ABSTRACT
Compared with mortality, the impact of weather and climate on human morbidity is less well understood, especially in the cold season. We examined the relationships between weather and emergency department (ED) visitation at hospitals in Roanoke and Charlottesville, Virginia, two locations with similar climates and population demographic profiles. Using patient-level data obtained from electronic medical records, each patient who visited the ED was linked to that day's weather from one of 8 weather stations in the region based on each patient's ZIP code of residence. The resulting 2010-2017 daily ED visit time series were examined using a distributed lag non-linear model to account for the concurrent and lagged effects of weather. Total ED visits were modeled separately for each location along with subsets based on gender, race, and age. The relationship between the relative risk of ED visitation and temperature or apparent temperature over lags of one week was positive and approximately linear at both locations. The relative risk increased about 5% on warm, humid days in both cities (lag 0 or lag 1). Cold conditions had a protective effect, with up to a 15% decline on cold days, but ED visits increased by 4% from 2 to 5 days after the cold event. The effect of thermal extremes tended to be larger for non-whites and the elderly, and there was some evidence of a greater lagged response for non-whites in Roanoke. Females in Roanoke were more impacted by winter cold conditions than males, who were more likely to show a lagged response at high temperatures. In Charlottesville, males sought ED attention at lower temperatures than did females. The similarities in the ED response patterns between these two hospitals suggest that certain aspects of the response may be generalizable to other locations that have similar climates and demographic profiles.
Subject(s)
Climate , Weather , Aged , Cities , Emergency Service, Hospital , Female , Humans , Male , Seasons , VirginiaSubject(s)
Emergency Service, Hospital/statistics & numerical data , Hot Temperature/adverse effects , Weather , Adolescent , Adult , Child , Child, Preschool , Female , Humans , Infant , Male , Retrospective Studies , Virginia , Young AdultABSTRACT
We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation.
Subject(s)
Anesthetics, Intravenous/administration & dosage , Propofol/administration & dosage , Anesthetics, Intravenous/adverse effects , Drug Dosage Calculations , Drug Therapy, Combination , Emergency Service, Hospital , Evidence-Based Medicine , Female , Humans , Infant , Infant, Newborn , Male , Practice Guidelines as Topic , Propofol/adverse effectsABSTRACT
The emergency providers generally encounters myeloproliferative disorders (MPNs) in 1 of 2 ways: as striking laboratory abnormalities of seeming unknown consequence, or in previously diagnosed patients presenting with complications. The course of patients with MPNs is highly variable, but major complications can arise. Emergent conditions related to hyperviscosity need to be recognized early and treated aggressively. Rapid hydration, transfusion, cytoreduction, and early hematology consultation can be lifesaving. Likewise, although management is not altered, a high index of suspicion for thrombotic complications is required in patients with known MPNs as these are a significant cause of morbidity and mortality.
Subject(s)
Emergency Medical Services/methods , Myeloproliferative Disorders/diagnosis , Myeloproliferative Disorders/therapy , Humans , Myeloproliferative Disorders/blood , Myeloproliferative Disorders/mortalityABSTRACT
Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.
ABSTRACT
Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.
ABSTRACT
INTRODUCTION: Addressing pain is a crucial aspect of emergency medicine. Prescription opioids are commonly prescribed for moderate to severe pain in the emergency department (ED); unfortunately, prescribing practices are variable. High variability of opioid prescribing decisions suggests a lack of consensus and an opportunity to improve care. This quality improvement (QI) initiative aimed to reduce variability in ED opioid analgesic prescribing. METHODS: We evaluated the impact of a three-part QI initiative on ED opioid prescribing by physicians at seven sites. Stage 1: Retrospective baseline period (nine months). Stage 2: Physicians were informed that opioid prescribing information would be prospectively collected and feedback on their prescribing and that of the group would be shared at the end of the stage (three months). Stage 3: After physicians received their individual opioid prescribing data with blinded comparison to the group means (from Stage 2) they were informed that individual prescribing data would be unblinded and shared with the group after three months. The primary outcome was variability of the standard error of the mean and standard deviation of the opioid prescribing rate (defined as number of patients discharged with an opioid divided by total number of discharges for each provider). Secondary observations included mean quantity of pills per opioid prescription, and overall frequency of opioid prescribing. RESULTS: The study group included 47 physicians with 149,884 ED patient encounters. The variability in prescribing decreased through each stage of the initiative as represented by the distributions for the opioid prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46% reduction, p<0.01), and Stage 3 mean 8% (60% reduction, p<0.01). The mean quantity of pills prescribed per prescription was 16 pills in Stage 1, 14 pills in Stage 2 (18% reduction, p<0.01), and 13 pills in Stage 3 (18% reduction, p<0.01). The group mean prescribing rate also decreased through each stage: 20% in Stage 1, 13% in Stage 2 (46% reduction, p<0.01), and 8% in Stage 3 (60% reduction, p<0.01). CONCLUSION: ED physician opioid prescribing variability can be decreased through the systematic application of sharing of peer prescribing rates and prescriber specific normative feedback.
