Training for Pediatric Cardiac and Pulmonary Point of Care Ultrasound in Eastern Uganda.

Caring for children with acute illness is a challenge in limited-resource settings, especially when diagnostic imaging is limited or unavailable. We developed a training program in cardiac and lung point-of-care ultrasound (POCUS) for pediatric patients in eastern Uganda. Fourteen trainees including physicians, resident physicians and midlevels received training in cardiac and lung POCUS. Training included formal lectures, hands-on skills practice and individualized teaching sessions. Assessment included written knowledge assessment, direct observation and longitudinal image review. Blinded review of 237 consecutive ultrasound studies revealed satisfactory image quality (94.2% for lung and 93% for cardiac) and accurate image interpretation. Sensitivity and specificity of image interpretation were 0.93 (0.75-0.99) and 0.94 (0.78-0.99) for lung and 0.86 (0.71-0.95) and 0.94 (0.84-0.99) for cardiac compared with expert review. All trainees passed written knowledge assessments. After training, 100% of trainees reported that they would use POCUS in clinical activity and thought it would improve patient outcomes. Our training program indicated that trainees were able to perform high-quality cardiac and lung POCUS for pediatric patients with accurate interpretation. This builds a foundation for future studies addressing how POCUS can change outcomes for children in limited-resource settings.

Utility of bedside assessment to evaluate for cervical-spine fracture post ground-level fall for patients 65 years and older.

OBJECTIVES: The effectiveness of current assessment tools for cervical fracture are mixed with respect to elderly patients. We aim to examine utility of history and physical exam to assess for cervical fracture for elderly patients suffering a ground-level fall. METHODS: Retrospective cohort from a tertiary-care ED for patients ≥65 years, including dementia, after ground-level fall. Logistic regression was used to examine predictability of various clinical factors. Neurologic deficits were considered a hard sign for imaging and were not assessed. RESULTS: Of 1035 patient encounters analyzed, 683 had CT cervical-spine (C-spine) imaging (66.0%) and 16 (1.5%) had cervical fracture. C-spine tenderness (OR 4.7, 95% CI 1.5-14.1), neck pain (OR 10.5, 95% CI 3.4-32.5), altered mental status (AMS) (OR 5.1, 95% CI 1.7-15.6), and external trauma above the clavicles (ETC) (OR 3.8, 95% CI 1.2-12.3) predicted cervical fracture. C-spine tenderness and neck pain were collinear and run-in separate models. Dementia (OR 0.2, 95% CI 0.4-0.9) did not predict cervical fracture in this population. A combination of ETC, C-spine tenderness, and AMS had a sensitivity = 100% and specificity = 40.0% for detection of cervical fracture. ETC was found in all but two fractures requiring intervention with negative predictive value = 99.3%. CONCLUSIONS: Clinical assessment for elderly patients without neurologic signs, together with the absence of ETC, cervical tenderness, and AMS may be reliable in ruling out cervical fracture after a ground-level fall, including patients with history of dementia. Fractures requiring intervention were rare in patients without ETC. However, findings are retrospective and prospective validation is required.

A One Health Approach to Compare Self-Prescribed Antibiotic Use across Rural and Semi-urban Populations in San Lucas Tolimán, Guatemala.

Antimicrobial resistance resulting from antibiotic overuse represents an increasing public health challenge. The purpose of this study was to investigate antibiotic self-medication practices in a rural, indigenous Guatemalan population, and to compare self-prescribing patterns in rural and semi-urban populations using a One Health integrated approach, a framework acknowledging that health arises at the interface of humans, animals, and the environment. We conducted a mixed methods study using semi-structured interviews in and around San Lucas Tolimán, Guatemala. Antibiotic self-medication was common in both rural and semi-urban populations, regardless of demographic characteristics. Antibiotic usage in animals, while less common, almost always occurred without a veterinary consult. Although subjects recognized that self-medication could be harmful to health, they face significant barriers to accessing appropriate care. These patterns of use have impacts on the rise of antimicrobial resistance locally, and have the potential to contribute to the spread of such resistance globally.

