A comparison of the effect of weather and climate on emergency department visitation in Roanoke and Charlottesville, Virginia.

Compared with mortality, the impact of weather and climate on human morbidity is less well understood, especially in the cold season. We examined the relationships between weather and emergency department (ED) visitation at hospitals in Roanoke and Charlottesville, Virginia, two locations with similar climates and population demographic profiles. Using patient-level data obtained from electronic medical records, each patient who visited the ED was linked to that day's weather from one of 8 weather stations in the region based on each patient's ZIP code of residence. The resulting 2010-2017 daily ED visit time series were examined using a distributed lag non-linear model to account for the concurrent and lagged effects of weather. Total ED visits were modeled separately for each location along with subsets based on gender, race, and age. The relationship between the relative risk of ED visitation and temperature or apparent temperature over lags of one week was positive and approximately linear at both locations. The relative risk increased about 5% on warm, humid days in both cities (lag 0 or lag 1). Cold conditions had a protective effect, with up to a 15% decline on cold days, but ED visits increased by 4% from 2 to 5 days after the cold event. The effect of thermal extremes tended to be larger for non-whites and the elderly, and there was some evidence of a greater lagged response for non-whites in Roanoke. Females in Roanoke were more impacted by winter cold conditions than males, who were more likely to show a lagged response at high temperatures. In Charlottesville, males sought ED attention at lower temperatures than did females. The similarities in the ED response patterns between these two hospitals suggest that certain aspects of the response may be generalizable to other locations that have similar climates and demographic profiles.

Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update.

We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation.

Correction: Correction to 'Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department' [Annals of Emergency Medicine 66 (2015) 322-333.e31].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Correction: Correction to 'Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department' [Annals of Emergency Medicine 63 (2014) 247-258.e18].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Clinical policy: procedural sedation and analgesia in the emergency department.

This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency department.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients undergoing procedural sedation and analgesia in the emergency department,does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration? (2) In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events? (3) In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications? (4) Inpatients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil and remifentanil be safely administered? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

ED use of etomidate for rapid sequence induction.

We present evidence-based clinical practice recommendations for the administration of etomidate for emergency department (ED) rapid sequence induction. We critically discuss indications and contraindications in typical ED patient subpopulations such as the traumatic, septic, neurologic, or pulmonary patient. Future research questions are considered.

Clinical practice advisory: Emergency department procedural sedation with propofol.

We present an evidence-based clinical practice advisory for the administration of propofol for emergency department procedural sedation. We critically discuss indications, contraindications, personnel and monitoring requirements, dosing, coadministered medications, and patient recovery from propofol. Future research questions are considered.

Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory.

Emergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. The advisory is not intended to assert a legal standard of practice or absolute requirement. It is expected that emergency physicians will at times appropriately deviate from it according to individualized judgment and unique clinical circumstances.

Myeloproliferative Disorders.

The emergency providers generally encounters myeloproliferative disorders (MPNs) in 1 of 2 ways: as striking laboratory abnormalities of seeming unknown consequence, or in previously diagnosed patients presenting with complications. The course of patients with MPNs is highly variable, but major complications can arise. Emergent conditions related to hyperviscosity need to be recognized early and treated aggressively. Rapid hydration, transfusion, cytoreduction, and early hematology consultation can be lifesaving. Likewise, although management is not altered, a high index of suspicion for thrombotic complications is required in patients with known MPNs as these are a significant cause of morbidity and mortality.

Quality Improvement Initiative to Decrease Variability of Emergency Physician Opioid Analgesic Prescribing.

INTRODUCTION: Addressing pain is a crucial aspect of emergency medicine. Prescription opioids are commonly prescribed for moderate to severe pain in the emergency department (ED); unfortunately, prescribing practices are variable. High variability of opioid prescribing decisions suggests a lack of consensus and an opportunity to improve care. This quality improvement (QI) initiative aimed to reduce variability in ED opioid analgesic prescribing. METHODS: We evaluated the impact of a three-part QI initiative on ED opioid prescribing by physicians at seven sites. Stage 1: Retrospective baseline period (nine months). Stage 2: Physicians were informed that opioid prescribing information would be prospectively collected and feedback on their prescribing and that of the group would be shared at the end of the stage (three months). Stage 3: After physicians received their individual opioid prescribing data with blinded comparison to the group means (from Stage 2) they were informed that individual prescribing data would be unblinded and shared with the group after three months. The primary outcome was variability of the standard error of the mean and standard deviation of the opioid prescribing rate (defined as number of patients discharged with an opioid divided by total number of discharges for each provider). Secondary observations included mean quantity of pills per opioid prescription, and overall frequency of opioid prescribing. RESULTS: The study group included 47 physicians with 149,884 ED patient encounters. The variability in prescribing decreased through each stage of the initiative as represented by the distributions for the opioid prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46% reduction, p<0.01), and Stage 3 mean 8% (60% reduction, p<0.01). The mean quantity of pills prescribed per prescription was 16 pills in Stage 1, 14 pills in Stage 2 (18% reduction, p<0.01), and 13 pills in Stage 3 (18% reduction, p<0.01). The group mean prescribing rate also decreased through each stage: 20% in Stage 1, 13% in Stage 2 (46% reduction, p<0.01), and 8% in Stage 3 (60% reduction, p<0.01). CONCLUSION: ED physician opioid prescribing variability can be decreased through the systematic application of sharing of peer prescribing rates and prescriber specific normative feedback.

