Research Ethics

This article explores the tenets of the responsible conduct of research. The proper treatment of human and animal subjects, recognition and avoidance of conflicts of interest, management of data to ensure privacy and confidentiality, authorship, academic freedom, and scientific misconduct are discussed. Historically significant events that have influenced the ethical climate, along with a review of guiding principles and regulations that define the conduct of ethical research are presented. Circumstances more specific to emergency medicine are examined in detail to provide meaningful guidance to practicing emergency medicine researchers.

Patients who leave without being seen: their characteristics and history of emergency department use

STUDY OBJECTIVE

We identify patient characteristics associated with uncompleted visits to the emergency department (ED).

METHODS

We used registration and billing data to conduct a pair-matched case-control study. ED patients who left without being seen (cases) between July 1 and December 31, 2004, were matched to patients who stayed and were treated (N=1,476 pairs) according to registration date and time (+/-2 hours) and triage level (controls). The association between sociodemographic characteristics, previous ED utilization, and proximity to the ED and the risk of an uncompleted visit was assessed by the odds ratio (OR) using conditional logistic regression.

RESULTS

During the 6-month study period, the overall left-without-being-seen rate was 6.4%. Seventeen percent of cases compared with 5% of controls had at least 1 previous uncompleted visit during the previous year. After adjusting for all patient characteristics, younger age, being uninsured (adjusted OR=1.73; 95% confidence interval [CI] 1.35 to 2.21) or covered by Medicaid (adjusted OR=1.67; 95% CI 1.27 to 2.20), and a previous uncompleted visit (adjusted OR=3.60; 95% CI 2.67 to 4.85) were significantly associated with the risk of an uncompleted visit.

CONCLUSION

Previous ED utilization is predictive of future ED utilization. EDs should make every effort to keep their left-without-being-seen rates to a minimum because patients who are the least likely to receive care elsewhere (ie, those uninsured or covered by Medicaid) are more likely to leave without being seen.

Healthcare worker competencies for disaster training

BACKGROUND

Although training and education have long been accepted as integral to disaster preparedness, many currently taught practices are neither evidence-based nor standardized. The need for effective evidence-based disaster training of healthcare staff at all levels, including the development of standards and guidelines for training in the multi-disciplinary health response to major events, has been designated by the disaster response community as a high priority. We describe the application of systematic evidence-based consensus building methods to derive educational competencies and objectives in criteria-based preparedness and response relevant to all hospital healthcare workers.

METHODS

The conceptual development of cross-cutting competencies incorporated current evidence through a systematic consensus building process with the following steps: (1) review of peer-reviewed literature on relevant content areas and educational theory; (2) structured review of existing competencies, national level courses and published training objectives; (3) synthesis of new cross-cutting competencies; (4) expert panel review; (5) refinement of new competencies and; (6) development of testable terminal objectives for each competency using similar processes covering requisite knowledge, attitudes, and skills.

RESULTS

Seven cross-cutting competencies were developed: (1) Recognize a potential critical event and implement initial actions; (2) Apply the principles of critical event management; (3) Demonstrate critical event safety principles; (4) Understand the institutional emergency operations plan; (5) Demonstrate effective critical event communications; (6) Understand the incident command system and your role in it; (7) Demonstrate the knowledge and skills needed to fulfill your role during a critical event. For each of the cross-cutting competencies, comprehensive terminal objectives are described.

CONCLUSION

Cross-cutting competencies and objectives developed through a systematic evidence-based consensus building approach may serve as a foundation for future hospital healthcare worker training and education in disaster preparedness and response.

Neighborhood characteristics and emergency department utilization

OBJECTIVES

Neighborhood environments have been linked to the prevalence and incidence rates of a variety of diseases and injuries. This study assessed the relations between neighborhood demographic and socioeconomic characteristics and emergency department (ED) utilization.

METHODS

Billing data for the calendar year 2000 for adult patients residing within a one-mile radius of the study ED were geo-coded based on home addresses and merged with neighborhood data from the U.S. Census Bureau. Annual ED visit rates per 100 population were computed for each census block within the study area and analyzed in relation to neighborhood characteristics.

