J Emerg Med
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Clinical Trial Controlled Clinical Trial
Test ordering guidelines can alter ordering patterns in an academic emergency department.
To determine the impact of an educational program designed to modify test ordering behavior in an academic Emergency Department (ED), an observational, before-and-after study was conducted at a university tertiary referral center and Emergency Medicine (EM) residency site. Test ordering standards were developed by EM faculty, RNs, and NPs based upon group consensus and published data. The standards were given to all ED staff beginning February 1996, and included in the evidence-based medicine orientation and educational program for all residents and medical students prior to beginning their rotation. ⋯ Chemistry test ordering frequency showed statistically significant increases. Overall, approximately $50,000 was saved by decreasing test ordering. Test ordering behavior can be modified and maintained by an educational program and may have significant economic effects.
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Multicenter Study
Primary care physician and patient factors that result in patients seeking emergency care in a hospital setting: the patient's perspective.
Much has been written about "abuse" and "overutilization" of Emergency Departments (EDs). We undertook to study, from the patient's perspective, physician and patient factors that influence the patient's decision to seek ED care. The study was designed as a convenience cohort, multi-centre survey, conducted in 13 hospitals in the Greater Toronto Area. ⋯ As many as 55% of patients presented to the ED because it was more convenient. Only a minority (23%) of patients felt their acuity of illness warranted an ED visit. Primary care physicians need to play a stronger role in educating their patients about the utilization of emergency care and the services offered in the office setting.
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The objectives of this study were to determine the optimal cutoff value (CV) and utility of a single serum beta human chorionic gonadotropin hormone (HCG) level in assessing the likelihood of ectopic pregnancy (ECP). A retrospective chart review was performed at an urban county hospital. The optimal CV was determined by comparing all available patients diagnosed with ECP and patients diagnosed with threatened abortion (TA) in the Emergency Department (ED) who subsequently delivered a baby at the same hospital. ⋯ When the test was applied to a group of 175 women who presented with pain or bleeding between 6 and 13 weeks EGA, the sensitivity and positive predictive value for an intrauterine pregnancy were 24% and 99.9 %, respectively. However, if this test was applied to all patients regardless of clinical findings, and then an ultrasound (U/S) algorithm was applied to the patients who had an HCG of less than 40K, it would predictably increase the rate of ECPs falsely identified as intrauterine pregnancies (IUPs) by 1%, regardless of the false-positive rate of the U/S algorithm itself. Given the potential morbidity and mortality of undiagnosed ectopic pregnancy, ultimately neither this test nor any other that is less than 100% specific for IUP can be recommended instead of an initial U/S evaluation for patients who present at risk for ECP.
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Randomized Controlled Trial Clinical Trial
Use of the Trousseau dilator in cricothyrotomy.
When performing cricothyrotomy, once the initial incision has been created, the scalpel handle may be inserted into the incision and rotated, or a Trousseau dilator may be used to widen the opening. During endotracheal (ET) tube passage, the Trousseau dilator may be left in place or a tracheal hook may be inserted for tracheal stabilization. This experimental crossover trial of cricothyrotomy in a cadaver model compared: 1) scalpel handle rotation to the use of a Trousseau dilator in widening the initial incision, and 2) the use of a tracheal hook to a Trousseau dilator during ET tube passage. ⋯ We found that the average size of the largest ET tube passed was significantly greater with the use of a tracheal hook (internal diameter mean 7.0 mm, median 7.0 mm) than with a Trousseau dilator (internal diameter mean 5.7 mm, median 5.5 mm). There was no damage to local tissue and no cuff ruptures. We conclude that the scalpel handle rotation technique is equal to the use of the Trousseau dilator with regard to opening size and maximal ET tube size but that use of a tracheal hook rather than a Trousseau dilator allows for passage of a larger ET tube in a cadaver model of cricothyrotomy.