What If I Do Not Match? Scrambling for a Spot and Going Outside the Match.

Matching into emergency medicine (EM) is getting progressively more competitive. Applicants must therefore prepare for the possibility of not matching and, accordingly, be ready to participate in the Supplemental Offer and Acceptance Program (SOAP). In this article, we elaborate on the SOAP and the options for applicants who fail to match during Match Week. Alternative courses of action include applying for a preliminary year, matching into a categorical residency program, or aiming to secure EM spots outside the Match through the Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine, and American Association of Medical Colleges.

Adirondack Park incidents: a retrospective review of search and rescue reports from 2008 and 2009.

BACKGROUND: The Adirondack Park is a 6 million acre recreational area in northeastern New York used for activities such as hiking, camping, canoeing, hunting, fishing, snowmobiling, skiing, and rock climbing. Given the large number of people who use the Adirondacks for recreation, there exists the potential for many accidents, injuries, and illnesses to occur in areas ranging from state-operated campgrounds to remote backcountry. OBJECTIVE: The aim of this study was to gain insight into the demographics of search and rescue (SAR) operations in the Adirondack Park. METHODS: This study is a retrospective review of the Adirondack Park Forest Ranger SAR reports from January 1, 2008, through December 31, 2009. Epidemiologic data were gathered from the NY State Department of Environmental Conservation for each report, including victim demographics, incident, reason for injury, medical care needed, preparation of victim, and prior medical conditions. RESULTS: In all, 239 SAR missions were carried out involving at least 349 victims. Of all cases, 28% (66) involved an injured victim, and 9% (21) involved illness; 56% (10) of the victims had a known prior illness or medical condition; and 21% (27) of cases were due to victims exceeding their abilities. Of the search missions, 54% of victims (93) had little experience with the activity, and 9% (15) had no experience. Only 43% (62) of victims had any form of orientation equipment. CONCLUSIONS: This study portrays the initial demographics of SAR efforts in Adirondack Park. It will aid in educating people on preparing for wilderness activities, as well as tailoring SAR resources to the demographics of injury and illness within the park.

Improved management of acute asthma among pregnant women presenting to the ED.

BACKGROUND: A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s. METHODS: We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge. RESULTS: Of 4,895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04). CONCLUSIONS: Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

Emergency Resuscitation of Patients Enrolled in the US Diaspirin Cross-linked Hemoglobin (DCLHb) Clinical Efficacy Trial.

INTRODUCTION: Optimal emergent management of traumatic hemorrhagic shock patients requires a better understanding of treatment provided in the prehospital/Emergency Medical Services (EMS) and emergency department (ED) settings. Hypothesis/Problem Described in this research are the initial clinical status, airway management, fluid and blood infusions, and time course of severely-injured hemorrhagic shock patients in the EMS and ED settings from the diaspirin cross-linked hemoglobin (DCLHb) clinical trial. METHODS: Data were analyzed from 17 US trauma centers gathered during a randomized, controlled, single-blinded efficacy trial of a hemoglobin solution (DCLHb) as add-on therapy versus standard therapy. RESULTS: Among the 98 randomized patients, the mean EMS Glasgow Coma Scale (GCS) was 10.6 (SD = 5.0), the mean EMS revised trauma score (RTS) was 6.3 (SD = 1.9), and the mean injury severity score (ISS) was 31 (SD = 17). Upon arrival to the ED, the GCS was 20% lower (7.8 (SD = 5.3) vs 9.7 (SD = 6.3)) and the RTS was 12% lower (5.3 (SD = 2.0) vs 6.0 (SD = 2.1)) than EMS values in blunt trauma patients (P < .001). By ED disposition, 80% of patients (78/98) were intubated. Rapid sequence intubation (RSI) was utilized in 77% (60/78), most often utilizing succinylcholine (65%) and midazolam (50%). The mean crystalloid volume infused was 4.2 L (SD = 3.4 L), 80% of which was infused within the ED. Emergency department blood transfusion occurred in 62% of patients, with an average transfused volume of 1.2 L (SD = 2.0 L). Blunt trauma patients received 2.1 times more total fluids (7.4 L vs 3.5 L, < .001) and 2.4 times more blood (2.4 L vs 1.0 L, P < .001). The mean time of patients taken from injury site to operating room (OR) was 113 minutes (SD = 87 minutes). Twenty-one (30%) of the 70 patients taken to the OR from the ED were sent within 60 minutes of the estimated injury time. Penetrating trauma patients were taken to the OR 52% sooner than blunt trauma patients (72 minutes vs 149 minutes, P < .001). CONCLUSION: Both GCS and RTS decreased prior to ED arrival in blunt trauma patients. Intubation was performed using RSI, and crystalloid infusion of three times the estimated blood loss volume (L) and blood transfusion of the estimated blood loss volume (L) were provided in the EMS and ED settings. Surgical intervention for these trauma patients most often occurred more than one hour from the time of injury. Penetrating trauma patients received surgical intervention more rapidly than those with a blunt trauma mechanism.

