Randomized trial of a novel lifestyle intervention compared with the Diabetes Prevention Program for weight loss in adult dependents of military service members.

BACKGROUND: Lifestyle interventions are the first-line treatment for obesity, but participant weight loss is typically low. OBJECTIVES: We evaluated the efficacy of an alternative lifestyle intervention [Healthy Weight for Living (HWL)] compared with a modified Diabetes Prevention Program (m-DPP). HWL was based on a revised health behavior change model emphasizing hunger management and the development of healthy food preferences. m-DPP was a standard Diabetes Prevention Program implemented with counselor time matched to HWL. Participants were adult dependents of military personnel and had overweight or obesity. METHODS: Participants were randomly assigned to HWL (n = 121) or m-DPP (n = 117), delivered primarily by group videoconference with additional midweek emails. The primary outcome was 12-mo weight change. Secondary outcomes included 6-mo changes in cardiometabolic risk factors and diet. Intention-to-treat (ITT) and complete case (CC) analyses were performed using linear mixed models. RESULTS: Retention did not differ between groups (72% and 66% for HWL and m-DPP at 12 mo, respectively; P = 0.30). Mean ± SE adjusted 12-mo weight loss in the ITT cohort was 7.46 ± 0.85 kg for HWL and 7.32 ± 0.87 kg for m-DPP (P = 0.91); in the CC cohort, it was 7.83 ± 0.82 kg for HWL and 6.86 ± 0.88 kg for m-DPP (P = 0.43). Thirty-eight percent of HWL and 30% of m-DPP completers achieved ≥10% weight loss (P = 0.32). Improvements in systolic blood pressure, LDL cholesterol, triglycerides, fasting glucose, general health, sleep, and mood were similar across groups; improvements in diastolic blood pressure were greater in m-DPP. Adjusted group mean reductions in energy intake were not significantly different between groups, but HWL participants were more adherent to their dietary prescription for lower glycemic index and high fiber and protein (P = 0.05 to <0.001 for ITT). CONCLUSIONS: HWL and m-DPP showed equivalent and clinically impactful mean weight loss with cardiometabolic benefits. These results identify an alternative approach for behavioral treatment of overweight and obesity.This trial was registered at clinicaltrials.gov as NCT02348853.

Assessing the Prevalence and Predictors of Bullying Among Emergency Medical Service Providers.

Background: Bullying as a stressor in the workplace has been evaluated in numerous settings. It has never been evaluated in the emergency medical service (EMS) environment where bullying can occur from many different sources. The Negative Acts Questionnaire-Revised (NAQ-R) is a 22-question validated tool for evaluating bullying. Our hypothesis was that we could identify a shortened version of the NAQ-R that identifies bullying as accurately as the full screening tool. Methods: This was a cross sectional study of EMS providers in our local EMS transport agency. The local EMS agency transports approximately 50,000 patients per year and is a paramedic level response system. Results on the NAQ-R were on a 5-point Likert scale for each of 22 different categories of bullying that were summed by adding each questions 1-5 response for the 22 questions. Respondents were also categorized as victims or non-victims of bullying based on being positive for any of the 22 types of bullying at least once a week. We performed a binomial decision tree analysis and a cross-validation. Results: Data were collected from 153 providers. Mean age was 33 ± 10 years and 50% were male. Total years in EMS were 8 ± 8 years. NAQ-R summed results in our group ranged between 22 and 88, with an average of 40 ± 15. A NAQ-R score of 33 or less was 91% accurate in identifying non-victims and a score of 45 or more was 94% accurate in identifying victims. The majority at 51% (77/152) of respondents were victims of one or more types of bullying. A combination of five questions was 94% accurate in identifying a victim of bullying among EMS providers. Cross validation resulted in a misclassification risk estimate of 0.12 ± .03. Conclusion: NAQ-R bullying scores in EMS are similar or higher than numbers in other fields. Five questions on the NAQ-R were 94% accurate in identifying victims of bullying in EMS providers.

Thyroid stimulating hormone testing in ED evaluation of patients with atrial fibrillation and various psychiatric diagnoses.

