J Emerg Med

The impact of two freestanding emergency departments on a tertiary care center.

May 072013

The impact of two freestanding emergency departments on a tertiary care center.

J Emerg Med. 2012 Dec;43(6):1127-31

Authors: Simon EL, Griffin PL, Jouriles NJ

Abstract
BACKGROUND: Freestanding emergency departments (FEDs) have become increasingly popular as the need for emergency care continues to grow.
OBJECTIVE: To analyze the impact of two FEDs on a local tertiary care center's patient volume and admission rates.
METHODS: A retrospective analysis examined monthly volume and admission rates for the main ED and two FEDs located 9.6 and 12 miles away. Main ED census records were divided into three distinct time frames: period A (control) was January 2007 through June 2007. Period B was July 2007 through July 2009 when one FED was open. Period C was August 2009 through June 2010 when both FEDs were open. A two-factor analysis of variance was used to analyze admission rates while adjusting for monthly variation.
RESULTS: The mean monthly patient volume for the main ED was 4709 for period A, but dropped significantly (p<0.01) to 4447 for period B, and again dropped significantly (p<0.01) to 4242 during period C. The volume for all facilities increased throughout the study period. A combined monthly volume increase to 5642 occurred in Period B, and increased to 6808 in Period C. The adjusted mean admission rate at the main ED for period A was 0.221, which dropped somewhat, though not significantly (p=0.3505) to 0.213 for period B, and then significantly (p<0.01) to 0.189 for period C.
CONCLUSION: Opening two FEDs decreased the volume and admission rates for the main ED and increased the overall ED volume for the health care system.

PMID: 22560268 [PubMed - indexed for MEDLINE]

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Hospitalizations of older patients with human immunodeficiency virus in the United States.

J Emerg Med Start a Discussion »

May 072013

Hospitalizations of older patients with human immunodeficiency virus in the United States.

J Emerg Med. 2012 Dec;43(6):1138-44

Authors: Tadros A, Shaver E, Davis SM, Davidov DM

Abstract
BACKGROUND: Older adults represent a growing percentage of the United States (US) population living with human immunodeficiency virus (HIV). The Emergency Department plays an integral role in the identification and initial evaluation and treatment of patients with HIV.
OBJECTIVE: We sought to estimate the number of hospitalizations of older adults (age ≥ 50 years) with HIV in the United States from 2000 to 2006 and compare features of this population to younger adults with HIV. Clinical and demographic characteristics of the younger cohort (19-49 years) and two older cohorts (ages 50-64 and ≥ 65 years) were examined and compared.
METHODS: Data from the Nationwide Inpatient Sample was used to compare the three groups of HIV-positive patients. Comparisons between the most common discharge diagnoses and primary procedures were also made.
RESULTS: Older adults with HIV constitute almost one quarter of the hospitalizations of adults with HIV. Older adults with HIV were more likely to be male, have a significantly higher average hospital charge, and have a longer length of stay than younger adults with HIV. Pneumonia and fluid and electrolyte disorders were common diagnoses among all three age cohorts.
CONCLUSIONS: Older HIV patients were more likely to die during hospitalization compared with younger adults with HIV and older adults without HIV. Admissions for older HIV patients almost doubled during the study period and future studies should examine whether this is due to aging of the current HIV population or new infections.

PMID: 22541875 [PubMed - indexed for MEDLINE]

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Utility of the digital rectal examination in the emergency department: a review.

J Emerg Med Start a Discussion »

May 072013

Utility of the digital rectal examination in the emergency department: a review.

J Emerg Med. 2012 Dec;43(6):1196-204

Authors: Kessler C, Bauer SJ

Abstract
BACKGROUND: The digital rectal examination (DRE) has been reflexively performed to evaluate common chief complaints in the Emergency Department without knowing its true utility in diagnosis.
OBJECTIVE: Medical literature databases were searched for the most relevant articles pertaining to: the utility of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive rate of fecal occult blood tests (FOBT) from stool obtained by DRE or spontaneous passage, and the correlation between DRE and anal manometry in determining anal tone.
DISCUSSION: Sixteen articles met our inclusion criteria; there were two for abdominal pain, five for appendicitis, six for anal tone, and three for fecal occult blood. The DRE was shown to add no additional diagnostic information and confounded the diagnosis in acute, undifferentiated abdominal pain. The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio for the DRE were too low to reliably diagnose acute appendicitis in children and adults. No statistical differences in the number of colonic pathologies were found between stool collection methods in those with positive FOBT. The DRE correlation with anal manometry in determining resting and squeeze anal tone ranged from 0.405 to 0.82 and 0.52 to 0.97, respectively.
CONCLUSION: We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal pain and acute appendicitis. Stool obtained by DRE doesn't seem to increase the false-positive rate of FOBTs, and the DRE correlated moderately well with anal manometric measurements in determining anal sphincter tone.

PMID: 22883714 [PubMed - indexed for MEDLINE]

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Viral meningitis: which patients can be discharged from the emergency department?

J Emerg Med Start a Discussion »

May 072013

Viral meningitis: which patients can be discharged from the emergency department?

