Overcrowding in the Emergency Department and Patient Safety

Emergency department (ED) overcrowding is a recognized problem worldwide. This chapter reviews the scope of the problem, manifestations, repercussions, and potential solutions to this problem

Thrombostatic Agents and Tissue Adhesives in the Emergency Department: Stopping the Bleeding, Closing the Wound, and Novel Applications

Complaints of bleeding are frequent presentations to the emergency department, and although most bleeding can be controlled with direct pressure, increased use of antiplatelet agents and anticoagulants complicates what might be otherwise simple bleeding. Industry has met the demand for hemostatic adjuncts, and a number of products are available for the emergency physician to assist in hemostatic control and wound closure. This chapter will cover the various available technologies, covering their preferred use and discussing particular bleeding scenarios and which technology may be best for each scenario

Punch Injuries: Insights into Intentional Closed Fist Injuries

Objectives: This study sought to investigate the patterns of injury resulting from a punch mechanism and to investigate the associated psychopathology present in patients with these injuries.Methods: Retrospective analysis of patients with hand radiographs ordered from the emergency department allowed for identification of patients with a punch mechanism. We recorded injury patterns and queried patients’ medical records for associated psychopathology.Results: 1,292 patients underwent hand radiographs during a one-year time period; 172 patients (13%) were radiographed following an intentional punch injury, identifying 76 fractures in 70 patients. Males contributed a greater proportion of patients presenting with punch injury when compared to females (80% vs. 20%). Males were more likely to sustain fracture from a punch mechanism (48% vs. 11%, OR 7 [95% CI 2.3-20.9]), but were less likely to have preexisting documented psychiatric disease (23% vs. 49%, OR 3.1 [95% CI 1.4-6.7]). Of all fractures, 61% were to the fifth metacarpal, 21% were to the remainder of the metacarpals, and the remaining were fractures to phalanges and bones of the wrist.Conclusion: Women are less likely to present with punch injury and are less likely to sustain a fracture when they do present but have more associated psychiatric disease. Both men and women presenting with punch injuries have a higher prevalence of psychiatric disease than the background incidence in the population as a whole. Although punch injuries result in a significant number of boxer fractures, a number of other injuries are associated with punch mechanisms. [West J Emerg Med. 2011;12(1):6-10.

Extra-adrenal Pheochromocytoma in an Adolescent

A 17-year-old male with symptoms of headache and diaphoresis presented to the emergency department. He had eight months of noted hypertension attributed to medications. On arrival his blood pressure was 229/117mmHg, and he was ill-appearing. His blood pressure was managed aggressively, and he was diagnosed with extra-adrenal pheochromocytoma by computed tomography. He eventually underwent resection of the mass. Children with severe, symptomatic hypertension should be evaluated for pheochromocytoma. Although rare, it is curable. Failure to diagnose carries a high risk of morbidity and mortality

Dedicated Shift Wrap-up Time Does Not Improve Resident Sign-out Volume or Efficiency

Objectives: Sign-out (SO) is a challenge to the emergency physician. Some training programs have instituted overlapping 9-hour shifts. The residents see patients for eight hours, and have one hour of wrap-up time. This hour helps them complete patient care, leaving fewer patients to sign-out. We examined whether this strategy impacts SO burden.Methods: This is a retrospective review of patients evaluated by emergency medicine (EM) residents working 9-hour (eight hours of patient care, one hour wrap-up time) and 12-hour shifts (12 hours patient care, no reserved time for wrap-up). Data were collected by reviewing the clinical tracker. A patient was assigned to the resident who initiated care and dictated the chart. SO was defined as any patient in the ED without disposition at change of shift. Patient turn-around-time (TAT) was also recorded.Results: One-hundred sixty-one postgraduate-year-one resident (PGY1), 264 postgraduate-year-two resident (PGY2), and 193 postgraduate-year-three resident (PGY3) shifts were included. PGY1s signed out 1.9 patients per 12-hour shift. PGY2s signed out 2.3 patients on 12-hour shifts and 1.8 patients on 9-hour shifts. PGY3s signed out 2.1 patients on 12-hour shifts and 2.0 patients on 9-hour shifts. When we controlled for patients seen per hour, SO burden was constant by class regardless of shift length, with PGY2s signing out 18% of patients seen compared to 15% for PGY3s. PGY1s signed out 18% of patients seen. TAT for patients seen by PGY1s and PGY2s was similar, at 189 and 187 minutes, respectively. TAT for patients seen by PGY3s was significantly less at 175 minutes.Conclusion: The additional hour devoted to wrapping up patients in the ED had no affect on SO burden. The SO burden represented a fixed percentage of the total number of patients seen by the residents. PGY3s sign-out a smaller percentage of patients seen compared to other classes, and have faster TATs. [West J Emerg Med. 2010; 11(1):35-39]

International Health Security: A Summative Assessment by ACAIM Consensus Group

International health security (IHS) encompasses any natural or anthropogenic occurrence that can threaten the safety of human health and well-being. The American College of Academic International Medicine IHS Consensus Group (ACAIM-CG) developed a summative assessment highlighting the main issues that can impact IHS including emerging infectious diseases; chronic health conditions; bioterrorism; planetary changes (volcanic eruptions, earthquakes, wildfires, and climate change); nuclear incidents; information and cyber health; industrialization; globalization; pharmaceutical production; and communication platforms (social media). These concerns can directly and indirectly impact IHS both in the long and short term. When considering IHS, we aim to emphasize the utility of applying a predefined framework to effectively approach health security threats. This framework comprises of prevention, detection, assessment, reporting, response, addressing needs, and the perpetual repetition of the above cycle (inclusive of appropriate mitigation measures). It is hoped that this collective work will provide a foundation for further research within the redefined, expanded scope of IHS

