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Study Objective: We assess the effectiveness of patient-controlled analgesia in the emergency department (ED). We hypothesized that decline in pain intensity from 30 to 120 minutes after initial intravenous opioid administration is greater in patients receiving morphine by patient-controlled analgesia compared with usual care and would differ by a clinically significant amount., Method: This was a pragmatic randomized controlled trial of patient-controlled analgesia and usual care (opioid and dose at physician's discretion) in 4 EDs. Entry criteria included age 18 to 65 years and acute pain requiring intravenous opioids. The primary outcome was decline in numeric rating scale pain score 30 to 120 minutes postbaseline. Secondary outcomes included satisfaction, time to analgesia, adverse events, and patient-controlled analgesia pump-related problems. We used a mixed-effects linear model to compare rate of decline in pain (slope) between groups. A clinically significant difference between groups was defined as a difference in slopes equivalent to 1.3 numeric rating scale units., Results: Six hundred thirty-six patients were enrolled. The rate of decline in pain from 30 to 120 minutes was greater for patients receiving patient-controlled analgesia than usual care (difference=1.0 numeric rating scale unit; 95% confidence interval [CI] 0.6 to 1.5; P<.001) but did not reach the threshold for clinical significance. More patients receiving patient-controlled analgesia were satisfied with pain management (difference=9.3%; 95% CI 3.3% to 15.1%). Median time to initial analgesia was 15 minutes longer for patient-controlled analgesia than usual care (95% CI 11.4 to 18.6 minutes). There were 7 adverse events in the patient-controlled analgesia group and 1 in the usual care group (difference=2.0%; 95% CI 0.04% to 3.9%), and 11 pump-programming errors., Conclusion: The findings of this study do not favor patient-controlled analgesia over usual ED care for acute pain management., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Timely diagnosis of ST-segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Obtaining this test within 10 minutes of ED arrival is critical to achieving the best outcomes. We investigated variability in the timely identification of STEMI across institutions and whether performance variation was associated with the ED characteristics, the comprehensiveness of screening criteria, and the STEMI screening processes., Methods and Results: We examined STEMI screening performance in 7 EDs, with the missed case rate (MCR) as our primary end point. The MCR is the proportion of primarily screened ED patients diagnosed with STEMI who did not receive an ECG within 15 minutes of ED arrival. STEMI was defined by hospital discharge diagnosis. Relationships between the MCR and ED characteristics, screening criteria, and STEMI screening processes were assessed, along with differences in door-to-ECG times for captured versus missed patients. The overall MCR for all 7 EDs was 12.8%. The lowest and highest MCRs were 3.4% and 32.6%, respectively. The mean difference in door-to-ECG times for captured and missed patients was 31 minutes, with a range of 14 to 80 minutes of additional myocardial ischemia time for missed cases. The prevalence of primarily screened ED STEMIs was 0.09%. EDs with the greatest informedness (sensitivity+specificity-1) demonstrated superior performance across all other screening measures., Conclusions: The 29.2% difference in MCRs between the highest and lowest performing EDs demonstrates room for improving timely STEMI identification among primarily screened ED patients. The MCR and informedness can be used to compare screening across EDs and to understand variable performance., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Objective: The objective was to determine whether sex was independently associated with door to ST-elevation myocardial infarction (STEMI) activation time. We hypothesized that women are more likely to experience longer delays to STEMI activation than men., Methods: We conducted a retrospective cohort study of adults ≥18 years who underwent STEMI activation at 3 urban emergency departments between 2010 and 2014. The Wilcoxon rank sum test and logistic regression were used to compare men and women regarding time to activation and proportion with times <15 minutes, respectively., Results: Of 400 eligible patients, we excluded 61 (15%) with prehospital activations, 44 (11%) arrests, and 3 (1%) transfers. Of the remaining 292 patients, mean age was 61±13 years, 64% were men, 57% were black, and 37% arrived by ambulance. Median door to STEMI activation time was 7.0 minutes longer for women than for men (25.5 vs 18.5 minutes, P=.028). In addition, men were more likely than women to have a door to STEMI activation time <15 minutes (45% vs 28%, P=.006). After adjusting for race, hospital site, Emergency Severity Index triage level, arrival mode, and chief concern of chest pain, the odds of men having STEMI activation times <15 minutes were 1.9 times more likely than women., Conclusions: Women have longer median door to STEMI activation times than men. A significantly lower proportion of women (28% vs 45%) are treated per American Heart Association guidelines of door to STEMI activation <15 minutes when compared with men, adjusting for confounders. Further investigation may identify possible etiology of bias and potential areas for intervention., (Copyright © 2016 Elsevier Inc. All rights reserved.)

