Factors associated with severity of accidental hypothermia: A cohort retrospective multi-institutional study.

BACKGROUND: Frequently it is difficult to determine illness severity in hypothermic patients. Our goal was to determine if there are factors associated with illness severity of hypothermic emergency department (ED) patients. METHODS: Multi-hospital retrospective cohort. Consecutive patients in 24 EDs (1-1-2012 to 4-30-2015). Hypothermic patients (≤35 °C) were identified using ICD codes. We used hospital admission as marker of illness severity. Student's t-test was used for differences between mean age and temperature for admitted and discharged patients. We calculated the percent of patients admitted by factor, the difference from overall admission rate and 95% confidence interval (CI) of difference. RESULTS: There were 2094 visits with hypothermia ICD code. Of these, 132 patients had initial rectal temperatures ≤35 °C. Females comprised 42%; the mean age was 55 ± 23 years, and overall admission rate was 62%. The percent of patients with alcohol, trauma and found indoors were 39%, 27% and 27%, respectively. For admitted and discharged patients the mean ages were 60 and 48 years, respectively (p = 0.01), and initial mean temperature 32.3 °C vs. 33 °C, respectively (p = 0.07). Found indoors was associated with an 86% admission rate, a 22% increase (95% CI, 3%-34%) compared to overall admission rate. There was no statistically significant difference in admission rates from overall admission rate based on gender, alcohol or trauma. CONCLUSIONS: For hypothermic ED patients increased severity of illness was associated with older age and found indoors but not associated with initial temperature, gender, alcohol or trauma. These findings may assist physicians in treatment and disposition decisions.

Emergency Department Visits for Gastroenteritis Before and After Rotavirus Vaccine Implementation in 2006.

OBJECTIVES: Gastroenteritis (GE) accounts for a significant number of emergency department (ED) visits in children. Several studies since the introduction of a new rotavirus vaccine in 2006 have found decreases in rotavirus illness. We sought to determine in a large multicenter ED database whether there was also a decrease in ED visits in young children for GE. DESIGN: Retrospective cohort of ED visits. SETTING: 28 EDs with annual visits between 22,000 and 82,000. POPULATION: Consecutive patients between January 1, 1996, and December 31, 2011. PROTOCOL: We identified GE visits using International Classification of Diseases 9th revision (ICD-9) codes. For each year, less than 5 years, we determined the average daily percent of total ED visits for GE. We calculated the decreases from 2005 to 2011 in the average daily percent GE visits for each year of life and their 95% confidence intervals. RESULTS: There were 7,740,823 total visits in the database, and 811,317 (10.5%) are younger than 5 years. The annual percent of GE visits rose for all years of life from 1999 to 2005 and then decreased from 2005 to 2011. The decreases from 2005 to 2011 were greatest in the earliest years of life ranging from 41% in the first year of life to 15% in the fifth year of life. CONCLUSIONS: We found a decrease in average daily ED visits for GE in each year of life for those younger than 5 years after the introduction of the rotavirus vaccine. This was most pronounced during the earliest years of life.

Prednisone for emergency department low back pain: a randomized controlled trial.

BACKGROUND: Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit. OBJECTIVE: To determine if a short course of oral corticosteroids benefits LBP ED patients. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Suburban New Jersey ED with 80,000 annual visits. PARTICIPANTS: 18-55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. PROTOCOL: At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0-3 scale (none, mild, moderate, severe) as well as functional status. RESULTS: The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0-3 scale (absolute difference 0.2, 95% confidence interval [CI] -0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%). CONCLUSION: We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.

Using n-Grams for Syndromic Surveillance in a Turkish Emergency Department Without English Translation: A Feasibility Study.

