What If I Do Not Match? Scrambling for a Spot and Going Outside the Match.

Matching into emergency medicine (EM) is getting progressively more competitive. Applicants must therefore prepare for the possibility of not matching and, accordingly, be ready to participate in the Supplemental Offer and Acceptance Program (SOAP). In this article, we elaborate on the SOAP and the options for applicants who fail to match during Match Week. Alternative courses of action include applying for a preliminary year, matching into a categorical residency program, or aiming to secure EM spots outside the Match through the Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine, and American Association of Medical Colleges.

Adirondack Park incidents: a retrospective review of search and rescue reports from 2008 and 2009.

BACKGROUND: The Adirondack Park is a 6 million acre recreational area in northeastern New York used for activities such as hiking, camping, canoeing, hunting, fishing, snowmobiling, skiing, and rock climbing. Given the large number of people who use the Adirondacks for recreation, there exists the potential for many accidents, injuries, and illnesses to occur in areas ranging from state-operated campgrounds to remote backcountry. OBJECTIVE: The aim of this study was to gain insight into the demographics of search and rescue (SAR) operations in the Adirondack Park. METHODS: This study is a retrospective review of the Adirondack Park Forest Ranger SAR reports from January 1, 2008, through December 31, 2009. Epidemiologic data were gathered from the NY State Department of Environmental Conservation for each report, including victim demographics, incident, reason for injury, medical care needed, preparation of victim, and prior medical conditions. RESULTS: In all, 239 SAR missions were carried out involving at least 349 victims. Of all cases, 28% (66) involved an injured victim, and 9% (21) involved illness; 56% (10) of the victims had a known prior illness or medical condition; and 21% (27) of cases were due to victims exceeding their abilities. Of the search missions, 54% of victims (93) had little experience with the activity, and 9% (15) had no experience. Only 43% (62) of victims had any form of orientation equipment. CONCLUSIONS: This study portrays the initial demographics of SAR efforts in Adirondack Park. It will aid in educating people on preparing for wilderness activities, as well as tailoring SAR resources to the demographics of injury and illness within the park.

Variables associated with discordance between emergency physician and neurologist diagnoses of transient ischemic attacks in the emergency department.

STUDY OBJECTIVE: Transient ischemic attack is a common clinical diagnosis in emergency department (ED) patients with acute neurologic complaints. Accurate diagnosis of transient ischemic attack is essential to help guide evaluation and avoid treatment delays. We seek to determine the prevalence of discordant diagnosis for patients receiving an ED diagnosis of transient ischemic attack compared with neurologist final diagnosis. Secondary goals are to evaluate the influence of atypical transient ischemic attack symptoms, the ABCD2 score, and emergency physician experience on discordant diagnoses. METHODS: We performed a retrospective cohort study evaluating all ED patients receiving a diagnosis of transient ischemic attack during a 4-year period. The emergency physician diagnosis was compared with that of the neurologist. The neurologist's final diagnosis was considered the criterion standard diagnosis. Subject demographic and clinical information was collected with a structured instrument. The following atypical symptoms present at the ED evaluation were evaluated with logistic regression: headache, tingling, involuntary movement, seeing flashing lights or wavy lines, dizziness, confusion, incontinence, and ABCD2 score of 4 or greater. Bivariate analysis was used to evaluate the influence of emergency physician experience (≤6 years versus >6 years) on discordant diagnosis. Odds ratios (ORs) and proportions are reported with 95% confidence intervals (CIs), interquartile range was used where appropriate. RESULTS: We evaluated 436 subjects, of whom 7 were excluded, allowing 429 subjects for evaluation. Of these individuals, 156 (36%; 95% CI 32% to 41%) received a discordant diagnosis. The median emergency physician time in clinical practice was 6 years (interquartile range 2 to 12 years). Features associated with a discordant transient ischemic attack diagnosis included headache (OR 2.52; 95% CI 1.59 to 3.99), involuntary movement (OR 3.19; 95% CI 1.35 to 7.54), and dizziness (OR 1.92; 95% CI 1.22 to 3.02). Incontinence, confusion, and seeing wavy lines or flashing lights were not significantly associated with a discordant diagnosis. Patients with tingling and a high ABCD2 score had an increased odds of concordant transient ischemic attack diagnosis (OR 0.54, 95% CI 0.32 to 0.92; OR 0.53, 95% CI 0.35 to 0.82, respectively). CONCLUSION: Discordant diagnoses between emergency physicians and neurologists were observed in 36% of patients. The presence of headache, involuntary movement, and dizziness predicted discordant diagnoses, whereas the presence of tingling and an increased ABCD2 score predicted concordant transient ischemic attack diagnosis.

