The incidence of dermatitis following application of foam tape in healthy volunteers-A prospective trial.

BACKGROUND: Foam tape is commonly used in the emergency department as a dressing over chest tubes owing to its occlusive and compressible properties. There is a paucity of data regarding the incidence of significant cutaneous reactions to this material. We conducted a prospective trial to evaluate the incidence of dermatitis following application of foam tape to the upper arm of a cohort of healthy volunteers. METHODS: This was a prospective, interventional trial. We enrolled a cohort of consenting, healthy physicians, nurses, and ancillary staff at a teaching facility who did not have known hypersensitivity to foam tape. Study investigators applied a 2 × 2 inch piece of 3 M microfoam adhesive to the medial aspect of each subject's upper arm. The contralateral arm served as a reference for comparison. The adhesive remained in place for 48 h and the study authors assessed patients utilizing the previously validated Cutaneous Irritancy Scoring System (CISS). Categorical variables analyzed by chi-square, continuous variables with t-tests. RESULTS: There were 40 subjects in the study group; 52% female, mean age 40±7 years, 55% non-White race. 10/40 (25%; 95%CI[14%, 41%]) of subjects had erythema; 9/40 (22%) had an erythema score of 1 and 1/40 (2.5%) had a score of 2. With respect to edema, 2/40 (5%; 95% CI[1%,18%]); 1/40(2.5%) had an edema score of 1, and 1/40(2.5%) had a score of 2. There were 9/40 subjects with an irritancy score > 0; (22%; 95%CI[12%,38%]); 7/40(18%) had an irritancy score of 1, and 2/4(5.0%) had a score of 2. In terms of the severity score, 10/40 (25%; 95%CI[14%, 41%]) had a score > 0; 9/40(22%) had a score of 1, and 1/40(2.5%) had a score of 2. Overall, 10/40 (25%; 95%CI[14%, 41%]) of subjects had at least one positive measure of a reaction of any kind. Subjects' age, gender and race were not found to be statistically significantly associated with the incidence of erythema, edema, or irritancy. In addition, these characteristics were not statistically significantly associated with severity score > 0. The p values for all the above bivariate analyses were > 0.05. CONCLUSIONS: Cutaneous reactions occurred in 25% of healthy volunteers after the application of foam tape to the arm. Patient characteristics were not associated with risk of a skin reaction. CLINICAL TRIALS REGISTRATION: #NCT06059417.

An analysis of racial inequities in emergency department triage among patients with stroke-like symptoms in the United States.

BACKGROUND: Racial inequities exist in treatment and outcomes in patients with acute stroke. OBJECTIVES: Our objective was to determine if racial inequities exist in the time-lapse between patient presentation and provider assessment in patients with stroke-like symptoms in Emergency Departments (ED) across the U.S. METHODS: This study is a retrospective, observational study of the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2014-2018. We identified visits with stroke-like symptoms and stratified the proportion of door-to-provider (DTP) times by racial groups. We used broad and narrow definitions of stroke-like symptoms. We performed bivariate and multivariate analyses using race and clinical and demographic characteristics as covariates. RESULTS: Between 2014-2018, there were an average of 138.58 million annual ED visits. Of the total ED visits, 0.36% to 7.39% of the ED visits presented with stroke-like symptoms, and the average DTP time ranged from 39 to 49 min. The proportion of the visits with a triage level of 1 (immediate) or 2 (emergent) ranged from 16.03% to 23.27% for stroke-like symptoms. We did not find statistically significant racial inequities in DTP or ED triage level. We found significantly longer DTP times in non-Hispanic blacks (15.88 min, 95% CI: 4.29-27.48) and Hispanics (by 14.77 min, 95% CI: 3.37-26.16) than non-Hispanic whites that presented with atypical stroke-like symptoms. We observed that non-Hispanic whites were significantly more diagnosed with a stroke/TIA than other racial minority groups (p = 0.045) for atypical stroke-like symptoms. CONCLUSION: In our population-based analysis, we did not identify systemic racial inequities in the DTP times or ED triage level at ED triage for stroke-like symptoms.

First and last authorship by gender in emergency medicine publications- a comparison of 2008 vs. 2018.

