Physiologic Effects and Symptoms Associated with Extended-Use Medical Mask and N95 Respirators.

OBJECTIVES: Compliance and tolerance of facemasks for extended periods are legitimate concerns. The goal of this study was to identify the physiologic and symptomatic effects of extended-use N95 filtering facepiece respirator (N95) compared with medical masks. We hypothesized that hospital personnel wearing medical masks alone would report fewer subjective complaints compared with personnel wearing an N95 with or without overlying medical mask. METHODS: This was a nonrandomized cohort study of hospital-based healthcare personnel at a single tertiary center wearing a medical mask alone or N95 with or without overlying medical mask during routine clinical activity. Potential subjects were consented and asked to complete a structured survey, including a 10-point Likert scale for subjective symptoms: headache, lightheadedness, breathlessness, facial bruising, facial irritation, mental fatigue, physical fatigue, and yawning. Study investigators also obtained vital signs on the participants. Results between subjects wearing a medical mask and subjects wearing an N95 were compared. A sample of 144 subjects, 72 in each mask cohort, was needed to detect a 20% difference in a composite outcome of headache, shortness of breath, or lightheadedness between groups with an alpha of 0.05 and power of 0.8. RESULTS: We enrolled 72 subjects in each group. There were no differences in baseline demographics. Overall 77% of the cohort reported subjective symptoms while donning a mask. There was no difference in the composite outcome, no difference recorded symptoms except facial bruising, and no difference in physiologic measures between groups. CONCLUSIONS: Most medical mask and N95 users reported symptoms during mask use. However, there was no difference in the symptom proportion or severity in either user.

Aortic Arch Thrombus and Pulmonary Embolism in a COVID-19 Patient.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with endothelial inflammation and a hypercoagulable state resulting in both venous and arterial thromboembolic complications. We present a case of COVID-19-associated aortic thrombus in an otherwise healthy patient. CASE REPORT: A 53-year-old woman with no past medical history presented with a 10-day history of dyspnea, fever, and cough. Her pulse oximetry on room air was 84%. She tested positive for severe acute respiratory syndrome coronavirus 2 infection, and chest radiography revealed moderate patchy bilateral airspace opacities. Serology markers for cytokine storm were significantly elevated, with a serum D-dimer level of 8180 ng/mL (normal < 230 ng/mL). Computed tomography of the chest with i.v. contrast was positive for bilateral ground-glass opacities, scattered filling defects within the bilateral segmental and subsegmental pulmonary arteries, and a large thrombus was present at the aortic arch. The patient was admitted to the intensive care unit and successfully treated with unfractionated heparin, alteplase 50 mg, and argatroban 2 µg/kg/min. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Mural aortic thrombus is a rare but serious cause of distal embolism and is typically discovered during an evaluation of cryptogenic arterial embolization to the viscera or extremities. Patients with suspected hypercoagulable states, such as that encountered with COVID-19, should be screened for thromboembolism, and when identified, aggressively anticoagulated.

Dedicated area within the emergency department versus an outside dedicated area for evaluation and management of suspected coronavirus disease 2019.

BACKGROUND: The circumstances of the coronavirus disease 2019 pandemic necessitated an alternate operations strategy for efficient patient management. Alternate care sites were a viable option for managing emergency department (ED) surge in previous epidemics and disasters. OBJECTIVE: This study describes the development of an alternate care site and evaluates efficiency by comparing key performance indicators between an ad hoc nested respiratory evaluation unit (NRU) within the ED and an alternate care site outside the ED. METHODS: This was a cohort study of 2 care models in the same ED during 2 different time periods. As coronavirus disease 2019 surged in March 2020, potential treat-and-release patients with fever or respiratory symptoms were triaged to a dedicated ED area (NRU). As ED volume grew, these low-acuity patients were triaged to an ACS. We compared ED length of stay, elopement, and left without being evaluated rates and ED recidivism between the 2 care models: NRU patients presented to the ED from March 16, 2020, to March 31, 2020, and ACS patients presented from April 1, 2020, to April 15, 2020. Continuous variables were compared using independent t test or Mann-Whitney test. Categorical variables were compared using χ2 test. RESULTS: There were 414 NRU patients and 146 alternate care site patients with no significant differences in sex or age. The mean ED length of stay was shorter for alternate care site patients: 155 versus 45 minutes (P < 0.01). Elopement and left without being evaluated rates were higher in the NRU. There was no significant difference in ED recidivism between groups: 10% versus 6% (P = 0.15). CONCLUSIONS: An alternate care site provided an efficient resource for the evaluation of patients with fever or respiratory symptoms during the coronavirus disease 2019 pandemic.

