Opportunities not missed--systematic influenza and pneumococcal immunization in a public inner-city emergency department

OBJECTIVE: To demonstrate the feasibility of systematic influenza and pneumococcal vaccination in a busy Emergency Department (ED). SETTING: A public, inner-city hospital with an annual adult ED census of 120,000. 93% of patients are people of color. 78% deny having either government or private insurance. Only 28% of patients report having a primary care provider. Only 15% present with complaints requiring immediate evaluation by a physician. METHODS: Two uncontrolled demonstration projects were conducted during two periods, from 10/21/96 through 12/2/96, (during the influenza immunization season) and from 5/27/97 to 7/26/97. During project one, nurses were given standing orders that all non-urgent patients meeting CDC recommended criteria were to be offered immunization against influenza and/or pneumococcus at triage. The date of immunization was entered into unused fields in the computerized patient registration system, making it available system-wide, to all providers having access to billing system terminals. From 11/4 through 11/18, an extra 'immunization nurse' was assigned to test for improvement in immunization figures. A time/motion study of the time required for each immunization was conducted using a convenience sample of eight nurses over all three shifts. During project two, responsibility for carrying out standing orders for immunization was transferred to the patient's nurses in the treatment area, and all high-risk patients were made eligible for immunization. An immunization card was issued to the patient at the time of each immunization. A monetary incentive to nurses was used to encourage completion of tracking forms. Computer record-keeping was continued. RESULTS: Both projects required intense supervision to ensure performance. Despite initial resistance, and extreme variation in individual performance, many nurses and physicians became supportive of ED immunization during the two projects. During project one, 2631 patients were screened, and 789 high-risk patients were identified. 1238 patients were immunized against influenza and 374 against pneumococcus. Immunizations per shift per nurse varied from 0 to 24. Median time for immunization was 4 min (range 2-10). The addition of an extra nurse at triage did not improve performance. During period two, 1907 patients were screened, 1532 high-risk patients were identified, and 1179 patients were immunized against pneumococcus. CONCLUSION: Systematic ED immunization of high-risk adults is feasible even in a busy public ED setting.     

Computer-aided-instruction in the emergency department

The Massachusetts General Hospital Laboratory of Computer Science created a library of computer-aided-instruction (CAI) programs in 1972. An experimental network of Cai programs, made possible by National Library of Medicine (NLM) support, was set up in July 1972, operating over commercial communication lines. Programs developed by Massachusetts General, Ohio State University and the University of Illinois Medical College were made available to users with terminals in about 36 cities through a local telephone number. During the first two years of the program over 80 institutions participated. A trial of the Massachusetts General programs, in conjunction with the Continuing Education Committee of the American College of Emergency Physicians, was conducted in five representative community hospitals. The hospitals put up the cost of the terminals and the telephone charges. Results of the study showed that 12 of the 40 (30%) emergency physicians in the target population took 10 or more programs. They gave the programs a favorable overall rating--1.6 on a scale of 1 (strongly positive) to 5 (strongly negative).     

Caring for Cambodian refugees in the emergency department

BACKGROUND: Platelet utilization has steadily increased throughout the past three decades. At the same time, there has been very little study of the current transfusion practices. STUDY DESIGN AND METHODS: A survey was conducted of institutional members of the American Association of Blood Banks (hospitals) that were actively involved in the care of pediatric and/or adult hematology and/or oncology patients. Inquiries were made relating to the extent of prophylactic versus therapeutic use of platelets, criteria used for prophylactic transfusion of platelets and type, and dose of platelets used. Data were analyzed according to patient age and type of hospital. RESULTS: Of 786 responding hospitals, 630 (80.2%) provided sufficient data for analysis; 126 of that 630 provided care for pediatric patients. The majority (60.9%) of responding hospitals had a minimum of four hematologists and/or oncologists. Eighty-four percent of hospitals reported transfusing some apheresis platelets. The dose of platelet concentrates most frequently used for adults ranged from 6 to 10, with pools of 10 more commonly used in community hospitals. More than 70 percent of hospitals reported transfusing platelets primarily for prophylaxis: 60 percent of hospitals set the threshold platelet count for prophylactic platelet transfusion at 20,000 per microL, with approximately 20 percent each transfusing at higher and lower levels. A platelet count of 50,000 per microL was most frequently required for performance of a minor invasive procedure. CONCLUSION: The data from this study show that the majority of institutions use prophylactic platelet transfusion in both pediatric and adult hematology and/or oncology patients. However, there is considerable variation in platelet transfusion practice.     

