Begin risk assessment for falls in women at 45, not 65.

The clinical and epidemiological literature provides guidelines for fall prevention starting at age 65; however, the focus on age ≥65 is not evidence based. Therefore, this study examined state-wide North Carolina emergency department visit data to examine the characteristics of falls across the age spectrum, identify the age at which the incidence of fall-related emergency department visits started to increase and determine whether these trends were similar for men and women. We determined that incidence rates of fall-related emergency department visits began to increase in early middle age, particularly for women. Since fall risk assessment and prevention activities should be initiated prior to an injurious fall, we recommend beginning these activities before age 65.

Emergency Department Visits by Older Adults with Mental Illness in North Carolina.

INTRODUCTION: We analyzed emergency department (ED) visits by patients with mental health disorders (MHDs) in North Carolina from 2008-2010 to determine frequencies and characteristics of ED visits by older adults with MHDs. METHODS: We extracted ED visit data from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). We defined mental health visits as visits with a mental health ICD-9-CM diagnostic code, and organized MHDs into clinically similar groups for analysis. RESULTS: Those ≥65 with MHDs accounted for 27.3% of all MHD ED visits, and 51.2% were admitted. The most common MHD diagnoses for this age group were psychosis, and stress/anxiety/depression. CONCLUSION: Older adults with MHDs account for over one-quarter of ED patients with MHDs, and their numbers will continue to increase as the "boomer" population ages. We must anticipate and prepare for the MHD-related needs of the elderly.

Diagnosis clusters for emergency medicine.

OBJECTIVES: Aggregated emergency department (ED) data are useful for research, ED operations, and public health surveillance. Diagnosis data are widely available as The International Classification of Diseases, version, 9, Clinical Modification (ICD-9-CM) codes; however, there are over 24,000 ICD-9-CM code-descriptor pairs. Standardized groupings (clusters) of ICD-9-CM codes have been developed by other disciplines, including family medicine (FM), internal medicine (IM), inpatient care (Agency for Healthcare Research and Quality [AHRQ]), and vital statistics (NCHS). The purpose of this study was to evaluate the coverage of four existing ICD-9-CM cluster systems for emergency medicine. METHODS: In this descriptive study, four cluster systems were used to group ICD-9-CM final diagnosis data from a southeastern university tertiary referral center. Included were diagnoses for all ED visits in July 2000 and January 2001. In the comparative analysis, the authors determined the coverage in the four cluster systems, defined as the proportion of final diagnosis codes that were placed into clusters and the frequencies of diagnosis codes in each cluster. RESULTS: The final sample included 7,543 visits with 19,530 diagnoses. Coverage of the ICD-9-CM codes in the ED sample was: AHRQ, 99%; NCHS, 88%; FM, 71%; IM, 68%. Seventy-six percent of the AHRQ clusters were small, defined as grouping <1% of the diagnosis codes in the sample. CONCLUSIONS: The AHRQ system provided the best coverage of ED ICD-9-CM codes. However, most of the clusters were small and not significantly different from the raw data.

Mid-level providers and emergency care: let's not lose the force.

The progressive rise of ED visits globally, and insufficient numbers of emergency physicians, has resulted in the use of mid-level providers as adjuncts for the provision of emergency care, especially in the US and Canada. Military medics, midwives, aeromedical paramedics, EMT-Ps, flight nurses, forensic nurses, sexual assault nurse examiner nurses--are some examples of well-established mid-level provider professionals who achieve their clinical credentials through accredited training programmes and formal certification. In emergency medicine, however, mid-level providers are trained for general care, and typically acquire emergency medicine skills through on-the-job experience. There are very few training programmes for NPs and PAs in emergency care. The manpower gap for physicians in general, and emergency physicians specifically, will not be eliminated in the reasonable future. Mid-level providers--ENTs, paramedics, NPs, PAs--are an excellent addition to the emergency medicine workforce. However, the specialty of emergency medicine developed because specific and focused training was needed for physicians to practice safe and qualify emergency care. This same principle applies to mid-level providers. Emergency Medicine needs to develop a vision and a plan to train emergency medicine specialist NPs and PAs, and explore other innovations to expand our emergency care workforce.

Toward a new paradigm: goal-based residency training.