ED handoffs: observed practices and communication errors.

OBJECTIVE: The study objectives were to identify emergency department (ED) handoff practices and describe handoff communication errors among emergency physicians. METHODS: Two investigators observed patient handoffs among emergency physicians in a major metropolitan teaching hospital for 8 weeks. A data collection form was designed to assess handoff characteristics including duration, location, interruptions, and topics including examination, laboratory examinations, diagnosis, and disposition. Handoff errors were defined as clinically significant examination or laboratory findings in physician documentation that were reported significantly differently during or omitted from verbal handoff. Multivariate negative binomial regression models assessed variables associated with these errors. The study was approved by the institutional review board. RESULTS: One hundred ten handoff sessions encompassing 992 patients were observed. Examination handoff errors and omissions were noted in 130 (13.1%) and 447 (45.1%) handoffs, respectively. More examination errors were associated with longer handoff time per patient, whereas fewer examination omissions were associated with use of written or electronic support materials. Laboratory handoff errors and omissions were noted in 37 (3.7%) and 290 (29.2%) handoffs, respectively. Fewer laboratory errors were associated with use of electronic support tools, whereas more laboratory handoff omissions were associated with longer ED lengths of stay. CONCLUSIONS: Clinically pertinent findings reported in ED physician handoff often differ from findings reported in physician documentation. These errors and omissions are associated with handoff time per patient, ED length of stay, and use of support materials. Future research should focus on ED handoff standardization protocols, handoff error reduction techniques, and the impact of handoff on patient outcomes.

Association of patient satisfaction with complaints and risk management among emergency physicians.

BACKGROUND: Patient-physician interactions in the emergency department (ED) are unique in that prior relationships may not exist; interactions are brief, and the environment is hectic. OBJECTIVES: The research hypotheses were that patient satisfaction scores on a commonly used national satisfaction survey are associated with patient complaints and risk management file openings or lawsuits (risk management episodes). METHODS: Administrative databases from an emergency physician management group that staffs 34 EDs in 8 states were merged with patient satisfaction data. Dates of inclusion were January 2002-April 2006. Estimates of physician contribution to satisfaction utilized a multi-level mixed-effects linear regression with a random-effect for practice site and physician, and fixed-effect adjustments for patient factors, time pressures, acuity mix, and physician productivity. Adjusted satisfaction scores were used to explore the relationship with complaints and risk management episodes. MAIN OUTCOME MEASURE: Association of patient satisfaction scores with risk of complaint and risk management episodes. RESULTS: There were 3947 physician-quarters of practice data analyzed, representing 2,462,617 patient visits. There were 375 complaints and 61 risk management episodes. Those in the lowest quartile of satisfaction were nearly twice as likely to have a complaint (adjusted odds ratio 1.84; 95% confidence interval [CI] 1.29-2.63) as those in the highest quartile. Satisfaction was not directly related to risk management episodes. Complaints were more strongly associated with risk management episodes than other variables: those receiving ≥ 2 complaints in a quarter were 4.13 (95% CI 1.12-15.2) times more likely to have a risk management episode. CONCLUSIONS: Patient satisfaction scores are not associated with increased risk management episodes but are closely related to receiving complaints. Receiving complaints is a strong marker for increased risk management episodes and should prompt early corrective action.

