Does interview date affect match list position in the emergency medicine national residency matching program match?

OBJECTIVE: Some residency applicants believe that the date on which they interview with a residency program influences how the program ranks them in the National Residency Matching Program (NRMP). Therefore, the authors studied whether interview date affects match list position in the emergency medicine (EM) residency match. METHODS: Forty-four Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs participated in this multicenter study. The interview date and match list position were collected for each interviewee for the 1997-98 season. Programs were also asked about factors that might potentially bias interview date assignment. Statistical analyses were performed both with and without these programs included. Interview dates and match list positions were standardized into percentile date and percentile rank for each program and were compared using linear regression analysis. Scatterplots graphed interview date vs match list position. Two-sample t-tests compared interview dates for ranked and nonranked interviewees. RESULTS: Data were collected for 3,800 individual interviews; 14% of these resulted in unranked applicants. Twenty-three programs, representing 1,997 interviews, reported potential bias in their interview date assignment. Regression analysis revealed an R(2) of 0.018268 (correlation coefficient = 0. 1352, 95% CI = 0.0992 to 0.1617) for all programs, R(2) of 0.010626 (correlation coefficient = 0.1031, 95% CI = 0.0571 to 0.1485) for programs without reported potential bias, and R(2) of 0.02444 (correlation coefficient = 0.1563, 95% CI = 0.10887 to 0.20309) for programs with reported bias. Scatterplots revealed no linear correlation. Two-sample t-tests for all programs, and programs with and without reported bias showed no significant difference in average interview date for ranked and unranked interviewees (both with p > 0.2). CONCLUSION: In this study, interview date for EM residency positions in the 1997-98 season did not affect match list position among ranked applicants. Moreover, interview date had nno effect on the decision to leave candidates unranked.

Pain reduction in lidocaine administration through buffering and warming.

This study compared the pain from intradermal infiltration of (1) plain lidocaine, (2) warmed lidocaine, (3) buffered lidocaine, and (4) warmed, buffered lidocaine. A randomized, double-blind, Latin Square design of 20 volunteers was used. Each volunteer was injected with a series of four test solutions on four separate occasions, for 16 total injections each. Each volunteer served as his or her own control. The mean pain scores for the four solutions were: 44.2 for plain lidocaine, 42.2 for warmed lidocaine, 36.7 for buffered lidocaine, and 29.2 for warmed, buffered lidocaine. Buffered lidocaine was statistically less painful than both plain lidocaine and warmed lidocaine. Warmed, buffered lidocaine was significantly less painful than all other solutions, including buffered lidocaine (P < .005). However, warmed lidocaine did not yield pain scores significantly different from plain lidocaine. In this experimental model, warmed lidocaine was not superior to plain lidocaine, but warmed, buffered lidocaine caused significantly less pain than plain lidocaine, buffered lidocaine, or warmed lidocaine. Thus, there may be benefit from heating the buffered lidocaine now in common clinical use.

Evaluation of the injured hand.

Hand disorders are common emergency department problems. They may be associated with long-term disability and significant financial impact for the patient and society. In many areas of clinical medicine, highly technical diagnostic and therapeutic modalities have taken center stage. In contrast, an accurate history and carefully performed physical examination of the hand retains a central and pivotal role in hand evaluation and treatment.

The cost of quality in health care.

The potential fiscal impact of improved quality on health care providers and organizations is substantial. In this era of dwindling health care resources, proposals that may limit cost increases while improving quality represent true win-win situations. There is a need for a substantial amount of health care research in this fertile area of quality improvement.

The management of patient complaints and dissatisfaction.

Patient satisfaction is an integral component of the measurement of health care quality. Proper attention to patient complaints is one part of a patient satisfaction management strategy aimed at revealing and alleviating the causes of patient dissatisfaction.

Peer review organization payment denials: comparative analysis of emergency department and non-emergency-department admissions.

The Health Care Financing Administration has contracted with regional peer review organizations to review Medicare admissions and to deny payment for hospital admissions that fail to meet peer review organization criteria. The purpose of this study was to compare emergency department admissions with non-emergency-department admissions with respect to rates of peer review organization denial and the reasons for those denials. All hospital Medicare admissions between January 1984 and April 1987 were retrospectively reviewed. Patients were excluded if they received peer review organization pre-authorization prior to admission. The rest were classified by 1) source of admission (emergency department or non-emergency department), 2) peer review organization decision, 3) reason for peer review organization denial, 4) whether the denial was appealed, 5) the results of appeal. Chi-square or Fisher's Exact Test analysis was performed, and P less than 0.05 was considered to be significant. During the 40-month study period, there were 19,847 emergency department Medicare admissions and 19,752 non-emergency-department Medicare admissions. Of the non-emergency-department admissions, 7887 received pre-authorization. None of the emergency department admissions received pre-authorization. Of the 19,847 emergency department admissions, 433 (2.23%) were denied. Of these denials, 269 (60.7%) were appealed by the hospital; 136 (50.5%) successfully. Of the 11,865 non-emergency department, non-pre-authorized admissions, 333 (2.81%) were denied. Of these denials, 174 (52.2%) were appealed, 76 (43.6%) successfully. Overall, emergency department admissions were significantly less likely to receive peer review organization denial than non-emergency-department, non-pre-authorized admissions (P less than 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency department complaint frequency: variation by patient median household income.