Electrical cardioversion of emergency department patients with atrial fibrillation.

STUDY OBJECTIVE: Electrical cardioversion of emergency department (ED) patients with atrial fibrillation has not been well investigated. The objective of this study is to identify the outcomes and complications associated with ED electrical cardioversion of patients with atrial fibrillation. METHODS: This retrospective health records survey investigated a consecutive cohort of ED patients with atrial fibrillation who underwent electrical cardioversion in 4 EDs during a 42-month period. Trained personnel reviewed medical records for demographic characteristics, clinical descriptors, medical interventions, complications, and ED return visits within 7 days. Data were analyzed using descriptive statistics. RESULTS: The study population consisted of 388 patients (mean age 61 years; range 20 to 93 years). Duration of atrial fibrillation was less than 48 hours in 99% of the cohort. Electrical cardioversion was successful in 332 (86%) patients. Twenty-eight complications were noted in 25 electrical cardioversion encounters: 22 attributed to procedural sedation and analgesia and 6 attributed to electrical cardioversion. Three hundred thirty-three (86%) patients were discharged to home from the ED: 301 after electrical cardioversion success and 32 with electrical cardioversion failure. Thirty-nine patients (10%) returned to the ED within 7 days, 25 of these patients (6% of successful electrical cardioversion patients) returned because of relapse of atrial fibrillation. CONCLUSION: In this multicenter cohort, selected ED patients with atrial fibrillation had high rates of electrical cardioversion success, infrequent hospital admission, and few immediate and short-term complications.

Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting.

OBJECTIVE: To determine the rate of unrecognized endotracheal tube misplacement when performed by emergency medical services (EMS) personnel in a mixed urban and rural setting. METHODS: The authors conducted a prospective, observational analysis of out-of-hospital endotracheal intubations (EIs) performed by EMS personnel serving a mixed urban, suburban, and rural population. From July 1, 1998, to August 30, 1999, emergency physicians assessed and recorded the position of out-of-hospital EIs using auscultation, direct laryngoscopy, infrared CO(2) detectors, esophageal detector devices, and chest x-ray. The state EMS database also was reviewed to determine the number of EIs involving patients transported to the authors' medical center and paramedic assessment of success for these encounters. RESULTS: A total of 167 out-of-hospital EIs were recorded, of which 136 (81%) were deemed successful by EMS personnel. Observational forms were completed for 109 of the 136 patients who arrived intubated to the emergency department. Of the studied patients, 12% (13 of 109) were found to have misplaced endotracheal tubes. For the patients with unrecognized improperly placed tubes, 9% (10 of 109) were in the esophagus, 2% (2 of 109) were in the right main stem, and 1% (1 of 109) were above the cords. Paramedics serving urban and suburban areas did not perform significantly better (p < 0.05) than intermediate-level providers serving areas that are more rural. CONCLUSIONS: The incidence of unrecognized misplacement of endotracheal tubes by EMS personnel may be higher than most previous studies, making regular EMS evaluation and the out-of-hospital use of devices to confirm placement imperative. The authors were unable to show a difference in misplacement rates based on provider experience or level of training.

Myeloproliferative disorders.

The emergency providers generally encounters myeloproliferative disorders (MPNs) in 1 of 2 ways: as striking laboratory abnormalities of seeming unknown consequence, or in previously diagnosed patients presenting with complications. The course of patients with MPNs is highly variable, but major complications can arise. Emergent conditions related to hyperviscosity need to be recognized early and treated aggressively. Rapid hydration, transfusion, cytoreduction, and early hematology consultation can be lifesaving. Likewise, although management is not altered, a high index of suspicion for thrombotic complications is required in patients with known MPNs as these are a significant cause of morbidity and mortality.

Producing a successful PeRLs video.

Academic Emergency Medicine publishes selected peer-reviewed videos that present state-of-the-art research, practice, and evidence in the field of emergency medicine. These videos are referred to as peer-reviewed lectures (PeRLs). This commentary reviews considerations for creating, filming, and producing high-quality PeRLs videos.