Efficacy of high-flow oxygen therapy in all types of headache: a prospective, randomized, placebo-controlled trial.

Am J Emerg Med. 2012 May 2;

Authors: Ozkurt B, Cinar O, Cevik E, Acar AY, Arslan D, Eyi EY, Jay L, Yamanel L, Madsen T

Abstract
OBJECTIVE: We aimed to assess the efficacy of oxygen inhalation therapy in emergency department (ED) patients presenting with all types of headache. METHOD: We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED with a chief complaint of headache. The patients were randomized to receive either 100% oxygen via nonrebreather mask at 15 L/min or the placebo treatment of room air via nonrebreather mask for 15 minutes in total. We recorded pain scores at 0, 15, 30, and 60 minutes using the visual analog scale. At 30 minutes, the patients were assessed for the need for analgesic medication. Patient headache type was classified by the treating emergency physician using standardized diagnostic criteria. RESULTS: A total of 204 patients agreed to participate in the study and were randomized to the oxygen (102 patients) and placebo (102 patients) groups. Patient headache types included tension (47%), migraine (27%), undifferentiated (25%), and cluster (1%). Patients who received oxygen therapy reported significant improvement in visual analog scale scores at all points when compared with placebo: 22 mm vs 11 mm at 15 minutes (P < .001), 29 mm vs 13 mm at 30 minutes (P < .001), and 55 mm vs 45 mm at 60 minutes (P < .001). When questioned at 30 minutes, 72% of patients in the oxygen group and 86% of patients in the placebo group requested analgesic medication (P = .005). CONCLUSION: In addition to its role in the treatment of cluster headache, high-flow oxygen therapy may provide an effective treatment of all types of headaches in the ED setting.

PMID: 22560101 [PubMed - as supplied by publisher]

Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms.

Am J Emerg Med. 2012 Mar 28;

Authors: Conti A, Poggioni C, Viviani G, Mariannini Y, Luzzi M, Cerini G, Canuti E, Zanobetti M, Innocenti F, Pini R

Abstract
BACKGROUND: Several risk scores are available for prognostic purpose in patients presenting with chest pain. AIM: The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergency setting. METHODS: Patients with nondiagnostic ECGs and normal troponins and without history of coronary disease underwent exercise ECG. Patients with positive testing underwent coronary angiography; otherwise, they were discharged. End point was the composite of coronary stenosis at angiography or cardiovascular death, myocardial infarction, angina, and revascularization at 12-month follow-up. RESULTS: Of 508 patients considered, 320 had no history of coronary disease: 29 were unable to perform exercise testing, and finally, 291 were enrolled. Areas under the receiver operating characteristic curves for Grace, Pursuit, TIMI, Goldman, Sanchis, and FPR were 0.59, 0.68, 0.69, 0.543, 0.66, and 0.74, respectively (P < .05 FPR vs Goldman and Grace). In patients with negative exercise ECG and overall low risk score, only the FPR effectively succeeded in recognizing those who achieved the end point; in patients with high risk score, the additional presence of carotid stenosis and recurrent angina predicted the end point (odds ratio, 12 and 5, respectively). Overall, logistic regression analysis including exercise ECG, coronary risk factors, and risk scores showed that exercise ECG was an independent predictor of coronary events (P < .001). CONCLUSIONS: The FPR effectively succeeds in ruling out coronary events in patients categorized with overall low risk score. Exercise ECG, nonetheless being an independent predictor of coronary events could be considered questionable in this subset of patients.

PMID: 22463966 [PubMed - as supplied by publisher]

Impact of metformin use on the prognostic value of lactate in sepsis.

