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There is a paucity of data looking at resident error or contrasting errors and adverse events among residents and attendings. This type of data could be vital in developing and enhancing educational curricula OBJECTIVES: Using an integrated, readily accessible electronic error reporting system the objective of this study is to compare the frequency and types of error and adverse events attributed to emergency medicine residents with those attributed to emergency medicine attendings.Individual events were classified into errors and/or adverse events, and were attributed to one of three groups-residents only, attendings only, or both (if the event had both resident and attending involvement). Error and adverse events were also classified into five different categories of events-systems, documentation, diagnostic, procedural and treatment. The proportion of error events were compared between the residents only and the attendings only group using a one-sample test of proportions. Categorical variables were compared using Fisher's exact test.Of a total of 115 observed events over the 11-month data collection period, 96 (83.4%) were errors. A majority of these errors, 40 (41.7%), were attributed to both residents and attendings, 20 (20.8%) were attributed to residents only, and 36 (37.5%) were attributed to attendings only. Of the 19 adverse events, 14 (73.7%) were attributed to both residents and attendings, and 5 (26.3%) adverse events were attributed to attendings only. No adverse events were attributed solely to residents (Table 1). Excluding events attributed to both residents and attendings, there was a significant difference between the proportion of errors attributed to attendings only (64.3%, CI: 50.6, 76.0), and residents only (35.7%, CI: 24.0, 49.0), p = 0.03. (Table 2). There was no significant difference between the residents only and the attendings only group in the distribution of errors and adverse events (Fisher's exact, p = 0.162). (Table 2). There was no statistically significant difference between the two groups in errors that did not result in adverse events and the rate of errors proceeding to adverse events (Fisher's exact, p = 0.15). (Table 3). There was no statistically significant difference between the two groups in the distribution of the types of errors and adverse events (Fisher's exact, p = 0.09). Treatment related errors were the most common error types, for both the attending and the resident groups.Resident error, somewhat expectedly, is most commonly related to treatment interventions, and rarely is due to an individual resident mistake. Resident error instead seems to reflect concomitant error on the part of the attending. Error, in general as well as adverse events, are more likely to be attributed to an attending alone rather than to a resident.

Introduction The evaluation of peer‐reviewed cases for error is key to quality assurance (QA) in emergency medicine, but defining error to ensure reviewer agreement and reproducibility remains elusive. The objective of this study was to create a consensus‐based set of rules to systematically identify medical errors. Methods This is a prospective, observational study of all cases presented for peer review at an urban, tertiary care, academic medical center emergency department (ED) quality assurance (QA) committee between October 13, 2015, and September 14, 2016. Our hospital uses an electronic system enabling staff to self‐identify QA issues for subsequent review. In addition, physician or patient complaints, 72‐hour returns with admission, death within 24 hours, floor transfers to ICU

BACKGROUND The Society for Academic Emergency Medicine Board of Directors convened a Task Force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The Task Force surveyed academic emergency department (ED) Chairs and Residency Program Directors. METHODS The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member Chairs and their respective Residency Program Directors (PDs) in 2021. We surveyed 125 Chairs with their self-identified PDs. The survey sampled hiring, state independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. RESULTS Of the AACEM-member Chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast track settings, 80% work in the main ED and 54% in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents report that APPs manage high-acuity patients without attending involvement. Two-thirds of Chairs believe that APPs contribute positively to the quality of patient care, while 44% believe APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. CONCLUSIONS APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic emergency department within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.

Burnout is a work-related condition. Although stress may be a part of emergency medicine, excessive levels of chronic stress can lead to maladaptive behaviors and burnout. Burnout can lead to decreased physician longevity and performance and poorer patient outcomes. The first step is recognizing burnout in providers. Efforts can then be made to identify modifiable or unnecessary sources of stress to help reduce chronic stress and burnout. Solutions should be found to eliminate or ameliorate individual-level and system-level sources of stress.

Study Objectives: Altered mental status (AMS) is frequently associated with poor outcomes across a wide spectrum of conditions including infections. This study aims to identify whether AMS in emergency department (ED) patients with COVID-19 is independently associated with in-hospital mortality. Methods: This was a retrospective multicenter cohort study. We included all patients with a positive SARS-CoV-2 PCR within 2 weeks of presentation, who were admitted from the ED of three hospitals in the greater Boston area between March and August 2020. The primary covariate of interest was ED AMS at ED arrival and the primary outcome was in-hospital mortality. The ED charts were abstracted for demographics, comorbid conditions, symptoms, laboratory testing, and radiology testing along with in-hospital outcomes. AMS was defined by documentation of changes in mental status from baseline. We used logistic regression modeling with backwards elimination to determine an adjusted estimate for the independent association of AMS with mortality. Results: We included 824 visits with 51% male, a mean age was 67.1 (SD 17.0) and 153 (18.6%) had AMS. There were 132 deaths for an overall mortality rate of 16.1%. Patients with AMS had in-hospital mortality of 38.2% (95% CI 30.4%-46.4%), compared to 11.1% (8.8%-13.7%) for patients without AMS (p

Minimizing and preventing adverse events and medical errors in the emergency department (ED) is an ongoing area of quality improvement. Identifying these events remains challenging.To investigate the utility of tracking patients transferred to the ICU within 24h of admission from the ED as a marker of preventable errors and adverse events.From November 2011 through June 2016, we prospectively collected data for all patients presenting to an urban, tertiary care academic ED. We utilized an automated electronic tracking system to identify ED patients who were admitted to a hospital ward and then transferred to the ICU within 24h. Reviewers screened for possible error or adverse event and if discovered the case was referred to the departmental Quality Assurance (QA) committee for deliberations and consensus agreement.Of 96,377 ward admissions, 921 (1%) patients were subsequently transferred to the ICU within 24h of ED presentation. Of these 165 (19%) were then referred to the QA committee for review. Total rate of adverse events regardless of whether or not an error occurred was 2.1%, 19/921 (95% CI 1.4% to 3.0%). Medical error on the part of the ED was 2.2%, 20/921 (95% CI 1.5% to 3.1%) and ED Preventable Error in 1.1%, 10/921 (95% CI 0.6% to 1.8%).Tracking patients admitted to the hospital from the ED who are transferred to the ICU24h after admission may be a valuable marker for adverse events and preventable errors in the ED.

