Consensus guidelines recommend sepsis screening for adults with systemic inflammatory response syndrome (SIRS), but the epidemiology of SIRS among adult emergency department (ED) patients is poorly ...understood. Recent emphasis on cost-effective, outcomes-based healthcare prompts the evaluation of the performance of large-scale efforts such as sepsis screening. We studied a nationally representative sample to clarify the epidemiology of SIRS in the ED and subsequent category of illness.
This was a retrospective analysis of ED visits by adults from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey (NHAMCS). We estimated the incidence of SIRS using initial ED vital signs and a Bayesian construct to estimate white blood cell count based on test ordering. We report estimates with Bayesian modified credible intervals (mCIs).
We used 103,701 raw patient encounters in NHAMCS to estimate 372,844,465 ED visits over the 4-year period. The moderate estimate of SIRS in the ED was 17.8% (95% mCI: 9.7 to 26%). This yields a national moderate estimate of approximately 16.6 million adult ED visits with SIRS per year. Adults with and without SIRS had similar demographic characteristics, but those with SIRS were more likely to be categorized as emergent in triage (17.7% versus 9.9%, p<0.001), stay longer in the ED (210 minutes versus 153 minutes, p<0.0001), and were more likely to be admitted (31.5% versus 12.5%, p<0.0001). Infection accounted for only 26% of SIRS patients. Traumatic causes of SIRS comprised 10% of presentations; other traditional categories of SIRS were rare.
SIRS is very common in the ED. Infectious etiologies make up only a quarter of adult SIRS cases. SIRS may be more useful if modified by clinician judgment when used as a screening test in the rapid identification and assessment of patients with the potential for sepsis. West J Emerg Med. 2014;15(3):329-336..
Purpose: The use of computed tomography (CT) to evaluate acute abdominal complaints has increased over the past two decades. We investigated how the clinical practice of patients with intestinal ...perforation has changed with the increasing use of abdominal CT in the emergency department (ED).
Methods: We compared ED arrival to CT time, ED arrival to surgical consultation time, and ED arrival to operation time according to the method of diagnosis from 2003-2004 and 2013-2014.
Results: In patients with gastrointestinal perforation, time from ED arrival to CT was shorter (111.4±66.2 min vs. 199.0±97.5 min, p=0.001) but time to surgical consultation was longer (135.1±78.8 vs. 77.9±123.7, p=0.006) in 2013-2014 than in 2003-2004. There was no statistically significant difference in time to operation for perforation confirmed either by plain film or CT between the two time periods. There was no statistically significant difference in length of hospital or ICU stay or mortality between the two groups.
Conclusion: With the increasing use of abdominal CT in ED, ED arrival to CT time has decreased and ED arrival to surgical consultation time has increased in gastrointestinal perforation. These changes of clinical performance do not delay ED arrival to operation time or adversely influence patient outcome. J Trauma Inj 2017; 30: 25-32
Simulation has been identified as a means of assessing resident physicians' mastery of technical skills, but there is a lack of evidence for its utility in longitudinal assessments of residents' ...non-technical clinical abilities. We evaluated the growth of crisis resource management (CRM) skills in the simulation setting using a validated tool, the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS). We hypothesized that the Ottawa GRS would reflect progressive growth of CRM ability throughout residency.
Forty-five emergency medicine residents were tracked with annual simulation assessments between 2006 and 2011. We used mixed-methods repeated-measures regression analyses to evaluate elements of the Ottawa GRS by level of training to predict performance growth throughout a 3-year residency.
Ottawa GRS scores increased over time, and the domains of leadership, problem solving, and resource utilization, in particular, were predictive of overall performance. There was a significant gain in all Ottawa GRS components between postgraduate years 1 and 2, but no significant difference in GRS performance between years 2 and 3.
In summary, CRM skills are progressive abilities, and simulation is a useful modality for tracking their development. Modification of this tool may be needed to assess advanced learners' gains in performance.
If no mass is appreciated, then the child likely has a communicating hydrocele due to a patent processus vaginalis, which is likely to develop into a hernia. ...the child will need elective repair. ...Reducible hernias will incarcerate while awaiting elective repair in 10% of normal infants, and approximately 30% of premature infants. ...some centres admit infants for expedited repair, which is different than in adults.
...called the lung recruitment manoeuvre, prone positioning in mechanically ventilated patients optimises functional residual capacity, redistributes blood flow (minimizes V-Q mismatch), aids in ...diaphragm excursion and improves secretion removal. Table 1 Grade Neurologic status 1 Asymptomatic or mild headache and slight nuchal rigidity 2 Severe headache, stiff neck, no neurologic deficit except cranial nerve palsy 3 Drowsy or confused, mild focal neurologic deficit 4 Stupor, moderate or severe hemiparesis 5 Coma, decerebrate posturing Hunt-Hess grades 1 and 2 have good survival rates, but grade 3 and above have >50% mortality.
High-fidelity patient simulation has been praised for its ability to recreate lifelike training conditions. The degree to which high fidelity simulation elicits acute emotional and physiologic stress ...among participants - and the influence of acute stress on clinical performance in the simulation setting - remain areas of active exploration. We examined the relationship between residents' self-reported anxiety and a proxy of physiologic stress (heart rate) as well as their clinical performance in a simulation exam using a validated assessment of non-technical skills, the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS).
This was a prospective observational cohort study of emergency medicine residents at a single academic center. Participants managed a simulated clinical encounter. Anxiety was assessed using a pre- and post-simulation survey, and continuous cardiac monitoring was performed on each participant during the scenario. Performance in the simulation scenario was graded by faculty raters using a critical actions checklist and the Ottawa GRS instrument.