The Use of Traditional and Complementary Medicine for Diabetes in Rural Guatemala.

OBJECTIVES: The global burden of type 2 diabetes mellitus is increasing, especially in Central America. In resource-limited settings, such as Guatemala, there are significant barriers to diabetes care and many Guatemalans use medicinal plants as treatment. The purpose of this study is to understand the use of medicinal plants in an indigenous population with diabetes in rural Guatemala. METHODS: Semi-structured interviews were conducted in communities around San Lucas Tolimán, Guatemala with people with diabetes, health promoters, and traditional healers. RESULTS: Out of the 55 people with diabetes interviewed, 35 (63.6%) had used medicinal plants, most frequently using Artemisia absinthium, Moringa oleifera, Carica papaya, and Neurolaena lobata. The majority of participants cited lack of access to medications as the reason for their use of medicinal plants. CONCLUSION: There is widespread use of medicinal plants in San Lucas Tolimán. More research is needed to understand the degree of glycemic control in these communities.

Using the Hendrich II Inpatient Fall Risk Screen to Predict Outpatient Falls After Emergency Department Visits.

OBJECTIVES: To evaluate the utility of routinely collected Hendrich II fall scores in predicting returns to the emergency department (ED) for falls within 6 months. DESIGN: Retrospective electronic record review. SETTING: Academic medical center ED. PARTICIPANTS: Individuals aged 65 and older seen in the ED from January 1, 2013, through September 30, 2015. MEASUREMENTS: We evaluated the utility of routinely collected Hendrich II fall risk scores in predicting ED visits for a fall within 6 months of an all-cause index ED visit. RESULTS: For in-network patient visits resulting in discharge with a completed Hendrich II score (N = 4,366), the return rate for a fall within 6 months was 8.3%. When applying the score alone to predict revisit for falls among the study population the resultant receiver operating characteristic (ROC) plot had an area under the curve (AUC) of 0.64. In a univariate model, the odds of returning to the ED for a fall in 6 months were 1.23 times as high for every 1-point increase in Hendrich II score (odds ratio (OR)=1.23 (95% confidence interval (CI)=1.19-1.28). When included in a model with other potential confounders or predictors of falls, the Hendrich II score is a significant predictor of a return ED visit for fall (adjusted OR=1.15, 95% CI=1.10-1.20, AUC=0.75). CONCLUSION: Routinely collected Hendrich II scores were correlated with outpatient falls, but it is likely that they would have little utility as a stand-alone fall risk screen. When combined with easily extractable covariates, the screen performs much better. These results highlight the potential for secondary use of electronic health record data for risk stratification of individuals in the ED. Using data already routinely collected, individuals at high risk of falls after discharge could be identified for referral without requiring additional screening resources.

Improved cookstoves and their effect on carbon monoxide levels in San Lucas Tolimán, Guatemala.

INTRODUCTION: Installation of ventilated cookstoves has been shown to improve 24-h carbon monoxide (CO) and particulate exposure in the Guatemalan highlands. However, a survey of villagers around San Lucas Tolimán found much higher than expected CO levels. Our purpose is to evaluate the effects of improved cookstoves on CO levels in these villagers. METHODS: This is cross sectional observational study in six rural communities. Blood carboxyhemoglobin (SpCO) was measured at three different times during the day. Stove type and location, as well as any respiratory, eye, or general symptoms reported were recorded. RESULTS: 122 patients were included. CO levels were much higher than would be expected in a non-smoking population, with an average level of 4.6 ± 2.3 percent. There was no significant correlation in CO level and stove type or in CO level and time of day. Reported frequency of respiratory and eye symptoms (dyspnea, p = 0.03; cough, p = 0.01; burning eyes, p = 0.001; and excessive tearing, p = 0.001) did vary significantly between improved and unimproved stove groups. CONCLUSION: This study found high average SpCO levels in all villagers. This suggests that some contributor other than cookstoves may be an additional driver of individual CO exposure in this area.

The Impact of an Emergency Department Front-End Redesign on Patient-Reported Satisfaction Survey Results.