Levalbuterol versuss levalbuterol plus ipratropium in the treatment of severe acute asthma.

BACKGROUND: The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines advise the addition of ipratropium bromide to short-acting ß-agonist therapy for the treatment of patients with severe acute asthma exacerbation. METHODS: This was a prospective, double-blind, randomized, controlled study involving 141 adults, presenting to two EDs with acute severe asthma exacerbation. Patients were treated using a standardized pathway with levalbuterol plus ipratropium or levalbuterol alone. Primary outcomes were changes from baseline in the percentage of predicted forced expiratory volume in 1 second (FEV1) at 30 minutes and 60 minutes after completion of treatment. Secondary outcomes included hospitalization and relapse rates. Occurrence of adverse events was recorded. RESULTS: Sixty-seven patients in the levalbuterol plus ipratropium group and 74 patients in the levalbuterol group completed the study. Overall, there was no significant difference in the improvement in percent predicted FEV1 between the two groups at 30 minutes [difference in change between study groups at 30 minutes: 1% (95% CI: ?3 to 2%) or at 60 minutes: 3% (95% CI: 1-6%)] No difference was noted in hospitalization rates between the treatment groups [combination therapy group, 33%; single therapy group, 47%, difference: -14% (95% CI: -30 to 20%)]. Post-hoc analysis revealed that patients receiving ipratropium in addition to levalbuterol were 1.5 times more likely to experience side effects (palpitations) than patients treated with levalbuterol alone (RR 1.5; 95% CI: 1.2-1.9) No differences in relapse rates were noted between the groups. Post-hoc analysis revealed more side effects in patients receiving levalbuterol plus ipratropium. CONCLUSION: We were unable to demonstrate superiority of adding ipratropium to levalbuterol in alleviating obstruction as measured by FEV1 or in decreasing the need for hospitalization among adult patients presenting to the ED with acute severe asthma exacerbation.

ED visit volume and quality of care in acute exacerbations of chronic obstructive pulmonary disease.

OBJECTIVE: The purpose of this study is to determine whether emergency department (ED) visit volume is associated with ED quality of care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: We performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. Using a standard protocol, we interviewed consecutive ED patients with COPD exacerbation, reviewed their charts, and completed a 2-week telephone follow-up. The associations between ED visit volume and quality of care (process and outcome measures) were examined at both the ED and patient levels. RESULTS: After adjustment for patient mix in the multivariable analyses, chest radiography was less frequent among patients with COPD exacerbations in the low-volume (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.4) and high-volume EDs (OR, 0.1; 95% CI, 0.05-0.5), with medium-volume EDs as the reference. Arterial blood gas testing was less frequent in the low-volume EDs (OR, 0.1; 95% CI, 0.02-0.8). Medication use was similar across volume tertiles. With respect to outcome measures, patients in high-volume EDs were more likely to be discharged (OR, 4.2; 95% CI, 2.2-7.7) and to report ongoing exacerbation at a 2-week follow-up (OR, 1.9; 95% CI, 1.02-3.5). CONCLUSIONS: Traditional positive volume-quality relationships did not apply to emergency care of COPD exacerbation. High-volume EDs used less guideline-recommended diagnostic procedures, had a higher admission threshold, and had a worse short-term patient-centered outcome.

Validation of self-reported chronic obstructive pulmonary disease among patients in the ED.