BACKGROUND: Previous studies of thyroid stimulating hormone (TSH) levels in Emergency Department (ED) patients largely have centered on patients with atrial fibrillation (AF). In our ED patients with AF as well as patients with Psychiatric diagnoses (psych) are screened. The purpose of the present study was to compare TSH levels in the 2 groups. Our hypotheses were that an abnormal TSH and/or AF predicted the need for hospital admission and that TSH is more likely decreased in AF and increased in psych patients. METHODS: Our goal in the study was to compare the use of TSH testing in two ED populations, AF vs. psych patients. The study was a cross sectional cohort of AF vs. psych patients who had TSH levels drawn in the ED over a two year period. Our laboratory ranges were used to determine high vs. low TSH. Two chart examiners collected data after a training process. Charts were reviewed extracting demographic data, TSH levels, outcome (admit vs. discharge), history of AF, thyroid disease, psych diagnoses, presence of CHF, diabetes, hypertension. We compared AF vs. Psych groups using chi square and t-tests for parametric data. Odds ratios were calculated for comparisons between the 2 groups. For non-parametric data Mann Whitney U was used. A logistic regression was performed with the outcome of admission vs. discharge to find predictors of hospital admission. Kappa was calculated for inter-rater agreement. An a priori power analysis showed 80% power with 2 groups of 100 with an absolute difference of 20% between the 2 groups. RESULTS: 252 patients were included, 101 with AF and 152 Psych. Demographics differed in age only with AF patients being older. Mean TSH for AF vs. 2.4 for AF, 2.9 for psych (NS) with no differences in percentages with high or low TSH in the 2 groups. Fifty-three patients had abnormal TSH levels (21%), 27% of AF and 17% of Psych patients (NS). There were significant differences in incidence of CHF, DM, HTN, and tachycardia with more in the AF group (P < 0.001). Significantly more of the psych patients had a history of hypothyroidism (OR 2.28). Our logistic regression showed that taking into account demographics including age, the only predictors of admission were the presence of CHF (aOR 18.6) and having a diagnosis of AF (aOR 4.0). CONCLUSION: There were no differences in TSH levels between the 2 groups. Twenty-one percent had an abnormal level. CHF and AF predicted hospital admission on regression analysis. Many with these AF or Psych diagnoses had abnormal ED TSH levels that could be useful in diagnosis, maintenance, or continuous treatment for their conditions diagnoses.

Sepsis alerts in EMS and the results of pre-hospital ETCO2.

BACKGROUND: Field sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection. METHODS: In 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a "sepsis alert" on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as >4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2. RESULTS: 351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was -0.45. A ROC curve analysis of ETCO2 vs. lactate >4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population. CONCLUSION: While ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.

Bathing Habits in Emergency Department Patients with Cellulitis or Abscess Versus Controls.

