Continuous performance improvement (PI) is an essential component of the practice of emergency medicine (EM), and physicians must recognize the importance of PI processes in the safe and effective care of patients. The ACGME's Program Requirements indicate that all residents must be involved with PI activities. The American Board of Emergency Medicine requires diplomates to participate in PI activity. In addition, future health care reimbursement models are expected to include significant requirements for quality measurement and improvement.

Study ObjectiveUpper gastrointestinal bleeds commonly present to the emergency department (ED), and account for 300,000 yearly US hospital admissions at a cost of $2.5 billion per year. Many upper gastrointestinal bleeding patients are at low risk for serious complications and could be managed in an outpatient setting. There are no validated US guidelines to aid the emergency physician in determining which patients can be safely discharged from the ED. The United Kingdom (UK) has developed a scoring system, the Glasgow-Blatchford bleeding score (GBS), which accurately predicts which patients are low-risk for 7-day complications and can have an outpatient evaluation. The objective of this study is to evaluate the usefulness of the GBS in determining if admitted low-risk ED patients with upper gastrointestinal bleeding experience serious adverse events.MethodsWe conducted a retrospective chart review of adult patients admitted to the hospital from the ED with upper gastrointestinal bleeding over a 3-year period. Charts were selected using ICD-9 code for GI bleed. Subjects with a GBS of zero (low-risk) were evaluated for complications. A GBS of zero was assigned if BUN<18.2, hemoglobin ≥13.0(male) or ≥12.0 (female), systolic blood pressure ≥110, pulse<100, the patient had no complaints of melena or syncope, and had no history of hepatic disease or congestive heart failure. A serious adverse event was defined as endoscopic treatment, blood transfusion, or surgery. The setting was a 76,000 visit ED community hospital with an emergency medicine residency program.ResultsFive hundred sixty-seven presentations of upper gastrointestinal bleeding were screened. Four hundred sixty-four of these patients were admitted to the hospital with a diagnosis of upper gastrointestinal bleeding. Twenty-one (4.5%, 95% CI: 3.0-6.8%) of these were low-risk (GBS score of 0). Nine of the 21 patients underwent UGI endoscopy in the hospital. Serious adverse events were as follows: 0 blood transfusions, 0 surgeries, and 1 endoscopic treatment (hemorrhagic gastric polyp banded), 4.8%, (95%CI: 0.1-26.5).ConclusionVery few (4.5%) of our low-risk upper gastrointestinal bleeding patients were admitted to the hospital. Of the 21 low-risk patients admitted, only 1 had an adverse event (4.8%). The GBS may not be applicable to the US health care system, due to the already low percent of low-risk upper gastrointestinal bleeding patients admitted. The reason might be more stringent admission criteria and the rapid availability of outpatient endoscopy. More low-risk patients need to be followed to determine safety of outpatient management. Study ObjectiveUpper gastrointestinal bleeds commonly present to the emergency department (ED), and account for 300,000 yearly US hospital admissions at a cost of $2.5 billion per year. Many upper gastrointestinal bleeding patients are at low risk for serious complications and could be managed in an outpatient setting. There are no validated US guidelines to aid the emergency physician in determining which patients can be safely discharged from the ED. The United Kingdom (UK) has developed a scoring system, the Glasgow-Blatchford bleeding score (GBS), which accurately predicts which patients are low-risk for 7-day complications and can have an outpatient evaluation. The objective of this study is to evaluate the usefulness of the GBS in determining if admitted low-risk ED patients with upper gastrointestinal bleeding experience serious adverse events. Upper gastrointestinal bleeds commonly present to the emergency department (ED), and account for 300,000 yearly US hospital admissions at a cost of $2.5 billion per year. Many upper gastrointestinal bleeding patients are at low risk for serious complications and could be managed in an outpatient setting. There are no validated US guidelines to aid the emergency physician in determining which patients can be safely discharged from the ED. The United Kingdom (UK) has developed a scoring system, the Glasgow-Blatchford bleeding score (GBS), which accurately predicts which patients are low-risk for 7-day complications and can have an outpatient evaluation. The objective of this study is to evaluate the usefulness of the GBS in determining if admitted low-risk ED patients with upper gastrointestinal bleeding experience serious adverse events. MethodsWe conducted a retrospective chart review of adult patients admitted to the hospital from the ED with upper gastrointestinal bleeding over a 3-year period. Charts were selected using ICD-9 code for GI bleed. Subjects with a GBS of zero (low-risk) were evaluated for complications. A GBS of zero was assigned if BUN<18.2, hemoglobin ≥13.0(male) or ≥12.0 (female), systolic blood pressure ≥110, pulse<100, the patient had no complaints of melena or syncope, and had no history of hepatic disease or congestive heart failure. A serious adverse event was defined as endoscopic treatment, blood transfusion, or surgery. The setting was a 76,000 visit ED community hospital with an emergency medicine residency program. We conducted a retrospective chart review of adult patients admitted to the hospital from the ED with upper gastrointestinal bleeding over a 3-year period. Charts were selected using ICD-9 code for GI bleed. Subjects with a GBS of zero (low-risk) were evaluated for complications. A GBS of zero was assigned if BUN<18.2, hemoglobin ≥13.0(male) or ≥12.0 (female), systolic blood pressure ≥110, pulse<100, the patient had no complaints of melena or syncope, and had no history of hepatic disease or congestive heart failure. A serious adverse event was defined as endoscopic treatment, blood transfusion, or surgery. The setting was a 76,000 visit ED community hospital with an emergency medicine residency program. ResultsFive hundred sixty-seven presentations of upper gastrointestinal bleeding were screened. Four hundred sixty-four of these patients were admitted to the hospital with a diagnosis of upper gastrointestinal bleeding. Twenty-one (4.5%, 95% CI: 3.0-6.8%) of these were low-risk (GBS score of 0). Nine of the 21 patients underwent UGI endoscopy in the hospital. Serious adverse events were as follows: 0 blood transfusions, 0 surgeries, and 1 endoscopic treatment (hemorrhagic gastric polyp banded), 4.8%, (95%CI: 0.1-26.5). Five hundred sixty-seven presentations of upper gastrointestinal bleeding were screened. Four hundred sixty-four of these patients were admitted to the hospital with a diagnosis of upper gastrointestinal bleeding. Twenty-one (4.5%, 95% CI: 3.0-6.8%) of these were low-risk (GBS score of 0). Nine of the 21 patients underwent UGI endoscopy in the hospital. Serious adverse events were as follows: 0 blood transfusions, 0 surgeries, and 1 endoscopic treatment (hemorrhagic gastric polyp banded), 4.8%, (95%CI: 0.1-26.5). ConclusionVery few (4.5%) of our low-risk upper gastrointestinal bleeding patients were admitted to the hospital. Of the 21 low-risk patients admitted, only 1 had an adverse event (4.8%). The GBS may not be applicable to the US health care system, due to the already low percent of low-risk upper gastrointestinal bleeding patients admitted. The reason might be more stringent admission criteria and the rapid availability of outpatient endoscopy. More low-risk patients need to be followed to determine safety of outpatient management. Very few (4.5%) of our low-risk upper gastrointestinal bleeding patients were admitted to the hospital. Of the 21 low-risk patients admitted, only 1 had an adverse event (4.8%). The GBS may not be applicable to the US health care system, due to the already low percent of low-risk upper gastrointestinal bleeding patients admitted. The reason might be more stringent admission criteria and the rapid availability of outpatient endoscopy. More low-risk patients need to be followed to determine safety of outpatient management.

New consensus guidelines for community-acquired pneumonia (CAP) were issued by the American Thoracic Society and the Infectious Disease Society of America. Recommendations include empiric antibiotic therapy, which subset of patients should receive blood cultures and sputum cultures, and which subset of patients should be admitted to the intensive dare unit (ICU). We compared the new guidelines to a cohort of pneumonia patients. Our objective was to determine if the new guidelines are appropriate for CAP patients admitted to our hospital through the emergency department (ED).