Recent news stories have explicitly stated that patients with symptoms of COVID‐19 were “turned away” from emergency departments. This commentary addresses these serious allegations, with an attempt to provide the perspective of academic emergency departments (EDs) around the Nation. The overarching point we wish to make is that academic EDs never deny emergency care to any person.

Study objective Single-payer health care is supported by most Americans, but the effect of single payer on any particular sector of the health care market has not been well explored. We examine the effect of 2 potential single-payer designs, Medicare for All and an alternative including Medicare and Medicaid, on total payments and out-of-pocket spending for treat-and-release emergency care (patients discharged after an emergency department [ED] visit). Methods We used the 2013 to 2016 Medical Expenditure Panel Survey to determine estimates of payments made for ED visits by insurance type, and the 2015 National Hospital Ambulatory Medical Care Survey to estimate the proportion of ED visits covered by each insurance type. Results We found that total payments were predicted to increase from $85.5 billion to $89.0 billion (range $81.3 to $99.8 billion) in the Medicare-only scenario and decrease to $79.4 billion (range $71.6 to $87.2 billion) under Medicare/Medicaid, whereas out-of-pocket costs were predicted to decrease from $116 per visit to $45 with Medicare and to $36 with Medicare/Medicaid. Conclusion In this study of ED treat-and-release patients, a transition to a Medicare for All system may increase ED reimbursement and reduce consumer out-of-pocket costs, whereas a system that maintains Medicaid in addition to Medicare could reduce total payments for emergency care.

Postgraduate training in emergency medicine (EM) varies in length among different programs. This fact creates a dilemma for applicants to the specialty of EM and prevents EM educators from reaching a consensus regarding the optimal length of training. Historically, EM training existed in the postgraduate year (PGY) 1-3, 2-4, and 1-4 formats, until the PGY 2-4 program became obsolete in 2011-2012. Currently, three-quarters of EM programs follow the PGY 1-3 format. In this article, we clarify for the applicants the main differences between the PGY 1-3 and PGY 1-4 formats. We also discuss the institutional, personal, and graduate considerations that explain why an institution or an individual would choose one format over the other.

Morbidity and Mortality (MM) rounds are peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. Their primary objective is to learn from complications and errors, modify behavior and judgment based on previous experiences, and prevent repetition of errors leading to complications. The objective of this study was to determine if MM conferences can reduce repetitive error making demonstrated by a shift of the incidence of cases presented at MM by chief complaint (CC) and experience of attendings.All MM cases from 1/1/2014-12/31/2017 derived from an urban, tertiary referral Emergency Department were reviewed and grouped into 12 different CC categories and by attending years of experience (1-4, 5-9 and 10+). Number and percent of MM cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed.350 MM cases were presented over the four-year study period. There was a significant difference between CC categories from year-to-year (p 0.001). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p 0.001).There was a persistent significant difference across CC categories of MM cases from year-to-year, with down-trending and up-trending of specific CCs suggesting that MM presentation may prevent repetitive errors. Newer attendings show increased rates of MM cases relative to more experienced attendings. There may be a distinctive educational benefit of participation at MM for attendings with fewer than five years of clinical experience.

Background: The value of systematic evaluation of both patient and physician identified QA issues in emergency medicine remains poorly characterized as a marker for Emergency Department (ED) quality assurance. Objective: The objective of this study was to determine whether systematic screening and evaluation of patient and physician concerns is useful for identifying physician errors resulting in either an adverse event or a near miss event. Methods: Retrospective, observational cohort study of consecutive patients presenting to an urban, tertiary care academic medical center ED with an annual volume of 57,000 patients between January 2008 and December 2014. Our hospital has an electronic system that easily allows physicians to register a concern or self-identify a potential QA issue for subsequent review. In our system, both patient and physician concerns are then assigned for review by physician evaluators not involved with the patients’ care. Patient complaints were initially prescreened by an experienced evaluator and those not pertaining to possible physician error, such as complaints related to billing, creature comfort, communication, nursing related complaints and waiting times were eliminated unless the reviewer identified a possible physician error. If in addition to these other factors, a potential QA issue was present, the case was referred to the QA committee Reviewers are prompted to use a structured 8-point Likert scale to assess for the presence of error and adverse events. If a reviewer assessed that the case involved a possible error or adverse event that resulted in the need for intervention, additional treatment, or caused patient harm, it was referred to a 20-member quality assurance (QA) committee of ED physicians and nurses who made a final determination as to whether or not an error or adverse event occurred. Results: We identified 570 concerns within a data-base of 383,419 ED presentations, of which 33 were patient-generated and 537 were physician-generated. In the subset of cases where there was a complaint by either patient or physician, physician errors that led to a preventable adverse event were detected in 2.9% of cases (95%CI 1.52% to 4.28%). Further analysis revealed that 9.1% (95%CI 2-24%) of patient complaints correlated to preventable errors leading to an adverse event. In contrast, 2.6% (2-4%) of QA concerns made by a physician alone were found to be preventable physician errors leading to an adverse event. Near miss events (errors without adverse outcome) were more accurately reported by physicians, with physician error found in 12.1% of reported cases (95%CI 10-15%) and in 9.1% of those reported by patients (95%CI 2-24%). Adverse events in general that were not deemed to be due to preventable physician error were found in 12.1% of patient complaints (95%CI 3-28%) and in 5.8% of physician QA concerns (95%CI 4-8%). Conclusion: Screening and systemized evaluation of emergency department patient and physician complaints may be an underutilized and efficient quality assurance tool. Patient complaints may more accurately identify physician errors that result in preventable adverse events, while physician QA concerns may be more likely to uncover a near miss that did not lead to an adverse event.

