Initial chest radiograph scores inform COVID-19 status, intensive care unit admission and need for mechanical ventilation.

AIM: To evaluate whether portable chest radiography (CXR) scores are associated with coronavirus disease 2019 (COVID-19) status and various clinical outcomes. MATERIALS AND METHODS: This retrospective study included 500 initial CXR from COVID-19-suspected patients. Each CXR was scored based on geographic extent and degree of opacity as indicators of disease severity. COVID-19 status and clinical outcomes including intensive care unit (ICU) admission, mechanical ventilation, mortality, length of hospitalisation, and duration on ventilator were collected. Multivariable logistic regression analysis was performed to evaluate the relationship between CXR scores and COVID-19 status, CXR scores and clinical outcomes, adjusted for code status, age, gender and co-morbidities. RESULTS: The interclass correlation coefficients amongst raters were 0.94 and 0.90 for the extent score and opacity score, respectively. CXR scores were significantly (p < 0.01) associated with COVID-19 positivity (odd ratio [OR] = 1.49; 95% confidence interval [CI]: 1.27 - 1.75 for extent score and OR = 1.75; 95% CI: 1.42 - 2.15 for opacity score), ICU admission (OR = 1.19; 95% CI: 1.09 - 1.31 for extent score and OR = 1.26; 95% CI: 1.10 - 1.44 for opacity score), and invasive mechanical ventilation (OR = 1.22; 95% CI: 1.11 - 1.35 for geographic score and OR = 1.21; 95% CI: 1.05 - 1.38 for opacity score). CXR scores were not significantly different between survivors and non-survivors after adjusting for code status (p>0.05). CXR scores were not associated with length of hospitalisation or duration on ventilation (p>0.05). CONCLUSIONS: Initial CXR scores have prognostic value and are associated with COVID-19 positivity, ICU admission, and mechanical ventilation.

Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores.

STUDY OBJECTIVES: Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. METHODS: We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART≤3, TIMI≤0, GRACE≤50, and EDACS≤15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics. RESULTS: The patients' median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92-0.97). CONCLUSIONS: Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE≤48, TIMI=0, EDACS≤11, HEART≤2) missed no case of AMI, but classified less patients as low-risk.

National analgesia prescribing patterns in emergency department patients with burns.

Previous studies suggest that many patients with burns receive inadequate analgesia. A secondary analysis of the 1992 to 1999 National Hospital Ambulatory Medical Care Survey (a national, weighted sample of emergency department [ED] encounters) was performed to estimate national analgesia prescribing patterns in ED patients with burns. In 1999, there were 21,103 patient encounters sampled from 376 EDs, resulting in an estimated 102.8 million ED visits in 1999. One hundred thirty-eight patients in the sample (0.7%) had burns for an estimated 827,000 annual burns. Patient mean age was 28 years. Forty-three percent were female, 25% were children under 18 years of age, and 81% were white. Pain assessments were performed in about half of the patients, and only half of the patients received analgesics. Analgesia administration did not differ by year, sex, age, race, ethnicity, geographic location, or insurance payment type, yet it was more likely with increased pain. We conclude that many patients with burns do not have documentation of pain assessment or analgesia administration while in the ED.

Magnetically guided orotracheal intubation.

OBJECTIVE: To describe a novel endotracheal intubation technique, magnetically guided intubation (MGI), and its rate of success in inexperienced medical students and interns using an airway mannequin model. METHODS: This was a prospective, descriptive study of 25 medical students and interns participating in an introductory course on emergency medicine without prior experience in human orotracheal intubation. Magnetically guided intubation consists of a strong external magnet placed over the cricothyroid membrane to guide the introduction of a standard endotracheal tube containing a stylet with a magnetized tip. An airway mannequin was placed in a rigid cervical spinal collar to increase the difficulty of the intubation, and each student performed two sequential intubation attempts using MGI. The proportions of successful intubations and the time to complete intubation were determined. Descriptive statistics were used to describe point estimates and 95% confidence intervals for means and proportions of continuous and categorical data, respectively. RESULTS: Of 25 participants, 19 were students and six were interns. Their mean age was 27 years, and 76% were male. The overall proportion of successful intubations using MGI was 80% (95% CI = 69% to 91%). Of 24 intubations, 48% were attempted without visualization of the vocal cords; 67% were successful (95% CI = 46% to 87%). The mean time required to complete intubation was 17.0 seconds (95% CI = 14.5 to 19.5 seconds). CONCLUSIONS: A novel method of orotracheal intubation using magnetic guidance is described as achieving a high rate of successful intubations when performed by inexperienced intubators.