In May 2015, the Academic Emergency Medicine consensus conference "Diagnostic imaging in the emergency department: a research agenda to optimize utilization" was held. The goal of the conference was to develop a high-priority research agenda regarding emergency diagnostic imaging on which to base future research. In addition to representatives from the Society of Academic Emergency Medicine, the multidisciplinary conference included members of several radiology organizations: American Society for Emergency Radiology, Radiological Society of North America, the American College of Radiology, and the American Association of Physicists in Medicine. The specific aims of the conference were to (1) understand the current state of evidence regarding emergency department (ED) diagnostic imaging utilization and identify key opportunities, limitations, and gaps in knowledge; (2) develop a consensus-driven research agenda emphasizing priorities and opportunities for research in ED diagnostic imaging; and (3) explore specific funding mechanisms available to facilitate research in ED diagnostic imaging. Through a multistep consensus process, participants developed targeted research questions for future research in six content areas within emergency diagnostic imaging: clinical decision rules; use of administrative data; patient-centered outcomes research; training, education, and competency; knowledge translation and barriers to imaging optimization; and comparative effectiveness research in alternatives to traditional computed tomography use.

The 2015 Academic Emergency Medicine (AEM) consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization," was held on May 12, 2015, with the goal of developing a high-priority research agenda on which to base future research. The specific aims of the conference were to: 1) understand the current state of evidence regarding emergency department (ED) diagnostic imaging utilization and identify key opportunities, limitations, and gaps in knowledge; 2) develop a consensus-driven research agenda emphasizing priorities and opportunities for research in ED diagnostic imaging; and 3) explore specific funding mechanisms available to facilitate research in ED diagnostic imaging. Over a 2-year period, the executive committee and other experts in the field convened regularly to identify specific areas in need of future research. Six content areas within emergency diagnostic imaging were identified prior to the conference and served as the breakout groups on which consensus was achieved: clinical decision rules; use of administrative data; patient-centered outcomes research; training, education, and competency; knowledge translation and barriers to imaging optimization; and comparative effectiveness research in alternatives to traditional computed tomography use. The executive committee invited key stakeholders to assist with planning and to participate in the consensus conference to generate a multidisciplinary agenda. There were 164 individuals involved in the conference spanning various specialties, including emergency medicine (EM), radiology, surgery, medical physics, and the decision sciences. This issue of AEM is dedicated to the proceedings of the 16th annual AEM consensus conference as well as original research related to emergency diagnostic imaging., (© 2015 by the Society for Academic Emergency Medicine.)

As part of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization," a panel of representatives from the National Institute of Health's Office of Emergency Care Research, the National Institute of Biomedical Imaging and Bioengineering, the Agency for Healthcare Research and Quality, and the Patient-Centered Outcomes Research Institute was assembled to discuss future opportunities for funding research in this particular area of interest. Representatives from these agencies and organizations discussed their missions and priorities and how they distribute funding. They also addressed questions on mechanisms for new and established researchers to secure future funding., (© 2015 by the Society for Academic Emergency Medicine.)

Diagnostic imaging is integral to the evaluation of many emergency department (ED) patients. However, relatively little effort has been devoted to patient-centered outcomes research (PCOR) in emergency diagnostic imaging. This article provides background on this topic and the conclusions of the 2015 Academic Emergency Medicine consensus conference PCOR work group regarding "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The goal was to determine a prioritized research agenda to establish which outcomes related to emergency diagnostic imaging are most important to patients, caregivers, and other key stakeholders and which methods will most optimally engage patients in the decision to undergo imaging. Case vignettes are used to emphasize these concepts as they relate to a patient's decision to seek care at an ED and the care received there. The authors discuss applicable research methods and approaches such as shared decision-making that could facilitate better integration of patient-centered outcomes and patient-reported outcomes into decisions regarding emergency diagnostic imaging. Finally, based on a modified Delphi process involving members of the PCOR work group, prioritized research questions are proposed to advance the science of patient-centered outcomes in ED diagnostic imaging., (© 2015 by the Society for Academic Emergency Medicine.)

While emergency diagnostic imaging use has increased significantly, there is a lack of evidence for corresponding improvements in patient outcomes. Optimizing emergency department (ED) diagnostic imaging has the potential to improve the quality, safety, and outcomes of ED patients, but to date, there have not been any coordinated efforts to further our evidence-based knowledge in this area. The objective of this article is to discuss six aspects of diagnostic imaging to provide background information on the underlying framework for the 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The consensus conference aims to generate a high priority research agenda for emergency diagnostic imaging that will inform the design of future investigations. The six components herein will serve as the group topics for the conference: 1) patient-centered outcomes research; 2) clinical decision rules; 3) training, education, and competency; 4) knowledge translation and barriers to image optimization; 5) use of administrative data; and 6) comparative effectiveness research: alternatives to traditional CT use., (© 2015 by the Society for Academic Emergency Medicine.)