INTRODUCTION: Syndromic surveillance is designed for early detection of disease outbreaks. An important data source for syndromic surveillance is free-text chief complaints (CCs), which are generally recorded in the local language. For automated syndromic surveillance, CCs must be classified into predefined syndromic categories. The n-gram classifier is created by using text fragments to measure associations between chief complaints (CC) and a syndromic grouping of ICD codes. OBJECTIVES: The objective was to create a Turkish n-gram CC classifier for the respiratory syndrome and then compare daily volumes between the n-gram CC classifier and a respiratory ICD-10 code grouping on a test set of data. METHODS: The design was a feasibility study based on retrospective cohort data. The setting was a university hospital emergency department (ED) in Turkey. Included were all ED visits in the 2002 database of this hospital. Two of the authors created a respiratory grouping of International Classification of Diseases, 10th Revision ICD-10-CM codes by consensus, chosen to be similar to a standard respiratory (RESP) grouping of ICD codes created by the Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE), a project of the Centers for Disease Control and Prevention. An n-gram method adapted from AT&T Labs' technologies was applied to the first 10 months of data as a training set to create a Turkish CC RESP classifier. The classifier was then tested on the subsequent 2 months of visits to generate a time series graph and determine the correlation with daily volumes measured by the CC classifier versus the RESP ICD-10 grouping. RESULTS: The Turkish ED database contained 30,157 visits. The correlation (R (2)) of n-gram versus ICD-10 for the test set was 0.78. CONCLUSION: The n-gram method automatically created a CC RESP classifier of the Turkish CCs that performed similarly to the ICD-10 RESP grouping. The n-gram technique has the advantage of systematic, consistent, and rapid deployment as well as language independence.

Developing syndrome definitions based on consensus and current use.

OBJECTIVE: Standardized surveillance syndromes do not exist but would facilitate sharing data among surveillance systems and comparing the accuracy of existing systems. The objective of this study was to create reference syndrome definitions from a consensus of investigators who currently have or are building syndromic surveillance systems. DESIGN: Clinical condition-syndrome pairs were catalogued for 10 surveillance systems across the United States and the representatives of these systems were brought together for a workshop to discuss consensus syndrome definitions. RESULTS: Consensus syndrome definitions were generated for the four syndromes monitored by the majority of the 10 participating surveillance systems: Respiratory, gastrointestinal, constitutional, and influenza-like illness (ILI). An important element in coming to consensus quickly was the development of a sensitive and specific definition for respiratory and gastrointestinal syndromes. After the workshop, the definitions were refined and supplemented with keywords and regular expressions, the keywords were mapped to standard vocabularies, and a web ontology language (OWL) ontology was created. LIMITATIONS: The consensus definitions have not yet been validated through implementation. CONCLUSION: The consensus definitions provide an explicit description of the current state-of-the-art syndromes used in automated surveillance, which can subsequently be systematically evaluated against real data to improve the definitions. The method for creating consensus definitions could be applied to other domains that have diverse existing definitions.

Delphi consensus on the feasibility of translating the ACEP clinical policies into computerized clinical decision support.

Clinical practice guidelines are developed to reduce variations in clinical practice, with the goal of improving health care quality and cost. However, evidence-based practice guidelines face barriers to dissemination, implementation, usability, integration into practice, and use. The American College of Emergency Physicians (ACEP) clinical policies have been shown to be safe and effective and are even cited by other specialties. In spite of the benefits of the ACEP clinical policies, implementation of these clinical practice guidelines into physician practice continues to be a challenge. Translation of the ACEP clinical policies into real-time computerized clinical decision support systems could help address these barriers and improve clinician decision making at the point of care. The investigators convened an emergency medicine informatics expert panel and used a Delphi consensus process to assess the feasibility of translating the current ACEP clinical policies into clinical decision support content. This resulting consensus document will serve to identify limitations to implementation of the existing ACEP Clinical Policies so that future clinical practice guideline development will consider implementation into clinical decision support at all stages of guideline development.

Circadian pattern of intubation rates in ED patients with congestive heart failure.

PURPOSE: A previous study showed that pulmonary edema patients presenting between noon and 4 pm have the highest rates of myocardial infarction and death. We hypothesized that the highest intubation rates would also occur at these times. BASIC PROCEDURES: We performed a retrospective cohort study of consecutive patients seen by emergency department physicians in 15 hospital emergency departments (1996-2003). MAIN FINDINGS: Of 3.6 million visits in the database, 39,795 (1.1%) patients had congestive heart failure. We found statistically significant circadian variations in intubation rates. Patients arriving between midnight and 4 am had the highest intubation rates (4.1%), and those arriving between noon and 4 pm had the lowest (1.2%) (difference, 2.9%; 95% confidence interval, 2.4%-3.4%; P < .0001). CONCLUSION: We found significant circadian variation in intubation rates, with a marked increase around midnight. Pathological mechanisms causing patients with congestive heart failure to require intubation may differ from those resulting in myocardial infarction or death.

The ngram chief complaint classifier: a novel method of automatically creating chief complaint classifiers based on international classification of diseases groupings.