RESULTS

The study area consisted of 714 census blocks and 42,278 adult residents, with a total of 16,427 visits to the study ED. Annual ED visit rates increased from 17 visits per 100 population for neighborhoods where less than 50% of the population were African American to 51 visits per 100 population for neighborhoods where all residents were African American (p < 0.001). Annual ED visit rates decreased from 53% for neighborhoods where <20% of housing units were owner-occupied to 27% for neighborhoods with >45% owner-occupied housing units (p < 0.001). Multivariate linear regression modeling revealed that proportions of African American residents and owner-occupied housing units were significantly associated with ED utilization, independent of age and gender compositions and the distance between residence and the study ED.

CONCLUSIONS

Even within a small geographic area, ED utilization may vary greatly by neighborhood characteristics. Neighborhood racial composition and housing tenure are independent predictors of ED visit rates in this urban community.

Preventive care in the emergency department: should emergency departments conduct routine HIV screening? a systematic review

OBJECTIVE

To perform a systematic review of the emergency medicine literature to assess the appropriateness of offering routine HIV screening to patients in the emergency department (ED).

METHODS

The systematic review was conducted with the aid of a structured template, a companion explanatory guide, and a grading and methodological scoring system based on published criteria for critical appraisal. Two reviewers conducted independent searches using OvidR, PubMed, MD Consult, and Grateful Med. Relevant abstracts were reviewed; those most pertinent to the stated objective were selected for complete evaluation using the structured template.

RESULTS

Fifty-two relevant abstracts were reviewed; of these, nine were selected for detailed evaluation. Seven ED-based prospective cross-sectional seroprevalence studies found HIV rates of 2-17%. Highest rates of infection were seen among patients with behavioral risks such as male homosexual activity and intravenous drug use. Two studies demonstrated feasibility of both standard and rapid HIV testing in the ED, with more than half of the patients approached consenting to testing by either method, consistent with voluntary testing acceptance rates described in other settings. Several cost-benefit analyses lend indirect support for HIV screening in the ED.

CONCLUSIONS

Multiple ED-based studies meeting the Centers for Disease Control and Prevention Guideline threshold to recommend routine screening, in conjunction with limited feasibility trials and extrapolation from cost-benefit studies, provide evidence to recommend that EDs offer HIV screening to high-risk patients (i.e., those with identifiable risk factors) or high-risk populations (i.e., those where HIV seroprevelance is at least 1%).

Detection of bacteremia in emergency department patients at risk for infective endocarditis using universal 16S rRNA primers in a decontaminated polymerase chain reaction assay

Prompt definitive diagnosis of acute bacterial endocarditis in febrile injection drug users (IDUs) remains problematic because of delays associated with blood culture. Rapid detection of bacteremia by polymerase chain reaction (PCR) by use of "universal" primers has been hampered by background bacterial contamination. Broad-range eubacterial primers selected from the 16S rRNA gene were used in a PCR assay coupled with a simple pre-PCR decontamination step. All PCR reagents were pretreated with the restriction enzyme AluI, which has multiple digestion sites in the amplicon but none in the primer sets. When 4 different bacterial species were spiked into healthy human blood specimens, the assay identified each pathogen with an analytic sensitivity of 5 bacteria/PCR reaction. A clinical trial with 51 febrile IDUs revealed that PCR had a sensitivity and specificity of 86.7% and 86.9%, respectively, versus blood culture. Importantly, all (8/8) patients with blood culture-positive infective endocarditis were determined to be positive by PCR. This assay provides a promising diagnostic for rapid identification of bacteremia, particularly valuable in acute care settings.

Quantitative multiprobe PCR assay for simultaneous detection and identification to species level of bacterial pathogens

We describe a novel adaptation of the TaqMan PCR assay which potentially allows for highly sensitive detection of any eubacterial species with simultaneous species identification. Our system relies on a unique multiprobe design in which a single set of highly conserved sequences encoded by the 16S rRNA gene serves as the primer pair and is used in combination with both an internal highly conserved sequence, the universal probe, and an internal variable region, the species-specific probe. A pre-PCR ultrafiltration step effectively decontaminates or removes background DNA. The TaqMan system described reliabAly detected 14 common bacterial species with a detection limit of 50 fg. Further, highly sensitive and specific pathogen detection was demonstrated with a prototype species-specific probe designed to detect Staphylococcus aureus. This assay has broad potential in the clinical arena for rapid and specific diagnosis of infectious diseases.

