Use of Emergency Ultrasound in Arizona Community Emergency Departments.

OBJECTIVES: Despite the increased educational exposure to point-of-care ultrasound (US) at all levels of medical training, there are utilization gaps between academic and nonacademic emergency department (ED) settings. The purpose of this study was to assess the current practices and potential barriers to the use of point-of-care US in nonacademic EDs throughout the state of Arizona. METHODS: We conducted a cross-sectional study. An online questionnaire was electronically sent to all nonacademic EDs in Arizona. The survey consisted of questions regarding demographics, current practice patterns, policies, interdepartmental agreements, and perceptions regarding the use of point-of-care US. RESULTS: Seventy nonacademic EDs were identified for inclusion in our study, and 58 EDs completed the survey, which represented an 83% response rate. Seventy-eight percent (95% confidence interval [CI], 67%-89%) perform or interpret point-of-care US examinations for patient care. The 3 most common applications of point-of-care US reported by respondents were focused assessment with sonography for trauma, cardiac US examinations, and line placement, and 36% (95% CI, 22%-50%) bill for point-of-care US examinations. At 75% (95% CI, 62%-88%) of EDs, no one is specifically responsible for reviewing point-of-care US examinations for quality assurance, and at 50% (95% CI, 35%-65%), no mechanism exists to archive images. Eighty-three percent (95% CI, 72%-94%) of EDs think that their groups will benefit from the American College of Emergency Physicians Clinical Ultrasound Accreditation Program. CONCLUSIONS: Ultrasound equipment is available in nearly all nonacademic EDs in Arizona. However, it appears that most providers lack US training, credentialing, quality assurance, and reimbursement mechanisms.

Evidence-based Comprehensive Approach to Forearm Arterial Laceration.

INTRODUCTION: Penetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or a complex injury involving other structures including veins, tendons and nerves. The management of forearm laceration with arterial injury involves both operative and nonoperative strategies. An evolution in management has emerged especially at urban trauma centers, where the multidisciplinary resource of trauma and hand subspecialties may invoke controversy pertaining to the optimal management of such injuries. The objective of this review was to provide an evidence-based, systematic, operative and nonoperative approach to the management of isolated and complex forearm lacerations. A comprehensive search of MedLine, Cochrane Library, Embase and the National Guideline Clearinghouse did not yield evidence-based management guidelines for forearm arterial laceration injury. No professional or societal consensus guidelines or best practice guidelines exist to our knowledge. DISCUSSION: The optimal methods for achieving hemostasis are by a combination approach utilizing direct digital pressure, temporary tourniquet pressure, compressive dressings followed by wound closure. While surgical hemostasis may provide an expedited route for control of hemorrhage, this aggressive approach is often not needed (with a few exceptions) to achieve hemostasis for most forearm lacerations. Conservative methods mentioned above will attain the same result. Further, routine emergent or urgent operative exploration of forearm laceration injuries are not warranted and not cost-beneficial. It has been widely accepted with ample evidence in the literature that neither injury to forearm artery, nerve or tendon requires immediate surgical repair. Attention should be directed instead to control of bleeding, and perform a complete physical examination of the hand to document the presence or absence of other associated injuries. Critical ischemia will require expeditious surgical restoration of arterial perfusion. In a well-perfused hand, however, the presence of one intact artery is adequate to sustain viability without long-term functional disability, provided the palmar arch circulation is intact. Early consultation with a hand specialist should be pursued, and follow-up arrangement made for delayed primary repair in cases of complex injury. CONCLUSION: Management in accordance with well-established clinical principles will maximize treatment efficacy and functional outcome while minimizing the cost of medical care.

Sedative dosing of propofol for treatment of migraine headache in the emergency department: a case series.