Data collection occurred during the 2011 academic year. Of 40 eligible residents, 34 were included in the analysis. The median baseline heart rate for participants was 70 beats per minute (IQR: 62 - 78). During the simulation, the median maximum heart rate was 140 beats per minute (IQR: 137 - 151). The median minimum heart rate during simulation was 81 beats per minute (IQR: 72 - 92), and mean heart rate was 117 beats per minute (95% CI: 111 - 123). Pre- and post-simulation anxiety scores were equal (mean 3.3, IQR: 3 to 4). The minimum and maximum Overall Ottawa GRS scores were 2.33 and 6.67, respectively. The median Overall score was 5.63 (IQR: 5.0 to 6.0). Of the candidate predictors of Overall performance in a multivariate logistic regression model, only PGY status showed statistical significance (P = 0.02).
Simulation is associated with physiologic stress, and heart rate elevation alone correlates poorly with both perceived stress and performance. Non-technical performance in the simulation setting may be more closely tied to one's level of clinical experience than to perceived or actual stress.
Emergency Medical Services Utilization by Children Dayal, Parul; Horeczko, Timothy; Wraa, Cheryl ...
Pediatric emergency care,
2019-December, 2019-Dec, 2019-12-00, 20191201, Volume:
35, Issue:
12
Journal Article
Peer reviewed
OBJECTIVEThe aim of this study was to compare demographic and clinical features of children (0–14 years old) who arrived at general emergency departments (EDs) by emergency medical services (EMS) to ...those who arrived by private vehicles and other means in a rural, 3-county region of northern California.
METHODSWe reviewed 507 ED records of children who arrived at EDs by EMS and those who arrived by other means in 2013. We also analyzed prehospital procedures performed on all children transported to an area hospital by EMS.
RESULTSChildren arriving by EMS were older (9.0 vs 6.0 years; P < 0.001), more ill (mean Severity Classification Score, 2.9 vs 2.4; P < 0.001), and had longer lengths of stay (3.6 vs 2.1 hours; P < 0.001) compared with children who were transported to the EDs by other means. Children transported by EMS received more subspecialty consultations (18.7% vs 6.9%; P < 0.05) and had more diagnostic testing, including laboratory testing (22.9% vs 10.6%; P < 0.001), radiography (39.7% vs 20.8%; P < 0.001), and computed tomography scans (16.8% vs 2.9%; P < 0.001). Children arriving by EMS were transferred more frequently (8.8% vs 1.6%; P < 0.001) and had higher mean Severity Classification Scores compared with children arriving by other transportation even after adjusting for age and sex (β = 0.48; 95% confidence interval, 0.35–0.61; P < 0.001). Older children received more prehospital procedures compared with younger children, and these were of greater complexity and a wider spectrum.
CONCLUSIONSChildren transported to rural EDs via EMS are more ill and use more medical resources compared with those who arrive to the ED by other means of transportation.
Background
Subdissociative‐dose ketamine (SDDK) is used to treat acute pain. We sought to determine if SDDK is effective in relieving acute exacerbations of chronic pain.
Methods
This study was a ...randomized double‐blind placebo‐controlled trial conducted May 2017 to June 2018 at a public teaching hospital (ClinicalTrials.gov #NCT02920528). The primary endpoint was a 20‐mm decrease on a 100‐mm visual analog scale (VAS) at 60 minutes. Power analysis using three groups (0.5 mg/kg ketamine, 0.25 mg/kg ketamine, or placebo infused over 20 minutes) estimated that 96 subjects were needed for 90% power. Inclusion criteria included age > 18 years, chronic pain > 3 months, and acute exacerbation (VAS ≥ 70 mm). Pain, agitation, and sedation were assessed by VAS at baseline and 20, 40, and 60 minutes after initiation of study drug. Telephone follow‐up at 24 to 48 hours used a 10‐point numeric rating scale for pain.
Results
A total of 106 subjects were recruited, with three excluded for baseline pain < 70 mm. After randomization, 35 received 0.5 mg/kg ketamine, 36 received 0.25 mg/kg ketamine, and 35 received placebo. Three subjects receiving 0.5 mg/kg withdrew during the infusion due to adverse effects, and one subject in each group had incomplete data, leaving 97 for analysis. Initial pain scores (91.9 ± 8.9 mm), age (46.5 ± 12.6 years), sex distribution, and types of pain reported were similar. Primary endpoint analysis found that 25 of 30 (83%) improved with 0.5 mg/kg ketamine, 28 of 35 (80%) with 0.25 mg/kg ketamine, and 13 of 32 (41%) with placebo (p = 0.001). More adverse effects occurred in the ketamine groups with one subject in the 0.25 mg/kg group requiring a restraint code for agitation. A total of 89% of subjects were contacted at 24 to 48 hours, and no difference in pain level was detected between groups.
Conclusion
Ketamine infusions at both 0.5 and 0.25 mg/kg over 20 minutes were effective in treating acute exacerbations of chronic pain but resulted in more adverse effects compared to placebo. Ketamine did not demonstrate longer‐term pain control over the next 24 to 48 hours.
Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services ...for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.
Pediatric Readiness in the Emergency Department Remick, Katherine; Gausche-Hill, Marianne; Joseph, Madeline M. ...
Annals of emergency medicine,
December 2018, 2018-12-00, 20181201, Volume:
72, Issue:
6
Journal Article
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