Emergency

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STUDY OBJECTIVE: Emergency department (ED) crowding is a common and complicated problem challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or treatments implemented by nurses before patients are treated by a physician or nurse practitioner have been suggested as a potential strategy to improve patient flow. METHODS: This is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay...

The objective of this study was to develop a comparative diagnostic model for computed tomography (CT) and ultrasound (US) in the assessment of acute appendicitis using Alvarado risk score as a predictor of pretest probability and Bayesian statistical model as a tool to calculate posttest probabilities for both diagnostic test. Stratification was made by applying the Alvarado score for the prediction of acute appendicitis. Likelihood ratios were calculated using sensitivity and specificity of both CT and US from a Meta-analysis...

We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care...

OBJECTIVES: The objectives of the study are to quantify trial-to-trial variability in antibiotic failure rates, in randomized clinical trials of cellulitis treatment and to provide a point estimate for the treatment failure rate across trials. METHODS: We conducted a structured search for clinical trials evaluating antibiotic treatment of cellulitis, indexed in PubMed by August 2015. We included studies published in English and excluded studies conducted wholly outside of developed countries because the pathophysiology of cellulitis is likely to be different in such settings...

AIMS: Intravenous procainamide and amiodarone are drugs of choice for well-tolerated ventricular tachycardia. However, the choice between them, even according to Guidelines, is unclear. We performed a multicentre randomized open-labelled study to determine the safety and efficacy of intravenous procainamide and amiodarone for the acute treatment of tolerated wide QRS complex (probably ventricular) tachycardia. METHODS AND RESULTS: Patients were randomly assigned to receive intravenous procainamide (10 mg/kg/20 min) or amiodarone (5 mg/kg/20 min)...

BACKGROUND: The 2012 Academic Emergency Medicine Consensus Conference, "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" noted that emergency medicine (EM) educators often rely on theory and tradition in molding their approaches to teaching and learning, and called on the EM education community to advance the teaching of our specialty through the performance and application of research in teaching and assessment methods, cognitive function, and the effects of education interventions...

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OBJECTIVES: Abscess incision and drainage (I&D) are painful and distressing procedures in children. Intranasal (IN) fentanyl is an effective analgesic for reducing symptomatic pain associated with fractures and burns but has not been studied for reducing procedural pain during abscess I&D. Our objective was to compare the analgesic efficacy of IN fentanyl with intravenous (IV) morphine for abscess I&D in children. METHODS: We performed a randomized noninferiority trial in children aged 4 to 18 years undergoing abscess I&D in a pediatric emergency department...

BACKGROUND: During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries. METHODS: A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) <9) and/or intubated major trauma (Injury Severity Scale (ISS) >12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012...

OBJECTIVE: The objective was to compare agreement between three non-invasive measures of temperature and rectal temperatures and to estimate the sensitivity and specificity of these measures to detect a rectal temperature of 38°C or higher. METHODS: We conducted a study of the diagnostic accuracy of oral, tympanic membrane (TM) and temporal artery (TA) thermometry to measure fever in an urban emergency department (ED). Data were collected from adult patients who received rectal temperature measurement...

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INTRODUCTION: For a patient nearing the end of his or her life, transfer from a nursing home to the ED can be inappropriate, with potentially negative consequences, but transfer in these circumstances is, regrettably, all too common. There is a lack of published literature exploring how paramedics make decisions in end-of-life care situations. This study aims to explore how paramedics make decisions when asked to transport nursing home residents nearing the end of their lives. METHODS: Phenomenological influenced design with a pragmatic approach...

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Standardization of medical care through protocols, order sets, and other tools is increasingly a part of efforts to improve quality. The authors, a physician beginning a new position as director of a community hospital quality program and the chief quality officer of a health care system and director of a course in health care delivery improvement, discuss the benefits and risks of standardization in health care. Recommendations for responsible standardization are presented.

BACKGROUND: Nausea and vomiting are common, but prevalence of antiemetic use in ED patients is unknown. OBJECTIVES: We determined the use of antiemetics in emergency department (ED) patients presenting with nausea and vomiting (NV). METHODS: We conducted a retrospective chart review of ED patients presenting to a local ED with NV and analyzed data from the National Hospital Ambulatory Care Survey for similar patients to determine the frequency of administration of antiemetics in the ED...

BACKGROUND: Anterior shoulder dislocation is a well-known injury for people working in emergency departments (EDs). Throughout the years, the focus has been shifted onto more gentle reduction techniques with less risk of iatrogenic injury, fracture displacement, and less pain for the patient. We present the results of one such technique, the Davos reduction maneuver, also known as the Boss-Holzach-Matter technique, as well as its advantages, disadvantages, and a few practical tips. DISCUSSION: We evaluated, retrospectively, 100 patients presenting with an anteroinferior shoulder dislocation, who were treated in the ED of the university hospital of Geneva, Switzerland, in a time period of 18 months...

There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis...

OBJECTIVE: The combination of constrained resources, patient complexity and rapidly increasing demand has meant that healthcare productivity constitutes a significant problem for emergency medicine. However, healthcare productivity remains a contentious issue, with some criticising the level of professional engagement. This paper will propose that productivity improvements in healthcare could occur (and be sustained) if professionals' perceptions and views of productivity were better understood...

We all think and assume that more is better, but unintended consequences can arise in a complex system. However, in our complex world, everything of consequence follows an inverted U curve. The inverted U curve helps us challenge our natural assumption that more is better. This leads us to the issue of overdiagnosis and the harms that result. Journals are now publishing lists of studies where more medical care caused harm. Changing diagnostic thresholds together with the fear of uncertainty by both patients and doctors has a synergistic and costly effect on the health system...