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Hsieh YH, Jung JJ, Shahan JB, Moring-Parris D, Kelen GD, Rothman RE. Emergency medicine resident attitudes and perceptions of HIV testing before and after a focused training program and testing implementation. Acad Emerg Med 2009; 16:1165-73. [PMID: 20053237 DOI: 10.1111/j.1553-2712.2009.00507.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives were to determine attitudes and perceptions (A&P) of emergency medicine (EM) residents toward emergency department (ED) routine provider-driven rapid HIV testing services and the impact of both a focused training program (FTP) and implementation of HIV testing on A&P. METHODS A three-phase, consecutive, anonymous, identity-unlinked survey was conducted pre-FTP, post-FTP, and 6 months postimplementation. The survey was designed to assess residents' A&P using a five-point Likert scale. A preimplementation FTP provided both the rationale for the HIV testing program and the planned operational details of the intervention. The HIV testing program used only indigenous ED staff to deliver HIV testing as part of standard-of-care in an academic ED. The impact of the FTP and implementation on A&P were analyzed by multivariate regression analysis using generalized estimating equations to control for repeated measurements in the same individuals. A "favorable" A&P was operationally defined as a mean score of >3.5, "neutral" as mean score of 2.5 to 3.5, and "unfavorable" as mean score of <2.5. RESULTS Thirty of 36 residents (83.3%) participated in all three phases. Areas of favorable A&P found in phase I and sustained through phases II and III included "ED serving as a testing venue" (score range = 3.7-4.1) and "emergency medicine physicians offering the test" (score range = 3.9-4.1). Areas of unfavorable and neutral A&P identified in phase I were all operational barriers and included required paperwork (score = 3.2), inadequate staff support (score = 2.2), counseling and referral requirements (score range = 2.2-3.1), and time requirements (score = 2.9). Following the FTP, significant increases in favorable A&P were observed with regard to impact of the intervention on modification of patient risk behaviors, decrease in rates of HIV transmission, availability of support staff, and self-confidence in counseling and referral (p < 0.05). At 6 months postimplementation, all A&P except for time requirements and lack of support staff scored favorably or neutral. During the study period, 388 patients were consented for and received HIV testing; six (1.5%) were newly confirmed HIV positive. CONCLUSIONS Emergency medicine residents conceptually supported HIV testing services. Most A&P were favorably influenced by both the FTP and the implementation. All areas of negative A&P involved operational requirements, which may have influenced the low overall uptake of HIV testing during the study period.
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Hoffmann B, Um P, Bessman ES, Ding R, Kelen GD, McCarthy ML. Routine screening for asymptomatic abdominal aortic aneurysm in high-risk patients is not recommended in emergency departments that are frequently crowded. Acad Emerg Med 2009; 16:1242-50. [PMID: 20053243 DOI: 10.1111/j.1553-2712.2009.00502.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objectives were to examine the feasibility of offering abdominal aortic aneurysm (AAA) screening to consecutive, asymptomatic high-risk patients in a busy emergency department (ED) and to compare the prevalence of undetected AAA among ED patients to the prevalence among similarly aged men from the general population. METHODS A prospective cohort study was conducted at an academic community ED with an annual census of 58,000 patients. Dedicated study coordinators attempted to approach all consecutive male ED patients >50 years who presented in June-August 2007 during hours of high patient volume. To be eligible, older males had to have a smoking history or a family history of AAA. Patients were excluded if they presented with AAA symptoms, had a previous history of AAA screening or repair, had hemodynamic instability, or had an altered mental status. Study coordinators completed a brief interview with all enrolled subjects to obtain demographic and health information. A credentialed ED provider performed the ultrasound (US) screening exam and documented all findings. The US director reviewed representative images of the sonographic exam for correct visualization and measurement during quality assurance. The ED sonographers also completed a survey regarding their attitudes toward AAA screening in the ED. The primary study outcomes were the feasibility of AAA screening in the ED (screening rate, enrollment rate, US success rate, and providers' opinions) and the prevalence of AAA (aortic diameter of > or =3.0 cm) in the study sample. RESULTS During the 12-week study period, the study coordinators successfully approached 96% (700/729) of males > 50 years who were in the ED during study enrollment hours. Of those approached, 278 were eligible (40%), 