Use of ultrasound guidance for central venous catheter placement: survey from the American Board of Emergency Medicine Longitudinal Study of Emergency Physicians.

OBJECTIVES: The objective was to survey practicing emergency physicians (EPs) across the United States regarding the frequency of using ultrasound (US) guidance in central venous catheter (CVC) placement and, secondarily, to determine factors associated with the use or barriers to the use of US guidance. METHODS: This was a cross-sectional survey mailed to presumed practicing EPs as part of the American Board of Emergency Medicine (ABEM)'s longitudinal study of EPs. The selection process used stratified, random sampling of cohorts thought to represent four different stages within the development of the specialty of emergency medicine (EM). Multivariable logistic regression was used to identify independent factors associated with both high comfort using US guidance and high-percentage usage of US guidance. RESULTS: The survey was mailed to 1,165 subjects, and the response rate was 79%. The median number of years of practice was 20 (interquartile range [IQR]=7 to 28 years). As their primary practice setting, 64% work in private or community hospitals, 60% received training in US-guided vascular access, and 44% never use US guidance in placing CVCs. Barriers differed in those who never use US and those who sometimes or always used US guidance. In those who never use US, top barriers were insufficient training (67%) and lack of equipment (25%). In those who use US, top barriers were the perceptions that US was too time-consuming (27%) and that the preferred site was not amenable to US (24%). Independent factors associated with high comfort and high-percentage use of US guidance were training in US-guided vascular access (adjusted odds ratio=5.1 [high comfort]; 95% confidence interval [CI]=2.6 to 10.1; adjusted odds ratio 11.1=(high percentage); 95% CI=5.0 to 24.8) and being a recent residency graduate. CONCLUSIONS: Among EPs, the translation of evidence to clinical practice regarding the benefits of US guidance for CVC placement is poor and still faces many barriers. Training and education are potentially the best ways to overcome such barriers.

Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting.

OBJECTIVE: To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention. METHODS: The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18-65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2). RESULTS: Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods. CONCLUSIONS: A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.

Cognitive and affective predictors of smoking after a sentinel health event.

OBJECTIVE: This study examined how smoking-related causal attributions, perceived illness severity, and event-related emotions relate to both intentions to quit and subsequent smoking behavior after an acute medical problem (sentinel event). METHODS: Three hundred and seventy-five patients were enrolled from 10 emergency departments (EDs) across the USA and followed for six months. Two saturated, manifest structural equation models were performed: one predicting quit attempts and the other predicting seven-day point prevalence abstinence at 14 days, three months, and six months after the index ED visit. Stage of change was regressed onto each of the other predictor variables (causal attribution, perceived illness severity, event-related emotions) and covariates, and tobacco cessation outcomes were regressed on all of the predictor variables and covariates. RESULTS: Non-White race, baseline stage of change, and an interaction between causal attribution and event-related fear were the strongest predictors of quit attempt. In contrast, abstinence at six months was most strongly predicted by baseline stage of change and nicotine dependence. CONCLUSION: Predictors of smoking behavior after an acute medical illness are complex and dynamic. The relations vary depending on the outcome examined (quit attempts vs. abstinence), differ based on the time that has progressed since the event, and include significant interactions.

Variables associated with discordance between emergency physician and neurologist diagnoses of transient ischemic attacks in the emergency department.

