Abstract Background On a daily basis, emergency physicians are confronted by patients with devastating neurological injuries and insults. Some of these patients, despite our best efforts, will not ...survive. However, from these tragedies, there may be benefit given to others who are awaiting organ transplantation. Steps taken in the emergency department (ED) can be critical to preserving the option of organ donation in patients whose neurologic insult places them on a potential path to declaration of brain death. Much of the literature on this subject has focused on the utilitarian value of clinical interventions in the potential organ donor to optimize the likelihood of effective organ procurement. Case Presentation In this article, we present an actual case that reveals additional ethical perspectives to consider in how emergency physicians manage patients in the ED who can be confidently predicted to progress to death, as attested by neurologic criteria, and become organ donors. The case involves a patient with a devastating, nonsurvivable intracerebral hemorrhage who rapidly progressed to hemodynamic instability. Discussion This case reveals how the current organ donor referral and maintenance system raises ethical tensions for emergency physicians and ED personnel. Conclusion This process imposes limitations on communication with patient surrogate decision-makers while calling for interventions with the primary purpose of benefiting off-site patients awaiting transplantation.
Abstract Background We sought to identify factors associated with Escherichia coli resistance to ciprofloxacin among discharged emergency department (ED) patient visits treated for a urinary tract ...infection (UTI). We hypothesized that specific historical factors available upon ED presentation would be associated with increased odds of ciprofloxacin resistance in this population. Methods We conducted a retrospective, observational cohort study of consecutive discharged adult ED patient visits with a primary diagnosis of UTI caused by E coli to a single center from 2011 to 2014. Two investigators separately abstracted to a preconstructed data collection form the following independent variables on each included visit: patient age, sex, residence, active immunosuppressive condition or medication, chronic indwelling Foley catheter, hospitalization or antibiotic use within 90 days prior to presentation, and history of recurrent UTIs. We used multivariable logistic regression after taking into account colinearity to identify those independent variables associated with increased odds of ciprofloxacin resistance and report descriptive characteristics of the study cohort, odds ratios (ORs) with 95% confidence interval (CI) and model strength. Results Age at least 65 years (OR, 3.15; 95% CI, 1.44-6.87; P = .004), recurrent UTI (OR, 6.23; 95% CI, 2.38-16.30; P < .001), and recent hospitalization (OR, 3.99; 95% CI, 1.56-10.23; P = .004) were significantly associated with ciprofloxacin-resistant E coli UTIs in relevant visits. Conclusion In this single-center study, age at least 65 years, recurrent UTI, and recent hospitalization were most clearly associated with increased odds of ciprofloxacin-resistant UTIs in discharged adult ED patient visits. If validated, these factors should suggest that alternative antimicrobial agents should be considered in the treatment of this condition among discharged adult ED patients.
A permanent magnet assisted synchronous reluctance generator (PMA-SynRG) and an induction generator (IG) were compared for portable generator applications. PMA-SynRG with two rotor configurations, ...namely rotors with ferrite magnet and NdFeB, were designed. Furthermore, a design strategy for both PMA-SynRG and IG is presented with their geometrical dimensions. The machine was designed and results were analyzed using finite element analysis. Results such as flux density, open circuit and full load voltages, torque in generating mode, weight comparison and detailed cost analysis were investigated. In addition, thermal analysis for various ambient conditions (−40 °C, +30 °C, +65 °C) was evaluated for both PMA-SynRG and IG. Furthermore, acoustic versus frequency plot and acoustic pressure level were investigated for both the generators. Finally, the results confirmed that the machine with a higher power-to-weight ratio was the right choice for military applications.
Abstract Objective We sought to determine whether racial disparities exist in emergency physician professional services reimbursement from insurance. We hypothesized that insured adult African ...American emergency department (ED) visits are reimbursed at a lower level than White visits. Methods We conducted a retrospective, observational cohort study of insured adult White and African American ED visits (January 1, 2012, to June 30, 2013) to a tertiary center. We downloaded for each included visit age, sex, race, residential zip code, insurance type, admission status, Current Procedural Terminology ( CPT ) Evaluation and Management (E/M) code charge reimbursement, and median household income for residential zip code. We chose as our primary outcome measure visit mean total insurance reimbursement/work relative value unit (wRVU). We report racial variation for this outcome measure with 95% confidence intervals (CI) and present the β coefficient related to African American race within a multivariable regression model. Results A total of 50 297 visits met inclusion criteria (35 574 Whites and 14 723 African Americans). Overall, mean total insurance reimbursement/wRVU for White visits was $39.99 (95% CI, 39.80-40.18), for African American visits, $34.15 (95% CI, 33.88-34.42); P < .01. At the CPT E/M code level, African American visit reimbursement was lower than for White visits, ranging from $2.18/wRVU (95% CI, 0.87-3.49) (99282) to $7.55/wRVU (95 CI, 6.52-8.58) (99285). At the primary insurance level, African American visits showed lower reimbursement than White visits, ranging from $1.70/wRVU (95% CI, 0.75-2.65) in commercial insurance to $7.70/wRVU (95% CI, 5.42-9.98) in other insurance. Within the multivariable regression model, the β coefficient for African American race was −$1.51/wRVU (95% CI, −1.85 to −1.18); P < .001. Conclusion In this single-center study, professional services reimbursement was lower for African American ED visits compared with those of Whites.