Effect of an emergency department (ED) managed acute care unit on ED overcrowding and emergency medical services diversion

OBJECTIVE

To determine the impact of an inpatient, emergency department (ED)-managed acute care unit (ACU) on ED overcrowding and use of ambulance diversion.

METHODS

Descriptive observational study with prospectively collected data from a 14-bed ACU recently opened remote from the main ED. Rates of patients who left without being seen (LWBS) and ambulance diversion frequency and duration were adjusted for ED patient volumes and compared with those for the period immediately before the ACU was opened and with those for a matching time period during the previous year.

RESULTS

There were 1,589 patients seen in the ACU during the first ten weeks of operation, representing about 14.5% of the ED volume (10,871). About 33% could be classified as post-ED management, 20% as admission processing, and the rest as primary evaluation. The number of patients who LWBS decreased from 10.1% of the ED census two weeks prior to opening of the ACU, and from 9.4% during the previous year, to 5.0% (range 4.2%-6.2%) during the ensuing ten weeks post opening. Ambulance diversion was a mean of 6.7 hours per 100 patients before the unit opened and 5.6 hours per 100 patients during the same time in the previous year, and decreased to 2.8 hours per 100 patients after the unit opened (p < 0.05, respectively). A six-month pre- and two-month post-examination revealed that the mean monthly hours of ambulance diversion for the ED decreased by 40% (202 hours vs 123 hours) (p < 0.05) in contrast to a mean increase of 44% (186 hours vs 266 hours) (p < 0.05) experienced by four proximate hospitals.

CONCLUSIONS

An ED-managed ACU can have significant impact on ED overcrowding and ambulance diversion, and it need not be located proximate to the ED.

Clinical aspects of diagnosis of gonorrhea and Chlamydia infection in an acute care setting

We found a 10.4% prevalence of unrecognized genital gonorrhea and Chlamydia infection among young adults of an urban emergency department. Intensified detection and treatment policies are needed to prevent continued transmission and complications of sexually transmitted infections.

Impact of ambulance diversion policies in urban, suburban, and rural areas of Central Maryland

As a method to control patient flow to overburdened hospitals, effective emergency medical services (EMS) systems provide policies for ambulance diversion. The Maryland state EMS system supports two types of alert for general hospital use: red alert, aimed at limiting the delivery of patients who may require intensive care unit (ICU) admission, and yellow alert, aimed at preventing further overload of already overtaxed emergency departments (EDs).

OBJECTIVE

To examine the effect of those alert policies in different geographical environments, urban, suburban, and rural.

METHODS

Alert data for 23 hospitals in Central Maryland and ambulance arrival data for approximately 138,000 ambulance calls during calendar year 1996 were combined and analyzed. The impacts of diversion practices in the geographic areas were compared.

RESULTS

Red alert reduced volume in all patient acuity levels in all geographic areas by a statistically significant 0.4 patient/hr. Yellow alert diverted low-acuity patients at the rate of 0.13 patient/hr (p<0.001) in urban areas and at the rate of 0.16 patient/hr (p<0.001) in suburban areas, but had minimal impact in the flow of patients in the rural environment.

CONCLUSIONS

The ED diversion policy has some limited effect in preventing further patient volume in urban and suburban areas, but has virtually no impact in rural areas. However, an ICU diversion policy diverts patients of all acuities uniformly and inordinately diverts patients not likely to require ICU admissions while having only minimal impact on patients who do require ICU resources. The impact of red alert is uniform in all geographic areas. The impact and efficacy of ambulance diversion policies should be evaluated to ensure they are having the intended effect. While perhaps initially effective, the impact of alert policies may change over time.

Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention

BACKGROUND

Urban emergency departments (EDs) providing services to patients at high risk for sexually transmitted infection may be logical sites for intervention.

GOAL

To determine the prevalence of gonorrhea (GC) and chlamydia (CT) in an adult ED patient population, and to assess risk factors for infection.

STUDY DESIGN

Cross-sectional study of patients aged 18 to 44 in an urban ED, seeking care of any medical nature. Main outcome was positive for GC or CT by urine ligase chain reaction assay.