Am J Emerg Med. 2012 Mar 16;

Authors: Green JP, Berger T, Garg N, Suarez A, Hagar Y, Radeos MS, Panacek EA

Abstract
OBJECTIVE: The objective of this study is to determine if metformin use affects the prevalence and prognostic value of hyperlactatemia to predict mortality in septic adult emergency department (ED) patients. METHODS: This is a single-center retrospective cohort study. Emergency department providers identified study subjects; data were collected from the medical record. PATIENTS: Adult ED patients with suspected infection and 2 or more systemic inflammatory response syndrome criteria were included. The outcome was 28-day mortality. The primary risk variable was serum lactate (<2.0, 2.0-3.9, ?4.0 mmol/L) categorized by metformin use; covariates: demographics, Predisposition, Infection, Response, Organ Dysfunction score and metformin use contraindications. SETTING: The study was conducted at an urban teaching hospital; February 1, 2007 to October 31, 2008. RESULTS: A total of 1947 ED patients were enrolled; 192 (10%) were taking metformin; 305 (16%) died within 28 days. Metformin users had higher median lactate levels than nonusers (2.2 mmol/L [interquartile range, 1.6-3.2] vs 1.9 mmol/L [interquartile range, 1.3-2.8]) and a higher, although nonsignificant, prevalence of hyperlactatemia (lactate ?4.0 mmol/L) (17% vs 13%) (P = .17). In multivariate analysis (reference group nonmetformin users, lactate <2.0 mmol/L), hyperlactatemia was associated with an increased adjusted 28-day mortality risk among nonmetformin users (odds ratio [OR], 3.18; P < .01) but not among metformin users (OR, 0.54; P = .33). In addition, nonmetformin users had a higher adjusted mortality risk than metformin users (OR, 2.49; P < .01). These differences remained significant when only diabetic patients were analyzed. CONCLUSIONS: In this study of adult ED patients with suspected sepsis, metformin users had slightly higher median lactate levels and prevalence of hyperlactatemia. However, hyperlactatemia did not predict an increased mortality risk in patients taking metformin.

PMID: 22424991 [PubMed - as supplied by publisher]

Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram.

Am J Emerg Med. 2012 Mar 16;

Authors: Conti A, Poggioni C, Viviani G, Luzzi M, Vicidomini S, Zanobetti M, Innocenti F, Pini R, Padeletti L, Gensini GF

Abstract
AIM: The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin. METHODS: Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged. END POINT: The end points are cardiac events at short- and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization. RESULTS: Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P < .001), as follows: in-hospital, 23% vs 10%, (P < .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P < .001). CONCLUSIONS: One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.

PMID: 22425002 [PubMed - as supplied by publisher]

To-Go medications for decreasing ED return visits.

Am J Emerg Med. 2012 Mar 16;

Authors: Hayes BD, Zaharna L, Winters ME, Feemster AA, Browne BJ, Hirshon JM

Abstract
OBJECTIVES: The primary objective was to determine if providing patients with a complete course of antibiotics for select conditions would decrease the rate of return to the emergency department (ED) within 7 days of the initial visit. METHODS: In an urban, academic medical center, we compared patients who received medications at discharge (To-Go medications) with patients who received standard care (a prescription at discharge). Emergency department patients were included if they were older than 18 years; had a discharge diagnosis International Classification of Diseases, Ninth Revision, code for urinary tract infection, pyelonephritis, cellulitis, or dental infection; and presented initially between January and December 2010. Candidates had limited health insurance or were discharged when nearby pharmacies were closed. Return visits were included if the condition was related to the initial diagnosis. Wound checks and scheduled revisits were excluded. Medications dispensed were penicillin, clindamycin, sulfamethoxazole-trimethoprim, and nitrofurantoin. RESULTS: A total of 4257 individuals were seen in initial ED visits for the included conditions. Comparing the 243 individuals given medications with the 4014 who were not given medications, the To-Go medications group was less likely to return than the comparison group (2.5% vs 5.9%; P = .026). The cellulitis subgroup also showed a significant reduction in return visits (1.6% vs 6.9%; P = .024). Three hundred eighteen courses of medication were given to the 243 individuals for a total cost of $1123. CONCLUSIONS: For a 1-year expense of $1123, we demonstrated a 50% reduction in ED return visits for patients who were given a free, complete course of antibiotics at discharge for select conditions.

