A Retrospective Review of Emergency Department Visits That May Be Appropriate for Management in Non-Emergency Settings.

BACKGROUND: Emergency departments (EDs) continue to struggle with overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients frequently choose the ED for non-emergent medical issues or injuries that could readily be handled in a primary care setting. We analyzed encounters in the ED at the Brooke Army Medical Center-the largest hospital in the Department of Defense-to determine the percentage of visits that could potentially be managed in a lower cost, appointment-based setting. MATERIALS AND METHODS: We conducted a retrospective chart review of patients within our electronic medical record system from September 2019 to August 2020, which represented equidistance from the start of the COVID-19 pandemic, resulting in a shift in ED used based on previously published data. Our study also compared the number of ED visits pre-covid vs. post-covid. We defined visits to be primary care eligible if they were discharged home and received no computed tomography imaging, ultrasound, magnetic resonance imaging, intravenous medications, or intramuscular-controlled substances. RESULTS: During the 12 month period, we queried data on 75,205 patient charts. We categorized 56.7% (n = 42,647) of visits as primary care eligible within our chart review. Most primary-care-eligible visits were ESI level 4 (59.2%). The largest proportion of primary-care-eligible patients (28.3%) was seen in our fast-track area followed by our pediatric pod (21.9%). The total number of ED visits decreased from 7,477 pre-covid to 5,057 post-covid visits. However, the proportion of patient visits that qualified as primary care eligible was generally consistent. CONCLUSIONS: Over half of all ED visits in our dataset could be primary care eligible. Our findings suggest that our patient population may benefit from other on-demand and appointment-based healthcare delivery to decompress the ED.

Innovative Solution for Airway Securement in Combat and Trauma Scenarios.

Airway management is one of the most challenging problems in prehospital combat casualty care. Airway assessment and intervention are second only to hemorrhage control in priority in the initial treatment of trauma patients, and airway compromise continues to account for approximately 1 in 10 preventable battlefield deaths. Combat medics often provide care in no- or low-light conditions, surrounded by the chaos of combat, and with the limited dexterity that accompanies bulky body armor, gloves, and heavy equipment. Far-forward medical care is also limited by available resources, which are often only what a combat medic can fit in the aid bag. Therefore, a procedure such as airway management that currently requires a high degree of skill becomes substantially more complex. Improved airway devices are listed among the top five in a comprehensive list of battlefield research and development priorities by the Defense Health Board, yet the challenge of airway management has received little investment compared to other causes of preventable battlefield death such as exsanguinating hemorrhage and traumatic brain injury.

Applying a Model of Teamwork Processes to Emergency Medical Services.

INTRODUCTION: Effective teamwork has been shown to optimize patient safety. However, research centered on the critical inputs, processes, and outcomes of team effectiveness in emergency medical services (EMS) has only recently begun to emerge. We conducted a theory-driven qualitative study of teamwork processes-the interdependent actions that convert inputs to outputs-by frontline EMS personnel in order to provide a model for use in EMS education and research. METHODS: We purposively sampled participants from an EMS agency in Houston, TX. Full-time employees with a valid emergency medical technician license were eligible. Using semi-structured format, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS. Phone interviews were recorded and transcribed. Using a thematic analytic approach, we combined codes into candidate themes through an iterative process. Analytic memos during coding and analysis identified potential themes, which were reviewed/refined and then compared against a model of teamwork processes in emergency medicine. RESULTS: We reached saturation once 32 respondents completed interviews. Among participants, 30 (94%) were male; the median experience was 15 years. The data demonstrated general support for the framework. Teamwork processes were clustered into four domains: planning; action; reflection; and interpersonal processes. Additionally, we identified six emergent concepts during open coding: leadership; crew familiarity; team cohesion; interpersonal trust; shared mental models; and procedural knowledge. CONCLUSION: In this thematic analysis, we outlined a new framework of EMS teamwork processes to describe the procedures that EMS operators employ to convert individual inputs into team performance outputs. The revised framework may be useful in both EMS education and research to empirically evaluate the key planning, action, reflection, and interpersonal processes that are critical to teamwork effectiveness in EMS.

Rectal Foreign Body Removal in the Emergency Department: A Case Report.

INTRODUCTION: Rectal foreign bodies (RFB) pose a challenge to emergency physicians. Patients are not often forthcoming, which can lead to delays to intervention. Thus, RFBs require a heightened clinical suspicion. In the emergency department (ED), extraction may require creative methods to prevent need for surgical intervention. CASE REPORT: The authors present a case of a successful extraction of a RFB in the ED and review of the literature. CONCLUSION: Retained RFBs are an unusually problematic reason for an ED visit. Thus, it is important for emergency physicians to be comfortable managing such cases appropriately.