BACKGROUND AND OBJECTIVES: Recently, investigators reported that there remain substantial disparities in the proportion of women within emergency medicine (EM) who have achieved promotion to higher academic rankings, received grant funding, and attained departmental leadership positions. In 2007, women were first authors on 24% of EM-based peer-reviewed articles. Currently, 28% of the academic EM physician workforce is comprised of women. The goal of this study was to identify whether the proportion of female first authors of original research published in three U.S.-based EM journals increased in 2018 as compared to 2008. METHODS: This was a retrospective review of published original research articles during 2008 and 2018 in the journals Academic Emergency Medicine (AEM), American Journal of Emergency Medicine (AJEM), and Annals of Emergency Medicine (Annals). Review articles, opinion pieces, consensus statements, practice recommendations based on current guidelines, and case reports were excluded from analysis. Investigators conducted a review of each article to identify the gender of the study's first and last authors. A study author blinded to the previous author's data abstraction reviewed a sample of 25 articles to assess for inter-rater reliability (kappa). Categorical data are presented as frequency of occurrence and analyzed by chi-square. RESULTS: Overall for the study journals, there were 368 original research articles published in 2008 vs. 580 in 2018. There were no significant differences noted for the proportion of female first author publications during 2008 vs 2018 overall (28% vs 30%; p = 0.38), within AJEM (29% vs 28%; p = 0.85), and observed at Annals (25% vs 24%; p = 0.82) respectively. However, there was a significant increase in the number of first author publications by females between the two periods within AEM (28% vs 45%; p < 0.01). There were no significant differences noted for the proportion of female last author publications during 2008 vs. 2018 overall (21% vs 22%; p = 0.70) and within each respective journal: AEM 22%% vs 26% (p = 0.51), AJEM 22% vs 19% (p = 0.55), and Annals 19% vs 22% (p = 0.20). Inter-rater reliability for author gender within the sample articles was excellent (0.83). CONCLUSION: While female physicians make up a disproportionate 28% of the academic workforce, we found that they were proportionally represented as first authors within several of the most prominent U.S.-based EM journals. Female resident physicians remain underrepresented as first authors and women remain underrepresented as last authors in the same journals.

A prospective study to assess the association of body mass index and contamination of urinalysis samples.

BACKGROUND: There is a commonly held belief that overweight women are more likely to offer contaminated urine samples (UAs) in the emergency department (ED) than women with normal body mass index (BMI). However, there is a paucity of research evaluating this potential concern. OBJECTIVE: We hypothesized that patients with higher BMI would be more likely to provide contaminated urine samples than women with low BMI. METHODS: This was a prospective, observational, cohort study evaluating consenting, adult, women that provided a clean catch, mid-stream sample at an inner-city ED. UAs were ordered at the discretion of the caring physician, cultures based on standardized parameters. The primary outcome parameter was the presence of UA contamination as defined by our microbiology lab. Demographic/historical data and BMI were recorded on a structured data sheet. Categorical data were analyzed by chi-square; continuous data by t-tests. Multivariable logistic regression was performed to control for confounding. RESULTS: There were 350 patients in the study group; 22% overweight, 35% obese, 17% morbidly obese, mean BMI 31. 5, and 60% provided contaminated specimens. The mean BMIs of the subjects with contaminated vs. uncontaminated UAs were significantly different (32.7 ±â€¯10.2 vs 29.7 ±â€¯8.8, p < 0.01). Within our multiple variable logistic regression model, obese and morbidly obese patients were more likely to provide contaminated UAs, while there were no significant associations for contamination with other variables except for hypertension (OR = 1.85, p = 0.02). CONCLUSION: Obesity was significantly associated with contamination of clean catch mid-stream samples in our population.

Sensitivity of urinary pathogens for patients discharged from the emergency department compared with the hospital antibiogram.

BACKGROUND: Data for hospital antibiograms are typically compiled from all patients, regardless of disposition, demographics and other comorbidities. OBJECTIVE: We hypothesized that the sensitivity patterns for urinary pathogens would differ significantly from the hospital antibiogram in patients that were discharged from the emergency department (ED). METHODS: We evaluated a retrospective cohort of all adult patients with positive urine cultures treated in the 2016 calendar year at an inner-city academic ED. Positive urine cultures defined by our institution's microbiology department. Investigators conducted a structured review of an electronic medical record (EMR) to collect demographic, historical and microbiology records. We utilized a one-sample test of proportion to compare the sensitivity of each organism for discharged patients to the hospital published antibiogram. Alpha set at 0.05. RESULTS: During the study period, 414 patients were discharged from the ED and found to have positive urine cultures; 20% age > 60 years old, 85% female, 79% Hispanic, 33% diabetic. The most common organisms was E. coli (78%). E. coli was sensitive to Trimethoprim-Sulfamethoxazole for 59% vs. 58% in our antibiogram (p = 0.77), Ciprofloxacin 81% vs. 69% (p < 0. 001), Nitrofurantoin 96% vs 95%; (p = 0.25). K. pneumoniae was sensitive to Trimethoprim-Sulfamethoxazole 87% vs. 80% in our antibiogram (p = 0.26), Ciprofloxacin 100% vs. 92% (p = 0.077), Nitrofurantoin 86% vs 41% (p < 0.001). CONCLUSIONS: For our predominantly Hispanic study group with a high prevalence of diabetes, we found that our hospital antibiogram had relatively good value in guiding antibiotic therapy though for some organism/antibiotic combinations sensitivities were higher than expected.