Introduction Differentiating shock etiologies is a challenging task in the Emergency Department (ED); even the strongest clinical predictors leave some diagnostic uncertainty. This study sought to establish an evidence base for using clinical covariates in the diagnostic evaluation of septic shock. Methods We conducted a prospective, observational study of consecutive ED patients with shock from November 11, 2012 to September 23, 2013. We included all patients at least 18 years old with shock, defined as new vasopressor requirement, systolic blood pressure less than 90 mmHg after at least 1 L of crystalloid or 2 units packed red blood cells, or systolic blood pressure less than 90 mmHg and fluids withheld due to concern for fluid overload. Multivariate logistic regression and recursive partitioning models were constructed, predicting septic cause of shock. The logistic regression model was derived using first 500 patients, and validated with the subsequent 200 patients. Results In the derivation cohort, 55.6% (95% confidence interval: 51.2%-60.0%) were septic, and 20.8% (17.2%-24.4%) died during hospitalization. The multivariate model (derivation area under the curve = 0.88, validation area under the curve = 0.89) identified predictors of septic shock, including temperature more than 100.4°F (odds ratio 4.6, 2.3-9.2) and history of fever (odds ratio 9.2, 4.4-19.2); however, only 153 of 277 (55.3%, 49.5%-61.2%) patients with septic shock had either of these findings. In the recursive partitioning model, if all predictors were absent, the probability of sepsis causing shock was 21% (16.6%-25.6%). Conclusions Clinical data can predict the presence of sepsis causing shock in the ED in most patients. The remaining diagnostic uncertainty provides an opportunity for adding novel diagnostic testing.

Chart review has been the mainstay of medical quality assurance practices since its introduction more than a century ago. The validity of chart review, however, has been vitiated by a lack of methodological rigor.By measuring the degree of interrater agreement among a 13-member review board of emergency physicians, we sought to validate the reliability of a chart review-based quality assurance process using computerized screening based on explicit case parameters.All patients presenting to an urban, tertiary care academic medical center emergency department (annual volume of 57,000 patients) between November 2012 and November 2013 were screened electronically. Cases were programmatically flagged for review according to explicit criteria: return within 72hours, procedural evaluation, floor-to-ICU transfer within 24hours of admission, death within 24hours of admission, physician complaints, and patient complaints. Each case was reviewed independently by a 13-member emergency department quality assurance committee all of whom were board certified in emergency medicine and trained in the use of the tool. None of the reviewers were involved in the care of the specific patients reviewed by them. Reviewers used a previously validated 8-point Likert scale to rate the (1) coordination of patient care, (2) presence and severity of adverse events, (3) degree of medical error, and (4) quality of medical judgment. Agreement among reviewers was assessed with the intraclass correlation coefficient (ICC) for each parameter.Agreement and the degree of significance for each parameter were as follows: coordination of patient care (ICC=0.67; P.001), presence and severity of adverse events (ICC=0.52; P=.001), degree of medical error (ICC=0.72; P.001), and quality of medical judgment (ICC=0.67; P.001).Agreement in the chart review process can be achieved among physician-reviewers. The degree of agreement attainable is comparable to or superior to that of similar studies reported to date. These results highlight the potential for the use of computerized screening, explicit criteria, and training of expert reviewers to improve the reliability and validity of chart review-based quality assurance.

Background The Joint Commission requires health care organizations to monitor and evaluate procedural sedation. However, the utility of mandatory review of procedural sedation in evaluating health care quality is unknown. Objective To determine whether procedural sedation is a useful marker for evaluating error in the emergency department (ED). Methods We prospectively collected data for patients presenting to an urban, tertiary care, academic medical center ED between October 2013 and June 2015. We used an automated, electronic tracking system to identify patients who underwent procedural sedation. We randomly assigned cases to physician reviewers. Reviewers used a structured tool to determine the presence of error and adverse events. If a reviewer felt that the case had an error or adverse event, it was referred to a quality assurance (QA) committee, which made a final determination as to whether or not an error or adverse event occurred. Results There were 166 cases of procedural sedation reviewed. Two errors were identified, for an error rate of 1.2% (95% confidence interval [CI] 0.003–0.043). Both errors occurred during the use of propofol to facilitate upper gastrointestinal endoscopy. Neither error resulted in an adverse event. One adverse event was identified that was unrelated to physician error (0.6%; 95% CI 0.001–0.033). Conclusion Routine review of procedural sedation performed in the ED offers little advantage over existing QA markers. Directed review of high-risk cases, such as those involving endoscopy or other longer-duration procedures, may be more useful. Future studies focusing quality review on projected high-risk sedation cases may establish more valuable markers for QA review.