INTRODUCTION: For emergency department (ED) patients, delays in care are associated with decreased satisfaction. Our department focused on implementing a front-end vertical patient flow model aimed to decrease delays in care, especially care initiation. The physical space for this new model was termed the Flexible Care Area (FCA). The purpose of this study was to quantify the impact of this intervention on patient satisfaction. METHODS: We conducted a retrospective study of patients discharged from our academic ED over a one-year period (7/1/2013-6/30/2014). Of the 34,083 patients discharged during that period, 14,075 were sent a Press-Ganey survey and 2,358 (16.8%) returned the survey. We subsequently compared these survey responses with clinical information available through our electronic health record (EHR). Responses from the Press-Ganey surveys were dichotomized as being "Very Good" (VG, the highest rating) or "Other" (for all other ratings). Data abstracted from the EHR included demographic information (age, gender) and operational information (e.g. - emergency severity index, length of stay, whether care was delivered entirely in the FCA, utilization of labs or radiology testing, or administration of opioid pain medications). We used Fisher's exact test to calculate statistical differences in proportions, while the Mantel-Haenszel method was used to report odds ratios. RESULTS: Of the returned surveys, 62% rated overall care for the visit as VG. However, fewer patients reported their care as VG if they were seen in FCA (53.4% versus 63.2%, p=0.027). Patients seen in FCA were less likely to have advanced imaging performed (12% versus 23.8%, p=0.001) or labs drawn (24.8% vs. 59.1%, p=0.001). Length of stay (FCA mean 159 ±103.5 minutes versus non-FCA 223 ±117 minutes) and acuity were lower for FCA patients than non-FCA patients (p=0.001). There was no statistically significant difference between patient-reported ratings of physicians or nurses when comparing patients seen in FCA vs. those not seen in FCA. CONCLUSION: Patients seen through the FCA reported a lower overall rating of care compared to patients not seen in the FCA. This occurred despite a shorter overall length of stay for these patients, suggesting that other factors have a meaningful impact on patient satisfaction.

Using Chief Complaint in Addition to Diagnosis Codes to Identify Falls in the Emergency Department.

OBJECTIVES: To compare incidence of falls in an emergency department (ED) cohort using a traditional International Classification of Diseases, Ninth Revision (ICD-9) code-based scheme and an expanded definition that included chief complaint information and to examine the clinical characteristics of visits "missed" in the ICD-9-based scheme. DESIGN: Retrospective electronic record review. SETTING: Academic medical center ED. PARTICIPANTS: Individuals aged 65 and older seen in the ED between January 1, 2013, and September 30, 2015. MEASUREMENTS: Two fall definitions were applied (individually and together) to the cohort: an ICD-9-based definition and a chief complaint definition. Admission rates and 30-day mortality (per encounter) were measured for each definition. RESULTS: Twenty-three thousand eight hundred eighty older adult visits occurred during the study period. Using the most-inclusive definition (ICD-9 code or chief complaint indicating a fall), 4,363 visits (18%) were fall related. Of these visits, 3,506 (80%) met the ICD-9 definition for a fall-related visit, and 2,664 (61%) met the chief complaint definition. Of visits meeting the chief complaint definition, 857 (19.6%) were missed when applying the ICD-9 definition alone. Encounters missed using the ICD-9 definition were less likely to lead to an admission (42.9%, 95% confidence interval (CI) = 39.7-46.3%) than those identified (54.4%, 95% CI = 52.7-56.0%). CONCLUSION: Identifying individuals in the ED who have fallen based on diagnosis codes underestimates the true burden of falls. Individuals missed according to the code-based definition were less likely to have been admitted than those who were captured. These findings call attention to the value of using chief complaint information to identify individuals who have fallen in the ED-for research, clinical care, or policy reasons.

Negative D-dimer testing excludes pulmonary embolism in non-high risk patients in the emergency department.