Ability of patients to accurately recall the severity of acute painful events.

OBJECTIVE: Pain studies require prospective patient enrollment to ensure accurate pain assessment. The authors correlated pain assessments of an acute painful episode over a one-week period and determined the accuracy of patient pain severity recall over time. METHODS: This was a prospective, descriptive, longitudinal study. Participants were a convenience sample of 50 emergency department patients with acute pain resulting from injuries or painful invasive procedures. A trained research assistant administered a structured pain survey containing demographic and historical features to all patients. Patients sequentially assessed their pain severity using a vertical 100-mm visual analog scale marked "most pain" at the top, a verbal numeric rating scale ranging from 0 to 100 from none to worst (NRS100), and a verbal numeric rating scale ranging from 0 to 10 from none to worst (NRS10). Patients were contacted by phone and asked to reassess their initial pain severity one and seven days later using the two verbal numeric rating scales. Analysis of pain assessments using the various scales at the three time intervals was performed with Pearson's and Spearman's coefficients and repeated-measures analysis of variance (ANOVA). RESULTS: There were 50 patients with a mean age of 41 years. Correlation between initial pain assessments on the three scales ranged from 0.83 to 0.92. Correlations between the initial and 24-hour assessments were NRS100-0.98 and NRS10-0.98. Correlations between the initial and one-week assessments were NRS100-0.96 and NRS10-0.97. Repeated-measures ANOVA showed no significant change in pain assessments over time for both verbal numeric scales. CONCLUSIONS: Pain severity assessments of acute painful events one and seven days later were similar and highly correlated with initial assessments using both verbal numeric scales. Patients accurately recall the severity of an acute painful episode for at least one week after its occurrence, which may allow retrospective pain assessments.

The effects of octylcyanoacrylate on scarring after burns.

OBJECTIVE: To compare the effects of octylcyanoacrylate (OCA), silver sulfadiazine (SSD), polyurethane film (PU), and dry gauze (G) on scarring three months after partial-thickness burns. METHODS: This was a prospective, blinded, controlled experimental trial using isoflurane-anesthetized swine. Standardized partial-thickness burns were inflicted by applying an aluminum bar preheated to 80 degrees C to the backs and flanks of a young pig for 20 seconds. Four equal sets of ten burns each were randomly treated with OCA spray, SSD, PU, or G. Dressing changes were performed on days 1, 2, 3, and 4 after injury. Digital images of the burns were obtained immediately and three months later for masked computerized determination of scar surface area. Full-thickness biopsies were taken at three months for masked histopathological evaluation. The primary outcome was the percent reduction in residual wound area (RWA) calculated by subtracting the area of each individual burn from the area of the largest burn and dividing this value by the area of the largest burn (intraobserver correlation, r = 0.99). Secondary outcomes were the proportion of burns with the presence of scar tissue (abnormal collagen under polarized light; intraobserver agreement, kappa = 0.93) and the cosmetic appearance on a 100-mm visual analog scale marked "best scar" at the high end (inter-observer correlation, r = 0.82). Analysis of variance (ANOVA) and chi(2) tests were used for group comparisons as appropriate. This study had 80% power to detect a 33-percentage-point difference in RWA among groups (alpha = 0.05). RESULTS: A total of 40 burns were inflicted on the pig. There was no difference in percent RWA across the groups (OCA = 25%, SSD = 40%, PU = 25%, G = 32%; p = 0.13). There was no difference in the proportion of wounds with scarring among the groups (OCA = 10%, SSD = 22%, PU = 2%, G = 30%; p = 0.89). There was also no difference in the cosmetic scores among the groups (OCA = 78 mm, SSD = 75 mm, PU = 74 mm, G = 74 mm; p = 0.96). CONCLUSIONS: The effects of OCA spray, SSD, PU, and dry gauze on scarring three months after burns in pigs are similar.

Patient priorities with traumatic lacerations.

