The effect of peer influence on the use of CT by emergency physicians for patients with headaches.

BACKGROUND: It is challenging for emergency physicians (EPs) to distinguish between patients with life-threatening and benign headaches. We examined the effect of peer influence on computed tomography use by EPs for patients with headache and evaluated the peer influence effect in EPs with different levels of risk tolerance. METHODS: We conducted a before- and after-retrospective case review, and administered the Risk-Taking subscale of the Jackson Personality Index to attending physicians. Each EP computed tomography (CT) use rate, patient number, and CT use, were e-mailed every two months to enhance EP team norm and establish a trend in behavior. RESULTS: Of the 665 (before intervention) and 669 (after intervention) patients with headache, 206 (31%) and 171 (25.6%) underwent brain CT scans, respectively. Decreased use of CT examination was found in the post-intervention group (OR = 0.758, 95% CI: 0.593-0.967), especially for most risk-tolerant physicians (OR = 0.530, 95% CI: 0.311-0.889). There was prolonged ED length of stay (LOS) in the pre-intervention group (OR = 51.52, 95% CI: 26.998-76.050). CONCLUSIONS: We observed that peer influence is an effective way to improve CT use rate and emergency department LOS for patients with isolated headache, especially for most risk-tolerant physicians. These findings could enhance the development of appropriate guidelines to assist ED physicians' CT use.

ICU admission following an unscheduled return visit to the pediatric emergency department within 72 hours.

INTRODUCTION: The purpose of this study was to describe the demographic characteristics and prognosis of children admitted to the intensive care unit (ICU) after a pediatric emergency department (PED) return visit within 72 h. METHOD: We conducted this retrospective study from 2010 to 2016 in the PED of a tertiary medical center in Taiwan and included patients under the age of 18 years old admitted to the ICU after a PED return visit within 72 h. Clinical characteristics were collected to perform demographic analysis. Pediatric patients who were admitted to the ICU on an initial visit were also enrolled as a comparison group for outcome analysis, including mortality, ventilator use, and length of hospital stay. RESULTS: We included a total of 136 patients in this study. Their mean age was 3.3 years old, 65.4% were male, and 36.0% had Chronic Health Condition (CHC). Disease-related return (73.5%) was by far the most common reason for return. Compared to those admitted on an initial PED visit, clinical characteristics, including vital signs at triage and laboratory tests on return visit with ICU admission, demonstrated no significant differences. Regarding prognosis, ICU admission on return visit has a higher likelihood of ventilator use (aOR:2.117, 95%CI 1.021~4.387), but was not associated with increased mortality (aOR:0.658, 95%CI 0.150~2.882) or LOHS (OR:-1.853, 95%CI -4.045~0.339). CONCLUSION: Patients who were admitted to the ICU on return PED visits were associated with an increased risk of ventilator use but not mortality or LOHS compared to those admitted on an initial visit.

Clinical Validation of the Shock Index, Modified Shock Index, Delta Shock Index, and Shock Index-C for Emergency Department ST-Segment Elevation Myocardial Infarction.

Background: ST-segment elevation myocardial infarction (STEMI) is a leading cause of death worldwide. A shock index (SI), modified SI (MSI), delta-SI, and shock index-C (SIC) are known predictors of STEMI. This retrospective cohort study was designed to compare the predictive value of the SI, MSI, delta-SI, and SIC with thrombolysis in myocardial infarction (TIMI) risk scales. Method: Patients > 20 years old with STEMI who underwent percutaneous coronary intervention (PCI) were included. Receiver operating characteristic (ROC) curve analysis with the Youden index was performed to calculate the optimal cutoff values for these predictors. Results: Overall, 1552 adult STEMI cases were analyzed. The thresholds for the emergency department (ED) SI, MSI, SIC, and TIMI risk scales for in-hospital mortality were 0.75, 0.97, 21.00, and 5.5, respectively. Accordingly, ED SIC had better predictive power than the ED SI and ED MSI. The predictive power was relatively higher than TIMI risk scales, but the difference did not achieve statistical significance. After adjusting for confounding factors, the ED SI > 0.75, MSI > 0.97, SIC > 21.0, and TIMI risk scales > 5.5 were statistically and significantly associated with in-hospital mortality of STEMI. Compared with the ED SI and MSI, SIC (>21.0) had better sensitivity (67.2%, 95% CI, 58.6−75.9%), specificity (83.5%, 95% CI, 81.6−85.4%), PPV (24.8%, 95% CI, 20.2−29.6%), and NPV (96.9%, 95% CI, 96.0−97.9%) for in-hospital mortality of STEMI. Conclusions: SIC had better discrimination ability than the SI, MSI, and delta-SI. Compared with the TIMI risk scales, the ACU value of SIC was still higher. Therefore, SIC might be a convenient and rapid tool for predicting the outcome of STEMI.