25% were ineligible, 20% were not at high risk, and for 15% we could not determine risk factor status because of altered mental status. Of the 278 eligible, 196 (70%) underwent an US exam; 10% were not scanned because the providers were too busy, and 20% declined participation. Of those scanned, the ED sonographer was able to completely visualize and correctly measure the abdominal aortas of 71% of subjects. The prevalence rate of AAA in the study sample was 5.7% (95% confidence interval [CI] = 1.9% to 9.6%), similar to reported rates of 6 or 7% in other studies. More than half of the ED sonographers reported that US screening for AAA improved the quality of ED care (58%) and patient satisfaction (63%). However, 47% reported that AAA screening reduced ED efficiency, and 74% felt that the ED was not an appropriate setting for routine AAA screening. CONCLUSIONS Routine screening for asymptomatic AAA required substantial ED resources for a relatively low success rate of completed screens. The prevalence rate of AAA in our ED sample was not significantly different than prevalence estimates obtained from older men in the general population. ED sonographers reported benefits of screening in terms of improving the quality of emergency care and patient satisfaction, but also reported that it reduced operational efficiency. For EDs that have problems with crowding, we do not recommend implementing a routine screening program for AAA, even among high-risk patients.
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Morton MJ, Kirsch TD, Rothman RE, Byerly MM, Hsieh YH, McManus JG, Kelen GD. Pandemic influenza and major disease outbreak preparedness in US emergency departments: a survey of medical directors and department chairs. Am J Disaster Med 2009; 4:199-206. [PMID: 19860162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
STUDY OBJECTIVES To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. METHODS, DESIGN, AND SETTING: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, chi2, and ANOVA. PARTICIPANTS ED medical directors and department chairs. RESULTS One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (= 30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak. CONCLUSIONS Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics.
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Kelen GD, Rothman RE. Emergency department-based HIV testing: too little, but not too late. Ann Emerg Med 2009; 54:65-71. [PMID: 19398241 DOI: 10.1016/j.annemergmed.2009.03.027] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 03/26/2009] [Accepted: 03/30/2009] [Indexed: 11/19/2022]
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Marco CA, Bessman ES, Kelen GD. Ethical issues of cardiopulmonary resuscitation: comparison of emergency physician practices from 1995 to 2007. Acad Emerg Med 2009; 16:270-3. [PMID: 19183108 DOI: 10.1111/j.1553-2712.2008.00348.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objectives were to determine current practice among emergency physicians (EPs) regarding the initiation and termination of cardiopulmonary resuscitative (CPR) efforts and to compare responses to those from a similar study performed in 1996. METHODS This anonymous self-administered survey was mailed to 4,991 randomly selected EPs. Main outcome measures included responses regarding current practices related to advance directives and initiation and termination of resuscitative attempts. Results from 1995 and 2007 surveys were compared, using 95% confidence intervals (CIs) of the difference between groups. RESULTS Among 928 respondents (18% response rate), most (86%) honor legal advance directives, an increase over 78% reported in 1996 (8% increase, 95% CI = 5% to 11%). Few honor unofficial documents (7%) or verbal reports (12%) of advance directives. Many (58%) make decisions regarding resuscitation because of fear of litigation or criticism. Most respondents (62%) attempt resuscitation in 10% or more of cases of cardiac arrest. A majority (56%) have attempted more than 10 resuscitations in the past 3 years, despite expectations that such efforts would be futile. Factors reported to be "very important" in making resuscitation decisions were advance directives (78%), witnessed arrest (77%), downtime (73%), family wishes (40%), presenting rhythm (38%), age (28%), and prearrest state of health (25%). A significant majority of respondents (80%) indicated that ideally, legal concerns should not influence physician practices regarding resuscitation, but that in the current environment, legal concerns do influence practice (92%). Other than the increase in respondents who honor legal advance directives, these results do not differ substantially from responses in 1996. CONCLUSIONS Most EPs attempt to resuscitate patients in cardiopulmonary arrest regardless of poor outcomes, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than professional judgment of medical benefit. Most results did not differ significantly from the previous study of 1995, although more physicians honor legal advance directives than previously noted.