Clinical trials should use outcomes that are important to patients. We sought to determine the aspects of laceration management that are most important to patients. A prospective observational survey was conducted at one suburban and one urban university ED during November to December 1998 that included ED patients and visitors with and without current or prior lacerations. Trained research assistants approached 747 people of which 724 (97%) completed a 25-item closed question survey that evaluated demographics, prior laceration repairs, and assessed the relative importance of least painful repair, ED length of stay, cosmetic outcome, functional recovery, practitioner compassion, avoidance of wound infection, total costs, and missed days of work or school using a five-item Likert scale (not important-extremely important). Additionally, the relative importance of these items was compared. Data were analyzed with descriptive statistics and 95% confidence intervals (CIs). Seven hundred twenty-four people participated; 383 (53%) had prior lacerations; 92 (14%) had lacerations at the time of the survey. The most important aspect of care for respondents were normal function (28%), avoiding infection (20%), cosmetic outcome (17%), and least painful repair (17%). Based on Likert scale data, most important aspects of care were: avoiding wound infection (mean [95% CI], 4.58 [4.52 to 4.64]), normal function (4.54 [4.48 to 4.6]), cosmetic outcome (3.78 [3.68 to 3.88]), and least painful repair (3.84 [3.76 to 3.92]). Cost, length of stay, missed work/school, and compassion were less important (range, 3.0 to 3.7). Patients with facial lacerations chose cosmetic outcome as the most important aspect of care while all others chose function. Patients prioritize the medical outcomes of laceration repair (function, avoiding infection, cosmesis, pain) more than cost, compassion, ED length of stay and inconvenience (missed work/school). Cosmetic outcome is particularly important to patients with facial lacerations. This information should be useful when designing outcome studies of laceration management.

Effects of prehospital nitroglycerin on hemodynamics and chest pain intensity.

OBJECTIVE: To assess the effects of prehospital nitroglycerin (NTG) on vital signs and chest pain intensity. METHODS: A retrospective review of advanced life support (ALS) run sheets was performed in a suburban volunteer emergency medical services (EMS) system receiving 8,000 annual ALS calls. All consecutive patients who were administered NTG by EMS were included. Standardized forms were used to collect data on patient demographics, history, and physical exam. Patients assessed their chest pain (CP) before and after NTG on a verbal numeric scale of 0-10 from least to most severe. The presence of syncope, dysrhythmias, or profound hypotension [loss of peripheral pulses, a systolic blood pressure (SBP) of <90 mm Hg after NTG, or a drop of >100 mm Hg in BP] was noted. Results. One thousand six hundred sixty-two patients received NTG over 18 months, their mean age was 66 years, and 48% were female. Indications for NTG included CP (83%), dyspnea (45%), and congestive heart failure (20%). After NTG administration, the CP score decreased from 6.9 to 4.4 (mean difference = 2.6; 95% CI = 2.4 to 2.8). The CP completely resolved in 10% of the patients. Mean decreases in SBPs and diastolic BPs were 11.8 mm Hg (95% CI = 10.7 to 13.0) and 4.0 mm Hg (95% CI = 2.9 to 5.1). The mean pulse rate increased by 2.7 beats/min (95% CI = 0.6 to 4.9). There were 12 patients with adverse events [0.7% (95% CI = 0.4% to 1.3%)], including profound bradycardia and hypotension (1), transient drop in SBP of 100 mm Hg responding to fluids (6), post-NTG SBP <90 mm Hg (4), and syncope (1). There were no deaths in the prehospital setting. CONCLUSIONS: Use of prehospital NTG appears safe. While NTG reduces CP, most patients have residual pain.

Development of a histomorphologic scale to quantify cutaneous scars after burns.

