Objectives:The National Heart, Lung, and Blood Institute guidelines for sickle cell disease (SCD) vaso-occlusive crisis (VOC) management recommend emergency departments (EDs) rapidly assess pain and administer pain medication following an individual's arrival. An ED's experience treating SCD along with co-occurring operational factors may affect guideline adherence. We investigated the effect of operational factors on VOC guideline adherence within a large New Jersey health system. Methods:Electronic health record data between January 2022 and September 2025 were analyzed. Outcomes: rate of guideline-concordance, time-to-first and time-to-second pain medication administration. Adherence was defined as first dose ≤30 minutes after triage and second dose ≤30 minutes after first. Predictors: SCD patient volume, ED volume, shift, and emergency severity index (ESI) score. Descriptive and mixed-effects regression analyses were conducted. Results:There were 7160 ED visits by 1401 patients. 14.2% of encounters were adherent for first pain medication, and 52.6% for second. SCD volume, ED volume, shift, and ESI score were associated with guideline-concordant encounter rates, but not site-level decreased average times. Shift timing was the only exposure significantly associated with mean times to both first and second pain medication administration. Individuals arriving during the evening shift received their first pain medication 15.93 minutes later (95% CI: 2.43 to 29.37) and their second pain medication 10.92 minutes later (95% CI: 4.01 to 17.83) than those arriving during the night shift. Conclusion:Several operational factors were associated with the likelihood of guideline-concordant encounters; whereas, only shift timing influenced mean times to pain medication administration, highlighting a distinction between guideline concordance and overall timeliness.

Introduction: Monoclonal antibody (MAB) infusion is the first treatment to manage coronavirus 2019 (COVID-19) in an outpatient setting. Yet increased risk of severe COVID-19 illness may occur from inequities in social determinants of health including access to quality healthcare. Given the safety-net nature of emergency departments (ED), a model that puts them at the center of MAB infusion may better reach underserved patients than models that require physician referral and distribute MAB at outpatient infusion centers. We examined characteristics of two groups of patients who received MAB infusion in the Robert Wood Johnson University Hospital (RWJUH) ED in New Brunswick, New Jersey: 1) patients who tested positive for COVID-19 in the ED and received ED infusion; and 2) patients who tested positive elsewhere and were referred to the ED for infusion. The process for the latter group was similar to the more common national model of patients testing COVID-19 positive in the community and then being referred to an infusion center for MAB therapy. Methods: We performed a cross-sectional retrospective health record review of all adult patients presenting to the ED from November 20, 2020–March 15, 2021 who received MAB infusion at RWJUH ED (N = 486). Patients were identified through the electronic health record system by an administrative query, with manual chart review for any additional characteristics not available through the query. We compared the two groups using chi-squared tests for categorical variables and t-tests for continuous variables. Results: We found higher proportions of Black (18% vs 6% P < 0.001, statistically significant), Hispanic (19% vs 11% P = 0.02), Medicaid (12% vs 9% P = 0.01), and uninsured (17% vs 8% P = 0.01) patients who tested positive for COVID-19 in their ED visit and then received MAB therapy during their visit than patients tested elsewhere in the community and referred to the ED for MAB therapy. Conclusion: These findings suggest that providing MAB infusion in the ED allows increased access for patients traditionally marginalized from the healthcare system, who may be at risk of longer disease duration and complications from COVID-19.