Effects of Fine Particulate Matter and Its Components on Emergency Room Visits for Pediatric Pneumonia: A Time-Stratified Case-Crossover Study.

Pneumonia, one of the important causes of death in children, may be induced or aggravated by particulate matter (PM). Limited research has examined the association between PM and its constituents and pediatric pneumonia-related emergency department (ED) visits. Measurements of PM2.5, PM10, and four PM2.5 constituents, including elemental carbon (EC), organic carbon (OC), nitrate, and sulfate, were extracted from 2007 to 2010 from one core station and two satellite stations in Kaohsiung City, Taiwan. Furthermore, the medical records of patients under 17 years old who had visited the ED in a medical center and had a diagnosis of pneumonia were collected. We used a time-stratified, case-crossover study design to estimate the effect of PM. The single-pollutant model demonstrated interquartile range increase in PM2.5, PM10, nitrate, OC, and EC on lag 3, which increased the risk of pediatric pneumonia by 18.2% (95% confidence interval (Cl), 8.8-28.4%), 13.1% (95% CI, 5.1-21.7%), 29.7% (95% CI, 16.4-44.5%), 16.8% (95% CI, 4.6-30.4%), and 14.4% (95% Cl, 6.5-22.9%), respectively. After PM2.5, PM10, and OC were adjusted for, nitrate and EC remained significant in two-pollutant models. Subgroup analyses revealed that nitrate had a greater effect on children during the warm season (April to September, interaction p = 0.035). In conclusion, pediatric pneumonia ED visit was related to PM2.5 and its constituents. Moreover, PM2.5 constituents, nitrate and EC, were more closely associated with ED visits for pediatric pneumonia, and children seemed to be more susceptible to nitrate during the warm season.

Characteristics of Febrile Children Admitted to the ICU Following an Unscheduled ED Revisit Within 72 h, a Case-Control Study.

Objective: The purpose of this article was to demonstrate related characteristics of intensive care unit (ICU) admission after an unscheduled revisit by febrile children visiting the emergency department (ED). Method: We performed a retrospective study in a tertiary medical center from 2010 to 2016. Patients whose chief complaint was fever and who were admitted to the ICU following a 72-h return visit to the ED were included, and we selected patients who were discharged from the same emergency department for comparison. Results: During the study period, 54 (0.03%) patients met the inclusion criteria, and 216 patients were selected for the matched control group. Regarding clinical variables on initial ED visit, visiting during the night shift (66.7 vs. 46.8%, p = 0.010), shorter length of 1st ED stay (2.5 ± 2.63 vs. 3.5 ± 3.44 h, p = 0.017), and higher shock index (SI) (1.6 ± 0.07 vs. 1.4 ± 0.02, p = 0.008) were associated with ICU admission following a return visit. On the return ED visit, we found that clinical variables such as elevated heart rate, SI, white blood cell count, and C-reactive protein level were all associated with ICU admission. Furthermore, elevated SI and pediatric age-adjusted (SIPA) values were observed in the study group in both the initial (42.2 vs. 20.1%, OR:2.3 (1.37-4.31), p = 0.002) and return ED visits (29.7 vs. 6.9%, OR: 4.6 (2.42-8.26), p < 0.001). Conclusion: For children who visited the emergency department with a febrile complaint, elevated SIPA values on the initial ED visit were associated with ICU admission following an unscheduled ED revisit within 72 h.

Influence of physicians' seniority on head computed tomography use for patients with isolated vertigo/dizziness.