OBJECTIVE: Cellulitis is a leading cause of emergency department (ED) visits, with more than 200 cases per 100,000 people per year. Although many risk factors have been identified, including edema, skin breakdown, and penetrance of the skin, there are few data available on whether personal hygiene habits (bathing and clean clothes) are associated with increased risk for soft tissue infection. Studies looking at chlorhexidine baths in the intensive care unit to prevent soft tissue infections have shown conflicting and limited efficacy. Our objective was to determine whether poor personal hygiene, as manifested in poor bathing habits, a lack of access to clean clothes, or frequent needle self-injections, are associated with cellulitis or abscesses. METHODS: The research is a cross-sectional cohort study of patients with either cellulitis, soft tissue abscess, or both (cases) versus a control group of patients with abdominal pain without prior surgeries in a large, urban ED in a convenience sampling. We asked about bathing habits, access to clean clothing, and skin breaks from intravenous (IV) drug use as risk factors. The two groups were compared using descriptive statistics, and a regression analysis was performed to determine the characteristics that are predictive of soft tissue infections. The study was powered at 0.8 to detect a 20% difference in adequate bathing habits with 100 per group. RESULTS: In an approximate 1-year study period, 108 cases were identified and compared with 104 abdominal pain controls selected at random from patients presenting to the same ED. In the cellulitis/abscess group the mean age was 47 and 81% were men, and in the control group the mean age was 45 and 39% were men. There were significantly more men in the cellulitis/abscess group (Diff 22%, 95% confidence interval [CI] 8-34, P < 0.01). Seventy percent (76 of 108) of cases versus 58% (80 of 104) of controls bathed daily (odds ratio [OR] 1.7, 95% CI 0.98-3.1, not significant). There was a significant difference between the two groups in laundry habits: 66% (71 of 108) of cases versus 42% (44 of 104) of controls did not have access to clean laundry daily (adjusted OR [AOR] 2.5, 95% CI 1.4-5.0, P < 0.01). The most profound and significant difference was noted between cases and controls regarding the use of IV drugs, in which 20 of 108 cases (19%) used IV drugs versus 3 of 104 controls (3%, P < 0.01). Finally, 35 of 108 (32%) of our cases had a history of infections, whereas only 5 of 104 (5%) of the controls had cellulitis or an abscess previously (P < 0.01). On regression analysis significant predictors of soft tissue infection were history of skin infection (AOR 7.0) and not cleaning clothes daily (AOR 2.5). CONCLUSIONS: There was no significant difference in bathing habits, but there was a significant difference in laundry habits between the case and control groups. Our study further confirms that IV drug use is a risk factor for cellulitis and no access to clean clothes daily was significantly related to the development of cellulitis. Failing to obtain daily showers was not associated with an increase in infection.

Implementation of electronic charting is not associated with significant change in physician productivity in an academic emergency department.

OBJECTIVES: To compare physician productivity and billing before and after implementation of electronic charting in an academic emergency department (ED). MATERIALS AND METHODS: This retrospective, blinded, observational study compared the 6 months pre-implementation (January to June 2012) with the 6 months post-implementation 1 year later (January to June 2013). Thirty-one ED physicians were recruited, with each physician acting as his/her own control in a before-after design. Productivity was measured via total number of encounters and "productivity index" defined as worked relative value units divided by the clinical full-time equivalent. Values for charges, encounters, and productivity index were determined during each study period and separately for procedures, observational stays, and critical care. RESULTS: No differences were found for total productivity index per month (758 [623-876] pre-group vs. 756 [673-886] post-group; P = 0.30). There was, however, a 9% decrease in total encounters per month (138 [101-163] pre-group vs. 125 [99-159] post-group; P = 0.01). Significant decreases were seen across all observation stay categories. Conversely, significant increases were seen across all critical care categories. There was no difference in total charges per month. DISCUSSION: This is one of few studies to demonstrate minimal disruption in physician productivity after transitioning to electronic documentation. The reasons for these findings are likely multi-factorial. CONCLUSION: In this study, implementation of electronic charting was not associated with decreases in productivity or billing for total ED care, but may be associated with increases for critical care and decreases for observational stays.

Cross-Sectional Study of the Relation of Health Literacy to Primary Language and Emergency Department Length of Stay.

OBJECTIVES: The primary aim of this study was to determine whether emergency department (ED) length of stay (LOS) or primary language was related to the degree of health literacy of patients. METHODS: Adult English-speaking and Spanish-speaking patients were recruited for the study. Participants completed the Newest Vital Sign (NVS) tool (English and Spanish versions), a 6-question validated scale. Patients with NVS scores of 0 to 3 were considered to be at risk for limited health literacy, whereas those with adequate health literacy were defined as scoring a 4 to 6. After completion of their ED visit, a retrospective chart review was performed to identify the patient's ED LOS (time from registration to time of disposition) and ED disposition. In addition, 2 single-item questions were compared with the NVS for validity. RESULTS: Participants included 250 English-speaking and 257 Spanish-speaking subjects. Per the NVS, 71% (359 of 507) of all patients had limited health literacy. By language group, significantly more Spanish-speaking than English-speaking patients had limited health literacy (93% vs 48%, diff 45%, 95% confidence interval 37-51). There was no significant difference in LOS between the limited health literacy group and adequate health literacy group (medians 440 vs 461 min). The 2 single-item questions had fair validity in comparison to the NVS scale (κ 0.2-0.3). CONCLUSIONS: There was a significant difference in health literacy based on language, with 93% of all Spanish-speaking patients in our sample having limited health literacy. We found no significant difference in ED LOS between patients with limited health and adequate health literacy in an academic urban ED setting.