In February 2021, the U.S. Food and Drug Administration (FDA) provided emergency use authorization for the Janssen vaccine—the first one-dose COVID-19 vaccine to become available in the United States. The one-dose regimen expanded the opportunity to vaccinate in settings that can reach vulnerable communities for which returning to a site for a second vaccine dose may prove difficult. With 139 million visits annually in the United States1 and a tendency to serve in a safety net capacity for underserved patients,2 the emergency department (ED) is one such setting. Simultaneously, throughout the United States, African American and Hispanic populations have received a smaller proportion of COVID-19 vaccine compared with their proportion of the population and their proportion of COVID-19 cases and deaths.3 This pattern is also seen in New Jersey and Middlesex County. As of March 31, 2021, Hispanic residents made up 20.9% of the population share4 and 24.9% of COVID-19 cases,5 but only 8.0% of the vaccinated5 in New Jersey and 22.1% of the population,4 24.1% of COVID-19 cases, and 6.0% of the vaccinated5 in Middlesex County. African Americans made up 15.1% of the population,4 16.5% of COVID-19 deaths,5 and only 5.0% of vaccinations5 in New Jersey, with similar rates in Middlesex County.4, 5 Additionally, more women than men have been vaccinated despite higher COVID-19 mortality rates in men.5 Similarly, likelihood of influenza vaccine6 and primary care utilization7 are significantly higher in women than men. Increasing avenues to vaccination, such as distribution in the ED, may improve uptake in these populations. The purpose of this study was to examine characteristics of patients who received a COVID-19 vaccination in the Robert Wood Johnson University Hospital (RWJUH) ED compared to everyone vaccinated in New Jersey and Middlesex County (where the hospital is located) to determine if vaccination distribution in the ED can better reach vulnerable populations. We analyzed patient data for RWJUH ED during the first 365 doses of COVID-19 vaccine distribution, which occurred from March 4 to March 23, 2021. RWJUH's ED is a level I trauma center that provides 24/7 care for approximately 71,000 adult (21+ years) patients annually. Located in New Brunswick, New Jersey, at the southern edge of the New York City Metropolitan area, it serves a population of mixed socioeconomic spectrum and ethnicity in a diverse urban/suburban environment. The ED's patient population is approximately 24% Hispanic, 21% non-Hispanic African American, 37% non-Hispanic White, 7% Asian, and 10% other race/ethnicity (remaining < 2% is unknown race/ethnicity). The vaccine was available to ED patients who presented for a non–COVID-19 complaint, were likely to be discharged after ED care, and were eligible for the COVID-19 vaccine based on New Jersey state guidelines at the time. From March 4 to 14, the following groups were eligible for the vaccine: health care workers, residents and workers of long-term care and high-risk congregate care facilities, first responders, individuals over 65 years, and those 16 to 64 years with medical conditions that increase risk of virus severity. On March 15, eligibility opened to pre–K-12 and childcare workers, transportation workers, public safety workers, migrant farm workers, trial communities, and homeless individuals. Patients could not get the vaccine if they came to the ED solely to get the vaccine and were directed to register online for a vaccine at a vaccine clinic in the health system. ED patients registered for emergency medical care in the ED registration area, per usual protocol. At triage, patients were asked if they have had the COVID-19 vaccine. If not, the triage nurse informed the patient that we have a limited supply of one-shot Janssen COVID-19 vaccine in the ED today that is being offered to eligible patients. If interested, patients then had the opportunity to be screened for eligibility for the vaccine. Before vaccination, the nurse provided the patient a paper copy of the Janssen emergency use authorization (EUA) fact sheet for patients and caregivers, reviewed it with the patient, asked if they had questions, and explained that they would be observed for 15 minutes after administration (or 30 minutes if patient has a history of severe allergic reaction). Vaccinated patients received their CDC vaccine record card and VSafe handout on the CDC's vaccine monitoring program. The nurse reviewed with vaccinated patients the EUA fact sheet for side effects, allergic reactions, and how to report these and reviewed with the patient the need to still wear a mask, wash hands, avoid crowds, and physically distance. For analysis, ED data were extracted from the system's electronic medical records, and New Jersey and Middlesex County data were extracted from the NJ COVID-19 dashboard website. We determined the proportion of demographics for people vaccinated in the ED and compared them to New Jersey and Middlesex County vaccination demographics using proportion tests. Analysis was performed using Stata version 16.0 (StataCorp). The study was approved by the Rutgers University Institutional Review Board. Table 1 shows the demographic breakdown of the patients who received the vaccine in the RWJUH ED compared to those who received it in New Jersey and Middlesex County. Vaccinations in the ED were distributed to a significantly higher proportion of Hispanic and African American persons (28.5%, 95% confidence interval [CI] = 23.9% to 33.1%) and 23.6% (95% CI = 19.2% to 27.9%, respectively) than vaccinations in New Jersey (8.0%, p < 0.001; and 5.0%, p < 0.001, respectively) and Middlesex County (6.0%, p < 0.001; and 4.0%, p < 0.001, respectively; Table 1). Significantly more men were vaccinated in the ED (54.0%, 95% CI, 48.8%-59.1%]) than in New Jersey (43.0%, p < 0.001) or Middlesex County (44.0%, p < 0.001). RWJUH ED (n = 365) % vaccinated (95% CI) New Jersey (n = 4,300,375) % vaccinateda p-value (ED compared to NJ) Middlesex County, NJ (n = 364,744) % vaccinateda p-value (ED compared to Middlesex County) The proportion of 18–29-, 30–49-, and 50–64-year-olds were significantly larger for persons vaccinated in the ED compared to New Jersey overall. The proportions of 65 to 79 and 80+ year olds were significantly lower for vaccinations in the ED compared to New Jersey. One-third of patients vaccinated in the ED had private insurance, one-quarter had Medicare, 22% had Medicaid, 13% were self-pay, and 5% were charity care. It is important to consider sustainability of a COVID-19 vaccination program in the ED. ED-based vaccination programs have proven successful prior to COVID-19.8 Likewise, COVID-19 vaccine distribution in the ED did not negatively affect the normal workflow of the ED, suggesting that the program is sustainable for continued vaccine distribution. After the study period, Janssen vaccine eligibility in New Jersey expanded to all people 18 years and older. Such expansion can further streamline the process as time to determine eligibility will not be needed. The biggest barrier to sustainability may be availability of the vaccine in the ED. After the first batch of doses were used, there was a wait for additional doses. As of May 2021, New Brunswick had the lowest vaccination rate (30%) of all New Jersey municipalities with population over 10,0009 suggesting a continued need to increase vaccinations in this community. Future work should explore reasons for vaccine refusal by eligible ED patients. Having a pool of ED patients who are eligible and refuse the vaccine presents a unique opportunity to reach people with vaccine hesitancy who might otherwise be difficult to reach by healthcare systems and researchers. We found that distribution of COVID-19 vaccination in the ED can reach vulnerable populations that are most susceptible to COVID-19. There were significantly higher proportions of African American, Hispanic, men, and younger age groups vaccinated in the ED than in New Jersey and Middlesex County. Considering that the 2019 U.S. Census estimates of persons without health insurance under age 65 years are 9.2% for New Jersey residents and 7.7% for Middlesex County residents,4 the proportion of people who received the vaccine in the ED with no insurance (self-pay and charity care) (18.4%) was much higher than the proportions in the general population. As the COVID-19 pandemic continues and for future vaccination campaigns for other diseases, it is important to vaccinate as many people as possible to keep people healthy and hospitals from reaching capacity. These findings should encourage other municipalities and health care systems to enlist EDs as an effective location for vaccine distribution to vulnerable populations. The authors have no potential conflicts to disclose. Sara W. Heinert conceived the study, analyzed the data, and led the writing. Jonathan McCoy assisted with interpretation of the data and drafting of the manuscript and provided critical revision of the manuscript for important intellectual content. Robert Eisenstein assisted with acquisition of the data and drafting of the manuscript and provided critical revision of the manuscript for important intellectual content. Jessica Rowley championed the vaccine program that was studied, assisted with drafting of the manuscript, and provided critical revision of the manuscript for important intellectual content.

