Adult Emergency Department Population Research Articles

Clinical performance of existing diagnostic criteria for pneumonia in older emergency patients: A prospective cohort study.

Pneumonia accounts for over half a million older adult emergency department (ED) visits annually, but ED pneumonia diagnosis is inaccurate. Geriatric-specific pneumonia diagnostic criteria exist for other settings; no prospective data exist to determine if application in the older adult ED population is feasible. The objective was to prospectively evaluate the utility of four current diagnostic criteria (Loeb; Modified McGeer; Infectious Disease Society of America/American Thoracic Society; American College of Emergency Physicians) in older adult ED patients. This was a prospective, observational cohort study of older adult ED patients ≥65 years of age in two U.S. EDs with suspected pneumonia defined as having chest radiography ordered and treating physician suspicion. The standard we used for defining the presence, absence, or inability to determine a diagnosis of pneumonia diagnosis was expert physician chart adjudication. We report the summary statistics for demographic characteristics and symptoms/exam findings and sensitivity, specificity, and likelihood ratios with 95% confidence intervals of the existing diagnostic criteria. Pre-specified cutoff values of a positive LR >10 and a negative LR <0.3 were considered clinically significant. Of 135 patients enrolled, 27 had pneumonia by adjudicator review. Typical patient-reported pneumonia symptoms, such as fever (18.5%) and new/worse cough (51.9%), were not consistently present in pneumonia. The IDSA/ATS and ACEP criteria had positive LR >10 and negative LR <0.3; however, all confidence intervals included pre-specified cutoffs. Older adults presented to the ED with low frequency of typical pneumonia symptoms. Although existing diagnostic definitions had promising test characteristics, they may not perform well enough for clinical application without refinement.

Evaluation of missed influenza vaccination opportunities in the emergency department

BackgroundSeasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018–2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data. MethodsThis was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 – April 30) over a two-years, 2018–2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity. ResultsA total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions. ConclusionPatients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.

Qatar Prediction Rule Using ED Indicators of COVID-19 at Triage.

Introduction: The presence of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and its associated disease, COVID-19 has had an enormous impact on the operations of the emergency department (ED), particularly the triage area. The aim of the study was to derive and validate a prediction rule that would be applicable to Qatar’s adult ED population to predict COVID-19-positive patients.Methods: This is a retrospective study including adult patients. The data were obtained from the electronic medical records (EMR) of the Hamad Medical Corporation (HMC) for three EDs. Data from the Hamad General Hospital ED were used to derive and internally validate a prediction rule (Q-PREDICT). The Al Wakra Hospital ED and Al Khor Hospital ED data formed an external validation set consisting of the same time frame. The variables in the model included the weekly ED COVID-19-positivity rate and the following patient characteristics: region (nationality), age, acuity, cough, fever, tachypnea, hypoxemia, and hypotension. All statistical analyses were executed with Stata 16.1 (Stata Corp). The study team obtained appropriate institutional approval.Results: The study included 45,663 adult patients who were tested for COVID-19. Out of these, 47% (n = 21461) were COVID-19 positive. The derivation-set model had very good discrimination (c = 0.855, 95% Confidence intervals (CI) 0.847–0.861). Cross-validation of the model demonstrated that the validation-set model (c = 0.857, 95% CI 0.849–0.863) retained high discrimination.A high Q-PREDICT score ( ≥ 13) is associated with a nearly 6-fold increase in the likelihood of being COVID-19 positive (likelihood ratio 5.9, 95% CI 5.6–6.2), with a sensitivity of 84.7% (95% CI, 84.0%–85.4%). A low Q-PREDICT ( ≤ 6) is associated with a nearly 20-fold increase in the likelihood of being COVID-19 negative (likelihood ratio 19.3, 95% CI 16.7–22.1), with a specificity of 98.7% (95% CI 98.5%–98.9%).Conclusion: The Q-PREDICT is a simple scoring system based on information readily collected from patients at the front desk of the ED and helps to predict COVID-19 status at triage. The scoring system performed well in the internal and external validation on datasets obtained from the state of Qatar.