OBJECTIVE: Cutaneous wound healing in adults invariably results in scarring; however, there are few scales to quantify the degree of such scarring. The authors developed a histomorphologic scale for quantifying scarring after cutaneous burn injury. METHODS: As part of a randomized trial comparing a variety of burn therapies, 40 partial-thickness burns were created on the backs and flanks of anesthetized pigs and treated with a tissue adhesive, antibiotic ointment, occlusive dressing, or dry gauze. Gross scar appearance was independently assessed by two investigators at 90 days on a 100-mm visual analog scale (VAS) marked "best appearance" at the high end. One of the investigators repeated the observation 30 days later. Full-thickness biopsies were taken 90 days after injury and evaluated histologically by a dermatopathologist for the presence of hyperkeratosis, epidermal hyperplasia, presence and depth of scar (defined as abnormally oriented collagen under polarized light), fibroplasia, vascular proliferation, and absence of adnexa, including hair follicles, apocrine glands, and smooth muscles. One point was assigned for each category in the presence of a normal finding, whereas an abnormal finding was assigned a score of zero. The normal dermis (absence of abnormal collagen) was given a score of 3, while decreasing scores of 2 to 0 were given for progressively deeper scars (i.e., 2 for papillary dermis, 1 for upper half of reticular dermis, and 0 for deep dermal lower half). The total histomorphologic score was derived by adding the scores on the individual items. The score ranges from 0 to 10 from worst scarring to absence of scarring, respectively. A subset of observations was evaluated a second time by one of the observers one month later. Intraobserver reliability of the histomorphologic scale was assessed with Spearman's correlation. Inter- and intraobserver Pearson's correlations for the gross scar VAS were calculated, and the correlation between gross and histomorphologic scores was assessed. RESULTS: Intraobserver correlation for individual histomorphologic categories ranged from 0.19 to 1.00. Intraobserver correlation for the total histologic score was 0.95. Inter- and intraobserver correlations for the gross scar VAS were 0.8 each. Correlation between the histomorphologic scale and the gross scar VAS was 0.38. CONCLUSIONS: A new reliable histomorphologic method for quantifying and scoring cutaneous scars is described together with a reliable scar VAS. However, these two scales are not highly correlated.

Standardized burn model using a multiparametric histologic analysis of burn depth.

OBJECTIVE: Burn depth and extent determine prognosis and therapy. The current classification into first-, second-, and third-degree burns is crude, making comparisons between studies difficult. The authors standardized a reproducible burn model and a precise histopathologic method for describing burn depth in swine. METHODS: This was a prospective, cross-sectional interventional animal study. Eighteen paired sets of burns were inflicted on the clipped flank skin of two anesthetized domestic pigs with a 2.5 cm by 2.5 cm by 7.5 cm aluminum bar preheated in water to 50 degrees C, 60 degrees C, 70 degrees C, 80 degrees C, 90 degrees C, degrees C or 100 degrees C. The bar was applied for 10, 20, or 30 seconds. Full-thickness skin biopsies were obtained 30 minutes after injury for blinded histopathologic evaluation using hematoxylin and eosin staining. Two dermatopathologists made two sets of measurements and were masked to each other's evaluations. The depth of injury was measured with an ocular microtome for each of five dermal parameters: collagen discoloration, intercollagen basophilic material, endothelial cell necrosis, epithelial cell necrosis, and mesenchymal cell necrosis. The correlation between burn depths of the paired sets of experiments was calculated to assess the reliability of the model. Inter- and intraobserver correlations were calculated to assess the reliability of the scale. Analysis of variance (ANOVA) was used to assess the relation between temperature and exposure times on burn depth. RESULTS: Depth of injury for all five dermal elements was related to temperature and exposure times (ANOVA, p < 0.001 for each). The depth of injury in the paired sets of burns was highly consistent (Pearson correlation, range = 0.88-0.95). Inter- and intraobserver correlations were excellent for all measured elements (range = 0.91-0.97 and 0.95-0.99, respectively). CONCLUSIONS: The authors describe a simple and reproducible animal burn model and histopathologic scale for measuring burn depth that they believe will facilitate standardization and comparison within future burn studies.

Research fundamentals: selection and development of clinical outcome measures.

Clinical outcomes measure patient health or well-being. The choice of an outcome measure for use in a clinical trial or study is complex. It is even more difficult when no appropriate outcome measure exists, necessitating the development of a novel one. The ideal clinical outcome should be credible, comprehensive, sensitive to change, accurate, biologically sensible, and feasible. This paper describes the attributes of clinical outcomes and illustrates how to develop novel outcomes, using as an example the authors' experience in developing a wound cosmesis outcome measure.

Octylcyanoacrylate versus polyurethane for treatment of burns in swine: a randomized trial.

