Improving handoffs in the emergency department.

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

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.

Nicotine dependence, motivation to quit, and diagnosis among adult emergency department patients who smoke: a national survey.

Patients in hospital emergency departments smoke more than the general population. Smoking profiles of these patients have largely been characterized in small, single-institution cohorts. Our objective was to survey adult smokers visiting a sample of U.S. emergency departments, as part of a study examining the efficacy of an educational intervention on physicians' knowledge, attitudes, and behavior regarding tobacco control. A convenience sample of patients in eight academic emergency departments was surveyed from May to July 2006. Eligible patients were aged 18 years or older, were every- or some-day smokers, spoke English or Spanish, were able to provide written informed consent, and were not actively psychotic. Descriptive statistics are reported using parametric and nonparametric measures. A total of 1,168 patients were interviewed (mean age = 40.7 years); 46.5% were female, 54.4% were uninsured or had Medicaid, and 29.9% had no usual source of care. Patients smoked a median of 10 cigarettes daily, with a median score on the Fagerstrom Test for Nicotine Dependence of 4, and a median score of 5 on the nine-point contemplation ladder, indicating a desire to quit within 6 months. Smokers with a diagnosis of cardiovascular, respiratory, or malignant disease were more interested in quitting than others (median ladder score = 4 vs. 6, p<.001), were more likely to believe they had a smoking-related illness, and were more likely to believe their emergency department visit was related to smoking. Smokers with a presenting complaint of chest pain or dyspnea were more interested in quitting than others (median ladder score = 4 vs. 6, p = .002). Emergency department patients smoked at moderate amounts, with moderate levels of addiction and interest in quitting. Smokers with tobacco-related diagnoses, or who believed their emergency department visit was related to smoking, were more interested in quitting. These findings suggest that the emergency department visit may provide a teachable moment to reach smokers who have tobacco-related problems.

Blind urethral catheterization in trauma patients suffering from lower urinary tract injuries.

OBJECTIVES: The goals of our study were to review all cases of urethral and bladder trauma that presented to the University of California, Los Angeles (UCLA) Medical Center between January 1998 and August 2005 and determine (1) the clinical characteristics of patients with urethral and/or bladder injuries as well as the sensitivities of those clinical characteristics; (2) whether or not a blind attempt to insert a urethral catheter was performed; and (3) whether there is any evidence that a blind attempt to insert a urethral catheter worsened the initial urinary tract injury. METHODS: This is a retrospective chart review. RESULTS: The study cohort comprised 46 patients with a mean age of 30 years, including 36 men (78.2%) and 10 women (21.8%). Bladder tears were found in 33 patients, 10 patients had urethral lacerations, and 3 patients had combined bladder and urethral lacerations. The most sensitive finding for urinary bladder or urethral injury was the presence of gross hematuria in the urethral catheter (100%, 95% confidence interval [CI] 0.63-0.89). Blinded insertion of a urethral catheter was attempted in 30 (90.9%, 95% CI 0.75-0.98) patients who suffered from urinary bladder injury, 6 (50%, 95% CI 0.26-0.87) patients who suffered from urethral injury and 1 (33%, 95% CI 0.0-0.9) patient who suffered from a combined urinary bladder and urethral injuries. We did not find evidence that a blind attempt to insert a urethral catheter worsened the initial urinary injury. CONCLUSION: Gross hematuria in the urethral catheter was the most sensitive sign for the presence of a urethral or urinary bladder injury in our study cohort, and often the only sign of such an injury. We found no evidence that a blind attempt to insert a urethral catheter in patients suffering from urethral and or urinary bladder injuries worsened the initial injury. Larger studies will be needed to determine the safety of blind urethral catheterization in patients that are suspected to suffer from a lower urological trauma. It is our opinion that the current guidelines should be revised to better reflect the current knowledge, technologies, and clinical practice.

Thermal chemistry of bicyclo[4.2.0]oct-2-enes.

