A public health approach to emergency medicine: preparing for the twenty-first century.

This paper focuses on the implications of an inadequate public health/preventive health care system for emergency medicine (EM), the role that EM providers can play in remedying critical health problems, and the benefits gained from a public health approach to EM. A broad definition of public health is adopted, suggesting shared goals of public health and EM. Critical problems posed for EM include alcohol, tobacco, and other drug abuse; injury; violence; sexually transmitted diseases and human immunodeficiency virus (HIV) infection occupational and environmental exposures; and the unmet health needs of minorities and women. A blueprint for future merging of public health issues with EM is presented that includes the application of public health principles to 1) clinical practice; 2) public education, community involvement, and public policy advocacy; 3) development of medical school and residency public health/prevention curricula and teaching methods; and 4) research opportunities and surveillance. Finally, recommendations are proposed that require restructuring the present health care system to provide resources, incentives, and organizational changes that promote an integration of public health and preventive services in the practice of EM.

"Bounces": an analysis of short-term return visits to a public hospital emergency department.

From July through September 1987, our emergency department registered 17,214 patients, of whom 569 (3%) returned within two days of initial registration. Cases were reviewed to identify factors associated with return visits. Patient-related factors were responsible for a majority of repeat visits (267 cases, 53%). Illness-related factors, particularly evolution of disease under close outpatient observation, prompted return in 68 cases (13%). An additional 60 patients (12%) returned with new problems unrelated to their initial presentation. Physician-related factors were the primary reason for return in 92 cases (18%). Problems with our public health-care system prompted return in 18 cases (4%). Eighty-seven returning patients (19%) required emergency hospitalization, including 28 discharged due to physician errors. Regular case review of short-term returns to the ED should be included in a comprehensive ED-based program of quality assurance.

Impact of portable pulse oximetry on arterial blood gas test ordering in an urban emergency department.

STUDY OBJECTIVE: To determine the impact of portable pulse oximetry on physician use of arterial blood gas tests (ABGs) in an urban emergency department. DESIGN: Prospective, controlled clinical trial. SETTING: The ED of the Regional Medical Center at Memphis, a publicly subsidized, 450-bed, acute care hospital staffed by residents and faculty of the University of Tennessee, Memphis. TYPE OF PARTICIPANTS: Rotating housestaff treating adult ED patients with a wide variety of medical and surgical problems. INTERVENTION: Introduction of a portable pulse oximeter for noninvasive measurement of blood oxygenation. MEASUREMENTS: Rates of ABG test ordering, housestaff reason(s) for ordering an ABG, and the incidence of adverse clinical outcomes before and after introduction of portable pulse oximetry. MAIN RESULTS: A total of 20,120 patient visits occurred during the four-month study. Before oximeter introduction, emergency physicians ordered 699 ABGs, 63% of which were indicated by explicit criteria. After oximeter introduction, 440 ABGs were ordered (a 37% decrease). Almost all of this decrease was due to fewer ABGs ordered to assess oxygenation (260 before vs 75 after; chi 2, P less than .001). These reductions were not explained by differences in total patient visits or case mix. Physicians decreased ordering of indicated ABGs by almost as great an extent as they reduced ordering of unindicated tests, suggesting they did not consistently distinguish between the two. However, decreased testing did not result in any serious adverse outcomes, defined as unanticipated respiratory or cardiac arrest in the ED, unanticipated arrest on the floor within 24 hours of admission, or death within two days of hospital discharge. CONCLUSION: Portable pulse oximetry can provide a simple, noninvasive way to determine oxygen saturation in the ED. Routine use of portable pulse oximetry may substantially reduce rates of ABG testing and associated patient charges without adversely affecting the quality of emergency care.

Emergency department diagnosis of ectopic pregnancy.

STUDY OBJECTIVES: To assess the accuracy of the history and physical examination as compared to the addition of serum progesterone screening for ectopic pregnancy in women presenting to the emergency department. DESIGN: Prospective, consecutive case series, N = 2,157. SETTING: ED of the Regional Medical Center at Memphis, a publicly subsidized, 450-bed acute care hospital staffed by residents and faculty of the University of Tennessee, Memphis. TYPE OF PARTICIPANTS: All ED patients with a positive urine pregnancy test treated between January 1 and December 31, 1988. INTERVENTIONS: Screening history, physical examination, and serum progesterone (P) and quantitative human chorionic gonadotropin (hCG) titer. MEASUREMENTS: All discharged patients were given follow-up appointments within two weeks; those found to have a P less than 25 ng/mL were called to return for repeat hCG and transvaginal ultrasound. MAIN RESULTS: One hundred sixty-one of 2,157 patients (7.5%) with a positive urine pregnancy test were found to have an ectopic pregnancy. All but five had a P of less than 25 ng/mL (sensitivity, 97%); four of these were admitted for immediate surgery because of symptoms. Overall, the ED physician detected 89 of 161 ectopics (55.3%) on initial presentation, 53 (60%) of which were ruptured at the time of surgery. Seventy-two patients (44.7%) who were discharged but later found to have an ectopic pregnancy had benign clinical presentations, including 41 with vaginal bleeding. There were no statistically significant differences in the presenting symptoms of patients with unruptured ectopics compared with normal intrauterine pregnancies. All but one of the 72 discharged patients were noted the following day to have a progesterone of less than 25 ng/mL and contacted to return. Eight of these were found to have a ruptured ectopic at the time of surgery. Only 91 of 161 patients (56.5%) with ectopic pregnancy acknowledged one or more clinical risk factors on follow-up questioning. CONCLUSION: The standard history and physical examination, including those performed by gynecologic specialists, are insufficiently sensitive for early detection of unruptured ectopic pregnancy. EDs with a high incidence of ectopic pregnancy should strongly consider implementation of a universal progesterone screening program to decrease unnecessary patient morbidity and the risk of mortality from undiagnosed ectopic pregnancy.