Diagnostic Reasoning for ST-Segment Elevation Myocardial Infarction (STEMI) Interpretation Is Preserved Despite Fatigue.

BACKGROUND: Fatigue and sleepiness contribute to medical errors, although the effect of circadian disruption and fatigue on diagnostic reasoning skills is largely unknown. OBJECTIVE: To determine whether circadian disruption and fatigue negatively affect the emergency medicine (EM) resident's ability to make important clinical decisions based on electrocardiogram (ECG) interpretation. METHODS: Senior EM residents at 2 programs completed a questionnaire consisting of various measures of fatigue followed by an ECG test packet of ST-segment elevation myocardial infarction (STEMI) and STEMI mimics. Participants were asked to examine each ECG and determine whether cardiac catheterization laboratory activation (CLA) was indicated, and to report their confidence in their decision making on an 11-point, numeric rating scale. The primary outcome measured was a pairwise difference in accuracy of CLA between daytime and overnight testing. RESULTS: A total of 23 residents were enrolled in 2011 and 2012. Subjects demonstrated significant differences in multiple measures of sleepiness and fatigue during overnight periods. The median (interquartile range [IQR]) accuracy of CLA was not significantly different between daytime and overnight (70% [IQR, 50-80] versus 70% [IQR, 60-70], P  =  .82). There were no significant differences in the median number of overcalls (CLA when not a STEMI) and undercalls (no CLA when a STEMI was present; P  =  .57 and .37, respectively). Diagnostic confidence and confidence in CLA were not statistically different between daytime and overnight. CONCLUSIONS: Despite a measurable degree of fatigue, senior EM residents experienced no decrease in their ability to accurately make CLA decisions based on ECG interpretation.

Changes in practice patterns with the opening of a dedicated pediatric emergency department.

OBJECTIVES: Dedicated pediatric emergency departments (ED) staffed by pediatric emergency medicine physicians are becoming more common. We compared processes of care and outcomes before and after opening a dedicated pediatric ED. METHODS: A before and after trial design was used to estimate whether there were any changes in ordering of laboratory tests, radiographic imaging, admission rates, ED length of stay (LOS), rates of left without being seen (LWBS) and patient satisfaction scores after opening a dedicated pediatric ED staffed by pediatric emergency medicine physicians. RESULTS: There were 34,961 pediatric patients; 16,311 (47%) presented before and 18,650 (53%) after opening the pediatric ED. Overall radiologic imaging decreased (42.5% vs. 39.3%; difference, 3.2%; 95% confidence interval [95% CI], 2.1%-4.2%) as did computed tomography (8.9% vs. 7.6%; difference, 1.2%; 95% CI, 0.7%-1.8%) but not magnetic resonance imaging. Laboratory testing decreased from 33.1% to 30.1% (difference, 3%; 95% CI, 2.1%-4.0%) of patients. Mean [SD] ED LOS (3.1 [2.5] vs. 2.8 [2.2] hours; difference, 0.36; 95% CI, 0.31-0.41) as well as the rate of LWBS (1.0% vs. 0.6%; difference, 0.4%; 95% CI, 0.2%-0.5%) also decreased. Admission rates (9.4% vs. 9.4%) and unscheduled return visits within 72 hours (3.2% vs. 3.5%) were unchanged. Mean (SD) monthly satisfaction scores increased from 81.3 (2.2) to 86.3 (2.2) (difference, 5; 95% CI, 3%-7%). CONCLUSIONS: Opening of a pediatric ED with pediatric emergency physicians was associated with decreases in ED LOS, rates of LWBS, general radiographic, and computed tomography imaging as well as laboratory testing, and increases in patient satisfaction scores. The clinical significance of these changes is unclear.