Introduction: Our aim was to determine what patient volume, if any, in-laboratory testing provides results faster than Point-of-Care-Testing (POCT). Methods: To evaluate POCT effectiveness during high volume situations, POCT was compared to in-laboratory testing during busy periods with large numbers of patients. Our setting was an urban level 1 trauma center with an academic emergency medicine department (ED) and annual patient volume of 70,000. Patients seen requiring laboratory testing during peak volume between 11 a.m. and 7 p.m. were enrolled over a five-week period. One tube of blood was sent to the laboratory and the other tube was run in the ED using POCT. Turnaround time was recorded as time from when the tube was received to when the result was available. We also completed a time-motion study to assess the number of POCT machines that would be needed to process the entire average hourly hospital laboratory volume. Results: We collected 539 hematology and chemistry specimens. The POCT group was significantly faster than in-laboratory testing, with mean POCT [complete blood count (CBC) and chemistry] 3.5 minutes compared to in-laboratory CBC test time of 30.9 minutes and chemistry test time of 55 minutes. As the volume of samples peaked, there was a slight but insignificant decrease in POCT turnaround time. If POCT was used to process the entire average hospital laboratory volume which approached 54 samples an hour, 3 POCT machines would be necessary to maintain turnaround times. Conclusion: Even during ED high volume situations, POCT provided results significantly faster than in-laboratory testing.