Patients Given Take Home Medications Instead of Paper Prescriptions Are More Likely to Return to Emergency Department.

Objective: The aim of this study was to compare the 30-day emergency department (ED) return rate between patients given a Take Home Medication pack (THM) versus a standard paper prescription (SPP) prior to discharge. Methods: This was an observational, prospective cohort study in an urban, university-affiliated, level I trauma center. Patients were identified through daily pharmacy reports. Consecutive adult patients discharged from the ED with either a THM or equivalent SPP were included. For each patient, baseline characteristics including age, gender, primary care provider (PCP), primary language, ethnicity, marital status, and insurance status were recorded from the electronic medical record (EMR). Review of the EMR was used to determine whether patients returned to the ED within 30 days and whether the return visit was for all-causes or for the same complaint targeted by the THM or SPP from the index visit. Similarly, visits to other providers in the health system within 30 days were recorded. Results: A total of 711 patients were included in the study, with 268 receiving a THM and 443 receiving a SPP. In comparison with the SPP group, the THM group was more likely to have an all-cause return (Relative Risk [RR] = 1.7, P < .01). Variables associated with increased odds of returning to the ED within 30 days included study group (adjusted Odds Ratio [aOR]: 1.7), male gender (aOR: 1.6), African American ethnicity (aOR: 3.0), public insurance (aOR: 3.3), and institutional financial assistance (aOR: 5.0). The difference between study groups for index visit complaint-specific returns was not significant. Conclusions: Patients receiving a THM demonstrated a higher all-cause return rate than patients receiving a SPP. A randomized study is needed evaluating the effect of THM on return ED visits.

A Comparison of QTc Intervals in Alcohol Withdrawal Patients Versus Acute Coronary Syndrome Patients.

OBJECTIVES: Patients with an alcohol use disorder experiencing acute intoxication or withdrawal may be at risk for electrocardiograph (ECG) abnormalities, including prolongation of repolarization (long QTc [corrected QT]) that may contribute to arrhythmias and may be associated with a threefold increase in the likelihood of sudden cardiac events. Patients with acute coronary syndrome may have prolonged QTc as well. To our knowledge, no previous studies have compared the QTc of ACS with acute ethanol (EtOH) withdrawal syndromes in the emergency department (ED). The purpose of our study was to compare the QTc of those with EtOH withdrawal emergencies with patients with ACS in our ED. Our hypothesis was that the QTc would be similarly prolonged in the two cohorts. METHODS: The study compared two cohort groups, those with ACS and those with EtOH withdrawal-related ED visits over a 1-year period. We compared ECG QTc, cardiac medication use, and electrolyte differences. We considered a QTc of >450 ms elevated for men and >470 ms elevated for women based on the literature. Fifty subjects in whom an ECG, serum osmolality, and EtOH level were recorded within 2 hours of one another and who were administered a Clinical Institute Withdrawal Assessment protocol were compared with 203 patients with ACS during the same period. We excluded patients with incomplete data. Medications compared included clopidogrel, acetylsalicylic acid, ß-blockers, angiotensin-converting enzyme inhibitors, and statins. ECG QT and QTc, as well as electrolytes, were recorded and compared. Data were extracted by two investigators with a 20% sample re-evaluated by the other extractor as a reliability measure. Descriptive statistics including medians and interquartile ranges were measured for continuous variables. Comparisons were made using two-tailed t tests for parametric data and the Mann-Whitney U test for nonparametric data. RESULTS: Agreement in the 20% sampling between investigators was high (96%). The mean QTc in the ACS group was 457 ms and the mean QTc in the EtOH withdrawal-related group was 468 ms (diff 11, not significant). Significantly more patients had a prolonged QTc in the EtOH withdrawal group than in the ACS group 62% vs 46%; diff 16; 95% CI (0.1, 30). There was significantly more use of clopidogrel, acetylsalicylic acid, angiotensin-converting enzyme inhibitors, and statins (P < 0.05 for all) in the ACS group compared with the EtOH withdrawal group; however, there was no difference in ß-blocker usage. There was a significantly higher admission rate: 100% of ACS compared with 76% of the EtOH withdrawal group (P < 0.01, diff 24, 95% confidence interval 18-29). Electrolytes were not significantly different in the two groups. CONCLUSIONS: More patients with EtOH withdrawal-related ED visits had a long QTc than patients presenting with ACS. ED physicians should carefully monitor patients experiencing EtOH withdrawal for cardiac arrhythmias and obtain an ECG. If any medications that prolong the QTc are considered, then an ECG should be obtained before administering medications that may affect the myocardium to make medication safer for the patient.