Patients overwhelmingly prefer inpatient boarding to emergency department boarding.

BACKGROUND: Boarding of admitted patients in the emergency department (ED) is a major cause of crowding. One alternative to boarding in the ED, a full-capacity protocol where boarded patients are redeployed to inpatient units, can reduce crowding and improve overall flow. OBJECTIVE: Our aim was to compare patient satisfaction with boarding in the ED vs. inpatient hallways. METHODS: We performed a structured telephone survey regarding patient experiences and preferences for boarding among admitted ED patients who experienced boarding in the ED hallway and then were subsequently transferred to inpatient hallways. Demographic and clinical characteristics, as well as patient preferences, including items related to patient comfort and safety using a 5-point scale, were recorded and descriptive statistics were used to summarize the data. RESULTS: Of 110 patients contacted, 105 consented to participate. Mean age was 57 ± 16 years and 52% were female. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. The overall preferred location after admission was the inpatient hallway in 85% (95% confidence interval 75-90) of respondents. In comparing ED vs. inpatient hallway boarding, the following percentages of respondents preferred inpatient boarding with regard to the following 8 items: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED. CONCLUSIONS: Patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital.

The Wong-Baker pain FACES scale measures pain, not fear.

OBJECTIVE: The Wong-Baker FACES pain rating scale (WBS) is preferred by parents and patients for reporting pain severity. However, it is speculated that the "no hurt" and "hurts worst" anchors confound pain measurement with nonnociceptive states. The objective of our study was to determine if fear confounds reporting of pain severity on the WBS. We hypothesized that the WBS would correlate with a psychometrically different pain severity scale (the visual analog scale [VAS]) and not correlate with a fear measure, the Child Medical Fear Scale (CMFS). METHODS: This was a prospective observational study of children 7 to 12 years presenting to a university-based suburban pediatric ED with acute pain. Patients rated pain severity on the WBS ordinal scale and a 100-mm unhatched VAS with marked end points of "no pain" and "worse pain ever." Patients also completed a 26-item CMFS. Correlations between the WBS and VAS with the CMFS total score were assessed with Spearman correlation and exploratory factor analysis. RESULTS: All 3 scales were completed in 197 children. Correlation between the severity scales (WBS-VAS) was moderate: 0.63 (95% confidence interval [CI], 0.54-0.71). However, correlations between the WBS-CMFS and VAS-CMFS were poor: -0.02 (95% CI, -0.16 to -0.12) and 0.01 (95% CI, -0.13 to 0.15), respectively. Correlations did not differ by sex, grade, pain location, or cause of pain (traumatic vs atraumatic). Exploratory factor analysis demonstrated excellent loadings within 2 factors: pain and fear. CONCLUSIONS: The WBS demonstrates moderate correlation with another measure of pain (VAS) and is not mistaken for fear among school-aged patients presenting to the ED with pain.

Synchronous collection of multisource feedback evaluations does not increase inter-rater reliability.