Subject(s)
Analgesics, Opioid/therapeutic use , Emergency Service, Hospital/statistics & numerical data , Guideline Adherence , Inappropriate Prescribing/statistics & numerical data , Pain/drug therapy , Practice Patterns, Physicians'/statistics & numerical data , Analysis of Variance , Guidelines as Topic , Humans , Pain/epidemiology , Program Evaluation , Quality Improvement , Retrospective Studies , United States/epidemiologySubject(s)
Emergency Service, Hospital , Fibrinolytic Agents/therapeutic use , Stroke/drug therapy , Tissue Plasminogen Activator/therapeutic use , Fibrinolytic Agents/administration & dosage , Fibrinolytic Agents/adverse effects , Humans , Infusions, Intravenous , Stroke/diagnosis , Time , Tissue Plasminogen Activator/administration & dosage , Tissue Plasminogen Activator/adverse effectsABSTRACT
The emergency providers generally encounters myeloproliferative disorders (MPNs) in 1 of 2 ways: as striking laboratory abnormalities of seeming unknown consequence, or in previously diagnosed patients presenting with complications. The course of patients with MPNs is highly variable, but major complications can arise. Emergent conditions related to hyperviscosity need to be recognized early and treated aggressively. Rapid hydration, transfusion, cytoreduction, and early hematology consultation can be lifesaving. Likewise, although management is not altered, a high index of suspicion for thrombotic complications is required in patients with known MPNs as these are a significant cause of morbidity and mortality.
Subject(s)
Myeloproliferative Disorders/diagnosis , Myeloproliferative Disorders/therapy , Emergency Medicine , Humans , Myeloproliferative Disorders/mortality , Prognosis , Risk FactorsABSTRACT
This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency department.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients undergoing procedural sedation and analgesia in the emergency department,does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration? (2) In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events? (3) In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications? (4) Inpatients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil and remifentanil be safely administered? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.
Subject(s)
Analgesia/standards , Conscious Sedation/standards , Emergency Service, Hospital/standards , Alfentanil , Analgesia/adverse effects , Anesthesia, General/standards , Capnography/standards , Conscious Sedation/adverse effects , Deep Sedation/standards , Dexmedetomidine , Etomidate , Humans , Ketamine , Piperidines , Propofol , Remifentanil , WorkforceABSTRACT
Academic Emergency Medicine publishes selected peer-reviewed videos that present state-of-the-art research, practice, and evidence in the field of emergency medicine. These videos are referred to as peer-reviewed lectures (PeRLs). This commentary reviews considerations for creating, filming, and producing high-quality PeRLs videos.
Subject(s)
Emergency Medicine/education , Video Recording/standards , Humans , Peer ReviewSubject(s)
Analgesia/standards , Conscious Sedation/standards , Credentialing , Deep Sedation/standards , Emergency Service, Hospital/standards , Medical Staff Privileges/standards , Anesthesia/standards , Emergency Service, Hospital/organization & administration , Humans , Monitoring, Physiologic/standards , Quality Assurance, Health Care/standardsABSTRACT
We present evidence-based clinical practice recommendations for the administration of etomidate for emergency department (ED) rapid sequence induction. We critically discuss indications and contraindications in typical ED patient subpopulations such as the traumatic, septic, neurologic, or pulmonary patient. Future research questions are considered.
Subject(s)
Anesthetics, Intravenous/administration & dosage , Etomidate/administration & dosage , Algorithms , Anesthetics, Intravenous/adverse effects , Clinical Trials as Topic , Contraindications , Emergency Service, Hospital , Etomidate/adverse effects , Evidence-Based Medicine , Humans , RiskSubject(s)
Databases, Factual , Information Systems/instrumentation , Ischemia/drug therapy , Recombinant Proteins/therapeutic use , Stroke/drug therapy , Tissue Plasminogen Activator/therapeutic use , Acute Disease , Adult , Aged , Aged, 80 and over , Clinical Trials as Topic , Female , Humans , Male , Middle AgedABSTRACT
We present an evidence-based clinical practice advisory for the administration of propofol for emergency department procedural sedation. We critically discuss indications, contraindications, personnel and monitoring requirements, dosing, coadministered medications, and patient recovery from propofol. Future research questions are considered.
Subject(s)
Conscious Sedation , Hypnotics and Sedatives , Propofol , Conscious Sedation/standards , Contraindications , Emergency Service, Hospital , Humans , Hypnotics and Sedatives/administration & dosage , Hypnotics and Sedatives/adverse effects , Propofol/administration & dosage , Propofol/adverse effectsABSTRACT
Emergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. The advisory is not intended to assert a legal standard of practice or absolute requirement. It is expected that emergency physicians will at times appropriately deviate from it according to individualized judgment and unique clinical circumstances.
Subject(s)
Analgesia , Clinical Protocols , Conscious Sedation , Emergency Service, Hospital , Contraindications , Fasting , Humans , Respiratory Aspiration/prevention & controlABSTRACT
BACKGROUND: To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization. METHODS: An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures-stable and unstable-were the primary investigational outcomes. RESULTS: There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI, 99.8-100). CONCLUSIONS: The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS-assessed trauma patients.