INTRODUCTION: The ngram classifier is created by using text fragments to measure associations between chief complaints (CC) and a syndromic grouping of ICD-9-CM codes. OBJECTIVES: For gastrointestinal (GI) syndrome to determine: (1) ngram CC classifier sensitivity/specificity. (2) Daily volumes for ngram CC and ICD-9-CM classifiers. DESIGN: Retrospective cohort. SETTING: 19 Emergency Departments. PARTICIPANTS: Consecutive visits (1/1/2000-12/31/2005). PROTOCOL: (1) Used an existing ICD-9-CM filter for "lower GI" to create the ngram CC classifier from a training set and then measured sensitivity/specificity in a test set using an ICD-9-CM classifier as criterion. (2) Compare daily volumes based on ICD-9-CM with that predicted by the ngram classifier. RESULTS: For a specificity of 0.96, sensitivity was 0.70. The daily volume correlation for ngram vs. ICD-9-CM was R=0.92. CONCLUSION: The ngram CC classifier performed similarly to manually developed CC classifiers and has advantages of rapid automated creation and updating, and may be used independent of language or dialect.

Increases in heart failure visits after Christmas and New Year's Day.

The authors hypothesized increased emergency department (ED) visits for heart failure (HF) during a 2-week Christmas holiday period similar to a recent study showing increased cardiac death rates. A retrospective analysis was performed from a database of 18 EDs in New Jersey and New York from January 1, 1996, to November 30, 2004, analyzing HF visits from December 1 to January 31. The authors compared the mean daily visits for the 2-week holiday period of December 25 to January 7, as well as December 26 to December 30 and January 2 to January 5, using the Student t test. A total of 4.7 million patients were studied, 65,646 with an ED diagnosis of HF and 11,525 during January and December. There was a 23% (95% confidence interval [CI], 14%-31%; P<.001) increase in daily visits for December 25 to January 7 and a 33% (95% CI, 16%-51%; P=.007) and 30% (95% CI, 22%-38%; P<.01) increase in the 4 days following Christmas and New Year's, respectively. The authors found a significant increase in daily HF visits in the 2-week holiday period and the 4 days following the holidays, even greater than that reported for sudden cardiac death.

Anxiety-related visits to New Jersey emergency departments after September 11, 2001.

The purpose of this study was to examine the effect of September 11, 2001 on anxiety-related visits to selected Emergency Departments (EDs). We performed a retrospective analysis of consecutive patients seen by emergency physicians in 15 New Jersey EDs located within a 50-mile radius of the World Trade Center from July 11 through December 11 in each of 6 years, 1996--2001. We chose by consensus all ICD-9 (International Classification of Diseases, 9th revision) codes related to anxiety. We used graphical methods, Box-Jenkins modeling, and time series regression to determine the effect of September 11 to 14 on daily rates of anxiety-related visits. We found that the daily rate of anxiety-related visits just after September 11th was 93% higher (p < 0.0001) than the average for the remaining 150 days for 2001. This represents, on average, one additional daily visit for anxiety at each ED. We concluded that there was an increase in anxiety-related ED visits after September 11, 2001.

Biosurveillance of ED visits for gastroenteritis.

OBJECTIVE: Our objective was to characterize emergency department (ED) visits for gastroenteritis by season and age and develop a predictive model. METHODS: We performed a retrospective cohort study of patients seen in 19 EDs from 1988 to 2002. We examined differences in the annual peaks of younger (<60 months) and older (>60 months) age groups and developed a time series regression model. RESULTS: Of the 5,182,019 total visits, 88,504 were for gastroenteritis. On average, the percentage of gastroenteritis on the peak days was higher in the younger (26%) than older group (4%), and the peaks for the younger group occurred 36 days after those for the older group. CONCLUSION: Emergency department visits for gastroenteritis vary greatly by season and age. Our time series predictive model was a good fit to actual incidence patterns. These variations should be accounted for in designing a system to detect bioterrorism and for surveillance of naturally occurring epidemics.

Diagnosis and satisfaction scores in emergency department patients who return a mailed survey.