OBJECTIVES: Most multisource feedback (MSF) evaluations are performed asynchronously, with raters reflecting on the subject's behavior. Numerous studies have demonstrated poor inter-rater reliability of MSF. This may be due to cognitive biases that are inherent in such a process. We sought to determine if within- and between-rater group reliability is increased when evaluations are gathered synchronously and relate to a specific patient interaction. METHODS: This was a survey at a university emergency department (ED) of 30 emergency medicine (EM) residents. ED nurses and faculty anonymously participated in asynchronous MSF assessment of resident performance from February to April 2010 using a Web-based survey, the Emergency Medicine Humanism Scale (EM-HS). In May 2010, a second round of MSF collection was conducted in the ED. At the conclusion of patient encounters, the EM-HS was synchronously obtained from ED nurses and faculty. Evaluators were instructed to assess the resident based on the patient encounter, placing aside any preconceptions of resident performance, attitude, or behavior. Evaluators rated resident performance using a 1-9 scale ("needs improvement" to "outstanding"). The mean rating for each of the questions and the total score provided by each evaluator class was calculated for each EM resident. Differences between the asynchronous and synchronous ratings were compared with t-tests. Pearson correlations were used to measure agreement in scores within and between nurse and faculty rater groups. Correlations > 0.70 were deemed acceptable and are reported with 95% confidence intervals (CIs). RESULTS: Twenty-one of 30 residents had assessments collected by both asynchronous and synchronous methods. A total of 699 Web-based (asynchronous) assessments were completed by nurses and 149 by faculty. Synchronous nurse and faculty assessments were obtained in 105 resident-patient encounters. There was no difference in faculty ratings between the MSF collection methods. Nurses assigned slightly (but significantly) higher ratings during synchronous collection. Correlation of the total MSF score between asynchronous and synchronous feedback collection methods within the faculty rater group was poor (0.18, 95% CI = -0.22 to 0.60). Correlation of the total MSF score between asynchronous and synchronous feedback collection methods within nurse rater groups was moderate (0.63, 95% CI = 0.27 to 0.83). Correlations between faculty-nurse rater groups for the total MSF collected asynchronously and synchronously were moderate (0.39, 95% CI = -0.05 to 0.7; and 0.44, 95% CI 0.01 to 0.73, respectively). CONCLUSIONS: Synchronous collection of MSF did not provide clinically different EM-HS scores within rater groups and did not result in improved correlations. Our small, single-center study supports asynchronous collection of MSF.

Patient history and physician suspicion accurately exclude pregnancy.

OBJECTIVES: Reliance upon patient assessment in excluding pregnancy is questionable. Physicians are encouraged to obtain pregnancy tests in all women of childbearing age. We affirmed the accuracy of women and their physicians in predicting pregnancy. METHODS: This was a prospective, observational study performed in a suburban academic emergency department on adult women with an ordered pregnancy test. A standardized gynecologic history was obtained by trained research assistants. Subjects estimated their likelihood of pregnancy as impossible, possible, or definite. Emergency department physicians estimated the likelihood of pregnancy as high, moderate, or low. All women had either a serum or urine ß-human chorionic antigen. The diagnostic characteristics of patient and physician predictions of pregnancy were calculated with 95% confidence intervals (CIs). RESULTS: We enrolled 377 subjects. Median age was 29 (interquartile range, 22-37) years. Twelve percent of the women were pregnant. Women's estimates of pregnancy were as follows: impossible, 64.7%; possible, 22.5%; and definite, 12.7%. The pregnancy rates among women with estimates of impossible, possible, and definite were 0% (95% CI, 0%-1.5%), 4.7% (95% CI, 1.9%-11.5%), and 89.6% (95% CI, 77.8%-95.5%) (P < .001). Physicians' suspicions of pregnancy were high (13.7%), moderate (11.3%), and low (75.1%). The rate of pregnancy among low, moderate, and high physician suspicion groups were 0% (95% CI, 0%-1.4%), 9.5% (95% CI, 3.8%-22%), and 84.3% (95% CI, 72%-92%) (P < .001). CONCLUSIONS: There were no pregnancies among women who estimated pregnancy as impossible or whose physicians thought that the likelihood of pregnancy was low. Routine pregnancy testing before radiological imaging and medication administration may not be required in adult women of childbearing age.

Feasibility and reliability of a multisource feedback tool for emergency medicine residents.