The Impact of Working with Medical Students on Resident Productivity in the Emergency Department

Introduction: Academic emergency departments (ED) strive to balance educational needs of residents and medical students with service requirements that optimize patient care. No study to date has evaluated whether resident precepting of medical students affects residents’ clinical productivity. Understanding the interplay of these variables may allow for ED staffing that maximizes productivity. We sought to determine whether the precepting of medical students impacts resident productivity.Methods: This study was performed at a tertiary care ED with a 70,000 annual patient census. We performed a computer-based (Verinet Systems, Alachua, Fl) retrospective review of patient encounters initiated by second- and third-year emergency medicine residents (PGY2 and PGY3) assigned to medical student precepting shifts and compared these shifts with those of the same residents when not working with students. Data collection over 12 months included shift length from the monthly schedule and number of patients and relative value units (RVUs) from the Verinet System. Patients seen per hour (pt/hr) and relative value unit per hour (RVUs/hr) were calculated. We compared parameters using two-tailed T-tests. The hospital’s institutional review board approved this study.Results: Daily census was 202 on days without medical student rotators and 200 on days with student rotators (P = 0.29). While precepting students, PGY3s saw 1.40 pt/hr versus 1.39 pt/hr without students (P = 0.88) and PGY2s saw 1.28 pt/hr with students compared to 1.28 pt/hr without students (P = 0.94). PGY3s generated 3.97 RVU/hr with students and 4.03 RVU/hr while working independently (P = 0.68) and PGY2s generated 3.82 RVU/hr working with students versus 3.74 RVU/hr without (P = 0.44). There were no productivity differences between resident precepting shifts and regular shifts.Conclusion: In this study, resident productivity was not affected by precepting medical students. [West J Emerg Med.2013;14(6):585–589.

The Impact of Working with Medical Students on Resident Productivity in the Emergency Department

INTRODUCTION: Academic emergency departments (ED) strive to balance educational needs of residents and medical students with service requirements that optimize patient care. No study to date has evaluated whether resident precepting of medical students affects residents’ clinical productivity. Understanding the interplay of these variables may allow for ED staffing that maximizes productivity. We sought to determine whether the precepting of medical students impacts resident productivity. METHODS: This study was performed at a tertiary care ED with a 70,000 annual patient census. We performed a computer-based (Verinet Systems, Alachua, Fl) retrospective review of patient encounters initiated by second- and third-year emergency medicine residents (PGY2 and PGY3) assigned to medical student precepting shifts and compared these shifts with those of the same residents when not working with students. Data collection over 12 months included shift length from the monthly schedule and number of patients and relative value units (RVUs) from the Verinet System. Patients seen per hour (pt/hr) and relative value unit per hour (RVUs/hr) were calculated. We compared parameters using two-tailed t-tests. The hospital’s institutional review board approved this study. RESULTS: Daily census was 202 on days without medical student rotators and 200 on days with student rotators (p=0.29). While precepting students, PGY3s saw 1.40 pt/hr versus 1.39 pt/hr without students (p=0.88) and PGY2s saw 1.28 pt/hr with students compared to 1.28 pt/hr without students (p=0.94). PGY3s generated 3.97 RVU/hr with students and 4.03 RVU/hr while working independently (p=0.68) and PGY2s generated 3.82 RVU/hr working with students versus 3.74 RVU/hr without (p=0.44). There were no productivity differences between resident precepting shifts and regular shifts. CONCLUSION: In this study, resident productivity was not affected by precepting medical students

The Impact of Working with Medical Students on Resident Productivity in the Emergency Department

Introduction: Academic emergency departments (ED) strive to balance educational needs of residents and medical students with service requirements that optimize patient care. No study to date has evaluated whether resident precepting of medical students affects residents’ clinical productivity. Understanding the interplay of these variables may allow for ED staffing that maximizes productivity. We sought to determine whether the precepting of medical students impacts resident productivity.Methods: This study was performed at a tertiary care ED with a 70,000 annual patient census. We performed a computer-based (Verinet Systems, Alachua, Fl) retrospective review of patient encounters initiated by second- and third-year emergency medicine residents (PGY2 and PGY3) assigned to medical student precepting shifts and compared these shifts with those of the same residents when not working with students. Data collection over 12 months included shift length from the monthly schedule and number of patients and relative value units (RVUs) from the Verinet System. Patients seen per hour (pt/hr) and relative value unit per hour (RVUs/hr) were calculated. We compared parameters using two-tailed T-tests. The hospital’s institutional review board approved this study.Results: Daily census was 202 on days without medical student rotators and 200 on days with student rotators (P = 0.29). While precepting students, PGY3s saw 1.40 pt/hr versus 1.39 pt/hr without students (P = 0.88) and PGY2s saw 1.28 pt/hr with students compared to 1.28 pt/hr without students (P = 0.94). PGY3s generated 3.97 RVU/hr with students and 4.03 RVU/hr while working independently (P = 0.68) and PGY2s generated 3.82 RVU/hr working with students versus 3.74 RVU/hr without (P = 0.44). There were no productivity differences between resident precepting shifts and regular shifts.Conclusion: In this study, resident productivity was not affected by precepting medical students. [West J Emerg Med.2013;14(6):585–589.