Areas of Potential Impact of the Patient Protection and Affordable Care Act on EMS: A Synthesis of the Literature.

INTRODUCTION: This comprehensive review synthesizes the existing literature on the Patient Protection and Affordable Care Act (ACA) as it relates to emergency medical services (EMS) in order to provide guidance for navigating current and future healthcare changes. METHODS: We conducted a comprehensive review to identify all existing literature related to the ACA and EMS and all sections within the federal law pertaining to EMS. RESULTS: Many changes enacted by the ACA directly affect emergency care with potential indirect effects on EMS systems. New Medicaid enrollees and changes to existing coverage plans may alter EMS transport volumes. Reimbursement changes such as adjustments to the ambulance inflation factor (AIF) alter the yearly increases in EMS reimbursement by incorporating the multifactor productivity value into yearly reimbursement adjustments. New initiatives, funded by the Center for Medicare & Medicaid Innovation are exploring novel and cost-effective prehospital care delivery opportunities while EMS agencies individually explore partnerships with healthcare systems. CONCLUSION: EMS systems should be aware of the direct and indirect impact of ACA on prehospital care due to the potential for changes in financial reimbursement, acuity and volume changes, and ongoing new care delivery initiatives.

Self-reported provider safety in an urban emergency medical system.

INTRODUCTION: Emergency Medical Service (EMS) personnel often respond to dangerous scenes and encounter hostile individuals without police support. No recent data describes the frequency of physical or verbal assaults or which providers have increased fear for their safety. This information may help to guide interventions to improve safety. Our objective was to describe self-reported abuse and perceptions of safety and to determine if there are differences between gender, shift, and years of experience in a busy two-tiered, third service urban EMS system. METHODS: This was a secondary analysis of an anonymous, cross-sectional work safety survey of EMS providers. This survey included demographics, years of experience, history of verbal and physical assault, safety behavior following an assault and perceptions of safety. Descriptive statistics were generated. RESULTS: Eighty-nine percent (196/221) of EMS providers completed the survey. Most were male (72%) and between the ages of 25 and 50 years (66%). The majority of providers had worked in this service for more than five years (54%), and many for more than ten years (37%). Verbal assaults were reported by 88% (172/196, 95% CI [82.4%-91.6%]). Although 80% (156/196, 95% CI [73.4%-84.6%]) reported physical assaults, only 40% (62/156, 95% CI [32.4%-47.6%]) sought medical care and 49% (76/156, 95% CI [41%-56.6%]) reported the assault to police. The proportion of those who sought medical care and reported the assault to the police was not the same across years of experience (p<0.0001). Fear for personal safety was reported by 68% (134/196, 95% CI [61.6%-74.5%]). There was no statistical difference in assault by gender; however, females feared more for their safety compared to men (38/50, 76% v 96/142, 68%, p=0.02). The proportion of those who have ever been physically assaulted was not the same across shift worked (p=0.01). CONCLUSION: The majority of EMS providers surveyed reported an assault and certain groups had a higher rate of assault. Most assaults were not reported to the police and medical care was infrequently sought following an event. The majority of providers reported feeling fear for their personal safety. Further research into enhancing safety mechanisms is needed.

Identification of disulfide bond formation between MitoNEET and glutamate dehydrogenase 1.

MitoNEET is a protein that was identified as a drug target for diabetes, but its cellular function as well as its role in diabetes remains elusive. Protein pull-down experiments identified glutamate dehydrogenase 1 (GDH1) as a potential binding partner. GDH1 is a key metabolic enzyme with emerging roles in insulin regulation. MitoNEET forms a covalent complex with GDH1 through disulfide bond formation and acts as an activator. Proteomic analysis identified the specific cysteine residues that participate in the disulfide bond. This is the first report that effectively links mitoNEET to activation of the insulin regulator GDH1.

Emergency department visits after hospital discharge: a missing part of the equation.

