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Sarafian JT, Eucker SA, Gillman M, DeLaroche AM, Rodriguez RM, Rayburn D, Nadeau NL, Drago LA, Cullen D, Kugler EM, Meskill SD, Bialeck S, Baumann BM. Impact of a hypothetical COVID-19 vaccine mandate on parental likelihood to vaccinate children: Exploring school-related concerns and vaccination decision-making. Vaccine 2023; 41:7493-7497. [PMID: 37973509 DOI: 10.1016/j.vaccine.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE We assessed the impact of a hypothetical school-entry COVID-19 vaccine mandate on parental likelihood to vaccinate their child. METHODS We collected demographics, COVID-19-related school concerns, and parental likelihood to vaccinate their child from parents of patients aged 3-16 years seen across nine pediatric Emergency Departments from 06/07/2021 to 08/13/2021. Wilcoxon signed-rank test compared pre- and post-mandate vaccination likelihood. Multivariate linear and logistic regression analyses explored associations between parental concerns with baseline and change in vaccination likelihood, respectively. RESULTS Vaccination likelihood increased from 43% to 50% with a hypothetical vaccine mandate (Z = -6.69, p < 0.001), although most parents (63%) had no change, while 26% increased and 11% decreased their vaccination likelihood. Parent concerns about their child contracting COVID-19 was associated with greater baseline vaccination likelihood. No single school-related concern explained the increased vaccination likelihood with a mandate. CONCLUSION Parental school-related concerns did not drive changes in likelihood to vaccinate with a mandate.
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Affiliation(s)
- Joshua T Sarafian
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Stephanie A Eucker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Michael Gillman
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA; Department of Pediatric Emergency Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA; College of Medicine, Central Michigan University, Mount Pleasant, MI, USA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California at San Francisco School of Medicine, San Francisco, CA, USA
| | - David Rayburn
- Department of Pediatric Emergency Medicine, Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Nicole L Nadeau
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lisa A Drago
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Danielle Cullen
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emmalee M Kugler
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Sarah Dennis Meskill
- Section of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Suzanne Bialeck
- Department of Emergency Medicine, Jackson Memorial Hospital/Holtz Children's Hospital, Miami, FL, USA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
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Eswaran V, Chang AM, Wilkerson RG, O’Laughlin KN, Chinnock B, Eucker SA, Baumann BM, Anaya N, Miller DG, Haggins AN, Torres JR, Anderson ES, Lim SC, Caldwell MT, Raja AS, Rodriguez RM. Facemasks: Perceptions and use in an ED population during COVID-19. PLoS One 2022; 17:e0266148. [PMID: 35417505 PMCID: PMC9007380 DOI: 10.1371/journal.pone.0266148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/15/2022] [Indexed: 12/02/2022] Open
Abstract
Study objective Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations. Methods This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them. Results Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks “all of the time” and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%). Conclusions Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.
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Affiliation(s)
- Vidya Eswaran
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
- National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco, CA, United States of America
- * E-mail:
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA, United States of America
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Kelli N. O’Laughlin
- Department of Emergency Medicine and Global Health, University of Washington, Seattle, WA, United States of America
| | - Brian Chinnock
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
| | - Stephanie A. Eucker
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | - Brigitte M. Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, United States of America
| | - Nancy Anaya
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
| | - Daniel G. Miller
- Departments of Emergency and Internal Medicine, University of Iowa Hospitals and Clinics, Iowa, IA, United States of America
| | - Adrianne N. Haggins
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jesus R. Torres
- Department of Emergency Medicine, Olive View UCLA Medical Center, University of California Los Angeles Schools of Medicine, Los Angeles, CA, United States of America
- National Clinician Scholars Program, University of California, Los Angeles, CA, United States of America
| | - Erik S. Anderson
- Department of Emergency Medicine, Alameda Health System, Oakland, CA, United States of America
| | - Stephen C. Lim
- Section of Emergency Medicine, University Medical Center New Orleans, Louisiana State University Health Sciences Center, New Orleans, LA, United States of America
| | - Martina T. Caldwell
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States of America
| | - Ali S. Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Robert M. Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, CA, United States of America
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Rodriguez RM, Torres JR, Chang AM, Haggins AN, Eucker SA, O'Laughlin KN, Anderson E, Miller DG, Wilkerson RG, Caldwell M, Lim SC, Raja AS, Baumann BM, Graterol J, Eswaran V, Chinnock B. The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study. Ann Emerg Med 2021; 78:502-510. [PMID: 34272104 PMCID: PMC8165082 DOI: 10.1016/j.annemergmed.2021.05.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/09/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022]
Abstract
Study objective Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care. Methods This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt. Results Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED. Conclusion ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA.
| | - Jesus R Torres
- Department of Emergency Medicine, Olive View UCLA Medical Center-University of California Los Angeles School of Medicine, Los Angeles, CA
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
| | | | - Stephanie A Eucker
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, NC
| | - Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, WA
| | - Erik Anderson
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Daniel G Miller
- Department of Emergency Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD
| | - Martina Caldwell
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - Stephen C Lim
- Section of Emergency Medicine, University Medical Center New Orleans, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Joseph Graterol
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Vidya Eswaran
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Brian Chinnock
- Department of Emergency Medicine, University of California San Francisco Fresno, Fresno, CA
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Peacock WF, Baumann BM, Rivers EJ, Davis TE, Handy B, Jones CW, Hollander JE, Limkakeng AT, Mehrotra A, Than M, Cullen L, Ziegler A, Dinkel‐Keuthage C. Using Sex-specific Cutoffs for High-sensitivity Cardiac Troponin T to Diagnose Acute Myocardial Infarction. Acad Emerg Med 2021; 28:463-466. [PMID: 32726505 PMCID: PMC8247402 DOI: 10.1111/acem.14098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- W. Frank Peacock
- From the Department of Emergency Medicine Baylor College of Medicine Houston TXUSA
| | - Brigitte M. Baumann
- the Department of Emergency Medicine Cooper Medical School of Rowan University Camden NJUSA
| | - E. Joy Rivers
- Agent representing Roche Diagnostics Indianapolis INUSA
| | - Thomas E. Davis
- the Indiana University School of Medicine Indianapolis INUSA
| | - Beverly Handy
- the Department of Laboratory Medicine University of Texas MD Anderson Cancer Center Houston TXUSA
| | - Christopher W. Jones
- the Department of Emergency Medicine Cooper Medical School of Rowan University Camden NJUSA
| | - Judd E. Hollander
- the Department of Emergency Medicine Thomas Jefferson University Philadelphia PAUSA
| | | | - Abhi Mehrotra
- the Department of Emergency Medicine University of North Carolina School of Medicine Chapel Hill NCUSA
| | - Martin Than
- the Emergency Department Christchurch Hospital Christchurch New Zealand
| | - Louise Cullen
- the Department of Emergency Medicine Royal Brisbane and Women's Hospital Brisbane QLD Australia
| | - André Ziegler
- Roche Diagnostics International Ltd Rotkreuz Switzerland
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Baumann BM, Cooper RJ, Medak AJ, Lim S, Chinnock B, Frazier R, Roberts BW, Epel ES, Rodriguez RM. Emergency physician stressors, concerns, and behavioral changes during COVID-19: A longitudinal study. Acad Emerg Med 2021; 28:314-324. [PMID: 33492755 PMCID: PMC8014663 DOI: 10.1111/acem.14219] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/23/2022]
Abstract
Objectives The objective was to provide a longitudinal assessment of anxiety levels and work and home concerns of U.S. emergency physicians during the COVID‐19 pandemic. Methods We performed a longitudinal, cross‐sectional email survey of clinically active emergency physicians (attending, fellow, and resident) at seven academic emergency departments. Follow‐up surveys were sent 4 to 6 weeks after the initial survey and assessed the following: COVID‐19 patient exposure, availability of COVID‐19 testing, levels of home and workplace anxiety/stress, changes in behaviors, and performance on a primary care posttraumatic stress disorder screen (PC‐PTSD‐5). Logistic regression explored factors associated with a high PC‐PTSD‐5 scale score (≥3), indicating increased risk for PTSD. Results Of the 426 surveyed initial respondents, 262 (61.5%) completed the follow‐up survey. While 97.3% (255/262) reported treating suspected COVID‐19 patients, most physicians (162/262, 61.8%) had not received testing themselves. In follow‐up, respondents were most concerned about the relaxing of social distancing leading to a second wave (median score = 6, IQR = 4–7). Physicians reported a consistently high ability to order COVID‐19 tests for patients (median score = 6, IQR = 5–7) and access to personal protective equipment (median score = 6, IQR = 5–6). Women physicians were more likely to score ≥ 3 than men on the PC‐PTSD‐5 screener on the initial survey (43.3% vs. 22.5%; Δ 20.8%, 95% confidence interval [CI] = 9.3% to 31.5%), and despite decreases in overall proportions, this discrepancy remained in follow‐up (34.7% vs. 16.8%; Δ 17.9%, 95% CI = 7.1% to 28.1%). In examining the relationship between demographics, living situations, and institution location on having a PC‐PTSD‐5 score ≥ 3, only female sex was associated with a PC‐PTSD‐5 score ≥ 3 (adjusted odds ratio = 2.48, 95% CI = 1.28 to 4.79). Conclusions While exposure to suspected COVID‐19 patients was nearly universal, stress levels in emergency physicians decreased with time. At both initial and follow‐up assessments, women were more likely to test positive on the PC‐PTSD‐5 screener compared to men.
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Affiliation(s)
- Brigitte M. Baumann
- Department of Emergency Medicine Cooper Medical School of Rowan University Camden New Jersey USA
| | - Richelle J. Cooper
- Department of Emergency Medicine University of California at Los Angeles School of Medicine Los Angeles California USA
| | - Anthony J. Medak
- Department of Emergency Medicine University of California at San Diego School of Medicine San Diego California USA
| | - Stephen Lim
- Section of Emergency Medicine Louisiana State University Health Sciences Center New Orleans Louisiana USA
| | - Brian Chinnock
- Department of Emergency Medicine UCSF–Fresno Medical Education Program Fresno California USA
| | - Remi Frazier
- Academic Research Systems University of California San Francisco California USA
| | - Brian W. Roberts
- Department of Emergency Medicine Cooper Medical School of Rowan University Camden New Jersey USA
| | - Elissa S. Epel
- Department of Psychiatry University of California at San Francisco School of Medicine San Francisco California USA
| | - Robert M. Rodriguez
- Department of Emergency Medicine University of California at San Francisco School of Medicine San Francisco California USA
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6
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Rodriguez RM, Medak AJ, Baumann BM, Lim S, Chinnock B, Frazier R, Cooper RJ. Academic Emergency Medicine Physicians' Anxiety Levels, Stressors, and Potential Stress Mitigation Measures During the Acceleration Phase of the COVID-19 Pandemic. Acad Emerg Med 2020; 27:700-707. [PMID: 32569419 PMCID: PMC7361565 DOI: 10.1111/acem.14065] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 12/20/2022]
Abstract
Objective The objective was to assess anxiety and burnout levels, home life changes, and measures to relieve stress of U.S. academic emergency medicine (EM) physicians during the COVID‐19 pandemic acceleration phase. Methods We sent a cross‐sectional e‐mail survey to all EM physicians at seven academic emergency departments. The survey incorporated items from validated stress scales and assessed perceptions and key elements in the following domains: numbers of suspected COVID‐19 patients, availability of diagnostic testing, levels of home and workplace anxiety, severity of work burnout, identification of stressors, changes in home behaviors, and measures to decrease provider anxiety. Results A total of 426 (56.7%) EM physicians responded. On a scale of 1 to 7 (1 = not at all, 4 = somewhat, and 7 = extremely), the median (interquartile range) reported effect of the pandemic on both work and home stress levels was 5 (4–6). Reported levels of emotional exhaustion/burnout increased from a prepandemic median (IQR) of 3 (2–4) to since the pandemic started a median of 4 (3–6), with a difference in medians of 1.8 (95% confidence interval = 1.7 to 1.9). Most physicians (90.8%) reported changing their behavior toward family and friends, especially by decreasing signs of affection (76.8%). The most commonly cited measures cited to alleviate stress/anxiety were increasing personal protective equipment (PPE) availability, offering rapid COVID‐19 testing at physician discretion, providing clearer communication about COVID‐19 protocol changes, and assuring that physicians can take leave for care of family and self. Conclusions During the acceleration phase, the COVID‐19 pandemic has induced substantial workplace and home anxiety in academic EM physicians, and their exposure during work has had a major impact on their home lives. Measures cited to decrease stress include enhanced availability of PPE, rapid turnaround testing at provider discretion, and clear communication about COVID‐19 protocol changes.