J Emerg Med. 2012 Dec;43(6):1181-7

Authors: Mohseni MM, Wilde JA

Abstract
BACKGROUND: Even in an era when cases of viral meningitis outnumber bacterial meningitis by at least 25:1, most patients with clinical meningitis are hospitalized.
OBJECTIVE: We describe the clinical characteristics of an unusual outbreak of viral meningitis that featured markedly elevated cerebrospinal fluid white blood cell counts (CSF WBC). A validated prediction model for viral meningitis was applied to determine which hospital admissions could have been avoided.
METHODS: Data were collected retrospectively from patients presenting to our tertiary care center. Charts were reviewed in patients with CSF pleocytosis (CSF WBC > 7 cells/mm(3)) and a clinical diagnosis of meningitis between March 1, 2003 and July 1, 2003. Cases were identified through hospital infection control and by surveying all CSF specimens submitted to the microbiology laboratory during the outbreak.
RESULTS: There were 78 cases of viral meningitis and 1 case of bacterial meningitis identified. Fifty-eight percent of the viral meningitis cases were confirmed by culture or polymerase chain reaction to be due to Enterovirus. Mean CSF WBC count was 571 cells/mm(3), including 20 patients with a CSF WBC count > 750 cells/mm(3) (25%) and 11 patients with values > 1000 cells/mm(3) (14%). Sixty-four of 78 patients (82%) were hospitalized. Rates of headache, photophobia, nuchal rigidity, vomiting, and administration of intravenous fluids in the Emergency Department were no different between admitted and discharged patients. Only 26/78 (33%) patients with viral meningitis would have been admitted if the prediction model had been used.
CONCLUSIONS: Although not all cases of viral meningitis are necessarily suitable for outpatient management, use of a prediction model for viral meningitis may have helped decrease hospitalization by nearly 60%, even though this outbreak was characterized by unusually high levels of CSF pleocytosis.

PMID: 22709622 [PubMed - indexed for MEDLINE]

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Does mandatory inpatient alcohol detoxification reduce emergency department recidivism, hospital admissions, and emergency medical services transports for patients with chronic, severe alcohol dependence?

J Emerg Med Start a Discussion »

Apr 232013

Does mandatory inpatient alcohol detoxification reduce emergency department recidivism, hospital admissions, and emergency medical services transports for patients with chronic, severe alcohol dependence?

J Emerg Med. 2012 Nov;43(5):883-8

Authors: Duong DK, Rathlev NK, McGrath ME, White LF, Mitchell P

Abstract
BACKGROUND: In Massachusetts, patients with chronic alcohol dependence can be committed to 30 days of mandatory inpatient alcohol detoxification (MAD).
STUDY OBJECTIVES: To examine the effects of MAD on the number of emergency department (ED) visits, hospital admissions, and emergency medical service (EMS) transports.
METHODS: This retrospective study identified patients in our urban ED committed to MAD. We compared the number of ED visits and admissions to our hospital and Boston EMS transports to any facility in the 1, 3, and 6 months pre- and post-MAD, excluding the 30-day MAD period. Paired t tests were used for analysis of mean values across time.
RESULTS: Ten subjects were enrolled. Comparing pre- and post-MAD, the mean number of ED visits fell 6.5 to 2.7 (p = 0.05) in the first month, 14.2 to 9.3 (p = 0.18) in 3 months, and 25.6 to 17.7 (p = 0.15) in 6 months. Mean number of hospital admissions declined: 1.3 to 0.1 (p = 0.03) in 1 month, 2.3 to 0.9 (p = 0.06) in 3 months, and 3.2 to 1.9 (p = 0.08) in 6 months. Mean number of EMS transports fell 4.6 to 2.3 (p = 0.21) in the first month, 9.2 to 5.6 (p = 0.14) in 3 months, and 13.9 to 10.0 (p = 0.26) in 6 months pre- and post-MAD.
CONCLUSIONS: MAD was associated with an immediate reduction in ED visits and hospital admissions that did not remain statistically significant long term, and a non-significant reduction in EMS transports.

PMID: 19944550 [PubMed - indexed for MEDLINE]

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Management of the post-cardiac arrest syndrome.

J Emerg Med Start a Discussion »

Jun 292012

Management of the post-cardiac arrest syndrome.

J Emerg Med. 2012 Apr;42(4):440-9

Authors: Reynolds JC, Lawner BJ

Abstract

BACKGROUND: Recent advances in resuscitation science have revolutionized care of the cardiac arrest patient. Dramatic departures from time-honored advanced cardiac life support therapies, such as cardiocerebral resuscitation and bundled post-arrest care, have given rise to a new paradigm of resuscitation practices, which has boosted the rate of neurologically intact survival.

OBJECTIVES: This article reviews the pathophysiology of the post-cardiac arrest syndrome, the collective pathophysiology after return of spontaneous circulation, and presents management pearls specifically for the emergency physician. This growing area of scientific inquiry must be managed appropriately to sustain improved outcomes.

DISCUSSION: The emergency physician must understand this pathophysiology, manage resuscitated patients according to the latest evidence, and coordinate with appropriate inpatient resources.

CONCLUSION: The new approach to cardiac arrest care is predicated on a chain of survival that spans the spectrum of care from the prehospital arena through the emergency, intensive, and inpatient settings. The emergency physician is a crucial link in this chain.

PMID: 22281034 [PubMed - indexed for MEDLINE]

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