STUDY OBJECTIVE: Current methods of measuring hospital readmissions capture only inpatient-to-inpatient hospitalization and ignore return visits to the emergency department (ED) that do not result in an admission. The relative importance of the return ED visit is currently not well established. We conduct this study to characterize the frequency of ED utilization within 30 days of inpatient hospital discharge. METHODS: This was a retrospective cohort study conducted with administrative data from an urban academic center from January 1 to June 30, 2010. We included patient-level and visit-level data from both inpatient and ED databases. All inpatient discharges from January 1 to May 31, 2010, were followed forward to determine whether any ED visits occurred within the subsequent 30 days. Each time a patient was admitted, the 30-day clock was reset on subsequent discharge. RESULTS: There were 15,519 inpatient discharges during the study period, which included 11,976 unique patients. Nearly one quarter (n=3,695; 23.8%) of these discharges resulted in at least 1 ED visit within the subsequent 30 days (total return ED visits=4,077), and more than half of the subsequent ED visits (n=2,204; 54%) did not lead to hospital readmission. CONCLUSION: Excluding a return to the ED misses more than 50% of all returns to the acute level of care after discharge. Inclusion of ED visits as a return to the acute care setting may enhance providers' efforts to identify opportunities to improve care transitions and intervene in a cycle of frequent rehospitalizations.

EMS providers' perceptions of safety climate and adherence to safe work practices.

BACKGROUND: Occupational injuries are an important source of morbidity for emergency medical services (EMS) providers. Previous work has shown that employee perceptions of an organization's commitment to safety (i.e., safety climate) correlate with adherence to safe practices. OBJECTIVE: To assess the association between perceived safety climate and compliance with safety procedures in an urban EMS system with >100,000 calls/year. METHODS: EMS providers were issued a self-administered survey that included questions on demographics, years of experience, perceived safety climate, and adherence to safety procedures. Safety climate was assessed with a 20-item validated instrument. Adherence to safety procedures was assessed with a nine-item list of safety behaviors. Strict adherence to safety procedures was defined as endorsing "agree" or "strongly agree" on 80% of items. The effect of safety climate on compliance with safe practices was estimated using multiple logistic regression. RESULTS: One hundred ninety-six of 221 providers (89%) completed surveys; 74% were male; the median age was 36-40 years; and the median amount of experience was 8 years. One hundred twenty-seven of 196 respondents (65%) reported strict adherence to safe work practice. Factor analysis confirmed the original six-factor grouping of questions; frequent safety-related feedback/training was significantly associated with safe practices (odds ratio [OR] = 2.14, 95% confidence interval [CI] = 1.01-4.51). CONCLUSION: EMS workers perceiving a high degree of perceived safety climate was associated with twofold greater odds of self-reported level of strict adherence to safe work practices. Frequent safety-related feedback/training was the one dimension of safety climate that had the strongest association with adherence to safe workplace behaviors.

Myocardial infarction associated with sibutramine use: case report and discussion.

We present the case of a young woman presenting to a military field hospital in Afghanistan with a non-ST-elevation myocardial infarction (NSTEMI) associated with the diet drug sibutramine. We also provide a brief literature review on the association between sibutramine and myocardial infarction.

Six-month follow-up of a brief intervention on self-reported safety belt use among emergency department patients.

OBJECTIVES: Safety belt use (SBU) reduces motor vehicle deaths by 45%. We previously reported that a brief intervention improved self-reported SBU among emergency department (ED) patients at 3 months. We sought to determine if these effects were sustained at 6 months postenrollment. METHODS: This was a prospective, randomized controlled trial of adult patients (age > or = 21 years) at an academic medical center ED from February 2006 to May 2006. Patients were systematically sampled for self-reported SBU. Those with self-reported SBU less than "always" were asked to participate. Subjects were surveyed at baseline with a nine-item series of situational SBU questions scored on a five-point Likert scale (e.g., 5 = always, 1 = never). This nine-item average comprised the mean SBU score. Subjects were randomized to a control group (CG) and an intervention group (IG). The CG received an injury prevention brochure; the IG received a brief motivation interview by a trained interventionist and the brochure. Subjects were phoned at 3 and 6 months to determine interval change in SBU scores via a standard script. Repeated-measures analysis of covariance and t-tests were used to analyze trends in mean SBU scores between groups, as well as to test mean changes in SBU scores from the 3- to 6-month intervals. RESULTS: Of 432 eligible patients, 292 enrolled (mean age = 35 years, SD +/- 11.2 years; 61% male). At baseline, there were no significant demographic differences; the IG (n = 147) and CG (n = 145) had similar mean SBU scores (2.8 vs. 2.6, p = 0.31), and 66% (n = 96 in each) completed both 3- and 6-month follow-up. The mean SBU score at 6 months in the IG was greater than in the CG group (3.6 vs. 2.9, p < 0.001), as were the mean SBU score differences from baseline (IG = 0.84 vs. CG = 0.29, p < 0.001). These differences were sustained from the 3-month interval (IG = -0.02 vs. CG = -0.06, p > 0.05). CONCLUSIONS: The previously reported finding that ED patients who received a brief motivation interview reported higher SBU scores at 3 months compared to a CG was sustained at 6-month follow-up. Although limited by self-report, a brief intervention may enhance lasting SBU behavior among high-risk ED patients.