Sensitivity of C-reactive protein cut-off values for pyogenic spinal infection in the emergency department.

The aim of this study was to describe the sensitivity of various C-reactive protein (CRP) cut-off values to identify patients requiring magnetic resonance imaging evaluation for pyogenic spinal infection among emergency department (ED) adults presenting with neck or back pain. We prospectively enrolled a convenience series of adults presenting to a community ED with neck or back pain in whom ED providers had concern for pyogenic spinal infection in a derivation cohort from 2004 to 2010 and a validation cohort from 2010 to 2018. The validation cohort included only patients with pyogenic spinal infection. We analysed diagnostic test characteristics of various CRP cut-off values. We enrolled 232 patients and analysed 201 patients. The median age was 55 years, 43.8% were male, 4.0% had history of intravenous drug use, and 20.9% had recent spinal surgery. In the derivation cohort, 38 (23.9%) of 159 patients had pyogenic spinal infection. Derivation sensitivity and specificity of CRP cut-off values were > 3.5 mg/L (100%, 24.8%), > 10 mg/L (100%, 41.3%), > 30 mg/L (100%, 61.2%), and > 50 mg/L (89.5%, 69.4%). Validation sensitivities of CRP cut-off values were > 3.5 mg/L (97.6%), > 10 mg/L (97.6%), > 30 mg/L (90.4%), and > 50 mg/L (85.7%). CRP cut-offs beyond the upper limit of normal had high sensitivity for pyogenic spinal infection in this adult ED population. Elevated CRP cut-off values of 10 mg/L and 30 mg/L require validation in other settings.

Emergency Department visits due to intoxications in a Dutch university hospital: Occurrence, characteristics and health care costs.

BackgroundIntoxications with alcohol and drugs are common in the Emergency Department. This study aimed to describe the occurrence and characteristics of intoxications (alcohol, Drugs of Abuse (DOA), pharmaceutical and chemical) presented to the Emergency Department and the health care costs of these intoxications.MethodsThis was a retrospective medical record study of all patients (≥ 16 years) who presented to the Emergency Department of an inner-city academic hospital in the Netherlands due to single or multiple intoxication(s) as the primary or secondary reason in the year 2016. An intoxication was reported as present if the attending physician described the intoxication in the patient’s medical record.ResultsA total of 783 patients were included, accounting for 3.2% of the adult Emergency Department population (age ≥ 16 year). In 30% more than one substance was used. Intoxications with alcohol, Drugs of Abuse and pharmaceuticals was reported in respectively 62%, 29% and 21% of the intoxicated patients. The mean costs per patient presenting with an intoxication to the Emergency Department was € 1,490. The mean costs per patient were highest for pharmaceutical intoxications (€ 2,980), followed by Drugs of Abuse (€ 1,140) and alcohol (€ 1,070).ConclusionsIntoxications among patients aged 16 years and older are frequently seen at the Emergency Department and are frequently caused by multiple substances. Alcohol is the most common intoxication. Substantial healthcare costs are involved. Therefore, this study suggests that further research into hazardous alcohol consumption and DOA abuse is warranted.

The diagnostic accuracy of hematological laboratory parameters in the diagnosis of acute appendicitis in the adult emergency department population

Introduction: The aim of this study was to assess the diagnostic accuracy of some hematological laboratory parameters: platelets (Plt), mean platelet volume (MPV), red cell distribution width (RDW), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), in the diagnosis of acute appendicitis (AA) in the adult emergency department population. Materials and methods: The study was performed according to the 2015 Standards for Reporting Diagnostic accuracy studies Guidelines. We consecutively included 78 patients admitted to the Emergency Department (ED) with suspected acute appendicitis. Parameters of the complete blood count were measured on Advia 2120i automated hematology analyzer (Siemens, Enlargen, Germany). The difference between two groups was tested with Mann-Whitney test. Logistic regression analysis was performed to identify the significant predictors of AA, among the proposed laboratory parameters. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value of the identified significant predictors. Statistical analyses were performed using MedCalc Statistical Software version 16.2.0 (MedCalc Software bvba, Ostend, Belgium). P 4.4 (P 4.4 can be useful aid in the differentiation between the patients with AA and symptomatic individuals with other diagnoses.