In order to determine whether the enhanced reepithelialization of second-degree burns treated with octylcyanoacrylate (OCA) was due to its occlusive nature we compared reepithelialization (REP) and infection rates of second degree burns treated with OCA and polyurethane film (Tegaderm) in swine. Forty-four standardized partial thickness burns were created by applying an aluminum bar preheated to 80 degrees C to the backs of pigs for 20 s and randomly treated with OCA or Tegaderm. Full thickness biopsies were taken at 7, 10 and 14 days for blinded histopathological evaluation of rates of infection and reepithelialization. T-tests and chi(2) tests were used for group comparisons. There were no between group difference in the rates of reepithelialization and infection. All wounds were reepithelialized by day 14 and there were no infections in either group. We conclude that treatment of partial thickness burns with OCA spray or Tegaderm results in similar rates of reepithelialization and infection, suggesting that the beneficial effects of OCA on reepithelialization are due to its occlusive nature.

Octylcyanoacrylate for the treatment of contaminated partial-thickness burns in swine: a randomized controlled experiment.

OBJECTIVE: To compare infection and reepithelialization rates of contaminated second-degree burns treated with octylcyanoacrylate (OCA), silver sulfadiazine (SSD), polyurethane (PU) film, and dry gauze (control; C) in swine. METHODS: Eighty standardized burns were created by applying an aluminum bar preheated to 80 degrees C to the backs and flanks of young pigs for 20 seconds. All burns were immediately contaminated with 0.1 mL of Staphylococcus aureus 10(5)/mL and randomly treated with OCA spray, SSD, PU, or dry gauze (C). Full-thickness biopsies were taken at 3, 7, and 14 days for blinded histopathologic evaluation using hematoxylin and eosin (H&E)-stained slides. Burns were considered infected in the presence of interstitial reticular dermal neutrophils containing bacteria (intraobserver agreement, kappa = 1.00). Quantitative wound cultures were performed on a second day-3 specimen. RESULTS: At day 3, wound infection rates were 30% (OCA), 50% (SSD), 55% (PU), and 50% (C); p = 0.40 (Kruskal-Wallis test). At day 7, infection rates were 35% (OCA), 85% (SSD), 70% (PU), and 65% (C); p = 0.01. Median bacterial counts at day 3 were 6,500 (OCA), 20,000 (SSD), 1,000,000 (PU), and 650,000 (C); p = 0.29. The proportion of completely reepithelialized wounds at day 14 were 75% (OCA), 90% (SSD), 85% (PU), and 90% (C); p = 0.50. CONCLUSIONS: Treatment of contaminated partial-thickness burns with OCA spray resulted in fewer infections at one week than with the other three treatments.

Do diabetic patients have higher in-hospital complication rates when admitted from the emergency department for possible myocardial ischemia?

OBJECTIVE: To compare in-hospital complication rates for diabetic and nondiabetic patients admitted from the emergency department (ED) for possible myocardial ischemia. METHODS: This was a prospective, observational study of consecutive consenting patients presenting to a suburban university hospital ED during study hours with typical and atypical symptoms consistent with cardiac ischemia. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Inpatient records were reviewed by trained data abstractors to ascertain hospital course and occurrence of complications. Final discharge diagnosis of acute myocardial infarction (AMI) was assigned by World Health Organization criteria. Categorical and continuous data were analyzed by chi-square and t-tests, respectively. All tests were two-tailed with alpha set at 0.05. RESULTS: There were 1,543 patients enrolled who did not have complications at initial presentation; 283 were diabetic. The rule-in rate for AMI was 13.8% for nondiabetic patients and 17.7% for diabetic patients (p = 0.09). Times to presentation were similar for nondiabetic vs diabetic patients [248 minutes (95% CI = 231 to 266) vs 235 minutes (95% CI = 202 to 269); p = 0.32]. Nondiabetic patients tended to be younger [56.6 years (95% CI = 55.8 to 57.4) vs 61.6 years (95% CI = 60.2 to 63.1); p = 0.001] and were less likely to be female (34.3% vs 48.1%; p = 0.001). The two groups had similar prevalences for initial electrocardiograms diagnostic for AMI (5.5% vs 7.4%; p = 0.21). There was no significant difference between nondiabetic and diabetic patients for the occurrence of the following complications after admission to the hospital: congestive heart failure (1.3% vs 1.1%, p = 0.77); nonsustained ventricular tachycardia (VT) (1.3% vs 1.2%, p = 0.93); sustained VT (1.2% vs 1.1%, p = 0.85); supraventricular tachycardia (1.7% vs 3.2%, p = 0.12); bradydysrhythmias (1.9% vs 1.1%, p = 0.33); hypotension necessitating the use of pressors (0.9% vs 1.1%, p = 0.76); cardiopulmonary resuscitation (0.2% vs 0.7%, p = 0.10); and death (0.3% vs 0.7%, p = 0.34). One or more complications occurred with similar frequencies for patients in the two groups (6.3% vs 5.7%; p = 0.70). CONCLUSIONS: No statistically significant difference was found in the postadmission complication rates for initially stable diabetic vs nondiabetic patients admitted for possible myocardial ischemia. Based on these results, the presence or absence of diabetes as a comorbid condition does not indicate a need to alter admitting decisions with respect to risk for inpatient complications.