Study objectives: The 1995 US Department of Transportation Nationwide Personal Transportation Survey reports that the crash involvement rate per 1 million miles traveled triples from age 65 up to age 85. The fatality rate per 1 million vehicle miles increases by 500% for the same populations. The Pennsylvania Vehicle Code requires physicians to report patients with a “condition that could impair their ability to drive” to the Pennsylvania Department of Transportation (PENNDOT). Thirteen diagnoses of disorder or disability are listed on the Department of Transportation Initial Reporting Form. We conduct a survey of elderly patients presenting to the emergency department (ED) to determine driving status, ED diagnosis compared with PENNDOT's reportable diagnoses, and driving recommendations by discharge physician. Methods: A 1-month convenience sample of patients aged 65 years or older was asked to participate in a study of their driving practices. The survey was conducted in a community teaching hospital ED with an annual census of 60,000. Verbal informed consent was obtained. Participants were asked whether they had a valid driver's license. Drivers were asked about their driving habits, whether their ability to drive had ever been questioned, and whether they felt safe to drive. Each driver's ED diagnosis, medication list, and potential reportable diagnoses were recorded. Physician driving recommendation at discharge was noted. One author (RSB) reviewed all medical records to determine potential reportable diagnoses. Institutional review board/Health Insurance Portability and Accountability Act–approval was obtained. Descriptive statistics were used. Results: Of 112 patients asked to participate, 31 (28%) were excluded because of the following: 24 declined consent; 4 younger than 65 years; 2 incomplete data; 1 surveyed twice on the same visit. Of the remaining 81 patients, 24 (30%) did not have a valid license or had voluntarily stopped driving. Thirty-nine (48%) patients were judged not to have a reportable diagnosis. Of the 18 patients judged to have a reportable medical condition, only 3 were instructed not to drive at discharge. There was no documentation on any record that a PENNDOT form was completed. Family had previously discussed driving ability with 9 patients. All 9 reported continued driving at the ED visit. Two other patients had voluntarily stopped driving after being told by their family physician to stop. Conclusion: Elderly patients often present to the ED with conditions that could impair their ability to drive. A sample of patients in our ED demonstrates a lack of discharge instructions about driving and underreporting of potentially hazardous conditions to PENNDOT. Of the 11 patients told by family or physician to stop driving, only the 2 patients instructed by the family physician discontinued driving. Emergency physicians should be educated about reporting requirements in their locale. Elderly ED patients should have a driving history obtained. Patients with conditions that could impair their ability to drive should be given driving-specific discharge instructions. Reporting to the appropriate agency should be completed if required by the practitioner's state. Study objectives: The 1995 US Department of Transportation Nationwide Personal Transportation Survey reports that the crash involvement rate per 1 million miles traveled triples from age 65 up to age 85. The fatality rate per 1 million vehicle miles increases by 500% for the same populations. The Pennsylvania Vehicle Code requires physicians to report patients with a “condition that could impair their ability to drive” to the Pennsylvania Department of Transportation (PENNDOT). Thirteen diagnoses of disorder or disability are listed on the Department of Transportation Initial Reporting Form. We conduct a survey of elderly patients presenting to the emergency department (ED) to determine driving status, ED diagnosis compared with PENNDOT's reportable diagnoses, and driving recommendations by discharge physician. Methods: A 1-month convenience sample of patients aged 65 years or older was asked to participate in a study of their driving practices. The survey was conducted in a community teaching hospital ED with an annual census of 60,000. Verbal informed consent was obtained. Participants were asked whether they had a valid driver's license. Drivers were asked about their driving habits, whether their ability to drive had ever been questioned, and whether they felt safe to drive. Each driver's ED diagnosis, medication list, and potential reportable diagnoses were recorded. Physician driving recommendation at discharge was noted. One author (RSB) reviewed all medical records to determine potential reportable diagnoses. Institutional review board/Health Insurance Portability and Accountability Act–approval was obtained. Descriptive statistics were used. Results: Of 112 patients asked to participate, 31 (28%) were excluded because of the following: 24 declined consent; 4 younger than 65 years; 2 incomplete data; 1 surveyed twice on the same visit. Of the remaining 81 patients, 24 (30%) did not have a valid license or had voluntarily stopped driving. Thirty-nine (48%) patients were judged not to have a reportable diagnosis. Of the 18 patients judged to have a reportable medical condition, only 3 were instructed not to drive at discharge. There was no documentation on any record that a PENNDOT form was completed. Family had previously discussed driving ability with 9 patients. All 9 reported continued driving at the ED visit. Two other patients had voluntarily stopped driving after being told by their family physician to stop. Conclusion: Elderly patients often present to the ED with conditions that could impair their ability to drive. A sample of patients in our ED demonstrates a lack of discharge instructions about driving and underreporting of potentially hazardous conditions to PENNDOT. Of the 11 patients told by family or physician to stop driving, only the 2 patients instructed by the family physician discontinued driving. Emergency physicians should be educated about reporting requirements in their locale. Elderly ED patients should have a driving history obtained. Patients with conditions that could impair their ability to drive should be given driving-specific discharge instructions. Reporting to the appropriate agency should be completed if required by the practitioner's state.