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Lyons MS, Lindsell CJ, Haukoos JS, Almond G, Brown J, Calderon Y, Couture E, Merchant RC, White DAE, Rothman RE, Aldridge C, Almond G, Andrade G, Arbelaez C, Archinard TM, Aronin SI, Barrera S, Bateganya M, Bell-Merriam J, Bongiovanni B, Brady K, Branson B, Brosgart C, Brown J, Cadoff E, Calderon Y, Chaille-Arnold L, Cheng B, Chiang W, Copeland B, Cousar RL, Couture E, Czarnogorski M, Delgado K, Erbelding E, Feldman J, Garcia O, Gaydos CA, Glick N, Gripshover B, Haukoos J, Hayes A, Heffelfinger J, Herrera L, Hilley A, Holtgrave D, Hoots B, Hopkins E, Houry D, Howell D, Hsieh YH, Hutchinson AB, Jackson B, Jaker M, Jones K, Jung J, Kampe L, Kan V, Kass N, Kelen GD, Kroc K, Kurth A, Lampe MA, Leider J, Lemanski M, Lindsell CJ, Lyons M, McGovern S, Mercer S, Merchant R, Miertschin N, Miller J, Mitchell P, Nelson S, Onaga L, Paltiel D, Paul S, Pollack H, Raffanti S, Randall L, Rothman R, Sabreen A, Sankoff J, Sasso V, Saylor NB, Schechter E, Schechtman B, Schrantz S, Scribner A, Shahan J, Skiest D, Spielberg F, Stennett IS, Sullivan P, Teahan C, Thompson S, Torres G, Totten V, Wagner K, Walensky R, Waxman M, Weddle A, White D, Widell T, Wilde JA, Wrenn K, Yonek J. Nomenclature and definitions for emergency department human immunodeficiency virus (HIV) testing: report from the 2007 conference of the National Emergency Department HIV Testing Consortium. Acad Emerg Med 2009; 16:168-77. [PMID: 19076107 PMCID: PMC3173973 DOI: 10.1111/j.1553-2712.2008.00300.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early diagnosis of persons infected with human immunodeficiency virus (HIV) through diagnostic testing and screening is a critical priority for individual and public health. Emergency departments (EDs) have an important role in this effort. As EDs gain experience in HIV testing, it is increasingly apparent that implementing testing is conceptually and operationally complex. A wide variety of HIV testing practice and research models have emerged, each reflecting adaptations to site-specific factors and the needs of local populations. The diversity and complexity inherent in nascent ED HIV testing practice and research are associated with the risk that findings will not be described according to a common lexicon. This article presents a comprehensive set of terms and definitions that can be used to describe ED-based HIV testing programs, developed by consensus opinion from the inaugural meeting of the National ED HIV Testing Consortium. These definitions are designed to facilitate discussion, increase comparability of future reports, and potentially accelerate wider implementation of ED HIV testing.
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Scheulen JJ, Thanner MH, Hsu EB, Latimer CK, Brown J, Kelen GD. Electronic Mass Casualty Assessment and Planning Scenarios (EMCAPS): Development and Application of Computer Modeling to Selected National Planning Scenarios for High-Consequence Events. Ann Emerg Med 2009; 53:226-232. [DOI: 10.1016/j.annemergmed.2008.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Revised: 08/19/2008] [Accepted: 09/16/2008] [Indexed: 11/30/2022]
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Pham JC, Story JL, Hicks RW, Shore AD, Morlock LL, Cheung DS, Kelen GD, Pronovost PJ. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med 2008; 40:485-92. [PMID: 18823735 DOI: 10.1016/j.jemermed.2008.02.059] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 02/19/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. STUDY OBJECTIVE To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. METHODS A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. RESULTS There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time. CONCLUSION ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.
