Urban Hospital Emergency Research Articles

Reducing thoracic and lumbar radiographs in an urban emergency department through a clinical champion led quality improvement intervention

BackgroundLow back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number.MethodsA multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months.ResultsThe percent of appropriately ordered radiographs increased from 5.8 to 53.9% and the monthly number of radiographs ordered decreased from 86 to 47 over the eight-month initiative. There were no compensatory increases in thoracic or lumbar computed tomography (CT) scans during this time frame.ConclusionA multi-component QI intervention led by a clinician champion is an effective way to reduce the overutilization of thoracic and lumbar radiographs in an urban public hospital emergency department.

A Narrative Approach to Identifying Some Underlying Problems in an Urban Hospital's Emergency Room

There is a shortage of nurses in America. This article provides an applied example of the value of ethnographic/qualitative research in an urban hospital's emergency room to identify factors associated with nurse turnover and low morale. A narrative that identifies some of the underlying problems in a hospital's emergency room is provided. The authors challenge public administration research methods courses to broaden their focus and incorporate more qualitiative methods.

Emergency Department Frequent Utilization for Non-Emergent Presentments: Results from a Regional Urban Trauma Center Study.

ObjectivesFirst, to test a model of the drivers of frequent emergency department utilization conceptualized as falling within predisposing, enabling, and need dimensions. Second, to extend the model to include social networks and service quality as predictors of frequent utilization. Third, to illustrate the variation in thresholds that define frequent utilization in terms of the number of emergency department encounters by the predictors within the model.Data SourcePrimary data collection over an eight week period within a level-1 trauma urban hospital’s emergency department.Study DesignRepresentative randomized sample of 1,443 adult patients triaged ESI levels 4–5. Physicians and research staff interviewed patients as they received services. Relationships with the outcome variable, utilization, were tested using logistic regression to establish odds-ratios.Principal Findings70.6 percent of patients have two or more, 48.3 percent have three or more, 25.3 percent have four or more, and 14.9 percent have five or more emergency department visits within 12 months. Factors associated with frequent utilization include gender, race, poor mental health, mental health drugs, prescription drug abuse, social networks, employment, perceptions of service quality, seriousness of condition, persistence of condition, and previous hospital admittance.ConclusionsInterventions targeting associated factors will change global emergency department encounters, although the mutability varies. Policy interventions to address predisposing factors such as substance abuse or access to mental health treatment as well as interventions that speak to enabling factors such as promoting the resiliency of social networks may result in decreased frequency of emergency department utilization.

The Total Pentad: a Case Report of Thrombotic Thrombocytopenic Purpura Presenting as an Acute Cerebrovascular Accident

Thrombotic Thrombocytopenic Purpura (TTP) is a rare blood-coagulation disorder that causes extensive thrombus formation within the blood vessels. Diagnosis of the disorder is made on the basis of identification of some or all of five clinical features, described as the typical “pentad”: thrombocytopenia, microangiopathic hemolytic anemia, fluctuating neurological symptoms, renal failure, and fever. We report the case of a middle aged female who presented to an urban teaching hospital emergency department. Her initial symptoms of TTP were subtle, making it difficult to achieve a definitive early diagnosis. Awareness of the disorder allowed us to follow through on monitoring for the pentad during the initial period of hospitalization and facilitated the diagnosis, which led to prompt and appropriate treatment. The patient made a complete and sustained recovery. Since prompt institution of plasmapheresis is essential to recovery, we share this case in order to increase the possibility that TTP will be considered in the differential diagnosis of patients presenting with all or part of the total pentad.

A Comparison of Concussive Symptoms Reported by Parents for Preschool Versus School-Aged Children

To compare parental report of symptoms of concussion for children with superficial head injury versus children with a diagnosis of a mild traumatic brain injury (mTBI). Urban hospital emergency department. Parents of 159 children aged 2 to 12 years who presented with an injury to the head. Parents were contacted within 1 week of injury and assigned into 3 groups according to their child's age and medical diagnosis (group 1, parents of 2- to 5-year-olds with mTBI (n = 39); group 2, parents of 6- to 12-year-olds with mTBI (n = 41); and group 3, parents of 2- to 12-year-olds with superficial injury to the head (n = 35). Symptoms of concussion were reported in all groups; however, significantly fewer symptoms were reported for children with superficial injuries to the head than for children with mTBI (M = 2.51 vs M = 6.91; P < .001). For mTBI, parents of younger children reported significantly fewer symptoms than parents of older children (M = 5.23 vs M = 8.51; P < .001). A careful approach needs to be taken when evaluating the severity of mTBI for preschool children. Failure to do so may result in misidentification and subsequent lack of management.