Comparison of QTc and Troponin Levels in ST Elevation MIs Compared with Non-ST Elevation MIs.

OBJECTIVES: ST elevation myocardial infarctions (STEMIs) and non-ST elevation myocardial infarctions (NSTEMIs) have differences that can be important to differentiate. Our primary hypothesis was that corrected QT (QTc) duration and troponin I levels were higher in STEMIs compared with NSTEMIs. The objective of our study was to compare STEMIs with NSTEMIs for QTc duration and troponin levels. METHODS: This was a retrospective case-control study of all STEMIs and a random sample of NSTEMIs during a 1-year period. STEMIs were retrieved by searching our electrocardiogram database for all of the cardiology-diagnosed STEMIs. NSTEMIs were found by selecting a randomized sample of all of the patients with a final discharge diagnosis of NSTEMI. Records and electrocardiograms were reviewed for initial troponin I levels and QTc duration. Data extractors were educated formally and a 5% sample was reevaluated by the other extractor as a reliability measure. Data analysis included χ2 tests and parametric or nonparametric analysis, where appropriate. A logistic regression model was created with variables selected a priori for predictors of STEMIs compared with NSTEMIs. RESULTS: A total of 92 STEMIs and 111 NSTEMIs were evaluated, and interrater reliability showed 90% agreement. Patients with NSTEMIs had significantly longer QTc. Troponin I did not differ on univariate analysis. In a logistic model, Hispanics were more likely than whites to have a STEMI (adjusted odds ratio [AOR] 2.2, 95% confidence interval [CI] 1.09-4.5). An increase in troponin I of 1 was associated with a 7% increase in the AOR of a STEMI (AOR 1.7, 95% CI 1.03-1.12) and an increase in QTc by 10 was associated with a 13% decrease in the AOR of a STEMI (AOR 0.87, 95% CI 0.78-0.93). CONCLUSIONS: Patients with NSTEMIs had longer QTc intervals and lower troponin I levels than those with STEMIs.

Impact of an emergency medicine pharmacist on antibiotic dosing adjustment.

OBJECTIVE: Overall medication-related errors in the emergency department (ED) are 13.5 times more likely to occur in the absence of an emergency medicine pharmacist (EMP). Although the effectiveness of pharmacist-driven renal dosing adjustment has been studied in the intensive care unit, data are lacking in the ED setting. The aim of our study was to evaluate the appropriateness of antibiotic dosing when an EMP is physically present in the ED compared to when absent. METHODS: This was a retrospective cohort study of patients treated in a level I trauma center with 75 adult and 12 pediatric beds and an annual census of 90000 patients. The study period was from March 1 to September 30, 2014. An EMP was physically present in the ED from 11:00 to 01:30 and absent from 01:31 to 10:59. Male and female patients 18years and older were considered for inclusion if cefazolin, cefepime, ciprofloxacin, piperacillin-tazobactam, or vancomycin was ordered. The primary outcome was the composite rate of correct antibiotic dose and frequency. Statistics included a multivariable logistic regression using age, sex, presence of EMP, and creatinine clearance as independent predictors of correct antibiotic use. RESULTS: A total 210 cases were randomly chosen for evaluation, half during times when EMPs were present and half when they were absent. There were 130 males (62%) with an overall mean age of 54±18years. Overall, 178 (85%) of 210 of the antibiotic orders were appropriate, with 95% appropriate when an EMP was present compared to 74% when an EMP was absent (odds ratio, 6.9; 95% confidence interval, 2.5-18.8). In a logistic regression model, antibiotic appropriateness was independently associated with the presence of the EMP and creatinine clearance. CONCLUSION: Antibiotics that require renal and/or weight dosing adjustment are 6.5 times more likely to be appropriate in the ED when an EMP is present. Prevalence of antibiotic dosing error is related to both the presence of EMPs and the degree of renal impairment.