Emergency medicine is one of the medical fields with the highest rates of physician burnout. Research demonstrates hospitalists believe increasing workloads contribute to decreases in patient safety and satisfaction, and increases in morbidity and mortality. Our objective was to identify if emergency physicians who believe workload impacts patient care also experience worse rates of burnout symptoms. This two-phase study used an online survey with cross-sectional design distributed to emergency medicine physicians following the New Jersey American College of Emergency Physicians (NJ ACEP) Scientific Assembly in May 2016 and members of the ACEP Well-Being Committee and Wellness Section in December 2016. Respondents felt the greatest workload burdens by being '…unable to fully discuss treatment options or answer questions of a patient or family member' or leading to 'Delay in admitting or discharging patients.' Excessive workload also contributed to respondents having to 'Admit to hospital instead of discharge' and resulted in 'Worsened patient satisfaction.' The 'Emotional Exhaustion' domain of the Maslach Burnout Inventory was the most highly affected by the perceived effects of workload on patient outcomes and 'Personal Accomplishment' was least affected. This research highlights the perception that workload contributing to patient harm may be associated with emergency medicine burnout.

We applaud the excellent depiction of hospital preparedness and response to a mass casualty event caused by terrorist bombing.1Gale S.C. Donovan C.M. Tinti M. et al.Organization and operations management at the health care facility.Ann Emerg Med. 2017; 69: S29-S35Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The authors do a fine job describing the response to a single mass casualty event affecting emergency medical services (EMS) and hospitals; however, the authors miss the context within which health care preparedness has evolved during the past decade, which we would like to briefly present here to add to the article’s important contributions. The US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response published the “2017-2022 Health Care Preparedness and Response Capabilities”2Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. 2017-2022 Health care preparedness and response capabilities. Available at: https://phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-healthcare-pr-capablities.pdf. Accessed January 17, 2017.Google Scholar to portray the importance of both interdisciplinary and regional integration in disaster response. Large-scale emergencies, such as a terrorist bombing, would require a complex response across an entire region. Hospitals, in conjunction with EMS and public health and emergency management agencies, must work together under the rubric of a health care coalition to ensure collaboration, coordination, and consistency in a systems approach to disaster planning and response. The capabilities are defined around 4 broad themes: ensuring a strong foundation for health care and medical readiness (including strong administrative and financial backing for disaster planning efforts), ensuring health care and medical response coordination by understanding that each of the key participants in the health care coalition has a role to support one another in response, promoting continuity of health care service delivery (recognizing that disruptions in service delivery constitute failure), and planning for medical surge to ensure timely and efficient care to patients even when the demand for health care services exceeds available supply. Health care coalitions play a key role coordinating available resources across regions and are instrumental in leading the transition from conventional to contingency or crisis surge response, and return to conventional care, when ready.3Hick J.L. Hanfling D. Cantrill S.V. Allocating scarce resources in disasters: emergency department principles.Ann Emerg Med. 2012; 59: 177-187Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 4Hanfling D. Role of regional healthcare coalitions in managing and coordinating disaster response, invited white paper, National Academies of Science, Engineering and Medicine. Available at: http://www.nationalacademies.org/hmd/∼/media/Files/Activity%20Files/PublicHealth/MedPrep/2013-JAN-23/Role%20of%20Regional%20Healthcare%20Coalitions%20in%20Managing%20and%20Coordinating%20Disaster%20Response_FINAL_01_2013.pdf. Accessed January 17, 2017.Google Scholar The article makes recommendations in regard to mass casualty response that could be more easily brokered and supported by the health care coalition, rather than by any single health care organization alone. Sharing regional resources, distributing patients among hospitals, expediting hospital-to-hospital transfers, and procuring additional security elements to improve the security posture of the affected facilities are functions that lend themselves to health care coalition coordination, freeing hospital incident management leadership to focus on the clinical response required to support the victims. Patient tracking and the use of regional EMS disaster tags (which, as a best practice, could also be used to initiate patient charting in the emergency department, given the very real challenges of managing a mass casualty incident by using current electronic medical records systems) are also better suited to regional initiatives. Achieving these capabilities will take continued effort, given the many moving pieces that compose a medical response to a bombing event. Therefore, realistic disaster drills and exercises that test not only the “whole of hospital” but also the “whole of community” must be an integral part of all hazards planning lest they be forgotten during the stress and pressure of response to such events. Organization and Operations Management at the Health Care FacilityAnnals of Emergency MedicineVol. 69Issue 1PreviewHere we describe the organizational and operational considerations for pre-event planning and postevent implementation in a health care facility in regard to a mass casualty incident created by an explosion. Although a blast event is a specific subset of mass casualty incidents, from the hospital perspective, it is distinguished from other mass casualty events by the nature of the injuries and the uncertainty of secondary attacks, which have the potential to be perpetrated on the hospital itself. Full-Text PDF In reply:Annals of Emergency MedicineVol. 70Issue 1PreviewWe thank Ms. Harvey and Drs. Hunt, Hick, and Hanfling, who are all leaders in the field of national health care preparedness, for their valuable comments. We agree wholeheartedly. Full-Text PDF