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Affiliation(s)
- Robert M. Rodriguez
- From the Department of Emergency Medicine University of California at San Francisco School of Medicine San Francisco CA USA
| | - Anthony J. Medak
- the Department of Emergency Medicine University of California at San Diego School of Medicine San Diego CA USA
| | - Brigitte M. Baumann
- the Department of Emergency Medicine Cooper Medical School of Rowan University Camden NJ USA
| | - Stephen Lim
- the Section of Emergency Medicine Louisiana State University Health Sciences Center New Orleans LA USA
| | - Brian Chinnock
- the Department of Emergency Medicine UCSF‐Fresno Medical Education Program Fresno CA USA
| | - Remi Frazier
- Academic Research Systems University of California San Francisco CA USA
| | - Richelle J. Cooper
- and the Department of Emergency Medicine University of California at Los Angeles School of Medicine Los Angeles CA USA
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7
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Yu L, Baumann BM, Raja AS, Mower WR, Langdorf MI, Medak AJ, Anglin DR, Hendey GW, Nishijima D, Rodriguez RM. Blunt Traumatic Aortic Injury in the Pan-scan Era. Acad Emerg Med 2020; 27:291-296. [PMID: 31811732 DOI: 10.1111/acem.13900] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/21/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND In the era of frequent head-to-pelvis computed tomography (CT) for adult blunt trauma evaluation, we sought to update teachings regarding aortic injury by determining 1) the incidence of aortic injury; 2) the proportion of patients with isolated aortic injury (without other concomitant thoracic injury); 3) the clinical implications of aortic injury (hospital mortality, length of stay [LOS], and rate of surgical interventions); and 4) the screening value of traditional risk factors/markers (such as high-energy mechanism and widened mediastinum on chest x-ray [CXR]) for aortic injury, compared to newer criteria from the recently developed NEXUS Chest CT decision instrument (DI). METHODS We conducted a preplanned analysis of patients prospectively enrolled in the NEXUS Chest studies at 10 Level I trauma centers with the following inclusion criteria: age > 14 years, blunt trauma within 6 hours of ED presentation, and receiving chest imaging during ED trauma evaluation. RESULTS Of 24,010 enrolled subjects, 42 (0.17%, 95% confidence interval [CI] = 0.13% to 0.24%) had aortic injury. Most patients (79%, 95% CI = 64% to 88%) had an associated thoracic injury, with rib fractures, pneumothorax/hemothorax, and pulmonary contusion occurring most frequently. Compared to patients without aortic injury this cohort had similar mortality (9.5%, 95% CI = 3.8% to 22.1% vs. 5.8%, 95% CI = 5.4% to 6.3%), longer median hospital LOS (11 days vs. 3 days, p < 0.01), and higher median Injury Severity Score (29 vs. 5, p < 0.001). High-energy mechanism and widened mediastinum on CXR had low sensitivity for aortic injury (76% [95% CI = 62% to 87%] and 33% [95% CI = 21% to 49%], respectively), compared to the NEXUS Chest CT DI (sensitivity 100% [95% CI = 92% to 100%]). CONCLUSIONS Aortic injury is rare in adult ED blunt trauma patients who survive to receive imaging. Most ED aortic injury patients have associated thoracic injuries and survive to hospital discharge. Widened mediastinum on CXR and high-energy mechanism have relatively low screening sensitivity for aortic injury, but the NEXUS Chest DI detected all cases.
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Affiliation(s)
- Louis Yu
- Department of Emergency Medicine The University of California at San Francisco San Francisco CA
| | - Brigitte M. Baumann
- Department of Emergency Medicine Cooper Medical School of Rowan University Camden NJ
| | - Ali S. Raja
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston MA
| | - William R. Mower
- Department of Emergency Medicine University of California at Los Angeles Los Angeles CA
| | - Mark I. Langdorf
- Department of Emergency Medicine University of California at Irvine Orange CA
| | - Anthony J. Medak
- University of California at San Diego School of Medicine La Jolla CA
| | - Deirdre R. Anglin
- Department of Emergency Medicine Keck School of Medicine University of Southern California Los Angeles CA
| | - Gregory W. Hendey
- Department of Emergency Medicine University of California at Los Angeles Los Angeles CA
| | - Daniel Nishijima
- Department of Emergency Medicine University of California at Davis School of Medicine Orange CA
| | - Robert M. Rodriguez
- Department of Emergency Medicine The University of California at San Francisco San Francisco CA
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8
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Bizimungu R, Baumann BM, Raja AS, Mower WR, Langdorf MI, Medak AJ, Hendey GW, Nishijima D, Rodriguez RM. Thoracic Spine Fracture in the Panscan Era. Ann Emerg Med 2020; 76:143-148. [PMID: 31983495 DOI: 10.1016/j.annemergmed.2019.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/14/2019] [Accepted: 11/20/2019] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE In the current era of frequent chest computed tomography (CT) for adult blunt trauma evaluation, many minor injuries are diagnosed, potentially rendering traditional teachings obsolete. We seek to update teachings in regard to thoracic spine fracture by determining how often such fractures are observed on CT only (ie, not visualized on preceding trauma chest radiograph), the admission rate, mortality, and hospital length of stay of thoracic spine fracture patients, and how often thoracic spine fractures are clinically significant. METHODS This was a preplanned analysis of prospectively collected data from the NEXUS Chest CT study conducted from 2011 to 2014 at 9 Level I trauma centers. The inclusion criteria were older than 14 years, blunt trauma occurring within 6 hours of emergency department (ED) presentation, and chest imaging (radiography, CT, or both) during ED evaluation. RESULTS Of 11,477 enrolled subjects, 217 (1.9%) had a thoracic spine fracture; 181 of the 198 thoracic spine fracture patients (91.4%) who had both chest radiograph and CT had their thoracic spine fracture observed on CT only. Half of patients (49.8%) had more than 1 level of thoracic spine fracture, with a mean of 2.1 levels (SD 1.6 levels) of thoracic spine involved. Most patients (62%) had associated thoracic injuries. Compared with patients without thoracic spine fracture, those with it had higher admission rates (88.5% versus 47.2%; difference 41.3%; 95% confidence interval 36.3% to 45%), higher mortality (6.3% versus 4.0%; difference 2.3%; 95% confidence interval 0 to 6.7%), and longer length of stay (median 9 versus 6 days; difference 3 days; P<.001). However, thoracic spine fracture patients without other thoracic injury had mortality similar to that of patients without thoracic spine fracture (4.6% versus 4%; difference 0.6%; 95% confidence interval -2.5% to 8.6%). Less than half of thoracic spine fractures (47.4%) were clinically significant: 40.8% of patients received thoracolumbosacral orthosis bracing, 10.9% had surgery, and 3.8% had an associated neurologic deficit. CONCLUSION Thoracic spine fracture is uncommon. Most thoracic spine fractures are associated with other thoracic injuries, and mortality is more closely related to these other injuries than to the thoracic spine fracture itself. More than half of thoracic spine fractures are clinically insignificant; surgical intervention is uncommon and neurologic injury is rare.
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Affiliation(s)
- Remy Bizimungu
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - William R Mower
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California-Irvine, Irvine, CA
| | - Anthony J Medak
- University of California-San Diego School of Medicine, San Diego, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California-Davis School of Medicine, Davis, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA.
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Baumann BM, Greenwood JC, Lewis K, Nuckton TJ, Darger B, Shofer FS, Troeger D, Jung SY, Kilgannon JH, Rodriguez RM. Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness. Am J Emerg Med 2019; 38:883-889. [PMID: 31320214 DOI: 10.1016/j.ajem.2019.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/20/2019] [Accepted: 07/02/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To determine if the addition of lactate to Quick Sequential Organ Failure Assessment (qSOFA) scoring improves emergency department (ED) screening of septic patients for critical illness. METHODS This was a multicenter retrospective cohort study of consecutive adult patients admitted to the hospital from the ED with infectious disease-related illnesses. We recorded qSOFA criteria and initial lactate levels in the first 6 h of ED stay. Our primary outcome was a composite of hospital death, vasopressor use, and intensive care unit stay ≤72 h of presentation. Diagnostic test characteristics were determined for: 1) lactate levels ≥2 and ≥4; 2) qSOFA scores ≥1, ≥2, and =3; and 3) combinations of these. RESULTS Of 3743 patients, 2584 had a lactate drawn ≤6 h of ED stay and 18% met the primary outcome. The qSOFA scores were ≥1, ≥2, and =3 in 59.2%, 22.0%, and 5.3% of patients, respectively, and 34.4% had a lactate level ≥2 and 7.9% had a lactate level ≥4. The combination of qSOFA ≥1 OR Lactate ≥2 had the highest sensitivity, 94.0% (95% CI: 91.3-95.9). CONCLUSIONS The combination of qSOFA ≥1 OR Lactate ≥2 provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds.
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Affiliation(s)
- Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza Camden, NJ 08103, United States of America.
| | - John C Greenwood
- Departments of Emergency Medicine and Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Kristin Lewis
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| | - Thomas J Nuckton
- Department of Medicine, Sutter Eden Medical Center, 20103 Lake Chabot Road Castro Valley, CA 94546, United States of America.
| | - Bryan Darger
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Dawn Troeger
- Department of Medicine, Sutter Eden Medical Center, 20103 Lake Chabot Road Castro Valley, CA 94546, United States of America.
| | - Soo Y Jung
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza Camden, NJ 08103, United States of America.
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
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Salzman M, Cruz L, Nairn S, Bechmann S, Karmakar R, Baumann BM. The Prevalence of Modifiable Parental Behaviors Associated with Inadvertent Pediatric Medication Ingestions. West J Emerg Med 2019; 20:269-277. [PMID: 30881547 PMCID: PMC6404704 DOI: 10.5811/westjem.2018.12.40952] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Our aim was to examine potential risk factors and modifiable behaviors that could lead to pediatric poisonings. Our secondary objectives were to explore socioeconomic factors associated with caregiver (parent/guardian) safe medication storage and knowledge of poison control contact information. Methods We conducted a prospective, cross-sectional survey of caregivers of patients 2–10 years old presenting to an inner city pediatric emergency department. Caregiver and patient demographic data, prescription and nonprescription medication type, storage and when and where taken, were recorded. We used multivariable regression to explore factors associated with secure prescription medication storage and knowledge of poison control center contact information. Results Of 1457 caregivers, 29% took daily prescription and 17% took daily non-prescription medications. Only 25% of caregivers stored their prescription medications in a secure place, and <3% stored medications in a locked drawer or safe. Of demographic and socioeconomic factors, only income ≥$80,000 was associated with storage of prescription medication in a secure place (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.27–4.81). When asked how they would access poison control in case of an ingestion, the majority, 86%, had an appropriate plan. In multivariable regression, the only factor associated with knowledge of poison control center contact information was college education in the caregiver (OR 1.6; 95% CI, 1.10–2.32). Conclusion A minority of caregivers store medications in a safe place and even fewer keep prescription medications under lock and key. The majority, however, were aware of how to contact a poison control center in case of ingestion.