INTRODUCTION: The pyruvate dehydrogenase complex (PDH) is an essential enzyme in aerobic metabolism;. Ketones are known to inhibit PDH activity, but the extent of this inhibition is unknown in patients with diabetic ketoacidosis (DKA).RESEARCH DESIGN AND METHODS: We enrolled adult patients presenting to the emergency department in hyperglycemic crisis. Patients were classified as DKA or hyperglycemia without ketoacidosis based on laboratory criteria. Healthy controls were also enrolled. PDH activity and quantity were measured in isolated peripheral blood mononuclear cells. We compared PDH values between groups and measured the relationship of PDH values to measures of acid-base status.RESULTS: 27 patients (17 with DKA) and 31 controls were enrolled. Patients with DKA had lower PDH activity and quantity as compared to the two other groups. PDH activity was significantly correlated with serum bicarbonate and pH, and inversely correlated with the anion gap.CONCLUSION: DKA is associated with greater suppression of PDH activity than hyperglycemia without ketoacidosis, and this is correlated with measures of acid-base status. Future studies may determine whether PDH depression plays a role in the pathophysiology of DKA and whether modification of PDH could decrease time to DKA resolution. This article is protected by copyright. All rights reserved.

Acute emergent presentations of the thyroid and parathyroids are rarer occurrences in the emergency department but essential to diagnose and treat early in the course of illness. Disorders of the parathyroids are typically related to circulating calcium levels and the metabolic effects thereof, whereas thyroid deficiency or excess can lead to profound shock, coma, hypothermia, hyperthermia, and death. The diagnosis of parathyroid disease should be considered in patients presenting with signs and symptoms consistent with hyper- or hypocalcemia. Myxedema coma should be considered in any patient presenting with evidence of severe sepsis or shock, particularly when there is a history of hypothyroidism. Thyroid storm should be suspected in any patient with unexplained increased adrenergic activity, hyperpyrexia, or multiorgan failure. Empirical treatment must begin prior to definitive diagnosis in all cases. This review demonstrates how to recognize and manage acute presentations of hypo- and hyperparathyroidism, myxedema coma, and thyroid storm in the emergency setting. Patients with nondiabetic endocrine emergencies may present in extremis, and immediate stabilization, typically without confirmatory testing, is necessary. Early intervention is key in treating such presentations. This review contains 3 figures, 8 tables and 28 references Key words: disorders of the parathyroids, hyperparathyroidism, hypoparathyroidism, hypothyroidism, myxedema coma, thyroid storm, thyrotoxicosis

Nondiabetic endocrine emergencies are less frequent but equally concerning as diabetic emergencies. The diagnosis of adrenal crises, pheochromocytoma, or pituitary deficiencies can be difficult in the emergent setting given the nonspecific findings frequently confused with other presenting illnesses. Although the differential is broad for patients presenting with shock and hypotension, as seen in adrenal crises, hypertensive emergencies in pheochromocytoma, or a litany of potential symptoms in pituitary abnormalities, the diagnosis should be considered in a patient presenting to the emergency department with severe metabolic abnormalities, undifferentiated shock, or cardiovascular lability. This review demonstrates how to recognize and manage acute adrenal crisis, pheochromocytoma, and pituitary deficiencies in the acute care setting. Patients with nondiabetic endocrine emergencies may present in extremis, and immediate stabilization, typically without confirmatory testing, is necessary. Early intervention is key in treating such presentations. This review contains 1 figure, 2 tables and 21 references Key words: adrenal crisis, adrenal insufficiency, catecholamine surge, pheochromocytoma, pituitary deficiency

Author(s): Henning, Daniel J.; Oedorf, Kimie; Day, Danielle E.; Redfield, Colby S.; Huguenel, Colin J.; Roberts, Jonathan C.; Sanchez, Leon D.; Wolfe, Richard E.; Shapiro, Nathan I. | Abstract: Introduction: Strategies to identify high-risk emergency department (ED) patients often use markedly abnormal vital signs and serum lactate levels. Risk stratifying such patients without using the presence of shock is challenging. The objective of the study is to identify independent predictors of in-hospital adverse outcomes in ED patients with abnormal vital signs or lactate levels, but who are not in shock.Methods: We performed a prospective observational study of patients with abnormal vital signs or lactate level defined as heart rate ≥130 beats/min, respiratory rate ≥24 breaths/min, shock index ≥1, systolic blood pressure l90mm/Hg, or lactate ≥4mmole/L. We excluded patients with isolated atrial tachycardia, seizure, intoxication, psychiatric agitation, or tachycardia due to pain (ie: extremity fracture). The primary outcome was deterioration, defined as development of acute renal failure (creatinine 2x baseline), non-elective intubation, vasopressor requirement, or mortality. Independent predictors of deterioration after hospitalization were determined using logistic regression.Results: Of 1,152 consecutive patients identified with abnormal vital signs or lactate level, 620 were excluded, leaving 532 for analysis. Of these, 53/532 (9.9±2.5%) deteriorated after hospital admission. Independent predictors of in-hospital deterioration were: lactate g4.0mmol/L (OR 5.1, 95% CI [2.1–12.2]), age ≥80 yrs (OR 1.9, CI [1.0–3.7]), bicarbonate l21mEq/L (OR 2.5, CI [1.3–4.9]), and initial HR≥130 (OR 3.1, CI [1.5–6.1]).Conclusion: Patients exhibiting abnormal vital signs or elevated lactate levels without shock had significant rates of deterioration after hospitalization. ED clinical data predicted patients who suffered adverse outcomes with reasonable reliability.