PURPOSE: The purpose of this study was to assess the ability of d-dimer testing to obviate the need for cross-sectional imaging for patients at "non-high risk" for pulmonary embolism (PE). METHODS: This is a retrospective study of emergency department patients at an academic medical center who underwent cross-sectional imaging (MRA or CTA) to evaluate for PE from 2008 to 2013. The primary outcome was the NPV of d-dimer testing when used in conjunction with clinical decision instruments (CDIs = Wells', Revised Geneva, and Simplified Revised Geneva Scores). The reference standard for PE status included image test results and a 6-month chart review follow-up for venous thromboembolism as a proxy for false negative imaging. Secondary analyses included ROC curves for each CDI and calculation of PE prevalence in each risk stratum. RESULTS: Of 459 patients, 41 (8.9%) had PE. None of the 76 patients (16.6%) with negative d-dimer results had PE. Thus, d-dimer testing had 100% sensitivity and NPV, and there were no differences in CDI performance. Similarly, when evaluated independently of d-dimer results, no CDI outperformed the others (areas under the ROC curves ranged 0.53-0.55). There was a significantly higher PE prevalence in the high versus "non-high risk" groups when stratified by the Wells' Score (p = 0.03). CONCLUSIONS: Negative d-dimer testing excluded PE in our retrospective cohort. Each CDI had similar NPVs, whether analyzed in conjunction with or independently of d-dimer results. Our results confirm that PE can be safely excluded in patients with "non-high risk" CDI scores and a negative d-dimer.

Anemia is not a risk factor for developing pulmonary embolism.

OBJECTIVE: Our aim was to validate the previously published claim of a positive relationship between low blood hemoglobin level (anemia) and pulmonary embolism (PE). METHODS: This was a retrospective study of patients undergoing cross-sectional imaging to evaluate for PE at an academic medical center. Patients were identified using billing records for charges attributed to either magnetic resonance angiography or computed tomography angiography of the chest from 2008 to 2013. The main outcome measure was mean hemoglobin levels among those with and without PE. Our reference standard for PE status included index imaging results and a 6-month clinical follow-up for the presence of interval venous thromboembolism, conducted via review of the electronic medical record. Secondarily, we performed a subgroup analysis of only those patients who were seen in the emergency department. Finally, we again compared mean hemoglobin levels when limiting our control population to an age- and sex-matched cohort of the included cases. RESULTS: There were 1294 potentially eligible patients identified, of whom 121 were excluded. Of the remaining 1173 patients, 921 had hemoglobin levels analyzed within 24 hours of their index scan and thus were included in the main analysis. Of those 921 patients, 107 (11.6%; 107/921) were positive for PE. We found no significant difference in mean hemoglobin level between those with and without PE regardless of the control group used (12.4 ± 2.1 g/dL and 12.3 ± 2.0 g/dL [P = .85], respectively). CONCLUSIONS: Our data demonstrated no relationship between anemia and PE.

Trends in the Use of Medical Imaging to Diagnose Appendicitis at an Academic Medical Center.

OBJECTIVE: To quantify the trends in imaging use for the diagnosis of appendicitis. METHODS: A retrospective study covering a 22-year period was conducted at an academic medical center. Patients were identified by International Classification of Diseases-9 diagnosis code for appendicitis. Medical record data extraction of these patients included imaging test used (ultrasound, CT, or MRI), gender, age, and body mass index (BMI). The proportion of patients undergoing each scan was calculated by year. Regression analysis was performed to determine whether age, gender, or BMI affected imaging choice. RESULTS: The study included a total of 2,108 patients, including 967 (43.5%) females and 599 (27%) children (<18 years old). CT use increased over time for the entire cohort (2.9% to 82.4%, P < .0001), and each subgroup (males, females, adults, children; P < .0001 for each). CT use increased more in females and adults than in males and children, but differences in trends were not statistically significant (male versus female, P = .8; adult versus child, P = .1). The percentage of patients who had no imaging used for the diagnosis of appendicitis decreased over time (P < .0001 overall and for each subgroup), and no difference was found in trends between complementary subgroups (male versus female, P = .53; adult versus child, P = .66). No statistically significant changes were found in use of ultrasound or MRI over the study period. With increasing BMI, CT was more frequently used. CONCLUSIONS: Of those diagnosed with appendicitis at an academic medical center, CT use increased more than 20-fold. However, no statistically significant trend was found for increased use of ultrasound or MRI.