CT imaging history for patients presenting to the ED with renal colic--evidence from a multi-hospital database.

BACKGROUND: Patients with renal colic have a 7% chance of annual recurrence. Previous studies evaluating cumulative Abbreviations: computed tomography (CT) exposure for renal colic patients were typically from single centers. METHODS: This was an observational cohort study. Inner-city ED patients with a final diagnosis of renal colic were prospectively identified (1/10/16-10/16/16). Authors conducted structured electronic record reviews from a 6-hospital system encompassing over 192,000 annual ED visits. Categorical data analyzed by chi-square; continuous data by t-tests. Primary outcome measure was the proportion of study group patients with prior history CT abdomen/pelvis CT. RESULTS: Two hundred thirteen patients in the study group; 59% male, age 38+/- 10 years, 67% Hispanic, 62% prior stone history, flank pain (78%), dysuria (22%), UA (+) blood (75%). 60% (95% CI = 53-66%) of patients received an EDCV CT; hydronephrosis seen in 55% (95% CI = 46-63%), stone in 90%(95% CI = 83-94%). No significant differences observed in the proportion of EDCV patients who received CT with respect to: female vs. male (62% vs. 56%; p = 0.4), mean age (37+/- 9 years vs. 39+/- 11 years; p = 0.2), and Hispanic vs. non-Hispanic white (63% vs.63%; p = 0.96). Patients with a prior stone history were more likely than those with no history to receive an EDCV CT (88% vs. 16%; p < 0.001). 118 (55%; 95% CI = 49-62%) of patients had at least one prior CT, 46 (22%; 95% CI = 16-28%) had ≥3 prior CTs; 29 (14%; 95% CI = 10-19%), ≥ 10 prior CTs. Patients who did not receive an EDCV CT had a significantly higher mean prior number of CTs than those who had EDCV CT (5.1+/- 7.7 vs 2.2+/- 4.9; p < 0.001). Patients with prior stone were more likely to receive only U/S during EDCV (33% vs. 15%; p = 0.003). CONCLUSIONS: Within our EDCV cohort of renal colic patients, 55% had at least one prior CT. The mean number of prior CTs was lower for patients receiving CT on EDCV, and Ultrasound (US) alone was used more often in patients with prior stone history vs. those with no prior history.

Prior CT imaging history for patients who undergo whole-body CT for acute traumatic injury and are discharged home from the emergency department.

BACKGROUND: Recurrent CT imaging is believed to significantly increase lifetime malignancy risk. We previously reported that high acuity, admitted trauma patients who received a whole-body CT in the emergency department (ED) had a history of prior CT imaging in 14% of cases. The primary objective of this study was to determine the CT imaging history for trauma patients who received a whole-body CT but were ultimately deemed safe for discharge directly home from the ED. METHODS: This was a retrospective cohort study conducted at an academic ED. All trauma patients who were discharged directly home from the ED after whole-body CT were analyzed. The decision to utilize whole-body CT was at the discretion of the caring physician during the study period. Clinical data for the most recent trauma visit was recorded in a structured fashion on a standardized data collection instrument utilizing the hospital system electronic medical record (EMR). Subsequently, study investigators reviewed a shared, electronic radiological archive for the 6-hospital system to evaluate prior CT exposure for each patient. RESULTS: 165 patients were in the study group. The mean age of the study group was 39+/- 16 years old, 40% were female and 64% were Hispanic. The most common mechanism of injury in our study group was motor vehicle crash (MVC) (66%). In our study group, 25% had at least one prior CT. The most common prior studies performed were: CT abdomen/pelvis (13%), CT head (9.1%), CT face (6.7%), and CT chest (1.8%). Within a multivariate logistic regression model we found that the large majority of patient characteristics and mechanisms of injury were not associated with a positive prior CT imaging history. CONCLUSION: We found a positive history for prior CT for 25% of trauma patients who received whole-body CT scan but were discharged from the ED to home.