Background The incidence of errors and adverse events in emergency medicine is poorly characterized. Objective The objective was to systematically determine the rates and types of errors and adverse events in an academic, tertiary care emergency department (ED). Methods Prospective data were collected on all patients presenting to a tertiary-care academic medical center ED with an annual census of 55,000 patients between January 2009 and November 2012. Cases of patients meeting predetermined criteria were systematically identified by an electronic medical record system. Criteria for review included patients who (1) returned to the ED within 72 hours and were admitted on their second visit, (2) were admitted from the ED to the floor and then transferred to the intensive care unit (ICU) within 24 hours, (3) expired within 24 hours of ED arrival, (4) required airway management, or (5) were referred to the QA committee as the result of complaints. Cases were randomly assigned to individual physicians not involved with the care. All cases were reviewed using a structured electronic tool that assessed the occurrence of error and adverse events. Institutional review board jurisdiction was waived by the Beth Israel Deaconess Medical Center IRB. Results During the study period, 152,214 cases were screened and 2131 cases (1.4%) met prespecified criteria for review. The incidence of error in these cases was 9.5% (95% confidence interval [CI], 8.3%-10.8%), representing an overall incidence of 0.13% among all ED patients. In cases that involved error, 50.5% occurred among patients who returned to the ED within 72 hours; 17.3% occurred among floor-to-ICU transfers; 5.4% occurred among mortality cases; 2.0% occurred among airway cases; and 24.8% occurred among cases referred as the result of complaints. The incidence of adverse events in the reviewed cohort was 8.3% (CI, 7.2%-9.6%), representing an overall incidence of 0.11% among all ED patients. In cases that involved adverse events, 48.6% occurred among patients who returned to the ED within 72 hours; 16.4% occurred among floor-to-ICU transfers; 9.0% occurred among mortality cases; 1.1% occurred among airway cases; and 24.9% occurred among cases referred as the result of complaints. Conclusion Although the overall incidence of error and adverse events in EDs is low, the likelihood of such events is markedly increased among patients who return to the ED within 72 hours, among patients who require floor-to-ICU transfer within 24 hours, and among those whose cases come to attention as the result of complaints.

Variceal hemorrhage is associated with high morbidity and mortality. A balloon tamponade device (BTD), such as the Sengstaken-Blakemore or Minnesota tube, may be used in cases of variceal hemorrhage. While these devices may be effective at controlling acute bleeding, the effect on patient outcomes remains less clear. We sought to describe the number of patients with variceal hemorrhage and a BTD who survive to discharge, survive to one-year, and develop complications related to a BTD.In this retrospective study, we identified patients at a single, tertiary care center who underwent placement of a BTD for upper gastrointestinal hemorrhage between 2003 and 2014. Patient characteristics and outcomes were summarized using descriptive statistics.34 patients with a BTD were identified. Median age was 57.5 (IQR 47-63) and 76% (26/34) were male. Approximately 59% (20/34) of patients survived to discharge, and 41% (13/32) were alive after one year. Two patients were lost to follow-up. Of those surviving to discharge, 95% (19/20) had undergone transjugular intrahepatic portosystemic shunt (TIPS), while 36% (5/14) of patients who did not survive to discharge had TIPS (p0.01). One complication, an esophageal perforation, was identified and managed conservatively.In this cohort of patients undergoing BTD placement for variceal hemorrhage, approximately 59% of patients were alive at discharge and 41% were alive after one year. Placement of a BTD as a temporizing measure in the management of acute variceal hemorrhage may be helpful, particularly when utilized as a bridge to more definitive therapy.

This study evaluates whether emergency department septic shock patients without a fever (reported or measured) receive less IV fluids, have decreased antibiotic administration, and suffer increased in-hospital mortality.This was a secondary analysis of a prospective, observational study of patients with shock.The study was conducted in an urban, academic emergency department.The original study enrolled consecutive adult (aged 18 yr or older) emergency department patients from November 11, 2012, to September 23, 2013, who met one of the following shock criteria: 1) systolic blood pressure less than 90 mm Hg after at least 1L IV fluids, 2) new vasopressor requirement, or 3) systolic blood pressure less than 90 mm Hg and IV fluids held for concern of fluid overload. The current study is limited to patients with septic shock. Patients were grouped as febrile if they had a subjective fever or a measured temperature100.4°F documented in the emergency department; afebrile patients lacked both.Among 378 patients with septic shock, 207 of 378 (55%; 50-60%) were febrile by history or measurement. Afebrile patients had lower rates of antibiotic administration in the emergency department (81% vs 94%; p0.01), lower mean volumes of IV fluids (2,607 vs 3,013 mL; p0.01), and higher in-hospital mortality rates (33% vs 11%; p0.01). After adjusting for bicarbonate less than 20 mEq/L, lactate concentration, respiratory rate greater than or equal to 24 breaths/min, emergency department antibiotics, and emergency department IV fluids volume, being afebrile remained a significant predictor of in-hospital mortality (odds ratio, 4.3; 95% CI, 2.2-8.2; area under the curve = 0.83).In emergency department patients with septic shock, afebrile patients received lower rates of emergency department antibiotic administration, lower mean IV fluids volume, and suffered higher in-hospital mortality.

Objectives To create a risk prediction rule for delirium in elderly adults in the emergency department (ED) and to compare mortality and resource use of elderly adults in the ED with and without delirium. Design Prospective observational study. Setting Urban tertiary care ED. Participants Individuals aged 65 and older presenting for ED care (N = 700). Measurements A trained research assistant performed a structured mental status assessment and attention tests, after which delirium was determined using the Confusion Assessment Method. Data were collected on participant demographics, comorbidities, medications, ED course, hospital and intensive care unit (ICU) admission, length of stay, hospital charges, 30-day rehospitalization, and mortality. Results Nine percent of elderly study participants had delirium. Using logistic regression, a delirium prediction rule consisting of older age, prior stroke or transient ischemic attack, dementia, suspected infection, and acute intracranial hemorrhage was created had good predictive accuracy (area under the receiver operating characteristic curve = 0.77). Admitted participants with ED delirium had longer median lengths of stay (4 vs 2 days) and were more likely to require ICU admission (13% vs 6%) and to be discharged to a new long-term care facility (37% vs 9%) than those without. In all participants, ED delirium was associated with higher 30-day mortality (6% vs 1%) and 30-day readmission (27% vs 13%). Conclusion This risk prediction rule may help identify a group of individuals in the ED at high risk of developing delirium who should undergo screening, but it requires external validation. Identification of delirium in the ED may enable physicians to implement strategies to decrease delirium duration and avoid inappropriate discharge of individuals with acute delirium, improving outcomes.