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McCarthy ML, Zeger SL, Ding R, Aronsky D, Hoot NR, Kelen GD. The challenge of predicting demand for emergency department services. Acad Emerg Med 2008; 15:337-46. [PMID: 18370987 DOI: 10.1111/j.1553-2712.2008.00083.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective was to develop methodology for predicting demand for emergency department (ED) services by characterizing ED arrivals. METHODS One year of ED arrival data from an academic ED were merged with local climate data. ED arrival patterns were described; Poisson regression was selected to represent the count of hourly ED arrivals as a function of temporal, climatic, and patient factors. The authors evaluated the appropriateness of prediction models by whether the data met key Poisson assumptions, including variance proportional to the mean, positive skewness, and absence of autocorrelation among hours. Model accuracy was assessed by comparing predicted and observed histograms of arrival counts and by how frequently the observed hourly count fell within the 50 and 90% prediction intervals. RESULTS Hourly ED arrivals were obtained for 8,760 study hours. Separate models were fit for high- versus low-acuity patients because of significant arrival pattern differences. The variance was approximately equal to the mean in the high- and low-acuity models. There was no residual autocorrelation (r = 0) present after controlling for temporal, climatic, and patient factors that influenced the arrival rate. The observed hourly count fell within the 50 and 90% prediction intervals 50 and 90% of the time, respectively. The observed histogram of arrival counts was nearly identical to the histogram predicted by a Poisson process. CONCLUSIONS At this facility, demand for ED services was well approximated by a Poisson regression model. The expected arrival rate is characterized by a small number of factors and does not depend on recent numbers of arrivals.
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Kelen GD. Public health initiatives in the emergency department: not so good for the public health? Acad Emerg Med 2008; 15:194-7. [PMID: 18275451 DOI: 10.1111/j.1553-2712.2008.00068.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hsu EB, Casani JA, Romanosky A, Millin MG, Singleton CM, Donohue J, Feroli ER, Rubin M, Subbarao I, Whyne DM, Snodgrass TD, Kelen GD. Critical assessment of statewide hospital pharmaceutical surge capabilities for chemical, biological, radiological, nuclear, and explosive incidents. Prehosp Disaster Med 2007; 22:214-8. [PMID: 17894215 DOI: 10.1017/s1049023x00004696] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION In recent years, government and hospital disaster planners have recognized the increasing importance of pharmaceutical preparedness for chemical, biological, radiological, nuclear, and explosive (CBRNE) events, as well as other public health emergencies. The development of pharmaceutical surge capacity for immediate use before support from the (US) Strategic National Stockpile (SNS) becomes available is integral to strengthening the preparedness of local healthcare networks. METHODS The Pharmaceutical Response Project served as an independent, multidisciplinary collaboration to assess statewide hospital pharmaceutical response capabilities. Surveys of hospital pharmacy directors were conducted to determine pharmaceutical response preparedness to CBRNE threats. RESULTS All 45 acute care hospitals in Maryland were surveyed, and responses were collected from 80% (36/45). Ninety-two percent (33/36) of hospitals had assessed pharmaceutical inventory with respect to biological agents, 92% (33/36) for chemical agents, and 67% (24/36) for radiological agents. However, only 64% (23/36) of hospitals reported an additional dedicated reserve supply for biological events, 67% (24/36) for chemical events, and 50% (18/36) for radiological events. More than 60% of the hospitals expected to receive assistance from the SNS within < or = 48 hours. CONCLUSIONS From a pharmaceutical perspective, hospitals generally remain under-prepared for CBRNE threats and many expect SNS support before it realistically would be available. Collectively, limited antibiotics and other supplies are available to offer prophylaxis or treatment, suggesting that hospitals may have insufficient pharmaceutical surge supplies for a large-scale event. Although most state hospitals are improving pharmaceutical surge capabilities, further efforts are needed.