Radiographic interpretation in the emergency department

This study examined the concordance of radiographic readings between emergency department (ED) attending physicians and radiologists in a community teaching hospital. In addition, the incidents of misinterpretations leading to an alteration in patient care were also reviewed. All radiographs obtained from January through October 1993 were initially interpreted by ED attending physicians with subsequent final review by attending radiology staff. Misread radiographs were placed into one of three categories. The groupings included overread radiographs with no change in treatment, underread radiographs with no change in treatment, and radiograph misinterpretations with a change in treatment. Of 15,585 radiographs obtained during the study period, there were 120 misreads; 12,099 (77.6%) of the 15,585 radiographs had an initial emergency physician interpretation. Radiographic misinterpretations included 7 (5.78%) overreads, 57 (47.1%) underreads, and 57 (47.51%) misreads requiring follow-up (MR-FU). The five most frequently misread radiographs were: abdominal, 12/247 (4.4%); rib, 3/99 (3.0%); foot, 13/621 (2.1%); hip, 3/152 (1.9%); and ankle 11/758 (1.4%). The most frequently obtained radiographs included: chest, 7,012 (0.33% MR-FU); cervical spine, 1,112 (0.18% MR-FU); ankle, 758 (0.66% MR-FU); knee, 633 (0.32% MR-FU); and foot, 621 (0.97% MR-FU). In this study, 99.0% of all emergency department radiographs were read correctly on initial review by ED attending physicians. Of all misread radiographs, less than half (46%) were deemed clinically significant and required a follow-up intervention.     

Computed tomography in the emergency department

We report a neonatal case of severe, life-threatening Kasabach-Merritt syndrome that was successfully treated with interferon-alpha: This patient had a huge hemangioma of the right leg and a general bleeding tendency. Although the condition initially responded to steroid and radiation therapy, after a relapse, no therapy including steroids, radiation, aspirin, and dipyridamole was effective. Because of severe thrombocytopenia and extension of the hemangioma to the pelvic region, surgical intervention was not indicated. Interferon-alpha therapy was started on day 61 of life. During the therapy the platelet counts increased by more than tenfold and reached the normal level in a month. The size of the hemangioma dramatically decreased. The administration of interferon-alpha might be indicated as a therapy for severe, life-threatening Kasabach-Merritt syndrome, especially when there is resistance to steroid or radiation therapy.     

Quality improvement in the emergency department

A neonate born with a normal heart developed acute myocardial infarction at 12 days of age. Trivial mitral regurgitation secondary to fibrosis of posteromedial papillary muscle progressed to heart failure at 6 months of age. Mitral valve annuloplasty improved her condition.     

The use of propofol for sedation in the emergency department

Coats' disease is an idiopathic, primary vascular anomaly of the retina often presenting with retinal detachment. In this report, the unusual radiologic findings of a 17-month-old patient with advanced Coats' disease are discussed. Computed tomography (CT) showed diffuse increased density of the right eye. Magnetic resonance imaging (MRI) demonstrated moderately hyperintense signal intensity on T1-weighted images, mildly hypointense signal intensity on T2-weighted images, and linear enhancement of the leaves of the detached retina with intense enhancement in the retinal periphery following gadolinium-diethylenetriamine penta-acetic acid (DTPA) contrast administration. The hypointense T2-weighted images and the linear enhancement of the detached retina have not been reported previously in cases of Coats' disease. These observations correlated with the histopathologic features, which showed a totally detached retina containing large telangiectatic vesses and a supretinal space occupied by eoinophilic proteinaceous exudates containing abundant cholesterol crystals. It appears that the MRI characteristics observed in Coats' disease may vary depending on the nature of the subretinal exudate and the severity of the disease.     

Special considerations for Orthodox Jewish patients in the emergency department

Orthodox Jews are a special cultural group; their entire lives revolve around the teaching of the Torah. Their religious beliefs are reflected in all aspects of their lives, in both health and illness. The emergency department at Maimonides Medical Center has strived to serve this community and has modified common patient care practices to meet the needs of this special population.     

Violence in the accident and emergency department

We characterized the regression pattern of retinopathy of prematurity (ROP) for 266 infants examined over a 22-month period. Infants were included in the evaluation with a birth weight of less than or equal to 1500 g. Regression of retinopathy was observed in all but 11 infants, who were treated for threshold ROP. ROP limited to the peripheral retina resolved around term (40 weeks postconceptional age). Posterior ROP and/or stage 3 ROP underwent a protracted course of resolution, often not reaching zone 3 until 42 to 45 weeks after conception. Permanent retinal/vascular sequelae of ROP were observed in 10% of infants with ROP. The most common abnormality was failure to completely vascularize the temporal retinal periphery. Overall, retinal morbidity from ROP was an infrequent occurrence (18 of 266 premature infants--6.8%).     

Evaluation of syncope in the emergency department

Treatment of acute myocardial infarction has evolved significantly in the past two decades. Reperfusion therapies of thrombolysis and percutaneous angioplasty are major advances that can be employed to save infarcting myocardium and reduce mortality. When reperfusion therapy is combined with the use of aspirin, beta-blockade, heparin, and nitroglycerin, the emergency management of the patient with myocardial infarction can be completed. Outcomes in patients are determined by what happens in the first few minutes to hours after onset, and any delay in diagnosis or treatment may have significant consequences. This article reviews intervention and treatment strategies for acute myocardial infarction.     