Previous studies of patient satisfaction scores (PSS) have been of insufficient size to examine the influence of diagnosis on PSS. Our objective was to utilize a large database to determine if PSS for patients who return a widely used mailed proprietary survey differ with different diagnoses. We retrospectively analyzed a cohort at 11 hospital emergency departments of non-admitted patients who returned a mailed satisfaction survey. We grouped patients according to International Classification of Diseases, 9(th) Revision (ICD9) diagnoses and calculated mean scores for each diagnostic group. We rank-ordered by mean scores all ICD diagnoses having at least 50 survey responses. Scores were compared using analysis of variance. We analyzed 14,098 surveys. Among all diagnoses, 65 had at least 50 responses. The analysis of variance for the scores showed significant differences (p < 0.0001). Scores differ with respect to diagnosis. This could be used to choose interventions to improve scores of patients who return a mailed survey.

Cardiac events in New Jersey after the September 11, 2001, terrorist attack.

The higher stress associated with the World Trade Center (WTC) attacks on September 11, 2001, may have resulted in more cardiac events particularly in those living in close proximity. Our goal was to determine if there was an increase in cardiac events in a subset of emergency departments (EDs) within a 50-mi radius of the WTC. We performed a retrospective analysis of consecutive patients seen by ED physicians in 16 EDs for the 60 days before and after September 11 in 2000-2002. We determined the number of patients admitted to an inpatient bed with a primary or secondary diagnosis of acute myocardial infarction (MI) or tachyarrhythmia. In each year, we compared patient visits for the 60 days before and after September 11 using the chi-square statistic. For the 360 days during the 3 years, there were 571,079 patient visits in the database of which 110,766 (19.4%) were admitted. Comparing the 60 days before and after September 11, 2001, we found a statistically significant increase in patients with MIs (79 patients before versus 118 patients after, P =.01), representing an increase of 49%. There were no statistically significant differences for MIs in 2000 and 2002 and in tachyarrhythmias for all three years. For the 60-day period after September 11, 2001, we found a statistically significant increase in the number of patients presenting with acute MI but no increase in patients admitted with tachyarrhythmias.

Disparate systems, disparate data: integration, interfaces, and standards in emergency medicine information technology.

As part of the broader informatics consensus initiative sponsored by Academic Emergency Medicine, this report addresses the issues of integration, interfaces, and data standards and how they are relevant to information management in emergency medicine. The purpose of this report, and the workgroup that contributed to its content, is to provide emergency physicians and other stakeholders in the emergency informatics community a sense of direction as they design, build, and/or choose systems. Problems are identified, strategies to address these problems are discussed, and consensus recommendations are provided.

The Frontlines of Medicine Project progress report: standardized communication of emergency department triage data for syndromic surveillance.

This article reports progress since the original publication of the Frontlines of Medicine Project. This project is a collaborative effort of emergency medicine (including emergency medical services and clinical toxicology), public health, other government agencies involved in health care and preparedness, law enforcement, and informatics to develop nonproprietary, standardized methods for reporting emergency department patient data. These data may be used for a variety of public health or clinical care initiatives, including syndromic surveillance for chemical and biological terrorism. This article reviews the outcome of the Project meeting in April 2002. Also, the article describes a Delphi Survey process to define the data elements in a triage surveillance report and to define a set of codified values for the chief complaint data element. An initial retrospective validation of the codified chief complaint values is provided, and prospective study of the proposed Frontlines' standards is encouraged.

Perspective of an emergency physician group as a data provider for syndromic surveillance.

The need for enhanced biologic surveillance has led to the search for new sources of data. Beginning in September 2001, Emergency Medical Associates (EMA) of New Jersey, an emergency physician group practice, undertook a series of surveillance projects in collaboration with state and federal agencies. This paper examines EMA's motivations and concerns and discusses the collaborative opportunities available to data suppliers for syndromic surveillance. Motivations for supplying data included altruism and public service, previous involvement in terrorism and disaster preparedness, academic research interests, and the opportunity to find added value in the group's existing information systems. Concerns and barriers included cost, maintaining patient confidentiality, and challenges in interacting with the public health community. The extensive and carefully maintained electronic medical record enabled EMA to conduct multiple studies in collaboration with state and federal agencies. The electronic medical record provides useful data that might be more sensitive and specific in detecting outbreaks than the patient-chief-complaint data more commonly used for surveillance. EMA's experience also indicates that opportunities exist for the public health community to work with emergency physicians and emergency physician groups as suppliers of data. Such collaborations not only are useful for syndromic surveillance systems but also can help build relations that might facilitate a response to an actual biologic attack.