PMID: 22424997 [PubMed - as supplied by publisher]

Utilization of coronary computed tomography angiography for exclusion of coronary artery disease in ED patients with low- to intermediate-risk chest pain: a 1-year experience.

Am J Emerg Med. 2012 Mar 16;

Authors: Singer AJ, Domingo A, Thode HC, Daubert M, Vainrib AF, Ferraro S, Minton A, Poon A, Henry MC, Poon M

Abstract
OBJECTIVE: We describe our preliminary experience with coronary computed tomography angiography (CCTA) in emergency department (ED) patients with low- to intermediate-risk chest pain. METHODS: A convenience cohort of patients with low- to intermediate-risk acute chest pain presenting to a suburban ED in 2009 were prospectively enrolled if the attending physician ordered a CCTA for possible coronary artery disease. Demographic and clinician data were entered into structured data collection sheets required before any imaging. The results of CCTA were classified as normal, nonobstructive (1%-50% stenosis), and obstructive (>50% stenosis). Outcomes included hospital admission and death within a 6-month follow-up period. RESULTS: In 2009, 507 patients with ED chest pain had a CCTA while in the ED. The median (interquartile range) age was 54 (47-62) years; 51.5% were female. Thrombolysis in myocardial infarction risk scores were 0 (42.6%), 1 (42.2%), 2 (11.8%), 3 (2.4%), and 4 (1.0%). The results of CCTA were normal (n = 363), nonobstructive (n = 123), and obstructive (n = 21). Admission rates by CCTA results were obstructive (90.5%), nonobstructive (4.9%), and normal (3.0%). None of the patients with normal or nonobstructive CCTA died within the 6-month follow-up period (0%; 95% confidence interval, 0-0.9%). CONCLUSIONS: Many ED patients with low- to intermediate-risk chest pain have a normal or nonobstructive CCTA and may be safely discharged from the ED without any associated mortality within the following 6 months.

PMID: 22424998 [PubMed - as supplied by publisher]

Factors associated with shock in anaphylaxis.

Am J Emerg Med. 2012 Mar 16;

Authors: Park HJ, Kim SH

Abstract
BACKGROUND: The aim of this study was to investigate the clinical characteristics of anaphylactic shock and the factors associated with anaphylactic shock in anaphylaxis. METHODS: Data were retrospectively collected from patients with anaphylaxis for 10 years. Study subjects were searched with broad disease codes including anaphyla-, adverse, angioedema, allergy, insect bite, bee, and hypersensitivity to prevent omission. All the 294 study subjects were divided into shock and nonshock groups. RESULTS: The mean age of the subjects was 43 years old, and males comprised 162 patients (55%). There were 119 patients (41%) in the shock group and 175 patients in the nonshock group. Age was older in the shock group than in the nonshock group; however, there was no difference in sex between 2 groups. Frequent causes of anaphylaxis were drugs in the shock group and food in the nonshock group. Nonsteroidal anti-inflammatory drugs and radiocontrast media were the most common cause of drug-induced anaphylaxis in the nonshock group and shock group, respectively. Cardiovascular symptoms were the most frequent symptoms in the shock group. Factors associated with the shock in cases with anaphylaxis were old age, emergency department (ED) arrival by emergency medical services use, radiocontrast material, symptoms with cyanosis, syncope, and dizziness. CONCLUSION: Elderly anaphylactic patients with symptoms of cyanosis, syncope, and dizziness were at increased risk for the development of shock. Physicians in the ED have to be alert to the possibility of progression to shock in patients with anaphylaxis, and early recognition of anaphylactic shock is critical for adequate treatment.

PMID: 22424990 [PubMed - as supplied by publisher]

The influence of physician seniority on disparities of admit/discharge decision making for ED patients.