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McCarthy ML, Shore AD, Li G, New J, Scheulen JJ, Tang N, Collela R, Kelen GD. Likelihood of reroute during ambulance diversion periods in central Maryland. PREHOSP EMERG CARE 2007; 11:408-15. [PMID: 17907025 DOI: 10.1080/10903120701536891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To determine the proportion of patients rerouted during ambulance diversion periods and factors associated with reroute. METHODS A retrospective cohort design was used to examine reroute practices of prehospital providers in central Maryland in 2000. Ambulance transport and diversion data were merged to identify transports that occurred during diversion periods. The proportion of patients rerouted when the closest hospital was on diversion was determined. Generalized estimating equation modeling identified patient, transport, and hospital factors that influenced the likelihood of reroute. RESULTS Central Maryland hospitals were on diversion 25% of the time in 2000, although it varied by hospital (range of 1-34%). There were 128,165 transports during the study period, of which 18,633 occurred when the closest hospital was on diversion. Of these, only 23% were rerouted. More than half of all transports during a diversion period (53%) occurred when multiple neighboring hospitals were also on diversion. The factors that influenced the likelihood of reroute the most were hospital-related factors. Large volume hospitals and hospitals that spent more time on diversion were less likely to have transports rerouted to them. CONCLUSIONS Rerouted transports more frequently go to lower volume, less busy hospitals. However, only a small proportion of patients were rerouted. Prehospital providers have limited options because often when one hospital is on diversion, other nearby hospitals are as well. Although ambulance diversion may be an important signal of hospital distress, in this region it infrequently resulted in its intended outcome, rerouting patients to less crowded facilities.
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Pham JC, Kelen GD, Pronovost PJ. National study on the quality of emergency department care in the treatment of acute myocardial infarction and pneumonia. Acad Emerg Med 2007; 14:856-63. [PMID: 17898249 DOI: 10.1197/j.aem.2007.06.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To measure the quality of emergency department (ED) care for patients with acute myocardial infarction (AMI) and pneumonia (PNA) and to estimate the number of preventable deaths in these patients. METHODS The authors performed a cross sectional study of ED visits with the diagnosis of AMI or PNA from 1998 to 2004. Data from the National Hospital Ambulatory Medical Care Survey were used. The study involved 544 EDs across the United States. The authors measured the proportion of patients receiving recommended therapies for AMI (aspirin and beta-blockers [BBs]) and PNA (appropriate antibiotics and pulse oximetry). The excess deaths associated with current care were estimated. RESULTS Aspirin was administered to 40% and BBs to 17% of patients with AMI. Recommended antibiotics were administered to 69% and pulse oximetry was measured in 46% of patients with PNA. During the study period, the percentage receiving BBs and recommended antibiotics increased. There were more than 2.7 million opportunities to improve care and 22,000 excess deaths per year associated with current treatment of AMI and PNA. CONCLUSIONS Quality of care in the ED management of AMI and PNA is below national goals. This deficiency accounts for significant preventable deaths.
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Li G, Lau JT, McCarthy ML, Schull MJ, Vermeulen M, Kelen GD. Emergency department utilization in the United States and Ontario, Canada. Acad Emerg Med 2007; 14:582-4. [PMID: 17470903 DOI: 10.1197/j.aem.2007.02.030] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The current crisis in the emergency care system is characterized by worsening emergency department (ED) overcrowding. Lack of health insurance is widely perceived to be a major contributing factor to ED overcrowding in the United States. This study aimed to compare ED visit rates in the United States and Ontario, Canada, according to demographic and clinical characteristics. METHODS This was a cross sectional study consisting of a nationally representative sample of 40,253 ED visits included in the 2003 National Hospital Ambulatory Medical Care Survey in the United States, and all ED visits recorded during 2003 by the National Ambulatory Care Reporting System in Ontario, Canada. The main outcome was the number of ED visits per 100 population per year. RESULTS The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6) per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population). In both the United States and Ontario, Canada, those aged 75 years and older had the highest ED visit rate and women had a slightly higher ED visit rate than men. The most common discharge diagnosis was injury/poisoning, accounting for 25.6% of all ED visits in the United States and 24.7% in Ontario, Canada. Overall, 13.9% of ED patients in the United States were admitted to hospitals, compared with 10.5% in Ontario, Canada. CONCLUSIONS ED visit rates and patterns are similar in the United States and Ontario, Canada. Differences in health insurance coverage may not have a substantial impact on the overall utilization of emergency care.