BACKGROUND: To determine whether the self-reported diagnosis of adults who present to the emergency department (ED) with an acute exacerbation of either asthma or chronic obstructive pulmonary disease (COPD) is validated by medical record review. METHODS: This is cross-sectional study of 78 consecutive adults, 55 years and older, presenting to 3 EDs with symptoms suggestive of an exacerbation of asthma or COPD. We used current spirometric guidelines for a "spirometrically validated" diagnosis of COPD (eg, postbronchodilator forced expiratory volume in 1 second/forced ventilatory capacity <70%). Patients without office spirometry result were classified with COPD using clinical validation based on at least one of the following: primary care physician diagnosis of COPD, chronic bronchitis, or emphysema in the medical record or chest radiography, chest computed tomography, or arterial blood gas (ABG) diagnostic of COPD. RESULTS: Among 60 patients who self-reported diagnosis of COPD, 98% (95% confidence interval, 89-100) had clinically validated or spirometrically validated COPD. In addition, 83% (95% confidence interval, 59-96) of patients who reported either asthma only or no respiratory disease had clinically validated or spirometrically validated COPD. In no case was the chest radiograph or the ABG useful as a stand-alone test in establishing the diagnosis of COPD. CONCLUSIONS: Patients 55 years and older presenting to the ED with acute asthma or COPD, even those with clinical symptoms but no diagnosis of COPD, are likely to have COPD. Clinicians should maintain a high index of suspicion for COPD when older asthma patients deny COPD.

The short-form chronic respiratory disease questionnaire was a valid, reliable, and responsive quality-of-life instrument in acute exacerbations of chronic obstructive pulmonary disease.

OBJECTIVE: To assess the psychometric properties of the short-form chronic respiratory disease questionnaire (SF-CRQ) as a quality-of-life (QOL) instrument in chronic obstructive pulmonary disease (COPD) exacerbations. STUDY DESIGN AND SETTING: In a prospective multicenter cohort study, consecutive emergency department (ED) patients with COPD exacerbation were interviewed using the SF-CRQ and other instruments. Baseline information was collected in the ED and from follow-up data 2 weeks later. The results of the SF-CRQ were compared with the results of the other instruments and clinical variables by correlation and factor analyses. RESULTS: Of the 301 enrolled patients, 80% reported improvements across each of the domains of the SF-CRQ over the 2-week post-ED period. Overall median changes for the dyspnea, fatigue, emotional function, and mastery domains were 2, 1, 1, and 1.5, respectively (P<0.001 for each domain). Correlation and factor analyses support their convergent/divergent validity and construct validity. The reliability for the change score of the SF-CRQ was high (Cronbach's alpha coefficient, 0.82). Overall minimal clinically important difference for improvement in the SF-CRQ was 1.01 (95% confidence interval, 0.72-1.31). CONCLUSION: SF-CRQ is a valid, reliable, and responsive instrument for the assessment of short-term QOL change in patients with COPD exacerbations.

Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians.

STUDY OBJECTIVE: The primary objective of this study is to measure career satisfaction among emergency physicians participating in the 1994, 1999, and 2004 American Board of Emergency Medicine Longitudinal Study of Emergency Physicians. The secondary objectives are to determine factors associated with high and low career satisfaction and burnout. METHODS: This was a secondary analysis of a cohort database created with stratified, random sampling of 1,008 emergency physicians collected in 1994, 1999, and 2004. The survey consisted of 25 questions on professional interests, attitudes, and goals; 17 questions on training, certification, and licensing; 36 questions on professional experience; 4 questions on well-being and leisure activities; and 8 questions about demographics. Data were analyzed with a descriptive statistics and panel series regression modeling (Stata/SE 9.2 for Windows). Questions relating to satisfaction were scored with a 5-point Likert-like scale, with 1=not satisfied and 5=very satisfied. Questions relating to stress and burnout were scored with a 5-point Likert-like scale, with 1=not a problem and 5=serious problem. During analysis, answers to the questions "Overall, how satisfied are you with your career in emergency medicine?" "How much of a problem is stress in your day-to-day work for pay?" "How much of a problem is burnout in your day-to-day work for pay?" were further dichotomized to high levels (4, 5) and low levels (1, 2). RESULTS: Response rates from the original cohort were 94% (945) in 1994, 82% (823) in 1999, and 76% (771) in 2004. In 2004, 65.2% of emergency physicians reported high career satisfaction (4, 5), whereas 12.7% of emergency physicians reported low career satisfaction (1, 2). The majority of respondents (77.4% in 1994, 80.6% in 1999, 77.4% in 2004) stated that emergency medicine has met or exceeded their career expectations. Despite overall high levels of career satisfaction, one-third of respondents (33.4% in 1994, 31.3% in 1999, 31% in 2004) reported that burnout was a significant problem. CONCLUSION: Overall, more than half of emergency physicians reported high levels of career satisfaction. Although career satisfaction has remained high among emergency physicians, concern about burnout is substantial.

Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement.

STUDY OBJECTIVE: Visualization of the vocal cords and end-tidal capnography are the usual standards in confirming endotracheal tube placement. Vocal cord visualization is, however, not always possible, and capnography is not 100% reliable and requires ventilation of the lungs to confirm placement. The goal of this study is to determine the accuracy of ultrasonography for detecting endotracheal tube placement into the trachea and esophagus in real time. METHODS: This was a prospective, randomized, controlled study. Eligible patients were adults undergoing elective surgery requiring intubation. Exclusion criteria were a history of difficult intubation, abnormal airway anatomy, aspiration risk factors, and esophageal disease. Thirty-three patients were enrolled. After induction of anesthesia and neuromuscular blockade, the anesthesiologist placed the endotracheal tube in the trachea and esophagus in random order with direct laryngoscopy. During the intubations, a high-frequency, linear transducer was placed transversely on the neck at the suprasternal notch. Two emergency physicians, blinded to the order and performance of the intubations, independently recorded the location of the endotracheal tube according to the real-time ultrasonographic image. A 2-by-2 table was used to calculate sensitivity and specificity of the emergency physicians' ability to detect placement of the endotracheal tube. RESULTS: For each physician, the sensitivity for identifying the first intubation as tracheal was 100% (95% confidence interval [CI] 77% to 100%) with a specificity of 100% (95% CI 82% to 100%). One endotracheal tube was unintentionally placed twice in the esophagus, but both tube placements were identified as esophageal by the emergency physicians. CONCLUSION: In this pilot study, 2 emergency physicians experienced in ultrasonography accurately detected placement of endotracheal tubes during intubation with ultrasonography in select patients in the controlled environment of the operating room. Future studies should examine the use of ultrasonography to visualize endotracheal tube placement in real time by emergency physicians with less ultrasonographic training; use of the technique in the emergency department on a wider range of patients, including patients with difficult airways; and assessment of the utility of ultrasonography in confirmation of endotracheal tube position in already intubated patients.

Randomized controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma.

OBJECTIVE: Emergency department (ED) visits for asthma are frequent and may indicate increased morbidity and poor primary care access. Our objective was to compare the effect of two interventions on primary care follow-up after ED treatment for asthma exacerbations. METHODS: We performed a randomized controlled trial of patients 2 to 54 years old who were judged safe for discharge receiving prednisone, and who were available for contact at 2 days and 30 days. Patients were excluded if they were previously enrolled or did not speak English. Patients received usual discharge care (group A); free prednisone, vouchers for transport to and from a primary care visit, and either a telephone reminder to schedule a visit (group B); or a prior scheduled appointment (group C). Follow-up with a primary care provider for asthma within 30 days was the main outcome. Secondary outcomes were recurrent ED visits, subsequent hospitalizations, quality of life, and use of inhaled corticosteroids 1 year later. RESULTS: Three hundred eighty-four patients were enrolled. Baseline demographics, chronic asthma severity, and access to care were similar across groups. Primary care follow-up was higher in group C (65%) vs group A (42%) or group B (48%) [p = 0.002]. Group C intervention remained significant (odds ratio, 2.8; 95% confidence interval, 1.5 to 5.1) when adjusted for other factors influencing follow-up (prior primary care relationship, insurance status). There were no differences in ED, hospitalizations, quality of life, or inhaled corticosteroid use at 1 year after the index ED visit. CONCLUSION: An intervention including free medication, transportation vouchers, and appointment assistance significantly increased the likelihood that discharged asthma patients obtained primary care follow-up but did not impact long-term outcomes.