Blast scene medical management requires out-of-hospital personnel to perform several roles for their patients, including rapid triage, direct patient care, and transport. They must also practice constant vigilance and situational awareness and attempt to preserve evidence when possible. Below we present a brief summary for out-of-hospital providers to remember when responding to an incident scene.

Blast injury is common in war and terrorism and is likely to become more common. Most of our knowledge about its management has come from military experience and previous mass casualty incidents. These actual scenarios have provided significant insight in preparing for situations involving explosives. However, as bombs and their associated technology evolve, providers must also broaden our horizons to optimize our current management and be aware of cutting-edge developments that will help improve patient care in the future.

The scene of a mass casualty incident is a chaotic, stressful environment. Explosive incident scenes, especially those related to terrorism, add increased levels of fear and potential injury to both civilians and health care providers. They frequently destabilize infrastructure in multiple ways. This article discusses best practices for management of the out-of-hospital explosion scene. The majority of the recommendations are based on expert panel consensus as described in the introductory article. On completion of this article, the reader will have been introduced to several key concepts that may be applied to his or her system in planning for an explosive incident. Because health care and emergency response systems vary considerably from region to region, we do not provide detailed incident plans, but offer a strategic base on which a more specific plan may be built.

Background: Emergency department (ED) and hospital crowding adversely impacts patient care. Although reduction methods for duration of stay in the ED have been explored, few focus on medical intensive care unit (MICU) patients. Objective: To quantify duration of stay or mortality changes associated with a policy intervention that changed the role of an MICU resident to "screen" and write MICU admission orders in the ED to instead meet the patient and write orders in the MICU if there was an available bed. The intervention moved "screening" bed management-appropriateness discussions to the MICU attending or fellow level. Methods: We performed a retrospective before and after study at an urban, level 1 trauma center of adults admitted to the MICU from the ED during the first 6 months in 2009 before, and the corresponding 6 months in 2010, after the intervention. We collected demographics, ED, MICU, and hospital duration of stay, duration of mechanical ventilation, Acute Physiology and Chronic Health Evaluation (APACHE) scores, and mortality from electronic medical records. Linear models compared duration of stay differences; logistic regression compared in-hospital mortality. T-tests assessed APACHE score changes before and after the policy change. Analyses were adjusted for age and sex. Results: We included 498 patients, average age 66 years (+/- 18), 52% male. Hospital duration of stay decreased 18% from 6.8 to 5.6 days (unadjusted p = 0.029). MICU duration of stay decreased from 3.5 to 3.3 days (unadjusted p = 0.34) and ED duration of stay from arrival to physical transfer decreased 40 min (375 to 324 min; unadjusted p = 0.006). Mortality and APACHE scores were unchanged. Conclusions: A streamlined admission intervention from the ED to the MICU was associated with decreased ED and hospital duration of stay without altering mortality. (C) 2015 Elsevier Inc.