Rising health care costs demands justifying prolonged hospitalization for syncope, yet predictors of shorter length of stay (LOS) have not been identified.The objective of this study is to identify independent predictors of LOS for syncope patients presenting to the emergency department (ED).We performed an analysis of a prospectively collected cohort of ED syncope patients. We examined risk factors from the patient's ED presentation and workup and used Spearman rank correlation to evaluate the relationship between these risk factors and LOS in a logistic regression model for prediction of hospitalization less than 1 day.Of 568 total syncope patients, 350 (61.6%) were admitted and comprise the study cohort. Mean age was 57 years (SD, ±25 years); 39.6% were male. Length of hospitalization was less than or equal to 1 in 179 patients (51.1%). The number of risk factors was associated with LOS (P.001). Most hospitalized patients with less than 1 predictor were hospitalized for less than 1 day (152/272; 55.9%). In multivariate logistic regression analysis, clear vasovagal etiology was positively correlated with LOS less than 1 day (odds ratio [OR], 1.92), whereas dysrhythmia (OR, 0.3), coronary artery disease (OR, 0.33), abnormal vital signs (OR, 0.35), implantable defibrillator/pacemaker (OR, 0.29), anemia/gastrointestinal bleeding (OR, 0.34), and central nervous system abnormalities (OR, 0.09; P.05 for all) were negatively correlated with LOS less than 1 day. Area under the curve for model accuracy was moderate: 0.70 (95% confidence interval, 0.65-0.76).Patients with less than 1 predictor of prolonged stay, who present to the ED with syncope, are unlikely to require hospitalization of more than 1 day. A set of predictors may help define which patients are appropriate for 24-hour observation rather than full hospitalization.

As part of a quality improvement initiative to reduce Emergency Department (ED) length of stay (LOS) for surgical consult patients, we e-mailed performance metrics to key stakeholders on a daily basis. ED and Surgery leadership used these daily metrics to identify and remedy contributing factors for increased ED LOS in patients who received surgical consults.To evaluate whether a quality improvement process driven by a daily performance metric e-mail would be associated with a change in ED LOS for surgical consult patients.Prospective before-after study looking at ED LOS for surgical consult patients after an e-mail intervention at a tertiary academic teaching hospital. All consecutive adult ED patients between July 1, 2010 and October 1, 2010 who received a general surgical consult were enrolled. The primary outcome measure was ED LOS, and secondary outcome measure was time to consultation.There were 916 patients who had surgical consults placed during the study period; 459 patients presented before the intervention and 457 patients presented after the intervention. The median LOS decreased 54 min, from 463 min (interquartile range [IQR] 326-617) before the intervention to 409 min (IQR 294.5-528.5) after the intervention (p0.001). Time to consultation decreased 25 min, from a median of 160 min (IQR 87-265) to 135 min (IQR 70-239.5) (p = 0.002). There was no difference in age, severity, number of consults, or disposition. There was also no difference in median LOS for other consultation services or in previous years during the same time period.ED LOS and time to consultation were decreased for surgical consult patients after initiation of daily performance metric e-mails.

Since the development of coronary care units (CCUs), telemetry has rapidly become the standard of care in evaluating patients with suspected acute coronary syndromes, regardless of the probability for ischemia. However, there is no data to support this practice. Our objective was to evaluate the utility of routine cardiac monitoring in a chest pain observation unit. We prospectively studied the utility of routine cardiac monitoring in 249 consecutive patients admitted to an observation unit in an academic Emergency Department over a 6-month period. All the patients presented with chest pain thought to be cardiac ischemia. Observation included serial cardiac enzymes, ECG cardiac monitoring, and exercise testing in a designated chest pain observation unit. These patients were determined to be at low risk for an acute coronary event by two criteria: first, the symptoms had resolved by the time of observation unit admission, and second, the initial ECG was normal, unchanged or non-diagnostic for acute ischemia. Adverse outcomes included cardiac arrest, hospital admission secondary to cardiac dysrhythmia, or alteration in the patient's medical therapy upon discharge from the observation unit, secondary to cardiac dysrhythmia. There were 249 patients included with a median age of 52 with 60% women. Fifteen percent of the patients were, subsequently, admitted to the hospital for further evaluation of ischemia based on enzyme, ECG, and exercise testing results. One patient with known Tachy-Brady syndrome was noted to have 1.5-2 s pauses while sleeping, and discharged with instructions to hold beta blocker therapy pending results of a continuous loop recorder. Of the remaining 248 patients, no patient suffered a cardiac arrest, no patient was admitted to the hospital secondary to cardiac dysrhythmia, and no alteration in a patient's medical therapy was made secondary to cardiac dysrhythmia. No patient returned to the Emergency Department within 72 h with cardiac arrest, acute dysrhythmia or acute myocardial infarction. Although telemetry may be the standard of care in evaluating the patients with suspected acute coronary syndromes, regardless of the probability of an acute ischemic syndrome, in those patients with a normal or non diagnostic ECG and resolved symptoms, routine cardiac monitoring is unnecessary.