Attitudes and practices regarding influenza vaccination among emergency department personnel.

In the United States, infections related to influenza result in a huge burden to the health care system and emergency departments (EDs). Influenza vaccinations are a safe, cost-effective means to prevent morbidity and mortality. We sought to understand the factors that contribute to the professional and personal influenza vaccination practices of health care workers in the ED setting by assessing their knowledge, attitudes, and practices with regards to the influenza vaccine. A cross-sectional study of all full-time ED staff (nurses, emergency medicine residents, and emergency medicine faculty) at an urban academic medical center in Boston treating > 90,000 ED patients annually, was performed. We examined knowledge, attitudes, and practices regarding personal influenza vaccination and support of an ED-based influenza vaccination program using an anonymous, self-administered questionnaire. Of 130 ED staff, 126 individuals completed the survey (97% response rate). Overall, 69% of respondents reported that they were very or extremely likely to be vaccinated before the coming influenza season. Residents (94%) and attending physicians (82%) were significantly more likely than nurses (42%) to be vaccinated (p < 0.001). Respondents likely to be vaccinated this year were more likely to support a vaccination program for ED patients (80% vs. 55% of those not vaccinated,p < 0.001). Providing regular education on the efficacy of preventive vaccination therapy and dispelling misconceptions regarding adverse effects may reduce barriers to vaccination programs. An educational initiative may result in acceptance of influenza vaccination by ED providers themselves, which could result in increased support for an influenza vaccination program for ED patients.

Stonefish envenomation.

As more Americans travel in greater numbers in search of exotic destinations, they may encounter dangerous marine life that hide in reefs and shallow marine waters. In this case report, we describe a case of stonefish envenomation and provide a review of the literature on management and prevention.

Brief motivational intervention to increase self-reported safety belt use among emergency department patients.

OBJECTIVES: Brief motivational interventions have shown promise in reducing harmful behaviors. The authors tested an intervention to increase safety belt use (SBU) among emergency department (ED) patients. METHODS: From February 2006 to May 2006, the authors conducted a randomized trial of adult ED patients at a teaching hospital in Boston. ED patients were systematically sampled for self-reported SBU. Those with SBU other than "always" were asked to participate. At baseline, participants answered a 9-item series of situational SBU questions, each scored on a 5-point Likert scale. SBU was defined as a continuous variable (9-item average) and as a dichotomous variable (response of "always" across all items). Participants were randomized to an intervention or a control group. The intervention group received a 5- to 7-minute intervention, adapted from classic motivational interviewing techniques, by a trained interventionist. Participants completed a 3-month follow-up phone survey to determine changes from baseline SBU. Continuous and dichotomous SBU were analyzed via analysis of covariance and chi-square testing. RESULTS: Of 432 eligible patients, 292 enrolled (mean age 35 years, standard deviation [SD] +/-11 years; 61% male). At baseline, the intervention and control groups had similar mean (+/-SD) SBU scores (2.8 [+/-1.1] vs. 2.6 [+/-1.1], p = 0.31) and SBU prevalence (each 0%). At 3 months, 81% completed follow-up. The intervention group had significantly greater improvement in mean (+/-SD) SBU scores than controls (0.76 [+/-0.91] vs. 0.34 [+/-0.88], p < 0.001). Also, SBU prevalence of "always" was higher for the intervention group than controls (14.4% vs. 5.9%, p = 0.03). CONCLUSIONS: Participants receiving a brief motivational intervention reported higher SBU at follow-up compared to controls. An ED-based intervention may be useful to increase SBU.

Chemical, thermal, and biological ocular exposures.

Chemical or radiant energy injuries to the eyes are considered ocular burns. The majority of these injuries are occupation-related. Chemical burns are by far more common and represent a true emergency. Thermal and UV injuries are associated with severe pain, but often result in less long-term sequelae than chemical injuries do. The term "biologic exposure" refers to an exposure to human blood or other body fluid. This article describes patterns of these injuries and exposures, with particular emphasis on emergent management and including acute diagnostic and treatment considerations.

Epidemiology of lower extremity injuries among U.S. high school athletes.