BACKGROUND:Acute gout attacks account for a substantial number of visits to the emergency department (ED). Our aim was to evaluate acute gout diagnosis and treatment at a University Hospital ED.METHODS:Our study was a retrospective chart review of consecutive patients with a diagnosis of acute gout seen in the ED 1/01/2004 - 12/31/2010. We documented: demographics, clinical characteristics, medications given, diagnostic tests, consultations and whether patients were hospitalized. Descriptive and summary statistics were performed on all variables.RESULTS:We found 541 unique ED visit records of patients whose discharge diagnosis was acute gout over a 7 year period. 0.13% of ED visits were due to acute gout. The mean patient age was 54; 79% were men. For 118 (22%) this was their first attack. Attack duration was ≤ 3 days in 75%. Lower extremity joints were most commonly affected. Arthrocentesis was performed in 42 (8%) of acute gout ED visits. During 355 (66%) of ED visits, medications were given in the ED and/or prescribed. An anti-inflammatory drug was given during the ED visit during 239 (44%) visits. Medications given during the ED visit included: NSAIDs: 198 (56%): opiates 190 (54%); colchicine 32 (9%) and prednisone 32 (9%). During 154 (28%) visits an anti-inflammatory drug was prescribed. Thirty two (6%) were given no medications during the ED visit nor did they receive a prescription. Acute gout rarely (5%) led to hospitalizations.CONCLUSION:The diagnosis of acute gout in the ED is commonly clinical and not crystal proven. Anti-inflammatory drugs are the mainstay of treatment in acute gout; yet, during more than 50% of ED visits, anti-inflammatory drugs were not given during the visit. Thus, improvement in the diagnosis and treatment of acute gout in the ED may be required.

Background: Hispanics have an increased incidence of ischemic stroke but may be less likely to use Emergency Medical Services (EMS) for stroke care. Objective: To examine disparities in pre-hospital triage and emergent evaluation of Hispanic stroke patients. We hypothesized that Hispanic stroke patients with pre-hospital notification experience less delay in emergent evaluation but the reduction may not be as pronounced as general stroke patients. Methods: Retrospective cohort study of all emergency department patients alerted as Brain Attack (BAT) between January 1, 2009 and August 31, 2012, at an urban comprehensive stroke center. We collected demographics, co-morbidities, and stroke severity from a quality assurance database. Outcome variables included EMS utilization, pre-hospital BAT activation, head CT timing & tissue plasminogen activator (TPA) timing. Effects of ethnicity and pre-hospital notification on evaluation and treatment times were measured using multivariate logistic regression models. The study was IRB approved. Results: During the study period, 832(64 Hispanic) patients were alerted as Brain Attacks. Hispanic patients were younger 56±17 vs. 68±16 years (p<0.0001), had trends for less EMS utilization (walk-in 35% vs. 22%) and lower NIHSS 9.3±4.3 vs. 12.8±8.3 (p=0.06), but did not differ in comorbidities. Patients with pre-hospital notification had significantly shorter times to stroke specialist arrival, door to head CT, and door to TPA irrespective of ethnicity. However, ethnicity did have independent effect on time to TPA administration. Please see Table 1. Conclusion: Pre-hospital notification is associated with faster stroke evaluation and treatment, including among Hispanic patients with acute stroke. Further study is needed to examine if outreach to increase EMS utilization will decrease disparities in this population.

OBJECTIVES:There has been a steady increase in emergency department (ED) patient volume and wait times. The desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow. The break-out session "Interventions to Improve the Timeliness of Emergency Care" at the June 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" posed the challenge for more research of the split Emergency Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3 patients from low-variability ESI 3 patients. The study objective was to determine the effect of implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients.METHODS:This was a retrospective chart review at an urban academic ED seeing over 70,000 adult patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to December 31, 2011, and were discharged. Controls were patients who presented on the same times and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to codify International Classification of Diseases, ninth version, into disease groups. Linear models compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an intake area consisting of an internal results waiting room, and a treatment area for patients after initial assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as well. This was done without additional beds. The intake area was staffed with an attending emergency physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe.RESULTS:There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7.2%; 2010, n = 20,215; 2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011, n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%).CONCLUSIONS:A split ESI 3 patient flow model improves door-to-discharge LOS in the ED.