Am J Emerg Med. 2012 Mar 16;

Authors: Wu KH, Chen IC, Li CJ, Li WC, Lee WH

Abstract
OBJECTIVES: Differences in disposition between emergency physicians (EPs) have been studied in select patient populations but not in general emergency department (ED) patients. After determining whether a difference existed in admit/discharge decision making of EPs for general ED patients, we focus our study in examining the influence of EP seniority on the decision to discharge ED patients. METHODS: In a 1-year retrospective study, we included a convenience sample of all 18 953 adult nontraumatic ED patients. We reviewed the admit/discharge dispositions at each shift made by 16 EPs. EPs were categorized by seniority to determine whether seniority influenced disposition. Three groups had 5, 4, and 7 EPs each, with >10 years, 5 to 9 years, and <5 years of working experience, respectively. RESULTS: Patient demographics, triage level, and number of patients per shift did not differ statistically between EPs and each group. The number of discharged patients per shift differed statistically between EPs (P < .001) and each group. The most senior EPs had the lowest discharge rates compared with EPs in intermediate and junior groups. They had lower discharge rates for patients at triage levels 1, 2, and 3 as well as for all patients. However, no difference in unscheduled ED revisit rates was found. CONCLUSIONS: EPs vary in their admit/discharge decision making for general ED patients. More importantly, the most senior EPs were found to have the lowest discharge rates compared with their junior colleagues.

PMID: 22424989 [PubMed - as supplied by publisher]

Combined copeptin and troponin to rule out myocardial infarction in patients with chest pain and a history of coronary artery disease.

Am J Emerg Med. 2012 Mar;30(3):440-8

Authors: Ray P, Charpentier S, Chenevier-Gobeaux C, Reichlin T, Twerenbold R, Claessens YE, Jourdain P, Riou B, Mueller C

Abstract
PURPOSE: The main objective of this multicentric study was to evaluate the additional value of copeptin to conventional cardiac troponin (cTn) for a rapid ruling out of acute myocardial infarction (AMI) in patients with acute chest pain and a previous history of coronary artery disease (CAD).
PATIENTS AND METHOD: Patients with a previous history of CAD presenting in the emergency department with acute chest pain lasting for 6 hours or less suggestive of non-ST-segment elevation AMI and negative cTn were selected. Levels of copeptin were blindly measured at presentation. The diagnosis was adjudicated by 2 independent experts using all available data including cTn.
RESULTS: A total of 451 patients were included (mean age, 67 ± 14; 330 [73%] men). The adjudicated final diagnosis was AMI in 36 (8%) patients, unstable angina in 131 (29%), and other diagnosis in 284 (63%). A negative cTn combined with a copeptin value lower than 10.7 pmol/L at presentation was able to rule out AMI, with a negative predictive value of 98% (95% confidence interval, 95%-99%).
CONCLUSION: In triage patients with acute chest pain lasting for less than 6 hours and a previous history of CAD, the combination of copeptin and cTn allows for the ruling out AMI, with a negative predictive value greater than 95%.

PMID: 22402136 [PubMed - in process]

Effect of advanced age and vital signs on admission from an ED observation unit.

Am J Emerg Med. 2012 Feb 29;

Authors: Caterino JM, Hoover EM, Moseley MG

Abstract
OBJECTIVES: The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. METHODS: We conducted a prospective, observational cohort study of ED patients placed in an ED-basedobservation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at acutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol. RESULTS: Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14?000/mm(3) or greater (OR, 11.35; 95% CI, 3.42-37.72). CONCLUSIONS: Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion.

PMID: 22386358 [PubMed - as supplied by publisher]

Inequalities in the early treatment of women and men with acute chest pain?

Am J Emerg Med. 2012 Feb 29;