The diagnostic accuracy of clinical and laboratory parameters in the diagnosis of acute appendicitis in the adult emergency department population - a case control pilot study.

IntroductionThe evaluation of patients with suspected appendicitis strives to identify all patients with presenting symptoms while minimizing negative appendectomy rate. The aim of the study was to identify the optimal combination of clinical and laboratory parameters that should facilitate the emergency department surgeon’s definite decision.Materials and methodsThe study group comprised 120 patients with suspicion of acute appendicitis (AA). In 60 patients the AA diagnosis was confirmed intraoperatively and by histological analysis. Clinical parameters included: appetite, vomiting, diarrhea, dysuria, signs of localized peritonitis and pain migration. Measured laboratory parameters were: C-reactive protein (CRP), complete blood count (CBC) and the urine test strip.ResultsThe control group of patients were more likely to present following symptoms: no changes in appetite (P < 0.001), diarrhea (P = 0.009) and dysuria (P = 0.047). CRP and white blood cell count (WBC) were significantly higher in the group with confirmed AA compared to the control group (44.7 vs. 6.6, and 13.6 ± 3.9 vs. 9.0 ± 3.4, respectively; P < 0.001). The multivariate logistic regression analysis identified lack of appetite (P = 0.013), absence of diarrhea (P = 0.004), and positive finding of signs of localized peritonitis (P = 0.013), as well as WBCs (P < 0.001) and negative urine test strip results (P = 0.009) as statistically significant predictors of AA. The highest percentage of correctly classified cases (82%) was achieved by combination of common clinical exam and basic inexpensive laboratory parameters (WBCs and urine test strip).ConclusionsAcute appendicitis in the emergency setting may be successfully ruled in based on elevated WBCs and negative urine test strip in combination with signs of localized peritonitis, lack of appetite and absence of diarrhea. Since CRP did not contribute to the overall diagnostic accuracy, its use in AA diagnostic protocols is of no value.

LO46: Sex-based differences in concussion symptom reporting and self-reported outcomes in a general adult ED population

Introduction: Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. To-date, study of sex-based concussion differences in general adult populations have been limited. This study examined sex-based differences in concussion outcomes. Methods: Adult (&gt;17 years) patients presenting to one of three urban EDs in Edmonton, Alberta with Glasgow coma scale score 13 within 72 hours of a concussive event were recruited by on-site research assistants. Follow-up calls at 30 and 90 days post ED discharge captured extent of PCS using the Rivermead Post-Concussion questionnaire (RPQ), effect on daily living activities measured by the Rivermead Head Injury Questionnaire (RHIQ), and overall health-related quality of life using the 12-item Short Form Health Survey (SF-12). Dichotomous and categorical variables were compared using Fishers exact test; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Results: Overall, 130/250 enrolled patients were female. The median age was 35 years; men trended towards being younger (median=32 years; IQR: 23, 45) than women (median=40 years; IQR: 22, 52). Compared to women, more men were single (56% vs 38% (p=0.007) and employed (82% vs 71% (p=0.055). Men and women experienced different injury mechanisms (p=0.007) with more women reporting injury due to a fall (44% vs 26%), while more men were injured at work (16% vs 7%) or due to an assault (11% vs. 3%). Men had a higher return to ED rate (13% vs. 5%; p=0.015). Women had higher RPQ scores at baseline (p&lt;0.001) and 30-day follow-up (p=0.001); this difference was not significant by 90 days (p=0.099). While women reported on the RHIQ at 30 days that their injury affected their usual activities significantly more than men (Median=5, IQR: 0, 11 vs. median=0.5, IQR: 0.5, 7; p=0.004), both groups had similar scores on the SF-12 physical composite and mental composite scales at all three measurement points. Conclusion: In a general ED concussion population, demographic differences exist between men and women. Based on self-reported and objective outcomes, womens usual activities may be more affected by concussion and PCS than men. Further analysis of these differences is required in order to identify different treatment options and ensure adequate care and treatment of injury.

An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department

Objective: To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician–pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). Methods: This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. Results: Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug–disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 (P < .0001). Conclusion: Academic detailing led by a physician–pharmacist pair resulted in improved confidence in physician residents’ ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.

A Randomized, Double-Blind Trial to Determine if Vapocoolant in the Adult Population Improves Patient Perception of Pain With Peripheral Intravascular Access.

The purpose of this study was to investigate whether the use of a topical anesthetic spray (vapocoolant) at the site of intravenous access reduces pain and anxiety associated with peripheral intravenous (PIV) catheter insertion in an adult emergency department population. A randomized, double-blind, placebo-controlled, single-center trial, conducted from July to August, in an adult emergency department where 72 patients with orders for PIV insertion receiving either topical vapocoolant spray (n = 38) or placebo spray (n = 34). Vapocoolant or placebo was applied to the intravenous site and allowed to evaporate before cleansing and insertion. The primary outcome was patient perception of pain and anxiety with PIV needle insertion using a 0-10 Likert scale. Secondary outcomes included patient/staff preference or desire for vapocoolant/placebo use in future procedures and staff perception of patient pain and anxiety. Patient groups did not vary significantly in the history of intravenous access, nor anxiety preprocedure, and the sprays did not affect ability to obtain intravenous access. Patient perception of pain did not vary significantly between vapocoolant (2) and placebo populations (2.5), nor did the scores vary significantly for patient-forecasted anxiety in future procedures using the same methods (0.5 for vapocoolant, 0 for placebo; p > 0.05). Eighty-nine percent of nurses and patients would use vapocoolant in future procedures, whereas 74% would use placebo; the difference was not significant (p > 0.05). No skin blanching or lesions were noted. Among adult patients in the Parkland Emergency Department receiving PIV access, no significant differences in pain relief or alleviation of anxiety were found between treatment using a topical anesthetic spray or placebo.

Characterization of Young Adult Emergency Department Users: Evidence to Guide Policy

PurposeThe purpose of this study was to characterize young adult patients aged 19–25 years who are emergency department (ED) frequent users and study factors associated with frequent ED use. MethodsED visits among 19- to 25-year olds were identified from administrative records in California, Florida, Iowa, Massachusetts, and New York, 2010. Patients were analyzed for 12 months to study the frequency of their ED utilization. ED visits were categorized according to primary diagnosis. Patients were stratified by frequency of ED use: one visit (single users), two to four visits (infrequent users), and five or more visits (frequent users) in a 1-year period. ResultsWe identified 1,711,774 young adult patients who made 3,650,966 ED visits. Sixty-six percent of patients were single users, 29% were infrequent users, and 4.6% were frequent users. Frequent users accounted for a disproportionate 28.8% of visits within the population studied. Frequent users had the largest proportion of visits for complications of pregnancy (13.6%) compared to single users (6.1%) and Medicaid (42.6%) compared to private insurance (17.3%). There was an increased risk of frequent ED use associated with females (odds ratio [OR]: 1.77), Medicaid (OR: 3.21), and Medicare insurance (OR: 4.22) compared to private insurance, and diseases of the blood (OR: 3.36) and mental illness (OR: 1.99) compared to injury and poisoning. ConclusionsFrequent users comprise a significant portion of the young adult ED population and present with a large proportion of visits for complications of pregnancy. Policies targeting this population might focus on improved access to primary and urgent care, acute obstetric care, and better coordination of care.