Dr. John Jesus:Today’s case is that of a 26-year-old righthand-dominant healthy patient who sustained a small puncture wound to the hand while disposing of a dead catfish at work. He presented to the Emergency Department (ED) approximately 12 h after his initial injury with significant malaise, chills, and rapidly increasing swelling in the affected hand. The patient reported puncturing the dorsal aspect of his right middle finger with one of the pectoral spines of a catfish at approximately 8:30 in the morning. He attempted to clean the wound by expressing blood from it and washing the wound with warm soapy water. He then went about his day, largely ignoring a seemingly innocuous wound. Shortly before presentation, the patient began to notice increasing pain, erythema, and swelling of the affected finger, quickly tracking up the finger to include the majority of the dorsum of his right hand (Figure 1). Dr. Richard Wolfe: Can you describe the initial appearance of the patient? Dr. Jesus: Upon arrival in the ED the patient was relatively comfortable, initially refusing pain medication. His right middle finger appeared edematous, with mild erythema that was subtle; the puncture wound itself was 3 mm in length, clean, closed, without drainage or visible foreign body. His initial vital signs were: temperature 38.6 C, heart rate 118 beats/min, blood pressure 179/ 93 mm Hg, respiratory rate 18 breaths/min, and an oxygen saturation of 99% on room air. Dr. Carrie Tibbles: Does the patient have any significant past medical history?

Background: Prior studies show that lactate is a useful prognostic marker in sepsis. Objective: To study the feasibility and accuracy of a point-of-care (POC) analyzer capable of performing bedside serum lactate measurements; and to determine if other measurements (pH, base excess) are predictive of mortality. Methods: Design: prospective cohort study of adult (age 18 years or older) Emergency Department (ED) patients with suspected infection during the study period of May 2006 through March 2007. Setting: A 55,000-annual-visit urban tertiary care ED. Intervention: A point-of-care device (i-STAT, Abbott Point of Care Inc., Princeton, NJ) was deployed using a standardized training and quality assurance process. Using POC testing, we measured serum lactate, pH, and base excess, as well as concomitant lactate measurement via a central laboratory. Statistics: Area under the curve (AUC) for receiver operator characteristic curve, Bland-Altman statistics along with a correlation coefficient, and relative risk with 95% confidence intervals reported. Results: There were 699 patients enrolled, of whom 34 (4.9%) died. The AUCs for mortality prediction were: POC lactate 0.72, laboratory lactate 0.70, pH measurement 0.60, and base excess 0.60. Bland-Altman showed that POC lactate was, on average, 0.32 (95% confidence interval −0.35–0.98) lower than laboratory lactate, with agreement kappa = 0.97. Conclusions: A point-of-care testing device provides a reliable and feasible way to measure serum lactate at the bedside. The pH and base excess were less helpful.

Dr. Daniel McGillicuddy: The patient is a 50-year-oldwoman who was involved in a single car, high-speed motorvehicle collision. The patient was an unrestrained driver ina car without air bags who sustained severe blunt forcefacial trauma secondary to the steering wheel, and wasbrought in as a non-trauma to this community hospital. Shewas also intoxicated and agitated. The patient was unableto provide a past medical history, social history or anyinformation with respect to the accident. The pre-hospitalfingerstick glucose level was normal. The patient’s vitalsigns were a heart rate of 88 beats/min, a blood pressure of160/palpation mmHg, a respiratory rate of 24 breaths/minand an oxygen saturation of 96% on room air. The patientdid not have a temperature recorded. The physical exami-nation revealed a patient who was awake, but agitated. Shewas in cervical spine immobilization as well as immobi-lized on a spine board. The head examination revealedblunt trauma to the left orbit and mid face. She had peri-orbital edema on the left, bilateral massive epistaxis, andshe was actively vomiting blood. The midface was stable,the trachea was midline, and she had normal bilateralbreath sounds. The heart sounds were regular, there was nojugular venous distention, and the pulses were fullthroughout. The abdomen was obese, soft and non-tender.The FAST examination was without free fluid. The pelviswas stable. The Glasgow Coma Score was 12 due toaltered speech. The back and extremity examinations werenormal.Dr. Peter Rosen: Dr. Ban, what is your assessment ofthis patient?Dr. Kevin Ban: The intoxicated, combative traumapatient presents unique challenges for the EmergencyPhysician (EP). The combative behavior may be secondaryto any number of underlying causes, including intoxication(drug or alcohol), head injury, hypoxemia, hypovolemicshock or underlying medical conditions (diabetes withhypoglycemia). The most important priority for the EP is toobtain immediate and definitive control of the patient’sairway to facilitate treatment and diagnosis of the severelyinjured patient. There is controversy as to whether or not toparalyze these patients or to sedate them without additionalneuromuscular blockade as is usually done in a rapidsequence intubation (RSI).Dr. Rosen: Dr. Davis, what is your opinion regardingintubation with sedation alone versus a RSI with neuro-muscular blockade?Dr. Daniel Davis: This is going to be a tough airway,and I’m a bit reluctant to paralyze someone like this. Shehas multiple features that raise concerns about being able tointubate her successfully: obesity, c-collar, facial trauma,blood in the airway. It is reasonable to consider ketamine inthis patient, which might allow an attempt to inspect the

OBJECTIVES: To determine the prevalence and associated characteristics of traumatic intracranial hemorrhage (ICH) in elderly fallers presenting to the emergency department (ED) without focal findings. DESIGN: Retrospective cohort study. SETTING: University-affiliated teaching hospital ED. PARTICIPANTS: Patients aged 65 and older presenting with a fall to the ED and undergoing a head computed tomography (CT) scan. MEASUREMENTS: Electronic medical records and CT scans of 404 consecutive patients were reviewed. Characteristics of patients with and without ICH were compared using unadjusted analyses. Patients taking warfarin, aspirin, or clopidogrel alone or in combination were compared with those not taking these medications. Multivariate logistic regression analyses were performed to determine variables independently associated with ICH. RESULTS: Forty-seven of 404 elderly fallers (11.6%) without focal findings had an ICH. Unadjusted analyses in these pilot data showed that warfarin was not significantly associated with ICH. Multivariate analyses indicated that elderly people living in at home were more likely to have ICH than those living in nursing homes or assisted living facilities (odds ratio (OR)=3.2, 95% confidence interval (CI)=1.30-8.13) and that those with head trauma were more likely to have ICH than those without (OR=3.9, 95% CI=1.25-7.80). Aspirin was found to be protective (OR=0.49, 95% CI=0.24-0.98). CONCLUSION: ICH is common in elderly fallers presenting to the ED without focal findings. Anticoagulation alone did not appear to increase the risk of ICH, and aspirin was found to be protective, but prospective studies are needed to better assess this relationship. Language: en