STUDY OBJECTIVE: To determine whether emergency department complaint frequency varies with patient median household income, as approximated by patient residence zip code. DESIGN: All patient visits and complaints received in one ED were reviewed. Median household income of patient residence zip codes was obtained from available demographic data. Patients were categorized into seven income categories. EXCLUSIONS: Cases in which zip codes could not be determined or zip code income data could not be obtained; complaints from physicians, not patients; and data from zip codes remote from the hospital. SETTING: Nine hundred twenty-nine-bed teaching hospital. TYPE OF PARTICIPANTS: All ED visits and all ED complaints over a four-year period. STATISTICAL ANALYSIS: Armitage's chi 2 test for trend of proportions was used to compare complaint frequencies in different income groups. RESULTS: A total of 277,210 patient visits and 675 complaints met study criteria. Complaint frequencies ranged from 1.65 to 3.14 per thousand visits. Higher-income patients were more likely to complain than lower-income patients (P = .0000058). CONCLUSION: In this setting, ED patients residing in higher median income zip codes are more likely to register complaints than those from lower-income zip codes. Complaint frequencies from hospitals with different demographics may not be comparable.

End-tidal CO2 measurement in the detection of esophageal intubation during cardiac arrest.

Measurement of end-tidal carbon dioxide (ETCO2) has been used to detect accidental esophageal tube placement in noncardiac arrest situations. The purpose of our study was to determine whether ETCO2 measurement could distinguish tracheal from esophageal tube placement during closed-chest massage (CCM). Twelve large dogs were anesthetized, and endotracheal tubes were placed in both the trachea and the esophagus. Placement was verified by fiberoptic endoscopy. Ventricular fibrillation was induced by a 60-Hz discharge through a right ventricular pacemaker. After four minutes of cardiac arrest, CCM was initiated and continued for 20 minutes. The dogs were divided into two groups: Group A was ventilated through the tracheal tube, and group B was ventilated through the esophageal tube. Unused tubes were removed. ETCO2 was recorded continuously beginning two minutes before arrest until the end of the experiment. There were no significant between-group differences in mean arterial pressure, weight, blood loss, IV fluid volume administered, or prearrest arterial blood gases. ETCO2 differed significantly between the two groups throughout CCM (P = .001). In group A, ETCO2 ranged from 13 to 34 mm Hg (median, 20 mm Hg). In group B, ETCO2 ranged from 2 to 11 mm Hg (median, 3 mm Hg). In this experimental model, measurement of ETCO2 reliably distinguished esophageal from tracheal intubation during cardiac arrest and CCM. If confirmed in human beings, this may prove to be a quick, reliable method of detecting esophageal intubation during cardiac arrest.

A microcomputer application curriculum for emergency medicine residents using computer-assisted instruction.

A microcomputer application curriculum using computer-assisted instruction was developed for emergency medicine residents. Other than introductory comments, the course was composed entirely of disk-based tutorials. No faculty time was necessary. Subjects covered included introduction to microcomputers, the disk operating system; word processing, data bases, and spread sheets. The entire course, including the tutorial floppy disks, was contained in one loose-leaf notebook. Residents who took the course were surveyed. The course took an average of three to six hours to complete. All found the course to be helpful, with word processing being the most useful module. The majority of residents thought that the course was so valuable that it should be given earlier in the residency. Thus, we have moved the course to the first postgraduate year, and the data base and spread-sheet modules have been made optional. The course is easily assembled, requires minimal faculty time, and can be modified to accommodate different hardware and software.

The alveolar-arterial oxygen gradient in patients with documented pulmonary embolism.

It has been reported that the finding of a normal PaO2 level on arterial blood gas analysis does not exclude the diagnosis of acute pulmonary embolism. We wished to determine whether a more thorough evaluation of the blood gases would prove more helpful; specifically, whether it is possible for a patient with acute pulmonary embolism to have a normal alveolar-arterial (A-a) oxygen gradient. We studied this question in a patient population in which the diagnosis was definitively made via pulmonary arteriography. Sixty-four patients met all study criteria. In these patients, the A-a gradient ranged from 11.6 to 83.9 mm Hg (mean, 41.8 mm Hg). In three patients, the A-a gradient was normal for age. We conclude that a normal A-a oxygen gradient does not exclude the diagnosis of acute pulmonary embolism, and should not preclude further diagnostic procedures if there is a high index of suspicion.