BACKGROUND: While the Accreditation Council for Graduate Medical Education recommends multisource feedback (MSF) of resident performance, there is no uniformly accepted MSF tool for emergency medicine (EM) trainees, and the process of obtaining MSF in EM residencies is untested. OBJECTIVE: To determine the feasibility of an MSF program and evaluate the intraclass and interclass correlation of a previously reported resident professionalism evaluation, the Humanism Scale (HS). METHODS: To assess 10 third-year EM residents, we distributed an anonymous 9-item modified HS (EM-HS) to emergency department nursing staff, faculty physicians, and patients. The evaluators rated resident performance on a 1 to 9 scale (needs improvement to outstanding). Residents were asked to complete a self-evaluation of performance, using the same scale. ANALYSIS: Generalizability coefficients (Eρ(2)) were used to assess the reliability within evaluator classes. The mean score for each of the 9 questions provided by each evaluator class was calculated for each resident. Correlation coefficients were used to evaluate correlation between rater classes for each question on the EM-HS. Eρ(2) and correlation values greater than 0.70 were deemed acceptable. RESULTS: EM-HSs were obtained from 44 nurses and 12 faculty physicians. The residents had an average of 13 evaluations by emergency department patients. Reliability within faculty and nurses was acceptable, with Eρ(2) of 0.79 and 0.83, respectively. Interclass reliability was good between faculty and nurses. CONCLUSIONS: An MSF program for EM residents is feasible. Intraclass reliability was acceptable for faculty and nurses. However, reliable feedback from patients requires a larger number of patient evaluations.

Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy.

OBJECTIVES: Acute back and neck strains are very common. In addition to administering analgesics, these strains are often treated with either heat or cold packs. The objective of this study was to compare the analgesic efficacy of heat and cold in relieving pain from back and neck strains. The authors hypothesized that pain relief would not differ between hot and cold packs. METHODS: This was a randomized, controlled trial conducted at a university-based emergency department (ED) with an annual census of 90,000 visits. ED patients >18 years old with acute back or neck strains were eligible for inclusion. All patients received 400 mg of ibuprofen orally and then were randomized to 30 minutes of heating pad or cold pack applied to the strained area. Outcomes of interest were pain severity before and after pack application on a validated 100-mm visual analog scale (VAS) from 0 (no pain) to 100 (worst pain), percentage of patients requiring rescue analgesia, subjective report of pain relief on a verbal rating scale (VRS), and future desire for similar packs. Outcomes were compared with t-tests and chi-square tests. A sample of 60 patients had 80% power to detect a 15-mm difference in pain scores. RESULTS: Sixty patients were randomized to heat (n = 31) or cold (n = 29) therapy. Mean (+/-standard deviation [SD]) age was 37.8 (+/-14.7) years, 51.6% were female, and 66.7% were white. Groups were similar in baseline patient and pain characteristics. There were no differences between the heat and cold groups in the severity of pain before (75 mm [95% CI = 66 to 83] vs. 72 mm [95% CI = 65 to 78]; p = 0.56) or after (66 mm [95% CI = 57 to 75] vs. 64 mm [95% CI = 56 to 73]; p = 0.75) therapy. Pain was rated better or much better in 16/31 (51.6%) and 18/29 (62.1%) patients in the heat and cold groups, respectively (p = 0.27). There were no between-group differences in the desire for and administration of additional analgesia. Twenty-five of 31 (80.6%) patients in the heat group and 22 of 29 (75.9%) patients in the cold group would use the same therapy if injured in the future (p = 0.65). CONCLUSIONS: The addition of a 30-minute topical application of a heating pad or cold pack to ibuprofen therapy for the treatment of acute neck or back strain results in a mild yet similar improvement in the pain severity. However, it is possible that pain relief is mainly the result of ibuprofen therapy. Choice of heat or cold therapy should be based on patient and practitioner preferences and availability.

Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients.