The effects of epidermal debridement of partial-thickness burns on infection and reepithelialization in swine.

OBJECTIVE: Early postburn debridement of burn blisters is controversial. This study was conducted to compare rates of infection and reepithelialization in debrided vs nondebrided second-degree burns in swine. METHODS: This was a prospective, blinded, controlled, experimental trial using isoflurane-anesthetized swine. Standardized partial-thickness burns were inflicted by applying an aluminum bar preheated to 80 degrees C to the backs and flanks of two young pigs for 20 seconds. In half of the burns the necrotic epidermis was manually debrided. All burns were randomly treated with octylcyanoacrylate spray (OCA) or dry gauze (C). Full-thickness biopsies were taken at 7, 10, and 14 days for blinded histopathologic evaluation. The primary outcomes were the proportions of infected burns at days 7 and 10 and the proportion of completely reepithelialized burns at day 14. Burns were considered infected in the presence of intradermal neutrophils containing bacteria (intraobserver agreement, K = 1.00). A secondary outcome was the proportion of burns with the presence of scar tissue (abnormal collagen under polarized light; intraobserver correlation, K = 0.93). Chi-square tests were used for group comparisons. This study had 90% power to detect a 40-percentage-point difference in infection rates (alpha = 0.05). RESULTS: A total of 126 biopsies from 42 burns were available for review. Infection rates were higher in the debrided burns both at day 7 (55% vs 4.5%, p < 0.001) and at day 10 (65% vs 9%, p < 0.001) after injury. The proportion of nondebrided burns that were completely reepithelialized was higher at days 10 (68% vs 0%, p < 0.001) and 14 (100% vs 65%, p = 0.003). The presence of scar tissue was more common in debrided burns (75% vs 4.5%, p < 0.001). Burns treated with OCA had fewer infections than controls (4% vs 55%, p < 0.001). Fewer OCA-treated debrided burns were reepithelialized at 14 days than those that were not debrided (30% vs 100%, p = 0.001). CONCLUSIONS: Under the current study conditions, early postburn epidermal debridement of second-degree burns resulted in more infections and slower reepithelialization rates in swine. The effects of early postburn epidermal debridement in humans should be explored.

Inadequate hospital reimbursement for victims of motor vehicle crashes due to health reform legislation.

STUDY OBJECTIVE: Effective for 1997, health reform legislation in New York resulted in a change in hospital reimbursement for victims of motor vehicle crashes. We evaluated the impact of this change from no-fault to Medicaid rates on the financial viability of a regional trauma center within an academic medical center. METHODS: This study represents a retrospective review of the trauma registry for all motor vehicle-related injuries (meeting the statewide definition of trauma) admitted to a regional trauma center for a 9-month period just before the legislation implementation date. Charges, costs, and projected reimbursement were calculated by standard hospital accounting methods. Profit or loss (reimbursement minus costs) was calculated by standard hospital accounting methods for each admission using no-fault and Medicaid reimbursement rates. RESULTS: One hundred seventy-three cases during the 9-month period generated total charges of $4,112,174, total costs of $3,447,110, and estimated total profit of $800,084 ($4,625 per case) using no-fault reimbursement and a total loss of $184,154 ($1,064 per case) using Medicaid reimbursement. For the 31 patients with diagnosis-related groups (DRGs) that were specifically created in New York to ensure adequate reimbursement for multiple significant trauma (730 through 734 and 792 through 794), no-fault reimbursement resulted in an average profit of $371 per case and Medicaid generated a loss of $6,118 per case. Actual payments for the study population were almost $500,000 less than estimated. CONCLUSION: Changes in rates of no-fault insurance payments to hospitals will result in inadequate reimbursement for motor vehicle crash victims admitted to a regional trauma center, undermining the viability of the regional trauma system.