Over-prescribing of antibiotics and imaging in the management of uncomplicated URIs in emergency departments.

BACKGROUND: Unnecessary use of resources for common illnesses has substantial effect on patient care and costs. Evidence-based guidelines do not recommend antibiotics or imaging for uncomplicated upper respiratory infections (URIs). The objective of the current study was to examine medical care providers' compliance with guidelines in treating uncomplicated URIs in emergency departments (EDs) in the US. METHODS: Nationally representative data from the NHAMCS 2007 and 2008 were used. Uncomplicated URIs were identified through ICD-9 codes of nasopharyngitis, laryngitis, bronchitis, URI not otherwise specified and influenza involving upper respiratory tract. Exclusion criteria were concurrent comorbidities, follow-up visits, and age < 18 or >64 years. Most frequently prescribed classes of antibiotics were identified. Multivariate analyses were conducted to identify the factors associated with the prescribing of antibiotics and use of imaging studies. RESULTS: In 2007 and 2008, there were 2.2 million adult uncomplicated URI visits without any other concurrent diagnoses in EDs in the US. Approximately 52% were given antibiotic prescriptions, over one-third of which were macrolides, and nearly half of the visits performed imaging studies. About 51% had a diagnosis of bronchitis, 35% URI NOS, 9% nasopharyngitis, laryngitis or influenza, and 4% multiple URI diagnoses. The diagnosis of bronchitis, fever at presentation, older ages, male gender, longer waiting time, and metropolitan areas were associated with a greater likelihood of prescribing antibiotics or imaging studies, controlling for confounding factors. CONCLUSION: Despite the recommendations and campaign efforts by the CDC and many medical associations, the prescribing of antibiotics in treating uncomplicated URIs in the EDs remains prevalent. Furthermore, overutilization of imaging studies is prevalent. Changes at levels of health care system and hospitals are needed to avoid unnecessary resource utilization. In addition, further patient education about antibiotic use in the community may greatly facilitate the transition out of an antibiotic-dependent consumer culture.

The Utility of Pain Scale to Assess Verifiable vs Non-Verifiable Pain in United States Emergency Departments.

INTRODUCTION: We sought to examine the utility of self-reported pain scale by comparing emergency department (ED) triage pain scores of self-reported but non-verifiable painful conditions with those of verifiable painful conditions using a large, nationally representative sample. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2015. Verifiable painful conditions were identified based on the final diagnoses in the five included International Classification of Diseases 9th revision codes. Non-verifiable painful conditions were identified by the five main reasons for visit. Only adults 18 years of age or older were included. The primary outcome variable was the pain scale from 0 to 10 at triage. We performed descriptive and multivariate analyses to investigate the relationships between the pain scale and whether the painful condition was verifiable, controlling for patient characteristics. RESULTS: There were 55 million pain-related adult ED visits in 2015. The average pain scale was 6.49. For verifiable painful diagnoses, which were about 24% of the total visits, the average was 6.27, statistically significantly lower than that for non-verifiable painful conditions, 6.56. Even after controlling for the confounding of patient characteristics and comorbidities, verifiable painful diagnoses still presented less pain than those with non-verifiable painful complaints. Older age, female gender, and urban residents had significantly higher pain scores than their respective counterparts, controlling for other confounding factors. Psychiatric disorders were independently associated with higher pain scores by about a half point. CONCLUSION: Self-reported pain scales obtained at ED triage likely have a larger psychological component than a physiological one. Close attention to clinical appropriateness and overall patient comfort are more likely to lead to better health outcomes and patient experiences than focusing on self-reported pain alone.

The changing profile of patients who used emergency department services in the United States: 1996 to 2005.