OBJECTIVES: The Wong-Baker FACES Pain Rating Scale (WBS), used in children to rate pain severity, has been validated outside the emergency department (ED), mostly for chronic pain. The authors validated the WBS in children presenting to the ED with pain by identifying a corresponding mean value of the visual analog scale (VAS) for each face of the WBS and determined the relationship between the WBS and VAS. The hypothesis was that the pain severity ratings on the WBS would be highly correlated (Spearman's rho > 0.80) with those on a VAS. METHODS: This was a prospective, observational study of children ages 8-17 years with pain presenting to a suburban, academic pediatric ED. Children rated their pain severity on a six-item ordinal faces scale (WBS) from none to worst and a 100-mm VAS from least to most. Analysis of variance (ANOVA) was used to compare mean VAS scores across the six ordinal categories. Spearman's correlation (rho) was used to measure agreement between the continuous and ordinal scales. RESULTS: A total of 120 patients were assessed: the median age was 13 years (interquartile range [IQR] = 10-15 years), 50% were female, 78% were white, and six patients (5%) used a language other than English at home. The most commonly specified locations of pain were extremity (37%), abdomen (19%), and back/neck (11%). The mean VAS increased uniformly across WBS categories in increments of about 17 mm. ANOVA demonstrated significant differences in mean VAS across face groups. Post hoc testing demonstrated that each mean VAS was significantly different from every other mean VAS. Agreement between the WBS and VAS was excellent (rho = 0.90; 95% confidence interval [CI] = 0.86 to 0.93). There was no association between age, sex, or pain location with either pain score. CONCLUSIONS: The VAS was found to have an excellent correlation in older children with acute pain in the ED and had a uniformly increasing relationship with WBS. This finding has implications for research on pain management using the WBS as an assessment tool.

The impact of communication barriers on diagnostic confidence and ancillary testing in the emergency department.

BACKGROUND: Communication barriers (CBs) compromise the diagnostic power of the medical interview and may result in increased reliance on diagnostic tests or incorrect test ordering. The prevalence and degree to which these barriers affect diagnosis, testing, and treatment are unknown. STUDY OBJECTIVES: To quantify and characterize CBs encountered in the Emergency Department (ED), and assess the effect of CBs on initial diagnosis and perceived reliance on ancillary testing. METHODS: This was a prospective survey completed by emergency physicians after initial adult patient encounters. CB severity, diagnostic confidence, and reliance on ancillary testing were quantified on a 100-mm Visual Analog Scale (VAS) from least (0) to most (100). RESULTS: Data were collected on 417 ED patient encounters. CBs were reported in 46%; with a mean severity of 50 mm on a 100-mm VAS with endpoints of "perfect communication and "no communication." Language was the most commonly reported form of CB (28%). More than one CB was identified in 6%. The 100-mm VAS rating of diagnostic confidence was lower in patients with perceived CBs (64 mm) vs. those without CBs (80 mm), p < 0.001. VAS ratings of physician reliance on ancillary testing was higher in patients with perceived CBs (50 mm) vs. patients without a perceived CB (38 mm), p < 0.001. CONCLUSIONS: Communication barriers in our ED setting were common, and resulted in lower diagnostic confidence and increased perception that ancillary tests are needed to narrow the diagnosis.

Pretreatment of patients requiring oral contrast abdominal computed tomography with antiemetics: a randomized controlled trial of efficacy.

STUDY OBJECTIVE: Ingestion of diatrizoate meglumine before abdominal computed tomography (CT) is time consuming. We hypothesized that pretreatment with metoclopramide or ondansetron would result in faster ingestion of diatrizoate meglumine than placebo. METHODS: The study was a double-blind, randomized controlled trial on adults requiring oral contrast abdominal CT. Patients were randomized to placebo, metoclopramide 10 mg, or ondansetron 4 mg intravenously 15 minutes before ingesting 2 L of diatrizoate meglumine. The primary outcome was time to complete diatrizoate meglumine ingestion. Secondary outcome measures included volume of diatrizoate meglumine ingested, 100-mm visual analog scale for nausea at 15-minute intervals, time to CT, vomiting, and use of rescue antiemetics. The study was powered to detect a 60-minute difference in diatrizoate meglumine ingestion time between saline and medication groups. RESULTS: One hundred six patients were randomized; placebo (36), metoclopramide (35), and ondansetron (35). Groups were similar in baseline characteristics. Median (interquartile range) times for diatrizoate meglumine ingestion were placebo 109 minutes (82 to 135 minutes); metoclopramide 105 minutes (75 to 135 minutes); and ondansetron 110 minutes (79 to 140 minutes) (P=.67). Vomiting was less frequent with metoclopramide (3%) than placebo (18%) or ondansetron (9%) (P=.11). The visual analog scale for nausea at each point was not significantly different between groups (P=.11). The need for rescue antiemetics was lowest for metoclopramide (3%) compared with placebo (27%) and ondansetron (12%) (P=.02). CONCLUSION: Pretreatment with ondansetron or metoclopramide does not reduce oral contrast solution ingestion time.

