Indirect impact of violent events on emergency department utilization and disease patterns.

BACKGROUND: The health effects of war and armed conflict on casualties and mental health of those directly exposed has been well described, but few studies have explored the indirect health effects of violent events. This paper assesses the indirect health impact of several violent events that took place in Beirut in 2013-2014 on ED visit utilization and disease patterns. METHODS: As tracked by media reports, there were 9 violent events in Beirut during 2013-2014. We compared visits to the Emergency Department of a major medical center during weeks when violent events happened and weeks without such events (the preceding week and the same week in preceding years). After re-coding de-identified data from the medical records of 23,067 patients, we assessed differences in the volume of visits, severity index, and discharge diagnoses. Individual control charts were used to analyze ED visit trends post-event. RESULTS: Comparisons of weeks with violent events and weeks without such events indicate that the socio-demographic characteristics of patients who visited the Emergency Department were similar. Patients seen during violent weeks were significantly more likely to be admitted to the hospital, and less likely to present with low acuity complaints, indicating greater complexity of their conditions. The discharge diagnoses that were significantly higher during violent event weeks included anxiety disorders, sprains, and gastritis. Daily ED visits dropped post events by 14.111%, p < 0.0001. CONCLUSIONS: The results indicate that violent events such as bombs, explosions, and terrorist attacks reverberate through the population, impact patterns of ED utilization immediately post-event and are associated with adverse health outcomes, even among those who are not directly affected by the events.

What Do Program Directors Look for in an Applicant?

Program directors (PDs) are faced with an increasing number of applicants to emergency medicine (EM) and a limited number of positions. This article will provide candidates with insight to what PDs look for in an applicant. We will elaborate on the performance in the emergency medicine clerkship, interview, clinical rotations (apart from EM), board scores, Alpha Omega Alpha membership, letters of recommendation, Medical Student Performance Evaluation or dean's letter, extracurricular activities, Gold Humanism Society membership, medical school attended, research and scholarly projects, personal statement, and commitment to EM. We stress the National Resident Matching Program process and how, ultimately, selection of a residency is equally dependent on an applicant's selection process.

Selecting a Medical School Advisor.

Having an advisor offers medical students many advantages, including increased likelihood of matching into their top choices. Interestingly, students who choose emergency medicine (EM) as a specialty are more likely to seek advising. However, finding and optimally utilizing an EM faculty advisor is often challenging for the medical student. In this article, we tackle the different ways to seek advising, including the 'virtual advisor program' implemented by the Society for Academic Emergency Medicine, the 'e-Advisor Program' instigated by the Clerkship Director in EM Group, the 'member exclusive mentorship program' of the Emergency Medicine Residency Association, as well as peer-based mentoring. More so, we discuss the consensus recommendations developed by the Student Advising Task Force to guide both students planning to apply to EM and their advisors to ensure high-caliber advising.

Improving Emergency Department radiology transportation time: a successful implementation of lean methodology.

BACKGROUND: Emergency Department overcrowding has become a global problem and a growing safety and quality concern. Radiology and laboratory turnaround time, ED boarding and increased ED visits are some of the factors that contribute to ED overcrowding. Lean methods have been used in the ED to address multiple flow challenges from improving door-to-doctor time to reducing length of stay. The objective of this study is to determine the effectiveness of using Lean management methods on improving Emergency Department transportation times for plain radiography. METHODS: We performed a before and after study at an academic urban Emergency Department with 49,000 annual visits after implementing a Lean driven intervention. The primary outcome was mean radiology transportation turnaround time (TAT). Secondary outcomes included overall study turnaround time from order processing to preliminary report time as well as ED length of stay. All ED patients undergoing plain radiography 6 months pre-intervention were compared to all ED patients undergoing plain radiography 6 months post-intervention after a 1 month washout period. RESULTS: Post intervention there was a statistically significant decrease in the mean transportation TAT (mean ± SD: 9.87 min ± 15.05 versus 22.89 min ± 22.05, respectively, p-value <0.0001). In addition, it was found that 71.6% of patients in the post-intervention had transportation TAT ≤ 10 min, as compared to 32.3% in the pre-intervention period, p-value <0.0001, with narrower interquartile ranges in the post-intervention period. Similarly, the "study processing to preliminary report time" and the length of stay were lower in the post-intervention as compared to the pre-intervention, (52.50 min ± 35.43 versus 54.04 min ± 34.72, p-value = 0.02 and 3.65 h ± 5.17 versus 4.57 h ± 10.43, p < 0.0001, respectively), in spite of an increase in the time it took to elease a preliminary report in the post-intervention period. CONCLUSION: Using Lean change management techniques can be effective in reducing transportation time to plain radiography in the Emergency Department as well as improving process reliability.

Improving Emergency Department Door to Doctor Time and Process Reliability: A Successful Implementation of Lean Methodology.

The aim of this study is to determine the effectiveness of using lean management methods on improving emergency department door to doctor times at a tertiary care hospital.We performed a before and after study at an academic urban emergency department with 49,000 annual visits after implementing a series of lean driven interventions over a 20 month period. The primary outcome was mean door to doctor time and the secondary outcome was length of stay of both admitted and discharged patients. A convenience sample from the preintervention phase (February 2012) was compared to another from the postintervention phase (mid-October to mid-November 2013). Individual control charts were used to assess process stability.Postintervention there was a statistically significant decrease in the mean door to doctor time measure (40.0 minutes ± 53.44 vs 25.3 minutes ± 15.93 P < 0.001). The postintervention process was more statistically in control with a drop in the upper control limits from 148.8 to 72.9 minutes. Length of stay of both admitted and discharged patients dropped from 2.6 to 2.0 hours and 9.0 to 5.5 hours, respectively. All other variables including emergency department visit daily volumes, hospital occupancy, and left without being seen rates were comparable.Using lean change management techniques can be effective in reducing door to doctor time in the Emergency Department and improving process reliability.