STUDY OBJECTIVE: Transient ischemic attack is a common clinical diagnosis in emergency department (ED) patients with acute neurologic complaints. Accurate diagnosis of transient ischemic attack is essential to help guide evaluation and avoid treatment delays. We seek to determine the prevalence of discordant diagnosis for patients receiving an ED diagnosis of transient ischemic attack compared with neurologist final diagnosis. Secondary goals are to evaluate the influence of atypical transient ischemic attack symptoms, the ABCD2 score, and emergency physician experience on discordant diagnoses. METHODS: We performed a retrospective cohort study evaluating all ED patients receiving a diagnosis of transient ischemic attack during a 4-year period. The emergency physician diagnosis was compared with that of the neurologist. The neurologist's final diagnosis was considered the criterion standard diagnosis. Subject demographic and clinical information was collected with a structured instrument. The following atypical symptoms present at the ED evaluation were evaluated with logistic regression: headache, tingling, involuntary movement, seeing flashing lights or wavy lines, dizziness, confusion, incontinence, and ABCD2 score of 4 or greater. Bivariate analysis was used to evaluate the influence of emergency physician experience (≤6 years versus >6 years) on discordant diagnosis. Odds ratios (ORs) and proportions are reported with 95% confidence intervals (CIs), interquartile range was used where appropriate. RESULTS: We evaluated 436 subjects, of whom 7 were excluded, allowing 429 subjects for evaluation. Of these individuals, 156 (36%; 95% CI 32% to 41%) received a discordant diagnosis. The median emergency physician time in clinical practice was 6 years (interquartile range 2 to 12 years). Features associated with a discordant transient ischemic attack diagnosis included headache (OR 2.52; 95% CI 1.59 to 3.99), involuntary movement (OR 3.19; 95% CI 1.35 to 7.54), and dizziness (OR 1.92; 95% CI 1.22 to 3.02). Incontinence, confusion, and seeing wavy lines or flashing lights were not significantly associated with a discordant diagnosis. Patients with tingling and a high ABCD2 score had an increased odds of concordant transient ischemic attack diagnosis (OR 0.54, 95% CI 0.32 to 0.92; OR 0.53, 95% CI 0.35 to 0.82, respectively). CONCLUSION: Discordant diagnoses between emergency physicians and neurologists were observed in 36% of patients. The presence of headache, involuntary movement, and dizziness predicted discordant diagnoses, whereas the presence of tingling and an increased ABCD2 score predicted concordant transient ischemic attack diagnosis.

Assessment and management of chronic obstructive pulmonary disease in the emergency department and beyond.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are common, can result in emergency department presentation and often result in hospitalization. After confirming the diagnosis and treating comorbidities, management of severe AECOPD includes bronchodilators, systemic corticosteroids, antibiotics, noninvasive ventilation and, occasionally, endotracheal intubation. Once discharged, delayed follow-up and suboptimal management often occurs. Antibiotics, systemic corticosteroids and optimization of nonpharmacological interventions (e.g., smoking cessation, immunization and pulmonary rehabilitation) are important discharge considerations. Improving linkages to primary providers who adhere to management involving a pharmacological and nonpharmacological evidence-based treatment plan is critical to preventing future AECOPDs, reducing healthcare utilization and maintaining the quality of life of patients following an AECOPD.

Ultrasound does not detect early blood loss in healthy volunteers donating blood.

BACKGROUND: Ultrasound has been suggested as a useful non-invasive tool for the detection of early blood loss. Two possible sonographic markers for hypovolemia are the diameter of the inferior vena cava (IVC) and the thickness of the left ventricle (LV). STUDY OBJECTIVES: The goal of the study was to evaluate the utility of ultrasound to detect signs of early hemorrhagic shock in healthy volunteers, compared with changes in vital signs. METHODS: In the current study, healthy volunteers from blood donation drives were used as models for early hemorrhage. Changes in vital signs, IVC diameter, and LV wall thickness were recorded after approximately 500 cc of blood loss. RESULTS: Thirty-eight subjects were enrolled and completed the study. After blood donation, there was a 7-mm Hg (8%) decrease in mean arterial pressure without a significant change in heart rate. There was a decrease in maximum IVC diameter (IVCmax) (12% decrease [95% confidence interval (CI) -6 to -19] in short axis and 20% decrease [95% CI -12 to -27] in long axis), but no change was seen in the respiratory caval index ((IVCmax - IVCmin)/IVCmax) × 100). There was no change in LV wall thickness. CONCLUSION: In this study, serial changes in vital signs, IVC diameter, and LV wall thickness were clinically insignificant after approximately 500 cc of blood loss in healthy volunteers.

Evaluating infant positioning for lumbar puncture using sonographic measurements.

OBJECTIVES: Hypoxia has been observed when infants undergo lumbar puncture in a tight flexed lateral recumbent position. This study used sonographic measurements of lumbar interspinous spaces to investigate the anatomic necessity and advantage derived from this tight flexed positioning in infants. METHODS: This was a brief, prospective, observational study of a convenience sample of patients. Twenty-one healthy infants under 1 month of age were scanned in two positions: prone in a spine-neutral position and lateral recumbent with their knees bent into their chest and their neck flexed. In each position, a 5- to 10-MHz linear array transducer was used to scan midline along the lumbar spinous processes in the sagittal plane. The distances between the spinous processes were measured near the ligamentum flavum using the ultrasound machine's calipers. Pulse oximetry was monitored on all infants during flexed positioning. RESULTS: In the spine-neutral position, all studied interspinous spaces were much wider than a 22-gauge spinal needle (diameter 0.072 cm). The mean (±SD) interspinous spaces for L3-4, L4-5, and L5-S1 in a spine-neutral position were 0.42 (±0.07), 0.37 (±0.06), and 0.36 (±0.11) cm, respectively. Flexing the infants increased the mean lumbar interspinous spaces at L3-4, L4-5, and L5-S1 by 31, 51, and 44%, respectively. CONCLUSIONS: This study verified that tight, lateral flexed positioning substantially enhances the space between the lumbar spinous processes and that a spine-neutral position also allows for a large enough anatomic interspinous space to perform lumbar puncture. However, further clinical research is required to establish the feasibility of lumbar puncture in a spine-neutral position.

Association of patient satisfaction with complaints and risk management among emergency physicians.

BACKGROUND: Patient-physician interactions in the emergency department (ED) are unique in that prior relationships may not exist; interactions are brief, and the environment is hectic. OBJECTIVES: The research hypotheses were that patient satisfaction scores on a commonly used national satisfaction survey are associated with patient complaints and risk management file openings or lawsuits (risk management episodes). METHODS: Administrative databases from an emergency physician management group that staffs 34 EDs in 8 states were merged with patient satisfaction data. Dates of inclusion were January 2002-April 2006. Estimates of physician contribution to satisfaction utilized a multi-level mixed-effects linear regression with a random-effect for practice site and physician, and fixed-effect adjustments for patient factors, time pressures, acuity mix, and physician productivity. Adjusted satisfaction scores were used to explore the relationship with complaints and risk management episodes. MAIN OUTCOME MEASURE: Association of patient satisfaction scores with risk of complaint and risk management episodes. RESULTS: There were 3947 physician-quarters of practice data analyzed, representing 2,462,617 patient visits. There were 375 complaints and 61 risk management episodes. Those in the lowest quartile of satisfaction were nearly twice as likely to have a complaint (adjusted odds ratio 1.84; 95% confidence interval [CI] 1.29-2.63) as those in the highest quartile. Satisfaction was not directly related to risk management episodes. Complaints were more strongly associated with risk management episodes than other variables: those receiving ≥ 2 complaints in a quarter were 4.13 (95% CI 1.12-15.2) times more likely to have a risk management episode. CONCLUSIONS: Patient satisfaction scores are not associated with increased risk management episodes but are closely related to receiving complaints. Receiving complaints is a strong marker for increased risk management episodes and should prompt early corrective action.

ED handoffs: observed practices and communication errors.