RESULTS

Test results for GC and/or CT were positive in 13.6% of 434 18 to 31 year-olds and in 1.8% of 221 32 to 44 year-olds. Of 63 infected individuals identified by the study, 15 (23.8%) were treated at the ED visit. Age < or =31 detected 88% of infections. Among 18- to 31-year-old patients, predictive risk factors by multivariate analysis included age <25, >1 sex partner in the past 90 days, and a history of sexually transmitted disease.

CONCLUSION

This study identified a high prevalence of GC and CT in patients seeking ED services. Many of these infections were clinically unsuspected. These data demonstrate that the ED is a high-risk setting and may be an appropriate site for routine GC and CT screening in 18- to 31-year-old patients.

Interpretation of Emergency Department radiographs: a comparison of emergency medicine physicians with radiologists, residents with faculty, and film with digital display

OBJECTIVE

We determined the relative value of teleradiology and radiology resident coverage of the emergency department by measuring and comparing the effects of physician specialty, training level, and image display method on accuracy of radiograph interpretation.

MATERIALS AND METHODS

A sample of four faculty emergency medicine physicians, four emergency medicine residents, four faculty radiologists, and four radiology residents participated in our study. Each physician interpreted 120 radiographs, approximately half containing a clinically important index finding. Radiographs were interpreted using the original films and high-resolution digital monitors. Accuracy of radiograph interpretation was measured as the area under the physicians' receiver operating characteristic (ROC) curves.

RESULTS

The area under the ROC curve was 0.15 (95% confidence interval [CI], 0.10-0.20) greater for radiologists than for emergency medicine physicians, 0.07 (95% CI, 0.02-0.12) greater for faculty than for residents, and 0.07 (95% CI, 0.02-0.12) greater for films than for video monitors. Using these results, we estimated that teleradiology coverage by faculty radiologists would add 0.09 (95% CI, 0.03-0.15) to the area under the ROC curve for radiograph interpretation by emergency medicine faculty alone, and radiology resident coverage would add 0.08 (95% CI, 0.02-0.14) to this area.

CONCLUSION

We observed significant differences between the interpretation of radiographs on film and on digital monitors. However, we observed differences of equal or greater magnitude associated with the training level and physician specialty of each observer. In evaluating teleradiology services, observer characteristics must be considered in addition to the quality of image display.

CK-MB isoforms for early risk stratification of emergency department patients

The potential clinical utility of single sample CK-MB isoforms measurement for early risk stratification of Emergency Department (ED) patients with possible myocardial ischemia was evaluated among 405 patients presenting to two urban EDs. Clinical and serologic data were prospectively collected and the occurrence of adverse events (AEs) and myocardial infarction (MI) during the 14-day outcome period was recorded and utilized to calculate and compare relative risks (RR) and predictive values of isoforms and CK-MB alone. Among the 405 patients, 67 accrued 105 AEs. Both isoforms and CK-MB alone were predictive of AEs with RR of 3.32 (2.09, 5.27) and 6.28 (4.64, 8.52), respectively. Isoforms had higher sensitivity for AEs compared to CK-MB (65.7% [54.3, 77.0] vs. 14.9% [6.4, 23.5]; p<0. 01) but lower specificity (69.2% [64.3, 74.2] vs. 99.7% [99.1,100. 0]; p<0.01). Isoforms' superior sensitivity allowed identification of many high risk patients missed by CK-MB alone. Further, for the prediction of MI, isoforms had superior diagnostic sensitivity and equivalent specificity. This investigation supports the emergency department use of early, single sample CK-MB isoform testing.

Myoglobin for early risk stratification of emergency department patients with possible myocardial ischemia

OBJECTIVES

To determine and compare the prognostic abilities of early, single-sample myoglobin measurement with that of creatine kinase-MB (CK-MB), with cardiac troponin T (cTnT), and with physician judgment in the absence of marker results among emergency department (ED) patients with possible myocardial ischemia.

METHODS

Prospective collection of clinical and serologic data using an identity-unlinked technique from patients with possible myocardial ischemia at two urban EDs. Outcome data concerning the occurrence of adverse events (AEs) during the 14 days after enrollment were used to calculate and compare the relative risks (RRs) and predictive values (with 95% confidence intervals) of the various markers for predicting AEs.