Emergency Department Patients' Perceptions of Radiation From Medical Imaging.

OBJECTIVE: To evaluate emergency department patients' knowledge of radiation exposure and subsequent risks from computed tomography (CT) and magnetic resonance imaging (MRI) scans. METHODS: This is a cross-sectional survey study of adult, English-speaking patients from June to August 2011 at 2 emergency departments--1 academic and 1 community-based--in the upper Midwest. The survey consisted of 2 sets of 3 questions evaluating patients' knowledge of radiation exposure from medical imaging and subsequent radiation-induced malignancies and was based on a previously published survey. The question sets paralleled each other, but one pertained to CT and the other to MRI. Questions in the survey ascertained patients' understanding of (1) the relative amount of radiation exposed from CT/MRI compared with a single chest x-ray; (2) the relative amount of radiation exposed from CT/MRI compared with a nuclear power plant accident; and (3) the possibility of radiation-induced malignancies from CT/MRl. Sociodemographic data also were gathered. The primary outcome measure was the proportion of correct answers to each survey question. Multiple logistic regression then was used to examine the relationship between the percentage correct for each question and sociodemographic variables, using odds ratios with 95% confidence intervals. P-values less than 0.05 were considered statistically significant. RESULTS: There were 500 participants in this study, 315 from the academic center and 185 from the community hospital. Overall, 14.1% (95% CI, 11.0%-17.2%) of participants understood the relative radiation exposure of a CT scan compared with a chest x-ray, while 22.8% (95% CI, 18.9%-26.7%) of respondents understood the lack of ionizing radiation use with MRI. At the same time, 25.6% (95% CI, 21.8%- 29.4%) believed that there was an increased risk of developing cancer from repeated abdominal CTs, while 55.6% (95% CI, 51.1%-60.1%) believed this to be true of abdominal MRI. Higher educational level and identification as a health care professional were associated with correct responses. However, even within these groups, a significant majority gave incorrect responses to all questions. CONCLUSION: Patients did not demonstrate understanding of the degree of radiation exposure from CT scans and the subsequent risks associated with this exposure, namely radiation-induced malignancies. Moreover, they did not understand that MRI scans do not expose them to ionizing radiation and therefore lack this downstream effect. While patient preference is integral to patient-centered care, physicians should be aware of the significant lack of knowledge as it pertains to the selection of medical imaging tests.

Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT.

OBJECTIVE: To determine whether clinical scoring systems or physician gestalt can obviate the need for computed tomography (CT) in patients with possible appendicitis. METHODS: Prospective, observational study of patients with abdominal pain at an academic emergency department (ED) from February 2012 to February 2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardised forms prior to CT. Physicians also estimated the likelihood of appendicitis. Test characteristics were calculated using clinical follow-up as the reference standard. Receiver operating characteristic curves were drawn. RESULTS: Of the 287 patients (mean age (range), 31 (12-88) years; 60% women), the prevalence of appendicitis was 33%. The Alvarado score had a positive likelihood ratio (LR(+)) (95% CI) of 2.2 (1.7 to 3) and a negative likelihood ratio (LR(-)) of 0.6 (0.4 to 0.7). The modified Alvarado score (MAS) had LR(+) 2.4 (1.6 to 3.4) and LR(-) 0.7 (0.6 to 0.8). The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score had LR(+) 1.3 (1.1 to 1.5) and LR(-) 0.5 (0.4 to 0.8). Physician-determined likelihood of appendicitis had LR(+) 1.3 (1.2 to 1.5) and LR(-) 0.3 (0.2 to 0.6). When combined with physician likelihoods, LR(+) and LR(-) was 3.67 and 0.48 (Alvarado), 2.33 and 0.45 (RIPASA), and 3.87 and 0.47 (MAS). The area under the curve was highest for physician-determined likelihood (0.72), but was not statistically significantly different from the clinical scores (RIPASA 0.67, Alvarado 0.72, MAS 0.7). CONCLUSIONS: Clinical scoring systems performed equally well as physician gestalt in predicting appendicitis. These scores do not obviate the need for imaging for possible appendicitis when a physician deems it necessary.

