Triage and Ongoing Care for Critically Ill Patients in the Emergency Department: Results from a National Survey of Emergency Physicians

Introduction: We conducted a cross-sectional study at the Icahn School of Medicine at Mount Sinai to elicit emergency physician (EP) perceptions regarding intensive care unit (ICU) triage decisions and ongoing management for boarding of ICU patients in the emergency department (ED). We assessed factors influencing the disposition decision for critically ill patients in the ED to characterize EPs’ perceptions about ongoing critical care delivery in the ED while awaiting ICU admission.Methods: Through content expert review and pilot testing, we iteratively developed a 25-item written survey targeted to EPs, eliciting current ICU triage structure, opinions on factors influencing ICU admission decisions, and views on caring for critically ill patients “boarding” in the ED for >4-6 hours.Results: We approached 732 EPs at a large, national emergency medicine conference, achieving 93.6% response and completion rate, with 54% academic and 46% community participants. One-fifth reported having formal ICU admission criteria, although only 36.6% reported adherence. Common factors influencing EPs’ ICU triage decisions were illness severity (91.1%), ICU interventions needed (87.6%), and diagnosis (68.2%), while ICU bed availability (13.5%) and presence of other critically ill patients in ED (10.2%) were less or not important. While 72.1% reported frequently caring for ICU boarders, respondents identified high patient volume (61.3%) and inadequate support staffing (48.6%) as the most common challenges in caring for boarding ICU patients.Conclusion: Patient factors (eg, diagnosis, illness severity) were seen as more important than system factors (eg, bed availability) in triaging ED patients to the ICU. Boarding ICU patients is a common challenge for more than two-thirds of EPs, exacerbated by ED volume and staffing constraints

The Association of Light Trucks and Vans with Pediatric Pedestrian Deaths

We investigated the hypothesis that relative to cars, light trucks and vans (including sports utility vehicles) are more likely to result in fatal pediatric pedestrian injury. It was further hypothesized that this increased risk is a result of head injuries. The study sample consisted of 18,117 police records of motor vehicles involved in crashes in which one or more pedestrian aged 5 to 19 years old was injured or killed. Frequencies and case fatality ratios for each vehicle body type were calculated. We conducted a logistic regression analysis with light truck or van versus car as the exposure variable and fatal / non-fatal pedestrian injury as the outcome variable. After controlling for driver age, driver gender, vehicle weight, road surface condition and presence of head injury, 5 to 19 year-olds struck by light trucks or vans were more than twice as likely to die than those struck by cars (OR = 2.3 95% CI 1.4, 3.9). For the 5 to 9 year-old age group, light trucks and vans were four times as likely to be associated with fatal injury (OR = 4.2 95 % CI 1.9, 9.5). There was an association between head injury and light trucks and vans (OR=1.2, 95% CI 1.1, 1.3). We conclude that vehicle body type characteristics play an important role in pediatric pedestrian injury severity and may offer engineering-based opportunities for injury control

Emergency department visits for behavioral and mental health care after a terrorist attack

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/55772/1/dimaggio_emergency department visits_2007.pd

Equus Unbound: Fairman Rogers and the Age of the Horse (Panel Discussion)

Podcast introduction, Kristin Winch, 00:00-01:17 Welcome and introduction, H. Carton Rogers, 01:17-05:06:30 Remarks by panel moderator Ann N. Greene, 06:35-20:15 Remarks by Herbert Moelis, 20:33-28:58 Remarks by Ellen Moelis, 28:58-39:45 Remarks by Dean Richardson, 39:45-46:45 Remarks by Douglas Kemmerer, 46:45-1:07:45 Questions and answers, 1:07:45-1:10:18 Concluding remarks, Lynne Farrington, 1:10:18-1:11:19 To download a podcast of this event, choose either the standard quality mp3 file (shorter download) or the high quality m4a file (longer download), below. To view the exhibition poster, select Download button at upper right

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

OBJECTIVES: To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use. DESIGN: Prospective observational cohort. SETTING: Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015. PARTICIPANTS: Individuals aged 65 and older in the ED (N = 57,287). INTERVENTION: The intervention was first TCN contact. Controls never saw a TCN during the study period. MEASUREMENTS: We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits. RESULTS: A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%). CONCLUSION: Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission

Formation of 3-nitrotyrosines in carbonic anhydrase III is a sensitive marker of oxidative stress in skeletal muscle