Evolution of abstracts presented at the annual scientific meetings of academic emergency medicine.

There has been a general trend in medicine towards greater sophistication in research design. In order to assess this trend in emergency medicine we compared the characteristics of abstracts presented at the 1974, 1983, 1989, and 1997 annual scientific meetings of academic emergency medicine. All 870 abstracts were reviewed by 1 of 3 investigators who determined research design attributes using a standardized classification scheme that has good interrater reliability. Over the last 25 years the following trends were noted: more surveys (0% v1% v3% v8%, P = 0.002), more randomized studies (0% v10% v12% v15%, P = 0.05), and more blinded studies (0% v7% v5% v11%, P = 0.01). Tests of statistical significance were reported with increasing frequency (8% v26% v59% v69%, P < 0.001) as were power calculations (0% v0% v1% v3%, P = 0.02). During the study period there were also increases in the median number of authors, proportion of foreign lead authors, and the proportion of studies involving human subjects. These results reflect considerable improvement in the degree of research design sophistication reported in selected abstracts of academic emergency medicine over the study period. Further strategies to assure continued enhancement of emergency medicine research should be explored.

How well do patients obtain short-term follow-up after discharge from the emergency department?

STUDY OBJECTIVE: We sought to determine the follow-up rate of discharged emergency department patients who were instructed to obtain reevaluation within 48 hours at our ED, a clinic, or a private physician's office and to determine the reasons why patients do not obtain short-term follow-up when instructed. METHODS: Emergency physicians prospectively enrolled a convenience sample of patients discharged from a university hospital ED who were believed to be at risk for clinical deterioration. Patients were instructed to obtain reevaluation within 48 hours at a public clinic, private physician's office, or our ED (without charge). A telephone interview was conducted after 48 hours had elapsed. RESULTS: Three hundred twenty-five patients were enrolled, 300 were included in data analysis, and 203 (67.7%) of these obtained follow-up as instructed. Those referred to the ED had a higher follow-up rate (105/127 [82.7%]) than those referred to clinics (59/99 [59.6%]) or private physicians (39/74 [52.7%]). Inability to obtain an appointment was cited by 34.3% of those who did not obtain follow-up care as instructed. CONCLUSION: Many patients discharged from the ED who were believed to be at risk for clinical deterioration did not obtain medical follow-up within 48 hours when so instructed. Free ED follow-up resulted in a better rate of short-term follow-up than that for clinics and private physicians and may be especially useful if a patient's ability to obtain follow-up is uncertain or if timely reevaluation is particularly imperative.

Evolution of abstracts presented at the annual scientific meetings of academic emergency medicine.

There has been a general trend in medicine toward greater sophistication in research design. To assess this trend in emergency medicine, we compared the characteristics of abstracts presented at the 1974, 1983, 1989, and 1997 annual scientific meetings of Academic Emergency Medicine. All 870 abstracts were reviewed by 1 of 3 investigators who determined research design attributes using a standardized classification scheme that has good interrater reliability. Over the last 25 years, the following trends were noted: more surveys (0% v1% v3% v8%, P=.002), more randomized studies (0% v10% v12% v15%, P=.05), and more blinded studies (0% v7% v5% v11%, P=.01). Tests of statistical significance were reported with increasing frequency (8% v26% v59% v 69%, P < .001), as were power calculations (0% v0% v1% v3%, P=.02). During the study period, there were also increases in the median number of authors, proportion of foreign lead authors, and the proportion of studies involving human subjects. These results reflect considerable improvement in the degree of research design sophistication reported in selected abstracts of academic emergency medicine over the study period. Further strategies to assure continued enhancement of emergency medicine research should be explored.