The effects of emergency department (ED) crowding on medical student education is poorly described but important to the education of our future physicians. Our hypothesis is that medical student education will be adversely affected by ED crowding as measured by the National Emergency Department Overcrowding Scale (NEDOCS).

Study Objectives: Ventilation/perfusion (VQ) scanning to diagnose pulmonary embolism has been largely supplanted by CT pulmonary angiography over the past decade. However, there remains a significant population in which computed tomography pulmonary angiography is not possible for a variety of reasons including renal insufficiency, poor venous access, and contrast allergy. The original Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study remains the basis for the algorithm of diagnosis of pulmonary embolism when computed tomography pulmonary angiography cannot be performed. Our primary objective was to determine whether there were discrepancies between the distributions of VQ scan results at our hospital and those in the original PIOPED study. Additional objectives included a comparison of distribution of results across ordering and interpreting physicians. Methods: A chart review was performed at our suburban academic emergency department (ED) with an annual volume of 63,000 adult patient visits. Patients between the ages of 18 and 89 from February 2007 through February 2010 who had a VQ scan ordered by an emergency physician were identified. Patient age and sex, ordering physician, interpreting radiologist, and VQ scan result were recorded. VQ scan results were classified according to the interpreting radiologist's reading as high probability, intermediate probability, low probability, and normal/near normal. Pearson's chi-square test was used to examine whether there were differences in the distribution of VQ scan results at our hospital as compared to the original PIOPED results. Chi-square tests were also used to examine differences in distributions of results across ordering physicians and across reading radiologists. If there were a large number of cells with small cell counts, an exact chi-square test via permutations was conducted. If, in addition, a table included a large number of cells making permutations computationally infeasible, Monte Carlo simulations were used to determine the null distribution of the chi-square and derive the p-value. Results: Our data included 648 scans with certain results. The distribution of results for our ED and PIOPED were significantly different (p<0.0001). Of the 648 patients in our study, 28 (4%) had a high probability scan, 59 (9%) had an intermediate probability scan, 469 (72%) had a low probability scan, and 92 (14%) had normal/near normal scans. In the original PIOPED study, in which 731 patients underwent both VQ scan and definitive angiograms, 116 (16%) had a high probability scan, 322 (44%) had an intermediate probability scan, 238 (33%) had a low probability scan, and 55 (8%) had normal/near normal scans. There was no significant difference between the distributions of results across ordering physicians with a p-value of 0.2819 (99%CI:0.2703,0.2935). There was a significant difference in the distribution of results across reading radiologists with a p-value<0.0001. Conclusion: There exists a significant discrepancy in the distribution of VQ scan results between our emergency department and the original PIOPED study. Further investigation is needed to determine whether this is due to differences in patient populations, clinician judgment in ordering the test, levels of comfort with interpretation of the test on the part of reading radiologists, evolution of the actual scanning procedure itself, or a combination of these or other factors.

Expertise in bedside ultrasonography is a skill that is essential to emergency physicians. Our department used a combination of live didactic lectures and hands-on practice using models to teach medical students (MS) in a fourth-year clerkship. While seemingly effective, this method required a significant amount of financial and faculty resources.

: The objective of the overall project was to develop a center of excellence in disaster preparedness and emergency response, linking together three major institutions and gaining research, education, and clinical synergies from the collaborations between their subject matter experts. The University Center for Disaster Preparedness and Emergency Response (UCDPER) has been established as a oint initiative of Rutgers, The State University of New Jersey, UMDNJ-Robert Wood Johnson Medical School, and Robert Wood Johnson University Hospital. UCDPER's missions include protection of the lives, health and well-being of the general public, vulnerable populations and the workforce - and protection of societal, economic and physical infrastructure - through research, education, community outreach and clinical advances in preparedness/response to all-hazards emergencies, disasters, and terrorism. The research projects conducted under the UCDPER umbrella have produced recommendations guidelines, and models focused on maximizing effectiveness and efficiency of disaster preparedness and emergency response in all-hazards scenarios. Collaboration across the three partner institutions has become robust over the course of the project. Follow-up projects are being planned.