P018: A prospective diagnostic support tool for the differentiation of abdominal pain in the adult emergency department population

Introduction: The chaotic environment of the emergency department has a deleterious effect on clinical judgement. The diagnosis of abdominal pathology is difficult to differentiate. There are also many diagnoses that could be considered abdominal in nature, exacerbating the task of diagnosing these patients. We propose a novel machine-learning method, Hierarchical Structured Models (HSMs), to provide an adjunct to clinician judgement, that provides a ranking of the probabilities of a patient having each of 39 abdominal pathologies, using only variables at the triage stage of emergency department care, and compare its performance to several machine-learning methods. Methods: This was a retrospective analysis of 25,861 patients that presented with one of 39 ICD-9 abdominal pathologies. 90% of the data was used to build and fine-tune the model, and 10% was used for testing. Predictors included age, gender, triage vitals and presenting complaint. All variables were solely collected from the Emergency Department Information System (EDIS). A decision tree structure was built using hierarchical clustering algorithms, and then a support vector machine (SVM) was fit at each node. To optimize the parameters for each node, a grid-search method was used to maximize ten-fold classification accuracy. The output of the decision tree was the probability of a particular presentation having each of the 39 diagnoses. This output was translated to a ranking of the relative likelihood of each of the diagnoses as a suggestion system for the treating physician. The accuracy of the system on the test set was compared to conventional machine-learning methods: pair-wise SVMs, gradient boosted models (GBM), neural networks (NN) and k-nearest neighbours (KNN). Results: The HSM ranked the correct diagnosis first 51.0% of the time, and ranked the correct diagnosis within the top three ranks 67.6% of the time. The most accurate model was GBMs (52.3%), and the least was neural networks (50.4%). Conclusion: The HSM approach using only variables available electronically at triage successfully ranked the correct diagnosis 51.0% of the time, and within the top three 67.6% of the time. Future research will focus on the inclusion of clinically lab results and radiology reports that are available electronically to improve HSM accuracy, and supplement physician diagnosis.

Incidence and pathology of repeat CT abdomen and pelvis in an adult emergency department population

IntroductionOur objective was to identify the incidence of adult patients who undergo more than one computed tomography (CT) abdomen and pelvis within 1 year and detect the incidence of significant pathology on these repeat scans. MethodsAll adults with an initial CT within 12 months and then during an emergency department visit were retrospectively identified. ResultsA percentage of 21.1 of the repeat CT scans were positive. Approximately 20% of positive repeat CT scans occurred within the first month and nearly 70% within 6 months of the initial CT scan. ConclusionsMany patients undergo multiple CT scans within a 1 year time frame with significant pathology identified.

119 Primary Predictors of Suicide Outcomes One Year After Screening Positive for Suicide Risk in the Emergency Department

Although suicide is difficult to predict in the general population, emergency department (ED) patients presenting with suicide risk factors such as substance abuse or depression are a readily identifiable population at elevated risk for suicidal behavior. However, little is known about which factors have the strongest association with future suicide outcomes. This study aimed to determine the predictors associated with suicide outcomes documented during the 12 months following an ED visit where the patient screened positive for active suicidal ideation or behavior. Data were collected during the first two phases of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE), a quasi-experimental suicide intervention study involving eight EDs across the U.S. Sites enrolled adults with active suicidal ideation or an attempt in the last week. Data collection included baseline interview; 6- and 12-month chart reviews; and 6-, 12-, 24-, 36-, and 52-week telephone follow-up assessments. The suicide composite outcome included reporting a preparatory act (eg, buying pills), interrupted or aborted attempt, a suicide attempt, or a suicide in the 12 months following the initial ED visit. Variables with a univariable association with suicide outcomes at P<.10 were included in the multivariable logistic regression model. In the final model, P<.05 was considered statistically significant. Among the 874 subjects (phase 1=497; phase 2=377), the median age was 37 years (interquartile range 27-47) with 56% female, 74% white, and 87% non-Hispanic. At baseline, 577 (66%) had suicidal ideation only and 297 (34%) a suicide attempt in the last month. Twelve-month outcomes were available for 782 (90%), who completed at least one of the 5 telephone follow-up assessments or had documentation of a suicide attempt or suicide completion during the 6- or 12-month chart review. In the one year after the initial ED visit, 430 (55%) reported a preparatory act, interrupted or aborted attempt, a suicide attempt, or had committed suicide. Subjects were more likely to have suicidal behavior within one year after the initial ED visit if they reported at the initial ED visit that they had a high school education or less (OR 1.63; 95% CI, 1.18-2.26; P=.003), had a primary care provider (OR 1.43; 95% CI, 1.01-2.00; P=.04), were unemployed (OR 1.64; 95% CI, 1.16-2.32; P=.006), had active suicidal ideation with a plan and intent to act (OR 10.2; 95% CI, 1.13-91.56; P=.04), had a severe health issue (eg, stroke, HIV) (OR 1.49; 95% CI, 1.06-2.10; P=.02), had a history of mental health problem(s) (OR 1.99; 95% CI, 1.14-3.47; P=.02), or a had a history of suicide attempt(s) (OR 1.60; 95% CI, 1.11-2.30; P=.01). The strongest predictors of reporting suicidal behavior within one year after the initial ED visit were related to patient characteristics (demographics and medical history) and past suicidal ideation and behavior. This suggests that in addition to psychiatric history, individual characteristics such as education level and employment as well as severe medical conditions should be considered when assessing suicide risk in an adult ED population. Understanding the factors that predict future suicide behaviors for this population will help guide the design and implementation of improved suicide-related interventions in the ED.