RESULTS

Among 396 analyzed patients, 65 (16.4%) accrued 104 AEs, including 13 deaths (3.3%) and 31 (7.8%) myocardial infarctions. Myoglobin predicted AEs (RR = 3.36 [95% CI = 2.19 to 5.15]) with significantly higher sensitivity (50.8% [95% CI = 38.6 to 62.9]) than either CK-MB (15.4% [95% CI = 6.6 to 24.2]) or cTnT (24.6% [95% CI = 14.1 to 35.1]), but with lower specificity (81.9% [95% CI = 77.7 to 86.0]; CK-MB = 99.7% [95% CI = 99.1 to 100]; cTnT = 93.1% [95% CI = 90.3 to 95.8]). Myoglobin had prognostic ability among patients with chest pain (3.86 [95% CI = 2.39 to 6.22]) and atypical (non-chest pain) presentations (2.71 [95% CI = 1.09 to 6.71]), including those with a nondiagnostic electrocardiogram (3.11 [95% CI = 1.44 to 6.69]). The combination of myoglobin and physician decision making identified 63 of the 65 patients (96.9% [95% CI = 92.7 to 100]) with subsequent AEs.

CONCLUSIONS

The early prognostic sensitivity of myoglobin may allow identification of some high-risk patients missed by physician judgment, CK-MB, and cTnT. Myoglobin should be considered for use in the ED based on both its diagnostic and prognostic abilities.

A decision guideline for emergency department utilization of noncontrast head computed tomography in HIV-infected patients

OBJECTIVE

To determine which neurologic signs or symptoms are predictive of new focal lesions on head CT in HIV-infected patients.

METHODS

Prospective study with convenience sample enrollment of HIV-infected patients who presented to a large inner-city university-based ED over an 11-month period. Patients were assessed using a standardized neurologic evaluation to ascertain whether they had developed new or changed neurologic signs or symptoms. Patients with any new or changed neurologic findings had a head CT scan in the ED. The association between individual complaints or findings and new focal lesions on head CT was assessed by univariate analysis, and sensitivity, specificity, and positive predictive values were calculated. Stepwise logistic regression analysis was then carried out to estimate the relative risk for those variables independently associated with new focal lesions on CT scans. A decision guideline was developed incorporating those variables.

RESULTS

One hundred ten patients were identified as having new or changed neurologic signs or symptoms and had a head CT done in the ED. Twenty-seven patients (24%) had focal lesions on head CT, of which 19 (18%) were identified as new focal lesions; eight of these (7%) demonstrated a mass effect. Clinical findings most strongly associated with new focal findings on head CT were: 1) new seizure, relative risk (RR) = 73.5, 95% CI = 6.2 to 873.0; 2) depressed or altered orientation, RR = 39.1, 95% CI = 4.6 to 330.0; and 3) headache, different in quality, RR = 27.0, 95% CI = 3.2 to 230.1. Use of these three findings as a screen for ordering head CT in the ED would have identified 95% (18/19) of the patients with new focal intracranial lesions, and resulted in a 53% reduction in the number of head CTs ordered in the ED. Inclusion of one additional parameter (prolonged headache, > or =3 days), would have resulted in identification of 100% of all new focal lesions, with a 37% reduction in the number of head CTs ordered. Among those patients with new focal findings, 74% required emergent management (i.e., seizure control, IV antibiotics, IV steroids or surgery). The most common intracranial lesion among patients with CD4 counts less than 200 cells/microL was toxoplasmosis, while cerebrovascular accidents (ischemic or hemorrhagic) were most common in those with CD4 counts greater than 200 cells/microL.

CONCLUSION

Specific clinical signs and symptoms were associated with the presence of new intracranial lesions in a group of HIV-infected patients who presented to the ED with neurologic complaints. These clinical findings can be incorporated into guidelines for determining the need for emergent head CT. Validation and widespread application of these guidelines could result in limiting the use of emergent neuroimaging to a more well-defined HIV-infected patient population.

Cardiopulmonary resuscitation in pediatric trauma patients: survival and functional outcome

BACKGROUND

Although injury is the leading cause of cardiac arrests in children older than 1 year, few studies have examined the survival and functional outcome of cardiopulmonary resuscitation (CPR) in pediatric trauma patients.

METHODS

A historical cohort of 957 trauma patients younger than 15 years who received CPR at the scene of injury or at the admitting hospital was constructed on the basis of the National Pediatric Trauma Registry. The rate of survival to discharge and factors related to survival were examined. Functional impairments were documented for surviving patients.