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Affiliation(s)
- Matthew Salzman
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Lia Cruz
- Cooper Medical School of Rowan University, Department of Pediatrics, Camden, New Jersey
| | - Sandra Nairn
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Samuel Bechmann
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Rupa Karmakar
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Brigitte M Baumann
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
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11
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Rodriguez RM, Greenwood JC, Nuckton TJ, Darger B, Shofer FS, Troeger D, Jung SY, Speich KG, Valencia J, Kilgannon JH, Fernandez D, Baumann BM. Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness. Emerg Med J 2018; 35:350-356. [PMID: 29720475 DOI: 10.1136/emermed-2017-207383] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/06/2018] [Accepted: 03/28/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We sought to compare the quick sequential organ failure assessment (qSOFA) to systemic inflammatory response syndrome (SIRS), severe sepsis criteria and lactate levels for their ability to identify ED patients with sepsis with critical illness. METHODS We conducted this multicenter retrospective cohort study at five US hospitals, enrolling all adult patients admitted to these hospitals from their EDs with infectious disease-related illnesses from 1 January 2016 to 30 April 2016. We abstracted clinical variables for SIRS, severe sepsis and qSOFA scores, using values in the first 6 hours of ED stay. Our primary outcome was critical illness, defined as one or more of the composite outcomes of death, vasopressor use or intensive care unit (ICU) admission within 72 hours of presentation. We determined diagnostic test characteristics for qSOFA scores, SIRS, severe sepsis criteria and lactate level thresholds. MAIN RESULTS Of 3743 enrolled patients, 512 (13.7%) had the primary composite outcome. The qSOFA scores were ≥1, >2 and 3 in 1839 (49.1%), 626 (16.7%) and 146 (3.9%) patients, respectively; 2202 (58.8%) met SIRS criteria and 1085 (29.0%) met severe sepsis criteria. qSOFA ≥1 and SIRS had similarly high sensitivity [86.1% (95% CI 82.8% to 89.0%) vs 86.7% (95% CI 83.5% to 89.5%)], but qSOFA ≥1 had higher specificity [56.7% (95% CI 55.0% to 58.5%) vs 45.6% (43.9% to 47.3%); mean difference 11.1% (95% CI 8.7% to 13.6%)]. qSOFA ≥2 had higher specificity than severe sepsis criteria [89.1% (88.0% to 90.2%) vs 77.5% (76.0% to 78.9%); mean difference 11.6% (9.8% to 13.4%)]. qSOFA ≥1 had greater sensitivity than a lactate level ≥2 (mean difference 24.6% (19.2% to 29.9%)). CONCLUSION For patients admitted from the ED with infectious disease diagnoses, qSOFA criteria performed as well or better than SIRS criteria, severe sepsis criteria and lactate levels in predicting critical illness.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas J Nuckton
- Department of Medicine, Sutter Eden Medical Center, San Francisco, California, USA
| | - Bryan Darger
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dawn Troeger
- Department of Medicine, Sutter Eden Medical Center, San Francisco, California, USA
| | - Soo Y Jung
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelly G Speich
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Joel Valencia
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Danny Fernandez
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
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Byrne R, Barbas B, Baumann BM, Patel SN. Medical Student Perception of Resident Versus Attending Contributions to Education on Co-Supervised Shifts During the Emergency Medicine Clerkship. AEM Educ Train 2018; 2:82-85. [PMID: 30051073 PMCID: PMC6001488 DOI: 10.1002/aet2.10091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/17/2018] [Accepted: 01/28/2018] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The objective was to assess medical student perception of resident and attending contributions to nine Accreditation Council for Graduate Medical Education educational objectives during their emergency medicine (EM) clerkship. METHODS This was a prospective survey study of fourth-year medical students during their EM clerkship in a single academic emergency department. Students anonymously completed end-of-shift surveys if supervised by both resident and attending physicians. Students estimated the relative educational contribution from resident and attending on a 100-point visual analog scale (-50 to 50) with -50 = 100% resident contribution, +50 = 100% attending contribution, and 0 = equal contributions by resident and attendings. Nine educational objectives were surveyed: evidence-based medicine (EBM), clinical knowledge, chart documentation, bedside teaching, patient throughput, interpersonal communication, oral patient presentations, efficiency, and procedural instruction. RESULTS We collected 274 surveys from 65 students. Of the nine objectives, students perceived that residents contributed more than attendings in eight of nine (results reported as mean values with 95% confidence intervals): clinical knowledge -4.5 (-7.3 to -1.7), chart documentation -8.0 (-12.0 to -4.0), bedside teaching -8.6 (-12.0 to -5.2), throughput -13.0 (-16.4 to -9.6), oral presentations -14.2 (-17.3 to -11), efficiency -14.4 (-17.6 to -11.3), procedural instruction -20.2 (-24.0 to -16.5), and interpersonal communication -13.5 (-17.7 to -9.4). The sole outlier favoring attendings was EBM: 5.5 (1.9 to 9.1). CONCLUSIONS Medical students perceive resident physicians to contribute more than attendings for most of their EM educational objectives, with faculty providing the greatest contribution to their EBM training.
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Affiliation(s)
- Richard Byrne
- Department of Emergency MedicineCooper Medical School of Rowan UniversityCamdenNJ
| | - Brian Barbas
- Department of Emergency MedicineCooper Medical School of Rowan UniversityCamdenNJ
| | - Brigitte M. Baumann
- Department of Emergency MedicineCooper Medical School of Rowan UniversityCamdenNJ
| | - Sundip N. Patel
- Department of Emergency MedicineCooper Medical School of Rowan UniversityCamdenNJ
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13
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Murphy CE, Raja AS, Baumann BM, Medak AJ, Langdorf MI, Nishijima DK, Hendey GW, Mower WR, Rodriguez RM. Rib Fracture Diagnosis in the Panscan Era. Ann Emerg Med 2017; 70:904-909. [PMID: 28559032 DOI: 10.1016/j.annemergmed.2017.04.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 03/22/2017] [Accepted: 04/04/2017] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE With increased use of chest computed tomography (CT) in trauma evaluation, traditional teachings in regard to rib fracture morbidity and mortality may no longer be accurate. We seek to determine rates of rib fracture observed on chest CT only; admission and mortality of patients with isolated rib fractures, rib fractures observed on CT only, and first or second rib fractures; and first or second rib fracture-associated great vessel injury. METHODS We conducted a planned secondary analysis of 2 prospectively enrolled cohorts of the National Emergency X-Radiography Utilization Study chest studies, which evaluated patients with blunt trauma who were older than 14 years and received chest imaging in the emergency department. We defined rib fractures and other thoracic injuries according to CT reports and followed patients through their hospital course to determine outcomes. RESULTS Of 8,661 patients who had both chest radiograph and chest CT, 2,071 (23.9%) had rib fractures, and rib fractures were observed on chest CT only in 1,368 cases (66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%; mean difference 42.9%; 95% confidence interval [CI] 41.4% to 44.4%) and mortality (5.6% versus 2.7%; mean difference 2.9%; 95% CI 1.8% to 4.0%) than patients without rib fracture. The mortality of patients with rib fracture observed on chest CT only was not statistically significantly different from that of patients with fractures also observed on chest radiograph (4.8% versus 5.7%; mean difference -0.9%; 95% CI -3.1% to 1.1%). Patients with first or second rib fractures had significantly higher mortality (7.4% versus 4.1%; mean difference 3.3%; 95% CI 0.2% to 7.1%) and prevalence of concomitant great vessel injury (2.8% versus 0.6%; mean difference 2.2%; 95% CI 0.6% to 4.9%) than patients with fractures of ribs 3 to 12, and the odds ratio of great vessel injury with first or second rib fracture was 4.4 (95% CI 1.8 to 10.4). CONCLUSION Under trauma imaging protocols that commonly incorporate chest CT, two thirds of rib fractures were observed on chest CT only. Patients with rib fractures had higher admission rates and mortality than those without rib fractures. First or second rib fractures were associated with significantly higher mortality and great vessel injury.
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Affiliation(s)
- Charles E Murphy
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Anthony J Medak
- Department of Emergency Medicine, University of California-San Diego School of Medicine, San Diego, CA
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California-Irvine, Irvine, CA
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California-Davis, Davis, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California-San Francisco Fresno Medical Education Program, Fresno, CA
| | - William R Mower
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA.
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Haskins BL, Davis-Martin R, Abar B, Baumann BM, Harralson T, Boudreaux ED. Health Evaluation and Referral Assistant: A Randomized Controlled Trial of a Web-Based Screening, Brief Intervention, and Referral to Treatment System to Reduce Risky Alcohol Use Among Emergency Department Patients. J Med Internet Res 2017; 19:e119. [PMID: 28461283 PMCID: PMC5432666 DOI: 10.2196/jmir.6812] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/02/2017] [Accepted: 02/06/2017] [Indexed: 11/17/2022] Open
Abstract
Background Computer technologies hold promise for implementing alcohol screening, brief intervention, and referral to treatment (SBIRT). Questions concerning the most effective and appropriate SBIRT model remain. Objective The aim of this study was to evaluate the impact of a computerized SBIRT system called the Health Evaluation and Referral Assistant (HERA) on risky alcohol use treatment initiation. Methods Alcohol users (N=319) presenting to an emergency department (ED) were considered for enrollment. Those enrolled (n=212) were randomly assigned to the HERA, to complete a patient-administered assessment using a tablet computer, or a minimal-treatment control, and were followed for 3 months. Analyses compared alcohol treatment provider contact, treatment initiation, treatment completion, and alcohol use across condition using univariate comparisons, generalized estimating equations (GEEs), and post hoc chi-square analyses. Results HERA participants (n=212; control=115; intervention=97) did not differ between conditions on initial contact with an alcohol treatment provider, treatment initiation, treatment completion, or change in risky alcohol use behavior. Subanalyses indicated that HERA participants, who accepted a faxed referral, were more likely to initiate contact with a treatment provider and initiate treatment for risky alcohol use, but were not more likely to continue engaging in treatment, or to complete treatment and change risky alcohol use behavior over the 3-month period following the ED visit. Conclusions The HERA promoted initial contact with an alcohol treatment provider and initiation of treatment for those who accepted the faxed referral, but it did not lead to reduced risky alcohol use behavior. Factors which may have limited the HERA’s impact include lack of support for the intervention by clinical staff, the low intensity of the brief and stand-alone design of the intervention, and barriers related to patient follow-through, (eg, a lack of transportation or childcare, fees for services, or schedule conflicts). Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): NCT01153373; https://clinicaltrials.gov/ct2/show/NCT01153373 (Archived by WebCite at http://www.webcitation.org/6pHQEpuIF)
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Affiliation(s)
- Brianna L Haskins
- University of Massachusetts Medical School, Worcester, MA, United States
| | | | - Beau Abar
- University of Rochester Medical Center, Rochester, NY, United States
| | | | - Tina Harralson
- Polaris Health Directions, Inc, Wayne, PA, United States
| | - Edwin D Boudreaux
- University of Massachusetts Medical School, Worcester, MA, United States
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15
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Raja AS, Mower WR, Nishijima DK, Hendey GW, Baumann BM, Medak AJ, Rodriguez RM. Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria. Acad Emerg Med 2016; 23:863-9. [PMID: 27163732 DOI: 10.1111/acem.13010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The use of chest computed tomography (CT) to evaluate emergency department patients with adult blunt trauma is rising. The NEXUS Chest CT decision instruments are highly sensitive identifiers of adult blunt trauma patients with thoracic injuries. However, many patients without injury exhibit one of more of the criteria so cannot be classified "low risk." We sought to determine screening performance of both individual and combined NEXUS Chest CT criteria as predictors of thoracic injury to inform chest CT imaging decisions in "non-low-risk" patients. METHODS This was a secondary analysis of data on patients in the derivation and validation cohorts of the prospective, observational NEXUS Chest CT study, performed September 2011 to May 2014 in 11 Level I trauma centers. Institutional review board approval was obtained at all study sites. Adult blunt trauma patients receiving chest CT were included. The primary outcome was injury and major clinical injury prevalence and screening performance in patients with combinations of one, two, or three of seven individual NEXUS Chest CT criteria. RESULTS Across the 11 study sites, rates of chest CT performance ranged from 15.5% to 77.2% (median = 43.6%). We found injuries in 1,493/5,169 patients (28.9%) who had chest CT; 269 patients (5.2%) had major clinical injury (e.g., pneumothorax requiring chest tube). With sensitivity of 73.7 (95% confidence interval [CI] = 68.1 to 78.6) and specificity of 83.9 (95% CI = 83.6 to 84.2) for major clinical injury, abnormal chest-x-ray (CXR) was the single most important screening criterion. When patients had only abnormal CXR, injury and major clinical injury prevalences were 60.7% (95% CI = 52.2% to 68.6%) and 12.9% (95% CI = 8.3% to 19.4%), respectively. Injury and major clinical injury prevalences when any other single criterion alone (other than abnormal CXR) was present were 16.8% (95% CI = 15.2% to 18.6%) and 1.1% (95% CI = 0.1% to 1.8%), respectively. Injury and major clinical injury prevalences among patients when two and three criteria (not abnormal CXR) were present were 25.5% (95% CI = 23.1% to 28.0%) and 3.2% (95% CI = 2.3% to 4.4%) and 34.9% (95% CI = 31.0% to 39.0%) and 2.7% (95% CI = 1.6% to 4.5%), respectively. CONCLUSIONS We recommend that clinicians check for the six clinical NEXUS Chest CT criteria and review the CXR (if obtained). If patients have one clinical criterion (other than abnormal CXR), they will have a very low risk of clinically major injury. We recommend that clinicians discuss the potential risks and benefit of chest CT in these cases. The risks of injury and major clinical injury rise incrementally with more criteria, rendering the risk/benefit ratio toward performing CT in most cases. If the patient has an abnormal CXR, the risks of major clinical injury and minor injury are considerably higher than with the other criteria-chest CT may be indicated in cases requiring greater anatomic detail and injury characterization.