Authors: Ravn-Fischer A, Karlsson T, Santos M, Bergman B, Herlitz J, Johanson P

Abstract
PURPOSE: The aim of this study was to identify sex differences in the early chain of care for patients with chest pain. DESIGN: This is a retrospective study performed at 3 centers including all patients admitted to the emergency department because of chest pain, during a 3-month period in 2008, in the municipality of Göteborg. Chest pain or discomfort in the chest was the only inclusion criterion. There were no exclusion criteria. DATA SOURCES: Data were retrospectively collected from ambulance and medical records and electrocardiogram (ECG), echocardiography, and laboratory databases. MAIN FINDINGS: A total of 2588 visits (1248 women and 1340 men) made by 2393 patients were included. When adjusting for baseline variables, female sex was significantly associated with a prolonged delay time (defined as above median) between (a) admission to hospital and admission to a hospital ward (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.03), (b) first physical contact and first dose of aspirin (OR, 2.22; 95% CI, 1.30-3.82), and (c) admission to hospital and coronary angiography (OR, 2.50; 95% CI, 1.29-5.13). Delay time to the first ECG recording did not differ significantly between women and men. PRINCIPAL CONCLUSIONS: Among patients hospitalized due to chest pain, when adjusting for differences at baseline, female sex was associated with a prolonged delay time until admission to a hospital ward, to administration of aspirin, and to performing a coronary angiography. There was no difference in delay to the first ECG recording.

PMID: 22386352 [PubMed - as supplied by publisher]

Killip classification in patients with acute coronary syndrome: insight from a multicenter registry.

Am J Emerg Med. 2012 Jan;30(1):97-103

Authors: El-Menyar A, Zubaid M, AlMahmeed W, Sulaiman K, AlNabti A, Singh R, Al Suwaidi J

Abstract
The purpose of this study was to assess the prognostic value of the Killip classification at the presentation in patients with acute coronary syndrome (ACS). In 2007 and over 5 months, 6704 consecutive patients with ACS were enrolled in the Gulf Registry of Acute Coronary Events. Patients were categorized according to Killip classification at presentation (Classes I, II, III, and IV). Patients' characteristics and in-hospital outcomes were analyzed. High Killip classes were defined in 22% of patients. In comparison to Killip Class I, patients with higher Killip class had greater prevalence of cardiovascular risk factors, presented late, were less likely to have angina, and were less likely to receive antiplatelet, statins, and ?-blockers. Classes II, III, and IV were associated with higher adjusted odds of death in ST-elevation myocardial infarction (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.25-3.69; OR 6.1, 95% CI 3.41-10.86; and OR 28, 95% CI 15.24-54.70, respectively) and non-ST-elevation acute coronary syndrome (adjusted OR 2.4, 95% CI 1.24-4.82; OR 3.2,95% 1.49-7.02; and OR 9.8, 95% CI 3.79-25.57, respectively). In conclusion, across ACS, patients with higher Killip class had worse clinical profile and were less likely to be treated with evidence-based therapy. High Killip class was independent predictors of mortality in ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. Physician in the emergency department should be aware of the importance of clinical examination in the risk stratification in patients presenting with ACS.

PMID: 21159479 [PubMed - indexed for MEDLINE]

Diagnostic performance of a pocket-sized ultrasound device for quick-look cardiac imaging.

Am J Emerg Med. 2012 Jan;30(1):32-6

Authors: Kimura BJ, Gilcrease GW, Showalter BK, Phan JN, Wolfson T

Abstract
BACKGROUND: Although pocket-sized, simplified ultrasound devices have emerged to enable subjective point-of-care assessment, few data on their cardiac application exist. We sought to examine the image quality and the accuracy of subjective diagnosis of video loops obtained from a pocket-sized ultrasound device for 2 significant cardiac abnormalities, left ventricular systolic dysfunction and left atrial enlargement, obtained from a single, quick-look view.
METHODS: Parasternal left ventricular long-axis images acquired with a miniaturized commercially available device (Acuson P10) were reviewed using subjective criteria for left ventricular systolic dysfunction and left atrial enlargement and were compared with M-mode measurements of left atrial systolic diameter and E-point septal separation from a fully featured echocardiograph in 78 inpatients referred for standard echocardiography. Interpretive confidence and image quality were evaluated with each interpretation.
RESULTS: Of 78 inpatient studies, 19% of pocket ultrasound and 13% of standard studies were technically limited (P = NS). Of 61 technically adequate studies, subjective interpretation of pocket ultrasound images had a sensitivity, specificity, and accuracy of 79%, 52%, and 64% for left atrial diameter more than 4 cm; 47%, 98%, and 82% for E-point septal separation more than 1 cm of; 83%, 62%, and 74% for either abnormality; and 92%, 82%, and 87% for either abnormality when interpretive confidence was present (n = 23). The pocket ultrasound image quality scores were significantly lower than the standard echocardiograph (P < .001).
CONCLUSION: The pocket-sized device provided adequate imaging for screening of 2 significant cardiac entities. Subjective interpretation of a single parasternal view may help identify patients with cardiac disease.