Agreement between axillary, tympanic, and mid-forehead body temperature measurements in adult emergency department patients

To assess the agreement between noncontact infrared thermometer (noncontact) with infrared tympanic thermometer (tympanic) and electronic axillary thermometer (axillary) in an adult emergency department population. This is a single-center, cross-sectional, prospective trial carried out in a Joint Commission accredited private hospital in Turkiye. All consecutive patients above 16 years were included in the study. The agreements between three methods were analyzed by Bland-Altman analysis with MedCalc 11.0.4 statistical software. Body temperatures were measured on 400 patients (48% were men, mean 35.9±17.3°C). Mean noncontact, tympanic, and axillary measurements (±SD) were 37.22±1.03, 36.72±0.95, and 36.91±0.96°C, respectively, whereas Intraclass Correlation Coefficient of all measurements was 0.892 (95% confidence interval 0.821-0.929). Binary comparisons between body temperature measurements produced mean differences Δ axillary-tympanic, Δ axillary-noncontact, and Δ tympanic-noncontact as 0.5±0.63, 0.2±0.71, and 0.31±0.61°C, respectively. However, the agreement limits for axillary and noncontact was between -1.2 and 1.6°C; -1.74 and 0.74°C for tympanic and noncontact, and -1.52 and 0.9°C for tympanic and noncontact. There is a lack of agreement between body temperature measurements by noncontact, tympanic, and axillary in the adult emergency department population. The easy application may lead noncontact to be the preferable method for healthcare providers but large agreement limits should be considered.

97: An Analysis of Emergency Department Utilization by Intellectually Disabled Adults

Intellectually disabled (ID) adults are a growing and rarely studied emergency department (ED) population. To aid in their ED management, our objectives were to identify what factors increase the likelihood of ED utilization among ID adults and determine how their ED and hospital discharge diagnoses differ from the general adult ED population.

High yield criteria for obtaining non-trauma chest radiography in the adult Emergency Department population