INTRODUCTION: Migraine headaches requiring an emergency department visit due to failed outpatient rescue therapy present a significant challenge in terms of length of stay (LOS) and financial costs. Propofol therapy may be effective at pain reduction and reduce that length of stay given its pharmacokinetic properties as a short acting intravenous sedative anesthetic and pharmacodynamics on GABA mediated chloride flux. METHODS: Case series of 4 patients presenting to an urban academic medical center with migraine headache failing outpatient therapy. Each patient was given a sedation dose (1 mg/kg) of propofol under standard procedural sedation precautions. RESULTS: Each of the 4 patients experienced dramatic reductions or complete resolution of headache severity. LOS for 3 of the 4 patients was 50% less than the average LOS for patients with similar chief complaints to our emergency department. 1 patient required further treatment with standard therapy but had a significant reduction in pain and a shorter LOS. There were no episodes of hypotension, hypoxia, or apnea during the sedations. CONCLUSION: In this small case series, sedation dose propofol appears to be effective and safe for the treatment of refractory migraines, and may result in a reduced LOS.

Environmental thermal stress.

Thermal stress from cold and heat can affect health and productivity in a wide range of environmental and workload conditions. Health risks typically occur in the outer zones of heat and cold stress, but are also related to workload. Environmental factors related to thermal stress are reviewed. Individuals undergo thermoregulatory physiologic changes to adapt and these changes are reviewed. Heat and cold related illnesses are reviewed as well as their appropriate therapy. Published standards, thresholds and recommendations regarding work practices, personal protection and types of thermal loads are reviewed.

Radiology resident evaluation of head CT scan orders in the emergency department.

BACKGROUND AND PURPOSE: Prior studies have revealed little difference in residents' abilities to interpret cranial CT scans. The purpose of this study was to assess the performance of radiology residents at different levels of training in the interpretation of emergency head CT images. METHODS: Radiology residents prospectively interpreted 1324 consecutive head CT scans ordered in the emergency department at the University of Arizona Health Science Center. The residents completed a preliminary interpretation form that included their interpretation and confidence in that interpretation. One of five neuroradiologists with a Certificate of Added Qualification subsequently interpreted the images and classified their assessment of the residents' interpretations as follows: "agree," "disagree-insignificant," or "disagree-significant." The data were analyzed by using analysis-of-variance or chi-squared methods. RESULTS: Overall, the agreement rate was 91%; the insignificant disagreement rate, 7%; and the significant disagreement rate, 2%. The level of training had a significant (P =.032) effect on the rate of agreement; upper-level residents had higher rates of agreement than those of more junior residents. There were 62 false-negative findings. The most commonly missed findings were fractures (n = 18) and chronic ischemic foci (n = 12). The most common false-positive interpretations involved 10 suspected intracranial hemorrhages and suspected fractures. CONCLUSION: The level of resident training has a significant effect on the rate of disagreement between the preliminary interpretations of emergency cranial CT scans by residents and the final interpretations by neuroradiologists. Efforts to reduce residents' errors should focus on the identification of fractures and signs of chronic ischemic change.

Rapid process redesign in a university-based emergency department: decreasing waiting time intervals and improving patient satisfaction.

Academic emergency departments are traditionally associated with inefficiency and long waits. The academic medical model presents unique barriers to system changes. Several non-university-based EDs have undertaken process redesign, with significant decreases in patient waiting time intervals. This is the presentation of a rapid process redesign in a university-based ED to reduce waiting time intervals. We present the application of a process-improvement team approach to evaluate and redesign patient flow. As a result of this effort, the median waiting room time interval (triage to patient room) decreased from 31 minutes in January 1998 to 4 minutes in July 1998. ED throughput times also decreased, from 4 hours, 21 minutes in January 1998 to 2 hours, 55 minutes in July 1998. Urgent care waiting room time intervals decreased from 52 minutes to 7 minutes and throughput times from 2 hours, 9 minutes to 1 hour, 10 minutes. Patient satisfaction evaluations by an independent institute demonstrated dramatic improvement and establishment of a new benchmark for academic EDs. Process redesign is possible in a busy, complex, tertiary-care ED, with decreases in waiting time intervals and improvement in patient satisfaction. Major sustained support from top-level hospital administrators and physician leadership are fundamental prerequisites. With these in place, a process improvement team approach for evaluating and redesigning the patient care system can be successful.