OBJECTIVE: The study objectives were to identify emergency department (ED) handoff practices and describe handoff communication errors among emergency physicians. METHODS: Two investigators observed patient handoffs among emergency physicians in a major metropolitan teaching hospital for 8 weeks. A data collection form was designed to assess handoff characteristics including duration, location, interruptions, and topics including examination, laboratory examinations, diagnosis, and disposition. Handoff errors were defined as clinically significant examination or laboratory findings in physician documentation that were reported significantly differently during or omitted from verbal handoff. Multivariate negative binomial regression models assessed variables associated with these errors. The study was approved by the institutional review board. RESULTS: One hundred ten handoff sessions encompassing 992 patients were observed. Examination handoff errors and omissions were noted in 130 (13.1%) and 447 (45.1%) handoffs, respectively. More examination errors were associated with longer handoff time per patient, whereas fewer examination omissions were associated with use of written or electronic support materials. Laboratory handoff errors and omissions were noted in 37 (3.7%) and 290 (29.2%) handoffs, respectively. Fewer laboratory errors were associated with use of electronic support tools, whereas more laboratory handoff omissions were associated with longer ED lengths of stay. CONCLUSIONS: Clinically pertinent findings reported in ED physician handoff often differ from findings reported in physician documentation. These errors and omissions are associated with handoff time per patient, ED length of stay, and use of support materials. Future research should focus on ED handoff standardization protocols, handoff error reduction techniques, and the impact of handoff on patient outcomes.

Levalbuterol versuss levalbuterol plus ipratropium in the treatment of severe acute asthma.

BACKGROUND: The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines advise the addition of ipratropium bromide to short-acting ß-agonist therapy for the treatment of patients with severe acute asthma exacerbation. METHODS: This was a prospective, double-blind, randomized, controlled study involving 141 adults, presenting to two EDs with acute severe asthma exacerbation. Patients were treated using a standardized pathway with levalbuterol plus ipratropium or levalbuterol alone. Primary outcomes were changes from baseline in the percentage of predicted forced expiratory volume in 1 second (FEV1) at 30 minutes and 60 minutes after completion of treatment. Secondary outcomes included hospitalization and relapse rates. Occurrence of adverse events was recorded. RESULTS: Sixty-seven patients in the levalbuterol plus ipratropium group and 74 patients in the levalbuterol group completed the study. Overall, there was no significant difference in the improvement in percent predicted FEV1 between the two groups at 30 minutes [difference in change between study groups at 30 minutes: 1% (95% CI: ?3 to 2%) or at 60 minutes: 3% (95% CI: 1-6%)] No difference was noted in hospitalization rates between the treatment groups [combination therapy group, 33%; single therapy group, 47%, difference: -14% (95% CI: -30 to 20%)]. Post-hoc analysis revealed that patients receiving ipratropium in addition to levalbuterol were 1.5 times more likely to experience side effects (palpitations) than patients treated with levalbuterol alone (RR 1.5; 95% CI: 1.2-1.9) No differences in relapse rates were noted between the groups. Post-hoc analysis revealed more side effects in patients receiving levalbuterol plus ipratropium. CONCLUSION: We were unable to demonstrate superiority of adding ipratropium to levalbuterol in alleviating obstruction as measured by FEV1 or in decreasing the need for hospitalization among adult patients presenting to the ED with acute severe asthma exacerbation.

ED visit volume and quality of care in acute exacerbations of chronic obstructive pulmonary disease.

OBJECTIVE: The purpose of this study is to determine whether emergency department (ED) visit volume is associated with ED quality of care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: We performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. Using a standard protocol, we interviewed consecutive ED patients with COPD exacerbation, reviewed their charts, and completed a 2-week telephone follow-up. The associations between ED visit volume and quality of care (process and outcome measures) were examined at both the ED and patient levels. RESULTS: After adjustment for patient mix in the multivariable analyses, chest radiography was less frequent among patients with COPD exacerbations in the low-volume (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.4) and high-volume EDs (OR, 0.1; 95% CI, 0.05-0.5), with medium-volume EDs as the reference. Arterial blood gas testing was less frequent in the low-volume EDs (OR, 0.1; 95% CI, 0.02-0.8). Medication use was similar across volume tertiles. With respect to outcome measures, patients in high-volume EDs were more likely to be discharged (OR, 4.2; 95% CI, 2.2-7.7) and to report ongoing exacerbation at a 2-week follow-up (OR, 1.9; 95% CI, 1.02-3.5). CONCLUSIONS: Traditional positive volume-quality relationships did not apply to emergency care of COPD exacerbation. High-volume EDs used less guideline-recommended diagnostic procedures, had a higher admission threshold, and had a worse short-term patient-centered outcome.