RESULTS

The overall survival rate was 23.5%. With adjustment for the Injury Severity Score, the risk of fatality after CPR increased for children with systolic blood pressure below 60 mm Hg at admission (odds ratio [OR] 24.5, 95% confidence interval [CI] 8.6-69.3), for those who were comatose at admission (OR, 4.7; 95% CI, 1.9-11.6), for those with penetrating injury (OR, 4.4; 95% CI, 1.5-13.3), and for those with CPR initiated at the hospital (OR, 2.4; 95% CI, 1.5-3.9). Surviving patients stayed in hospitals for an average of 24.3 days; at discharge, 64% had at least one impairment in the functional activities of daily living.

CONCLUSIONS

Survival outcome of CPR in pediatric trauma patients appears to be comparable to that reported in adults of mixed arrest causes. Future research needs to identify factors underlying the excess mortality associated with penetrating trauma.

Alcohol and other psychoactive drugs in trauma patients aged 10-14 years

OBJECTIVE

To examine the prevalence of alcohol and/or other psychoactive drugs, such as marijuana and cocaine (AODs), involved in preteen trauma patients.

METHODS

Toxicological testing results were analyzed for 1356 trauma patients aged 10-14 years recorded in the National Pediatric Trauma Registry for the years 1990-95.

RESULTS

Of the 1356 patients who received toxicological screening at the time of admission, 116 (9%) were positive for AODs. AOD involvement increased with age. Patients with pre-existing mental disorders were nearly three times as likely as other patients to be AOD positive (23% v 8%, p < 0.01). AOD involvement was more prevalent in intentional injuries and in injuries that occurred at home.

CONCLUSIONS

AODs in preteen trauma are of valid concern, in particular among patients with mental disorders or intentional injuries. The role of AODs in childhood injuries needs to be further examined using standard screening instruments and representative study samples.

A clinical trial to improve high blood pressure care in young urban black men: recruitment, follow-up, and outcomes

This randomized trial recruited and followed underserved, inner-city, hypertensive (HTN), young black men and investigated whether a nurse-community health worker team in combination with usual medical care (SI) increased entry into care and reduced high blood pressure (HBP), in comparison to usual medical care (UC) alone. Emergency department records, advertising, and BP screenings identified potential participants with HBP. Telephone calls and personal contacts tracked enrollees. Of 1391 potential participants, 803 (58%) responded to an invitation to be screened and scheduled a visit. Of these, 528 (66%) kept an appointment, 207 (35%) were BP eligible, and 204 (99%) consented to enroll. At 12 months 91% of men were accounted for and 85.8% (adjusted for death, in jail, or moved away) were seen. Mean BP changed from 153(16)/98(10) to 152(19)/94(11) mm Hg in the SI group and 151(18)/98(11) to 147(21)/92(14) mm Hg in the UC group (P = NS). High rates of participation are attainable in this population; however, culturally acceptable ways of delivering HBP care are needed.

Feasibility of an emergency department-based tuberculosis counseling and screening program

OBJECTIVE

To assess the feasibility and effectiveness of an ED-based tuberculosis (TB) screening program.

METHODS

A TB screening program of adult ED patients was conducted at a university hospital ED with 46,000 annual visits that serves a poor urban community. Patients were screened on weekdays during business hours. ED patients were counseled about the disease and the screening procedure and, after consent, purified protein derivative (PPD) tests were placed. Patients returned in 48-72 hours for reaction reading and post-test counseling. PPD-positive patients received a physical examination, chest x-ray, and HIV testing and were referred to a city TB clinic for possible treatment.

RESULTS

Overall, 873 patients were counseled, 630 were eligible for screening, and 374 (59.4%) consented to PPD testing. Of the 203 (54.1%) who returned, 32 (15.8%) were PPD-positive. No active case was detected, but 26 patients were referred to the health department. Eighteen kept their appointments and all 13 who were started on therapy completed treatment. Targeted screening of groups aged 55 years or more, nonwhite groups, and those with other high-risk factors would detect 84% of PPD-positive cases while testing only 48% of eligible patients.

CONCLUSION

An ED-based TB screening program is feasible and can identify many patients requiring treatment. Targeted screening of high-risk groups could reduce the program cost, but would miss some cases.

Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing

STUDY OBJECTIVE

We sought to (1) determine whether some emergency departments could play an important role in the national strategy of early HIV detection through the implementation of a voluntary HIV screening program and (2) describe the experience with standard and rapid HIV testing.

METHODS

Consenting adults were enrolled during 3 distinct phases between 1993 and 1995 for the assessment of routine testing only, routine versus rapid testing, and rapid testing only. Patients administered the rapid test were given information at the time of the visit. We assessed the cost of the program.

RESULTS

Of 3,048 patients approached, 1,448 (48%) consented, 981 to standard and 467 to rapid testing. Of these, 6.4% and 3.2%, respectively, were newly identified as being HIV seropositive. More than twice as many new infections were diagnosed among those discharged from the ED as among those admitted (55 versus 21). Even among those previously tested, 5% proved seropositive. The mean+/-SD time to obtain results for the rapid assay performed in the hospital's main laboratory was 107+/-52 minutes, with 55% leaving the ED before receiving the results. Rapid assays performed in the ED satellite laboratory required 48+/-37 minutes, and only 20% left before getting the results. Follow-up among HIV-seropositive patients was 64% for the standard protocol and 73% for the rapid protocol (P >. 20). The prearranged HIV clinic intake appointment was kept by 62%. Rapid test sensitivity and specificity were 100% and 98.9%, respectively, with 5 initial false-positives and no false-negatives. Cost per patient enrolled and counseled was $38. Cost per infection detected was $601 for the routine test and $1,124 with the rapid test; these prices are competitive with those incurred at other sites.

CONCLUSION

Emergency department-based HIV testing was well accepted and detected a significant number of new HIV infections earlier than might have otherwise been, particularly among patients sent home. The rapid test is best performed on-site and is very sensitive. Confirmation of initial results is required because of the occurrence of occasional false-positive results. With relatively high HIV detection and return rates, it is evident that some EDs could play a major role in the national strategy of early HIV detection.

Compliance with prehospital triage protocols for major trauma patients

BACKGROUND

The extent to which severely injured patients receive definitive care at trauma centers is determined by the accuracy of prehospital major trauma criteria in predicting severe injuries and by the level of compliance with these triage instructions by prehospital providers. This study was conducted to evaluate the level of compliance with triage criteria in an established trauma system.

METHODS

The study involved a retrospective analysis of the 1995 Maryland statewide prehospital ambulance data. Prehospital providers in Maryland are instructed to consider transporting patients meeting any of the three nonexclusive major trauma criteria-physiology, injury, and mechanism-to designated trauma centers. Compliance with these criteria was defined as the proportion of patients transported to designated trauma centers among those meeting prehospital triage criteria as documented on the ambulance trip report. Special emphasis was placed on differences in the levels of compliance by age of the trauma patients.

RESULTS

A total of 32,950 transports were analyzed. Patients meeting injury criteria were most likely to be transported to trauma centers (86%), followed by those meeting mechanism criteria (46%), and physiology criteria (34%). When the level of compliance was stratified by age, there was no age difference in the level of compliance for patients meeting injury criteria (90.5% for patients aged 0-54 years vs. 88.7% for patients aged 55+ years; p = 0.197). For older patients meeting physiology criteria only or for those meeting mechanism criteria only, however, compliance was differentially low. For patients meeting physiology criteria only, the compliance was 40.3% for patients aged 0 to 54 years and 23.9% for patients aged 55 years and older (p = 0.0001); for patients meeting mechanism criteria only, compliance was 47.0% for patients aged 0 to 54 years and 39.7% for patients aged 55+ years (p = 0.002).

CONCLUSION

The majority of patients meeting prehospital major trauma criteria were transported to designated trauma centers. Patients meeting only physiology criteria, however, were much less likely to be transported to trauma centers, and there was a differentially low compliance for elderly trauma patients meeting physiology criteria alone. The causes and consequences of lower compliance with triage instructions for the elderly population deserve further investigation.

The prognostic significance of troponin I and troponin T

OBJECTIVES

To determine and compare the prognostic abilities of early, single-sample measurements of cardiac troponin I (cTn-I), cardiac troponin T (cTn-T), and creatine kinase-MB (CK-MB) among ED patients with possible myocardial ischemia.