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Trautman DE, McCarthy ML, Miller N, Campbell JC, Kelen GD. Intimate Partner Violence and Emergency Department Screening: Computerized Screening Versus Usual Care. Ann Emerg Med 2007; 49:526-34. [PMID: 17276547 DOI: 10.1016/j.annemergmed.2006.11.022] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Revised: 11/07/2006] [Accepted: 11/13/2006] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To compare a computer-based method of screening for intimate partner violence (intimate partner violence) with usual care in an emergency department (ED) setting. METHODS During 3 distinct but consecutive 2-week periods, women who presented to the ED were asked to complete a computer-based health survey with or without intimate partner violence screening questions in addition to receiving usual intimate partner violence care (ie, screened voluntarily by ED providers and documented in medical record). The screening, detection, referral and service rates were compared between women who completed the computer-based health survey with the intimate partner violence screening questions to usual care. RESULTS Of the 411 women who completed the computer-based health survey with the intimate partner violence questions, 99.8% were screened for intimate partner violence compared to 33% of the 594 women who received usual care (67.1% difference; 95% CI 63.3%, 70.9%). The computer-based health survey detected 19% intimate partner violence positive whereas usual care detected 1% (17.8% difference; 95% CI 13.9%, 21.7%). Referral to social work was higher among those screened by the computer-based health survey (10%) versus usual care (<1%) (9.7% difference; 95% CI 6.7%, 12.7%). Only 20 subjects received intimate partner violence services, although it was slightly higher among those screened by the computer-based health survey (4%) compared to usual care (1%) (4.0% difference; 95% CI 2.0%, 6.1%). CONCLUSION We found that a computer-based approach led to significantly higher intimate partner violence screening and detection rates compared to usual care. Receipt of intimate partner violence services was also higher than usual care but was not optimal. Computer technology makes routine screening easier and allows us to redirect our energies to addressing patients' intimate partner violence problems.
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Rothman RE, Quianzon CC, Kelen GD. In reply. Acad Emerg Med 2007. [DOI: 10.1197/j.aem.2006.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Ritsema TS, Kelen GD, Pronovost PJ, Pham JC. The national trend in quality of emergency department pain management for long bone fractures. Acad Emerg Med 2007; 14:163-9. [PMID: 17192448 DOI: 10.1197/j.aem.2006.08.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving. OBJECTIVES To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001. METHODS The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998-2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment. RESULTS There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998-2000 and 1,230 from 2001-2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates. CONCLUSIONS Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.
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Hsu EB, Casani JA, Romanosky A, Millin MG, Singleton CM, Donohue J, Feroli ER, Rubin M, Subbarao I, Whyne DM, Snodgrass TD, Kelen GD. Are regional hospital pharmacies prepared for public health emergencies? Biosecur Bioterror 2007; 4:237-43. [PMID: 16999585 DOI: 10.1089/bsp.2006.4.237] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION In the event of a major chemical, biological, radiological, nuclear, or explosive (CBRNE) attack or a natural disaster, large quantities of pharmaceuticals and medical supplies may be required with little or no warning. Pharmaceutical surge capacity for immediate response, before Strategic National Stockpile (SNS) supplies become available, remains a significant gap in emergency preparedness. To date, limited attempts have been made to assess collective regional hospital pharmaceutical response capabilities. In this project, we characterized the level of hospital pharmaceutical response preparedness in a major metropolitan region. METHODS The Johns Hopkins Office of Critical Event Preparedness and Response (CEPAR) convened a collaborative partnership to assess hospital pharmaceutical response capabilities. A survey was developed to characterize pharmaceutical response preparedness to CBRNE threats. RESULTS All 22 acute care hospitals in the Maryland region were sent pharmaceutical response surveys, and responses were received from 86% (19/22). Within the past year, 84% (16/19) of hospitals had implemented an exercise with pharmacy participation. More than half of the hospitals expect to receive assistance from the SNS in 48 hours or less. Seventy-four percent (14/19) of the hospitals reported an additional dedicated reserve supply for biological events, 74% (14/19) for chemical events, and 58% (11/19) for radiological events. CONCLUSION Many hospitals in this metropolitan region have taken important steps toward enhancing pharmaceutical preparedness. However, hospitals generally remain underprepared for CBRNE threats and collectively have limited supplies of antibiotics to provide prophylaxis or treatment for hospital staff, their families, and patients in the event of a significant biological incident.