Prospective multicenter study of acute asthma in younger versus older adults presenting to the emergency department.

OBJECTIVES: To describe acute asthma in younger versus older adults presenting to the emergency department (ED). DESIGN: Prospective cohort study. Asthmatic adults were divided into three age groups: 18 to 34, 35 to 54, and 55 and older. The analysis was restricted to never smokers and smokers with fewer than 10 pack-years. SETTING: ED. PARTICIPANTS: Two thousand sixty-four patients aged 18 and older with a physician diagnosis of asthma. MEASUREMENTS: Medications and peak expiratory flow. RESULTS: There were 1,158 (56%) subjects aged 18 to 34; 777 (37%) aged 35 to 54; and 129 (6%) aged 55 and older. Older patients were most likely to have a primary care provider (65%, 74%, and 91%, respectively; P<.001); most were not taking inhaled corticosteroids (39%, 55%, and 48%, respectively; P<.001). Older patients reported fewer ED visits for asthma (2, 2, and 1, respectively; P=.001) but were more likely to report asthma hospitalization (24%, 31%, and 37%, respectively; P<.001). All groups had severe exacerbations (initial percentage predicted peak flow: 47, 47, and 47, respectively; P=.50), but older patients were least likely to report severe symptoms (72%, 79%, and 67%, respectively; P=.001). Older patients did not respond as well to bronchodilators, even after controlling for other demographic factors, markers of asthma severity, and ED management (change between initial and final peak expiratory flow, using subjects aged 18 to 34 as reference: aged 35-54, beta=-0.7 (95% CI=-9.4-8.0); aged > or = 55, beta=-18.4 (-31.9 to -4.9)). The smaller change in peak expiratory flow contributed most to older patients' greater likelihood of hospitalization. CONCLUSION: Older asthma patients were less responsive to emergency bronchodilation. This may reflect chronic undertreatment with inhaled corticosteroids.

Acute asthma during pregnancy.

In addition to preventing maternal and fetal hypoxia, the goals of treating acute asthma exacerbation during pregnancy mirror those in the nongravid patient: rapid reversal of airflow obstruction with aerosolized bronchodilators,reduction of likelihood of recurrence by the addition of corticosteroids, and ongoing assessment of mother and fetus. Disposition decisions are multifaceted and must take into account the health and well-being of the pregnant patient and that of her fetus. Discharge planning includes prescription of scheduled 3-2 agonist treatments until symptoms resolve, intensification of daily treatment as needed, prescriptions for systemic and ICSs, as well provision of patient education, a personalized action plan, and close follow-up.

Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations.

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Lifelong learning.

Early American physician education lacked quality and consistency. Poorly funded institutions with weak curricula and little patient contact before graduation trained our earliest doctors. With the advent of the twentieth century, a reformation of medical education took place that created the foundation of our modern American medical education system. The importance of physician education increased, leading to the production of specialty boards and requirements for continuing medical education and culminating in a continuous certification process now required of all specialties including the American Board of Emergency Medicine. While the utility of continuing medical education has been questioned, technological advances, the Internet, and improved education techniques are helping physicians practice modern medicine in a time of rapidly expanding science.

Inadequate follow-up controller medications among patients with asthma who visit the emergency department.