Electromechanical dissociation in human beings: an echocardiographic evaluation.

Electromechanical dissociation (EMD) has been described as "organized electrical depolarization of the heart without synchronous myocardial fiber shortening and, therefore, without cardiac output." However, little evidence demonstrating this description exists. We wished to determine whether mechanical activity is present during EMD. Twenty-two patients presenting with, or subsequently developing EMD in the emergency department from April 1986 to January 1987 were studied. Echocardiograms were performed during five-second pauses in CPR, using the subxiphoid approach. Nineteen patients (86%) had synchronous myocardial wall motion. In two others, there was a rhythmic change in the echocardiographic density of the myocardium, without visible chamber narrowing. In one there was no visible myocardial response associated with the QRS complex. One or more cardiac valves were visualized in 17 patients. Of these, valvular motion was seen in 15 (88%), but only four exhibited visible valve closure. In our study population, the majority of patients in EMD had myocardial wall and valve motion. Thus, the term "electromechanical dissociation" may be a misnomer.

Myocardial salvage: angioplasty and coronary artery bypass.

Percutaneous transluminal coronary angioplasty has shown great promise in the treatment of acute myocardial infarction, both alone and in combination with thrombolysis. Because of time constraints, intravenous thrombolysis probably will emerge as the initial therapy of choice in most settings. Because thrombolysis often has a high incidence of reocclusion and recurrent ischemia, angioplasty will continue to play a role in relieving residual coronary artery stenosis. Coronary artery bypass surgery is not often used currently as sole therapy for acute myocardial infarction. Nonetheless, like angioplasty, bypass surgery plays a supporting role in relieving post-thrombolytic stenosis, as well as in treating complications of angioplasty.

New noninvasive technologies in emergency medicine.

Noninvasive technology offers many present and future benefits for emergency patients, including the painless, instantaneous and real-time tracking of oxygenation, ventilation and perfusion, as well as the quick and reliable detection of esophageal intubation. Other noninvasive technologies, such as echocardiography, are also being increasingly studied in the Emergency Department. In the future a host of new and innovative concepts, such as transthoracic bioimpedance, pulsed Doppler flowmetry, and laser Doppler velocrimetry may permit continuous and accurate noninvasive cardiac output.

Emergency department complaints: a one-year analysis.

We conducted an analysis of all complaints received in a busy suburban emergency department during 1985. All complaints were handled in a standardized fashion, and were categorized as billing, physician, nursing, or miscellaneous. Data were expressed as a "complaint frequency" (complaints per 1,000 patient visits). Complaints were analyzed for the following characteristics: reason, gender of the patient, gender of the complaining party, relationship of the complaining party to the patient, health care provider, patient age, and patient disposition. The chi-square method was used to identify characteristics associated with a high risk for complaints. There were a total of 244 complaints, arising from 64,910 patient visits, yielding an overall complaint frequency of 3.8. The largest number of complaints (135), involved billing (frequency, 2.0). The most common (60) was insurance carrier rejection of the bill as a nonemergency. The next most common billing complaint (25) was a charge mistakenly billed too high by the ED. There were 70 complaints regarding emergency physicians, for a complaint frequency of 1.1. Of these, 17 were due to a perceived lack of communication with the patient, the patient's family, or the patient's private physician. Eighteen complaints were regarding a perceived misdiagnosis. One physician had a significantly higher complaint frequency than the group as a whole (P less than .005). There were 17 complaints regarding the nursing staff, for a complaint frequency of 0.2. Twenty-two complaints were classified as miscellaneous. Expressing data as complaint frequencies allows comparison of trends in a department, staff members, and different EDs with varied patient populations.(ABSTRACT TRUNCATED AT 250 WORDS)

A computer-assisted emergency department chart audit.

We present a method for a microcomputer-assisted emergency department daily chart audit using a spreadsheet format. Computer technology allows the extraction of a large amount of information from audit data with a minimum of clerical time. The software automatically tabulates, sorts, and updates audit data, and depicts physician performance in a quantitative manner. The software is able to generate a variety of graphics that visually depict physician and departmental performance. The spreadsheet model is flexible, and can be adapted to the needs of various emergency departments or quality assurance activities. The audit has a rapid turnaround time, with charts audited and returned to physicians for feedback within 24 hours of the patient being discharged. Individual physician confidentiality is maintained throughout.