Study objectives: The American Thoracic Society and the American Society for Infectious Diseases recommend 2 sets of blood cultures as part of the evaluation of hospitalized pneumonia patients. Several studies have questioned the utility of blood cultures in community-acquired pneumonia, suggesting positive cultures seldom lead to important therapeutic changes. Our institution uses a pneumonia pathway requiring 2 sets of blood cultures with antibiotic guidelines for different clinical situations. Our objective is to identify risk factors that would enable emergency department (ED) clinicians to reduce or eliminate blood cultures in pneumonia patients. Methods: York Hospital institutional review board approval was obtained. A retrospective chart review using a standardized data collection form was conducted by the 3 investigators. The study was conducted in a community teaching hospital with an ED residency program and an annual census of 60,000 patients. Patients admitted through the ED during calendar years 2001 and 2002 with an admission diagnosis of pneumonia (diagnosis-related group 96, 97) were reviewed. Patients younger than 18 years or with a hospital discharge diagnosis other than pneumonia were excluded. Antibiotics were started in the ED according to a pneumonia pathway order set. The following risk factors were evaluated for positive blood culture results: pneumonia severity index (PSI), recent hospitalization, immunocompromised state, nursing home residency, and chronic obstructive pulmonary disease. Sensitivity to standard pneumonia pathway antibiotics was reviewed. Data were analyzed by descriptive statistics. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Results: Six hundred eighty-six charts were reviewed. Eighty-two (12%) were excluded because of nonpneumonia discharge diagnoses, which resulted in 604 eligible charts. Of 44 (7.3%) positive blood cultures identified, 25 (4.1%) were found to be contaminants, and 19 (3.1%) were true positives (Streptococcus pneumoniae, group B streptococcus, Staphylococcus aureus, Escherichia coli, Haemophilus influenzae). All organisms were sensitive to standard pneumonia pathway antibiotics. The antibiotic was changed from Levofloxacin to penicillin in 1 positive culture for S pneumoniae. PSI level V (OR 3.2, 95% CI 1.306 to 7.850) was the only statistically significant risk factor for a positive blood culture result. All other PSI scores, individually or combined, had ORs less than 1. Other risk factors examined did not reach statistical significance: recent hospitalization (OR 0.805, 95% CI 0.232 to 2.797), nursing home resident (OR 0.560, 95% CI 0.162 to 1.938), chronic obstructive pulmonary disease (OR 0.480, 95% CI 0.158 to 1.455), and immunocompromised state (OR 1.112, 95% CI 0.319 to 3.880). Conclusion: Only PSI level V patients had a statistically significant OR for positive blood culture results. All positive blood culture results were sensitive to pneumonia pathway antibiotics. The only culture-driven antibiotic change was to an antibiotic with a narrower spectrum. In our community hospital population, the addition of blood cultures did not affect clinical management, suggesting that cultures could be eliminated in many patients. We recommend drawing blood cultures and ordering their completion for PSI level V patients. Study objectives: The American Thoracic Society and the American Society for Infectious Diseases recommend 2 sets of blood cultures as part of the evaluation of hospitalized pneumonia patients. Several studies have questioned the utility of blood cultures in community-acquired pneumonia, suggesting positive cultures seldom lead to important therapeutic changes. Our institution uses a pneumonia pathway requiring 2 sets of blood cultures with antibiotic guidelines for different clinical situations. Our objective is to identify risk factors that would enable emergency department (ED) clinicians to reduce or eliminate blood cultures in pneumonia patients. Methods: York Hospital institutional review board approval was obtained. A retrospective chart review using a standardized data collection form was conducted by the 3 investigators. The study was conducted in a community teaching hospital with an ED residency program and an annual census of 60,000 patients. Patients admitted through the ED during calendar years 2001 and 2002 with an admission diagnosis of pneumonia (diagnosis-related group 96, 97) were reviewed. Patients younger than 18 years or with a hospital discharge diagnosis other than pneumonia were excluded. Antibiotics were started in the ED according to a pneumonia pathway order set. The following risk factors were evaluated for positive blood culture results: pneumonia severity index (PSI), recent hospitalization, immunocompromised state, nursing home residency, and chronic obstructive pulmonary disease. Sensitivity to standard pneumonia pathway antibiotics was reviewed. Data were analyzed by descriptive statistics. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Results: Six hundred eighty-six charts were reviewed. Eighty-two (12%) were excluded because of nonpneumonia discharge diagnoses, which resulted in 604 eligible charts. Of 44 (7.3%) positive blood cultures identified, 25 (4.1%) were found to be contaminants, and 19 (3.1%) were true positives (Streptococcus pneumoniae, group B streptococcus, Staphylococcus aureus, Escherichia coli, Haemophilus influenzae). All organisms were sensitive to standard pneumonia pathway antibiotics. The antibiotic was changed from Levofloxacin to penicillin in 1 positive culture for S pneumoniae. PSI level V (OR 3.2, 95% CI 1.306 to 7.850) was the only statistically significant risk factor for a positive blood culture result. All other PSI scores, individually or combined, had ORs less than 1. Other risk factors examined did not reach statistical significance: recent hospitalization (OR 0.805, 95% CI 0.232 to 2.797), nursing home resident (OR 0.560, 95% CI 0.162 to 1.938), chronic obstructive pulmonary disease (OR 0.480, 95% CI 0.158 to 1.455), and immunocompromised state (OR 1.112, 95% CI 0.319 to 3.880). Conclusion: Only PSI level V patients had a statistically significant OR for positive blood culture results. All positive blood culture results were sensitive to pneumonia pathway antibiotics. The only culture-driven antibiotic change was to an antibiotic with a narrower spectrum. In our community hospital population, the addition of blood cultures did not affect clinical management, suggesting that cultures could be eliminated in many patients. We recommend drawing blood cultures and ordering their completion for PSI level V patients.

UNLABELLED:Emergency physicians commonly perform death notifications. Physician training in death notification has been limited. Resident physicians are rarely evaluated in their performance of death notifications.OBJECTIVE:To evaluate death notification skills by direct observation of actual notifications performed by trained emergency medicine (EM) residents.METHODS:This was a prospective, observational study of EM resident death notification performance. EM residents received training and then were directly observed and evaluated by trained evaluators during actual death notifications in a 64,000-visit community teaching hospital emergency department.RESULTS:There were 327 evaluations of 70 different EM residents. Overall performance evaluations were 55% excellent, 40% satisfactory, and 5% unsatisfactory. Third-year EM residents and female EM residents were more likely to be rated excellent.CONCLUSIONS:Death notification is a skill that can be evaluated like other EM skills. Trained EM residents performed well in actual death notifications when directly observed and evaluated. Senior residents and female residents were more likely to be rated excellent.