OBJECTIVES: Despite the health benefits of organized sports, high school athletes are at risk for lower extremity sports-related injuries (LESRIs). The authors documented the epidemiology of LESRIs among U.S. high school athletes. METHODS: Via two-stage sampling, 100 U.S. high schools were randomly selected. During the 2005 school year, LESRIs in nine sports were reported: boys' baseball, football, and wrestling; girls' softball and volleyball; and boys' and girls' basketball and soccer. The authors calculated rates as the ratio of LESRIs to the number of athlete exposures. National estimates were generated by assigning injuries a sample weight based on the inverse probability of the school's selection into the study. RESULTS: Among high school athletes in 2005, 2,298 of 4,350 injuries (52.8%) were LESRIs. This represents an estimated 807,222 LESRIs in U.S. high school athletes in nine sports (1.33/1,000 athlete exposures). Football had the highest LESRI rate for boys (2.01/1,000) and soccer the highest for girls (1.59/1,000). Leading diagnoses were sprains (50%), strains (17%), contusions (12%), and fractures (5%). The ankle (40%), knee (25%), and thigh (14%) were most frequently injured. Fractures occurred most often in the ankle (42%), lower leg (29%), or foot (18%). Girls with ligamentous knee injuries required surgery twice as often as boys (67% vs. 35%; p < 0.01). Girls had 1.5 times the proportion of season-ending LESRIs of boys (12.5% vs. 8%; p < 0.01). CONCLUSIONS: While LESRIs occur commonly in high school athletes, team- and gender-specific patterns exist. Emergency department staff will likely encounter such injuries. To optimize prevention strategies, ongoing surveillance is needed.

Brief interventions to reduce harmful alcohol use among military personnel: lessons learned from the civilian experience.

Unhealthy alcohol use is among the leading causes of morbidity and mortality in the United States. Among military personnel, service members between the ages 18 and 25 had a 27.3% prevalence of heavy drinking in the previous 30 days, compared to 15.3% among civilians in the same age group. In the civilian world, > 100 million patients are treated in U.S. emergency departments (ED) annually; 7.9% of these visits are alcohol related. Alcohol is associated with a broad range of health consequences that may ultimately present in the ED setting: traumatic injuries (e.g., motor vehicle crashes, intentional violence, falls); environmental injuries (e.g., frostbite); cardiovascular problems (e.g., hypertension, dilated cardiomyopathy); gastrointestinal disorders (e.g., hepatitis, pancreatitis, gastrointestinal bleeding); neurological problems (e.g., encephalopathy, alcohol withdrawal, withdrawal seizures), as well as psychological problems (e.g., depression, suicide). Seminal work has been done to create behavioral interventions for at-risk drinkers. These motivational interventions have been found to be successful in encouraging clients to change their risky behaviors. We present such a technique, called the Brief Negotiated Interview as performed in a civilian ED setting, in hopes of adapting it for use in the military context. Military health care providers could easily adapt this technique to help reduce risky levels of alcohol consumption among service members, retirees, or military dependents.

Self-reported safety belt use among emergency department patients in Boston, Massachusetts.

BACKGROUND: Safety belt use is 80% nationally, yet only 63% in Massachusetts. Safety belt use among potentially at-risk groups in Boston is unknown. We sought to assess the prevalence and correlates of belt non-use among emergency department (ED) patients in Boston. METHODS: A cross-sectional survey with systematic sampling was conducted on non-urgent ED patients age > or = 18. A closed-ended survey was administered by interview. Safety belt use was defined via two methods: a single-item and a multiple-item measure of safety belt use. Each was scored using a 5-point frequency scale. Responses were used to categorize safety belt use as 'always' or less than 'always'. Outcome for multivariate logistic regression analysis was safety belt use less than 'always'. RESULTS: Of 478 patients approached, 381 (80%) participated. Participants were 48% female, 48% African-American, 40% White, median age 39. Among participants, 250 (66%) had been in a car crash; 234 (61%) had a valid driver's license, and 42 (11%) had been ticketed for belt non-use. Using two different survey measures, a single-item and a multiple-item measure, safety belt use 'always' was 51% and 36% respectively. According to separate regression models, factors associated with belt non-use included male gender, alcohol consumption >5 drinks in one episode, riding with others that drink and drive, ever receiving a citation for belt non-use, believing that safety belt use is 'uncomfortable', and that 'I just forget', while 'It's my usual habit' was protective. CONCLUSION: ED patients at an urban hospital in Boston have considerably lower self-reported safety belt use than state or national estimates. An ED-based intervention to increase safety belt use among this hard-to-reach population warrants consideration.