Diagnostic imaging is a cornerstone of patient evaluation in the acute care setting, but little effort has been devoted to understanding the appropriate influence of sex and gender on imaging choices. This article provides background on this issue and a description of the working group and consensus findings reached during the diagnostic imaging breakout session at the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes." Our goal was to determine research priorities for how sex and gender may (or should) affect imaging choices in the acute care setting. Prior to the conference, the working group identified five areas for discussion regarding the research agenda in sex- and gender-based imaging using literature review and expert consensus. The nominal group technique was used to identify areas for discussion for common presenting complaints to the emergency department where ionizing radiation is often used for diagnosis: suspected pulmonary embolism, suspected kidney stone, lower abdominal pain with a concern for appendicitis, and chest pain concerning for coronary artery disease. The role of sex- and gender-based shared decision-making in diagnostic imaging decisions is also raised., (© 2014 by the Society for Academic Emergency Medicine.)

Background: Emergency department (ED) crowding negatively affects quality of care and disproportionately affects medium-acuity (Emergency Severity Index [ESI] level 3) patients. The effect of a dedicated area in the ED focused on these patients has not been well studied., Objectives: The objective was to find out the operational effect of a midtrack area dedicated to the evaluation and safe disposition of uncomplicated medium-acuity (ESI 3) patients., Methods: This was a 24-month pre-/postintervention study to evaluate the effect of implementation of a dedicated midtrack area at an urban tertiary academic adult ED. The midtrack had three examination rooms and three hallway stretchers for ongoing treatment staffed by an attending physician and two registered nurses (RNs). Besides the two additional RNs representing a 3.4% increase in total daily nursing hours, the intervention required no additional ED resources. The midtrack area was open from 1 p.m. to 9 p.m. on weekdays, corresponding to peak ED arrival rates. All patients presenting during weekdays were included, excluding patients triaged directly to the trauma bay or psychiatric unit or who expired in the ED. The main outcomes were left without being seen (LWBS) rates and ED length of stay (LOS), adjusting for patient volume, daily total patient hours (a proxy for ED crowding), and acuity., Results: A total of 91,903 patients were included for analysis during the study period including 261 pre- and 256 postintervention days. Comparing the pre- and postintervention periods, mean ED daily visits (173 vs. 182) and mean total daily patient hours (889 vs. 942) were all significantly higher in the postintervention period (p<0.0001). There was no significant change in percentage of patients with high triage acuity levels. Despite this increase in volume and crowding, the unadjusted and adjusted LWBS rates decreased from 6.85% to 4.46% (p<0.0001) and from 7.33% to 3.97% (p<0.0001), respectively. The mean LOS for medium-acuity patients also decreased by 39.2 minutes (p<0.0001). For high-acuity patients, there was no significant change in the mean time to room (14.69 minutes vs. 15.21 minutes, p=0.07); however, their mean LOS increased by 24 minutes (331 minutes vs. 355 minutes, p<0.0001)., Conclusions: Implementation of a midtrack area dedicated to caring for uncomplicated medium-acuity (ESI 3) patients was associated with a decrease in overall ED LWBS rates and ED LOS for medium-acuity patients., (© 2014 by the Society for Academic Emergency Medicine.)

Rationale and Objectives: Present methods for measuring adherence to national imaging quality measures often require a resource-intensive chart review. Computerized decision support systems may allow for automated capture of these data. We sought to determine the feasibility of measuring adherence to a national quality measure (NQM) regarding computed tomography pulmonary angiograms (CTPAs) for pulmonary embolism using measure-targeted clinical decision support and whether the associated increased burden of data captured required by this system would affect the use and yield of CTs., Materials and Methods: This institutional review board-approved prospective cohort study enrolled patients from September 1, 2009, through November 30, 2011, in the emergency department (ED) of a 776-bed quaternary-care adults-only academic medical center. Our intervention consisted of an NQM-targeted clinical decision support tool for CTPAs, which required mandatory input of the Wells criteria and serum D-dimer level. The primary outcome was the documented adherence to the quality measure prior and subsequent to the intervention, and the secondary outcomes were the use and yield of CTPAs., Results: A total of 1209 patients with suspected PE (2.0% of 58,795 ED visits) were imaged by CTPA during the 12-month control period, and 1212 patients were imaged in the 12 months after the quarter during which the intervention was implemented (2.0% of 59,478 ED visits, P = .84). Documented baseline adherence to the NQM was 56.9% based on a structured review of the provider notes. After implementation, documented adherence increased to 75.6% (P < .01). CTPA yield remained unchanged and was 10.4% during the control period and 10.1% after the intervention (P = .88)., Conclusions: Implementation of a clinical decision support tool significantly improved documented adherence to an NQM, enabling automated measurement of provider adherence to evidence without the need for resource-intensive chart review. It did not adversely affect the use or yield of CTPAs., (Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.)