Triage pain scores and the desire for and use of analgesics.

STUDY OBJECTIVE: Inadequate analgesia (oligoanalgesia) is a common phenomenon. In an effort to improve pain recognition and management, pain scores are mandated by The Joint Commission. When patients with pain do not receive analgesics, treatment is considered deficient. However, the mere presence of pain does not imply that all patients desire analgesics. We determine how often patients in pain desire and receive analgesics in the emergency department (ED). We hypothesize that many ED patients in pain do not desire analgesics and that most who want them receive them. METHODS: We conducted a prospective observational study of pain-related visits to an academic ED during the spring of 2007. Standardized collection of demographic and clinical data was performed, and patients rated their pain severity on a 0 to 10 numeric rating scale. The main outcome measures were the desire for and administration of analgesics during the ED visit. Univariate and multivariate logistic regression was used to identify factors associated with patient desire for and administration of analgesics. RESULTS: We enrolled 392 patients. Mean (SD) age was 39 years (19), 50% were female patients, 76% were white. Mean (SD) initial pain score was 7.1 (2). Of the 392 patients, 199 (51% [95% confidence interval (CI) 46% to 56%]) desired analgesics and 227 (58% [95% CI 53% to 63%]) received analgesics within 92 (SD 106) minutes. Of patients desiring analgesics, 162 (81% [95% CI 75% to 86%]) received them. Reasons for not wanting analgesics included pain tolerable (47%), analgesic taken at home (11%), and wanting to remain alert (7%). Pain scores were higher in those patients who wanted analgesics than in those patients who did not want analgesics (7.8 [95% CI 7.5 to 8.1] versus 6.4 [95% CI 6.1 to 6.7]; difference 1.4 [95% CI 0.9 to 1.8]). In multivariate analysis, pain scores (odds ratio [OR] 1.3 for every 1-point increase in pain score) and constant pain (OR 2.0) were significant factors that predicted wanting analgesics, whereas pain scores (OR 1.2) and desiring analgesics (OR 7.4) were significant predictors of receiving analgesics. CONCLUSION: Nearly half of all ED patients in pain do not desire analgesics and most who desire analgesics receive them. Although the average pain score for patients not wanting analgesics was lower, it was often in the moderate to severe range. Patients should be asked whether they have pain and whether they want analgesics regardless of their pain scores.

Reappraisal of criteria used to predict serious bacterial illness in febrile infants less than 8 weeks of age.

OBJECTIVE: To re-evaluate the Philadelphia protocol and the Rochester criteria for identifying infants at low risk for serious bacterial illness (SBI) in a new population. METHODS: The authors prospectively enrolled infants 56 days of age or younger with rectal temperatures greater than 100.6 degrees F. Physicians assigned an overall impression of sepsis and objectively scored each infant using the Infant Observation Score. Following a history and physical examination, a complete sepsis evaluation was performed. Infants were considered to have SBI if their blood, urine, cerebrospinal fluid, or stool cultures grew pathogenic bacteria. Infants were assigned to high- and low-risk groups for SBI according to the Philadelphia protocol and the Rochester criteria by a single investigator blinded to the final culture results. The test performance parameters of the Philadelphia protocol and the Rochester criteria in this population were compared with those reported from previous validation studies. RESULTS: One hundred eighty-one infants were assigned to risk groups using the Philadelphia protocol, and 259 infants using the Rochester criteria. In this population, the negative predictive value (NPV) of the Philadelphia protocol was 97.1% (95% confidence interval [95% CI] = 85.1% to 99.8%), compared with 99.7% in the original report, and the NPV of the Rochester criteria was 97.3% (95% CI = 90.5% to 99.2%), compared with a prior report of 98.9%. CONCLUSIONS: The Philadelphia protocol and the Rochester criteria maintained their previously reported NPVs when applied to a new population of febrile infants. These data illustrate the usefulness of retesting clinical decision rules in new populations prior to their universal acceptance.