To develop a clinical decision rule for predicting significant chest radiography abnormalities in adult Emergency Department (ED) patients, a prospective, observational study was conducted of consecutive adults (≥18 years old) who underwent chest radiography for nontraumatic complaints at an urban ED with an annual census of 85,000. The official radiologist interpretation of the film was used as the gold standard for defining radiographic abnormalities. Using predefined criteria and author consensus, patients were divided into two groups: those with clinically significant abnormalities (CSA) and those with either normal or nonclinically significant abnormalities. Chi square recursive partitioning was used to derive a decision rule. Odds ratios and kappa statistics were calculated for derived criteria. The results showed 284 (17%) of 1650 patients had clinically significant abnormal radiographs. The presence of any of 10 criteria (age ≥ 60 years, temperature ≥ 38°C, oxygen saturation < 90%, respiratory rate > 24 breaths/min, hemoptysis, rales, diminished breath sounds, a history of alcohol abuse, tuberculosis, or thromboembolic disease) was 95% sensitive (95% CI: 92-98%) and 40% specific (95% CI: 37-43%) in detecting CSA radiographs. Positive and negative predictive values were 25% (95% CI: 23-27%) and 98% (95% CI: 96-99%), respectively. A highly sensitive decision rule for detecting clinically significant abnormalities on chest radiographs in nontraumatized adults has been developed. If prospectively validated, these criteria may permit clinicians to confidently reduce the number of radiographs in this population.

The accuracy of the enzyme-linked immunosorbent assay D -dimer test in the diagnosis of pulmonary embolism: A meta-analysis

Study objective: We sought to determine the sensitivity and specificity of the enzyme-linked immunosorbent assay (ELISA) D -dimer test in the diagnosis of pulmonary embolism (PE) in the adult emergency department population. Methods: A search of MEDLINE, EMBASE, and bibliographies of previous systematic reviews was conducted, with no language restriction. Experts in the field of PE research were contacted to identify unpublished studies. Prospective investigations involving a predominately outpatient population suspected of PE that used ELISA D -dimer tests were included. Two authors extracted data independently and assessed study quality on the basis of the patient spectrum and reference standard. Consensus was reached by means of conference. The analysis was based on a summary receiver operating characteristic curve and pooled estimates for sensitivity and specificity by using a random-effects model. Results: The search yielded 52 publications. No unpublished studies were found. Eleven studies met the inclusion criteria and provided a sample of 2,126 patients. The summary receiver operating characteristic curve analysis found significant heterogeneity among the 11 studies. Subgroup analysis of the 9 studies that used traditional ELISA D -dimer methods yielded the most valid pooled estimates, with a sensitivity of 0.94 (95% confidence interval [CI] 0.88 to 0.97) and a specificity of 0.45 (95% CI 0.36 to 0.55). Advanced age resulted in a lower specificity. A prolonged duration of symptoms decreased the sensitivity and specificity. Conclusion: The ELISA D -dimer test is highly sensitive but nonspecific for the detection of PE in the clinical setting. This test might help clinicians safely rule out PE, especially in the face of low and low-to-moderate pretest probabilities. [Brown MD, Rowe BH, Reeves MJ, Bermingham JM, Goldhaber SZ. The accuracy of the enzyme-linked immunosorbent assay D -dimer test in the diagnosis of pulmonary embolism: a meta-analysis. Ann Emerg Med. August 2002;40:133-144.]

Establishing an NP-Staffed Minor Emergency Area

Patients with problems of high acuity need fully trained emergency physicians and nurses. Some patients with nonurgent problems can be cared for within the emergency department (ED) in a lower-cost setting designed and staffed specifically for this purpose. Staffing a fast track or minor emergency area (MEA) with nurse practitioners (NPs) is one way to satisfy the ED's care needs. One site analysis of the effectiveness of NPs indicates that patients are satisfied with their care, that nurses' interpersonal skills are better than those of physicians, that technical skills are equivalent, that patient outcomes are equivalent or superior and that NPs improve access to care. A nurse practitioner-staffed minor emergency area provides high quality care for approximately 21% of this site's adult emergency department population. Patients are triaged based on set criteria, allowing for short treatment times. The physical layout, triage criteria, and the NPs' scope of practice in the level 1 trauma center's ED are detailed.

Establishing an NP-Staffed Minor Emergency Area

A nurse practitioner-staffed minor emergency area provides high quality care for approximately 21% of their adult emergency department population. Patients are triaged based on set criteria, allowing for short treatment times. The physical layout, triage criteria and the NPs' scope of practice in the Level I trauma center's ED are detailed.