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Affiliation(s)
- Ali S. Raja
- Department of Emergency Medicine; Massachusetts General Hospital and Harvard Medical School; Boston MA
| | - William R. Mower
- Department of Emergency Medicine; University of California; Los Angeles CA
| | | | - Gregory W. Hendey
- Department of Emergency Medicine; San Francisco Fresno Medical Education Program; San Francisco CA
| | - Brigitte M. Baumann
- Department of Emergency Medicine; Cooper Medical School of Rowan University; Camden NJ
| | - Anthony J. Medak
- Department of Emergency Medicine; University of California at San Diego School of Medicine; San Diego CA
| | - Robert M. Rodriguez
- Department of Emergency Medicine; University of California; San Francisco CA
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16
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Rodriguez RM, Friedman B, Langdorf MI, Baumann BM, Nishijima DK, Hendey GW, Medak AJ, Raja AS, Mower WR. Pulmonary contusion in the pan-scan era. Injury 2016; 47:1031-4. [PMID: 26708426 DOI: 10.1016/j.injury.2015.11.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/14/2015] [Accepted: 11/25/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although pulmonary contusion (PC) is traditionally considered a major injury requiring intensive monitoring, more frequent detection by chest CT in blunt trauma evaluation may diagnose clinically irrelevant PC. OBJECTIVES We sought to determine (1) the frequency of PC diagnosis by chest CT versus chest X-ray (CXR), (2) the frequency of PC-associated thoracic injuries, and (3) PC patient clinical outcomes (mortality, length of stay [LOS], and need for mechanical ventilation), considering patients with PC seen on chest CT only (SOCTO) and isolated PC (PC without other thoracic injury). METHODS Focusing primarily on patients who had both CXR and chest CT, we conducted a pre-planned analysis of two prospectively enrolled cohorts with the following inclusion criteria: age >14 years, blunt trauma within 24h of emergency department presentation, and receiving CXR or chest CT during trauma evaluation. We defined PC and other thoracic injuries according to CT reports and followed patients through their hospital course to determine clinical outcomes. RESULTS Of 21,382 enrolled subjects, 8661 (40.5%) had both CXR and chest CT and 1012 (11.7%) of these had PC, making it the second most common injury after rib fracture. PC was SOCTO in 739 (73.0%). Most (73.5%) PC patients had other thoracic injury. PC patients had higher admission rates (91.9% versus 61.7%; mean difference 30.2%; 95% confidence interval [CI] 28.1-32.1%) and mortality (4.7% versus 2.0%: mean difference 2.8%; 95% CI 1.6-4.3%) than non-PC patients, but mortality was restricted to patients with other injuries (injury severity scores>10). Patients with PC SOCTO had low rates of associated mechanical ventilation (4.6%) and patients with isolated PC SOCTO had low mortality (2.6%), comparable to that of patients without PC. CONCLUSIONS PC is commonly diagnosed under current blunt trauma imaging protocols and most PC are SOCTO with other thoracic injury. Given that they are associated with low mortality and uncommon need for mechanical ventilation, isolated PC and PC SOCTO may be of limited clinical significance.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, The University of California San Francisco, United States.
| | - Benjamin Friedman
- Department of Emergency Medicine, The University of California San Francisco, United States
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California Irvine, United States
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, United States
| | - Daniel K Nishijima
- Department of Emergency Medicine, The University of California Davis, United States
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California San Francisco Fresno Medical Education Program, United States
| | - Anthony J Medak
- Department of Emergency Medicine, University of California San Diego School of Medicine, United States
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, United States
| | - William R Mower
- Department of Emergency Medicine, University of California Los Angeles, United States
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17
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Raja AS, Lanning J, Gower A, Langdorf MI, Nishijima DK, Baumann BM, Hendey GW, Medak AJ, Mower WR, Rodriguez RM. Prevalence of Chest Injury With the Presence of NEXUS Chest Criteria: Data to Inform Shared Decisionmaking About Imaging Use. Ann Emerg Med 2015; 68:222-6. [PMID: 26607334 DOI: 10.1016/j.annemergmed.2015.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/15/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE The NEXUS chest decision instrument identifies a very-low-risk population of patients with blunt trauma for whom chest imaging can be avoided. However, it requires that all 7 National Emergency X-Ray Utilization Study (NEXUS) chest criteria be absent. To inform patient and physician shared decisionmaking about imaging, we describe the test characteristics of individual criteria of the NEXUS chest decision instrument and provide the prevalence of injuries when 1, 2, or 3 of the 7 criteria are present. METHODS We conducted this secondary analysis of 2 prospectively collected cohorts of patients with blunt trauma who were older than 14 years and enrolled in NEXUS chest studies between December 2009 and January 2012. Physicians at 9 US Level I trauma centers recorded the presence or absence of the 7 NEXUS chest criteria. We calculated test characteristics of each criterion and combinations of criteria for the outcome measures of major clinical injuries and thoracic injury observed on chest imaging. RESULTS We enrolled 21,382 patients, of whom 992 (4.6%) had major clinical injuries and 3,135 (14.7%) had thoracic injuries observed on chest imaging. Sensitivities of individual test characteristics ranged from 15% to 56% for major clinical injury and 14% to 53% for thoracic injury observed on chest imaging, with specificities varying from 71% to 84% for major clinical injury and 67% to 84% for thoracic injury observed on chest imaging. Individual criteria were associated with a prevalence of major clinical injury between 1.9% and 3.8% and of thoracic injury observed on chest imaging between 5.3% and 11.5%. CONCLUSION Patients with isolated NEXUS chest criteria have low rates of major clinical injury. The risk of major clinical injury for patients with 2 or 3 factors range from 1.7% to 16.6%, depending on the combination of criteria. Criteria-specific risks could be used to inform shared decisionmaking about the need for imaging by patients and their physicians.
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Affiliation(s)
- Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA.
| | - Jennifer Lanning
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Arian Gower
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California, Irvine, CA
| | | | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California, San Francisco Fresno Medical Education Program, San Francisco, CA
| | - Anthony J Medak
- Department of Emergency Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - William R Mower
- Department of Emergency Medicine, University of California, Los Angeles, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, CA
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Hong R, Meenan M, Prince E, Murphy R, Tambussi C, Rohrbach R, Baumann BM. Comparison of three prehospital cervical spine protocols for missed injuries. West J Emerg Med 2015; 15:471-9. [PMID: 25035754 PMCID: PMC4100854 DOI: 10.5811/westjem.2014.2.19244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 09/19/2013] [Accepted: 02/21/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction We wanted to compare 3 existing emergency medical services (EMS) immobilization protocols: the Prehospital Trauma Life Support (PHTLS, mechanism-based); the Domeier protocol (parallels the National Emergency X-Radiography Utilization Study [NEXUS] criteria); and the Hankins’ criteria (immobilization for patients <12 or >65 years, those with altered consciousness, focal neurologic deficit, distracting injury, or midline or paraspinal tenderness).To determine the proportion of patients who would require cervical immobilization per protocol and the number of missed cervical spine injuries, had each protocol been followed with 100% compliance. Methods This was a cross-sectional study of patients ≥18 years transported by EMS post-traumatic mechanism to an inner city emergency department. Demographic and clinical/historical data obtained by physicians were recorded prior to radiologic imaging. Medical record review ascertained cervical spine injuries. Both physicians and EMS were blinded to the objective of the study. Results Of 498 participants, 58% were male and mean age was 48 years. The following participants would have required cervical spine immobilization based on the respective protocol: PHTLS, 95.4% (95% CI: 93.1–96.9%); Domeier, 68.7% (95% CI: 64.5–72.6%); Hankins, 81.5% (95% CI: 77.9–84.7%). There were 18 cervical spine injuries: 12 vertebral fractures, 2 subluxations/dislocations and 4 spinal cord injuries. Compliance with each of the 3 protocols would have led to appropriate cervical spine immobilization of all injured patients. In practice, 2 injuries were missed when the PHTLS criteria were mis-applied. Conclusion Although physician-determined presence of cervical spine immobilization criteria cannot be generalized to the findings obtained by EMS personnel, our findings suggest that the mechanism-based PHTLS criteria may result in unnecessary cervical spine immobilization without apparent benefit to injured patients. PHTLS criteria may also be more difficult to implement due to the subjective interpretation of the severity of the mechanism, leading to non-compliance and missed injury.
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Affiliation(s)
- Rick Hong
- Cooper University Hospital, Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Molly Meenan
- Cooper University Hospital, Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Erin Prince
- Cooper University Hospital, Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Ronald Murphy
- Cooper University Hospital, Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Caitlin Tambussi
- Cooper University Hospital, Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Rick Rohrbach
- Cooper University Hospital, Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
| | - Brigitte M Baumann
- Cooper University Hospital, Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey
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Rodriguez RM, Langdorf MI, Nishijima D, Baumann BM, Hendey GW, Medak AJ, Raja AS, Allen IE, Mower WR. Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT). PLoS Med 2015; 12:e1001883. [PMID: 26440607 PMCID: PMC4595216 DOI: 10.1371/journal.pmed.1001883] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients. METHODS AND FINDINGS From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients-6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection. CONCLUSIONS We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.
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Affiliation(s)
- Robert M. Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
- * E-mail:
| | - Mark I. Langdorf
- Department of Emergency Medicine, University of California, Irvine, California, United States of America
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California, Davis, California, United States of America
| | - Brigitte M. Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
| | - Gregory W. Hendey
- Department of Emergency Medicine, UCSF Fresno Medical Education and Research, Fresno, California, United States of America
| | - Anthony J. Medak
- Department of Emergency Medicine, School of Medicine, University of California, San Diego, California, United States of America
| | - Ali S. Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
| | - Isabel E. Allen
- University of California, San Francisco, California, United States of America
| | - William R. Mower
- Department of Emergency Medicine, University of California, Los Angeles, California, United States of America
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Pescatore RM, Hong R, Sexton RJ, Carroll GG, Curcio EE, Blevins G, Baumann BM. Automated external defibrillator prevalence among the municipal police agencies of New Jersey: how regional differences affect national data. Public Health 2015; 129:1652-5. [PMID: 26188851 DOI: 10.1016/j.puhe.2015.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 06/10/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Affiliation(s)
- R M Pescatore
- Department of Emergency Medicine, Cooper University Healthcare, Camden, NJ, USA.
| | - R Hong
- Department of Emergency Medicine, Cooper University Healthcare, Camden, NJ, USA
| | - R J Sexton
- Department of Emergency Medicine, Cooper University Healthcare, Camden, NJ, USA
| | - G G Carroll
- Department of Emergency Medicine, Cooper University Healthcare, Camden, NJ, USA
| | - E E Curcio
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - G Blevins
- Department of Emergency Medicine, Cooper University Healthcare, Camden, NJ, USA
| | - B M Baumann
- Department of Emergency Medicine, Cooper University Healthcare, Camden, NJ, USA
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Langdorf MI, Medak AJ, Hendey GW, Nishijima DK, Mower WR, Raja AS, Baumann BM, Anglin DR, Anderson CL, Lotfipour S, Reed KE, Zuabi N, Khan NA, Bithell CA, Rowther AA, Villar J, Rodriguez RM. Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Ann Emerg Med 2015; 66:589-600. [PMID: 26169926 DOI: 10.1016/j.annemergmed.2015.06.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 05/23/2015] [Accepted: 06/01/2015] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention. METHODS Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury. RESULTS Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). CONCLUSION In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries.