This study compared the sensitivity and specificity of computed tomography (CT) scan and ventilation-perfusion (V-P) scan in detecting pulmonary embolism (PE) with pulmonary angiogram (AG) as the reference standard. Following a comprehensive search of the indexed medical literature, CT scan studies related to PE diagnosis were systematically evaluated to select those using AG as the reference standard and meeting specified methodologic criteria. Studies were further grouped by those reporting results for central PE findings only versus central and peripheral PE combined. A composite analysis of data derived from seven selected publications yielded sensitivity and specificity estimates for CT scan in detecting PE, which were statistically compared to the published results of a multi-center study reporting the sensitivity and specificity of the V-P scan with pulmonary AG as the reference standard. The calculated CT scan sensitivity was 77% for central PE only data and 81% for central and peripheral PE combined data, and the CT scan specificity was 91% and 98%, respectively. High-probability V-P scan sensitivity was 41% and specificity 97%; high- and intermediate-probability V-P scans combined yielded sensitivity 83% and specificity 52%. The sensitivity for PE detection was significantly greater for CT scan than for high-probability V-P scan; CT scan sensitivity was equivalent to V-P when high- and intermediate-probability scans were considered together. CT scan specificity for central and peripheral PE combined was equivalent to that of the high-probability V-P scan, but significantly greater than that of high- and intermediate-probability V-P scans considered together. Considering that only a small proportion of patients with suspected PE yield high-probability V-P scan results (which are usually indicative of PE), while as many as one-half of patients may yield intermediate-probability results (which are commonly not useful in PE diagnosis), our results suggest the CT scan may be an appropriate study for use by Emergency Physicians in the clinical evaluation of suspected PE.

OBJECTIVES:A clinical pathway standardizing management for patients with an admission diagnosis of pneumonia was initiated after a previous study found delayed time to initial antibiotic administration, a longer length of stay, and higher mortality rate for the authors' patients as compared with those in a "benchmark" hospital. The current study was undertaken to determine whether implementation of the clinical pathway resulted in statistically significant decreases for these measures, both in the initial year following pathway implementation and two years later.METHODS:A retrospective chart review was completed for three cohorts of pneumonia patients admitted via the ED: 1) three months immediately prior to pathway implementation, 2) 10-12 months after implementation of the pathway, and 3) 34-36 months after implementation of the pathway. Four standard antibiotic regimens were used following pathway implementation: community-acquired, community-acquired penicillin-allergic, nursing home-acquired, and nursing home-acquired penicillin-allergic. Demographics, medical history, presentation signs and symptoms, process of care, and outcome data were abstracted from each patient's medical record.RESULTS:The mean time to antibiotic administration decreased from 315 minutes prepathway to approximately 175 minutes during the first postpathway period and 171 minutes at three years (ANOVA, p < 0.0001). The percentage of patients who received antibiotics in the ED increased from 58% prepathway to 94% during the first postpathway period and 97% at three years (chi square, p < 0.0001). Length of stay decreased from 9.7 prepathway to 8.9 days during the first postpathway period and 6.4 days at three years (ANOVA, p < 0.0001). There was no significant change of in-hospital mortality (9.6% prepathway to 5.2% and 4.9%) in the two respective periods.CONCLUSIONS:This study demonstrates that implementation of a pneumonia clinical pathway for the management of hospitalized patients admitted via the ED decreases the time to initial antibiotic treatment and increases the proportion of patients initially treated with antibiotics in the ED. These effects were evident in the first year following pathway implementation and sustained at the three-year study interval.

The high sensitivity analysis of H and D in thin foils (25 μm or less) using 4He induced elastic recoils is described. Using 4–6 MeV He ions, background count rates corresponding to hydrogen concentrations of approximately 1 ppm (atomic) are demonstrated for both isotopes.

The 20Ne(3He, n)22Mg reaction has been studied with particular emphasis on some unusual angular distributions observed at bombarding energies between 4 and 6 MeV. A satisfactory explanation of the ground state group differential cross sections is given by assuming interference between direct interaction and compound-nucleus formation. The 22Mg half-life was measured to be 3.97 ± 0.09 s, and an excitation curve for the 22Mg(β+) activity was obtained.