Background: Patients with Crohn's disease (CD) are frequently exposed to diagnostic radiation in emergency departments (EDs). We aimed to examine clinical predictors of urgent abdominopelvic computed tomography (APCT) findings in this population., Methods: A retrospective cross-sectional study was performed among adults with CD presenting to 2 emergency departments with a gastrointestinal chief complaint. The outcome, APON (abscess, perforation, obstruction, new or worsening non-CD-related findings), included APCTs with new or worsening CD-related or non-CD-related urgent findings. Variables with P < 0.05 in bivariate analyses were included in a multivariable logistic regression model, which was also used to develop a risk score for APON., Results: A total of 481 APCTs were performed and 166 (34.5%) identified APON. Variables retained in the final model were history of intestinal obstruction (odds ratio [OR]: 3.78, 95% confidence interval [CI]: 2.27-6.28), history of intraabdominal abscess (OR: 2.64, 95% CI: 1.43 to 4.88), current hematochezia (OR: 0.38, 95% CI: 0.21 to 0.68), and white blood cell count >12,000/μL (OR: 2.49, 95% CI: 1.63 to 3.84). The c-statistic was 0.72. The risk score subtracts 1 point for hematochezia, and adds 1 point for each of the other variables. Among patients with a risk score of -1, the predicted and observed risk for APON was 9% and 6%, respectively. Any score greater than -1 had a predicted and observed risk of 19.8% and higher., Conclusions: An APON risk score of -1 is associated with a low risk of urgent APCT findings in patients with CD in the emergency department. Implementation of such a tool may support clinical decision-making in the ED setting.

Background: Clinical decision rules have been developed and validated for the evaluation of patients presenting with suspected pulmonary embolism (PE) to the emergency department (ED)., Objectives: The objective was to assess the percentage of computed tomographic pulmonary angiography (CT-PA) procedures that could have been avoided by use of the Wells score coupled with D-dimer testing (Wells/D-dimer) or pulmonary embolism rule-out criteria (PERC) in ED patients with suspected PE., Methods: The authors conducted a prospective cohort study of adult ED patients undergoing CT-PA for suspected PE. Wells score and PERC were calculated. A research blood sample was obtained for D-dimer testing for subjects who did not undergo testing as part of their ED evaluation. The primary outcome was PE by CT-PA or 90-day follow-up. Secondary outcomes were ED length of stay (LOS) and CT-PA time as defined by time from order to initial radiologist interpretation., Results: Of 152 suspected PE subjects available for analysis (mean ± SD age = 46.3 ± 15.6 years, 74% female, 59% black or African American, 11.8% diagnosed with PE), 14 (9.2%) met PERC, none of whom were diagnosed with PE. A low-risk Wells score (≤4) was assigned to 110 (72%) subjects, of whom only 38 (35%) underwent clinical D-dimer testing (elevated in 33/38). Of the 72 subjects with low-risk Wells scores who did not have D-dimers performed in the ED, archived research samples were negative in 16 (22%). All 21 subjects with low-risk Wells scores and negative D-dimers were PE-negative. CT-PA time (median = 160 minutes) accounted for more than half of total ED LOS (median = 295 minutes)., Conclusions: In total, 9.2 and 13.8% of CT-PA procedures could have been avoided by use of PERC and Wells/D-dimer, respectively., (© 2012 by the Society for Academic Emergency Medicine.)

Recent-onset atrial fibrillation, defined as a first detected or recurrent episode of atrial fibrillation lasting less than 48 hours, is a commonly encountered dysrhythmia in the emergency department (ED). Cardioversion of stable patients in the ED with recent-onset atrial fibrillation without antecedent anticoagulation would allow for these patients to be discharged directly to home. We searched the literature to determine whether any studies have investigated the safety of this management strategy and identified five that addressed this question. These studies are reviewed herein; importantly, not one ED patient who was cardioverted in any of the five studies suffered a thromboembolic event - the feared complication responsible for most of the controversy surrounding the ED management of atrial fibrillation. According to the available evidence, we conclude that it would be within the standard of care to discharge home stable patients with recent-onset atrial fibrillation after cardioversion in the ED with adequate follow-up. It should be noted that although this strategy is safe and effective, the return visit rate for relapsed atrial fibrillation is 3% to 17%, and patients should be made aware of this possibility.