At 300 degrees C, bicyclo[4.2.0]oct-2-ene (1) isomerizes to bicyclo[2.2.2]oct-2-ene (2) via a formal [1,3] sigmatropic carbon migration. Deuterium labels at C7 and C8 were employed to probe for two-centered stereomutation resulting from C1-C6 cleavage and for one-centered stereomutation resulting from C1-C8 cleavage, respectively. In addition, deuterium labeling allowed for the elucidation of the stereochemical preference of the [1,3] migration of 1 to 2. The two possible [1,3] carbon shift outcomes reflect a slight preference for migration with inversion rather than retention of stereochemistry; the si/sr product ratio is approximately 1.4. One-centered stereomutation is the dominant process in the thermal manifold of 1, with lesser amounts of fragmentation and [1,3] carbon migration processes being observed. All of these observations are consistent with a long-lived, conformationally promiscuous diradical intermediate.

Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations.

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations.

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills.

OBJECTIVE: To determine whether full-scale simulation (SIM) is superior to interactive problem-based learning (PBL) for teaching medical students acute care assessment and management skills. DESIGN: Randomized controlled trial. SETTING: Simulation center at a U.S. medical school. SUBJECTS: Thirty-one fourth-year medical students in a week-long acute care course. INTERVENTIONS: After institutional review board approval and informed consent, eligible students were randomized to either the SIM or PBL group. On day 1, all subjects underwent a simulator-based initial assessment designed to evaluate their critical care skills. Two blinded investigators assessed each student using a standardized checklist. Subsequently, the PBL group learned about dyspnea in a standard PBL format. The SIM group learned about dyspnea using the simulator. To equalize simulator education time, the PBL group learned about acute abdominal pain on the simulator, whereas the SIM group used the PBL format. On day 5, each student was tested on a unique dyspnea scenario. MEASUREMENTS AND MAIN RESULTS: Mean initial assessment and final assessment checklist scores and their change for the SIM and PBL groups were compared using the Student's t-test. A p < .05 was considered significant. The SIM and PBL groups had similar mean (PBL 0.44, SIM 0.47, p = .64) initial assessment scores (earned score divided by maximum score) and were deemed equivalent. The SIM group performed better than the PBL group on the final assessment (mean, PBL 0.53, SIM 0.72, p < .0001). When each student's change in score (percent correct on final assessment minus percent correct on the initial assessment) was compared, SIM group students performed better (mean improvement, SIM 25 percentage points vs. PBL 8 percentage points, p < .04) CONCLUSIONS: For fourth-year medical students, simulation-based learning was superior to problem-based learning for the acquisition of critical assessment and management skills.

Thermal reactions of 8-methylbicyclo[4.2.0]oct-2-enes: competitive diradical-mediated [1,3] sigmatropic, stereomutation, and fragmentation processes.

[reaction: see text] At 275 degrees C, 8-exo-methylbicyclo[4.2.0]oct-2-ene (1a) undergoes a [1,3] sigmatropic rearrangement to 5-methylbicyclo[2.2.2]oct-2-enes, of which the orbital symmetry-allowed si product is only marginally favored over the forbidden sr product; that is, si/sr is 2.4. Accompanying the [1,3] shift are significant amounts of epimerization and fragmentation. The 8-endo epimer 1b, which yields no [1,3] product, experiences primarily direct fragmentation and secondarily epimerization. A diradical intermediate can account for all such observations.

Diagnosis and treatment of hypothermia.

Although hypothermia is most common in patients who are exposed to a cold environment, it can develop secondary to toxin exposure, metabolic derangements, infections, and dysfunction of the central nervous and endocrine systems. The clinical presentation of hypothermia includes a spectrum of symptoms and is grouped into the following three categories: mild, moderate, and severe. Management depends on the degree of hypothermia present. Treatment modalities range from noninvasive, passive external warming techniques (e.g., removal of cold, wet clothing; movement to a warm environment) to active external rewarming (e.g., insulation with warm blankets) to active core rewarming (e.g., warmed intravenous fluid infusions, heated humidified oxygen, body cavity lavage, and extracorporeal blood warming). Mild to moderate hypothermia is treated easily with supportive care in most clinical settings and has good patient outcomes. The treatment of severe hypothermia is more complex, and outcomes depend heavily on clinical resources. Prevention and recognition of atypical presentations are essential to reducing the rates of morbidity and mortality associated with this condition.