STUDY OBJECTIVE: Because of the vital role of emergency departments (EDs) in the US health care system, it is important to monitor the changes in the patient mix over time to identify existing problems and ways to improve the system. The current study aimed to identify raw and population-adjusted time trends for demographic characteristics, socioeconomic characteristics, access to care, utilization of care, and general health of ED users and heavy ED users. METHODS: Ten years' worth of nationally representative data was derived from the Medical Expenditure Panel Survey, 1996 to 2005. Raw time trends of various patient characteristics for ED users, nonusers, and heavy users were estimated to demonstrate changes in ED patient mix. Population-attributable fraction was used to generate population-adjusted trends that elucidate the net changes in subpopulations' propensities to ED use in relation to those of the general population. RESULTS: Between 1996 and 2005, the total number of noninstitutionalized individuals who used ED services increased from 34.2 to 40.8 million. That is, the proportion of ED users in the US population increased from 12.7% to 13.8%. Increasing proportions of elderly and those who perceived themselves to be in poor or fair physical health among ED users, particularly heavy users, were found in both raw and population-adjusted trends. Several subpopulations demonstrated increasing levels of ED use after population adjustment: blacks, patients within 100% to 199% of the federal poverty line, patients with only Medicare, patients with greater than or equal to 2 types of insurance, and patients with at least 1 inpatient stay. Decreasing population-adjusted trends were found in the proportions of female patients, Hispanics, patients at greater than or equal to 200% of the federal poverty line, the uninsured, and patients with only private insurance, respectively. CONCLUSION: EDs play a larger role in the management of geriatric patients over time. The increasing burden of the aging population in the EDs poses challenges in the training of future emergency physicians, care for older patients, public health insurance, and health care system reform.

A Comparison of Nonobese Versus Obese Emergency Department Patient Satisfaction Scores Utilizing Standard U.S. Hospital Survey Query Methodology.

BACKGROUND: Prior research reveals that overweight patients have higher emergency department (ED) utilization rates, longer length of stay, and face increased misdiagnosis risk. OBJECTIVE: The objective of this study was to evaluate the association between obesity and ED patient satisfaction. METHODS: This study was a cross-sectional study. A convenience sample of inner-city ED patients completed a written survey, then rated overall satisfaction with ED care (10-point scale), and rated components of satisfaction (4-point scale; never to always). Body mass index (BMI) was calculated using triage records (obesity = BMI >30). RESULTS: Five hundred and sixty-four patients were included in the study group (50.5%: obese, 55.4%: female, mean age: 43.2 ± 25.4 years). With respect to overall visit satisfaction (rating 8 or greater on 10-point scale), bivariate analysis revealed no differences between nonobese versus obese patients (74.6% vs. 73.9%; P = 0.85). There were no significant differences for score of 4 (always) for components of ED satisfaction: physician courtesy (87.9% vs. 90.4%; P = 0.34), nurse courtesy/respect (89.2% vs. 88.7%; P = 0.87), doctor listened (85.4% vs. 87.1%; P = 0.5), doctor explained (80.2% vs. 85.0%; P = 0.14), and recommend to friend (72.5% vs. 81.1%; P = 0.02). Within our multivariate model, obesity was not associated with overall satisfaction (scores of 8 or greater) (P = 0.97; odds ratio = 0.99 [95% confidence interval = 0.65-1.5]). CONCLUSIONS: Despite research that suggests that overweight patients have characteristics of their ED visit that might increase dissatisfaction risk, we found no difference in satisfaction scores between nonobese and obese patients.

Costs and Characteristics of Undocumented Immigrants Brought to a Trauma Center by Border Patrol Agents in Southern Texas.

BACKGROUND: The objective of this study was to evaluate the costs, characteristics, and outcomes of patients brought to a Texas trauma center emergenct department after apprehension by Border Patrol (BP)/Immigration and Customs Enforcement (BP/ICE). MATERIALS AND METHODS: This is a secondary analysis of a trauma registry/financial records (1/1/11-12/31/14). Data were extracted utilizing a structured form. A multivariate ordinary least square was estimated to identify variables associated with hospital charges. RESULTS: A total of 128 patients were enrolled as the study group; mean age was 28.6 ± 6 years, 20.3% were female, 100% were Hispanic, the most common mechanism of injury (MOI) was motor vehicle crash (75%), and mean charge was $162,152 ± $295,441. Mean length of stay (LOS) was 13.2 ± 29.8 days; 92.2% survived to discharge. Bivariate analysis revealed that MOI differed by gender (P = 0.021). In the multivariate analysis, the only variable that associated with increased charge was LOS. Total charges for the 128 patients were $20.6M, total costs were $4.5M, and total payments were $0.99M. CONCLUSIONS: Undocumented immigrants apprehended by BP/ICE and brought to our trauma center utilized significant health-care resources.