Oligoantiemesis or Inadequate Prescription of Antiemetics in the Emergency Department: A Local and National Perspective.

BACKGROUND: Nausea and vomiting are common, but prevalence of antiemetic use in ED patients is unknown. OBJECTIVES: We determined the use of antiemetics in emergency department (ED) patients presenting with nausea and vomiting (NV). METHODS: We conducted a retrospective chart review of ED patients presenting to a local ED with NV and analyzed data from the National Hospital Ambulatory Care Survey for similar patients to determine the frequency of administration of antiemetics in the ED. RESULTS: Of 3876 patients presenting to a local ED with NV in 2014, 2637 (68% [95% confidence interval (CI) 67-69%]) received an antiemetic. Of an estimated 11.3 million U.S. ED visits for NV in 2011 (the latest year available), antiemetics were prescribed in 56% (95% CI 53-59%). Females, older patients, and those with vomiting were more likely to receive antiemetics. Use of antiemetics was associated with reduced admissions in the single institution (odds ratio [OR] 0.62, 95% CI 0.52-0.74), but not in the national database (OR 1.08, 95% CI 0.74-1.60). CONCLUSIONS: Many patients presenting with NV do not receive antiemetics while in the ED. Effort should be made to further study and reduce the phenomenon of undertreatment of nausea or vomiting, coined "oligoantiemesis."

Council of Emergency Medicine Residency Directors' standardized letter of recommendation: the program director's perspective.

OBJECTIVES: The standardized letter of evaluation (SLOE) was created in 1997 to provide residency program directors (PDs) with a summative evaluation that incorporates normative grading (i.e., comparisons to peers applying to emergency medicine [EM] training). Although the standard letter of recommendation (SLOR) has become increasingly popular and important in decision-making, it has not been studied in the past 12 years. To assess the SLOR's effectiveness and limitations, the perspective of EM PDs was surveyed in this study. METHODS: After validation of the questionnaire by 10 retired PDs, the survey was sent to the PD of each of the 159 EM residencies that existed at that time. The survey was circulated via the Council of Emergency Medicine Residency Directors' (CORD) listserv from January 24, 2013, to February 13, 2013. Weekly e-mail reminders to all PDs served to increase participation. RESULTS: A total of 150 of 159 PDs (94.3%) completed the questionnaire. Nearly all respondents (149 of 150; 99.3%) agreed that the SLOR is an important evaluative tool and should continue to be used. In the application process, 91 of 150 (60.7%) programs require one or more SLORs, and an additional 55 (36.7%) recommend but do not require a SLOR to be considered for interview. When asked to identify the top three factors in deciding who should be interviewed, the SLOR was ranked first (139 of 150; 92.7%), with EM rotation grades ranked second (73 of 150; 48.7%). The factors that were most often identified as the top three that diminish the value of the SLOR in order were 1) "inflated evaluations" (121 of 146; 82.9%), 2) "inconsistency between comments and grades" (106 of 146; 72.6%), and 3) "inadequate perspective on candidate attributes in the written comments" and "inexperienced authors" (60 of 146; 41.1% each). CONCLUSIONS: The SLOR appears to be the most important tool in the EM PD's armamentarium for determining which candidates should be interviewed for residency training. Although valuable, the SLOR's potential utility is hampered by a number of factors, the most important of which is inflated evaluations. Focused changes in the SLOR template should be mindful that it appears, in general, to be successful in its intended purpose.

Reaction toward a new treatment paradigm for acute otitis media.

OBJECTIVE: Recent evidence suggests that oral antibiotics may not be required in all children with acute otitis media (AOM). We determined whether parents and pediatricians were aware of and comfortable with a policy of selective use of antibiotics for AOM. DESIGN: Descriptive survey. SETTINGS: Suburban academic emergency department, urgent care center, and private pediatric practices. PARTICIPANTS: Parents of children presenting to an emergency department and urgent care center and pediatricians in faculty and private practice. INTERVENTIONS AND OUTCOMES: Parents were asked whether they were aware of any side effects associated with antibiotic use or of research that supports selective use of antibiotics for AOM. Physicians were queried regarding the methods used to diagnose AOM and their patterns of prescribing antibiotics for AOM. Parents and physicians were questioned regarding their comfort with withholding antibiotics for AOM using a 6-point Likert scale ranging from very uncomfortable to very comfortable. RESULTS: Six hundred fifty-four parents and 84 physicians were surveyed. Sixty-one percent of parents were unaware of the potential side effects of antibiotics, and 72% were unaware of research supporting selective use of antibiotics. Fifty-three percent of parents and 73% of physicians were somewhat comfortable to very comfortable with an observation option for AOM. Half of all pediatricians stated that they always prescribe antibiotic for AOM. CONCLUSIONS: Although most parents are unaware of selective use of antibiotics and half of all surveyed pediatricians stated that they always prescribed antibiotics for AOM, many parents and pediatricians felt comfortable with selective use of antibiotics.