Applicant considerations associated with selection of an emergency medicine residency program.

OBJECTIVES: The primary objective of this study was to assess variables that residency applicants ranked as influential in making residency choices. The secondary objective was to determine if residents were satisfied with their residency choices. METHODS: A secondary analysis was performed on a cohort database from a stratified, random sampling of 322 emergency medicine (EM) residents collected in 1996-1998 and 2001-2004 from the American Board of Emergency Medicine Longitudinal Study on Emergency Medicine Residents (ABEM LSEMR). Residents rated the importance of 18 items in response to the question, "How much did each of the following factors influence your choice of residency program location?" The degree to which residents' programs met prior expectations and the levels of satisfaction with residency programs were also assessed. All analyses were conducted using descriptive statistics. RESULTS: Three-hundred twenty-two residents participated in the survey. Residents considered the following to be the most important variables: institutional reputation, hospital facilities, program director reputation, and spousal influence. Several geographic and gender differences were noted. Ninety percent (95% confidence interval [CI] = 86% to 93%) of residents surveyed in their final year answered that the residency program met or exceeded expectations. Seventy-nine percent (95% CI = 76% to 82%) of residents identified themselves as "highly satisfied" with their residency choice. CONCLUSIONS: The most influential factors in residency choice are institutional and residency director reputation and hospital facilities. Personal issues, such as recreational opportunities and spousal opinion, are also important, but are less influential. Significant geographic differences affecting residency choices exist, as do minor gender differences. A majority of residents were highly satisfied overall with their residency choices.

Efficacy of a brief intervention to improve emergency physicians' smoking cessation counseling skills, knowledge, and attitudes.

The objective of this study was to test whether a brief educational/administrative intervention could increase tobacco counseling by emergency physicians (EPs). Pre-/post-study at eight emergency departments (EDs) with residency programs were carried out. EPs received a 1-hour lecture on the health effects of smoking and strategies to counsel patients. After the lecture, cards promoting a national smokers' quitline were placed in EDs, to be distributed by providers. Providers completed pre-/ post-intervention questionnaires. Patients were interviewed pre-/post-intervention to assess provider behavior. Two hundred eighty-seven EPs were enrolled. Post-intervention, providers were more likely to consider tobacco counseling part of their role, and felt more confident in counseling. Data from 1168 patient interviews and chart reviews showed that, post-intervention, providers were more likely to ask patients about smoking, make a referral, and document smoking counseling. Post-intervention, 30% of smokers were given a Quitline referral card. An educational intervention improved ED-based tobacco interventions. Controlled trials are needed to establish these results' durability.

Validation of self-reported chronic obstructive pulmonary disease among patients in the ED.

BACKGROUND: To determine whether the self-reported diagnosis of adults who present to the emergency department (ED) with an acute exacerbation of either asthma or chronic obstructive pulmonary disease (COPD) is validated by medical record review. METHODS: This is cross-sectional study of 78 consecutive adults, 55 years and older, presenting to 3 EDs with symptoms suggestive of an exacerbation of asthma or COPD. We used current spirometric guidelines for a "spirometrically validated" diagnosis of COPD (eg, postbronchodilator forced expiratory volume in 1 second/forced ventilatory capacity <70%). Patients without office spirometry result were classified with COPD using clinical validation based on at least one of the following: primary care physician diagnosis of COPD, chronic bronchitis, or emphysema in the medical record or chest radiography, chest computed tomography, or arterial blood gas (ABG) diagnostic of COPD. RESULTS: Among 60 patients who self-reported diagnosis of COPD, 98% (95% confidence interval, 89-100) had clinically validated or spirometrically validated COPD. In addition, 83% (95% confidence interval, 59-96) of patients who reported either asthma only or no respiratory disease had clinically validated or spirometrically validated COPD. In no case was the chest radiograph or the ABG useful as a stand-alone test in establishing the diagnosis of COPD. CONCLUSIONS: Patients 55 years and older presenting to the ED with acute asthma or COPD, even those with clinical symptoms but no diagnosis of COPD, are likely to have COPD. Clinicians should maintain a high index of suspicion for COPD when older asthma patients deny COPD.