ED Attendances Research Articles

Research subject enroller program: a key to successful emergency medicine research.

To describe the successful use and impact of individuals paid to enroll clinical research subjects in support of emergency medicine (EM) research. Paramedics and college students were hired to identify/enroll subjects in EM research studies 14 hours/day, 7 days/week. Potential subjects were identified by monitoring emergency medical services radios, routine rounding in the ED, and communication with the ED attending and charge nurse. Enrollers were trained in phlebotomy, obtaining ECGs, obtaining consent in appropriate studies, and post-ED follow-up. They supported ED prospective studies and multicenter clinical trials, as well as departmental surveys and retrospective studies. Survey support included mailing list development, mailing completion, survey database design, and data entry. Over 18 months, 17 prospective studies and 8 surveys/retrospective studies were completed. 2,175 subjects were enrolled in prospective studies and 6,500 surveys/retrospective reviews were completed. In the year prior to enroller program initiation, < 100 subjects were enrolled in 3 departmental studies. Use of paid, clinical research subject enrollers supports successful recruitment of study subjects and the completion of EM research studies.

Evaluation of the Ottawa Clinical Decision Rules for the Use of Radiography in Acute Ankle and Midfoot Injuries in the Emergency Department: An Independent Site Assessment

Study objective: Decision rules for the use of radiography in acute ankle and midfoot injuries have been developed. Radiographs are indicated if there is tenderness at the posterior edge or tip of either malleolus or at the navicular or base of the fifth metatarsal or there is inability to both weight bear immediately after the injury and ambulate four steps in the emergency department. This study assessed the efficacy of these rules with health care providers who had not been involved in their development. Design: Prospective patient survey by emergency department attending physicians and triage nurses. Setting: EDs of a university hospital and a community hospital with a combined annual volume of 100,000. Participants: One hundred ten patients older than 16 years who presented with acute blunt ankle and midfoot trauma during the 3 months of summer 1993. Results: Fourteen fractures were diagnosed. When used by ED attending physicians, the decision rules had a sensitivity of 1.0 and specificity of 0.19 in detecting all midfoot and ankle fractures. When used by triage nurses, the sensitivity was 0.9 and specificity was 0.1. The negative predictive values of the decision rules were 1.0 for ED attending physicians and 0.88 for triage nurses. ED attending physicians and triage nurses agreed in 90% of cases regarding the overall decision to obtain radiographs. However, there was only a 47% agreement on all components of the clinical decision rules, with κ values ranging from 0.60 to 0.76. The accuracies of the predictive rules were similar as applied by the ED attending physicians and the triage nurses (χ 2 , P = .23). Application of the Ottawa predictive rules by ED attending physicians would have resulted in a 19% reduction in use of midfoot and ankle radiographs. Conclusion: Use of the Ottawa ankle and midfoot clinical decision rules by ED attending physicians of institutions not familiar with the rules' development resulted in 100% sensitivity for all fractures and would have allowed these physicians to safely reduce the number of radiographs ordered by 19%. [Pigman EC, Klug RK, Sanford S, Jolly BT: Evaluation of the Ottawa clinical decision rules for the use of radiography in acute ankle and midfoot injuries in the emergency department. Ann Emerg Med July 1994;24:41-45.]

Prospective evaluation of adverse drug interactions in the emergency department

To determine the incidence and risk factors of clinically relevant adverse drug interactions occurring in emergency department patients. This report describes the drug interactions identified in an emergency population. Patients' drug regimens were evaluated prospectively at the time of the emergency evaluation. University hospital ED. Convenience sample of 341 patients. Patients' medications on arrival at the ED (current medications) and medications initiated in the ED were entered into Hansten's computer-based drug interaction program to identify potential drug interactions. All potential drug interactions were brought to the attention of the attending emergency physician, whose subsequent actions were noted. Clinically relevant interactions were determined by a physician panel based on the ED attendings' actions, set criteria, and a review of hospital charts and four-week telephone follow-up of patients with potential drug interactions. Three hundred forty patients were enrolled. One hundred thirty-five potential drug interactions were identified in 61 patients. Among these 135 potential drug interactions and 61 patients, we identified 20 clinically relevant interactions in 15 patients. The incidence of clinically relevant interactions was significantly higher (chi 2 = 3.95, P = .047) among current medication (9.7%) than medication added in the ED (3.1%). Clinically relevant interaction from both current and ED-initiated medication was associated with taking three or more medications on ED arrival (P = .016 and .045, respectively). Multiple regression showed age of 60 years or older to be the sole predictor of clinically relevant interaction among current medication (P = .05). Clinically relevant adverse drug interaction was significantly less from medication administered or prescribed in the ED than from current medication.

Cot deaths and medical communication

<h3>Introduction</h3> Trisomy 21, also known as Down syndrome (DS), is a clinical disorder where a third copy of chromosome 21 is present. Approximately 95% of DS are due to a meiotic nondisjunction, with the remaining 5% caused by chromosomal translocation or mosaicism. Children with DS are predisposed to recurrent respiratory infections due to a number of anatomical and immunological features. Our project investigated whether there is evidence supporting or refuting the use of antibiotic prophylaxis for recurrent respiratory infections in the DS population. <h3>Methods</h3> A systematic literature review was conducted of published medical literature within the following databases: MEDLINE, Science Direct, and The Cochrane Library. A systematic search for ongoing clinical trials and guidelines/consensus statements was performed using various clinical trial registers and professional organisation websites. Search terms included ‘DS’, ‘Trisomy 21’, ‘paediatric’, ‘respiratory infections’, ‘recurrent respiratory infections’, ‘prophylaxis’ and ‘antibiotics’. Systematic reviews, meta-analyses, randomised controlled trials, case-control studies and case-series were considered. <h3>Results</h3> A systematic search revealed 0 published articles and 0 clinical trials meeting the necessary inclusion criteria. 1 guideline was found meeting our inclusion criteria; the Nottingham Guideline which outlines the role of prophylactic antibiotics in the DS population. Given the dearth of evidence in this area, we formulated a clinical trial to investigate the utility of prophylactic antibiotics for current respiratory infections in the DS population. Azithromycin was chosen as the antibiotic of choice for its anti-inflammatory and immunomodulatory properties. Primary endpoints would be the number of respiratory infections experienced over the course of the treatment period requiring a GP or ED attendance. Secondary endpoints include the severity of respiratory infections, both the number and severity of adverse events experienced over the period of the trial, along with the patient and parent/legal guardian self-reported quality of life. <h3>Conclusion</h3> There is a current lack of evidence supporting or refuting the use of prophylactic antibiotics for recurrent respiratory infections in DS. Basic scientific studies need to be performed elucidating the role of anatomical and immunological features in predisposing children with DS to recurrent respiratory infections. Clinical trials are needed to elucidate whether prophylactic antibiotics are useful in this cohort and to investigate the optimal timing and combination of antibiotics. Guidelines are needed to support physicians in clinical decision making.