Systematic review and meta-analysis of the accuracy of MRI to diagnose appendicitis in the general population.

PURPOSE: To perform a systematic review and meta-analysis of all published studies since 2005 that evaluate the accuracy of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis in the general population presenting to emergency departments. MATERIALS AND METHODS: All retrospective and prospective studies evaluating the accuracy of MRI to diagnose appendicitis published in English and listed in PubMed, Web of Science, Cinahl Plus, and the Cochrane Library since 2005 were included. Excluded studies were those without an explicitly stated reference standard, with insufficient data to calculate the study outcomes, or if the population enrolled was limited to pregnant women or children. Data were abstracted by one investigator and confirmed by another. Data included the number of true positives, true negatives, false positives, false negatives, number of equivocal cases, type of MRI scanner, type of MRI sequence, and demographic data including study setting and gender distribution. Summary test characteristics were calculated. Forest plots and a summary receiver operator characteristic plot were generated. RESULTS: Ten studies met eligibility criteria, representing patients from seven countries. Nine were prospective and two were multicenter studies. A total of 838 subjects were enrolled; 406 (48%) were women. All studies routinely used unenhanced MR images, although two used intravenous contrast-enhancement and three used diffusion-weighted imaging. Using a bivariate random-effects model the summary sensitivity was 96.6% (95% confidence interval [CI]: 92.3%-98.5%) and summary specificity was 95.9% (95% CI: 89.4%-98.4%). CONCLUSION: MRI has a high sensitivity and specificity for the diagnosis of appendicitis, similar to that reported previously for computed tomography. J. Magn. Reson. Imaging 2016;43:1346-1354.

Rhythm disturbances.

Patients with cardiac rhythm disturbances may present in a variety of conditions. Patients may be unstable, requiring immediate interventions, or stable, allowing for a more deliberate approach. Rapid assessment of patient stability, underlying rhythm, and determination of appropriate interventions guides timely therapy. This article discusses the differential diagnosis and treatment of adult patients presenting with primary bradyarrhythmias and tachyarrhythmias, with the exception of atrial fibrillation and atrial flutter, covered elsewhere in this issue. A concise approach to diagnosis and determination of appropriate therapy is presented.

Hypertension in the ED: still an unrecognized problem.

INTRODUCTION: Hypertension is prevalent in the general population. Emergency Department (ED) follow-up studies show persistence of blood pressure elevations in up to 50% of patients, and ED screening for hypertension has been recommended. Blood pressure elevations are often ignored or attributed to pain or anxiety. Our purpose was to document the incidence and recognition of hypertension in the ED and to assess its relation to pain scores and age. METHODS: This was a retrospective study. Patients presenting to the ED during a 1-month period were included. Age, blood pressure, and pain scores were reviewed. Discharge instructions and diagnoses were assessed as to whether blood pressure was recognized or follow-up was recommended. RESULTS: There were 2821 patients. Fifteen percent were less than 18 years old. Twenty-six percent had an elevated blood pressure (40% of pediatric patients). There was no correlation between the distribution of pain scores in either children or adults. There was almost no recognition of the problem. Follow-up for elevated blood pressure was recommended in only 4%. Of these, only 46% actually received follow-up. Twenty-four percent of patients with elevated blood pressure received follow-up for other reasons. Blood pressure was still elevated in 47%. CONCLUSION: Hypertension was a common problem in our patient population. Elevated blood pressure readings were almost uniformly ignored or unrecognized, particularly in children. There was no correlation of elevated blood pressure readings and acute pain scores. Elevated blood pressure readings should not be attributed solely to anxiety or acute pain on presentation.

Ketamine for prehospital use: new look at an old drug.