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Kelen GD, Kraus CK, McCarthy ML, Bass E, Hsu EB, Li G, Scheulen JJ, Shahan JB, Brill JD, Green GB. Inpatient disposition classification for the creation of hospital surge capacity: a multiphase study. Lancet 2006; 368:1984-90. [PMID: 17141705 PMCID: PMC7138047 DOI: 10.1016/s0140-6736(06)69808-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The ability to provide medical care during sudden increases in patient volume during a disaster or other high-consequence event is a serious concern for health-care systems. Identification of inpatients for safe early discharge (ie, reverse triage) could create additional hospital surge capacity. We sought to develop a disposition classification system that categorises inpatients according to suitability for immediate discharge on the basis of risk tolerance for a subsequent consequential medical event. METHODS We did a warfare analysis laboratory exercise using evidence-based techniques, combined with a consensus process of 39 expert panellists. These panellists were asked to define the categories of a disposition classification system, assign risk tolerance of a consequential medical event to each category, identify critical interventions, and rank each (using a scale of 1-10) according to the likelihood of a resultant consequential medical event if a critical intervention is withdrawn or withheld because of discharge. FINDINGS The panellists unanimously agreed on a five-category disposition classification system. The upper limit of risk tolerance for a consequential medical event in the lowest risk group if discharged early was less than 4%. The next categories had upper limits of risk tolerance of about 12% (IQR 8-15%), 33% (25-50%), 60% (45-80%) and 100% (95-100%), respectively. The expert panellists identified 28 critical interventions with a likelihood of association with a consequential medical event if withdrawn, ranging from 3 to 10 on the 10-point scale. INTERPRETATION The disposition classification system allows conceptual classification of patients for suitable disposition, including those deemed safe for early discharge home during surges in demand. Clinical criteria allowing real-time categorisation of patients are awaited.
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McCarthy ML, Aronsky D, Kelen GD. The measurement of daily surge and its relevance to disaster preparedness. Acad Emerg Med 2006; 13:1138-41. [PMID: 17032946 DOI: 10.1197/j.aem.2006.06.046] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This article reviews what is known about daily emergency department (ED) surge and ED surge capacity and illustrates its potential relevance during a catastrophic event. Daily ED surge is a sudden increase in the demand for ED services. There is no well-accepted, objective measure of daily ED surge. The authors propose that daily and catastrophic ED surge can be measured by the magnitude of the surge, as well as by the nature and severity of the illnesses and injuries that patients present with during the surge. The magnitude of an ED surge can be measured by the patient arrival rate per hour. The nature and severity of the surge can be measured by the type (e.g., trauma vs. infection vs. biohazard) and acuity (e.g., triage level) of the surge. Surge capacity is defined as the extent to which a system can respond to a rapid and sizeable increase in the demand for resources. ED surge capacity includes multiple dimensions, such as systems, space, staffing, and supplies. A multidimensional measure is needed that reflects both the core components and their relative contribution to ED surge capacity. Although many types of factors may influence ED surge capacity, relatively little formal research has been conducted in this area. A better understanding of daily ED surge capacity and influencing factors will improve our ability to simulate the potential impact that different types of catastrophic events may have on the surge capacity of hospital EDs nationwide.
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Abstract
The 2006 Academic Emergency Medicine Consensus Conference discussed key concepts within the field of surge capacity. Within the breakout session on research priorities, experts in disaster medicine and other related fields used a structured nominal-group process to delineate five critical areas of research. Of the 14 potential areas of discovery identified by the group, the top five were the following: 1) defining criteria and methods for decision making regarding allocation of scarce resources, 2) determining effective triage protocols, 3) determining key decision makers for surge-capacity planning and means to evaluate response efficacy (e.g., incident command), 4) developing effective communication and information-sharing strategies (situational awareness) for public-health decision support, and 5) developing methods and evaluations for meeting workforce needs. Five working groups were formed to consider the above areas and to devise sample research questions that were refined further by the entire group of participants.
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Rothman RE, Quianzon CCL, Kelen GD. Narrowing in on JCAHO recommendations for community-acquired pneumonia. Acad Emerg Med 2006; 13:983-5. [PMID: 16946291 DOI: 10.1197/j.aem.2006.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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