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Affiliation(s)
- Mark I Langdorf
- Department of Emergency Medicine, University of California-Irvine, Orange, CA.
| | - Anthony J Medak
- Department of Emergency Medicine, University of California-San Diego, La Jolla, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California-San Francisco, Fresno, Fresno, CA
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California-Davis, Davis, CA
| | - William R Mower
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Deirdre R Anglin
- Department of Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Craig L Anderson
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Shahram Lotfipour
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Karin E Reed
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Nadia Zuabi
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Nooreen A Khan
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Chelsey A Bithell
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Armaan A Rowther
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Julian Villar
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
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Perez MR, Rodriguez RM, Baumann BM, Langdorf MI, Anglin D, Bradley RN, Medak AJ, Mower WR, Hendey GW, Nishijima DK, Raja AS. Sternal fracture in the age of pan-scan. Injury 2015; 46:1324-7. [PMID: 25817167 DOI: 10.1016/j.injury.2015.03.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/08/2015] [Accepted: 03/05/2015] [Indexed: 02/02/2023]
Abstract
STUDY OBJECTIVE Widespread chest CT use in trauma evaluation may increase the diagnosis of minor sternal fracture (SF), making former teaching about SF obsolete. We sought to determine: (1) the frequency with which SF patients are diagnosed by CXR versus chest CT under current imaging protocols, (2) the frequency of surgical procedures related to SF diagnosis, (3) SF patient mortality and hospital length of stay comparing patients with isolated sternal fracture (ISF) and sternal fracture with other thoracic injury (SFOTI), and (4) the frequency and yield of cardiac contusion (CC) workups in SF patients. METHODS We analyzed charts and data of all SF patients enrolled from January 2009 to May 2013 in the NEXUS Chest and NEXUS Chest CT studies, two multi-centre observational cohorts of blunt trauma patients who received chest imaging for trauma evaluation. RESULTS Of the 14,553 patients in the NEXUS Chest and Chest CT cohorts, 292 (2.0%) were diagnosed with SF, and 94% of SF were visible on chest CT only. Only one patient (0.4%) had a surgical procedure related to SF diagnosis. Cardiac contusion was diagnosed in 7 (2.4%) of SF patients. SF patient mortality was low (3.8%) and not significantly different than the mortality of patients without SF (3.1%) [mean difference 0.7%; 95% confidence interval (CI) -1.0 to 3.5%]. Only 2 SF patient deaths (0.7%) were attributed to a cardiac cause. SFOTI patients had longer hospital stays but similar mortality to patients with ISF (mean difference 0.8%; 95% CI -4.7% to 12.0). CONCLUSIONS Most SF are seen on CT only and the vast majority are clinically insignificant with no change in treatment and low associated mortality. Workup for CC in SF patients is a low-yield practice. SF diagnostic and management guidelines should be updated to reflect modern CT-driven trauma evaluation protocols.
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Affiliation(s)
- Michael R Perez
- Department of Emergency Medicine, The University of California San Francisco, United States.
| | - Robert M Rodriguez
- Department of Emergency Medicine, The University of California San Francisco, United States
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, United States
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California Irvine, United States
| | - Deirdre Anglin
- Department of Emergency Medicine, Keck School of Medicine - University of Southern California, United States
| | - Richard N Bradley
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, United States
| | - Anthony J Medak
- University of California San Diego School of Medicine, Department of Emergency Medicine, United States
| | - William R Mower
- Department of Emergency Medicine, University of California Los Angeles, United States
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California San Francisco Fresno Medical Education Program, United States
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis, United States
| | - Ali S Raja
- Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School, United States
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Mills AM, Baumann BM, Chen EH, Zhang KY, Glaspey LJ, Hollander JE, Pines JM. The Impact of Crowding on Time until Abdominal CT Interpretation in Emergency Department Patients with Acute Abdominal Pain. Postgrad Med 2015; 122:75-81. [DOI: 10.3810/pgm.2010.01.2101] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Cienki JJ, Guerrera AD, Steed NR, Kubo EN, Baumann BM. Impact of an Electronic Medical Record System on Emergency Department Discharge Instructions for Patients With Hypertension. Postgrad Med 2015; 125:59-66. [DOI: 10.3810/pgm.2013.09.2702] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hong R, Sexton R, Sweet B, Carroll G, Tambussi C, Baumann BM. Comparison of START triage categories to emergency department triage levels to determine need for urgent care and to predict hospitalization. Am J Disaster Med 2015; 10:13-21. [PMID: 26102041 DOI: 10.5055/ajdm.2015.0184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To compare Emergency Severity Index (ESI) triage levels and Simple Triage and Rapid Treatment (START) triage colors for urgent care and hospitalization. DESIGN Cross sectional. SETTING Inner city emergency department (ED). PARTICIPANTS Patients years transported by Emergency Medical Services (EMS) participating in the state triage tag exercise, October 9-15, 2011. INTERVENTIONS EMS assigned each patient a START triage tag. ED staff recorded tag number and color. Demographics, vital signs, 22 emergent interventions, and disposition were obtained via chart review. Institutional review board approval was obtained. MAIN OUTCOME MEASURES Presence of more than two abnormal vital sign on arrival and need for more than one emergent intervention in ED were considered indicators of acuity and severity. START triage colors were recategorized as urgent (Red, Yellow) and less acute (Green, White), and ESI was recategorized as urgent (1, 2, 3) and less acute (4, 5). RESULTS Both ED and EMS staff were blinded to the study, and 95% confidence intervals were presented for statistical significance. Of 233 participants, START triage colors were Black=0, Red=12 percent, Yellow=26 percent, Green=53 percent, and White=9 percent. ESI triage levels were level 1=1 percent, level 2=34 percent, level 3=51 percent, level 4=14 percent, and level 5=1 percent. ESI (1, 2, 3) identified 88 percent (75-95 percent) of 49 patients with abnormal vital signs; START (Red, Yellow) only identified 51 percent (35-64 percent). Twenty-one patients needed emergent intervention. ESI (1, 2, 3) identified 95 percent (76-99 percent) of these patients; START (Red, Yellow) identified 33 percent (17-55 percent). ESI (1, 2, 3) identified 98 percent of the 96(92-100 percent) admitted patients; only 48 percent (38-58 percent) were tagged START (Red, Yellow). CONCLUSION ESI better identified patients with abnormal vital signs, those who needed emergent interventions, and those admitted than START.
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Affiliation(s)
- Rick Hong
- Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Ryan Sexton
- Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Benjamin Sweet
- Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Gerard Carroll
- Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Caitlin Tambussi
- Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
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Sarwer DB, Ritter S, Reiser K, Spitzer JC, Baumann BM, Patel SN, Mazzarelli AJ, Levin LS, Doll S, Caplan AL. Attitudes Toward Vascularized Composite Allotransplantation of the Hands and Face in an Urban Population. ACTA ACUST UNITED AC 2014. [DOI: 10.4161/23723505.2014.975021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Varon J, Soto-Ruiz KM, Baumann BM, Borczuk P, Cannon CM, Chandra A, Cline DM, Diercks DB, Hiestand B, Hsu A, Jois-Bilowich P, Kaminski B, Levy P, Nowak RM, Schrock JW, Peacock WF. The management of acute hypertension in patients with renal dysfunction: labetalol or nicardipine? Postgrad Med 2014; 126:124-30. [PMID: 25141250 DOI: 10.3810/pgm.2014.07.2790] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
STUDY OBJECTIVES To compare the safety and efficacy of U.S. Food and Drug Administration (FDA)-recommended doses of labetalol and nicardipine for hypertension (HTN) management in a subset of patients with renal dysfunction (RD). DESIGN Randomized, open label, multicenter prospective clinical trial. SETTING Thirteen United States tertiary care emergency departments. PATIENTS OR PARTICIPANTS Subgroup analysis of the Evaluation of IV Cardene (Nicardipine) and Labetalol Use in the Emergency Department (CLUE) clinical trial. The subjects were 104 patients with RD (i.e., creatinine clearance < 75 mL/min) who presented to the emergency department with a systolic blood pressure (SBP) ≥ 180 mmHg on 2 consecutive readings and for whom the emergency physician felt intravenous antihypertensive therapy was desirable. INTERVENTIONS The FDA recommended doses of either labetalol or nicardipine for HTN management. MEASUREMENTS The number of patients achieving the physician's predefined target SBP range within 30 minutes of treatment. RESULTS Patients treated with nicardipine were within target range more often than those receiving labetalol (92% vs. 78%, P = 0.046). On 6 SBP measures, patients treated with nicardipine were more likely to achieve the target range on either 5 or all 6 readings than were patients treated with labetalol (46% vs. 25%, P = 0.024). Labetalol patients were more likely to require rescue medication (27% vs. 17%, P = 0.020). Adverse events thought to be related to either treatment group were not reported in the 30-minute active study period, and patients had slower heart rates at all time points after 5 minutes (P < 0.01). CONCLUSIONS In severe HTN with RD, nicardipine-treated patients are more likely to reach a target blood pressure range within 30 minutes than are patients receiving labetalol. CLINICAL IMPLICATIONS Within 30 minutes of administration, nicardipine is more efficacious than labetalol for acute blood pressure control in patients with RD.
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Affiliation(s)
- Joseph Varon
- Department of Emergency Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX.
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Rodriguez RM, Baumann BM, Raja AS, Langdorf MI, Anglin D, Bradley RN, Medak AJ, Mower WR, Hendey GW. Diagnostic yields, charges, and radiation dose of chest imaging in blunt trauma evaluations. Acad Emerg Med 2014; 21:644-50. [PMID: 25039548 DOI: 10.1111/acem.12396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/09/2014] [Accepted: 01/13/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chest radiography (CXR) is the most common imaging in adult blunt trauma patient evaluation. Knowledge of the yields, attendant costs, and radiation doses delivered may guide effective chest imaging utilization. OBJECTIVES The objectives were to determine the diagnostic yields of blunt trauma chest imaging (CXR and chest computed tomography [CT]), to estimate charges and radiation exposure per injury identified, and to delineate assessment points in blunt trauma evaluation at which decision instruments for selective chest imaging would have the greatest effect. METHODS From December 2009 to January 2012, we enrolled patients older than 14 years who received CXR during blunt trauma evaluations at nine U.S. Level I trauma centers in this prospective, observational study. Thoracic injury seen on chest imaging and clinical significance of the injury were defined by a trauma expert panel. Yields of imaging were calculated, as well as mean charges and effective radiation dose (ERD) per injury. RESULTS Of 9,905 enrolled patients, 55.4% had CXR alone, 42.0% had both CXR and CT, and 2.6% had CT alone. The yields for detecting thoracic injury were CXR 8.4% (95% confidence intervals [CIs]) = 7.8% to 8.9%), chest CT 28.8% (95% CI = 27.5% to 30.2%), and chest CT after normal CXR 15.0% (95% CI = 13.9% to 16.2%). The mean charges and ERD (millisievert [mSv]) per injury diagnosis of CXR, chest CT, and chest CT after normal CXR were $3,845 (0.24 mSv), $10,597 (30.9 mSv), and $20,347 (59.3 mSv), respectively. The mean charges and ERD per clinically major thoracic injury diagnosis on chest CT after normal CXR were $203,467 and 593 mSv. CONCLUSIONS Despite greater diagnostic yield, chest CT entails substantially higher charges and radiation dose per injury diagnosed, especially when performed after a normal CXR. Selective chest imaging decision instruments should identify patients who require no chest imaging and patients who may benefit from chest CT after a normal CXR.