Abstract Objective Our objective was to identify demographic, clinical, and operational variables associated with discrepancy between point-of-care (POC) and central laboratory international ...normalized ratio (INR) results in emergency department (ED) patients with acute cerebrovascular disease. Methods We conducted a retrospective, observational cohort study of a series of 637 patients with acute cerebrovascular disease over 30 months who underwent simultaneous POC, using the i-STAT POC analyzer (Abbott, Princeton, NJ), and central laboratory INR testing at ED presentation. Point-of-care INR results greater than ± 0.25 INR units from the central laboratory INR value were considered discrepant. We analyzed potential predictors of POC INR discrepancy from demographic, clinical, and operational variables using multivariable logistic regression. We evaluated the change in POC INR discrepancy incidence over the study interval using analysis of variance methodology. Results The final diagnoses of the 637 subjects were acute ischemic stroke (n = 427), transient ischemic attack (n = 105), and intracranial hemorrhage (n = 105). Discrepant POC INR results occurred in 21.5% (137/637) of subjects. The mean bias between POC and central laboratory INR was 0.24 ± 0.69 (range, 0-11.3). Significant covariates of POC INR discrepancy were oral anticoagulant use (odds ratio, 3.03; confidence interval, 1.37-6.68) and increasing activated partial thromboplastin time (aPTT) (odds ratio, 1.07; confidence interval, 1.02-1.12). We observed a significant reduction trend in the incidence of POC-central laboratory discrepancy over the study period, decreasing on average at 0.42% per month ( F = 5.59, P = .025). Conclusion In this retrospective study, oral anticoagulant use and increasing aPTT were significantly associated with POC INR discrepancy in ED patients with acute cerebrovascular disease. Point-of-care INR discrepancy incidence decreased over the study interval.
With the aging of the general population and the ability of intensivists to support patients using ventilator support, tracheostomy has become a vital tool in the medical management of critically ill ...patients. While much of the medical literature on tracheostomy has focused on the optimal timing of and indications for performing this procedure, little is written on the ethical tensions that can revolve around decisions by patients, surrogates, and physicians on its use.This article will elucidate the ethical dilemmas that can arise surrounding the use of tracheostomy in critically ill patients and how ethics consultants and committees can approach these cases to allow resolution.
Abstract Introduction Patients intubated in the emergency department (ED) often have extended ED stays. We hypothesize that ED intubated patients receive inadequate postintubation anxiolysis and ...analgesia after rapid sequence induction (RSI). Methods This was a retrospective cohort study of every adult intubated in a tertiary-care ED (July 2003-June 2004). Patients were included if they underwent RSI, remained in the ED for more than 30 minutes post intubation, and survived to admission. Presuming a mean patient weight of 70 kg, we defined adequacy of anxiolysis and analgesia on the provision postintubation of weight-based doses of lorazepam (0.77 mg/h) or midazolam (4.2 mg/h) and fentanyl (35 μ g/h), referenced from pharmaceutical texts. Demographic data, time in ED, and dosage of each medication given were abstracted. The proportion, with 95% confidence intervals (CIs), of patients receiving inadequate anxiolysis and analgesia were computed. Results One hundred seventeen patients met the inclusion criteria. Mean time in the ED was 4.2 hours (SD ± 3.1 hours). Thirty-nine patients received no anxiolytic (33%, CI 25%-43%), and 62 received no analgesic (53%, CI 44%-62%). Twenty-three patients received neither anxiolytic nor analgesic (20%, CI 13%-28%). Of 70 patients given postintubation vecuronium, 67 received either no or inadequate anxiolysis or analgesia (96%, CI 87%-99%). Overall, 87 of 117 patients received no or inadequate anxiolysis (74%, CI 65%-82%); and 88 of 117 received no or inadequate analgesia (75%, CI 66%-83%). Conclusion Patients undergoing RSI in the ED frequently receive inadequate postintubation anxiolysis and analgesia.
Abstract Objectives We sought to identify factors increasing the odds of ED utilization among intellectually disabled (ID) adults and differentiate their discharge diagnoses from the general adult ED ...population. Methods This was a retrospective, observational open cohort study of all ID adults residing at an intermediate care facility and their ED visits to a tertiary center (January 1, 2007–July 30, 2008). We abstracted from the intermediate care facility database subjects' demographic, ID, health and adaptive status variables, and their requirement of ED care/hospitalization. We obtained from the hospital database the primary International Classification of Diseases 9 ED/hospital discharge diagnoses for the study and general adult population. Using multivariate logistic regression, we computed odds ratios (OR) for ED utilization/hospitalization in the cohort. Using the conditional large-sample binomial test, we differentiated the study and general populations' discharge diagnoses. Results A total of 433 subjects met the inclusion criteria. Gastrostomy/jejunostomy increased the odds of ED utilization (OR, 4.16; confidence interval CI, 1.64-10.58). Partial help to feed (OR, 2.59; CI, 1.14-5.88), gastrostomy/jejunostomy (OR, 3.26; CI, 1.30-8.18), and increasing number of prescribed medications (OR, 1.08; CI, 1.03-1.14) increased the odds of hospitalization. Auditory impairment (OR, 0.45; CI, 0.23-0.88) decreased the odds of hospitalization. For ED discharge diagnoses, ID adults were more likely ( P < .05) than the general population to have diagnoses among digestive disorders and ill-defined symptoms/signs. For hospital discharge diagnoses, ID adults were more likely ( P < .05) to have diagnoses among infectious/parasitic, nervous system, and respiratory disorders. Conclusion Among ID adults, feeding status increased the odds of ED utilization, feeding status, and increasing number of prescribed medications of that hospitalization. Intellectually disabled adults' discharge diagnoses differed significantly from the general adult ED population.
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