OBJECTIVES: To identify independent risk factors for death in elderly emergency department (ED) patients admitted for infection and to derive and validate a mortality-prediction rule for such patients. DESIGN: Prospective cohort study. SETTING: Tertiary hospital ED with 55,000 annual visits. PARTICIPANTS: ED patients aged 65 and older admitted for infection between December 2003 and September 2004 in the derivation cohort and October 2005 and October 2006 in the validation cohort. MEASUREMENTS: Primary outcome: 28-day in-hospital mortality. Data were extracted from charts, and multivariate logistic regression were performed to identify independent mortality predictors. A prediction model was constructed and then validated in a second cohort. RESULTS: Nine hundred thirty-five patients were included in the derivation cohort and 2,015 in the validation cohort. Mortality was 6% in the derivation cohort and 7% in the validation cohort. In the derivation cohort, logistic regression revealed five independent mortality predictors: respiratory compromise (respiratory rate >20 breaths per minute or hypoxemia) (odds ratio (OR)=4.0, 95% confidence interval (CI)=1.7–9.4), tachycardia (heart rate ≥120 betas per minute; OR=3.2, 95% CI=1.6–6.3), cardiovascular failure (systolic blood pressure

Dr. Carlo Rosen: The patient was a 67-year-old manwho just got off an airplane from Florida complaining ofanterior neck swelling that developed either late the nightprior or early that morning. He was concerned enough inFlorida that he wanted to come to Boston, where all hisdoctors were, so he obtained a flight to Boston with hiswife. He said over the past few hours, the swelling hadgotten worse, and that he had developed a little bit of ahoarse voice. Initially he got put into one of our resusci-tation rooms, and a quick history revealed that he was oncoumadin for atrial fibrillation. He also denied fevers,denied any history of anything like this happening in thepast, denied rash or any pain or discomfort anywhere else,and was able to give a full history by himself. Other pastmedical history was significant for a previous carotid stentand asthma. He did say he had allergies to shellfish,associated with a rash, and took no other medications butthe coumadin. Are there any questions?Dr. Richard Wolfe: How many hours passed from theonset of his symptoms to the point he presented?Dr. C. Rosen: He was vague about the exact timing. Heprobably had symptoms the night before starting with theswelling, and the voice change happened over the past fewhours.Dr. Wolfe: You saw him roughly at what time?Dr. C. Rosen: Probably early afternoon. He took a taxifrom the airport to the Emergency Department (ED).Dr. C. Rosen: Tomethereweretwoworrisomepartsto the history. One was the swelling which had gone onfor probably 18 h. The second, and more concerning,was the voice change, which hesaidhadoccurredover2–3 h.Dr. Wolfe: I am not clear why he was taking coumadin.There was absolutely no history of any trauma, correct?Dr. C. Rosen: There was no history of trauma. He wason coumadin for atrial fibrillation, and said he had beentaking his usual dose. On physical examination the vitalswere: temperature of 36.5 C (97.7 F,) pulse 117 beats perminute, blood pressure 156/88 torr., respirations 25 breathsper minute, and oxygen saturation 99% on room air. Helooked very comfortable. The only alarming thing aboutthe examination was he had a slightly hoarse voice. I thinkwe picked up the voice changes more than he himself or hiswife did. He clearly had anterior submandibular neckswelling from the whole anterior mid to upper part of theneck. He had some tongue elevation and some sublingualecchymosis; it was not woody, but it was definitely feelingfull. The rest of the examination was normal. He wastotally appropriate and wide awake and not in a whole lotof distress.

The study objective was to derive and validate a clinical decision rule for obtaining blood cultures in Emergency Department (ED) patients with suspected infection. This was a prospective, observational cohort study of consecutive adult ED patients with blood cultures obtained. The study ran from February 1, 2000 through February 1, 2001. Patients were randomly assigned to derivation (2/3) or validation (1/3) sets. The outcome was "true bacteremia." Features of the history, co-morbid illness, physical examination, and laboratory testing were used to create a clinical decision rule. Among 3901 patients, 3730 (96%) were enrolled with 305 (8.2%) episodes of true bacteremia. A decision rule was created with "major criteria" defined as: temperature39.5 degrees C (103.0 degrees F), indwelling vascular catheter, or clinical suspicion of endocarditis. "Minor criteria" were: temperature 38.3-39.4 degrees C (101-102.9 degrees F), age65 years, chills, vomiting, hypotension (systolic blood pressure90 mm Hg), neutrophil%80, white blood cell count18 k, bands5%, platelets150 k, and creatinine2.0. A blood culture is indicated by the rule if at least one major criterion or two minor criteria are present. Otherwise, patients are classified as "low risk" and cultures may be omitted. Only 4 (0.6%) low-risk patients in the derivation set and 3 (0.9%) low-risk patients in the validation set had positive cultures. The sensitivity was 98% (95% confidence interval [CI] 96-100%) (derivation) and 97% (95% CI 94-100%) (validation). We developed and validated a promising clinical decision rule for predicting bacteremia in patients with suspected infection.