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Affiliation(s)
- Robert M. Rodriguez
- Department of Emergency Medicine; The University of California at San Francisco; San Francisco CA
| | - Brigitte M. Baumann
- The Department of Emergency Medicine; Cooper Medical School of Rowan University; Camden NJ
| | - Ali S. Raja
- The Department of Emergency Medicine; Brigham and Women's Hospital/Harvard Medical School; Boston MA
| | - Mark I. Langdorf
- The Department of Emergency Medicine; University of California at Irvine; Irvine CA
| | - Deirdre Anglin
- The Department of Emergency Medicine; Keck School of Medicine-University of Southern California; Los Angeles CA
| | - Richard N. Bradley
- The Department of Emergency Medicine; The University of Texas Health Science Center at Houston; Houston TX
| | - Anthony J. Medak
- The Department of Emergency Medicine; University of California at San Diego School of Medicine; San Diego CA
| | - William R. Mower
- The Department of Emergency Medicine; University of California at Los Angeles; Los Angeles CA
| | - Gregory W. Hendey
- The Department of Emergency Medicine; University of California at San Francisco Fresno Medical Education Program; Fresno CA
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Rodriguez RM, Anglin D, Langdorf MI, Baumann BM, Hendey GW, Bradley RN, Medak AJ, Raja AS, Juhn P, Fortman J, Mulkerin W, Mower WR. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 2013; 148:940-6. [PMID: 23925583 DOI: 10.1001/jamasurg.2013.2757] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Chest radiography (chest x-ray [CXR] and chest computed tomography [CT]) is the most common imaging in blunt trauma evaluation. Unnecessary trauma imaging leads to greater costs, emergency department time, and patient exposure to ionizing radiation. OBJECTIVE To validate our previously derived decision instrument (NEXUS Chest) for identification of blunt trauma patients with very low risk of thoracic injury seen on chest imaging (TICI). We hypothesized that NEXUS Chest would have high sensitivity (>98%) for the prediction of TICI and TICI with major clinical significance. DESIGN, SETTING, AND PARTICIPANTS From December 2009 to January 2012, we enrolled blunt trauma patients older than 14 years who received chest radiography in this prospective, observational, diagnostic decision instrument study at 9 US level I trauma centers. Prior to viewing radiographic results, physicians recorded the presence or absence of the NEXUS Chest 7 clinical criteria (age >60 years, rapid deceleration mechanism, chest pain, intoxication, abnormal alertness/mental status, distracting painful injury, and tenderness to chest wall palpation). MAIN OUTCOMES AND MEASURES Thoracic injury seen on chest imaging was defined as pneumothorax, hemothorax, aortic or great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion or laceration seen on radiographs. An expert panel generated an a priori classification of clinically major, minor, and insignificant TICIs according to associated management changes. RESULTS Of 9905 enrolled patients, 43.1% had a single CXR, 42.0% had CXR and chest CT, 6.7% had CXR and abdominal CT (without chest CT), 5.5% had multiple CXRs without CT, and 2.6% had chest CT alone in the emergency department. The most common trauma mechanisms were motorized vehicle crash (43.9%), fall (27.5%), pedestrian struck by motorized vehicle (10.7%), bicycle crash (6.3%), and struck by blunt object, fists, or kicked (5.8%). Thoracic injury seen on chest imaging was seen in 1478 (14.9%) patients with 363 (24.6%) of these having major clinical significance, 1079 (73.0%) minor clinical significance, and 36 (2.4%) no clinical significance. NEXUS Chest had a sensitivity of 98.8% (95% CI, 98.1%-99.3%), a negative predictive value of 98.5% (95% CI, 97.6%.6-99.1%), and a specificity of 13.3% (95% CI, 12.6%-14.1%) for TICI. The sensitivity and negative predictive value for TICI with clinically major injury were 99.7% (95% CI, 98.2%-100.0%) and 99.9% (95% CI, 99.4%-100.0%), respectively. CONCLUSIONS AND RELEVANCE We have validated the NEXUS Chest decision instrument, which may safely reduce the need for chest imaging in blunt trauma patients older than 14 years.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, The University of California San Francisco School of Medicine, San Francisco General Hospital
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Boudreaux ED, Abar B, Baumann BM, Grissom G. A randomized clinical trial of the health evaluation and referral assistant (HERA): research methods. Contemp Clin Trials 2013; 35:87-96. [PMID: 23665335 DOI: 10.1016/j.cct.2013.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/26/2013] [Accepted: 04/29/2013] [Indexed: 10/26/2022]
Abstract
The Health Evaluation and Referral Assistant (HERA) is a web-based program designed to facilitate screening, brief intervention, and referral to treatment (SBIRT) for tobacco, alcohol, and drug abuse. After the patient completes a computerized substance abuse assessment, the HERA produces a summary report with evidence-based recommended clinical actions for the healthcare provider (the Healthcare Provider Report) and a report for the patient (the Patient Feedback Report) that provides education regarding the consequences of use, personally tailored motivational messages, and a tailored substance abuse treatment referral list. For those who provide authorization, the HERA faxes the individual's contact information to a substance abuse treatment provider matched to the individual's substance use severity and personal characteristics, like insurance and location of residence (dynamic referral). This paper summarizes the methods used for a randomized controlled trial to evaluate the HERA's efficacy in leading to increased treatment initiation and reduced substance use. The study was performed in four emergency departments. Individual patients were randomized into one of two conditions: the HERA or assessment only. A total of 4269 patients were screened and 1006 participants enrolled. The sample was comprised of 427 tobacco users, 212 risky alcohol users, and 367 illicit drug users. Forty-two percent used more than one substance class. The enrolled sample was similar to the eligible patient population. The study should enhance understanding of whether computer-facilitated SBIRT can impact process of care variables, such as promoting substance abuse treatment initiation, as well as its effect on subsequent substance abuse and related outcomes.
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Affiliation(s)
- Edwin D Boudreaux
- The Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
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Cannon CM, Levy P, Baumann BM, Borczuk P, Chandra A, Cline DM, Diercks DB, Hiestand B, Hsu A, Jois P, Kaminski B, Nowak RM, Schrock JW, Varon J, Peacock WF. Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial. BMJ Open 2013; 3:e002338. [PMID: 23535700 PMCID: PMC3612758 DOI: 10.1136/bmjopen-2012-002338] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 02/16/2013] [Accepted: 02/22/2013] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD). DESIGN Secondary analysis of the multicentre prospective, randomised CLUE trial. SETTING 13 academic emergency departments in the USA. PARTICIPANTS Eligible patients had two systolic blood pressure (SBP) measures ≥180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival. INTERVENTIONS Medications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP ±20 mm Hg was achieved. PRIMARY OUTCOME MEASURE Percentage of participants achieving a predefined target SBP range (TR) defined as an SBP within ±20 mm Hg as established by the treating physician. RESULTS Of the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2±13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72). CONCLUSIONS In the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol. CLINICAL TRIAL REGISTRATION NCT00765648, clinicaltrials.gov.
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Affiliation(s)
- Chad M Cannon
- Department of Emergency Medicine, University of Kansas Hospital, Kansas City, Kansas, USA
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University, Detroit, Michigan, USA
- Cardiovascular Research Institute, Wayne State University, Detroit, Michigan, USA
| | - Brigitte M Baumann
- Division of Clinical Research, Cooper University Hospital, Camden, New Jersey, USA
- Department of Emergency Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Abhinav Chandra
- Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - David M Cline
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Deborah B Diercks
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, California, USA
| | - Brian Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Amy Hsu
- Cardiovascular Medicine, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Preeti Jois
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Richard M Nowak
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jon W Schrock
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Joseph Varon
- Department of Medicine and Acute and Continuing Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- The University of Texas Medical Branch at Galveston, Houston, Texas, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
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Boudreaux ED, Bedek KL, Byrne NJ, Baumann BM, Lord SA, Grissom G. The Computer-Assisted Brief Intervention for Tobacco (CABIT) program: a pilot study. J Med Internet Res 2012. [PMID: 23208070 PMCID: PMC3799483 DOI: 10.2196/jmir.2074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Health care providers do not routinely carry out brief counseling for tobacco cessation despite the evidence for its effectiveness. For this intervention to be routinely used, it must be brief, be convenient, require little investment of resources, require little specialized training, and be perceived as efficacious by providers. Technological advances hold much potential for addressing the barriers preventing the integration of brief interventions for tobacco cessation into the health care setting. Objective This paper describes the development and initial evaluation of the Computer-Assisted Brief Intervention for Tobacco (CABIT) program, a web-based, multimedia tobacco intervention for use in opportunistic settings. Methods The CABIT uses a self-administered, computerized assessment to produce personalized health care provider and patient reports, and cue a stage-matched video intervention. Respondents interested in changing their tobacco use are offered a faxed referral to a “best matched” tobacco treatment provider (ie, dynamic referral). During 2008, the CABIT program was evaluated in an emergency department, an employee assistance program, and a tobacco dependence program in New Jersey. Participants and health care providers completed semistructured interviews and satisfaction ratings of the assessment, reports, video intervention, and referrals using a 5-point scale. Results Mean patient satisfaction scores (n = 67) for all domains ranged from 4.00 (Good) to 5.00 (Excellent; Mean = 4.48). Health care providers completed satisfaction forms for 39 patients. Of these 39 patients, 34 (87%) received tobacco resources and referrals they would not have received under standard care. Of the 45 participants offered a dynamic referral, 28 (62%) accepted. Conclusions The CABIT program provided a user-friendly, desirable service for tobacco users and their health care providers. Further development and clinical trial testing is warranted to establish its effectiveness in promoting treatment engagement and tobacco cessation.
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Affiliation(s)
- Edwin D Boudreaux
- University of Massachusetts Medical School, Emergency Medicine, Worcester, United States.
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Tappe KA, Boudreaux ED, Bock B, O'Hea E, Baumann BM, Hollenberg SM, Becker B, Chapman GB. Smoking, cardiac symptoms, and an emergency care visit: a mixed methods exploration of cognitive and emotional reactions. Emerg Med Int 2012; 2012:935139. [PMID: 22997584 PMCID: PMC3444830 DOI: 10.1155/2012/935139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 05/20/2012] [Accepted: 07/12/2012] [Indexed: 11/17/2022] Open
Abstract
Emergency departments and hospitals are being urged to implement onsite interventions to promote smoking cessation, yet little is known about the theoretical underpinnings of behavior change after a healthcare visit. This observational pilot study evaluated three factors that may predict smoking cessation after an acute health emergency: perceived illness severity, event-related emotions, and causal attribution. Fifty smokers who presented to a hospital because of suspected cardiac symptoms were interviewed, either in the emergency department (ED) or, for those who were admitted, on the cardiac inpatient units. Their data were analyzed using both qualitative and quantitative methodologies to capture the individual, first-hand experience and to evaluate trends over the illness chronology. Reported perceptions of the event during semistructured interview varied widely and related to the individual's intentions regarding smoking cessation. No significant differences were found between those interviewed in the ED versus the inpatient unit. Although the typical profile was characterized by a peak in perceived illness severity and negative emotions at the time the patient presented in the ED, considerable pattern variation occurred. Our results suggest that future studies of event-related perceptions and emotional reactions should consider using multi-item and multidimensional assessment methods rated serially over the event chronology.