Acceptability of Fingerstick Versus Oral Fluid Rapid HIV Testing

Oral rapid HIV testing has been reported to have a lower sensitivity and specificity than rapid HIV testing with whole blood and has been associated with clusters of false-positive results. Patient preference for oral rapid HIV testing compared with more invasive whole blood fingerstick may influence the acceptance of rapid HIV testing. To compare HIV test acceptance rates among patients routinely offered fingerstick compared with those routinely offered oral fluid screening in an urban hospital emergency department. The Universal Screening for HIV Infection in the Emergency Room Phase II was a single-center, prospective, randomized controlled trial that randomized subjects to either fingerstick or oral rapid HIV screening in an urban academic emergency department. From May 5, 2009, to January 4, 2010, eligible patients aged 18-75 years were invited to participate in the trial. The primary outcome measure was HIV test acceptance rate. : 2012 eligible patients were approached, of whom 1651 (82%) consented to trial participation and enrolled. Among those enrolled, 830 and 821 were randomized to the fingerstick and oral fluid arms, respectively. Acceptance of rapid HIV testing was similar in both arms; 67% (553 of 830) of subjects accepted fingerstick testing compared with 69% (565 of 821) who accepted oral (P = 0.34). Although fingerstick rapid HIV testing is more invasive than oral fluid testing, test acceptance rates did not differ. Given the option, preference should therefore be given to fingerstick testing because of its slightly superior test characteristics. System factors such as ease of staff use, necessary Clinical Laboratory Improvement Amendments waivers, laboratory capacity, and HIV prevalence should also be considered.

Acceptability of Fingerstick vs. Oral Fluid Rapid HIV Testing

Oral rapid HIV testing has been reported to have a lower sensitivity and specificity than rapid HIV testing with whole blood and has been associated with clusters of false-positive results. Patient preference for oral rapid HIV testing compared with more invasive whole blood fingerstick may influence the acceptance of rapid HIV testing.To compare HIV test acceptance rates among patients routinely offered fingerstick compared with those routinely offered oral fluid screening in an urban hospital emergency department.The Universal Screening for HIV Infection in the Emergency Room Phase II was a single-center, prospective, randomized controlled trial that randomized subjects to either fingerstick or oral rapid HIV screening in an urban academic emergency department. From May 5, 2009, to January 4, 2010, eligible patients aged 18-75 years were invited to participate in the trial. The primary outcome measure was HIV test acceptance rate.: 2012 eligible patients were approached, of whom 1651 (82%) consented to trial participation and enrolled. Among those enrolled, 830 and 821 were randomized to the fingerstick and oral fluid arms, respectively. Acceptance of rapid HIV testing was similar in both arms; 67% (553 of 830) of subjects accepted fingerstick testing compared with 69% (565 of 821) who accepted oral (P = 0.34).Although fingerstick rapid HIV testing is more invasive than oral fluid testing, test acceptance rates did not differ. Given the option, preference should therefore be given to fingerstick testing because of its slightly superior test characteristics. System factors such as ease of staff use, necessary Clinical Laboratory Improvement Amendments waivers, laboratory capacity, and HIV prevalence should also be considered.

Race and Emotion in Computer-Based HIV Prevention Videos for Emergency Department Patients

Computer-based video provides a valuable tool for HIV prevention in hospital emergency departments. However, the type of video content and protocol that will be most effective remain underexplored and the subject of debate. This study employs a new and highly replicable methodology that enables comparisons of multiple video segments, each based on conflicting theories of multimedia learning. Patients in the main treatment areas of a large urban hospital's emergency department used handheld computers running custom-designed software to view video segments and respond to pre-intervention and postintervention data collection items. The videos examine whether participants learn more depending on the race of the person who appears onscreen and whether positive or negative emotional content better facilitates learning. The results indicate important differences by participant race. African American participants responded better to video segments depicting White people. White participants responded better to positive emotional content.