Oxidation of skeletal muscle proteins has been reported to occur following contractions, with ageing, and with a variety of disease states, but the nature of the oxidised proteins has not been identified. A proteomics approach was utilised to identify major proteins that contain carbonyls and/or 3-nitrotyrosine (3-NT) groups in the gastrocnemius (GTN) muscles of adult (5–11 14months of age) and old (26–28 14months of age) wild type (WT) mice and adult mice lacking copper, zinc superoxide dismutase ( Sod1 −/− mice), manganese superoxide dismutase ( Sod2 +/− mice) or glutathione peroxidase 1 ( GPx1 −/− mice). In quiescent GTN muscles of adult and old WT mice, protein carbonylation and/or formation of 3-NT occurred in several proteins involved in glycolysis, as well as creatine kinase and carbonic anhydrase III. Following contractions, the 3-NT intensity was increased in specific protein bands from GTN muscles of both adult and old WT mice. In quiescent GTN muscles from adult Sod1 −/− , Sod2 +/− or GPx1 −/− mice compared with age-matched WT mice only carbonic anhydrase III showed a greater 3-NT content. We conclude that formation of 3-NT occurs readily in response to oxidative stress in carbonic anhydrase III and this may provide a sensitive measure of oxidative damage to muscle proteins.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/56035/1/362_ftp.pd

Unmet supportive care needs of breast, colorectal and testicular cancer survivors in the first 8 months post primary treatment:A prospective longitudinal survey

Objectives To explore the supportive care needs of cancer survivors, the characteristics of patients with high levels of unmet need, changes in unmet need after treatment ends and differences in unmet needs of breast, colorectal and testicular survivors. Methods The method used was a prospective longitudinal mailed survey. Unmet needs, measured by 25-item modified Cancer Survivors Unmet Needs survey at baseline (immediately post-treatment) and 8 months later, were analysed descriptively. Results Of 434 breast, 186 colorectal and 75 testicular patients responding at baseline, 56.2%, 65.6% and 50.7%, respectively, had no unmet needs, the top decile having >= 10 (breast) or seven (colorectal and testicular) different needs and seven different unmet needs. The most frequently reported unmet need (all groups) was fear of cancer recurrence. Unmet needs fell significantly at 8 months for breast patients. Some patients reported new needs. Needs were lowest amongst colorectal survivors and differed between the three groups. Higher levels of unmet needs (breast and colorectal) were associated with having had chemotherapy. Conclusion Most survivors reported few unmet needs, but a small proportion have persisting or emerging needs. Routine or regular monitoring of unmet needs is required so that healthcare professionals can deliver personalised care based on individual needs, preferences and circumstances

Opinion: Focus on preclinical sex differences will not address women’s and men’s health disparities

Histor

Wildfire impact : natural experiment reveals differential short-term changes in soil microbial communities

A wildfire which overran a sensor network site provided an opportunity (a natural experiment) to monitor short-term post-fire impacts (immediate and up to three months post-fire) in remnant eucalypt woodland and managed pasture plots. The magnitude of fire-induced changes in soil properties and soil microbial communities was determined by comparing (1) variation in fire-adapted eucalypt woodland vs. pasture grassland at the burnt site; (2) variation at the burnt woodland-pasture sites with variation at two unburnt woodland-pasture sites in the same locality; and (3) temporal variation pre- and post-fire. In the eucalypt woodland, soil ammonium, pH and ROC content increased post-fire, while in the pasture soil, soil nitrate increased post-fire and became the dominant soluble N pool. However, apart from distinct changes in N pools, the magnitude of change in most soil properties was small when compared to the unburnt sites. At the burnt site, bacterial and fungal community structure showed significant temporal shifts between pre- and post-fire periods which were associated with changes in soil nutrients, especially N pools. In contrast, microbial communities at the unburnt sites showed little temporal change over the same period. Bacterial community composition at the burnt site also changed dramatically post-fire in terms of abundance and diversity, with positive impacts on abundance of phyla such as Actinobacteria, Proteobacteria and Firmicutes. Large and rapid changes in soil bacterial community composition occurred in the fire-adapted woodland plot compared to the pasture soil, which may be a reflection of differences in vegetation composition and fuel loading. Given the rapid yet differential response in contrasting land uses, identification of key soil bacterial groups may be useful in assessing recovery of fire-adapted ecosystems, especially as wildfire frequency is predicted to increase with global climate change