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Affiliation(s)
- Karyn A. Tappe
- Department of Biostatistics and Epidemiology, Center for Health Behavior Research, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edwin D. Boudreaux
- Departments of Emergency Medicine, Psychiatry, and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Beth Bock
- Centers for Behavioral and Preventive Medicine, Providence, RI 02903, USA
| | - Erin O'Hea
- Department of Psychology, Stonehill College, Easton, MA 02357, USA
| | - Brigitte M. Baumann
- Division of Clinical Research, Department of Emergency Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Steven M. Hollenberg
- Division of Cardiovascular Diseases, Cooper University Hospital, Camden, NJ 08103, USA
| | - Bruce Becker
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
| | - Gretchen B. Chapman
- Department of Psychology, Rutgers University, Piscataway, NJ 08854-8097, USA
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Mills AM, Huckins DS, Kwok H, Baumann BM, Ruddy RM, Rothman RE, Schrock JW, Lovecchio F, Krief WI, Hexdall A, Caspari R, Cohen B, Lewis RJ. Diagnostic characteristics of S100A8/A9 in a multicenter study of patients with acute right lower quadrant abdominal pain. Acad Emerg Med 2012; 19:48-55. [PMID: 22221415 DOI: 10.1111/j.1553-2712.2011.01259.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVES Over the past decade, clinicians have become increasingly reliant on computed tomography (CT) for the evaluation of patients with suspected acute appendicitis. To limit the radiation risks and costs of CT, investigators have searched for biomarkers to aid in diagnostic decision-making. We evaluated one such biomarker, calprotectin or S100A8/A9, and determined the diagnostic performance characteristics of a developmental biomarker assay in a multicenter investigation of patients presenting with acute right lower quadrant abdominal pain. METHODS This was a prospective, double-blinded, single-arm, multicenter investigation performed in 13 emergency departments (EDs) from August 2009 to April 2010 of patients presenting with acute right lower quadrant abdominal pain. Plasma samples were tested using the investigational S100A8/A9 assay. The primary outcome of acute appendicitis was determined by histopathology for patients undergoing appendectomy or 2-week telephone follow-up for patients discharged without surgery. The sensitivity, specificity, negative likelihood ratio (LR-), and positive likelihood ratio (LR+) of the biomarker assay were calculated using the prespecified cutoff value of 14 units. A post hoc stability study was performed to investigate the potential effect of time and courier transport on the measured value of the S100A8/A9 assay test results. RESULTS Of 1,052 enrolled patients, 848 met criteria for analysis. The median age was 24.5 years (interquartile range [IQR] = 16-38 years), 57% were female, and 50% were white. There was a 27.5% prevalence of acute appendicitis. The sensitivity and specificity for the investigational S100A8/A9 assay in diagnosing acute appendicitis were estimated to be 96% (95% confidence interval [CI] = 93% to 98%) and 16% (95% CI = 13% to 19%), respectively. The LR- ratio was 0.24 (95% CI = 0.12 to 0.47), and the LR+ was 1.14 (95% CI = 1.10 to 1.19). The post hoc stability study demonstrated that in the samples that were shipped, the estimated time coefficient was 7.6 × 10(-3) ± 2.0 × 10(-3) log units/hour, representing an average increase of 43% in the measured value over 48 hours; in the samples that were not shipped, the estimated time coefficient was 2.5 × 10(-3) ± 0.4 × 10(-3) log units/hour, representing a 13% increase on average in the measured value over 48 hours, which was the maximum delay allowed by the study protocol. Thus, adjusting the cutoff value of 14 units by the magnitude of systematic inflation observed in the stability study at 48 hours would result in a new cutoff value of 20 units and a "corrected" sensitivity and specificity of 91 and 28%, respectively. CONCLUSIONS In patients presenting with acute right lower quadrant abdominal pain, we found the investigational enzyme-linked immunosorbent assay (ELISA) test for S100A8/A9 to perform with high sensitivity but very limited specificity. We found that shipping effect and delay in analysis resulted in a subsequent rise in test values, thereby increasing the sensitivity and decreasing the specificity of the test. Further investigation with hospital-based laboratory analyzers is the next critical step for determining the ultimate clinical utility of the ELISA test for S100A8/A9 in ED patients presenting with acute right lower quadrant abdominal pain.
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Affiliation(s)
- Angela M Mills
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Cassidy-Smith T, Mistry RD, Russo CJ, McCans K, Brown N, Capano-Wehrle LM, Drago LA, Vitale PA, Baumann BM. Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children. Am J Emerg Med 2012; 30:104-9. [DOI: 10.1016/j.ajem.2010.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 10/18/2010] [Accepted: 10/19/2010] [Indexed: 10/18/2022] Open
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Cassidy-Smith TN, Kilgannon JH, Nyce AL, Chansky ME, Baumann BM. Impact of a teaching attending physician on medical student, resident, and faculty perceptions and satisfaction. CAN J EMERG MED 2011; 13:259-66. [PMID: 21722555 DOI: 10.2310/8000.2011.110289] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine if a dedicated teaching attending for medical student education improves medical student, attending physician, and resident perceptions and satisfaction. METHODS Two dedicated teaching attending physician shifts were added to the clinical schedule each week. A before-after trial compared medical student evaluations from 2000 to 2004 (preteaching attending physician) to medical student evaluations from 2005 to 2006 (teaching attending physician). Attending physician and resident perceptions and satisfaction with the teaching attending physician shifts using a 5-point Likert-type scale (1 = poor to 5 = excellent) were also assessed. RESULTS Eighty-nine (100%) medical students participated, with 63 preteaching attending physician and 26 teaching attending physician rotation evaluations. The addition of teaching attending physician shifts improved mean medical student satisfaction with bedside teaching (4.1 to 4.5), lecture satisfaction (4.2 to 4.8), preceptor scores (4.3 to 4.8), and perceived usefulness of the rotation (4.5 to 5.0) (all p < 0.05). Thirteen attending physicians (93%) participated in the cross-sectional questionnaire. The addition of teaching attending physician shifts improved faculty ratings of their medical student interactions by ≥ 1.5 points for all items (p ≤ 0.001). Faculty perceptions of their resident interactions improved for quality of bedside teaching (3.1 to 4.0), their availability to hear resident presentations (3.4 to 4.2), and their supervision of residents (3.4 to 4.1) (p ≤ 0.01). Residents (n = 35) noted minor improvements with the timeliness of patient dispositions, faculty bedside teaching, and attending physician availability. CONCLUSIONS The addition of select teaching attending physician shifts had the greatest effect on medical student and faculty perceptions and satisfaction, with some improvements for residents.
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Affiliation(s)
- Tara N Cassidy-Smith
- Department of Emergency Medicine, Cooper University Hospital and University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School at Camden, Camden, NJ 08103, USA
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Abar B, Baumann BM, Rosenbaum C, Boyer E, Boudreaux ED. Readiness to change alcohol and illicit drug use among a sample of emergency department patients. Journal of Substance Use 2011. [DOI: 10.3109/14659891.2011.580413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
OBJECTIVE This study examined whether rulers of importance, readiness and confidence (IRC) in quitting smoking could be used to identify subgroups of smokers, with the future goal of potentially tailoring interventions to specific readiness profiles. METHODS Consecutive emergency department patients ≥18 years old were considered for enrolment. Participants provided information on their tobacco use and motivation to quit smoking using 10-point IRC rulers. We used latent profile analysis on the IRC rulers to identify subgroups of smokers and examined associations between profile membership and participant's nicotine dependence and demographics. RESULTS A total of 1549 patients were screened, yielding a sample of 609 tobacco users. According to statistical fit indices, a four-profile solution fits best: 32% displayed maximum importance and readiness with strong confidence, 43% of the sample displayed relatively average levels of all three variables, 17% displayed below average importance with least favourable readiness and confidence and 7% displayed least favourable importance and readiness but relatively high confidence. Profiles were then shown to differ on nicotine dependence and educational level. CONCLUSIONS Four distinct profiles of IRC responses were observed. Identifying and describing these patterns has the potential to enhance future targeted intervention efforts and has implications for theory development.
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Affiliation(s)
- Beau Abar
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ, USA
| | - Christopher Rosenbaum
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Edward Boyer
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Douglas Ziedonis
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Edwin D Boudreaux
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA ; Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA ; Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Baumann BM, Cline DM, Pimenta E. Treatment of hypertension in the emergency department. ACTA ACUST UNITED AC 2011; 5:366-77. [DOI: 10.1016/j.jash.2011.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 04/22/2011] [Accepted: 05/06/2011] [Indexed: 12/18/2022]
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Peacock WF, Varon J, Baumann BM, Borczuk P, Cannon CM, Chandra A, Cline DM, Diercks D, Hiestand B, Hsu A, Jois-Bilowich P, Kaminski B, Levy P, Nowak RM, Schrock JW. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Crit Care 2011; 15:R157. [PMID: 21707983 PMCID: PMC3219031 DOI: 10.1186/cc10289] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 05/31/2011] [Accepted: 06/27/2011] [Indexed: 01/07/2023]
Abstract
Introduction Our purpose was to compare the safety and efficacy of food and drug administration (FDA) recommended dosing of IV nicardipine versus IV labetalol for the management of acute hypertension. Methods Multicenter randomized clinical trial. Eligible patients had 2 systolic blood pressure (SBP) measures ≥180 mmHg and no contraindications to nicardipine or labetalol. Before randomization, the physician specified a target SBP ± 20 mmHg (the target range: TR). The primary endpoint was the percent of subjects meeting TR during the initial 30 minutes of treatment. Results Of 226 randomized patients, 110 received nicardipine and 116 labetalol. End organ damage preceded treatment in 143 (63.3%); 71 nicardipine and 72 labetalol patients. Median initial SBP was 212.5 (IQR 197, 230) and 212 mmHg (IQR 200,225) for nicardipine and labetalol patients (P = 0.68), respectively. Within 30 minutes, nicardipine patients more often reached TR than labetalol (91.7 vs. 82.5%, P = 0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within TR than labetalol (47.3% vs. 32.8%, P = 0.026). Rescue medication need did not differ between nicardipine and labetalol (15.5 vs. 22.4%, P = 0.183). Labetalol patients had slower heart rates at all time points (P < 0.01). Multivariable modeling showed nicardipine patients were more likely in TR than labetalol patients at 30 minutes (OR 2.73, P = 0.028; C stat for model = 0.72) Conclusions Patients treated with nicardipine are more likely to reach the physician-specified SBP target range within 30 minutes than those treated with labetalol. Trial registration ClinicalTrials.gov: NCT00765648
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Affiliation(s)
- W Frank Peacock
- Department of Emergency Medicine, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA.
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Baumann BM, Russo CJ, Pavlik D, Cassidy-Smith T, Brown N, Sacchetti A, Capano-Wehrle LM, Mistry RD. Management of pediatric skin abscesses in pediatric, general academic and community emergency departments. West J Emerg Med 2011; 12:159-67. [PMID: 21691519 PMCID: PMC3099600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 08/27/2010] [Accepted: 09/17/2010] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To compare the evaluation and management of pediatric cutaneous abscess patients at three different emergency department (ED) settings. METHOD We conducted a retrospective cohort study at two academic pediatric hospital EDs, a general academic ED and a community ED in 2007, with random sampling of 100 patients at the three academic EDs and inclusion of 92 patients from the community ED. Eligible patients were ≤18 years who had a cutaneous abscess. We recorded demographics, predisposing conditions, physical exam findings, incision and drainage procedures, therapeutics and final disposition. Laboratory data were reviewed for culture results and antimicrobial sensitivities. For subjects managed as outpatients from the ED, we determined where patients were instructed to follow up and, using electronic medical records, ascertained the proportion of patients who returned to the ED for further management. RESULT Of 392 subjects, 59% were female and the median age was 7.7 years. Children at academic sites had larger abscesses compared to community patients, (3.5 versus 2.5 cm, p=0.02). Abscess incision and drainage occurred in 225 (57%) children, with the lowest rate at the academic pediatric hospital EDs (51%) despite the relatively larger abscess size. Procedural sedation and the collection of wound cultures were more frequent at the academic pediatric hospital and the general academic EDs. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence did not differ among sites; however, practitioners at the academic pediatric hospital EDs (92%) and the general academic ED (86%) were more likely to initiate empiric MRSA antibiotic therapy than the community site (71%), (p<0.0001). At discharge, children who received care at the community ED were more likely to be given a prescription for a narcotic (23%) and told to return to the ED for ongoing wound care (65%). Of all sites, the community ED also had the highest percentage of follow-up visits (37%). CONCLUSION Abscess management varied among the three settings, with more conservative antibiotic selection and greater implementation of procedural sedation at academic centers and higher prescription rates for narcotics, self-referrals for ongoing care and patient follow-up visits at the community ED.
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Affiliation(s)
- Brigitte M. Baumann
- Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School at Camden, NJ,Address for Correspondence: Brigitte M. Baumann, MD, MSCE, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103.
| | - Christopher J. Russo
- Division of Emergency Medicine, A.I. duPont Hospital for Children, Wilmington, DE, Department of Emergency Medicine, St. Christopher’s Hospital for Children, Philadelphia, PA
| | - Daniel Pavlik
- Department of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, NJ
| | - Tara Cassidy-Smith
- Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School at Camden, NJ
| | - Naomi Brown
- Division of Emergency Medicine Children’s Hospital of Philadelphia, PA
| | - Alfred Sacchetti
- Department of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, NJ
| | - Lisa M. Capano-Wehrle
- Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School at Camden, NJ
| | - Rakesh D. Mistry
- Division of Emergency Medicine Children’s Hospital of Philadelphia, PA
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Ozhathil DK, Abar B, Baumann BM, Camargo CA, Ziedonis D, Boudreaux ED. The effect of removing cost as a barrier to treatment initiation with outpatient tobacco dependence clinics among emergency department patients. Acad Emerg Med 2011; 18:662-4. [PMID: 21518096 DOI: 10.1111/j.1553-2712.2011.01048.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The campaign against tobacco addiction and smoking continues to play an important role in public health. However, referrals to outpatient tobacco cessation programs by emergency physicians are rarely pursued by patients following discharge. This study explored cost as a barrier to follow-up. METHODS The study was performed at a large urban hospital emergency department (ED) in Camden, New Jersey. Enrollment included adults who reported tobacco use in the past 30 days. Study participants were informed about a "Stop Smoking Clinic" affiliated with the hospital and, depending on enrollment date, cost of treatment was advertised as $150 (standard fee), $20 (reduced fee), or $0 (no fee). Monitoring of patient inquiries and visits to the clinic was performed for 6 months following enrollment of the last study subject. RESULTS The analyzed sample consisted of 577 tobacco users. There were no statistically significant demographic differences between treatment groups (p > 0.05). Two-hundred forty-seven (43%) participants reported "very much" interest in smoking cessation. However, there was no significant difference in initiating treatment with the Stop Smoking Clinic across experimental condition. Only a single subject, enrolled in the no-fee phase, initiated treatment with the clinic. CONCLUSIONS Cost is unlikely to be the only barrier to pursing outpatient tobacco treatment after an ED visit. Further research is needed to determine the critical components of counseling and referral that maximize postdischarge treatment initiation.