Impact of Wearable Alcohol Gel Dispensers on Hand Hygiene in an Emergency Department

Compliance with hand hygiene (HH) by health care workers is widely recognized as the most effective way to decrease transmission of infection among patients. However, compliance remains poor, averaging about 40%. A potential barrier to compliance is convenience and accessibility of sinks or alcohol hand sanitizer dispensers. The purpose of this study was to assess the use of a personal alcohol gel dispensing system, compared with the traditional wall-mounted alcohol gel dispenser and sinks in an urban hospital's emergency department (ED). This was a quasi-experimental trial of a personal wearable alcohol hand sanitizer dispenser. Observations of ED staff HH were performed in the month before intervention and during three intervention phases over a 2.5-month period. A total of 757 HH opportunities were observed: 112 before and 432 after patient contact, 72 after contact with the patient's environment, 24 before invasive procedures, and 117 after body fluid contact. HH compliance improved during the first intervention period, but improvement was not sustained. There was no significant improvement in HH from baseline to the final intervention period. The wearable alcohol gel dispenser was used for 9% of HH episodes. Availability of a wearable dispenser was not associated with a significant improvement in use of alcohol products for HH. These results support other studies in which only transient success was reported with a single intervention; greater success in sustaining increased HH compliance has been reported with use of multimodal approaches in which increased availability of products may be a part of the intervention.

Outcomes following discharge from an urban county hospital emergency room with a primary diagnosis of heart failure J. Eduardo Rame, Michael A. Sheffield, Daniel L. Dries, Elizabeth B. Gardner, Kathleen H. Toto, Clyde W. Yancy, Mark H. Drazner. University of Texas Southwestern Medical Center, Dallas, TX, Parkland Memorial Hospital, Dallas, TX

Outcomes following discharge from an urban county hospital emergency room with a primary diagnosis of heart failure J. Eduardo Rame, Michael A. Sheffield, Daniel L. Dries, Elizabeth B. Gardner, Kathleen H. Toto, Clyde W. Yancy, Mark H. Drazner. University of Texas Southwestern Medical Center, Dallas, TX, Parkland Memorial Hospital, Dallas, TX

Aortic-carotid artery pressure differences and cephalic perfusion pressure during cardiopulmonary resuscitation in humans

Animal studies have shown an aortic-carotid artery pressure difference during cardiopulmonary resuscitation (CPR), which compromises cerebral perfusion. This pressure difference is most marked with prolonged CPR and can be abolished with administration of high doses of epinephrine. To better understand the mechanism of cerebral blood flow during CPR in humans, we determined the aortic-carotid artery pressure difference, the cephalic perfusion pressure (the carotid artery-jugular vein pressure difference), and thoracic inlet venous "valving" (the central venous-jugular vein pressure difference), while administering standard doses of epinephrine. Prospective study with randomization as to which side the carotid artery was catheterized. The resuscitation room of a large urban hospital's emergency department. Fifteen adults in normothermic, nontraumatic prehospital cardiac arrest treated according to Advanced Cardiac Life Support guidelines, including administration of 1 mg epinephrine iv every 5 mins. The descending aorta, cervical common carotid artery, internal jugular vein, and central venous system were catheterized. Pressures were recorded during standard CPR for 5 mins after administration of 1 mg epinephrine iv. Most patients received CPR for greater than 20 mins before the first epinephrine dose and for greater than 45 mins before pressure recording as described above. There was no significant difference between aortic and carotid artery compression and relaxation phase pressures. The mean +/- SD compression central venous-jugular vein pressure difference was 22.1 +/- 15.0 mm Hg, and the mean cephalic perfusion pressure was 20.8 +/- 19.5 mm Hg. There is no clinically important aortic-carotid artery pressure difference during human CPR using the standard dose of epinephrine, even with prolonged CPR. Despite carotid artery patency and thoracic inlet venous valving, the cephalic perfusion pressure is low during CPR in humans.

The holding area: new arm of the ED

This in-depth study of a large urban hospital's emergency department holding area sheds light on the relation of the patient's age, sex, race and diagnosis to the utilization of this important but often misunderstood area.