Objectives: A novel wound closure device combining a mesh tape and octylcyanoacrylate (OCA) topical skin adhesive (TSA) was developed to facilitate wound closure and enhance the adhesive's strength. The objective of this study was to determine whether the incidence of wound dehiscence after laceration repair with the new device was equivalent to that after use of a high-viscosity OCA. We hypothesized that the rate of complete wound edge apposition would be equivalent for the two closure devices., Methods: This was a multicenter, randomized clinical trial in nine academic and community emergency departments (EDs) and urgent care centers. Patients with simple traumatic lacerations were included. Lacerations were randomly closed with a high-viscosity OCA or mesh tape-OCA combination. The rate of complete wound edge apposition at 14 days, rates of wound infection at 14 and 30 days, and the percentage of optimally appearing scars at 30 days after closure were assessed. Assuming a maximal clinically acceptable difference for equivalence of 8% in the rate of completely apposed wound edges, a sample of at least 138 patients in the tape-OCA group and at least 69 in the OCA-only group would give 80% power and a one-sided significance level of 5%., Results: During the study period the investigators enrolled 216 subjects, of whom 143 were randomized to the tape-OCA combination and 73 to the OCA-only group. Most wounds were located on the face and the upper extremities. Mean laceration length was similar in patients in both groups (tape-OCA 2.1 cm vs. OCA-only 2.0 cm; difference 0.1 cm, 95% confidence interval [CI] = -0.45 to 0.58 cm). The rate of complete wound edge apposition at 14 days was higher in wounds treated with the tape-OCA combination than in wounds treated with OCA alone (86.0% vs. 78.1%). The upper bound of the one-sided CI was 1.0% for the intention-to-treat population, which was less than the predetermined acceptable difference of less than 8%. There were no between-group differences in rates of infection and optimally appearing scars., Conclusions: When compared with OCA alone, the novel tape-OCA combination is equivalent with regard to complete wound edge apposition and cosmetic appearance., (© 2011 by the Society for Academic Emergency Medicine.)

Background: Necrotizing fasciitis (NF) is a rapidly progressive disease that requires urgent surgical debridement for survival. Interhospital transfer (IT) may be associated with delay to operation, which could increase mortality. We hypothesized that mortality would be higher in patients undergoing surgical debridement for necrotizing fasciitis after IT compared to Emergency Department (ED) admission., Methods: We performed a retrospective cohort analysis from 2000-2006 using the Nationwide Inpatient Sample. Inclusion criteria were age >18 years, primary diagnosis of NF, and surgical therapy within 72 hours of admission. Logistic regression was used to assess the relationship between admission source, patient and hospital variables, and mortality., Results: We identified 9,958 cases over the study period. Patients in the ED group were more likely to be nonwhite and of lower income when compared with patients in the IT group. Unadjusted mortality was higher in the IT group than ED group (15.5% vs 8.7%, P < .001). After adjusting for potential confounders, odds of mortality were still greater in the IT (OR 2.04, CI 95% 1.60-2.59, P < .001)., Conclusion: Interhospital transfer is associated with increased risk of in-hospital mortality after surgical therapy for NF, a finding which persists after controlling for patient and hospital level variables., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objective: Research on how race affects access to analgesia in the emergency department (ED) has yielded conflicting results. We assessed whether patient race affects analgesia administration for patients presenting with back or abdominal pain., Methods: This is a retrospective cohort study of adults who presented to 2 urban EDs with back or abdominal pain for a 4-year period. To assess differences in analgesia administration and time to analgesia between races, Fisher exact and Wilcoxon rank sum test were used, respectively. Relative risk regression was used to adjust for potential confounders., Results: Of 20,125 patients included (mean age, 42 years; 64% female; 75% black; mean pain score, 7.5), 6218 (31%) had back pain and 13,907 (69%) abdominal pain. Overall, 12,109 patients (60%) received any analgesia and 8475 (42%) received opiates. Comparing nonwhite (77 %) to white patients (23%), nonwhites were more likely to report severe pain (pain score, 9-10) (42% vs 36%; P < .0001) yet less likely to receive any analgesia (59% vs 66%; P < .0001) and less likely to receive an opiate (39% vs 51%; P < .0001). After controlling for age, sex, presenting complaint, triage class, admission, and severe pain, white patients were still 10% more likely to receive opiates (relative risk, 1.10; 95% confidence interval, 1.06-1.13). Of patients who received analgesia, nonwhites waited longer for opiate analgesia (median time, 98 vs 90 minutes; P = .004)., Conclusions: After controlling for potential confounders, nonwhite patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: The authors assessed the association between measures of emergency department (ED) crowding and treatment with analgesia and delays to analgesia in ED patients with back pain., Methods: This was a retrospective cohort study of nonpregnant patients who presented to two EDs (an academic ED and a community ED in the same health system) from July 1, 2003, to February 28, 2007, with a chief complaint of "back pain." Each patient had four validated crowding measures assigned at triage. Main outcomes were the use of analgesia and delays in time to receiving analgesia. Delays were defined as greater than 1 hour to receive any analgesia from the triage time and from the room placement time. The Cochrane-Armitage test for trend, the Cuzick test for trend, and relative risk (RR) regression were used to test the effects of crowding on outcomes., Results: A total of 5,616 patients with back pain presented to the two EDs over the study period (mean+/-SD age=44+/-17 years, 57% female, 62% black or African American). Of those, 4,425 (79%) received any analgesia while in the ED. A total of 3,589 (81%) experienced a delay greater than 1 hour from triage to analgesia, and 2,985 (67%) experienced a delay more than 1 hour from room placement to analgesia. When hospitals were analyzed separately, a higher proportion of patients experienced delays at the academic site compared with the community site for triage to analgesia (87% vs. 74%) and room to analgesia (71% vs. 63%; both p<0.001). All ED crowding measures were associated with a higher likelihood for delays in both outcomes. At the academic site, patients were more likely to receive analgesia at the highest waiting room numbers. There were no other differences in ED crowding and likelihood of receiving medications in the ED at the two sites. These associations persisted in the adjusted analysis after controlling for potential confounders of analgesia administration., Conclusions: As ED crowding increases, there is a higher likelihood of delays in administration of pain medication in patients with back pain. Analgesia administration was not related to three measures of ED crowding; however, patients were actually more likely to receive analgesics when the waiting room was at peak levels in the academic ED., (Copyright (c) 2010 by the Society for Academic Emergency Medicine.)

Objective: We assessed the relationship between emergency department (ED) crowding and delays in care in patients presenting with abdominal pain who receive abdominal computed tomography (CT)., Methods: Prospective cohort study of adults who presented over a 1-year period to 2 urban academic EDs with abdominal pain and received CT. Each subject had 3 validated crowding measures assigned at enrollment (ED census, waiting room number, number of admitted patients). These were normalized to quartiles to signify least to most crowded. The Cuzick test was used for trend and log-linear regression and tested the association between ED crowding and time from triage to CT read. The time interval was further decomposed into triage to room, room to CT order, and order to CT read times. The adjusted analysis controlled for age, sex, race, pain score, time of day, triage level, and site., Results: 767 patients were enrolled (mean age, 44 +/- 17 years; 61% female; 60% black). Median time from triage to CT read was 375 minutes (interquartile range [IQR], 276-497). Individual time intervals included triage to room (46 minutes [IQR, 16-111]), room to CT order (83 minutes [IQR, 38-151]), and order to CT read (203 minutes [IQR, 138-375]). Across waiting room quartiles, triage to CT read was associated with progressively longer times (318 vs 364 vs 414 vs 445 minutes; P < 0.001 for trend). Similar trends were noted for waiting room number and admitted patients (P < 0.001). In multivariable analysis, the association between ED crowding and time from triage to CT read remained significant and consistent across all crowding measures (P < 0.001). When decomposed into time intervals, triage to room time showed the greatest difference (22 vs 38 vs 72 vs 92 minutes; P < 0.001)., Conclusion: ED crowding is associated with an approximately 2-hour delay to CT interpretation availability. Attempts to reduce delays in abdominal CTs may include earlier provider evaluation and placement in the queue for scanning.

Objectives: The authors assessed the effect of emergency department (ED) crowding on the nontreatment and delay in treatment for analgesia in patients who had acute abdominal pain., Methods: This was a secondary analysis of prospectively enrolled nonpregnant adult patients presenting to an urban teaching ED with abdominal pain during a 9-month period. Each patient had four validated crowding measures assigned at triage. Main outcomes were the administration of and delays in time to analgesia. A delay was defined as waiting more than 1 hour for analgesia. Relative risk (RR) regression was used to test the effects of crowding on outcomes., Results: A total of 976 abdominal pain patients (mean [+/-standard deviation] age = 41 [+/-16.6] years; 65% female, 62% black) were enrolled, of whom 649 (67%) received any analgesia. Of those treated, 457 (70%) experienced a delay in analgesia from triage, and 320 (49%) experienced a delay in analgesia after room placement. After adjusting for possible confounders of the ED administration of analgesia (age, sex, race, triage class, severe pain, final diagnosis of either abdominal pain not otherwise specified or gastroenteritis), increasing delays in time to analgesia from triage were independently associated with all four crowding measures, comparing the lowest to the highest quartile of crowding (total patient-care hours RR = 1.54, 95% confidence interval [CI] = 1.32 to 1.80; occupancy rate RR = 1.64, 95% CI = 1.42 to 1.91; inpatient number RR = 1.57, 95% CI = 1.36 to 1.81; and waiting room number RR = 1.53, 95% CI = 1.31 to 1.77). Crowding measures were not associated with the failure to treat with analgesia., Conclusions: Emergency department crowding is associated with delays in analgesic treatment from the time of triage in patients presenting with acute abdominal pain.