METHODS

Prospective collection of clinical and serologic data using an identity-unlinked technique from patients with possible myocardial ischemia at 2 urban EDs. Outcome data concerning the occurrence of adverse events (AEs) during the 14 days after enrollment were used to calculate and compare the relative risks (RRs) and predictive values (with 95% confidence intervals) of the 3 markers for predicting AEs.

RESULTS

Among the 401 study patients, 105 AEs occurred in 67 patients. cTn-I, cTn-T, and CK-MB were all significantly predictive of AEs, with RRs of 3.87 (2.39, 6.26), 3.03 (1.92, 4.79), and 6.45 (4.74, 8.77), respectively. For prediction of AEs, sensitivity for each of the 3 markers was low (cTn-I = 15.38, cTn-T = 24.62, CK-MB = 15.38), while specificity was high (cTn-I = 97.62, cTn-T = 93.15, CK-MB = 99.70). No significant difference in predictive ability was found between cTn-I and cTn-T. However, a positive CK-MB result was a stronger predictor of AEs than either cTn-I (p = 0.01) or cTn-T (p = 0.001).

CONCLUSIONS

No significant difference in predictive abilities was found between cTn-I and cTn-T. However, routine testing for both CK-MB and either of the troponins may optimize early identification of high-risk patients so they may be targeted for a higher level of care and consideration of more aggressive therapies.

Epidemiology of alcohol-related emergency department visits

OBJECTIVE

To examine the population and geographic patterns, patient characteristics, and clinical presentations and outcomes of alcohol-related ED visits at a national level.

METHODS

Cross-sectional data on a probability sample of 21,886 ED visits from the 1995 National Hospital Ambulatory Medical Care Survey were analyzed with consideration of the individual patient visit weight. The annual number and rates of alcohol-related ED visits were computed based on weighted analysis in relation to demographic characteristics and geographic region. Specific variables of alcohol-related ED visits examined included demographic and medical characteristics, patient-reported reasons for visit, and physicians' principal diagnoses.

RESULTS

Of the 96.5 million ED visits in 1995, an estimated 2.6 million (2.7%) were related to alcohol abuse. The overall annual rate of alcohol-related ED visits was 10.0 visits per 1,000 population [95% confidence interval (CI) 8.7-11.3]. Higher rates were found for men (14.7 per 1,000, 95% CI 12.5-16.9), adults aged 25 to 44 years (17.8 per 1,000, 95% CI 15.0-20.6), blacks (18.1 per 1,000, 95% CI 14.0-22.1), and residents living in the northeast region (15.2 per 1,000, 95% CI 12.1-18.2). Patients whose visits were alcohol-related were more likely than other patients to be uninsured, smokers, or depressive. Alcohol-related ED visits were 1.6 times as likely as other visits to be injury-related, and 1.8 times as likely to be rated as "urgent" or "emergent." The leading principal reasons for alcohol-related ED visits were complaints of pain, injury, and drinking problems. Alcohol abuse/dependence was the principal diagnosis for 20% of the alcohol-related visits.

CONCLUSION

Alcohol abuse poses a major burden on the emergency medical care system. The age, gender, and geographic characteristics of alcohol-related ED visits are consistent with drinking patterns in the general population.

Are female drivers safer? An application of the decomposition method

Using the decomposition method and national data for the year 1990, we examined gender and age differences in involvement rates in fatal motor vehicle crashes. The fatal crash involvement rate per driver is expresses as a multiplicative function of the crash fatality rate (defined as the proportion of fatal crashes involved among all crashes involved), crash incidence density (that is, number of crashes per million person-miles), and exposure prevalence (that is, annual average miles driven per driver). The fatal crash involvement rate per 10,000 drivers for men was three times that for women (5.3 vs 1.7) and was highest among teenagers. Of the male-female discrepancy in the fatal crash involvement rates, 51% was attributed to the difference between sexes in crash fatality rates, 41% to the difference in exposure prevalence, and 8% to the difference in crash incidence density. Age-related variations in the fatal crash involvement rates resulted primarily from the differences in crash incidence density. The results indicate that, despite having lower fatal crash involvement rates, female drivers do not seem to be safer than their male counterparts when exposure is considered. The decomposition method is valuable as both a conceptual framework and an exploratory tool for understanding the contributing factors related to cause-specific injury mortality and the differences in death rates among populations.