Evaluating chest pain in the emergency department

1. Purification of horse-liver glutathione reductase was obtained by affinity chromatography on N6-(6-aminohexyl)-adenosine-1'5'-bisphosphate Sepharose (N6-2'5'-ADP-Sepharose) and Reactive Red-120-Agarose, and chromatography on DEAE-Sephadex and Sephacryl S-300. 2. The final preparation had 248 U/mg specific activity after 11,174-fold purification with 47% final recovery, and was homogeneous by SDS-electrophoresis. It showed charge heterogeneity in non-denaturing electrophoresis and chromatofocusing, with several peaks of pI between 5.7 and 6.7. 3. The enzyme was homodimeric (107,000 native MW), with S20w = 6.31 S, and 41.22 A of hydrodynamic radius. It showed absorption peaks at 270, 370 and 462 nm, a characteristic of flavoproteins. 4. When NADPH was substituted by deamino-NADPH or NADH the enzyme showed 69 and 8.5% activity, respectively, while with glutathione-CoA mixed disulfide the enzyme had 23% of the activity shown with GSSG. Apparent Km values of 8.8, 680, 59, and 560 microM were measured for NADPH, NADH, GSSG and ferricyanide, respectively.     

Neuromuscular blocking agents in the emergency department

The pbp4 gene of a Staphylococcus aureus strain selected stepwise in vitro for growth on increasing concentrations of penicillin and of its susceptible parent strain showed overall identity except in the promoter region. In the mutant a deletion upstream of the pbp4 structural gene removed 90 nucleotides (nt) that were framed by a 12 nt inverted repeat. This deletion occurred in step 4 of the in vitro selection procedure and was paralleled by a significant increase in the penicillin-binding protein 4 (PBP4) production. The in vitro step selected mutant showed a remarkable increase in the cross-linking of the peptidoglycan compared to its parent. This was linked to morphological changes in the appearance of the cells, which were surrounded by a very thick and fuzzy cell wall.     

Critical pharmacologic management in the emergency department

PURPOSE: Starting from a status hypercoagulability previous to substitutive hip and knee surgery, the aim of this work was to investigate the influence of different osteoarthropatic pictures for which arthroplasty is indicated in the activation of the clotting cascade, rheumatoid arthritis (RA) being one of such pictures. PATIENTS AND METHODS: Of 79 patients suitable for prosthetic surgery of hip (53) and knee (26), the preoperative values of several markers, namely, D dimers (D-D), thrombin-antithrombin (TAT) complex, and F1 + 2 prothrombin fragment (F1 + F2) were assessed by enzymoimmunoasay. The mean age of the patients was 65.5 years, and their sex distribution was 50 women and 29 men. The indications for arthroplasty were as follows: osteoarthrosis (62), aseptic necrosis (11), RA (9), articular gout (2), previous fracture (2), more than one diagnosis overlapped in some cases. The results attained were compared with a control group comprised of 33 subjects (16 women and 17 men) with mean age similar to the patient's group (68.06 years). RESULTS: The D-D values in the patients suitable for hip arthroplasty and the TAT values in patients suitable for both types of surgery were significantly higher than those found in the control group (p = 0.012 and 0.01, respectively). The preoperative TAT levels of the RA patients were significantly higher (p = 0.025) than those found in the patients with the other surgical indications. CONCLUSIONS: Previously to the performance of arthroplasty, the patients show hypercoagulative marker values higher than those of age-matched controls. The significant rising of TAT found in RA patients is concordant with the literature, and this fact makes it advisable to include RA among the pathologic situations associated with hypercoagulability, as this is a common indication for substitutive hip and knee surgery with high risk of venous thromboembolic disease.     

Public complaints and the emergency department

The effect of various cytokines including rIL-1, rIL-2, rIL-3, rIL-4, rIL-6, and growth factors including rNGF, rILGF and rEPGF on the post transplant immunodeficiency after allogeneic bone marrow transplantation was explored in 8 patients. The results show that neither cytokine alone was able to increase the proliferative capability in post transplant lymphocytes, however, when added in conjunction a significant increase in PHA driven proliferation was noted. Any significant lack of growth factors is probably not the only cause of immunodeficiency post transplant, since addition of any of these compounds did not have any influence on the lymphocyte proliferation, and so the data presented here suggest that therapeutic application of any of the investigated cytokines or growth factors to such patients is unlikely to be successful in overcoming the defects of T cell function post grafting.     

Evaluation of acute scrotum in the emergency department

A 2-year retrospective review of 238 cases of acute scrotal pain encountered in a children's hospital emergency department is presented. The incidences of testicular torsion, torsion of a testicular appendage, and epididymitis were 16%, 46%, and 35%, respectively. Testicular salvage was critically dependent on the interval between onset of pain and surgical intervention. No testis likely to have been viable at the time of presentation was "lost." The diagnostic error rate on first encounter was 7%, resulting in 10 negative scrotal explorations. With the exception of cases of far-advanced necrotic testes, both color Doppler ultrasound and radioisotope imaging were highly specific diagnostic modalities. Thirty-nine percent of the children with epididymitis who underwent investigation were found to have either structural or functional urinary tract abnormalities. Noninvasive urodynamic studies appear to be useful screening modalities in older children with epididymitis.