Review of local wound management for scleroderma-associated digital ulcers.

Digital ulcers (DU) are a common clinical problem in systemic sclerosis (SSc); however, there is no standardization of local wound care protocols for management of these lesions. There is a well-recognized need to develop and standardize non-pharmacological management of DU in patients with SSc, and to adopt these protocols in future clinical trials that focus on DU healing. The purpose of this review is to outline the types of DU that occur in SSc, and provide an update on the principles of wound management for these lesions based on the current literature and expert opinion.

Cardiology consultation reduces provocative testing rates in an ED observation unit.

BACKGROUND: In evaluating patients with chest pain, emergency department observation units (EDOUs) may use a staffing model in which emergency physicians determine patient testing (EP model) or a model similar to a chest pain unit (CPU) in which cardiologists determine provocative testing (CPU model). METHODS: We performed a prospective study with 30-day telephone follow-up for all chest pain patients placed in our EDOU. Halfway through the study period, our EDOU transitioned from an EP model to a CPU model. We compared provocative testing rates and outcomes between the 2 models. RESULTS: Over the 34-month study period, our EDOU evaluated 1190 patients for chest pain. Patients placed in the EDOU during the 17-month CPU model were more likely to be moderate risk (Thrombolysis in Myocardial Infarction score 3-5) than those during the 17-month EP model: 24.9% vs 18.8%, P = .011. Despite this difference, rates of provocative testing (stress testing or coronary computed tomography) were lower during the CPU model: 47.1% vs 56.5%, P = .001. This reduction was particularly evident among low-risk patients (Thrombolysis in Myocardial Infarction score 0-2): 49.8% vs 58.1%, P = .011. Rates of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft were similar between the 2 groups (2.8% vs 3.2%, P = .140). We noted no significant events or missed diagnoses in either group during the 30-day follow-up. CONCLUSION: An EDOU model that used mandatory cardiology consultation resulted in decreased provocative testing, particularly among low-risk chest pain patients. Future research should explore the cost-effectiveness of this model.

EDOU staffing by PAs: what are the effects on patient outcomes?

OBJECTIVE: An emergency department observation unit (EDOU) opened in April 2006 staffed by physician assistants (PAs) and nurse practitioners (NPs). This study describes the complexity and outcomes of the EDOU patients to determine the effectiveness of staffing by PAs. METHODS: A retrospective chart review was performed of chest pain and trauma patients in the EDOU from April 2006 through May 2007. Patient characteristics, length of stay (LOS), and admission rates were recorded. Adverse events were monitored, and trauma patients were followed for 30 days to evaluate for missed injuries. RESULTS: 531 chest pain patients and 364 trauma patients were admitted to the EDOU during the study period. Average chest pain patient LOS was 14 hours and 32 minutes, and 12.2% of patients were admitted from the EDOU to an inpatient unit. For trauma patients, average LOS was 12 hours and 46 minutes, and 11.5% of patients were admitted to an inpatient unit. There were no deaths, intubations, or loss of vital signs. In 30-day follow-up, there were no significant missed injuries among trauma patients. CONCLUSION: PAs effectively cared for patients of moderate complexity in the two largest groups of utilizers of the EDOU.

Patients with coronary disease fail observation status at higher rates than patients without coronary disease.

BACKGROUND: Few studies have evaluated emergency department (ED) observation unit chest pain protocols for optimal patient characteristics and admission rates. At our 35 000-visits/y ED, we implemented a chest pain protocol for our observation unit that allowed emergency physicians to admit patients with known coronary artery disease (CAD). METHODS: We performed a retrospective chart review of all observation unit patients admitted under the chest pain protocol from April 1, 2006, to May 31, 2007. We compared the outcomes of patients who had a history of CAD with those who did not. RESULTS: Five hundred thirty-one patients were admitted to the observation unit under the chest pain protocol for the 14-month study period. Of these patients, 125 (23.5%) had a history of CAD. Patients with a history of CAD had a higher inpatient admission rate ( 24% vs 8.6%; P < .001), higher rate of a positive stress test or positive coronary computed tomographic scan (32.3% vs 6.9%; P < .001), a higher rate of cardiac catheterization (12% vs 5.9%; P = .02), and a higher rate of stent placement or coronary artery bypass graft (CABG) (7.2% vs 2.2%; P = .007). In multivariate analysis, patient history of CAD was an independent predictor of hospital admission (P = .005) and stent placement or CABG (P = .030). CONCLUSION: Patients with known CAD who were admitted to the ED observation unit failed observation status (ie, required hospitalization) and had higher rates of positive testing than those without CAD.