Improving hospital discharge time: a successful implementation of Six Sigma methodology.

Delays in discharging patients can impact hospital and emergency department (ED) throughput. The discharge process is complex and involves setting specific challenges that limit generalizability of solutions. The aim of this study was to assess the effectiveness of using Six Sigma methods to improve the patient discharge process. This is a quantitative pre and post-intervention study. Three hundred and eighty-six bed tertiary care hospital. A series of Six Sigma driven interventions over a 10-month period. The primary outcome was discharge time (time from discharge order to patient leaving the room). Secondary outcome measures included percent of patients whose discharge order was written before noon, percent of patients leaving the room by noon, hospital length of stay (LOS), and LOS of admitted ED patients. Discharge time decreased by 22.7% from 2.2 hours during the preintervention period to 1.7 hours post-intervention (P < 0.001). A greater proportion of patients left their room before noon in the postintervention period (P < 0.001), though there was no statistical difference in before noon discharge. Hospital LOS dropped from 3.4 to 3.1 days postintervention (P < 0.001). ED mean LOS of patients admitted to the hospital was significantly lower in the postintervention period (6.9 ±â€Š7.8 vs 5.9 ±â€Š7.7 hours; P < 0.001). Six Sigma methodology can be an effective change management tool to improve discharge time. The focus of institutions aspiring to tackle delays in the discharge process should be on adopting the core principles of Six Sigma rather than specific interventions that may be institution-specific.

Acute allergic reactions in the emergency department: characteristics and management practices.

OBJECTIVE: The objective of this study is to determine the incidence of emergency department (ED) visits for acute allergic reactions, identify the triggers, assess the severity, evaluate the management practices, and examine patient outcomes at a single-center ED in Lebanon. PATIENTS AND METHODS: A retrospective review of all patient charts presenting with a final diagnosis of acute allergic reaction to a single ED within a 6-month period (July-December 2009) was carried out. Age, sex, triggers, management in the ED and at discharge, disposition, and return visit were determined. RESULTS: Two hundred and forty-five patients were identified (82.4% mild, 15.1% moderate, and 2.6% severe, respectively). This accounted for 0.96% of all ED visits. Drugs were the most commonly identified trigger (23.7%). In the ED, 72.7% of patients received H1-antihistamines, 51.8% received corticosteroids, 7.3% received H2-antihistamines, and 7.3% received inhaled B2 agonists. Only 15.9% of anaphylaxis cases received epinephrine in the ED. Similarly, the majority of patients were discharged on H1-antihistamines (93.9%), with only 4.5% of patients with anaphylaxis receiving prescriptions for epinephrine injections. All patients except one were discharged home. No fatalities were noted and the return visit rate within 1 week was 9.8%. CONCLUSION: The incidence of ED visits for acute allergic reaction was high compared with other studies, although the majority of cases were mild. Deviations from published guidelines on the treatment of anaphylaxis are common, with rare use of epinephrine and heavy reliance on H1-antihistamines both in the ED and at discharge. This did not seem to result in any measurable impact on mortality.

Media exposure, mediated social comparison to idealized images of muscularity, and anabolic steroid use.

This study examined the association between anabolic-androgenic steroid (AAS) use and dominant sociocultural factors, specifically media exposure to idealized images of male muscularity, and mediated social comparison trends among a sample of young Arab adults. The study found evidence that participants more exposed to content that promotes muscularity and those who idealize images of muscularity and perceive them as motivators for achieving muscularity are more likely to be AAS users. It also found that a significant percentage of participants used at least one kind of dietary supplement and that the level of AAS use among health club participants indicates it is a significant public health problem in Lebanon. The study suggests that dealing with this problem requires a unique approach, beyond the typical awareness of risks strategy, since some users were well aware of the risks yet continue to use AAS, and their motivations pertain more to body image and sexuality. A stronger approach that utilizes critical media literacy teaching that ingrains these issues into school and university curricula will have a more lasting impact.

Improving door-to-antibiotic time in severely septic emergency department patients.

BACKGROUND: The Surviving Sepsis Campaign (SSC) guidelines recommend that broad-spectrum antibiotics be administered to severely septic patients within 3 h of emergency department (ED) admission. Despite the well-established evidence regarding the benefit of timely antibiotics, adoption of the SSC recommendation into daily clinical practice has been slow and sporadic. STUDY OBJECTIVE: To study the impact of storing broad-spectrum antibiotics in an ED automated dispensing cabinet (ADC) on the timeliness of antibiotic administration in severely septic patients presenting to the ED. METHODS: Retrospective observational study of timeliness of antibiotic administration in severely septic patients presenting to a community ED before and after adding broad-spectrum antibiotics to the ED ADC. Data on 56 patients before and 54 patients after the intervention were analyzed. The primary outcome measure was mean order-to-antibiotic time. Secondary outcome measures included mean door-to-antibiotic time and percentage of patients receiving antibiotics within 3 h. RESULTS: The final analysis was on 110 patients. Order-to-antibiotic administration time was reduced by 29 min post-intervention (55 min vs. 26 min, 95% confidence interval [CI] 12.5-45.19). Mean door-to-antibiotic time was also reduced by 70 min (167 min vs. 97 min, 95% CI 37.53-102.29). The percentage of severely septic patients receiving antibiotics within 3h of arrival to the ED increased from 65% pre-intervention to 93% post-intervention (95% CI 0.12-0.42). CONCLUSION: Storing key antibiotics in an institution's severe sepsis antibiogram in the ED ADC can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival.