chart documentation.

Emergency Medicine plays a vital role in the health care continuum in the United States. Michael Porters' five forces model of industry analysis provides an insight into the economics of emergency care by showing how the forces of supplier power, buyer power, threat of substitution, barriers to entry, and internal rivalry affect Emergency Medicine. Illustrating these relationships provides a view into the complexities of the emergency care industry and offers opportunities for Emergency Departments, groups of physicians, and the individual emergency physician to maximize the relationship with other market players.