The meaning of elevated troponin I levels: not always acute coronary syndromes.

BACKGROUND: Troponin elevation can be caused by etiologies other than acute coronary syndromes (ACS). Our hypothesis was that elevated troponins occur more frequently in non-ACS cases but that ACS cases (type 1 ST-elevation myocardial infarction [STEMI] and type 1 non-STEMI [NSTEMI]) have significantly higher troponin elevations. METHODS: This was a cross-sectional cohort analysis of a random subset of all patients with elevated troponins (defined as ≥0.06 ng/mL) over a 1-year period from July 2013 to June 2014. The first positive troponin I and the peak were used in this study. All included patients had medical record reviews looking for whether our cardiologists or hospitalists attributed the elevated troponin to an ACS (NSTEMI or STEMI) or non-ACS cause. Non-ACS causes were categorized as infection, cancer, renal diseases, cardiovascular disease, pulmonary disease, trauma, cardiac arrest, neurologic disease, hypertension, or other. Data were extracted by 2 investigators on the cause of the elevated troponin. Three sessions to educate data extractors were arranged and methods of data extraction discussed, then a 5% sample was reevaluated by the other extractor to determine interrater agreement measures. Parametric data were evaluated with t test and analysis of variance. Dichotomous variables were compared using χ(2) test. Troponin data were evaluated using nonparametric Kruskal-Wallis or Mann-Whitney U. A logistic regression model was created with variables selected a priori to evaluate the predictive ability of these variables in differentiating ACS vs non-ACS causes of elevated troponin. RESULTS: We evaluated 458 randomly selected patients from 1317 unique cases of all patients with initial elevated troponins at least 0.06 mg/mL during the study period. There was 84% interrater agreement in the 5% sampling. Seventy-nine percent had a non-ACS cause of elevated troponin, and the average initial positive troponin I level was significantly lower in the non-ACS cases (0.14; 95% confidence interval [CI], 0.08-0.37) than those with documented STEMI (10.2; 95% CI, 0.75-20.1) or NSTEMIs (0.4; 95% CI, 0.13-1.7). In the non-ACS group, the median initial troponin was 0.14 ng/mL (0.08-0.37 ng/mL). Peak troponin levels were highest in STEMI, next NSTEMI, and lowest in non ACS causes. The most frequent subgroups in the non-ACS group were non-ACS cardiovascular, infectious, renal, or hypertensive causes. In a linear regression model adjusting for age and sex, higher troponin levels had higher odds of being related to ACS causes (adjusted odds ratio, 1.4; 95% CI, 1.2-1.6) than non-ACS causes. CONCLUSION: The etiology for most initial elevated troponin I levels in a randomly selected population is the result of non-ACS causes. As initial + troponin levels increased, they were more likely associated with ACS causes than with non-ACS causes. Average initial + and peak troponin values were highest in STEMIs, next highest in NSTEMIs, and lowest overall in non-ACS causes.

Disparity in Patients' Self-Reported and Charted Medication Allergy Information.