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Boudreaux ED, Moon S, Baumann BM, Camargo CA, O'Hea E, Ziedonis DM. Intentions to quit smoking: causal attribution, perceived illness severity, and event-related fear during an acute health event. Ann Behav Med 2011; 40:350-5. [PMID: 20827518 DOI: 10.1007/s12160-010-9227-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Experiencing a serious consequence related to one's health behavior may motivate behavior change. PURPOSE This study sought to examine how causal attribution, perceived illness severity, and fear secondary to an acute health event relate to intentions to quit smoking. METHODS Using a cross-sectional survey design, adult emergency department patients who smoked provided demographic data and ratings of nicotine dependence, causal attribution, perceived illness severity, event-related fear, and intentions to quit smoking. RESULTS A linear regression analysis was used to examine the relations between the independent variables and quit intentions. We enrolled 186 participants. After adjusting for nicotine dependence, smoking-related causal attribution and event-related fear were associated with intentions to quit (β = 0.26, p < 0.01 and β = 0.21, p < 0.01, respectively). Perceived illness severity was correlated with event-related fear (r = 0.46, p < 0.001) but was not associated with intentions to quit (β = -0.08, p = 0.32). CONCLUSION While causal attribution and event-related fear were modestly associated with quit intentions, perceived illness severity was not. Longitudinal studies are needed to better explicate the relation between these variables and behavior change milestones.
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Affiliation(s)
- Edwin D Boudreaux
- Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lakeshore Avenue, Worcester, MA 01655, USA.
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Baumann BM, Chen EH, Mills AM, Glaspey L, Thompson NM, Jones MK, Farner MC. Patient perceptions of computed tomographic imaging and their understanding of radiation risk and exposure. Ann Emerg Med 2010; 58:1-7.e2. [PMID: 21146900 DOI: 10.1016/j.annemergmed.2010.10.018] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 10/20/2010] [Accepted: 10/25/2010] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE We describe patient perceptions of computed tomography (CT) and their understanding of radiation exposure and risk. METHODS This was a cross-sectional study of acute abdominal pain patients aged 18 years or older. Confidence in medical evaluations with increasing levels of laboratory testing and imaging was rated on a 100-point visual analog scale. Knowledge of radiation exposure was ascertained when participants compared the radiation dose of one abdomen-pelvis CT with 2-view chest radiography. To assess cancer risk knowledge, participants rated their agreement with these factual statements: "Approximately 2 to 3 abdominal CTs give the same radiation exposure as experienced by Hiroshima survivors" and "2 to 3 abdominal CTs over a person's lifetime can increase cancer risk." Previous CT was also assessed. RESULTS There were 1,168 participants, 67% women and mean age 40.7 years (SD 15.9 years). Median confidence in a medical evaluation without ancillary testing was 20 (95% confidence interval [CI] 16 to 25) compared with 90 (95% CI 88 to 91) when laboratory testing and CT were included. More than 70% of participants underestimated the radiation dose of CT relative to chest radiography, and cancer risk comprehension was poor. Median agreement with the Hiroshima statement was 13 (95% CI 10 to 16) and 45 (95% CI 40 to 45) with the increased lifetime cancer risk statement. Seven hundred ninety-five patients reported receiving a previous CT. Of 365 patients who reported no previous CT, 142 (39%) had one documented in our electronic medical record. CONCLUSION Patients are more confident when CT imaging is part of their medical evaluation but have a poor understanding of the concomitant radiation exposure and risk and underestimate their previous imaging experience.
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Mumma BE, Baumann BM, Diercks DB, Takakuwa KM, Campbell CF, Shofer FS, Chang AM, Jones MK, Hollander JE. Sex bias in cardiovascular testing: the contribution of patient preference. Ann Emerg Med 2010; 57:551-560.e4. [PMID: 21146255 DOI: 10.1016/j.annemergmed.2010.09.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 09/02/2010] [Accepted: 09/24/2010] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVE Women with potential acute coronary syndromes are less likely to receive cardiac catheterization or revascularization than men. We hypothesize that this may be due to different diagnostic test preferences of female and male patients. METHODS We conducted a cohort study at 4 emergency departments enrolling patients who presented with symptoms of potential acute coronary syndromes. After hearing the potential benefits and harms of each test, subjects completed a 21-item survey assessing their preference for noninvasive testing versus cardiac catheterization. Based on hypothetical test results, similar questions about medical versus interventional management were asked. Subjects were also queried about likelihood of following physician recommendation for each test or intervention. Actual 30-day testing and interventions were recorded. The main outcome was patient preference about each procedure and the likelihood of patient saying they would accept the physician recommendation. RESULTS One thousand eighty patients enrolled; 652 (60%) were admitted to the hospital. With regard to diagnostic test preference, both women and men preferred stress test to catheterization (women 58% versus men 52%; difference 6% [95% confidence interval {CI} -0.06% to 12%]), and the proportion of women and men who would accept the physician recommendation for stress tests was similar (85% for both); however, the stated acceptance rate for cardiac catheterization was lower for women (65% versus 75%; difference -10% [95% CI -15% to -4%]). Women were 6% less likely (67% versus 73%; 95% CI for difference 12% to 0.5%) to accept percutaneous coronary intervention over medical therapy and 7% less likely (61% versus 68%; 95% CI for difference -13% to 1%) to desire coronary artery bypass grafting over medical therapy. The survey results are consistent with the patients' clinical course. During the initial hospitalization, women were less likely to receive diagnostic testing of any type (38% versus 45%; difference -7%; 95% CI for the difference -13% to -1.5%) and cardiac catheterization (10% versus 17%; difference -7% [95% CI -11% to -2%]). Revascularization was infrequent in both groups (4% versus 6%; difference -2% [95% CI -5% to 0.6%]). CONCLUSION Although women and men had similar preferences about cardiac diagnostic tests and treatment options, women were less likely than men to say they would accept the physician recommendation for any intervention. Patient preference may partially explain the disparity in cardiovascular testing between women and men.
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Affiliation(s)
- Bryn E Mumma
- Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Abstract
We report the case of a 62-year-old African American woman with poorly controlled diabetes who presented with the complaint of not being able to remove her stockings from her left foot. The patient had long-standing peripheral neuropathy from diabetes. Her physical examination in the emergency department was challenging because of extensive infection in her left lower extremity. Careful removal of the stockings resulted in the debridement of the lower third of her left leg and entire foot. Her laboratory findings were notable for a white blood cell count of 11.7 x 10(3) cells/mm(3) with 18% bands, an erythrocyte sedimentation rate of 100 mm/hour, and glycated hemoglobin of 11.5%. This case is unique in that the patient presented with both wet and dry gangrene of her lower extremities. We discuss the spectrum of infectious processes in diabetic foot infections and discuss the management of patients with necrotizing fasciitis.
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Affiliation(s)
- Brigitte M Baumann
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ, USA.
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Malizia RW, Baumann BM, Chansky ME, Kirchhoff MA. Ambulatory Dysfunction Due to Unrecognized Pernicious Anemia. J Emerg Med 2010; 38:302-7. [DOI: 10.1016/j.jemermed.2007.05.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Revised: 03/05/2007] [Accepted: 05/25/2007] [Indexed: 10/22/2022]
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Wang Z, Baumann BM, Slutsky K, Gruber KN, Jean S. Respiratory sound energy and its distribution patterns following clinical improvement of congestive heart failure: a pilot study. BMC Emerg Med 2010; 10:1. [PMID: 20078862 PMCID: PMC2821310 DOI: 10.1186/1471-227x-10-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 01/15/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although congestive heart failure (CHF) patients typically present with abnormal auscultatory findings on lung examination, respiratory sounds are not normally subjected to additional analysis. The aim of this pilot study was to examine respiratory sound patterns of CHF patients using acoustic-based imaging technology. Lung vibration energy was examined during acute exacerbation and after clinical improvement. METHODS Respiratory sounds throughout the respiratory cycle were captured using an acoustic-based imaging technique. Twenty-three consecutive CHF patients were imaged at the time of presentation to the emergency department and after clinical improvement. Digital images were created (a larger image represents more homogeneously distributed vibration energy of respiratory sound). Geographical area of the images and respiratory sound patterns were quantitatively analyzed. Data from the CHF patients were also compared to healthy volunteers. RESULTS The median (interquartile range) geographical areas of the vibration energy image of acute CHF patients without and with radiographically evident pulmonary edema were 66.9 (9.0) and 64.1(9.0) kilo-pixels, respectively (p < 0.05). After clinical improvement, the geographical area of the vibration energy image of CHF patients without and with radiographically evident pulmonary edema were increased by 18 +/- 15% (p < 0.05) and 25 +/- 16% (p < 0.05), respectively. CONCLUSIONS With clinical improvement of acute CHF exacerbations, there was more homogenous distribution of lung vibration energy, as demonstrated by the increased geographical area of the vibration energy image.
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Affiliation(s)
- Zhen Wang
- Division of Critical Care Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
- Department of Emergency Medicine, Beijing Shi-ji-tan Hospital, 10 Tie Yi Rd., Haidian District Beijing 100038, PR China
| | - Brigitte M Baumann
- Department of Emergency Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
| | - Karen Slutsky
- Department of Emergency Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
| | - Karen N Gruber
- Department of Emergency Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
| | - Smith Jean
- Division of Critical Care Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
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Drago LA, Singh SB, Douglass-Bright A, Yiadom MY, Baumann BM. Efficacy of ShotBlocker in reducing pediatric pain associated with intramuscular injections. Am J Emerg Med 2009; 27:536-43. [PMID: 19497458 DOI: 10.1016/j.ajem.2008.04.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 04/01/2008] [Accepted: 04/09/2008] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE The aim of the study was to determine the efficacy of ShotBlocker (Bionix, Toledo, Ohio) in reducing pediatric pain with intramuscular (IM) injections. METHODS A prospective randomized controlled trial was conducted in children aged 2 months to 17 years who required an IM injection. Children were randomized to the no-intervention group or the ShotBlocker group. Demographic data and the number of IM injections were recorded. Perceived pain scores were obtained from nurses and caregivers using a 6-point Likert-type scale. Baker Wong Faces scale was used in children 36 months or older. Difficulty using the device was also rated by nurses on a 6-point scale. RESULTS One hundred sixty-five children were enrolled with 80 in the no-intervention arm and 85 in the ShotBlocker arm. The mean age of children was 45 months and 56% were male. Perceived pain scores by nurses were higher for the no-intervention group (2.6 vs 1.8, P < .001) as well as by caregivers (2.6 vs 2.1, P = .04). Children aged 36 months and older (n = 64) did not report a difference in pain scores (1.5 vs 1.3, P = .6); however, in a subgroup of children 72 months or older, pain scores trended higher in the no-intervention group (1.3 vs 0.5, P = .051). Nurse-perceived difficulty of ShotBlocker use was low 1.39 (+/-1.1). CONCLUSIONS Nurses and caregivers noted lower pain scores in children assigned to the ShotBlocker group. These differences were not as evident when children rated their own pain.
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Affiliation(s)
- Lisa A Drago
- Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Medical School at Camden, NJ 08103, USA.
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