PMID: 21035983 [PubMed - indexed for MEDLINE]

Small-bore catheter versus chest tube drainage for pneumothorax.

Am J Emerg Med. 2012 Jan 2;

Authors: Contou D, Razazi K, Katsahian S, Maitre B, Mekontso-Dessap A, Brun-Buisson C, Thille AW

Abstract
STUDY OBJECTIVE: The aim of the study was to compare the effectiveness of drainage via a single-lumen (5F catheter) central venous catheter (CVC) to a conventional (14-20F catheter) chest tube (CT) for the management of pneumothoraces, including primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), and traumatic and iatrogenic pneumothoraces. PATIENTS: All consecutive patients admitted to the intermediate intensive care unit of a university hospital for pneumothorax were retrospectively screened over an 8-year period. Patients were preferentially treated using CT from 2003 to 2007 and using CVC from 2008 to 2010. Drainage failure was defined as the need for a second drainage procedure or for surgery. RESULTS: Of 212 patients included, 117 (55%) had PSP, 28 (13%) had SSP associated with chronic obstructive pulmonary disease, 19 (9%) had traumatic pneumothorax, and 48 (23%) had iatrogenic pneumothorax. The failure rate was 23% in PSP, 36% in SSP, 16% in traumatic pneumothorax, and only 2% in iatrogenic pneumothorax. After adjustment, iatrogenic pneumothorax was the only factor that had an influence on drainage failure. The failure rate was similar between the 112 patients treated using CVC and the 100 patients treated using CT (18% vs 21%, P = .60). However, the durations of drainage (3.3 ± 1.9 vs 4.6 ± 2.6 days, P < .01) and of hospital stay were significantly shorter in patients treated using CVC as compared with CT. CONCLUSION: Our findings suggest that drainage via a catheter or via a CT is similarly effective in the management of pneumothorax. We recommend considering drainage via a small-bore catheter as a first-line treatment in patients with pneumothorax, whatever its cause.

PMID: 22217820 [PubMed - as supplied by publisher]

Hospital-level variation in the percentage of admissions originating in the emergency department.

Am J Emerg Med. 2011 Dec 26;

Authors: Studnicki J, Platonova EA, Fisher JW

Abstract
PURPOSE: Well over half of all US hospital patients are now admitted directly through the emergency department (ED) rather than scheduled through the admissions department by a referring member of the medical staff. This study sought to understand hospital-level variation in the percentage of admissions originating in the ED. BASIC PROCEDURES: This was a retrospective, cross-sectional analysis of 5 748 375 ED visits and 2 265 478 inpatient discharge occurring in 192 short-term acute Florida hospitals in calendar year 2005. MAIN FINDINGS: Hospitals with increasing percentages of patients admitted through the ED are smaller in scale with fewer admissions, beds, and smaller medical staffs but admit a higher percentage of their ED visits to the hospital. Patients in these hospitals are increasingly Hispanic, older, Medicare insured, and likely to represent a preventable ambulatory sensitive condition. CONCLUSIONS: The increasing rate of admissions from the ED department is a national trend, but there is substantial variation at the hospital level. In Florida, measures of hospital scale and an older population with some limitations in access to, or the quality of, primary care are the factors influencing hospital-level variation. Factors implicated in increased ED use such as ED visit acuity, lack of insurance, and race are not important contributory variables. The process of admission and, particularly, the role of the organized medical staff in this process are evolving, and the consequences of these changes require further research.

PMID: 22205007 [PubMed - as supplied by publisher]