OBJECTIVES: The objective of this study was to compare current adverse drug/allergy reaction reporting in patient electronic medical records/charts against information gathered during patient interviews in the emergency department. Our hypothesis was that current methods for allergy reporting results in significant discrepancy between what is documented and the actual allergy history upon interviewing the patient. METHODS: The study was conducted between December 2011 and April 2012 in an academic emergency department. This was a convenience sample study comparing a prospective patient interview with previously documented allergy histories. Demographics for sex, age, and race were recorded. Patients to be interviewed were adults with at least one documented allergy in their chart. Descriptive statistics and percentages were used for demographic and prevalence data. Agreement between interviews and charts was assessed for both the reaction type and the reaction descriptor. RESULTS: There were 101 patients interviewed during this 4-month period, and a total of 235 adverse drug reactions were recorded. There were 66 women and 35 men included in this study. The mean age was 51 ± 17 years. The median number of allergy instances for women was 2 (interquartile range 1-3) and for men the median number of allergy instances was 1 (interquartile range 1-2). The percentage of agreements for overall allergies was 85% and 50% for the type of reaction. Total profile agreement occurred in nine patients. CONCLUSIONS: The percentage of agreement between interviews and charting for reaction type was 50%. Even with the use of electronic medical records, better methods are needed to properly record allergies to ensure patient safety and care.

Acute sigmoid diverticulitis within a nonincarcerated hernia.

Separately, diverticulitis and inguinal hernias are both common findings in emergency medicine. However, diverticulitis within a reducible hernia has not been previously reported.We present a case of sigmoid diverticulitis within a non incarcerated easily reducible hernia treated with conservative management. Our review of literature did not reveal any previously documented cases of this type of presentation.

Emergency department orthopedics observation unit as an alternative to admission.

OBJECTIVES: Inclusion of select orthopedic problems in the orthopedics observation unit (OOU) may reduce hospital admissions. Our system allows OOU status for 24 hours, but the effect on admissions is unknown. Our primary hypothesis was that we could predict which OOU patients required admission based on the presence of uncontrolled pain. METHODS: Data were prospectively collected for all OOU patients in this prospective observational study, including data on extremity cellulitis, fractures, and spine injuries awaiting brace placement.The primary outcome variable was admission to the hospital versus discharge home. The a priori hypotheses were that patients with more persistent or worsening pain would require admission more often and that the OOU would result in fewer patients needing a costlier inpatient admission to the hospital. An a priori power analysis showed adequate power of 80% to detect a difference between admitted and discharged patients. RESULTS: Data were prospectively collected from August 2011 to August 2012 for 199 consecutive OOU patients, 62% of whom were men. Diagnoses included infection (cellulitis or abscess of extremity) in 76%, fracture in 15% and other in 9% of the patients. Sixty-two patients (31%) were admitted and 7 patients (4%) made return visits for the same problem within a 30-day period. No significant relations existed between any of the independent variables and admission on bivariate analysis. Multivariable logistic regression found no significant predictors of hospital admission. Logistic regression was not performed on 30-day returns because of the low event rate (4%). CONCLUSIONS: An OOU prevented 138 of 199 (69%) patients from being admitted to a hospital. There were no significant predictors of which patients would require admission. Pain was not a predictor of need for admission. The lack of significant predictors is important in suggesting that without the ability to predict which patients require admission, a system using an OOU can reduce admissions by more than two-thirds.

Evaluating community ED crowding: the Community ED Overcrowding Scale study.

OBJECTIVES: The goals of this study were to (1) identify valid variables that correlate with emergency department (ED) crowding and (2) determine a model that could be used to accurately reflect the degree of ED crowding. METHODS: A site sampling form was applied to convenience sampling of 13 community hospitals in California between April 6, 2011, and May 1, 2011. The outcome variable was average perception of crowding by the ED physician and charge nurse on a 100-mm visual analog scale. We focused on 20 candidate predictor variables that represented counts and times in the ED that were collected every 4 hours. A prediction model was developed using multivariable linear regression to determine the measures that predicted ED crowding. A parsimonious model was developed to allow for a clinical useful tool that that explained a significant amount of variability predicted by the full ED crowding model. RESULTS: A total of 2006 data sets were collected for each of the participating hospitals. A total of 1628 time entries for the hospitals were included in the study. Hospital EDs had censuses ranging from 18 000 to 98 000. Full evaluation was completed on 1489 data sets. Twenty variables were considered for the full model with 7 removed due to multicollinearity. The remaining 13 variables constituted the full model and explained 50.5% of the variability in the outcome variable. Five predictors were found to represent 92% of the variability represented by the full model. CONCLUSIONS: Five variables were highly correlated with community ED crowding and could be used to model the full set of all variables in explaining ED crowding.