OBJECTIVES: Many factors affect the clinical training experience of emergency medicine (EM) residents, and length of training currently serves as a proxy for clinical experience. Very few studies have been published that provide quantitative information about clinical experience. The goals of this study were to determine the numbers of clinical encounters for each resident in emergency department (ED) rotations during training in a 3-year program, to characterize these encounters by patient acuity and age, to determine the numbers of encounters for selected clinical disorders, and to assess the variation in clinical experience between residents. METHODS: This was a retrospective analysis of the ED clinical and administrative databases at two hospitals that provide EM training for a southeastern U.S. EM residency program. Data were gathered for three complete cohorts of residents, with entering years of 2003, 2004, and 2005, so the total study period was 2003-2008. ED clinical encounter information included hospital training site (tertiary or community), postgraduate year (PGY) of the resident, patient triage acuity reflected by the Emergency Severity Index (ESI); patient International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code; and patient age group. RESULTS: There were 25 residents with 120,240 total ED clinical encounters from 2003 to 2008. The median number of ED clinical encounters for a resident during his or her training was 4,836 (range = 3,831 to 5,780), based on a maximum of an 80-hour work week, and 24 or 25 four-week blocks of EM rotations. Overall, clinical encounters increased by 30% from PGY 1 to PGY 2, and another 14% from PGY 2 to PGY 3. There was 30% to 60% variation in clinical encounters between individual residents. Variability was most prominent in the care of children and in the care of time-sensitive critical illness. Resident encounters with lower-acuity problems during training were much less than the anticipated lower-acuity burden during practice. Additionally, residents did not encounter some high-risk conditions clinically during the study period. CONCLUSIONS: Methods should be developed to decrease resident variance in both numbers and types of clinical encounters and to provide curriculum supplementation for individuals and for the entire residency cohort in areas that are important for the clinical practice of EM, but that are rare or not encountered during residency training.

Epidemiology of burn injuries presenting to North Carolina emergency departments in 2006-2007.

UNLABELLED: Approximately 600,000 burns present to Emergency Departments each year in the United States, yet there is little systematic or evidence-based training of Emergency Physicians in acute burn management. We retrospectively accessed the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) database to identify all thermal burns and electrical injuries with associated thermal burns presenting to 92% of North Carolina Emergency Departments over a 1-year period. RESULTS: 10,501 patients met inclusion criteria, 0.3% of all state-wide reported ED visits. Ninety-two percent of burn visits were managed exclusively by Emergency Physicians without acute intervention by burn specialists, including 87% of first degree, 82% of second degree, and 53% of third degree injuries. Only 4.3% were admitted; 4.3% were transferred to another institution. Fifty-five percent were male; 33% were aged 25-44 and 33% presented on weekends. CONCLUSION: This is the first state-wide study of burn injury and identifies Emergency Physicians as the major providers of acute burn care. Ninety-two percent of 10,501 burn visits, including the majority of severe injuries, were managed exclusively by Emergency Physicians. This supports a need for improved, evidence-based training of Emergency Physicians in the acute management of burns of all types.

North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) and the National Hospital Ambulatory Medical Care Survey (NHAMCS): comparison of emergency department data.

The North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) is a near-real-time database of emergency department (ED) visits automatically extracted from hospital information system(s) in the state of North Carolina. The National Hospital Ambulatory Medical Care Survey (NHAMCS) is a retrospective probability sample survey of visits to U.S. hospital EDs. This report compares data from NC DETECT (2006) with NHAMCS (2005) ED visit data to determine if the two data sets are consistent. Proportions, rates, and confidence intervals (CIs) were calculated for ED visits by age and gender; arrival method and age; expected source of payment; disposition; hospital admissions; NHAMCS top 20 diagnosis groups and top five primary diagnoses by age group; International Classifications of Disease, 9th revision, Clinical Modification (ICD-9-CM) primary diagnosis codes; and cause of injury. North Carolina DETECT captured 79% of statewide ED visits. Twenty-eight persons for every 100 North Carolina residents visited a North Carolina ED that reports to NC DETECT at least once in 2006, compared to 20% nationally. Twenty-seven percent of ED visits in North Carolina had private insurance as the expected payment source, compared with 40% nationwide. The proportion of injury-related ED visits in North Carolina is 25%, compared to 36.4% nationally. Rates and proportions of disease groups are similar. Similarity of NC DETECT rates and proportions to NHAMCS provides support for the face and content validity of NC DETECT. The development of statewide near-real-time ED databases is an important step toward the collection, aggregation, and analysis of timely, population-based data by state, to better define the burden of illness and injury for vulnerable populations.

Toward vocabulary control for chief complaint.

The chief complaint (CC) is the data element that documents the patient's reason for visiting the emergency department (ED). The need for a CC vocabulary has been acknowledged at national meetings and in multiple publications, but to our knowledge no groups have specifically focused on the requirements and development plans for a CC vocabulary. The national consensus meeting "Towards Vocabulary Control for Chief Complaint" was convened to identify the potential uses for ED CC and to develop the framework for CC vocabulary control. The 10-point consensus recommendations for action were 1) begin to develop a controlled vocabulary for CC, 2) obtain funding, 3) establish an infrastructure, 4) work with standards organizations, 5) address CC vocabulary characteristics for all user communities, 6) create a collection of CC for research, 7) identify the best candidate vocabulary for ED CCs, 8) conduct vocabulary validation studies, 9) establish beta test sites, and 10) plan publicity and marketing for the vocabulary.