INTRODUCTION: Ketamine has been used extensively for analgesia and anesthesia in many situations, including disaster surgery where extra personnel and advanced monitoring are not available. There are many features of ketamine that seem to make it an ideal drug for prehospital use. The reported use of ketamine in the prehospital environment is limited, however. The purpose of this study is to review the experience in the use of ketamine in a regional air ambulance service and suggest indications for its use in the prehospital setting. METHODS: This was a retrospective study of all patients transported by a regional aeromedical program. Patients were included in this study if the crew had used ketamine at any time during the flight. Data regarding the transport collected included patient age, type of transport, indications for ketamine use, and adverse reactions. RESULTS: During the period studied, ketamine was used in 40 patients. The age range was 2 months to 75 years. The indications and situations requiring use were varied and included both trauma and medical patients. Hypotension with need for analgesia, agitation or combativeness and intact airway, or pain unresponsive to narcotic medications were the most common indications for use. Ketamine was used both intravenous and intramuscular, even without intravenous access. There were no adverse reactions. CONCLUSIONS: Ketamine is an ideal drug for use in many prehospital situations. Our experience suggests that it is safe, effective, and may be more appropriate than drugs currently used by prehospital providers.

Effectiveness of nonnarcotic protocol for the treatment of acute exacerbations of chronic nonmalignant pain.

INTRODUCTION: Emergency department (ED) overcrowding is a growing problem. Frequent visits for chronic pain are a significant subset of patients. The use of narcotics in these patients is controversial. The purpose of this study was to test a strict nonnarcotic protocol in reducing need for and number of ED visits for chronic pain while at the same time addressing their pain. METHODS: This was a prospective observational study. We identified patients with more than 10 ED visits for exacerbations of chronic nonmalignant pain in the last 12 calendar months. Each patient and their physician were sent letters informing them of the concern of frequent ED use and the use of opioids for rescue therapy. Furthermore, the patient would receive medications other than narcotics in subsequent ED visits, and follow-up with the primary physician for alternatives was encouraged. Use of the ED for pain-related visits was then monitored for the subsequent 12-month period. Clinic use and outpatient medication uses were also monitored. RESULTS: Fifteen patients were identified for the initial study. These patients averaged 19 ED visits per 12 months for pain-related complaints. All of them had a regular physician. After notification of the new protocol, ED visits decreased to an average of 2 visits per year. Visits with primary care physicians also dropped from an average of 19 visits per year to 7 visits. There were 7 patients who had been weaned off narcotic medications, 4 who had been converted to methadone maintenance, and 1 who had been switched to a fentanyl patch. CONCLUSIONS: Initiation of a strict nonnarcotic protocol for treatment of patients with frequent ED visits for chronic nonmalignant pain results in a significant drop in the number of pain-related visits to the ED. These visits were not offset by a significant elevation in the number of clinic visits for pain complaints, and many were weaned off narcotics. Nonnarcotic protocols for acute exacerbations of chronic nonmalignant pain may be a viable alternative for reducing frequent pain-related ED visits in a select population.

Lack of correlation in welfare check distribution and transport patterns in a rural critical care transport service.

INTRODUCTION: Understanding patterns of use of emergency medical services is important for planning adequate programs, budgets, and schedules. Understanding the factors associated with use of these services can help systems target high-risk populations or behaviors and allocate budgetary resources appropriately. Previous data have shown an association between the use of emergency health care use and distribution of welfare check distribution in both the United States and Canada. These data have limitations. In these studies, no attempt was made to investigate whether this increase in use was for particular types of complaints (medical or traumatic) or true outside of an urban community. The purpose of this study was to investigate whether there were similar monthly associations in patterns of use of a regional transport service for either medical or traumatic complaints. METHODS: Med Flight is a regional aeromedical service operated by the University of Wisconsin. The service provides transport services to all hospitals and emergency medical services for critically ill or injured patients inside a radius of approximately 75 miles. The program transports approximately 1200 patients per year. Data for all transports for the years 1998-2004 were obtained. Daily numbers of transports were then compared for all patients and subsets of those with specifically traumatic or cardiac-related complaints. RESULTS: There were 7756 transports during the study period: 34% of the transports were trauma related; 30% were cardiac related. There was a significant association between trauma-related flights and both month of the year (P < .0001) and day of the week (P < .001), but not for total or cardiac-related flights. There was no association between day or week of the month and transports. CONCLUSION: In contrast to previous studies, these findings show no association between use of a regional transport service and time of the month. Determinants of use of emergency services may differ between urban and nonurban areas.