A cost-efficiency analysis to increase clinician staffing in an academic emergency department.

PURPOSE: To develop a software-based model to determine which combination of attendings working with/without residents and/or midlevel providers (MLP) was most cost-efficient for incremental staffing in an academic emergency department (ED). METHOD: A decision tree model using standard decision analysis software was created to compare different staffing configurations for the Rhode Island Hospital ED. The productivity, salary, and working hour data of different staffing configurations were determined using data from the ED, reported productivity data, and assumptions based on the authors' experience. Attending physician productivity alone was assumed to be 2.1 patients per hour, and each additional resident and/or MLP was assumed to add smaller net productivity gains (the first one adds 0.75 patients/hour; the second, 0.5 patients/hour; the third, 0.33 patients/hour). Resident and MLP productivity were assumed to be equivalent in the base case and varied during subsequent analysis. Noneconomic variables were not included in the model. RESULTS: The lowest base case cost option is to pair one attending with one resident; all other approaches are more expensive. The difference between most options is less than $5/patient. Only at extremes of variables do overall choices differ. CONCLUSIONS: Incrementally staffing an academic ED with a ratio of one attending per resident achieves the lowest cost, but other models are minimally more expensive. The model allows an ED administrator to determine the costs of different models.

Does 16-detector computed tomography improve detection of non-traumatic subarachnoid hemorrhage in the Emergency Department?

The diagnosis of subarachnoid hemorrhage remains difficult to establish, yet the sensitivity of increasingly available 16-detector computed tomography (CT) has not been evaluated. The objective of this study was to estimate the sensitivity of 16-detector CT for the diagnosis of non-traumatic subarachnoid hemorrhage in the Emergency Department (ED). A retrospective review was performed in an academic tertiary care hospital. Patients presenting to the ED from September 2003 through December 2004 with symptoms suggestive of subarachnoid hemorrhage and having a final diagnosis of non-traumatic subarachnoid hemorrhage were eligible for study. Diagnosis was established by positive 16-detector CT examination of the brain, or spinal fluid analysis. Patient demographics and results of CT, angiogram, and spinal fluid analysis were reviewed. Sensitivity of 16-detector CT was calculated by comparing CT results and cerebral angiogram results. Refined Wilson Simple Asymptotic 95% confidence intervals were calculated. Sixty-one consecutive patients met the study criteria and had a final diagnosis of non-traumatic subarachnoid hemorrhage. One of these patients did not have subarachnoid hemorrhage identified by 16-detector CT, but had a positive lumbar puncture and an aneurysm confirmed on cerebral angiography. Sensitivity of 16-detector CT for subarachnoid hemorrhage was 97% (95% confidence interval 84-100%). Sixteen-detector CT did not improve detection of non-traumatic subarachnoid hemorrhage when compared with studies using single-detector CT. If there is high clinical suspicion for non-traumatic subarachnoid hemorrhage and non-contrast 16-detector CT scan is negative, further evaluation is suggested.

Xanthrochromia? By what method? A comparison of visual and spectrophotometric xanthrochromia.

STUDY OBJECTIVE: Most US hospitals use visual inspection for the detection of cerebrospinal fluid xanthrochromia. We compared visual inspection with spectrophotometric xanthrochromia and studied the effect of tube diameter on the sensitivity of visual inspection. METHODS: Blinded, experienced laboratory technicians visually examined unmarked samples to determine the presence or absence of xanthrochromia. Samples were prepared by lysing RBCs in distilled water. Serial dilutions were placed in clear polystyrene tubes obtained from standard lumbar puncture trays. Laboratory technicians were asked to examine each sample for xanthrochromia using visual inspection. Next, they were asked to interpret the same set of samples with the assistance of a threshold standard. Last, they were asked to interpret the same dilutions, but this time presented in a larger-diameter tube. The absorbance of each sample was measured in a double-beam spectrophotometer at wavelengths between 300 and 700 nm. Samples were said to demonstrate spectrophotometric xanthrochromia if they had an absorbance greater than 0.023 at 415 nm. RESULTS: Sixteen laboratory technicians were shown a total of 160 samples, of which 64 (40%) demonstrated spectrophotometric xanthrochromia. Visual inspection of the samples was 26.6% sensitive (95% confidence interval [CI] 16% to 38%) and 97.9% specific (95% CI 95% to 100%) for spectrophotometric xanthrochromia. Using a reference standard did not improve the performance of visual inspection, but increasing collection-tube diameter increased the sensitivity to 55% (95% CI 43% to 68%). CONCLUSION: Visual inspection is not sensitive for the detection of spectrophotometric xanthrochromia. Increasing the diameter of the collection tubes did improve sensitivity. Emergency physicians should be aware of how xanthrochromia is determined at their institutions and understand the implications of using visual detection to determine the presence or absence of xanthrochromia.

Xanthochromia is not pathognomonic for subarachnoid hemorrhage.

OBJECTIVE: To test the hypothesis that xanthochromia may be observed in traumatic lumbar puncture (LP). Xanthochromia, the yellow discoloration of cerebrospinal fluid (CSF) caused by hemoglobin catabolism, is classically thought to arise within several hours after subarachnoid hemorrhage (SAH). The presence of xanthochromic supernatant is often used to distinguish the elevated red blood cell (RBC) count observed in the CSF of SAH from the elevated RBC count observed after traumatic LP. METHODS: The authors developed a model of traumatic LP by adding whole blood to pigment-free CSF to obtain RBC concentrations of 0, 5000, 10000, 20000, 30000, and 40000 RBC/ microL. Supernatant from centrifuged samples was assessed for xanthochromia by spectrophotometry. Xanthochromia was considered present if the absorption followed a characteristic oxyhemoglobin curve with a maximal absorption greater than 0.023 at 415 nm. RESULTS: Samples with at least 30000 RBC/ microL demonstrated xanthochromia immediately. Samples with 20000 RBC/ microL demonstrated xanthochromia within one hour, and samples with 10000 RBC/ microL or less, within two hours. CONCLUSIONS: Cerebrospinal fluid xanthochromia may be observed within two hours after traumatic LP and sooner in samples with greater than 10000 RBC/ microL. Conversely, xanthochromia in traumatic LP with less than 5000 RBC warrants further investigation for SAH. When the CSF RBC count is elevated above 10000 RBC/ microL, or the time between sample acquisition and analysis is prolonged, the clinician should not rely on xanthochromia to confirm SAH.

Late postpartum eclampsia: a common presentation of an uncommon diagnosis.

We present two cases of late postpartum eclampsia. Both patients presented with a chief complaint of headache, and were diagnosed with eclampsia after the onset of seizures. Neither patient had proteinuria or edema. Further evaluation did not yield another diagnosis for the seizures, and treatment with i.v. magnesium sulfate was successful in stopping the seizures. No further seizure activity occurred in either patient.