STUDY OBJECTIVE: The purpose of this study is to determine the frequency with which primary care physicians add inhaled corticosteroids to the regimen of asthmatic patients after a visit to the emergency department (ED) among patients not previously prescribed inhaled corticosteroids and to determine the rate at which inhaled corticosteroids prescribed in the ED were continued by primary care physicians. METHODS: We conducted a structured retrospective cohort study using electronic medical record review of consecutive patients aged 6 to 45 years, treated for acute asthma exacerbation (International Classification of Diseases, Ninth Revision code 493.00 through 493.99) in the ED during a specified 6-month period, and followed up for 1 year. The patients' first ED visit for asthma exacerbation during the study period was considered the index visit for purposes of this study. RESULTS: Six hundred twenty-nine patients met study inclusion criteria, 414 of whom were not previously receiving inhaled corticosteroid therapy. On ED or hospital discharge, 99 (24%) of these 414 patients were prescribed an inhaled corticosteroid. Of these 99 patients, 37 patients had a primary care follow-up visit within 6 months, with 4 receiving an inhaled corticosteroid dose change and no patients having the inhaled corticosteroids discontinued. Of the 315 patients not prescribed an inhaled corticosteroid on ED or hospital discharge, 128 had a primary care follow-up visit within 6 months, with 32 (25%) patients having an inhaled corticosteroid added to their therapeutic regimen. After primary care follow-up, only 69 (42%) of the 165 patients treated in clinic were receiving an inhaled corticosteroid for control of their asthma. Patients without insurance (odds ratio 0.14; 95% confidence interval 0.027 to 0.71) and patients initially discharged home from the ED (odds ratio 0.17; 95% confidence interval 0.05 to 0.53) were much less likely to receive inhaled corticosteroids at follow-up on multivariate logistic regression adjusting for race, sex, insurance status, and initial disposition. CONCLUSION: Primary care physicians infrequently add controller medications (inhaled corticosteroids) at follow-up to the regimen of asthmatic patients after a visit to the ED. Emergency physicians should be encouraged to evaluate chronic asthma burden among patients presenting with exacerbation, educate asthmatic patients, and prescribe controller medications, such as inhaled corticosteroids, for those with persistent symptoms.

Improved management of acute asthma among pregnant women presenting to the ED.

BACKGROUND: A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s. METHODS: We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge. RESULTS: Of 4,895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04). CONCLUSIONS: Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

Prospective multicenter study of relapse following emergency department treatment of COPD exacerbation.

STUDY OBJECTIVES: To determine the incidence and risk factors of relapse after an emergency department (ED) visit for COPD exacerbation. DESIGN: Prospective cohort study as part of the Multicenter Airway Research Collaboration. SETTING: Twenty-nine North American EDs. PATIENTS: ED patients with COPD exacerbations, age > or =55 years. For the present analysis of post-ED relapse, the cohort was restricted to COPD patients who had been discharged from the ED directly to home. MEASUREMENTS AND RESULTS: Eligible patients underwent a structured interview to assess their demographic characteristics, COPD history, and details of the current COPD exacerbation. Data on ED medical management and disposition were obtained by chart review. Patients were contacted by telephone 2 weeks later regarding incident relapse events (ie, urgent clinic or ED visit for worsening COPD). The cohort consisted of 140 COPD patients. Over the next 2 weeks, patients demonstrated a consistent daily relapse rate that summed to 21% (95% confidence interval, 15 to 28%) at day 14. In a multivariate model, the significant risk factors for relapse were the number of urgent clinic or ED visits for COPD exacerbation in the past year (odds ratio [OR], 1.49 [per five visits]), self-reported activity limitation during the past 24 h (OR, 2.93 [per unit on scale of 1 [none] to 4 [severe]), and respiratory rate at ED presentation (OR, 1.76 [per 5 breaths/min]). CONCLUSIONS: Among patients discharged to home after ED treatment of a COPD exacerbation, one in five patients will experience an urgent/emergent relapse event during the next 2 weeks. Both chronic factors (ie, a history of urgent clinic or ED visits) and acute factors (ie, activity limitations and initial respiratory rate) are associated with increased risk. Further research should focus on ways to decrease the relapse rate among these high-risk patients. The clinicians may wish to consider these historical factors when making ED decisions.