Objectives: Oligoanalgesia for acute abdominal pain historically has been attributed to the provider's fear of masking serious underlying pathology. The authors assessed whether a gender disparity exists in the administration of analgesia for acute abdominal pain., Methods: This was a prospective cohort study of consecutive nonpregnant adults with acute nontraumatic abdominal pain of less than 72 hours' duration who presented to an urban emergency department (ED) from April 5, 2004, to January 4, 2005. The main outcome measures were analgesia administration and time to analgesic treatment. Standard comparative statistics were used., Results: Of the 981 patients enrolled (mean age +/- standard deviation [SD] 41 +/- 17 years; 65% female), 62% received any analgesic treatment. Men and women had similar mean pain scores, but women were less likely to receive any analgesia (60% vs. 67%, difference 7%, 95% confidence interval [CI] = 1.1% to 13.6%) and less likely to receive opiates (45% vs. 56%, difference 11%, 95% CI = 4.1% to 17.1%). These differences persisted when gender-specific diagnoses were excluded (47% vs. 56%, difference 9%, 95% CI = 2.5% to 16.2%). After controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes)., Conclusions: Gender bias is a possible explanation for oligoanalgesia in women who present to the ED with acute abdominal pain. Standardized protocols for analgesic administration may ameliorate this discrepancy.

Objectives: We hypothesize that nonpediatric and pediatric residents are exposed to a very low percentage of critically ill patients in a high-volume children's hospital emergency department (ED)., Methods: Retrospective chart review of resident-patient encounters during a 1-year period using a patient tracking system. Critically ill patients included those who were triaged as "critical," died in the ED, or admitted to the intensive care unit. Descriptive data are presented as means +/- SD, frequencies, and percentages. Analysis of variance was used for continuous data and the chi test for categorical data., Results: A total of 3048 (4.2% of the total ED volume) critically ill patients with a mean age of 6 (+/- 5.6) years were evaluated. One hundred four emergency medicine (EM) residents were involved in the care of 903 (30%), 136 pediatric residents managed 2003 (65%), and 36 family medicine residents managed 142 (5%) critically ill patients. There was no significant difference in the mean age of evaluated patients compared by type of training program. On average, EM residents evaluated 5 patients per 10 shifts compared with pediatric residents ([9 patients per 10 shifts] P < 0.0001). Unlike pediatric residents, the number of patients cared for by EM or family medicine residents did not increase with the level of resident training. Sixty-seven life-saving procedures were performed, of which 32 (48%) were cardiopulmonary resuscitations and 35 (52%) were intubations., Conclusions: Pediatric and nonpediatric residents who rotate through a high-volume children's hospital ED are exposed to a very low number of critically ill children. Other educational formats, such as mock resuscitations or standardized patient encounters, may be required to correct this deficit.

Objective: We hypothesized that emergency physicians would use more resources to evaluate acute abdominal pain in obese patients as compared with that in nonobese patients., Methods: We conducted a secondary analysis of a prospective cohort of adults with acute abdominal pain. Collected data included self-reported height and weight, demographics, medical history, laboratory and x-ray results, and final diagnosis. We followed the patients until they obtained their final diagnosis or for up to 21 days. Patients were grouped according to their body mass index (BMI): nonobese (BMI < 30 kg/m2), obese (BMI = 30-40 kg/m2), and morbidly obese (BMI > 40 mg/m2). The main outcome measure was laboratory and radiographic testing. chi2 Tests and analysis of variance were used as appropriate., Results: Of the 971 patients (mean age, 41 years; 62% black; 65% female), 665 (68%) were nonobese, 246 (25%) were obese, and 60 (6%) were morbidly obese. In comparing nonobese patients with obese patients, we found no difference in laboratory or radiographic testing (3.20 vs 3.21 tests; mean difference, 0.004; 95% confidence interval [CI], -0.26 to 0.27), physicians' pre-computed tomographic scan confidence level in their diagnosis (6.17 vs 6.04, mean difference, -0.13; 95% CI, -0.76 to 0.49), and emergency department (ED) length of stay (LOS; 7.40 vs 7.57 hours; mean difference, -0.17; 95% CI, -0.49 to 0.83). In comparing all 3 groups, we found no difference in diagnostic testing, ED LOS, surgical intervention (10% vs 5% vs 9%, P = .2), disposition, and final diagnosis (P > .05)., Conclusions: Physicians do not use more resources to identify the etiology of acute abdominal pain in obese patients as compared with that in nonobese patients. Furthermore, ED LOS, likelihood of surgical intervention, physicians' confidence level in their preimaging diagnosis, and final diagnosis do not appear to be influenced by BMI.