OBJECTIVE: Vertigo/dizziness is a common reason for emergency department (ED) visits. Emergency physicians (EPs) must distinguish patients with dizziness/vertigo owing to serious central nervous system (CNS) disorders. We aimed to evaluate the association between physician seniority and use of head computed tomography (CT) and ED length of stay (LOS) in patients presenting to the ED with isolated dizziness/vertigo. METHODS: This retrospective cohort study included adult patients with non-traumatic dizziness/vertigo in the ED. EPs were categorized according to seniority: junior (less than 6 years' clinical experience), intermediate (7-12 years), and senior (≥12 years). RESULTS: Among 2589 patients with isolated dizziness/vertigo, 460 (17.8%) received brain CT; 46 (1.78%) had CNS disorder as a final diagnosis. Junior and intermediate EPs ordered more CT examinations than senior EPs: (odds ratio [OR] = 1.329, 95% confidence interval [CI]: 1.002-1.769 and OR = 1.531, 95% CI: 1.178-2.001, respectively). Patients treated by junior and intermediate EPs had lower patient ED LOS (OR = -0.432, 95% CI: -0.887 to 0.024 and OR = -0.436, 95% CI: -0.862 to -0.011). CONCLUSIONS: We revealed different judgment strategies among senior, intermediate, and junior EPs. Senior EPs ordered fewer CT examinations for patients with isolated vertigo/dizziness but had longer patient LOS.

Effectiveness of peer pressure on computed tomography use for dizziness/vertigo patients.

Dizziness/vertigo is a common complaint in the emergency department (ED). We aimed to evaluate the effect of peer pressure on decision making in emergency physicians (EPs) to use computed tomography (CT) for patients with dizziness/vertigo.We conducted a before-and-after retrospective case review of patients who visited the ED with dizziness/vertigo. EPs were categorized into 3 groups according to seniority (in years of experience: >12, 7-12, and <7). The rate of CT use for EPs, patient number, and CT use were e-mailed monthly to update the EP team on the benchmark rate and shape of the behavior.Among the 1657 (preintervention) and 1508 (postintervention) patients with dizziness/vertigo, 320 (19.3%) and 230 (15.3%), respectively, underwent brain CT. A decrease in the rate of CT use was observed in the postintervention group (odds ratio [OR] = 0.743, 95% confidence interval [CI] = 0.615-0.897), especially in junior EPs (years of experience, <7; OR = 0.667, 95% CI: 0.474-0.933) and younger patients (age, <60) (OR = 0.625, 95% CI: 0.453-0.857).The intervention strategy created peer pressure through e-mail reminders and decreased the rate of CT use for patients with isolated dizziness/vertigo, especially in junior EPs and younger patients.

Comparing the Outcomes of Reporting and Trigger Tool Methods to Capture Adverse Events in the Emergency Department.

BACKGROUND: Little is known about which methods are best for detecting adverse events in the emergency department (ED). OBJECTIVES: This study compared the ability of trigger tool and reporting methods to capture adverse events in the ED and investigated the characteristics of the adverse events identified by each. METHODS: This 1-year prospective observational cohort study evaluated a monitoring system that combined 2 reporting methods and 5 trigger tool methods to capture adverse events in the ED of an academic medical center. Measurement outcomes included the number, type, and physical impact of the captured adverse events. RESULTS: Among 69,327 adult nontrauma ED visits, 285 adverse events were identified. Of these adverse events, 77.2% were identified using reporting methods, 26% using trigger tool methods, and 3.2% using both methods. Most patients (81.7%) incurred temporary, minor physical impacts. Of the adverse events that occurred, 86.7% were related to clinical performance. Compared with reporting methods, trigger tool methods had a lower positive predictive rate to identify adverse events (odds ratio [OR], 0.1; 95% confidence interval [CI], 0.09-0.16), a greater proportion of adverse events occurring during the preinterventation and postintervention phases (OR, 17.0; 95% CI, 8.48-34.16), and more cases of severe physical impact or death (OR, 5.4; 95% CI, 2.62-11.10). CONCLUSIONS: The reporting methods more effectively captured greater numbers of adverse events, whereas the adverse events captured by the trigger tool methods were more likely to be severe physical impacts. The combined use of the different methods had synergistic benefits for monitoring adverse events in the ED.