Study Objective: Despite creatinine clearance (CrCl) being a better estimate of renal function, serum creatinine (Cr) is more commonly used to screen for renal insufficiency in patients scheduled for an enhanced abdominal computed tomography (CT) in an attempt to reduce the likelihood of contrast-induced nephropathy (CIN). Our objective was to determine the incidence of renal insufficiency (a CrCl <60 mL/min) among patients who have serum Cr below 1.5 mg/dL (the most commonly accepted Cr cutoff for the administration of intravenous contrast). This study was conducted in a population of emergency department patients with acute abdominal pain being considered for CT scan., Methods: We performed post hoc analysis of a prospective cross-sectional study that enrolled nongravid adults with acute nontraumatic abdominal pain. Patients on dialysis were excluded. The data that we collected included demographics, history, duration/description of pain, patient reported weight, laboratory data, imaging studies, and final diagnosis. Creatinine clearance values (< or >60 mL/min) were compared to Cr values of 1.0, 1.2, 1.5, and 1.8 mg/dL to determine the percentage of patients at risk for nephropathy after contrast injection at each Cr cutoff. Descriptive statistics were used with 95% confidence intervals (CIs)., Results: Seven hundred sixty-five patients were enrolled; 59% (451/765) had an abdominal CT scan. Of 108 patients with CrCl less than 60 mL/min, 59 patients had a Cr less than 1.8 mg/dL (55%; 95% CI, 45%-64%); 43 had a Cr less than 1.5 mg/dL, the most commonly accepted Cr cutoff for contrast administration (40%; 95% CI, 31%-50%); 21 patients had a Cr less than 1.2 mg/dL (19%; 95% CI, 12%-28%); and 10 had a Cr less than 1.0 mg/dL (9%; 95% CI, 5%-16%)., Conclusion: The most commonly used Cr cutoff (1.5 mg/dL) for contrast administration fails to identify 40% of the patients at risk for CIN. Future studies should address whether using CrCl rather than serum Cr decreases the incidence of contrast-induced nephropathy.

Background: Emergency department (ED) overcrowding threatens quality of care by delaying the time to diagnosis and treatment of patients with time-sensitive diseases, such as acute stroke., Objective: The authors hypothesized that the presence of a trauma alert evaluation would impede the time to head computed tomography (hCT) in patients with stroke-like symptoms., Methods: This was a secondary analysis of prospectively collected data on patients with potential stroke who received an hCT in an urban trauma center ED from January 1, 2004, to November 30, 2004. Structured data collection included historical and examination items, National Institutes of Health (NIH) stroke scale score, laboratory and radiographic results, and final diagnosis. Admitted patients were followed in hospital. Patients who presented within one hour following a trauma evaluation were compared with patients who presented without concurrent trauma for triage time until completion of hCT. Chi-square, t-tests, and 95% confidence intervals (95% CIs) were used for comparisons., Results: The 171 patients enrolled had a mean (+/- standard deviation) age of 60.7 (+/- 7) years; 60% were female; and 58% were African American. Of these, 72 patients had a significant cerebrovascular event (38 [22%] ischemic stroke, 25 [15%] transient ischemic attack, seven [4%] intracranial hemorrhage, one [0.6%] subarachnoid hemorrhage, and one [0.6%] subdural hematoma). The remaining diagnoses included 4.6% migraine, 2.3% seizure, 2.9% syncope, 2.3% Bell's palsy, and 2.9% vertigo. There was no significant difference in time to hCT in patients who presented during a trauma activation and those who did not (99 minutes [interquartile range (IQR) = 24-156] vs. 101 minutes [IQR = 43-151.5]; p = 0.537). In subgroup analysis of patients with a significant cerebrovascular event, times to hCT were also similar (24 minutes [IQR = 12-99] vs. 61 minutes [IQR = 15-126]; p = 0.26)., Conclusions: In the authors' institution, the presence of concurrent trauma evaluation does not delay CT imaging of patients with potential stroke.